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PROPOSED INTERVENTIONS FOR GERIATRIC CARE In the previous article, an effort has been made to describe the multifaceted

problems faced by the geriatric population. This article will focus upon the various proposed interventions regarding the geriatric care Old age can be termed as second childhood because an aged person needs the same amount of care and attention as a child. In India there are few hospitals which are providing specialized care for aged people. Those hospitals are either private hospitals or apex institutions but patients find it difficult to locate the unit. Private hospitals and nursing homes rarely invest in geriatric health care. Doctors and nurses dont consider as prolific field. Geriatric health care is capital intensive and at the same time it does not yield much profit. The status of existing infrastructure is such that the patients are admitted along with other patients and so they do not get the special attention they are supposed to. Although India participated in the world health assembly in 1982, there is great reluctance in caring for aged people and this concept is still not popular among professionals, family members, community, popular media or the government. Many countries have initiated programmes to tackle the issue of ageing population. Japan has put in place a health-care financing system that gives essentially free care (only a 5% of copayment is required) for all persons over age. A 'Golden Plan' was announced in 1990 for expanding home and community-based services, particularly rehabilitation and adult day care. The People's Republic of China having world's largest population has initiated the policy of one child per family, if fully implemented, would alter remarkably the responsibility of the individual to his or her parents and grandparents; potentially, the one child would bear responsibility to two parents and four grandparents.

The United Kingdom has incorporated Geriatric medicine in the postwar National Health Service. The Union of Soviet Socialist Republics (USSR) has one of the first research institutes on ageing. Australia has developed an extensive health care policy, including programs for geriatric assessment. Social security benefits are based on need. As of now, not much importance has been given to geriatric care in India. The time has come to plan cost effective, and community friendly approach for comprehensive health care delivery to the large geriatric population. The responsibility of the state for its senior citizens is enshrined in Article 41 of the Constitution. While the welfare of the aged is a State subject, the nodal responsibility for the aged is vested with the Centre. The public policies of oldage income support takes three forms: retirement benefits for those in the formal sector, voluntary insurance schemes encouraged through tax exemptions, and direct government programmes to help the needy elderly. The eligibility rules are often complicated and the pension amount varies across States - from Rs.55 to Rs.300 a month. The National Old Age Pension scheme offers a mere Rs.75 a month for those over 65. And even these inadequate schemes together cover only 10 per cent of the elderly. An NSS survey (52 Round, 1995-96) shows that 79 per cent of the elderly in the rural areas (who were engaged in wage/salaried jobs or were casual labourers) and 35 per cent in the urban areas did not receive any benefit after retirement. The ministry of welfare makes financial assistance available to voluntary agencies to run daycare centers, often called activity centre, hobby club or golden age centers. However, even in urban areas, many older people do not have any idea of the relevance of such centers. The scheme of giving rebate on income tax was introduced in 1992. Law also helps retired citizens in evicting tenants who occupy their houses and concessions in train and airfare but 2

environment is not as elderly-friendly as in developed countries. There is no serious efforts to redesign public transport, public buildings, govt offices to make their use easier for older people. However, India today has a vast network of governmental, voluntary and private infrastructure manned by large number of medical and paramedical persons. However, integrated program for older persons through Panchayati Raj resulted in financial assistance to 323 old age homes, 281 daycare centers and 42 mobile units in different parts of the country during 2003-04. Following steps are recommended to improve the situation: Increase budegetary allocation toward social pension (National old age pension scheme).. Private initiatives like that of SEWA should be encouraged for older people to save for old age. Involve IRDA and private insurers in social commitment to disadvantaged elderly and also package pensions with medical insurance facility. Suggestions for improvement in present health care system are Introduce community based/cooperative models of health care where the members mange it by self financing the facility. Reorient the primary health care system and encourage mobile facilities. Insurance companies to work out realistically the expenditure involved in extending these services to older persons and then find ways and means of sharing that expenditure with others like state, family, company and the individual. A medical claim policy is compulsorily terminated at age 80, after which no health cover insurance is provided. Thus, the medical cover is forcibly withdrawn at the age 80 when it is required most. This is arbitrary and unjustified. It discriminates against older persons. Instructions need to be given by IRDA to the insurance companies to remove this bar. IRDA may be asked to enforce a uniform policy on all insurance companies, particularly government owned companies, to continue

