SCHOOL OF SCIENCE AND HUMANITIES

DEPARTMENT OF PSYCHOLOGY

UNIT – I -INTRODUCTION -GERONTOLOGY PSYCHOLOGY-SPSY1401

 Introduction

Gerontology

With an understanding of gerontology, an individual can make plans for her or his own
life course and needs, and communities and legislators can make necessary public policy
choices. Public policy decisions are critical because of the tremendous growth of our population
aged 65. Georgia’s older adult population is the fourth fastest growing in the nation and currently
numbers 1.2 million. The South added nearly 2.5 million older adults between 2000 and 2010.
Nationally, it is projected that the older population will double to 89 million by 2050 – a rate of
growth that is twice as fast as the under age 50 population. The demand for professionals with
expertise in gerontology will mirror these increases.

Definition of Gerontology

Gerontology is the study of aging and older adults. The science of gerontology has evolved as
longevity has improved. Researchers in this field are diverse and are trained in areas such as
physiology, social science, psychology, public health, and policy. A more complete definition of
gerontology includes all of the following:

 Scientific studies of processes associated with the bodily changes from middle age
through later life;
 Multidisciplinary investigation of societal changes resulting from an aging population
and ranging from the humanities (e.g., history, philosophy, literature) to economics; and
 Applications of this knowledge to policies and programs.
Gerontology is the study of aging. It comes from the Greek words geron, meaning “old man”,
and -ology, a suffix meaning “the study of”. Gerontology is a multidisciplinary field. It involves
the scientific study of physical, mental, and social changes that occur in older people, the
investigation of societal changes from an economic, historical, and philosophical standpoint, and
the carrying out of policies and procedures to aid older people with information from
gerontology in mind. Gerontologists in the field of biology study the biological changes that
occur in older individuals. Gerontology is not to be confused with geriatrics, which specifically
refers to the medical care and treatment of older people.

History of Gerontology

People have been fascinated with aging since ancient times. Of course, many ancient
cultures, much like today’s society, were highly interested in slowing the aging process or
reversing it. The earliest known recipe for an anti-aging ointment is from an Egyptian papyrus
dating back to 2800-2700 B.C. called “The Book for Transforming an Old Man into a Youth of
Twenty”. It claimed to beautify the skin and remove any disfiguring signs of age. Another
ancient papyrus from 1550 B.C. describes some of the biological changes that can occur with
aging, such as heart pain, deafness, blindness, and what would later be known as cancer.

Gerontology research, and other forms of scientific research, really took off during the
19th Century, when the use of the compound microscope became widespread. Many scientists at
first began to study bacteria under the microscope in order to study senescence, or aging, but this
proved difficult because bacteria reproduce by dividing themselves into two cells and do not
become senescent in the way that the cells of multicellular organisms do. Multicellular animal
models had to be used instead, and this is one reason why the use of mice became so ubiquitous
in research. With the use of the microscope, scientific knowledge advanced a great deal. For the
first time, researchers could examine the processes of aging at the cellular level, and really begin
to understand the specific changes that take place in the cells of older people. People began to
develop theories about why aging occurs; August Weissman, a German embryologist, proposed
that lifespan was related to an evolutionary selective advantage, and that species with different
body sizes, intelligence, and ecology had different lifespans. The term gerontology was coined in
1903 by Élie Metchnikoff, a Russian zoologist who did immunology research and won the Nobel
Prize in Physiology or Medicine for his work.

In the mid-20th century when the structure of DNA was uncovered, another paradigm
shift occurred in gerontology research. Scientists could now study genetics relating to aging; for
example, they looked at unique mutations in abnormally long-lived or short-lived fruit flies.
Other ways of extending an organism’s lifespan were also found, like putting mice on calorie-
restricted diets or putting fruit flies in very small cages so that they couldn’t fly as much. Further
progress was made when age-related decline in certain hormones, like growth hormone, thyroid
hormone, and estrogen, was discovered. More recently, genome sequencing has been used to
identify genes associated with aging.

A New Concept:
Ageing is not an event but a process. For the development theorists and practitioners
ageing is one of the most neglected issues mainly because aged people are considered as
disempowered and non-resourceful persons. They are not considered as a class category or status
group neither by economists nor by sociologists. Though ageing is universal, till a decade back
ageing is considered as natural and evolutionary process and hence it is not taken seriously. Till
1980s the problems of the old were not known to the state in the developing countries and
therefore they were not attended. There are many ways to reduce the child population whereas
the old population cannot be stopped as the developing countries like Asian countries
methodically ignored the structure of the population.

Ageing can generally be described as the process of growing old and is an intricate part
of the life cycle. Basically it is a multi-dimensional process and affects almost every aspect of
human life. Introduction to the study of human ageing have typically emphasized changes in
demography focusing on the ‗ageing of population‘- a trend, which has characterized industrial
societies throughout the twentieth century but in recent decades, has become a worldwide
phenomenon.
Population ageing is the most significant result of the process known as demographic
transition. Two dimensions of demographic transition are:
a) Reduction of fertility that leads to a decline in theproportion of the young in the population.
b) Reduction of mortality which means a longer life span forindividuals.
Jean Bourgeois Pichat (1979) has called attention to two process in ageing which reflects the two
dimension of demographic transition.
a) Ageing at the base b) Ageing at the apex.
 Ageing at the base occurs when fertility falls, thus decreasing the proportion of children
and ageing at the apex occurs when the proportion of aged persons increases presumably due to
declining mortality at older ages.
Population ageing involves a shift fromhigh mortality / high fertility to low mortality /
lowfertility and consequently an increased proportionof older people in the total population
(Prakash,1999).

Dimensions and definition of Ageing

Ageing has been defined in various ways by different scholars and it is measured in many
ways according to the academic background of the person who study them. Some have regarded
ageing as period of physiological deterioration, others regard it as simply the advancement of
years and still others have emphasized that ageing involves a restriction on cultural roles.
According to Bhatia (1983) the term ‗ageing‘ is a broad one and can be studied under three types
– Biological, Psychological, and Socio-cultural.
In the broadest sense, Charles S Becker (1959) defines ageing ‗as those changes
occurring in an individual, which are the result of the passage of time‘. These may be, according
to him, anatomical, physiological, psychological and even social and economic. He further adds:
Ageing consists of two simultaneous components – anabolic building up and catabolic breaking
down. In the middle years there is an essential balance between expansion and decay, while
growth predominates in youth; degenerative changes which start occurring very clearly in life
pre-dominate in the late life span. Edward J. Stieglitz (1960) defines ageing as ‗the element of
time in living‘. According to him, ‗ageing is a part of living. Ageing begins with conception and
terminates with death. It cannot be arrested unless we arrest life.
According to Tibbitts (1960) ageing may be best defined as the survival of a growing number of
people who have completed the traditional roles of making a living and child rearing and years
following the completion of these tasks represent an extension of life.‖ He also says, ageing is an
inevitable and irreversible biological process.
According to Hooyman and Kiyak (1994), the gerontologist view ageing in terms of the
following four distinct process or dimensions:
Four dimensions of ageing are commonly identified: chronological, biological, psychological
and social ageing.
Chronological ageing refers to the number of years since someone was born Chronological age
also provides individuals with a means of distinguishing roles and relationships in terms of the
behaviour and expectations that are linked to different chronological groupings. But it is
generally not recognised as an adequate measure of the extent of ageing because, as a process, it
is thought to vary between individuals.
Biological ageing, often known as senescence (declines of a cell or organism due to ageing) and
sometimes functional ageing, refers to biological events occurring across time which
progressively impair the physiological system so that the organism becomes less able to
withstand disease, ultimately increasing its susceptibility to death. From this perspective, the
ageing process stems from several physiological factors, and is modified throughout the life
course by environmental factors (such as nutrition), experiences of disease, genetic factors and
life stage. This is usually associated with decline in the regulation and proper functioning of the
vital organs of the body. However, not all people experience decreased organ function in the
same proportion. Some individuals have healthier hearts at age 80 than others do at age 60.
Psychological ageing focuses upon changes that occur during adulthood to an individual‘s
personality,mental functioning (e.g. memory, learning and intelligence) and sensory and
perceptual processes. Jegede (2003) stated that the indices of psychological ageing include
feelings, motivation, memory, emotions, and experience and self-identify. For instance, people
who had intention of traveling abroad may decide to drop the idea and contribute to the growth
of their own economy. Psychological ageing is heterogeneous and continuous as an individual
passes through life.
Social ageing refers to the changing experiences that individuals will encounter in their roles and
relationships with other people and as members of broader social structures (such as a religious
group) as they pass through different phases of their life course. In sociological ageing, personal
or attitude and interaction within the community are used to assess a person‘s maturation and
ageing. As a person ages socially, he/she calculates his/her utterances, limits the use of vulgar
language, prunes relationship to mature friends, changes his/her mode of dressing, reduces
nocturnal clubs. As a person ages socially, he/she tends to be guided by the norms of the society
to which the person belongs.As an individual experience, social ageing affects perceptions of
who we are, but can also be shaped or ‗constructed‘ by social and cultural contexts which dictate
the normative expectations about the roles, positions and behaviour of older people in society.
While all three dimensions of biological, social and psychological ageing generally interact, the
pace at which each dimension is experienced may be different for the same individual. This is
usually how a person relates with others in the society.
Strehler (1962) has proposed four criteria for ageing, reported in Tyagi (1999). They are:
Ageing is universal, which means it occurs in all members of population.
Ageing is progressive, a continuous process.
Ageing is intrinsic to the organism
Ageing is degenerative

Thus, ageing is an inevitable, ubiquitous and universal phenomena of human life because
it is a natural process. Finally, population ageing, sometimes referred to as societal ageing, is a
process whereby a group (such as a country or an ethnic group) experiences the progressive
increase in the actual numbers and proportion of older people within its total population. This
change, brought about largely by socio-economic improvements in health and living standards,
progressively reduces mortality and fertility, resulting in increased life expectancy and fewer
births, and ultimately, an increase in the older population in relation to younger age groups.
Population ageing has long-term implications for governments in terms, for example, of the cost
of health and social care for an increasingly important number ofolder people.
Cavanaught (1993) in Osunde and Obiunu (2005) divided ageing into three types, the primary
ageing, the secondary ageing and the tertiary ageing.
The Primary Ageing: Primary ageing is considered as the normal process which has
nothing to do with illness. It simply involves changes in the biological, social and psychological
domains. These occur due to tear and wear of vital organs of the body

The Secondary Ageing: This process is associated with different kinds of terminal illness
which prevent normal functioning of the individual.
The Tertiary Ageing: This occurs when there are loses brought about by death or
disasters like war(s) on a family member or close friends that could lead to a gradual decline in
the proper functioning of the individual.
Demographic dividend:The growing global economic support ratio could have beneficial
effects on the macro-economy, through the so-called demographic dividend. The demographic
dividend is defined as the increase of per capita consumption brought about by a growing
economic support ratio. Demographic dividend, as defined by the United Nations Population
Fund (UNFPA) means, ―the economic growth potential that can result from shifts in a
population‘s age structure, mainly when the share of the working-age population (15 to 64) is
larger than the non-working-age share of the population (14 and younger, and 65 and older).‖ In
other words it is ―a boost in economic productivity that occurs when there are growing numbers
of people in the workforce relative to the number of dependents.‖ UNFPA stated that, ―A
country with both increasing numbers of young people and declining fertility has the potential to
reap a demographic dividend.

