Health issues

P.C. Joshi and S.N. Sengupta

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AT a recent meeting with a senior citizens’ forum in Delhi, we raised the possibility of initiating a long-term medical study on the elderly. ‘So you want to treat us as guinea pigs,’ was the first query regarding our motive. The discussion then turned to the general issues of the elderly – from old age pensions and railway concessions, to health-related advancements and genetic factors in dementia. Clearly, the group was highly aware and keenly debated not just the latest media stories but the current scenario of the aged.

The elderly in India, especially the urban, have long been active advocates of a policy on ageing. They see the issue as concerning not only the social welfare department but the planning commission, since every department of the government is now involved with the special needs and requirements of the elderly.

The impetus to contemporary elderly concerns in India can be traced to three main developments. The first is the evolution of civil society and a mature democracy resulting in an expanding social commitment of the state. Beginning with the scheduled castes and tribes, the state has gradually accepted its legitimate responsibility to care for the disabled, destitute, mentally deranged and the elderly. This expansion has kept pace with the evolving image of these sections in broader society itself.

The second factor relates to the demographic transition in the country. From 12 million in 1901 the number of the old rose to 57 millions in 1990 and is expected to cross the 100 million mark in 2013. Not only has the absolute number of the elderly increased, their proportion in the population too has risen. From a mere 5.1% in 1901, the elderly will become 21% of the population by the year 2050, estimates a United Nations projection.

The third factor is related to the growth of activism and advocacy spearheaded by groups of the elderly, non-government organizations and academicians. As a consequence, a national policy for older persons has finally been formulated, enshrining the state’s commitment towards its ageing population.

In our presentation the elderly population will be taken to mean people aged 65 and above. Although this definition is somewhat arbitrary, this criteria is used by many countries to decide eligibility for purposes of recruitment and rehabilitation in other societal programmes.



Population ageing in developed countries is a reflection of a decline in both mortality and fertility. In some developed countries, 15% or more of the population is already 65 and older while 3.4% are aged 80 or older.1 Although the percentage of the elderly in the population in developing countries is substantially lower than in developed countries, the absolute numbers of old people worldwide are considerable. For example, in India where only 3.4% are 65 and above, they still number 30 million. In 1988, there were an estimated 159 million persons aged 65 and older in developing countries compared to 140 million in developed countries and over 60% of the monthly global net increase in older persons was in the developing countries.

Between 1990 to 2025, the percentage of the population aged 65 and older is expected to increase to just over 20% in Europe and North America and to double from 5 to 10% in Asia, Latin America and the Caribbean.


Projected Total Population and Elderly Population, 1990-2020

(in million: projections are medium variant)








3. 80


3. 65

3 80


³ 65

³ 80











Developed Countries










Developing Countries











The above projections indicate that by the year 2020, there will be 470 million people aged 65 and older in developing countries, more than double the number in developed countries. Three of the four countries projected to have the largest number of old people in the year 2025 are China, India and Indonesia.2 The growth projected for older population in developing countries has considerable implications for health and social policies. The old population itself is getting older with people over 80 years of age forming the fastest growing subgroup of the population in many countries. Developing countries too are likely to experience a modest increase in the proportion of the population in the oldest age range.

In most developed countries, there are about 65 men for every 100 women in the age group of 65 and above. Generally in developing countries, especially India, there are more old men than old women. The sex ratio will probably fall in many developing countries with female life expectancy projected to increase faster than male life expectancy. In most developing countries, more than 50% of women aged 65 years and older are widowed and in some countries more than 75% of the women aged 75 and older are widowed. In contrast, there is no country in which more than 40% of men aged 75 and older are single.

Marital status has the greatest impact on living arrangements of the elderly population. In developing countries, the proportion of persons aged 65 and above who live alone ranges from 10% (Japan) to 90% (Sweden). This proportion is smaller in developing countries where there is a tradition of multi-generation households and both married and widowed older persons commonly live with their children and grandchildren.

The past century saw a remarkable improvement in life expectancy although tremendous disparities exist between developed and developing countries. Life expectancy at birth in most developed countries is 70-75 years for men and 76-81 years for women; it is 11 years less in developing countries. In the past few decades, there has also been a substantial reduction in mortality among older persons resulting in an increase in life expectancy at age 65.

A nationwide survey conducted by the National Sample Survey Organization,3 reported that 45% of the elderly suffered chronic illnesses. Nearly 70% in the urban and 34% in the rural areas were economically dependent. The percentage of the elderly living alone was 6 and 8% respectively for the urban and rural areas. This proportion is, however, expected to increase in the coming years, necessitating appropriate measures for the rehabilitation of the elderly. These socio- demographic factors not only influence the extent and severity of morbidity among the elderly but also their quality of life.

