Elderly Care in India: Way Forward

Ageing is a global phenomenon. India is no exception to this demographic transition. The problems and issues of its greying population occupy the back seat. The current need is to conduct research and explore new directions in research on population ageing. Multi-disciplinary approaches to geriatric care can be fostered by collaborative training among medical, paramedical and other professionals. Future care giving for the elderly will also require models of both formal and informal care and systems for supporting caregivers. Community based geriatric services should be envisioned with active participation of all stake holders and players of social, economic and political leadership from the grass root level to the national level. Collaborations between the government, care providers, insurers and patients are a precursor to any significant change involving elderly care. Appropriate policies to address health care challenges of ageing population is crucial for India if it has to simultaneously meet the health care needs


Introduction
Ageing is a global phenomenon. The world's population is ageing due to increasing life spans and decreasing birth rates. India is no exception to this demographic transition. It is projected that the proportion of Indians aged 60 and older will rise from 7.5% in 2010 to 11.1% in 2025 [1]. In 2010, India had more than 91.6 million elderly and the number of elderly in India is projected to reach 158.7 million in 2025 [1]. The ageing population will present a major challenge for the public health care system in near future. India today is confronted with the enormous challenge of preparing to meet the demands of an ageing population. The problems and issues of its greying population occupy the back seat. India should prepare to meet the growing challenge of caring for its elderly population. This article points to the fact that ageing should be one of the most important issues that need to be addressed in India.
Elderly care in India is fast emerging as a critical element of both the public and private concern. The traditional ancient culture with joint families and common land holding never posed a problem for elderly care. But in the last few decades due to modernization the elderly today do not enjoy the same status as they enjoyed in past. The fast pace of social change is affecting traditional care giving mechanisms for the elderly. Hence, there is need for a dynamic action plan to utilize the resources of the elderly and enhance their social status in the community. Geriatrics is relatively new in India. Negative attitudes and limited awareness, knowledge or acceptance of geriatrics as a legitimate discipline contribute to inaccessible and poor quality care for India's old [2]. Migration of younger generation, lack of proper care in the family, insufficient housing, economic hardship and break-up of joint family have made the old age homes seem more relevant even in the Indian context [3]. To add to the woes of elderly, geriatric care is conspicuously missing from the medical education curriculum. Similarly, the nursing and other paramedical staff members are not formally trained in providing care for elderly patients. There is no specialized training in geriatrics in most medical schools in India [4].

The Changing Social Scenario
The traditional norms and values of Indian society also laid stress on showing respect and providing care for the elderly. However, with the emerging prevalence of nuclear family set-ups in recent years, the elderly are likely to be exposed to emotional, physical and financial insecurity in the years to come [5]. Family structure changes from joint to nuclear structure have affected not only the position of elderly but also the family's capability to care. Community based voluntary support might address this issue especially for those suffering from chronic diseases and disabilities. Needs of the elderly are not only economical but also social, psychological and physical. Institutional changes are required to ensure their social and psychological wellbeing [6]. Health problems also need multi-disciplinary specialist care from various disciplines e.g. orthopedics, dental, ophthalmology, cardiovascular, psychiatry and urology. The elderly population suffers high rates of morbidity and mortality due to infectious diseases. Given the challenges of an ageing population, the need for elderly immunization should be addressed by all stakeholders. Health-care systems will need to shift their emphasis away from acute care to managing chronic diseases and to disease prevention by vaccination of elderly. It is time for policymakers in India to put elderly immunization at the top of their agendas. It must be remembered that improving the quality-of-life of the elderly calls for immunization of elderly [7]. Thus, a model of care providing comprehensive health services to elderly at all levels of health care delivery is imperative to meet the growing health care needs of the elderly. The healthy ageing should include comprehensive promotional, preventive and rehabilitative aspects of health [8].