Demographic profile of the older population

Ageing is taking place in the world‘s adult population and within the older population
itself. The proportion of persons aged 80 years or over within the older population increased
from 7 percent in 1950 to 14 per cent in 2013.
According to the projection, this proportion of ―oldest-old‖ within older persons is
expected to reach 19 per cent in 2050 and 28 per cent in 2100.
If this projection is realized, there will be 830 million persons aged 80 years or over by
the end of the century, seven times as many as in 2013.
The rise in the population aged 80 years or over is occurring at a faster pace in the less
developed regions than in the more developed regions.
In 1950, there were 6 million people aged 80 years or over in the less developed regions
and 8 million in the more developed regions, but by 2013, people aged 80 years or over are
already slightly more numerous in the less developed regions than in the more developed regions

The present number of persons aged 80 years or over is the result of

a) The birth rates of many decades ago, which determined the initial size of these cohorts and
b) The survival rates, which have been improving dramatically since these cohorts were born.
The number and proportion of centenarians (people aged 100 years or more) is growing even
faster. The number of centenarians in the world is projected to increase rapidly from
approximately 441,000 in 2013 to 3.4 million in 2050 and 20.1 million in 2100.
DEMOGRAPHIC TRANSITION IN INDIA
Population ageing is the most significant result of the process known as demographic
transition. Population ageing involves a shift from high mortality/high fertility to low
mortality/low fertility and consequently an increased proportion of older people in the total
population. India is undergoing such a demographic transition. In 1947, when India became
independent from British rule, life expectancywas around 32 years.
The National Sample Survey Organisation (NSSO) for the first time, conducted a survey on the
elderly(persons of age 60 years and above), along with the survey on social consumption in its
42ndround (July1986 – June 1987), to assess the nature and dimensions of the socio-economic
problems of the aged.Again NSSO repeated the survey on social consumption in its 52ndround
(July 1995 – June 1996) and in 60thRound (January – June, 2004). Information on the socio-
economic condition of the aged, data onsome chronic diseases and physical disabilities were also
collected during these rounds of the NSS surveys where the main objective was to focus on the
socio-economic and health conditions of the current aged population, and the emerging policy
issues for elderly care in India in the coming years.

2 DEMOGRAPHIC TRANSITIONS Ageing is a global phenomenon. Ageing plays a vital role

in the global demographic transition. According to projections by the UN Population Division,
there will be two old age persons for every child in the world by 2050. This implies that the aged
60 and above, which currently constitute less than 20% of the population will account for 32% of
the population by 2050 . The world old age population (aged 60+) in 1980 accounted for 8.6% of
the total population and is fast growing and would reach 12.9% in the year 2020. Old age
population is growing twice as fast in developing countries. The old age people in India
accounted for 5.7% in 1990 and it is estimated to reach 12.6% in the year 2020 AD. Other
predictions indicate that India will be having the second largest population of elderly in the
world in 2025 with 13% of the total population8 . The projected increase in both the absolute and
relative size of the old age population in many third world countries is a subject for concern.
Thus the aged population is becoming an important segment of the population pyramid for public
policy making. In India, the population of the old age is growing rapidly and is emerging as a
serious area of concern for the government and the policy planners. According to data on the age
of India‟s population, as per the Census 2001, there are a little over 76.6 million people above 60
years, constituting 7.2 per cent of the population. The number of people over 60 years in 1991
was 6.8 per cent of the country‟s population. Recently, with 90 million persons over 60 years of
age, India has the second largest population of older people in the world. Furthermore, between
now and 2050 the Indian population over 60 years of age will almost quadruple. The low level of
benefits and their limited coverage push large numbers of older people, particularly older
women, to continue working in the informal economy. The combination of old-age, lack of
access to decent work, poverty and exclusion is therefore of great concern 9 . According to
Irudaya Rajan in 2008, globally, life expectancy at birth increased from 47 years in the 1950s to
67 in 2008, an increase of 20 years in the space of half a century. In India, the increase has been
21 years. On average, an older person is expected to live 18-20 years upon reaching 60. Some
consequence of ageing population are declining participation of in economy by the old age
people, financial strains on account of retirement trends and increasing demand for health care
and other welfare measures. In India the process of industrialization and urbanization has
weakened the joint family system. Migration of youth to other cities and developed regions had
brought problems to old age people, which were unheard of in the past. Hence research on
ageing in India has gained importance and is very vital for allocation of resources, effective
planning and utilization of human resources and to design welfare packages. According to
Easwaramoorthy 1995, The concept of quality of life has gained significance in Gerontology due
to the need for an integrated approach towards understanding the aged and requirement for an
outcome measure for health care and welfare policies. Moreover ageing is a multidimensional
phenomenon and this is in fact empirically well established. There are economic, physical,
psychological and social dimensions acting on an ageing individual, variables related to these
dimensions are interactive and interdependent and can be best understood in the light of a
multidimensional approach. Many governments in the world, including Government of India,
have their support systems in place for old age persons such as social security welfare measures
and free or discounted medical care. For example, however, most of these systems were built on
the premise that there will always be significantly fewer older persons than younger or middle-
aged individuals living at one time. Because of declining death rates, these systems are beginning
to feel a strain that will only increase over time. Additionally, the older-person support ratio is
falling in both more and less developed regions, which could further lessen the ability of
societies and governments to care for their ageing populations. These demographic trends create
unique challenges for all people, particularly for the governments of nation-states around the
globe. There is also a prevalent belief among many that old age persons are worthless in today‟s
fast-paced, globalize and increasingly industrialized world. Obviously, with the number of old
age population is rising rapidly, there is an increased urgency to address the rights and roles of
old age persons in our world10 . The family provides the ambience for affection and social
bonding throughout the life-cycle. It is not only supportive by nature but also contributes to the
social integration of the old age people. It is within the domain of the family that the old age
people seek care, and for emotional, social, economic and health support in old age. Caring for
the old age people constitutes a major concern for most families especially in rural sector and
remains to be a problem, despite changes such as accelerated ageing, urbanization,
industrialization and modernization taking place in society. These are likely to have
consequences on family structure and individual lifestyles. These, in turn, will have a bearing on
the well being of the old age people. The life expectancy has also gone beyond 70 years today.
Better medical facilities, care and liberal family planning policies made the old age persons the
fastest
The UN defines a country as „agein will have exceeded that proportion (7.7%) and is
expected to reach 12.6% in 2025. g‟ where the proportion of people over 60 reaches 7 per
cent.By 2000 India growing section of the society in India11. With fast changing socio-economic
scenario, industrialization, rapid urbanization, higher aspirations among the youth and the
increasing participation of women in the workforce, roots of traditional joint family system has
been eroding very fast. In urban areas of the country, traditional joint family system has become
a matter of past. In such changing situations, majority of older persons, who have passed most
part of their life with their joint or extended families are on the verge of isolation or
marginalization in old age. At this age, when they need family support, mostly they have to live
on their own. Even basic needs and rights of many of them are not addressed. Social
marginalization, loneliness, isolation and even negligence in old age lead violation of Human
Rights of Old age Persons. Ironically, in India, older generations are not aware of human rights
due to high prevalence of illiteracy and lack of awareness12. On the other hand, due to
comparatively high physical as well as psychological vulnerability their cries for help remain
within four-walls, that‟s why only a few cases of violation of human rights of old age people
come out. Ever-increasing numbers of distress calls from older persons clearly indicate
disturbing condition of Human Rights of Old age Persons in India. According to Universal
Declaration of Human Rights Definition as per Article 25, “Everyone has the right to a standard
of living adequate for the health and well-being of himself and of his family, including food,
clothing, housing and medical care and necessary social services, and the right to security in the
event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in
circumstances beyond his control.”
Characteristics of the older population
HEALTH OF THE OLDER POPULATION
The health profile of populations has changed in parallel with the demographictransition.
The importance of communicable or infectious diseases hasdeclined and that of non-
communicable or chronic diseases has increased. This phenomenon is referred to as the
epidemiological transition. Its implications,particularly for the delivery of health and long-term
care services to older persons, needs to be examined.
While episodes of communicable disease can have disabling consequences, non-
communicable diseases, such as cardiovascular disease and cancer,often bring about a long
period of poor health and diminished functioning.In addition, some non-fatal (but often chronic)
conditions can have animportant impact on the quality of life and health-care costs for
olderindividuals. Examples of such conditions include hearing and vision loss,musculoskeletal
conditions such as osteoarthritis, and cognitive impairments including Alzheimer's disease and
other dementias.
Increasing life expectancy raises the question of whether longer life spans result in more
years of life in good health, or whether it is associated with increased morbidity and more years
spent in prolonged disability and dependency.
The major causes of disability and healthproblems in old age are non-communicable diseases
including the ―four giants of geriatrics,‖ namely:
1. Memory loss,
2. Urinary incontinence,
3. Depression and falls or immobility,
4. Communicable diseases and injuries.
As population ageing takes place, health expenditures tend to grow rapidly since older persons
usually require more health care in general and more specialized services to deal with their more
complex pathologies. The number of deaths also increases sharply due to the exponential
increase in mortality with age. Furthermore, older women generally experience higher rates of
morbidity and disability than older men, in large part because of their longer life expectancy
(WHO, 2007).
The world‘s crude death rate is defined as the ratio of annual total deaths to the total population.
This is increasing because population ageing shifts the age distribution
towards the older ages, which are subject to higher risk of mortality. Because of this, population
ageing causes two seemingly contrasting situations:
(1) An increase in the crude death rates despite the increasingly longer life expectancy and
(2) Highest crude death rates observed in regions with the lowest overall levels of mortality.
The annual number of deaths in the world was rather stable, even slightly declining from 1960
to 1970, a decade in which the lowest level—51 million—of deaths per annum was recorded.
From then on, the annual number of deaths has been rising; in 2010, it reached 64 million.
The global crude death rate is expected to reach its lowest point in 2015 with about 8.0 deaths
per 1,000 population per year, and to gradually increase thereafter, reaching 9.8 deaths per 1,000
population by 2050.
In 1950-1955, 45 per cent of deaths were of children under the age of 15, while deaths of
persons aged 65 years or older represented only 22 per cent of the total.
As countries have made progress in their demographic transitions, the distribution of deaths
has shifted towards older ages.
In 2005-2010, over half (53 per cent) of all deaths in the world were concentrated in the
population aged 65 years or over, while the proportion of deaths among children (aged 0-14) had
declined to 15 per cent.