medical insurance for whole life at a commensurate premium. It should also provide cover for medicines and pathological tests. Then, moreover the existing health system requires redesigning if it envisages encompassing the health care needs of the growing population into the mainstream. The hospitals did not have the special provisions for the older persons. Problems of the old are different and should be dealt accordingly. Elderly people suffer from social, emotional and psychological problems more than physical problems. However, existing health care delivery system is not equipped to address these dimensions of the health of the older people. Starting special OPDs, physiotherapy services, in- patient ward for the elderly, services with free access to medicines and investigations. Separate registration system, special OPDs and separate queue for the elderly should be provided. Some package of health care services should be evolved and executed for the elderly. The package should include special geriatric clinic and counseling, referral and multidisciplinary services for catering the health needs of the elderly. Health service providers at all levels must undergo training on the elderly needs, old age care, Geriatric medicines and general counseling. Integrated diagnostic services which are age friendly need to be established. Diagnostic kit for older persons at PHC level. Private sector need to be sensitized regarding the needs of the geriatric people and make necessary arrangements for the subsidized elderly health cares services. Health care package should consist of multivitamins, B-complex, iron, calcium, micronutrients, anti-oxidant, antidiabetic, antidepressant and

some general medicines like analgesics, sedatives, laxatives, digestive enzymes, dietary products and antibiotics. Besides these, National conference held in New Delhi recommended that a National institute of ageing be established in order to 1. Undertake multidisciplinary research on all basic issues related to ageing. 2. Train gerontological workers. 3. Evaluate such training programmes. 4. Monitor work of old age home. 5. Initiate and maintain networking among institutions involved in gerontological works. 6. Act as a documentation centre and dissemination centre. Still recently, Indian Medical Association has launched a rural health plan with an ambitious project Aao Gaon Chalen to provide health to every village in the country. Major emphasis has been on the control of epidemics and endemics, maternal and child health, FUTURE CHALLENGE Projection studies indicate that the number of 60+ in India will increase to 100 million in 2013 and to 198 million in 2030. The special features of the elderly population in India are (a) a majority (nearly 80%) will be in the rural areas, thus making service delivering a challenge, (b) increase in the number of old (85+) and (c) a large percentage (30%) below poverty line. However, the state is not likely to have adequate resources to meet the demands in its services created by large number of elderly people. India, as one of the largest and most stable democracies in the Asian region, has its share of developmental problems. There are many priorities that may push the interest of the older people into the background. THE elderly require special care. Most hospitals in the country do not have a special geriatric facility and if there is one, it is prohibitively expensive. Yet, on an geriatric care and adolescent health (Rural health plan/ Indian Medical Association.htm.18/06/05).

average, 10-15 per cent of hospital beds are occupied by the elderly. According to the principles of health economics, the elderly requiring treatment for longer periods are best kept at home for better resource utilisation. But with increasing female participation in the labour force, caring of the elderly at home has come down sharply. Housing shortages and the consequent reduction in space are increasingly eroding the rights of the elderly to privacy. According to the ICMR, the special problems of the elderly are best dealt with within a geriatric unit with trained geriatricians and nursing staff, putting special emphasis on early rehabilitation, remedial exercise and occupational and psychiatric therapy. According to the ICMR study, geriatric clinics can be set up successfully at the rural primary health centres with the existing infrastructure. The paramedical staff can be trained to recognize major physical illnesses and find appropriate medical, community or social interventions. The study showed that sleeplessness, vague body pain and backache responded well to intervention by health workers, while other symptoms such as a visual handicap, giddiness and pain in the joints showed marginal improvement. Counselling proved very useful in cases where lack of family and social integration led to depression, which was the most common problem. Such patients responded well to intervention. Among those living with their families, many reported lack of integration. Screening and referrals greatly decrease the load on tertiary care services for the elderly. Some hospitals do have geriatric outpatient services, but very few have in-patient facilities, especially for the aged. This may be because the elderly are mostly in the "young elderly" group (60-75 years), in which case there is little demand for long-term health care. Goals of Geriatric Care 1. Provide a safe and supportive environment for chronically ill and dependent people.