In a developing country like India, the elderly people suffer from the dual medical problems of both communicable as well as degenerative disease. This is further compounded by impairments of special sensory functions like vision and hearing. The elderly are highly vulnerable to infectious diseases because of a decline in their immune functions and atrophic changes in various organs. The physiological changes in the old age lead to impaired cough reflex, impaired circulation and tissue perfusion. There is deficient collagen synthesis and poor wound healing. Further, incidence of infection remains high because of poor nutrition and high intake of immunosuppressive drugs.



Among infectious diseases, pneumonia is 50 times more common in the elderly than in adolescents and it accounts for half the deaths caused due to respiratory diseases, excluding cancer. Urinary tract infections are particularly common in the elderly. Asymptomatic bacteriuria affects 30% of elderly women and 7% of elderly men. The common cause of urinary tract infection in the elderly is insertion of catheter and other instruments.

The prevalence of TB is higher among the elderly than younger individuals. A study of 100 elderly people in Himachal Pradesh,4 found that most of the patients came from a rural background. They were also smokers and alcoholics. Endocarditis thus is a major factor in elderly mortality, accounting for 50% of the cases. Besides these common infections, the elderly are also susceptible to gastrointestinal infections, pressure sores, septic arthritis, septicaemia and meningitis. The susceptibility of the elderly to these infections along with factors such as poverty, lack of proper nutrition and absence of comprehensive health care calls for special immunization programmes.



The chronic illnesses in the elderly usually include hypertension, coronary heart disease and diabetes mellitus. The prevalence of hypertension was found to be higher in females, affecting as many as 323 per 1000 females in the rural areas.5 Coronary heart disease was found to be more common in urban areas, and higher for males than females. Given dietary changes and lifestyle factors, such diseases will show an increase in the coming years, thereby requiring special health, nutrition and lifestyle counselling. Diabetes mellitus, which affected 5 million elderly in 1996, is also higher in urban than rural areas.

To check for malignancy, population based cancer registries were initiated to estimate the incidence of cancer under the National Cancer Registry Programme of ICMR in Mumbai, Chennai and Bangalore in 1982 and in Delhi and Bhopal in 1987. The incidence of cancer was higher in both elderly males and females as compared to the total population. In 1996, the total number of elderly persons with cancer was around 0.35 million. Cancer prostrate is the commonest malignancy in males. The chance for contracting this disease among males over 50 years is 30% and mortality is 25%.

The WHO defines stroke or cardiovascular disease (CVD) as the rapidly developing clinical sign of focal or global disturbance of cerebral functions with symptoms lasting 24 hours or more or leading to death. The crude prevalence rate computed from different community surveys is about 200/100,000 persons. Hypertension, tobacco use, obesity and diabetes mellitus are important risk factors for stroke. Stroke victims impose enormous economic burden on our meagre health care resources.

Cataract is the most common cause of blindness among the elderly in India. Nearly 1.5% are blind, a majority of them in the rural areas. Alongside physical disability blindness also impinges on the mental, social and financial status of the individuals and their families. The WHO-NCPB survey estimated that 12 million Indians were blind and in need of eye care services in 1989.6



A study on the health care for the rural aged in Madurai district, Tamil Nadu,7 reported that of the 1910 elderly screened, 88% had visual complaints, 40% had locomotion difficulties, followed by symptoms of central nervous system (14%), cardiovascular (17%), respiration (16%), dermatological (13%), gastrointestinal (10%), psychiatric (4%) and acoustic (8%). 2% of those sampled suffered from neoplasm. A study of the knowledge, attitude and practices8 regarding nutrition among the elderly, observed that fruits, leafy green vegetables and milk were rarely consumed in adequate amounts in a general belief that such expensive foods should be given to younger people. No wonder most of our elderly population reports nutritional problems.

According to Government of India statistics,9 cardiovascular disorders account for one-third of elderly mortality. Respiratory disorders cause 10% mortality while infections and tuberculosis account for another 10%. Neoplasm accounts for 6% and accidents, poisoning and violence constitute less than 4% of elderly mortality with similar rates for nutritional, metabolic, gastrointestinal and genito-urinary infections.



Elderly individuals usually face a higher risk of developing mental as well as physical morbidity. Their vulnerability to mental problems is due to ageing of the brain, physical problems, socio-economic factors, cerebral pathology, emotional attitude and family structure. The biochemical and morphological changes in the ageing brain of normal individuals are similar to those suffering from dementia. In most cases, mental illnesses coexist alongside physical problems in the elderly persons. Chronic physical disorders and sensory impairments (vision and hearing defects) are known to be especially associated with mental problems of the elderly.