As more people are living longer almost everywhere in the world, the causes of death
anddisability are changing from infectious to non-communicable diseases, and in some countries,
to injuries. The disability-adjusted life years (DALY) measure the burden of disease, injury and
death in a given population. The main causes of DALY for the older population are almost
everywhere non-communicable diseases such as heart disease, cancer and diabetes, in all
development groups.
The distribution of DALYs by age group varies greatly across development regions and it is
closely associated with the level of development.
In the more developed regions, 33 per cent of persons aged 60 years or above in 2004 had
Disability Adjusted life years.
By contrast, in the less developed regions, only around 12 per cent were affected with DALY,
and in the least developed countries, the proportion was even lower, of only 6 per cent.
At the world level, 85 per cent of persons aged 60 years or above died from non-
communicable diseases in 2008.

The percentage by region for persons aged 60 years or above who died from non-
communicable diseasesare
More developed regions –92%,
Less developed regions --83%and
Least developed countries–74%.
Furthermore, the increasing levels of exposure to risk factors such as tobacco use, unhealthy
diet, physical inactivity, sedentary lifestyle and the harmful use of alcohol enhances the chances
of non-communicable diseases (Palloni, 2013).
Communicable diseases are also responsible for death among elderly but it varies according to
regions. In 2008, the proportions of old-age deaths due to communicable diseases were
More developed regions –5%,
Less developed regions –13%and
Least developed countries–21%.
Deaths caused by communicable diseases are commonly associated with low income, poor
diets and limited sanitary, health care infrastructure, low awareness, and less government
intervention found in developing regions (WHO and U.S. NIA, 2011).
Per capita health expenditure, both public and private, tends to increase with population
ageing.Population ageing is associated with higher health expenditure due to the increase in the
proportion of older persons, which have higher prevalence of morbidity and demand for health
care than younger adults. Again, because of scientific developments life expectancy has
increased which leads to survival ofall old age groups (60 and above) and this lengthens the
period between onset of significant morbidity or disability and death.
In the more developed regionswith comprehensive social security systems, the majority of the
health expenditure is covered by social insurance schemes. In the less developed regions with
low levels of health care coverage, health expenditure is mainly financed with private spending
by individuals.
Introduction Most people are not comfortable to hear that they are ageing or growing old.
This is simply because it tends to suggest advance in age, decline of organ function, and loss of
flexibility, hearing and vision decline, lessen of muscular strength, flexibility of the skin and
blood vessels, appearance of wrinkles on the skin etc. But it is a known fact that the process of
maturation and ageing in living organisms (human beings) are inevitable because life cycle
continues and is not reversible until death comes. Ageing, should be conceived as a natural stage
of development which comes when it should come. Ageing comes about as a result of the
cessation of cell division that takes place in human beings. Today, ageing and anti-ageing have
become a global phenomenon and the endless struggle against becoming old, the refusal to
accept changes in the body and the millions of money spent on cosmetic and plastic surgery all
point to the fact that nobody wants to get old. However, ageing just like death, is inevitable. No
matter how you try to conceal it, it will definitely manifest with time. Osunde and Obiunu (2005)
stated that ageing goes beyond biological change. It includes physical, mental, social, and
intellectual decline. All these negative indicators which show decline in the functions of body
organs due to ageing make the adult person feel uncomfortable to be associated with ageing. This
feeling affects the adult person emotionally, and psychologically. The ageing population (the
retired and the retrenched adult person) need relevant adult education programmes to enable
them cope and adjust to changing and challenging conditions of their lives and to enable them
feel they are still relevant in human society. Such adult education programmes should be able to
motivate the retired adult and make him feel that he can still learn new tricks in order to continue
to exist comfortable in human environment or society. Osunde and Obiunu (2005) stated that for
elderly adults to say they are too old to learn make them shun their responsibilities as active
members of the society.

2. Perspectives of Ageing The ageing process can be viewed from three major perspectives;
namely, biological ageing, sociological ageing and psychological ageing.

Biological Ageing: This is usually associated with decline in the regulation and proper
functioning of the vital organs of the body. However, not all people experience decreased organ
function in the same proportion. Some individuals have healthier hearts at age 80 than others do
at age 60.

Sociological Ageing: This is usually how a person relates with others in the society. In
sociological ageing, personal or attitude and interaction within the community are used to assess
a person’s maturation and ageing.

As a person ages socially, he/she calculates his/her utterances, limits the use of vulgar language,
prunes relationship to mature friends, changes his/her mode of dressing, reduces nocturnal clubs.
As a person ages socially, he/she tends to be guided by the norms of the society to which the
person belongs. Psychological Ageing: Jegede (2003) stated that the indices of psychological
ageing include feelings, motivation, memory, emotions, experience and self-identify. For
instance, people who had intention of traveling abroad may decide to jettison the idea and
contribute to the growth of their own economy. Psychological ageing is heterogeneous and
continuous as an individual passes through life. Cavanaught (1993) in Osunde and Obiunu
(2005) divided ageing into three viz, the primary ageing, the secondary ageing and the tertiary
ageing.

The Primary Ageing: Primary ageing is considered as the normal process which has noting to do
with illness. It simply involves changes in the biological, social and psychological domains.
These occur due to tear and wear of vital organs of the body.

The Secondary Ageing: This process is associated with different kinds of terminal illness which
prevent normal functioning of the individual.
The Tertiary Ageing: This occurs when there are loses brought about by death or disasters like
war(s) on a family member or close friends that could lead to a gradual decline in the proper
functioning of the individual.

Gerontology Gerontology is derived from two Greek words “geron” which means “old man” and
“logos” which means “discourse” or “study”. Gerontology is the study of the phenomenon of old
age. It is the study of the social psychological and biological aspects of ageing in an adult person.
Gerontology is distinguished from geriatrics which is the branch of medicine that studies the
diseases and care of the elderly person. The elderly adult deserves intensive medical attention as
he continues to grow old. The Oxford Minireference Dictionary defined gerontology as the study
of ageing. The new Websters Dictionary of English Language (1994) edition, defines
gerontology as a study of the phenomenon of old age. Also, the encyclopedia on ageing (volume
2, 297-298) defined gerontology as the scientific study of ageing and older population. As the
adult advances in age, the need for gerontology becomes necessary. Contemporary gerontology
concerns itself with the ageing population. Considering the above definitions and explanations,
gerontology encompasses the following: i) Studying the physical, mental and social changes in
people (adults) as they age. ii) Investigating the ageing process itself (biogerontology). iii)
Investigating the interface of normal ageing and age related diseases (geroscience). iv)
Investigating the effects of our ageing population on our society; including the fiscal effects of
pensions, entitlements, life and health insurance and retirement planning. v) Applying knowledge
to policies and programmes; including a macroscopic perspective i.e. (running a nursing home).
These five scopes of gerontology can simply be referred to as multidisciplinary. This is so
because there are a number of sub-fields in it, as well as psychology and sociology. The field of
gerontology is relatively a late developed field of study. This simply means it is a recent field of
study. This made it possible for it to lack structural and institutional support required. However,
the huge increase in the elderly population in the post industrial western nations made
gerontology to become most rapidly growing field of study. Currently, gerontology is a well paid
field for many all over the world.

The Myths and Stereotypes of Aging

Ageist stereotypes about seniors are unfortunately pervasive in our culture. In films, on
television and even in the jokes we hear, misconceptions about aging and seniors are ever
present.

Some of the top myths and stereotypes of aging include:

1. Myth: Aging Dulls Wits

While aging can create cognitive changes, older people may perform better in certain areas of
intelligence and poorer in others. While seniors may have slower reaction times, “mental
capabilities that depend most heavily on accumulated experience and knowledge, like settling
disputes and enlarging one’s vocabulary, clearly get better over time,” writes Patricia Cohen in
the New York Times.
2. Myth: Aging Erases Your Libido

Discussing the love and sex lives of seniors is largely taboo and has led to the stereotype that the
elderly are sexless. This stereotype is harmful because it can cause seniors to have conflicted
feelings or unnecessary guilt about their sexuality, while simultaneously causing younger people
to hold misconceptions about aging and the elderly. As a state of Oregon document notes:
“Research has found that sexual activity and enjoyment do not decrease with age. People with
physical health, a sense of well-being and a willing partner are more likely to continue sexual
relations. People who are bored with their partner, mentally or physically tired, afraid of failure
or overindulge in food or drink are unlikely to engage in sexual activity. These reasons do not
differ a great deal when considering whether or not a person will engage in sex at any age.”
3. Myth: Aging Is Depressing

Contrary to the myth that aging is depressing, many studies find that seniors are among the
happiest age group. Happiness levels by age follow a U-shaped curve, with self-reported levels
of happiness at their lowest at age 40, but then growing thereafter.
4. Myth: Aging Leads to Loneliness
Though social isolation can be a problem for seniors, especially to those who have limited
mobility, most seniors are able to stay socially engaged. Activities with family and friends and
visits at places such as the local senior center or a place of worship, also help seniors stay active
and happy.
5. Myth: Aging Makes You Less Creative

There are countless examples that dispel the myth that aging makes you less creative. In fact,
many artists actually find their calling or achieve mastery in their later years. A great example is
American artist “Grandma Moses,” who held her first one-woman art show in 1940 when she
was 80 and continued to paint until she was 101.
6. Myth: Aging Makes You More Religious

Seniors certainly have a higher rate of religious attendance, but this is a generational
phenomenon rather than an aging phenomenon. If you regularly attended church growing up,
you’re likely to continue to do so as you age. Today’s senior’s haven’t become more religious
with time. Instead, they grew up in a time when more people went to church, which is why
seniors are the most religious age group.

