Presidential address at the 18th Annual Conference of Indian Psychiatric Society. Kerala State Branch

CARE OF THE ELDERLY-MYTHS, FACTS, STRATEGIES

Dr. KURUVILLA THOMAS
At the outset, I express my gratitude to all members of IPS Kerala State Branch for giving me the opportunity to serve the highest office for the next one year. I assure that the trust bestowed upon me by the Society will be honored to the best of my ability. I am greatly indebted to all my teachers for sharing their knowledge with me and leading me towards the path of wisdom. The bouquet of thanks will be devoid of roses if at this moment of happiness I fail to remember my patients whose cooperation helped me to transform my theoretical knowledge into practice. 
It is customary that we focus on the current issues related to the field. I have been working in Consultation- Liaison Psychiatry for nearly to decades now. In the last few years, I have observed a steep increase in the mental health problems of the elderly. Hence I decided to talk on "Care of the Elderly-myths, facts, strategies",
Traditionally Indian culture gives lot of respect for the elderly. Celebrations like Shastyabdapoorthi, Sapthadi and Sathabhishekem - living long enough to see one thousand moons - are evidences of the value given to the elderly, Article 41 of the Constitution of India stipulates that the State should make provision for assistance in old age. Article 25 of United Nations (1984) resolution on Universal Declaration of Human Rights, state that everyone has the right to a standard of living, which is adequate for health and well being of him and family. All are created equal and independent. From equal creation the concept of certain individual rights being natural, inherent and inalienable has emerged. With the fast growth in the number and problems of the elderly, are we prepared to manage it and prevent a crisis ? Economist Lester C. T said the conflict between the rich and the poor is now replaced by that between the young and the old. Pulitzer prize winner Robert Butler said that old age was the disease of the 20th century; in the 21st century it would become epidemic. October 1st is the Elders day. The year 1999 was celebrated as the International Year of the Elderly by the United Nations.
Let us have a look at the present statistics related to the elderly as a group. According to the population Division of the Department of Economic and Social Affairs, by 2050 the United Nations projects that one out of every five persons will be 60 or older and that by 2150 this ratio will be one out of three persons. By 2050 the actual number of people over the age of 60 is projected to be almost.
Two billion at which point the population of older people will outnumber children. Today one out of every 10 persons is 60 years old or over. The State Planning Board reports that 10% of the State's population-3.2 million are above 60 and fall in the category of elderly. In the State, the number of elderly is expected to rise to 4.1 million in 2011 and 5.8 million in 2021, that is 2.6 million more elderly in 20 years than at present. At the time of independence the average life span of an Indian was 32 Years, which has increased to 70now. Shaji et al found that the prevalence of Dementia in Thiruvaniyoor Panchayat of Ernakulam District is 3.4%. Global Burden of Disease 2000 estimates the Disability adjusted life years (DALY's) due to dementias as 0.84% and years of life lived with disability (YLD's) as 2.0%. Approximately 10% of the people who reach the age of 65 will develop Alzheimer's disease (AD)  or another type of dementia. Since women marry men older than them and have a greater longevity, more number of women are found with old age problems and many of them have to cope up it without their companion.
Socio-cultural changes, advances in medical science, improved awareness about health and availability of medical services are the important causes for stretching life span to the present state. Life span of citizen need not be directly related to the wealth of a country. Noble laurate Amritya Sen in his paper "Economics and Health" Compared Kerala, a State with six Countries, China, Sri Lanka, Namibia, Brazil, South Africa and Gabon.
From the graph it is clear that the life expectancy in Kerala is more though the Gross National Product per head is less. Professor Sen rightly attributes it to the better public health care and better awareness about health in Kerala. It is a matter of pride for all of us to see this graph. But instead of prolonging the agony of old age we should ensure improvement in the quality of life. As Alexis Carrel, The French vascular surgeon who received the Nobel Prize for Physiology or Medicine in 1912 said "What matters is not to add years to our life, but to add life to years".
Though improved awareness about health problems is highlighted as one of the achievements of public health programs in the last century, it is questionable whether it applies to mental health. The myth that all problems of the elderly are apart of the life cycle and are not benefited by treatment prevents effective management of many geriatric disorders. Psychiatrists need to educate the public, primary care physicians, older individuals and their family members that many behavioural problems in the elderly do respond to treatment and thereby interpersonal conflicts are resolved.
Honorable Supreme Court in its decision on February 5, 2002 (SCC3, 31, 2002) has directed the Central and State Governments to undertake comprehensive awareness campaign with special rural focus to educate people "that mental patients should be sent to doctors and not to temples and dargahs: This observation was made by the apex court in the Suo Moto vase to prevent events like Ervadi tragedy in Tamil Nadu. It is a welcome step but how far the administrators have taken it up is yet to be seen.
The stigma attached to mental health problems is still rampant. The elderly are vulnerable to all psychiatric disorders, but very often denied proper treatment due to the stigma. It is to be noted that stigma is still a universal phenomenon.
United State Surgeon General's report of 1999 noted that "Despite the efficacy of treatment options and the many possible ways of obtaining a treatment of choice, nearly half of all Americans who have a severe mental illness do not seek treatment. Most often reluctance to seek care is an unfortunate outcome of real barriers. Foremost among these is the stigma that many in our society attach to mental illness" . I have highlighted his words only to emphasize that if it is the situation in a developed country, it requires lot of effort on our part to overcome it. Last year World Health Day was celebrated with the slogan "Stop Exclusion, Dare To Care" to improve the acceptance of mental illness in the society.
The problems that the elderly encounter are due to socio-cultural changes like urbanization, disintegration of joint family system, migration to foreign countries, financial constraints etc Children of the elderly are often sandwiched between the needs of their parents and that of their children. With the stress of modern life there is a shift in the attitude of the younger generation.