2. Restore

and

maintain

the

highest

possible

level

of

functional

independence. 3. Preserve individual autonomy. 4. Maximize quality of life, perceived well-being, and life satisfaction. 5. Provide comfort and dignity for terminally ill patients and their loved ones. 6. Stabilize and delay progression, whenever possible, of chronic medical conditions. 7. Prevent acute medical and iatrogenic illnesses and identify and treat them rapidly when they do occur. Elements of comprehensive geriatric health care in India As the issue of providing care to the elderly population is of recent origin due considerations are not being given to the comprehensive geriatric health care which comprises of home care and institutional care. In Indian socio economic situation the elderly population in majority of cases (upto 70%) are living in a joint family set up and members of the family provide them care and comfort. But the situation is changing because of industrialisation and post liberalisation economic scenario resulting in migration of younger population in search of better future. Comprehensive geriatric health care comprises of physical, psychiatric, social, family, economic, nutritional and rehabilitation aspects. Acute Hospitals . There is a need for low-cost convalescence homes atleast in all districts of country i.e. approx. 550. In this area, N.G.O.'s and International agencies can contribute.

Hospice Growing numbers of people concerned about protecting the dignity and comfort of the terminally ill have developed units within hospitals and medical centers or have founded specific care facilities. The goal of hospice care is to control pain so that the individual can remain an active participant in life until death. Psychological, spiritual and social support, as well as legal and financial counselling, should be available to both family and patient. Personal physical care for the patient is assured. A geriatric nursing assistant or home health aide can provide most of the care under the direction of a professional hospice nurse. Hospice care can meet the needs of terminal oncology patients (those with incurable malignant tumors), and can also be extended to include others with a life expectancy of six months or less. Support groups can by formed to visit terminal patients in conjuction with hospice teams. Many volunteers serve as "special friends," making regular visits and working on a one-to-one basis with the patient and family. In India, there are very few hospices, and most of them are only located in metropolitans. Organisation like Mother Teresa has done lot of work in this direction to give dignity to dyeing poor. First in Calcutta, later in other parts of country. Such facilities could also exist in district level. Charitable and welfare organisation can play an active role. Day care/Day Hospital One big advantage of day care is the cost, which is usually less than the cost of care in a nursing home. In addition to providing treatment for the patient, the day care center can assist families in making adjustments and finding aid. A day care facility can often make it possible to avoid or delay institutionalization.

Rehabilitation Centres and Teams Rehabilitation services can be directed by a team of professional people, working together to establish and reach realistic goals. At times, the team will consist of medicine, recreational therapy, occupational therapy, psychotherapy, physiotherapy, social service and nursing. The nurse can serve as coordinator for the combined effort. At other times, the nurse, doctor, and a few specialists make up the team. With team approach, each team member sees the patient from a slightly different viewpoint. From the consensus, a specific rehabilitation plan is devised and recorded on the patient care plan. Home Care In India because of close social links, families and also because of economic compulsion, geriatric population has to entirely depend upon near and dear ones. Lack of health education and awareness of geriatric needs, certain practices may actually harm the health of geriatric patient. Therefore, there is need for development of reading material for home care of geriatric patients. Audiovisual media (T.V., Radio etc.) could greatly help in this regard. Manpower Development Medical Manpower Undergraduate and post graduate courses should have curriculum for geriatric medicine. In service training for doctors at all levels of health car (primary, secondary, tertiary) should be imparted. Nursing Manpower Geriatric nursing care should be part of curriculum for nursing courses or a special post graduate course could be designed for geriatric nursing. Geriatric Health Care Assistant/Home Health Assistant

This category of workers should be trained in gereotology and basic nursing skills. Geriatric health care Assistant may function as home health aids or may be employed in a nursing facility. At the peripheral level, male and female health workers should be imparted this training to help the chunk of elderly population living in rural areas and dependent on primary health care centres.

Ideally, a Geriatric Care Unit should have Patient Care

Out-patient consultancy 3 clinics and followups Therapeutic Workshops Health Education (professional as well as non-medical) Physical fitness programme Obesity Clinic Drug Bank Memory Clinic Menopausal consultancy Blood Investigation Supervised Health Education Programme Quarterly Bulletin Professional Geriatric Education Programmes Library Health camps/ check-ups/ educative

Education

Community Services

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exhibitions and lectures Research


Clinical Geriatrics Social Geriatrics Psycho Geriatrics Aging Syndrome

Source: KEM Hospital which is the only hospital providing the above services Reference: Khan AM. Health services for the Elderly: A Brief Note for the Consideration of Health Planners. Help Age India- Research and Development Journal 2007; Vol.13(1): 30-31. Editorial. Expectations of Senior Citizens from the Government and Suggestions for Age-friendly Policies. Help Age India- Research and Development Journal 2007; Vol.13(1): 4-5. Dhar HL. Emerging Geriatric Challenge. JAPI 2005;Vol.53(10).

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