7. Myth: Aging Makes You Unable to Adapt to New Situations

Older people are not only able to adapt to new situations, they are actually experts at adapting.
By the time one has become a senior, they have had to adapt to innumerable changes and
transitions in life. Seniors may be slower to change their opinions, but one of humanity’s’
greatest traits, adaptability, is generally retained as we grow old.

8. Myth: Aging Makes You Unproductive

Though retired people may have left the workforce, they are hardly unproductive. They
contribute countless hours to activities like helping with child-rearing and volunteering, which
makes an enormous impact on society. In fact, a report by the Bureau of Labor Statistics
indicates 24% of senior citizens report engaging in volunteer work after retirement.
 SCHOOL OF SCIENCE AND HUMANITIES

DEPARTMENT OF PSYCHOLOGY

UNIT – II -PHYSIOLOGICAL AND PSYCHOLOGICAL PROBLEMS OF

ELDERLY -GERONTOLOGY PSYCHOLOGY-SPSY1401
 Biological Changes That Occur During Aging

Young adulthood: The period of young adulthood begins from the age of twenty years
onward. The major concerns of young adults in 20s are to establish themselves in life, job, and
family. The young adult wants to seek social and economic security in preparing for a role of
greater independence and responsibility in society.

Middle Age: From the period of his twenties and thirties, the individual arrives at
middle age in the forties and fifties. Middle age is characterized by competence, maturity,
responsibility and stability. These are the important characteristics formiddle-aged adults. This is
the time when one wants to enjoy the success of job, satisfaction derived from family and social
life. The individual looks forward to the successes of children. Attention gets more focussed on
health, the fate of children, aging parents, use of leisure time and plans for old age. For women,
menopause occurs between the age of forty-five and fifty. Menopause is sometimes accompanied
by some distressing physical and psychological symptoms in women. Men during this period
show greater amount of concern towards their health, strength, power, and sexual potency.

Old Age: The period of old age begins at the age of sixty. At this age most individuals
retire from their jobs formally. They begin to develop some concern and occasional anxiety over
their physical and psychological health. In our society, the elderly are typically perceived as not
so active, deteriorating intellectually, narrow-minded and attaching new significance to religion.
Many of the old people lose their spouses and because of which they may suffer from emotional
insecurity. ‘Nobody has ever died of old age’, is a true statement. Since old age is close to the
end point of life, death has been associated with old age. Death is actually caused by disease,
pollution, stress, and other factors acting on the body. In the biological sense, some organs and
systems of the body may start deteriorating. In the psychological sense, there may be measurable
changes in the cognitive and perceptual abilities. There are also changes in the way a person
feels about him/ herself.
 You must have come across old people who are very active in life and socially very
particiaptive. Such persons seem to be productive and stable and happy. Mental or physical
decline does not necessarily have to occur. Persons can remain vigorous, active, and dignified
until their eighties or even nineties. In fact, the older persons have vast reservoir of knowledge,
experience, and wisdom on which the community can draw. In view of increase in life
expectancy increasingly greater proportion of society is joining the group of aged people. Hence
they need greater attention in national planning and making them feel as an integral part of
society.

PHYSICAL AND COGNITIVE CHANGES

DURING ADULTHOOD AND AGING

Normally people see old age as a period of decline in physical and mental health. This
section deals with physical and psychological aspects of aging. With advancing age, there are
certain inevitable and universal changes such as chemical changes in cells, or gradual loss of
adaptive reserve capacity. There are also certain cognitive changes taking place from middle
adulthood onwards. These changes are slow and gradual. They become more prominent among
the elderly people.

(a) Physical Changes

It has been found that the organ system of most persons show a 0.8 to 1 percent decline per year
in functional ability after the age of 30. Some of this decline is normal, some is disease related
and some are caused by factors such as stress, occupational status, nutritional status and various
environmental factors.

Major physical changes with ageing are described as

(1) external changes

(2) internal changes, and

(3) changes in sensory capacities.

1. External Changes

External changes refer to the outward symptoms of growing old. The more observable
changes are those associated with the skin, hair, teeth, and general posture. There are changes in
the skin. The most pronounced change is wrinkling. Wrinkling process begins during middle
years. Skin also becomes thick, hard and less elastic. It becomes brittle and dry. With advancing
age, the hair of the person continues to turn white and loses its luster. It continues to thin. By the
age of fifty-five, about 65 percent of men become bald. It is estimated that at age 65, fifty
percent people have lost all their teeth. For many, dentures become a way of life. Over the time,
the production of saliva is diminished. This increases the risk of tooth decay.

Physical strength begins to decline from age 30 to age 80 and above. Most weakening
occurs in the back and leg muscles, less in the arm muscles. There is a progressive decline in
energy production. Bones become increasingly brittle and tend to break easily. Calcium deposits
and disease of the joints increase with age. Muscle tissue decreases in size and strength. Muscle
tone becomes increasingly difficult to maintain with age because of an increase in fatty substance
within the muscle fibres. This is often caused by the relative inactive role thrust on the elderly in
our society. Exercise can help maintain power and sometimes even restore strength to the unused
muscles. Changes in the general posture become more evident in old age. The loss of teeth,
balding and greying of the hair, wrinkling of the skin, and lack of physical strength all have a
potentially negative effect on an individual’s self-concept and confidence.

2. Internal Changes

Internal changes refer to the symptoms of growing old that are not visible or obvious.
We shall examine some of the changes taking place with increasing age in the respiratory
system, gastrointestinal system, cardiovascular system, and central nervous system.

The Respiratory System: With increasing age, there is reduction in breathing

efficiency. The lungs of an old person do not expand to take in as much air as the lungs of a
young person. Decreased oxygen supply makes the old person less active, less aware and less
strong. This decline seems to be part of normal aging process.
 The Gastrointestinal System : With increasing age there is decreased capacity for
biting and chewing, decrease in the production of digestive enzymes, decreased gastric and
intestinal mobility and lack of appetite.

The Cardiovascular System: Cardiovascular system which includes the heart and the
blood vessels show the effects of normal aging rather slowly. With the aging process there is a
decrease in the elasticity of blood vessels and blood cell production also. Increase-in time
required for heart to return to rest and arterial resistance to the passage of blood is also found.
Many old individuals are found to be suffering from high blood pressure. However, healthy old
individuals are found to have blood pressure similar to those of young healthy indiciduals.

The Central Nervous System (CNS) : The CNS shows certain universal changes as a
function of age. There is decreasing rate of arterial and venous flow. Beginning at about age 60,
there is a reduction of cerebral blood flow. There is also a decline in oxygen and glucose
consumption. Number of cells and cell endings are found to be decreasing. The most definite
change is the slowing down of responses.

3. Changes in Sensory Capacities

With advancing age, there is gradual slow down in the sensory abilities. We
communicate with the outer world through our senses. Losses in any senses can have profound
psychological consequences.

Vision: Increasing age brings in several problems in vision. The lens continues to lose
elasticity. The pupils become smaller, irregular in shape. The eyelids have a tendency to sag.
Colour vision becomes less efficient. Cataract and glaucoma are commonly found among the
elderly. People with cataracts have blurred vision. This also interferes with normal vision.

Hearing: Hearing seems to be at best around the age 20. From then onwards there is a
gradual decline. Most hearing loss is not noticed. However, in the case of hearing problem, it can
be improved by a hearing aid.
 Other senses: The senses of taste and smell decline with old age. This decline affects
appetite and nutritional requirements of the elderly. You must have noticed that many old
persons demand food that is overly sweet or spicy. This is because the four basic tastes, sweet,
bitter, sour, and salty, all generally diminish in sensitivity. Sensitivity to touch appears to
increase from birth to about 45 and then decreases sharply.

4 COGNITIVE CHANGES DURING ADULTHOOD AND AGING

The term ‘Cognition’ refers to the processes by which information is acquired, stored,
and used. In this section, four major aspect of cognition-memory, learning, attention and
intelligence will be discussed in relation to adulthood and aging.

a) Memory

Memory is one of the most central aspects of cognition. Memory has been defined as
‘the mental processes of retaining information for later use and retrieving such information’. No
significant age differences may be found in short-term memory task like forward digit span or
word span. Older subjects do not perform as well on the tasks that demand repeating numbers in
reverse order. Old persons are found to perform poorer than young ones on long-term memory
tasks which require processing of information and organization of material.

b) Memory of the Elderly

Memory performance with advanced age is affected by several factors. Some of the
important factors are given below.

(i) Beliefs about Memory

Old persons’ beliefs and attitudes about their memory ability affect their memory
performance. Research shows the role of beliefs, perceptions, attitudes, and knowledge in
memory abilities. Questionnaires typically ask respondents how frequently they forget names
and events, how anxious they are about forgetting, what they know about how to improve
memory and what strategies they employ in remembering. Older adults have been found to have
more difficulties with their memory than do younger adults. The common expression among
elderly has been ‘I am getting old’. Elderly persons are often found to be complaining about their
memory failures.

(ii) Use of Memory Strategies

Memory requires the use of strategies. Memory performance would be better for those
who can use effective memory strategies. An example of memory strategy is repeating to
yourself over and over again the items you want to buy is connected with something that is
familiar. For example, if you want to remember the name of somebody, you may associate that
person with some popular figure. You can also use memory aids such as a diary or writing out a
list of items you want to buy at the grocery store. Most of us use some such strategies every now
and then but we are not aware of using them. In their everyday lives, the elderly persons are
more likely to use diaries, making lists of things to buy, etc. than using rehearsal or association
strategy.