The Way Forward
Health-care system in India needs to address ageism. Care for the elderly is fast emerging as a critical element of both the public and private concern [9]. The current need is to conduct research and explore new directions in research on population ageing. Also, sub national networks can be established for the research. These networks can facilitate exchange of information, resource sharing and training opportunities. Such networks may be developed by the relevant national agencies in conjunction with appropriate persons at the International level to ensure optimal cooperation and success of research endeavors. There is a need to reorient health sectors toward managing chronic diseases and the special needs of the elderly. All the stakeholders have reached consensus on the need to educate and train healthcare providers in geriatrics to address issues of provider shortages, distribution, education, and quality as well as training in elderly care. As pointed by Dey et al.
[10], the key challenges to access and affordability for elderly population include reduced mobility, social and structural barriers, wage loss, familial dependencies, and declining social engagement. Community volunteers and medical, paramedical, and indigenous providers must be trained to identify issues common among elderly patients, to conduct comprehensive surveys of morbidity and functional status, and to engage in capacity building of geriatric services in local communities [11]. Multidisciplinary approaches to geriatric care can be fostered by collaborative training among medical, paramedical and other professionals. Future care giving for the elderly will also require models of both formal and informal care and systems for supporting caregivers. Disability significantly affects quality of life in old age. Caring for the elderly in a way that addresses disability and maintains good quality of life has become a global challenge. Considering this there is an urgent need to train more professional caregivers to focus on elder care in order to meet current and future demand. The same has been urged by World Health Organization (WHO) in its publication towards and International Consensus on Policy for Long-Term Care of the Ageing [12].
Population ageing will have major consequences and implications on all facets of human life like social, political and economic. All these will have an impact on elderly care. In the social context, population ageing influences family composition and living arrangements, housing demand, migration trends, epidemiology, and the need for healthcare services [13]. The National Programme for health care for the elderly (NPHCE) should have enough flexibility for adaptation based on local needs and preferences for elderly care at all levels [8].
The government of India should be made aware of this "time bomb" before the situation gets out of hand because there is almost no social security benefits for most of the aged in India. Hence, it is important that the government is sufficiently sensitized towards the consequences and implications of the phenomenon of population ageing. This can be accomplished by highlighting the challenges precipitated by population ageing, identifying research gaps and to put forward if any plausible solutions.
The elderly tend to be cared for in a variety of settings: home, nursing home, day-care centre, geriatric outpatient department, medical units or intensive care unit depending on the nature of the clinical problem. Care of elderly necessitates addressing several social issues. The needs and problems of the elderly vary significantly according to their age, socio-economic status, health, living status and other such background characteristics [9]. Recently, under the universal health coverage (UHC) framework recommendations have prioritized primary and secondary prevention and health promotion, with the goal of creating enabling environments for healthy lifestyles, early detection, and routine screening among the aged and avoiding institutionalization [10]. Government of India has made efforts to tackle the problem of elders' economic insecurity by launching schemes such as the National Policy on Older Persons, the National Old Age Pension Programme and the Annapurna Programme. It must be remembered that comprehensive care to the elderly is possible only with the involvement and collaboration of family, community and the Government. All social service institutions in the country need to address the social challenges to elderly care in order to improve their quality of life. In addition, there is also a need to develop an integrated and responsive system to meet the care needs and challenges of elderly in India.
Community based geriatric services should be envisioned with active participation of all stake holders and players of social, economic and political leadership from the grass root level to the national level. Developing an age friendly city will should be a long-term goal.
Social and technological innovations are required to respond to the population ageing. The priority initiative will be to have a minimal needs programme that should include primary care, nutritional needs, provision of assisted devices, counseling services, social security and pension, community training for elderly care at home and referral care for those who need it. The Government of India should initiate steps in terms of financing and empowering family members/caregivers to support the elderly. With a high percentage of population not being able to afford healthcare and a rapidly ageing population, there is a dire need for a structured and well-financed elderly care infrastructure.
Healthy aging is a complex and comprehensive issue. The years ahead will continue to be characterized by a comprehensive pursuit of successful social, health, and economic policies towards healthy ageing and disease prevention in all stages of life. Effectively addressing elderly care requires collaborative action between government and private sector. Collaborations between the government, care providers, insurers and patients are a precursor to any significant change involving elderly care [14]. Appropriate policies to address health care challenges of ageing population is crucial for India if it has to simultaneously meet the health care needs of the elderly.