The incidence of mental illness is strongly influenced by socio economic factors like educational levels, degree of economic support, whether living alone, and so on. The presence of dissatisfaction with life and feelings of loneliness and self-pity show a high correlation with mental problems. So does the family structure and situational factors such as a widowed status and fall in income. All these significantly contribute to emotional problems in old age.



The magnitude of mental morbidity in the Indian situation is a serious cause of concern. In India, nearly 4 million elderly persons (age 60 and above) are mentally ill, which, although lower than in western countries, requires to be taken seriously as the necessary psychiatric services fall woefully short of our requirements. Two-third of mental morbidity is affective disorders especially depression and late onset of psychosis, while one-third is dementia.

According to one estimate,10 the prevalence of depression ranged between 13 and 22% among the elderly and it was most often associated with cerebral pathology. Many of the elderly suffer from higher mental function disturbances like memory problems. Another common problem reported in a major hospital study11 was mania, accounting for 16% of the psychiatric diagnosis. Mania was more common in males and often accompanied by organic brain syndrome.

The risk factors for mental morbidity in the ageing population stand comparatively higher than for the general population, estimated at 7 per lakh for the general population as compared to 12 per lakh for the elderly. The main risk factors are loss of fortune, fall in self-esteem, sense of helplessness, poor education, substandard health, social and gender discrimination, financial debt and status as a widowed person.

Anxiety disorders are more common in the elderly population. Generalized anxiety disorders are accompanied by depression. In the category of late onset psychosis, the delusions in late paraphrenia may be persecutory, sexual and hypochondiacal. The hallucinations in the elderly are often multi-modal and associated with sensory impairments.



The psycho-physical problems which the elderly confront due to ageing and associated socio-cultural, nutritional and environmental factors demand that we perceive the health of the elderly within a holistic perspective. The maxim of adding years to life implies that the elderly receive adequate state and social support to live an active and socially productive life. At the minimum we require comprehensive health care directed to the elderly, in particular equipping our PHCs in geriatric care. Equally, it is important to learn from the experience of other countries where too the elderly face enormous problems due to weak social support mechanisms.

Fortunately, our cultural ethos gives a special place to the elderly as wise people and counsellors of society. Both geriatric support and social engineering aimed at improving the competence of the elderly and ensuring their active participation in society should be considered together in evolving any policy on ageing care. The experience and wisdom of old age is a treasure for any society; its gainful utilization would be beneficial for both the elderly as well as the younger generation.




1. K. Kinsella and C.M. Taeubar, An Aging World II, US Government Printing Office, Washington D.C., 1992. Also, UNDP, Human Development Report 1990, Oxford University Press, New York, 1990.

2. J.S. Siegel and S.L. Hoover, ‘Demographic Aspects of the Health of the Elderly to the Year 2000 and Beyond’, World Health Statistical Quarterly 35, 1982, pp. 132-202.

3. NSSO, ‘Socio-economic Profile of Aged Persons’, Sarvekshana 15(1-2), 1991.

4. V.K. Arora and R.S. Bedi, ‘Geriatric Tuberculosis in Himachal Pradesh: A Clinical Radiological Profile’, Journal of the Association of Physicians in India 37, 1989, pp. 205-207.

5. R. Kutty, S. Radhakrishna, K. Ramachandran and N. Gopinath, ‘Prevalence of Coronary Heart Disease in the Rural Population of Thiruvananthapuram, Kerala’, India International Journal of Cardiology 39, 1963, pp. 59-70.

6. M. Mohan, ‘Survey of Blindness in India (1986-89)’, in Present Status of National Programme of Control of Blindness, Directorate of Health Services, Ministry of Health and Family Welfare, New Delhi, 1992, pp. 80-100.

7. A. Venkoba Rao, Health Care of Rural Aged, Indian Council of Medical Research, New Delhi, 1990.

8. M. Srivastava, U. Kapil, V. Kumar, A.B. Dey, K.M. Nagarkar and G. Sekaran, ‘Knowledge, Attitude and Practices Regarding Nutrition in Patients Attending Geriatric Clinic at AIIMS’, in V. Kumar (ed), Ageing: Indian Perspective and Global Scenario, AIIMS, New Delhi, 1996, pp. 407-409.

9. S. Guha Ray, ‘Morbidity Related Epidemiological Determinants in Indian Aged – An Overview’, in C.R. Ramachandran and B. Shah (eds), Public Health Implications of Ageing in India, Indian Council of Medical Research, New Delhi, 1994.

10. A. Venkoba Rao, ‘Mental Health and Ageing in India’, Indian Journal of Psychiatry 23, 1981, pp. 11-20.

11. L. Thomas, Late Night Thoughts of Listening to Mahler’s Ninth Symphony, Bantam Books, New York, 1984.