(iii) Life Styles of Elderly

The type of daily activities in which elderly persons engage determines their memory
performance. The elderly persons who engage in daily activities like playing chess or bridge,
their performance on some of the memory and reasoning tasks is found to be better than elderly
non-players. Another aspect of lifestyle determining cognitive performance is regularity in the
structure of daily life. Regularity of sleep patterns, daily exercise, following regular schedule of
every day activities helps to maintain everyday cognitive functioning.

b. Learning

Learning involves formation of new association. It means acquisition of general rules

and knowledge about the world. It is believed that learning performance tends to be poorer
during late than early adulthood. Can older people acquire new information and skills? Can they
try new careers? Such questions are difficult to answer. We must note that the ability to learn
may be relatively unchanged in old persons. Factors such as poor motivation, lack of
confidence, test anxiety, etc. may lower performance on learning tasks.Old persons’ learning
performance maybe very close to that of young persons if older persons are allowed more time or
can self-pace the tests. They were found to perform better when there is no time pressure and the
material is presented very distinctly and in a simplified manner.

c. Attention

The term attention refers to the manner in which we focus on what we are doing. People
vary in how wide their attention span is. If attention span is too narrow, one looses a lot of
information. Old people may not differ from young people in terms of their attention span as
such. However, they get easily distracted by any kind of interference. With training, attention can
be improved.

d. Intelligence

As has been pointed out earlier many of our impressions of old age originate from
inaccurate knowledge or misconceptions. How do elderly persons perform on intelligence test?
Most of the intelligence tests require speed of performance. We have already discussed that old
persons are slower on reaction time. Thus lower performance on intelligence tests may be due to
slower reaction time than due to a decline in intellectual functions. General knowledge does not
decline with age. Among the elderly, we often find reduced abilities for complex decision
makingand slowing of performance. Hardly any losses in verbal comprehension, social
awareness and the application of experience may be noticed among the older people. Intelligence
in adulthood and aging maybe viewed as enabling the individual to cope with a variety of
demanding everyday tasks and events. Everyday intelligence of the elderly maybe determined by
their ability in reading road maps, understanding labels, filling out forms, understanding charts,
conversations, TV programmes, doing shopping, driving during rush hours, and performing
many other daily jobs. You may remember that we have already discussed that elderly work best
when they are away from pressure and can set their own pace. Moreover, the factor of general
health is very important to be considered. Healthy individuals and those who lead happy and
active life generally show no or little loss of intellectual abilities during old age.
 Many changes occur during normal aging. Genetics and lifestyle both play a role in signs

of aging exhibited by the body. Skin becomes dryer and less elastic, leading to lines and

wrinkles. Hair thins, and gray hair increases. High-pitched sounds become harder to hear, and

vision declines; most people need reading glasses when they’re in their 40s. Changes in sleep

patterns also occur, with older people generally needing less sleep and waking up more during

the night. Bones may become less dense, height decreases, metabolism slows, and blood flow to

the brain decreases. Sexual functioning also decreases. Men produce fewer sperm, and women

go through menopause and stop ovulating (and menstruating), which means that they can no

longer get pregnant. All of these changes are found to some extent in older people, but the

choices a person makes—such as eating healthy and exercising—can help moderate the effects

of aging.

In individual cells, senescence occurs when a cell can no longer divide. Cells at first

divide quickly, then more slowly, until eventually mitosis stops. The size and shape of the cells

changes, and debris accumulates inside them. In addition, genetic damage can accumulate in

cells over time through exposure to sunlight and radiation, and through free radicals that are cell

by-products. Telomeres, which are regions of DNA at the end of a chromosome, are ultimately

responsible for the stopping of mitosis. Telomeres shorten with each cell division, and over time

when they become very short, the cell can no longer divide.

Mental Illness in the Elderly

Elderly behavioral problems can stem from a decline in mental health. In seniors,
these issues frequently go undiagnosed or unaddressed. In fact, about 20% of U.S. adults age 55
or older experience some type of mental health concern, but nearly one in three of those seniors
do not receive treatment.Data from CDC. The statistics on mental illness in seniors are sobering,
but with knowledge and vigilance, caregivers can stay aware of the emotional and mental health
of their older loved ones and make sure they are properly treated if they are experiencing a
problem.
You might not be surprised to read that the most common mental health issue among the
elderly is severe cognitive impairment or dementia. An estimated 5 million adults 65 and older
currently have Alzheimer’s disease — about 11% of seniors, according to the Alzheimer’s
Association. Depression and mood disorders are also fairly widespread among older adults, and
disturbingly, they often go undiagnosed and untreated. The CDC reports that 5% of seniors 65
and older reported having current depression and about 10.5% reported a diagnosis of depression
at some point in their lives.
Often going along with depression, anxiety is also one of the more prevalent mental
health problems among the elderly. Anxiety disorders encompass a range of issues,
from hoarding syndrome and obsessive-compulsive disorder to phobias and post-traumatic stress
disorder (PTSD). About 7.6% of those over 65 have been diagnosed with an anxiety disorder at
some point in their lives, says the CDC.
Assessing Common Areas of Elderly Behavior Problems

A number of issues may arise as a result of elderly behavior problems. A Place for Mom
medical expert geriatrician Dr. Leslie Kernisan recommends 5 areas to assess when visiting your
loved ones and some tips on what you can do when elderly loved ones resist help.
Risk Factors for Mental Illness

One of the ongoing problems with diagnosis and treatment of mental illness in seniors is
the fact that older adults are more likely to report physical symptoms than psychiatric
complaints. However, even the normal emotional and physical stresses that go along with aging
can be risk factors for mental illnesses, like anxiety and depression.

The Geriatric Mental Health Foundation lists a number of potential triggers for mental illness
in the elderly:
 Alcohol or substance abuse
 Change of environment, like moving into assisted living
 Dementia-causing illness (e.g. Alzheimer’s disease)
 Illness or loss of a loved one
 Long-term illness (e.g., cancer or heart disease)
 Medication interactions
 Physical disability
 Physical illnesses that can affect emotion, memory and thought
 Poor diet or malnutrition
10 Symptoms of Mental Illness

As our loved ones age, it’s natural for some changes to occur. Regular forgetfulness is
one thing, however; persistent cognitive or memory loss is another thing and potentially serious.
The same goes for extreme anxiety or long-term depression. Caregivers should keep an eye out
for the following warning signs, which could indicate a mental health concern:

1. Changes in appearance or dress, or problems maintaining the home or yard.

2. Confusion, disorientation, problems with concentration or decision-making.
3. Decrease or increase in appetite; changes in weight.
4. Depressed mood lasting longer than two weeks.
5. Feelings of worthlessness, inappropriate guilt, helplessness; thoughts of suicide.
6. Memory loss, especially recent or short-term memory problems.
7. Physical problems that can’t otherwise be explained: aches, constipation, etc.
8. Social withdrawal; loss of interest in things that used to be enjoyable.
9. Trouble handling finances or working with numbers.
10. Unexplained fatigue, energy loss or sleep changes.

Depression
Depression is a type of mood disorder that ranks as the most pervasive mental health
concern among older adults. If untreated, it can lead to physical and mental impairments and
impede social functioning. Additionally, depression can interfere with the symptoms and
treatment of other chronic health problems.

Common symptoms of depression include ongoing sadness, problems sleeping, physical pain or
discomfort, distancing from activities previously enjoyed, and a general “slowing down.”
 Seniors suffering from depression generally visit ERs and doctors more frequently, take more
medications, and experience longer hospital stays than their same-age peers. Women are more
likely to be affected than men.

Late-Onset Depression Risk Factors to Watch Out For

 Physical Illness
 Widowhood
 Lack of education (below high school level)
 Diminished functional status
 Heavy drinking

On the bright side, depression can typically be successfully treated in older adults. If you suspect
a loved one or client is showing signs of depression, seek help immediately.

Dementia symptoms
The most common form of dementia is Alzheimer’s disease, which causes cells in the brain that
control memory to die. It is an irreversible condition that occurs in severe and moderate stages in
three million people over the age of 65.

While dementia does affect all individuals differently, the main symptoms of dementia include:

 Difficulty communicating. Dementia patients often have a difficult time completing sentences
or finding the right words. Also, words can get mixed up or used incorrectly.
 Increased memory issues. Forgetfulness will start to occur more and more often, along with
problems remembering how to do daily activities like cooking, cleaning and dressing.
 General confusion. Those with dementia begin getting confused about what time of day it is, or
even what year they’re living in. They also have a hard time recognizing friends and family
members or think they are someone else entirely. Dementia patients may also start losing or
misplacing items, even accusing others of stealing their belongings.
 Personality and emotional changes. Dementia will cause personality changes to individuals,
and can affect their moods as well. Those with dementia are often fearful or depressed and
experience severe mood swings.
 Common Mental Illnesses in the Elderly
If a senior is displaying signs of mental illness, it’s important to recognize the symptoms and
seek treatment as soon as possible. Some of the common mental illnesses the elderly experience
are:

 Depression. Depression is considered the most common mental disorder among seniors. Social
isolation plays a major role in emotional wellness, so when a senior spends long periods alone
because they are unable to drive or live far away from friends and family, depression can easily
set in. It is also a symptom of dementia and tends to get overlooked as a treatable ailment.
 Late onset bipolar. Most bipolar patients are diagnosed in early adulthood. Late onset bipolar
can be difficult to diagnose because of its similarities to dementia symptoms like agitation,
manic behavior and delusions.
 Late onset schizophrenia. This disorder also presents a challenge to diagnose. It can manifest in
adults after age 45 and appears as the patient ages. Symptoms are similar to dementia, once
again, with hallucinations and paranoia the most common, but these symptoms are milder than
when this illness appears in younger adults.
Mental illnesses are treatable, but the trick is a correct diagnosis. Even if a senior had good
mental health throughout their entire life, the risk of mental illness in later years is still there.
Seek medical treatment as soon as possible if there are any noticeable changes beginning to
occur.

Loneliness is a painful universal phenomenon that has an evolutionary basis. Loneliness reminds
us of the pain and warns us of the threat of becoming isolated. Loneliness is the absence of
imperative social relations and lack of affection in current social relationships. Loneliness is one
of the main indicators of social well-being. Loneliness is caused not by being alone, but by being
without some definite needed relationship or set of relationships. Research addressing loneliness
has increased dramatically over the past 2 decades; however, despite the mental health risks
associated with being lonely, the relationship between loneliness and psychiatric disorders has
not been sufficiently explored. In India very little research has been done on psychological and
physical affect of loneliness. There are just a few studies in India, in which relationship of
loneliness with other psychiatric disorders has been studied .However most of these studies were
done in elderly patients only.
 Loneliness is a common experience with 80% of population below 18 years of age and 40% of
population above 65 years of age report loneliness at least sometimes in their life. Loneliness is
generally reported more among adolescents and young children, contrary to the myth that it
occurs more in elderly. The reason for this is that elder people have definite copying skills and
can adjust accordingly to solitude, while as adolescents lack definite copying skills and
adolescent period is the time of life when being accepted and loved is of such major importance
to the formation of one’s identity. However elderly who have physical illness and disability
report higher prevalence of loneliness, compared to elderly without physical illness and
disability. In India elderly patient population is increasing and their psychological problems are
on a rise. India is destined to become the second largest population of elderly people in the
coming years. Therefore it is necessary to intervene at the right time to prevent the psychological
problems and physical disorders arising due to affects of loneliness in elderly population. Further
loneliness gradually diminishes through the middle adult years, and then again increases in old
age (i.e., ≥70 years) .

