`Old age is not synonymous with ill health'

Interview with Dr. Koshy Eapen

"There is no need for the elderly to suffer as they do now. There are simple, cost-effective ways of managing most of their illnesses," says Dr. Koshy Eapen, a medical researcher on the epidemiology of geriatric care at the University of London. Winner of several awards including this year's University of London's Excellence and Achievement Award, and the 2002 Outstanding Young Indian of the Year Award for his services to geriatric care, Dr. Eapen is passionate about his work.

His research focuses on how India can emulate the developed countries in taking care of the aged at a low cost by properly using available resources. He aims to help India develop a comprehensive, cost-effective health policy for the aged.

His primary work is to develop health-care systems for the elderly who constitute over 12 per cent of the population in India.

Dr. Eapen has also financially contributed to the cause of medical studies in India. He recently set up a charitable trust in Kerala to fund fully the medical education of 50 needy students. He hopes these scholarships will encourage students to work in areas where India lacks expertise.

Before joining the University of London, Dr. Eapen was at the University of Cambridge - he was the first Indian doctor to be awarded the full Cambridge Commonwealth Scholarship for his studies on the health care of the elderly. A Cambridge-Nehru scholar, he won the prestigious Harrison Watson and the Cambridge Commonwealth/JNMT scholarships.

He also won awards that enabled him to visit and research at the National Institute of Health at Johns Hopkins University and the University of North Carolina in the U.S., and Erasmus University, Holland. After a fellowship in clinical training in Oxford, Dr. Eapen joined the University of London where he is now on a Mountbatten Scholarship.

In an email interview, Dr. Eapen spoke to Asha Krishnakumar on the importance of geriatric care, the main constituents of geriatric management in a resource-poor setting and the need to put in place a comprehensive healthcare package for the elderly in India. Excerpts:

When and why did the study of geriatrics emerge as an independent discipline?

Geriatrics is the branch of medicine that deals with the diseases of old age. At present, there is no such specialty in India though 20 per cent of doctor visits, 30 per cent of hospital days and 50 per cent of bed-ridden days relate to the elderly.

Most of the elderly do not need institutional care if they are treated early in their illness. They often silently suffer the progression of diseases leading to an abrupt functional decline, which is then wrongly attributed to ageing. Therefore, geriatrics involves treating acute illnesses as well as managing the rehabilitative and long-term care of the aged.

How is geriatrics different from general medicine?

Geriatrics differs from general medicine not in quality, but in the probability structures of diagnosis, presentation of illness and the need for an explicit determination to intervene. Older people need more investigations for comparable levels of diagnostic accuracy. For example, age-related impairment of immunity is associated with increasing lethality and reactivation of latent infections. This cryptic presentation of illness makes even severe infections such as endocarditis, peritonitis and tuberculosis difficult to diagnose in the elderly.

In addition, the old are more prone to developing side effects to drugs. Though the educational and clinical issues in geriatrics in India are similar to those in developed nations, the large population and the lack of funds make it much more challenging.

How has geriatrics as a special discipline developed in India?

There is only one medical college - located in Chennai - that has a Geriatric Medicine Department at the postgraduate level. Research in geriatrics in India provides a few sketchy disease statistics only. The Medical Council of India is in the process of introducing geriatric medicine in about 150 medical schools.

It is striking that the development of paediatric medical specialty in India became the scaffold around which the government took up a large number of successful programmes such as the maternal and child health programme, the Anganwadis, the immunisation schedule, periodical check-ups, and so on, which improved the health and nutritional standards of millions of children. If the development of a paediatric specialty could change life and control illnesses of children so dramatically, I am sure it can happen for the elderly too.

In India, anyone who lives over 80 is reckoned to have had a "fair innings". This is then the argument for rationing health care resources. But it is important to understand that it is the maintaining of the elderly in hospitals and not the ageing population per se that costs money. The objective of geriatric care is not to make all elderly persons die in ICUs [intensive care units] but to achieve a minimum quality of dignified and healthy life for the elderly.

Why is the study of geriatrics important, particularly in India?

Most problems in India deal with numbers. Geriatrics is no exception. It is currently estimated that adults over 60 years make up 8 per cent of India's population and by 2021 that number will be 137 million. India now has the second largest aged population in the world. The small-family norm means that fewer working, younger individuals are called upon to care for an increasing number of economically unproductive, elderly persons.

If you consider work participation among the elderly as an index of poverty (if you work when you are old, you only do so because you need to), then in India approximately 60 per cent continue to work beyond 60 years whereas in some developed nations only 2 per cent over 65 are part of the labour force. In India, even in the above-80 group, about 20 per cent are forced to work.

It is not that the elders who do not participate in the workforce do not contribute to the economy - only it is not taken into account. They contribute by bringing up grandchildren, doing voluntary service, caring for the sick, and often counsel and resolve conflict by virtue of their position. In many cases they are also repositories of knowledge, experience, culture and religious heritage.

What are the common geriatric problems? What infrastructure is needed to handle these problems? Is India capable of handling them?

The needs of the elderly are unique and distinctive as they are vulnerable. Health, economic and psychological needs are most important. Among the medical problems, vision (cataract) and degenerative joint disease top the list, followed by neurological, cardiovascular and urinary diseases. Malignant diseases account for a sizeable extent of morbidity. Other problems of concern are malnutrition, frequent falls and cognitive dysfunction. To compound this, the aged often have more than one illness.

Are there any protocols to treat the elderly?

Clear guidelines for hospice care and what to offer the terminally ill are lacking in India. Life and death decisions cannot be left to doctors alone; the wishes of patients and their relatives have to be sought. None of this happens in India in the absence of clear guidelines.