One the most dreaded areas for the dependent elderly person is the vulnerability for exploitation. The types of abuse that they may face can be physical, psychological (treats, harassment) and medical (denying medical consultation, withholding medicine etc.) More emphasis on the need to respect the elderly in the school curriculum and religious discourses would help.
Increased medical expenditure is one of the factors having an impact on the care of the elderly. Some of the suggested methods are not practicable for our setup. Attractive policy benefits claimed by Insurance companies are not helping the common man. Without money for even day to day expenditure, it is not possible for a large section of the society to pay medical insurance premium. Mental illnesses are not covered in the policy and so psychiatric patients are not benefited. Coexisting psychiatric problems often complicate the outcome of a physical illness, increase the hospital stay and thereby increase the expenditure. Insurance companies fail to understand that the claim for physical illness is partly contributed by psychiatric problems. It is the duty of the State to ensure health care to citizens. Though a meager sum considering the actual need, the 150 crores of rupees allotted to mental health in the current tenth five year plan should be utilized in the most beneficial way.
Last few decades have shown a shift in the focus of care of the mentally ill from institutions to the community. WHO report (2001) states that 24% of patients in primary health care have a mental disorder. But the fact remains that very often these diseases, especially in the elderly are unrecognized. Even if detected sub therapeutic dose of medication is given (Norman Sartorius 2001). So there is an urgent need to train primary care physicians. Dr. Gro Harlem Brundtland. Director General of WHO in the World Health Report 2001 states, "talking about health without mental health is little like tuning and instrument and leaving a few discordant notes".
District Mental Health Programme (DMHP) under the National Mental Health Programme, 1982 was allotted to Kerala in 1999. It is interesting to note the money spent in one of the districts. Total grant for 1999-2000 was Rs. 28,50,000 (27%). Money spent for Salary increased from Rs. 7 lakhs to Rs. 9,20,000 (31%) while total expenditure for the program (awareness campaign, training of medical and non medical personnel, medicines etc. fell from Rs. 21,50000 to Rs. 11,50000 (47%). The figures speak who the real beneficiaries are. There was no special focus on the elderly.
Emphasis should be given about the problems of the elderly in the under graduate curriculum. The postgraduate training in psychiatry should include Geriatric Psychiatry as a specialty. The budding Psychiatrist should be trained to recognize the physical causes of behavioural problems. I feel the most gratifying experience for any Psychiatrist is to make the important diagnoses of "no mental disorder" in an elderly with behavioural problems. This would enable the physician to make an assessment and detect treatable physical condition like silent myocardial infarction or hyponatremia presenting as behaviour disorder. It points towards the comprehensive care required for the elderly, which can availed at the General Hospital Psychiatry Units where the services of all specialists are available.
But unfortunately due to the licensing procedure under the Mental Health Act, 1987, which the State Government is implementing, many General Hospital Psychiatry Units are on the verge of closure. Facilities as stipulated by the Act are impracticable and the power of the Government inspecting officer to question the patient at many time is violation of Article 21 of the Constitution of India that guarantees the patient's right to privacy. It makes the patient in the psychiatric ward different from patients admitted in other wards. It is will increase the stigma attached to mental illness. It defeats the objects and reasons of the Mental Health Act,1987 which states "thus the  mentally ill persons are to be treated like any other sick person and the environment around them should be made as normal as possible". Licensing should be there only for custodial care. Considering the fallacy, either parliament should make amendments or Central Government should propose a new Act in consultation with the Mental Health Professionals and it should include provision to protect the elderly. Programme for the elderly that can be implemented:
1. Day care center for the elderly, which would provide an avenue to meet and communicate with each other.
2. Arrangements for periodical health check up.
3. Counseling session to mentally prepare the elderly to gracefully accept the old age.
4. Elderly people can be utilized for community work like teaching children, conducting literacy programs etc.
5. Senior Citizen's Association meetings with public lectures.
In India the elderly who do not receive any form of retirement benefits are 79 % in the rural areas and 35% in urban areas. The Social Security division of Ministry of Social Justice and Empowerment has a National Project titled OASIS (Old Age Social and Income Security). The project has to make concrete recommendations to the Government of India, so that every young worker can build up enough saving during his/her working life, which would serve as a shield against poverty in their old age and reduce the burden on the state. The local administration should take it up and guide people to avail the benefit.
The National Policy on older persons released in 199 considers good affordable health services for the elderly. The aim is to give financial security, health care, shelter, walfare, and other needs of older persons, provide protection against abuse and exploitation and provide services to improve the quality of life. However the draft National Health policy does not consider older persons as a focus group at all.
Care of the terminally ill is another area of concern. Home Nurses are not adequately trained and so complications are not prevented. Diseases that cause severe pain are common at the end of  life in old age. Good Palliative Care Centers are lacking in most of the places. Basically physicians are trained to wage war with diseases. Instead of pursuing aggressive measures, prognosis of the disease and financial constraints of the patient should be taken into consideration. The aim of Palliative Care is to allow a patient to die with dignity. Psychiatrist can play a vital role by treating emotional disorders, but also by participating in important decision making.
Problems of the caregivers are often ignored. Unless adequate supportive measures are there, they may become vulnerable for emotional problems. Resorting to unscientific treatment modalities and falling victims to quackery could be the result of disappointment. Group meetings for the caregivers may be helpful to ventilate their feelings and gain from the experience of others so that adequate care can be extended to the elderly.
I have laid out some of the important issues in the care of the elderly. My request to the members of the Society is to think over how best we as a group can contribute to find out a solution for this vexing situation.