Risk factors: The risk factors associated with loneliness include being female, being widowed,
living alone, being aged, health factors, material resources and a limited number of ‘social’
resources .

Types of loneliness

There are 3 types of loneliness i.e. situational loneliness, developmental loneliness and internal
loneliness .

1. Situational Loneliness: The various factors associated with situational loneliness are
environmental factors (unpleasant experiences, discrepancy between the levels of his/her needs),
migration of people, inter personal conflicts, accidents and disasters, etc .

2. Developmental Loneliness: The various factors associated with developmental loneliness are
personal inadequacies, developmental deficits, significant separations, poverty, living
arrangements, and physical/psychological disabilities .
3. Internal Loneliness: The various factors associated with internal loneliness are personality
factors, locus of control, mental distress, low self-esteem, guilt feeling , and poor coping
strategies with situations .

Further Weiss et al., reported 2 types of loneliness i.e. emotional and social loneliness.
Emotional loneliness defined by the absence of an attachment figure and social isolation,
characterized by the absence of a social network .

Psychiatric Disorders and Loneliness

1. Depression : Lonely people suffer from more depressive symptoms, as they have than been
reported to be less happy, less satisfied and more pessimistic [16]. Further loneliness and
depression share common symptoms like helplessness and pain. There is so much similarity
in between loneliness and depression that many authors consider it a subset of depression.
However the distinction can be made by the fact that loneliness is characterized by the hope that
all would be fine, if the lonely person could be united with another longed for person [2]. In
patients, who are both lonely and depressed, loneliness is positively correlated with negative
feelings and negative judgment of personality attributes and negatively correlated with it .It has
been seen that there is an association between insecure attachment styles and depression. Several
studies further suggest insecure attachment styles increases vulnerability to depression. The
vulnerability to depression can be due to the fact that insecurely attached have tendency to
develop low self esteem, difficulty or inability in developing and maintaining relationships with
others, poor problem solving skills, and an unstable self- concept [17]. In a study done by Singh
A et al., of elder persons in the age group of 60-80 in Delhi (India) based regions (living in
various housing societies), found out an increase in level of depression with increase in level of
loneliness. However no gender difference in elder males and females was found between
loneliness and depression. The absence of significant gender difference is in contrast to the
belief, as well as what has been reported in the literature that older females are more vulnerable
to depression. The reason for this could be that all elderly females were not working women
before 60 years of age. The transition in their lifestyle in their old age included breaking ties with
their colleagues, friends and loss of status. However the transition in their lifestyle was slow,
which could have prevented any change in mood [4]. In a study done by Bhatia SPS et al., found
 higher mean loneliness score in elderly women , compared to elderly males. He further
concluded that older people, who were living alone were experiencing higher loneliness
,compared to who were living with their spouses or their families.

1. Alzheimer’s disease : Loneliness is associated with more then two fold risk of dementia, as
loneliness is associated with loss of cognition in old age. In fact some authors signal it as
prodromal stage of dementia. In loneliness, there is more rapid decline in global cognition,
semantic memory, perceptual speed, and visuospatial ability. The basis of association of
loneliness with Alzheimer’s disease (AD) can be attributed to two possibilities. First possibility
is that loneliness is a consequence of dementia, perhaps as a behavioral reaction to diminished
cognition or as a direct result of the pathology contributing to dementia. Second possibility is
that loneliness might somehow compromise neural systems underlying cognition and memory,
thereby making lonely individuals more vulnerable to the deleterious effects of age-related
neuropathology and thereby decreasing neural reserves. In one study, the incidence of AD was
predicted by degree of baseline loneliness, after adjusting for age, sex, and education. It was
found that those in the top deciles of loneliness scores were 2.1 times more likely to develop AD
than those in the bottom deciles of loneliness scores. The prevalence of AD is lower in India
compared to other countries. There are wide variations in the incidence rates in community based
as well as urban based studies in India. Various risk factors have been identified in the causation
of AD in India. However, to the best of the knowledge of the author, there are no studies which
assesses relationship of loneliness with AD.

2. Alcoholism: Loneliness is recognized as a contributing, maintaining and poor prognostic factor

in the development of alcohol abuse. Further it is recognized as an essential risk factor in all the
stages of alcoholism. Various studies have demonstrated lonely people with heavy drinking are
more vulnerable to alcohol related problems. The reasons attributed to this are due to lack of
social support, and distinct perceptions of community pressure. However presently in India as
well as in the world, there are no studies which compares loneliness in alcoholics with loneliness
in nonalcoholic.

3. Child abuse : Loneliness is more prevalent among child abusers and those who disregard than
who take good care of their children. Women abused in the past were noted to be more lonely
and had more negative network orientation, compared to women, who were not abused. Further
 in whom abuse lasted for a longer duration period and involving multiple incidents were more
loneliness and had lower network orientation. In a study conducted by Dhal A et al., of 110
adolescents of Delhi (India) found that two third of children reported higher level of loneliness
and one third of children reported lower level of loneliness. Further low self esteem in the
adolescents was associated with loneliness .The adolescents with low self esteem develop
loneliness ,as they feel rejected.They also lacked confidence and skills in initiating and
maintaining relationships. Psychological intervention like copying skills, talking with friends and
maintaining relationships can benefit adolescents in dealing with psychological affects of
loneliness.

4. Bereavement: Loneliness is expected when people grieve the loss of someone to whom they
were closely attached. Widows express loneliness usually with the absence of a spouse or a
social support. Various studies report 86% of widows experience loneliness, however the
proportion decreases with increasing number of children and with the support system. It must be
noted that loneliness in grief is associated with acute absence of an attachment figure, rather than
absence of a social support. Further loneliness in bereavement is in itself a risk factor for the
development of depression.

5. Stress, Immune system: Loneliness is not only a source of acute stress, but also chronic stress.
Recently, there has been extensive research on psychosocial effects of stress on neuroendocrine
and immune systems. Whether loneliness qualifies as stress may be debatable [2,20,28].
However there is ample data, which gives evidence of immune system getting involved in
loneliness. Loneliness has been associated with impaired cellular immunity, as reflected by lower
natural killer (NK) cell activity and higher antibody titers. In addition, loneliness among middle-
age adults has been found associated with smaller increase in NK cell numbers ,in response to
acute stress associated with various tasks.

6. Suicide: Research on suicide has revealed that there is a strong association between suicide
ideation, parasuicide and loneliness .The prevalence of suicide ideation and parasuicide rises
with the degree of loneliness. Further the peak season for loneliness has been reported to be
winter and spring, the same season for which peak incidence of suicide has been reported.
However there is minimal differences in suicide between men and women related to loneliness.
SC Tiwari attributes loneliness as an important factor in etiology of suicide and parasuicide .He
 also considers loneliness as a disease and wants its place in classification of psychiatric
disorders.

7. Personality disorder : The various personality disorders associated with loneliness include
borderline personality disorder and schizoid personality disorder Intolerance of aloneness is
considered a core feature of borderline personality disorder (BPD). Loneliness also potentiates
other symptoms associated with BPD. The various Theories of Aloneness in BPD are The Need
for Time Alone, Signaling the Need, Development of the Capacity to be Alone, The Holding
Environment and Internal Representation. Several psychoanalytic theorists have suggested that
emotional deprivation plays a critical role in the development of schizoid personality disorder.
As a result of emotional deprivation and lack of ability to gain security, a lack of contentedness
in interpersonal relationships has been observed as components in attachment distortion. Further
contributing to the development of schizoid personality disorder is the maladaptive schema’s and
attached cognitive behavior associated with emotional deprivation. In India, there are no studies
which assess relationship of personality disorders with loneliness. In future, research should be
done in India, which focuses on psychological affects of loneliness on various personality
disorders.

8. Sleep: Loneliness has been associated with poor sleep quality with daytime dysfunction like low
energy, fatigue. However loneliness has no relationship with sleep duration. As greater daytime
dysfunction is a marker of poor sleep quality, loneliness has been found associated with greater
day time dysfunction. Numerous studies have demonstrated greater daytime dysfunction
accompanied by more nightly micro-awakenings with loneliness, thus demonstrating a role of
loneliness with poor sleep quality .

Physical illness and Loneliness: Loneliness related chronic stress can cause low- grade
peripheral inflammation. The low- grade peripheral inflammation in turn has been linked to
inflammatory diseases .The inflammatory diseases include diabetes ,autoimmune disorders like
rheumatoid arthritis, lupus and cardiovascular diseases like coronary heart disease, hypertension
(HTN). In a study conducted by Hawkley et al., of young adults, loneliness was found associated
with elevated levels of total peripheral resistance (TPR).TPR is the primary determinant of SBP,
which suggests that loneliness- related elevations in TPR may lead to higher blood pressure.
Loneliness related chronic stress can also cause low- grade peripheral inflammation. The low-
grade peripheral inflammation in turn has been linked to cardiovascular disease like
atherosclerosis etc. There have been various studies, showing relationship of loneliness with
obesity, physiological aging,cancer, poor hearing and poor health. In a study by SK Mishra et al.,
in 380 HIV (Human immunodeficiency virus) patients of Andhra Pradesh (India) found that
66.57% of patients were found to be lonely and loneliness was associated with depression
(71.84%) in them. He also concluded that in physical illnesses like HIV infection, the mental
health indicators like loneliness and depression needs more stress in the continuum of care of
patients .

Interventions for loneliness:

Left untended, loneliness has serious consequences mental and physical well being of people.
Therefore it is important to intervene at the right time to prevent loneliness. There are broadly 4
types of interventions. The four main types of interventions: (1) Developing social skills, (2)
Giving social support, (3) Developing opportunities for social interaction, and (4) Recognizing
maladaptive social cognition.