For an elderly person belonging to the lower strata of society, an illness can be a calamity. He or she cannot go to the hospital alone and it is difficult for a family member, often a daily wage earner, to accompany him. Thus, treatment rarely happens in such cases, as the family has not only to forego its income but also pay for the treatment. Even if they do go to a government hospital there is often no doctor there. So, most elderly people, especially in the rural areas, remain untreated.

How can geriatrics be managed in a country like India with limited resources? How have the developed countries coped? Are there any lessons to be learnt?

As with everything else, it is often argued that care provided to the aged in India is inadequate as a result of meagre resources. However, if Kerala could have a life expectancy and a health-care system on a par with the best in the world at a fraction of the cost incurred there, it is certainly possible to replicate this success for the elderly too. Elderly people value small improvements in health care more highly than young people and so it is often not difficult to satisfy these needs but only the government must have the will to do so.

What kind of research is on in geriatric management and care?

First, it is necessary to dispel the belief that old age is synonymous with ill health and disability. Many of the chronic disabling conditions can certainly be prevented or postponed. This is adequately proved by the experiences in different countries. For example, the Japanese show that with ageing there is much less increase in chronic problems such as cancer, heart diseases, cataract and glaucoma than in the case of Europeans. However, the Japanese migrants to the U.S. who have adapted to Western lifestyles have much higher cholesterol levels and heart disease rates than the Americans. This shows that it is lifestyle and not genetic factors that lead to these diseases and, hence, are eminently modifiable.

Current research also shows that the age of onset of ill health rises faster than increases in the life span, resulting in a "compression of morbidity" (only a short period of ill health before death). This, then, is the aim of geriatric care: to reduce or postpone the onset of age-related illness so that an elderly person suffers ill health only for a short period before death and is able to lead a healthy life then.

Experience from other countries shows that elderly patients need a more broadbased, inter-disciplinary approach to managing their health as problems are often multi-dimensional - biological, social, emotional, psychological and financial. If tackled by the medical fraternity alone, it touches only the tip of the iceberg. Geriatric care requires integration of medicine with community management.

It is also essential to keep the elderly in the confines of their homes for as long as possible and admit [them to hospitals] for long-term care only after a careful medical/psycho-social assessment and trial of rehabilitation. This is because the morbid elderly living with their families at home recover faster than those in the hospital.

In the West, geriatric patients requiring hospitalisation are first admitted to an acute geriatric assessment unit for a comprehensive analysis of their medical, functional and psycho-social problems. Thus, if they are admitted to a hospital, there is a specific plan and aim for treatment with the consent of both the patient and his relatives. Such an approach concentrates on the features that people themselves value on discharge - mobility, self care, ability to pursue their usual activities and being free of pain, anxiety and depression.

The healthcare system in India relies on the patient approaching the health provider, but this is precisely what the aged do not do. What is needed is a more active health team that goes into the rural areas and slums providing free medical care and counselling for the elderly at their doorsteps. This would be particularly useful for those who are immobile.

The unit can also undertake general screening of the elderly for medical problems, psychological problems such as dementia and depression, strength of arms and legs (to assess risk of falls and arthritis); and living conditions - daily exercise (it protects against many illnesses), quality of the home (for risk of falls), and access to health care. Such a proactive approach adopted in richer nations has been the backbone of their success in geriatric care. This is eminently possible in India, even with its limited resources.

There are several ways to look after the aged. Discussion groups and physical fitness regimes with both young and old members have also proven effective to maintain agility of the mind and body. Schools could introduce an "adopt a granny" scheme to support people who are too old, ill or immobile. The government could consider job-sharing agreements for the aged, so that two or three persons might be able to do a single person's full-time job between them, allowing individuals to age with dignity and to lead productive lives for as long as they are able.

In India, where 90 per cent of the total workforce is employed in the informal sector, the social security offered by the National Old Age Pension scheme is available only to the 10 per cent retiring from the organised sector. Even this is merely Rs.60-150 every month, which is insufficient by any standard. Even when offering pensions, the economic needs of an elderly person must be taken into account and pension should not be fixed merely as a percentage of the last drawn pay.

It is also imperative to train doctors, especially those working in the rural areas, to handle specific illnesses associated with ageing. A laudable effort in this context is the Kaliandiri experiment in Tamil Nadu, which demonstrates that total health care for the rural aged is possible within the existing infrastructure.

What is the role of the government in managing the elderly? What has been the government's response in India?

Several agencies approached me, learning of my interest among the aged, to start old age homes as a business proposition. These are excellent provisions for those who can afford it. For the frail elderly who opt to stay at home, there can also be on offer a home-help service that assists in cooking or meal delivery, laundry and transport.

But with India's large and rising elderly population, concentrated mostly in the rural areas and among the poor, it is impossible for any agency other than the government to find the will or the resources to implement any programme for geriatric health care at the national level. The stress should be on a community approach to primary health care. But the government is hardly doing anything.

The government must take the initiative to set up senior citizen centres in both rural and urban areas for those who can no longer live alone. For those not requiring hospitalisation, day-care facilities can be attached to these centres, providing physical rehabilitation and the opportunity to socialise. Health promotion, education and engaging in income-generating activities are all possible at such centres. To enrich the life of advanced cancer patients in a non-clinical environment, hospices are also essential to provide both hospital day-care and home-care services.

Innovative methods and research on approaches best suited for India are cardinal in providing adequate and cost-effective care for the aged. It only needs the will of the government.