Lewy body dementia signs and symptoms may include:

 Visual hallucinations. Hallucinations may be one of the first symptoms, and they often
recur. They may include seeing shapes, animals or people that aren't there. Sound (auditory),
smell (olfactory) or touch (tactile) hallucinations are possible.
 Movement disorders. Signs of Parkinson's disease (parkinsonian signs), such as slowed
movement, rigid muscles, tremor or a shuffling walk may occur. This can also result in falls.
 Poor regulation of body functions (autonomic nervous system). Blood pressure, pulse,
sweating and the digestive process are regulated by a part of the nervous system that is often
affected by Lewy body dementia. This can result in dizziness, falls and bowel issues such as
constipation.
 Cognitive problems. You may experience thinking (cognitive) problems similar to those of
Alzheimer's disease, such as confusion, poor attention, visual-spatial problems and memory
loss.
 Sleep difficulties. You may have rapid eye movement (REM) sleep behavior disorder, which
can cause you to physically act out your dreams while you're asleep.
 Fluctuating attention. Episodes of drowsiness, long periods of staring into space, long naps
during the day or disorganized speech are possible.
 Depression. You may experience depression sometime during the course of your illness.
 Apathy. You may have loss of motivation.

The symptoms of panic disorder

Symptoms of panic disorder often begin to appear in teens and young adults under the age of 25.
If you have had four or more panic attacks, or you live in fear of having another panic attack
after experiencing one, you may have a panic disorder.

Panic attacks produce intense fear that begins suddenly, often with no warning. An attack
typically lasts for 10 to 20 minutes, but in extreme cases, symptoms may last for more than an
hour. The experience is different for everyone, and symptoms often vary.

Common symptoms associated with a panic attack include:

 racing heartbeat or palpitations

 shortness of breath

 feeling like you are choking

 dizziness (vertigo)

 lightheadedness

 nausea

 sweating or chills

 shaking or trembling

 changes in mental state, including a feeling of derealization (feeling of unreality) or

depersonalization (being detached from oneself)

 numbness or tingling in your hands or feet

 chest pain or tightness

 fear that you might die

The symptoms of a panic attack often occur for no clear reason. Typically, the symptoms are not
proportionate to the level of danger that exists in the environment. Because these attacks can’t be
predicted, they can significantly affect your functioning.

Fear of a panic attack or recalling a panic attack can result in another attack.

Anxiety Disorders
Like depression, anxiety is a very common mood disorder among the elderly. In fact, these two
problems often appear in tandem. Statistics from the CDC show that nearly half of older adults
with anxiety also experience depression.

Anxiety in seniors is thought to be underdiagnosed because older adults tend to emphasize

physical problems and downplay psychiatric symptoms. Women in this age group are more
likely to be diagnosed with an anxiety disorder than men.

Risk Factors for Anxiety Disorders in Old Age

Anxiety in the elderly is linked to a number of risk factors, including but not limited to: [ix]

 General feelings of poor health

 Sleeping problems
 COPD, certain cardiovascular diseases, diabetes, thyroid disease, and related chronic
conditions
 Side effects caused by certain medications
 The abuse/misuse of alcohol, street drugs, or prescription drugs
 Physical impairments limiting daily functioning
 Stressful events like the death of a spouse, serious medical condition, or other life-
altering event
 Traumatic or difficult childhood
 Perseveration on physical symptoms

There are several different types of anxiety disorders, with the most common being generalized
anxiety disorder and phobias. Here is a list of anxiety disorders you may observe:

Generalized Anxiety Disorder

This form of anxiety presents a state of constant worry with little to no cause. Older
adults with GAD have difficulty relaxing, sleeping, concentrating, and startle easily. Symptoms
include fatigue, chest pains, headaches, muscle tension, muscle aches, difficulty swallowing,
trembling, twitching, irritability, sweating, nausea, lightheadedness, having to go to the bathroom
frequently, feeling out of breath, and hot flashes.
The effects of generalized anxiety include persistent worry or fear, which can get progressively
worse with time.

These symptoms eventually interfere with socialization, job performance, and day-to-day
activities. Seniors with anxiety tend to become more withdrawn and reclusive.

Symptoms and Signs of Generalized Anxiety Disorders in Seniors

Elderly individuals with generalized anxiety may experience the following symptoms: [x]

 Excessive, uncontrollable worry/anxiety

 Edginess, nervousness, or restlessness
 Chronic fatigue or tiring out easily
 Become irritable or agitated
 Poor quality of sleep or difficulty falling/staying asleep
 Tense muscles

In addition to generalized anxiety disorder, seniors can be diagnosed with the following related
disorders including:

Phobia: An extreme, paralyzing fear of something that usually poses no threat, phobias can
cause individuals to avoid certain things or situations due to irrational fears. Examples can
include fear of social situations, flying, germs, driving, etc.

Panic disorder: This disorder is characterized by periods of sudden, intense fear that can be
accompanied by heart palpitations or pounding, rapid heartbeat, shaking, sweating, difficulty
breathing, or experiencing feelings of doom.

Symptoms of Panic Disorder

 Sudden, repeated bouts of intense fear

 Feeling powerless or out of control
 Persistent worry about the “next” attack
 Avoiding situations where past panic attacks have occurred

Social Anxiety Disorder: This social phobia causes individuals to fear being in certain social
situations where they feel they might be judged, embarrassed, offensive to others, or rejected.

Social Phobia Symptoms

 Extreme anxiousness about being with others

 Difficulty talking to others in social situations
 Self-consciousness in social settings
 Fear of being judged, humiliated, or rejected
 Fear of offending others
 Worrying about attending social events long before they take place
  Avoiding social situations
 Difficulty with friendships
 Feeling queasy around other people
 Sweating, blushing or shaking around others

Post-Traumatic Stress Disorder:

PTSD is a disorder that usually manifests following a traumatic event that threatens a person’s
safety or survival, greatly impacting his or her quality of life.

Symptoms of PTSD

 Emotional numbness
 Flashbacks to the event
 Nightmares
 Depression
 Irritability
 Easily distracted or startled
 Anger

Obsessive-Compulsive Disorder: Those who suffer from OCD experience uncontrollable

recurring thoughts (obsessions) or rituals (compulsions). Examples of rituals include washing
hands, checking if appliances are on or off, counting, or other behaviors typically done to quell
obsessive thoughts (e.g. washing hands repeatedly to remove germs and avoid getting sick).

Treatments for Anxiety Disorders

A variety of techniques, supports, and treatments, including medication, psychotherapy, or a
combination of both, are available to address various anxiety disorders in seniors. If you suspect
someone you care for has symptoms of an anxiety disorder, get in touch with their care team as
soon as possible.

3. Bipolar Disorders
Bipolar disorders, or manic-depressive illnesses, are often marked by unusual mood shifts and
are frequently misdiagnosed in senior citizens because the symptoms presented are typical with
the aging process, especially related to dementia and Alzheimer’s. Bipolar disorder occurs
equally among women and men in this age group.

While younger people in the manic phase of bipolar disorder will show classic signs like elation
and risky behavior, seniors are likely to become more agitated or irritable. [xi]

Late-Onset Bipolar Disorder Symptoms

 Confusion
 Agitation
  Irritability
 Hyperactivity
 Psychosis
 Cognitive issues including memory problems, trouble problem solving, loss of judgment,
and loss of perception

It is worth noting that the effects of certain medications and some types of illnesses show similar
symptoms. The individual should be seen and diagnosed by a medical professional to determine
the root cause of any symptoms as well as the best options for treatment.

Panic disorder

Panic disorder occurs when you experience recurring unexpected panic attacks. The DSM-5
defines panic attacks as abrupt surges of intense fear or discomfort that peak within minutes.
People with the disorder live in fear of having a panic attack. You may be having a panic attack
when you feel sudden, overwhelming terror that has no obvious cause. You may experience
physical symptoms, such as a racing heart, breathing difficulties, and sweating.

Most people experience a panic attack once or twice in their lives. The American Psychological
Association reports that 1 out of every 75 people might experience a panic disorder. Panic
disorder is characterized by persistent fear of having another panic attack after you have
experienced at least one month (or more) of persistent concern or worry about additional panic
attacks (or their consequences) recurring.

Even though the symptoms of this disorder can be quite overwhelming and frightening, they can
be managed and improved with treatment. Seeking treatment is the most important part of
reducing symptoms and improving your quality of life.
 SCHOOL OF SCIENCE AND HUMANITIES

DEPARTMENT OF PSYCHOLOGY

UNIT – III -POLICIES AND PROGRAMMES FOR AGED -

GERONTOLOGY PSYCHOLOGY-SPSY1401
National policies and programmes for elderly
The problems of the elderly in India were not serious in the past because the numbers were small
and the elderly were provided with social protection by their family members. But owing to
relatively recent socio-economic changes, ageing of the population is emerging as a problem that
requires consideration before it becomes critical. However a few studies indicate that family and
relatives still play a dominant role in providing economic and social security for the elderly. But
still the majority of elderly need social, economic and health support.
Over the years, the government has launched various schemes and policies for elderly persons.
These policies and schemes are meant to promote the health, well-being and independence of
elderly people around the country. Some of these provisions have been discussed in this chapter
as follows:
I Relevant Constitutional Provisions
II Legislations
III Various policies and programmes of Central Government for Elderly People
IV Some other important activities
V Specific Measures / Schemes implemented by Punjab Government
I Relevant constitutional provisions
(i) Article 41 of the Constitution:
Article 41 of Directive Principles of State Policy has particular relevance to Old Age Social
Security. According to Article 41 of
the constitution of India, “the state shall, within the limits of its economic capacity and
development, make effective provision for
securing the right to work, to education and to public assistance in cases of unemployment, old
age, sickness and disablement
and in other cases of undeserved want.”
(ii) Article 47 of the Constitution:
Article 47 of the constitution of India provides that the state shall regard the raising of the level
of nutrition and the standard
of living of its people and improvement of public health as among its primary duties.
(iii) Some Other Constitutional Provisions:
Entry 24 in list III of schedule VII of constitution of India deals with the welfare of labour,
including conditions of work, provident funds, liability for workmen’s compensation, invalidity
and old age pension and maternity benefits. Further, item 9 of the state list and item 20, 23 and
24 of concurrent list relates to old age pension, social security and social insurance, and
economic and social planning. The right of parents, without any means, to be supported by their
children having sufficient means has been recognized by section 125(1) (d) of the Code of
Criminal Procedure 1973, and section 20 (1 & 3) of the Hindu Adoption and Maintenance Act, 1
956. Among the administrative setup, the Ministry of Social Justice and Empowerment focuses
on policies and programmes for the elderly in close collaboration with State Governments, Non-
governmental Organisations and Civil Society. The programmes aim at their welfare and
maintenance especially for indigent elderly, by supporting old age
homes, day care centers, mobile medical units etc.
II LEGISLATIONS
Maintenance and Welfare of Parents and Senior Citizens Act, 2007
The Maintenance and Welfare of Parents and Senior Citizens Act, 2007 was enacted in
December 2007, to ensure need based maintenance for parents and senior citizens and their
welfare. Section 19 of the Maintenance and Welfare of Parents and Senior Citizens Act,2007
envisages provision of at least one old age home for indigent senior citizens with a capacity of
150 persons in every district of the country.
The objectives of the Act are:
o Revocation of transfer of property by senior citizens in case of negligence by relatives.
o Maintenance of Parents/senior citizens by children/ relatives made obligatory and justiciable
through Tribunals.
o Pension provision for abandonment of senior citizens.
o Adequate medical facilities and security for senior citizens.
o Establishment of Old Age Homes for indigent Senior Citizens.
The Act was enacted on 31st December 2007. It accords prime responsibility for the
maintenance of parents on their children, grand children or even relatives who may possibly
inherit the property of a senior citizen. It also calls upon the state to provide facilities for poor
and destitute older persons.
The Act has to be brought into force by individual State Government. Himachal Pradesh is the
first state and Punjab is the fifth state where old parents can legally stake claim to financial aid
from their grown-up children for their survival and a denial would invite a prison term. As on
03.02.2010, the Act had been notified by 22 states and all UTs.
III VARIOUS POLICIES AND PROGRAMMES OF CENTRAL
GOVERNMENT FOR ELDERLY PEOPLE
Several initiative steps for various policies and programmes for the elderly have been taken by
the government. Some of them have been discussed as below:
National Policy for Older Persons (NPOP) 1999
The National Policy on older Persons was announced by the Central Government of India
in the year, 1999 to reaffirm the commitment to ensure the well-being of the older persons. It
was a step to promote the health, safety, social security and well-being of elderly in India. The
policy recognizes a person aged 60 years and above as elderly. This policy enables and supports
voluntary and nongovernmental organizations to supplement the care provided by the family and
provide care and protection to vulnerable elderly people. It was a step in the right direction in
pursuance of the UN General Assembly Resolution 47/5 to observe 1999 as International Year of
Older Persons and in keeping with the assurances to elderly people contained in the Constitution.
The policy envisages state support in a number of areas – financial and food security, healthcare
and nutrition, shelter, education, welfare, protection of life and property etc. for the well being of
elderly people in the country.
The primary objectives of this policy are to:
o ensure the well-being of the elderly so that they do not become marginalised, unprotected or
ignored on any count.
o encourage families to take care of their older family members by adopting mechanisms for
improving inter generational ties so as to make the elderly a part and parcel of families.
o encourage individuals to make adequate provision for their own as well as their spouse’s old
age.
o provide protection on various grounds like financial security, health care, shelter and welfare,
including protection against abuse and exploitation.
o enable and support voluntary and non-governmental organizations to supplement the care
provided by the family and recognising the need for expansion of social and community services
with universal accessibility.
o provide care and protection to the vulnerable elderly people by ensuring for the elderly an
equitable share in the benefits of development.
o provide adequate healthcare facility to the elderly.
o promote research and training facilities to train care givers and organizers of services for the
elderly.
o create awareness regarding elderly persons to help them lead productive and independent life.
This policy has resulted in the opening of new schemes such as –
o Promotion of the concept of healthy ageing.
o Setting up of Directorates of Older Persons in the States.
o Training and orientation to medical and paramedical personnel in health care of the elderly.
o Assistance to societies for production and distribution of material on elderly care.
o Strengthening of primary health care system to enable it to meet the health care needs of older
persons.
o Provision of separate queues and reservation of beds for elderly patients in hospitals.
o Extended coverage under the Antodaya Schemes especially emphasis for elderly people.
National Council for Older Persons (NCOP)
A National Council for Older Persons (NCOP) was constituted in 1999 under the
chairpersonship of the Ministry of Social Justice and Empowerment to operationalize the
National Policy on Older Persons. The NCOP is the highest body to advise the Government in
the formulation and implementation of policy and programmes for the elderly.
The basic objectives of this council are to:
o advise the Government on policies and programmes for older persons.
o represent the collective opinion of elderly persons to the government.
o suggest steps to make old age productive and interesting.
o provide feedback to the government on the implementation of the NPOP as well as on specific
programme initiatives for elderly.
o suggest measures to enhance the quality of inter-generational relationships.
o provide a nodal point at the national level for redressing the grievances of older persons which
are of an individual nature provide lobby for concessions, rebates and discounts for older persons
both with the Government as well as with the corporate sector.
o work as a nodal point at the national level for redressing the grievances of elderly people.
o undertake any other work or activity in the best interest of elderly people.
The council was re-constituted in 2005 and met at least once every year. At present there are 50
members in it, comprising representatives of Central and State Governments, NGO’s, citizens’
group, retired persons’ associations, and experts in the fields of law, social welfare and medicine.
Central Sector Scheme of Integrated Programme for Older Persons (IPOP)
An integrated Programme for Older Persons (IPOP) is being implemented since 1992
with the objective of improving the quality of life of senior citizens by providing basic amenities
like food, shelter, medical care and entertainment opportunities and by encouraging productive
and active ageing. Under this scheme financial assistance up to 90 percent of the project cost is
provided to Non-Governmental Organizations for running and maintenance of old age homes,
day care centers and mobile medicine units. The scheme has been made flexible so as to meet the
diverse needs of the older persons including reinforcement and strengthening of the family,
awareness generation on issues pertaining to older persons, popularisation of the concept of
lifelong preparation for old age etc.
Several innovative projects have also been added which are as follows:
o Maintenance of respite care homes and continuous carre homes.
o Sensitizing programmes for children particularly in schools and colleges.
o Regional resource and training centers for caregivers of elderly persons.
o Volunteer Bureau for elderly persons
o Formation of associations for elderly.
o Helplines and counselling centers for older persons.
o Awareness Generation Programmes for elderly people and caregivers.
o Running of day care centers for patients of Alzheimer’s Disease/Dementia, and physiotherapy
clinics for elderly people.
o Providing disability and hearing aids for the elderly people. The eligibility criteria for
beneficiaries of some important projects
supported under IPOP Scheme are:
o Old age homes – for destitute elderly persons.
o Respite care homes and continuous care homes – for elderly persons who are seriously ill and
require continuous nursing care and respite
o Mobile Medicare units – for older persons living in slums, rural and inaccessible areas where
proper health facilities are not available. The scheme has been revised in April, 2008. Besides an
increase in amount of financial assistance for existing projects,
Governments/Panchayati Raj institutions/local bodies have been made eligible for getting
financial assistance.
Inter-Ministerial Committee on Older Persons
An Inter-Ministerial Committee on Older Persons comprising twenty-two
Ministries/Departments, and headed by the secretary,
Ministry of Social Justice and Empowerment is another coordination mechanism in
implementation of the NPOP. Action Plan on ageing issues for implementation by various
Ministries/Departments concerned is considered from time to time by the committee.
National Old Age Pension (NOAP) Scheme
Under NOAP Scheme, in 1994 Central Assistance was available. The amount of old age
pension varies in the different States as per their share to this scheme. It is implemented in the
State and Union Territories through Panchayats and Minicipalities.
The assistance was available on fulfillment of the following criteria:-
o 65 years or more should be the age of the applicant (male or female)
o The applicants who have no regular means of subsistence from their own source of income or
through financial support from family members or others. The Ministry is now implementing the
Indira Gandhi National Old Age Pension Scheme (IGNOAPS). Under this scheme Central
assistance in form of Pension is given to persons, above 65 years @ Rs. 200/- per month,
belonging to a below poverty line family. This pension amount is meant to be supplemented by
at least same contribution by the States so that each applicant gets at least Rs. 400/- per month as
pension. The number of beneficiaries receiving central assistance, in the form of pension, was
171 lakh as on 31st March, 2011.

Further the Ministry has lowered the age limit from the existing 65 years to 60 years and
the pension amount for elderly of 80 years and above has also been increased from Rs. 200/- to
Rs. 500/- per month with effect from 01.04.2011. This decision of the Government of India has
been issued to all States/UTs vide letter no. J- 11015/1/2011-NSAP dated 30th June, 2011.
National Programme for Health Care of Elderly (NPHCE)
National Programme for Health Care of Elderly (NPHCE) is an articulation of the international
and national commitments of the government as envisaged under (UNCRPD), National Policy
on older Persons (NPOP) adopted by the Government of India in 1999 and Section 20 of “The
Maintenance and Welfare of Parents and Senior Citizens Act, 2007” dealing with provisional for
medical care of senior citizen. Ministry of Health and Family Welfare (MOHFW) has taken
appropriate steps in this regard by launching the National Programme for Health Care of Elderly
(NPHCE) as a centrally sponsored scheme under the new initiatives in the XI five years plan.
Presently, it is being rolled out in 100 districts.
The vision of the NPHCE is:
o To provide accessible, affordable and high quality long-terms comprehensive and dedicated
care services to an Ageing
population.
o Creating a new “architecture” for Ageing.
o To build a frame-work to create an enabling environment for “a society for all ages”.
o To promote the concept of Active and Healthy Ageing.
o Convergence with National Rural Health Mission, AYUSH and other line departments like
Ministry of Social Justice and Empowerment.
Specific Objectives of NPCHE are:

o To identify the health problems in the elderly and provide appropriate health interventions in
the community with a strong
referral backup support.
o To provide an easy access to promotional, preventive, curative and rehabilitative services to the
elderly through community based primary health care approach.
o To build capacity of the medical and paramedical professional as well as the care-takers within
the family for providing health care to the elderly.
o To provide referral services to the elderly patients through district hospitals, regional medical
institutions. Core Strategies to achieve the objective of the Programme
o Community based Primary Health Care approach including domiciliary visits by trained health
care workers.
o Dedicated services at PHC/CHC level including provision of machinery, equipment, training,
additional human resources
(CHC), IEC etc.
o Dedicated facilities at District Hospital with 10 bedded wards, additional human resources,
machinery, and equipment,
consumable and drugs, training and IEC.
o Strengthening of 8 Regional Medical Institutes to provide dedicated tertiary level medical
facilities for the elderly, introducing PG courses in Geriatric Medicine, and in-service training of
health personnel at all levels.
o Information, Education and Communication (IEC) using mass media, folk media and other
communication channels to reach out to the target community.
o Continuous monitoring and independent evaluation of the programme and research in
Geriatrics and implementation of NPHCE.
o Promotion of public and private partnerships in Geriatric Health Care.
o Mainstreaming AYUSH – revitalizing local health traditions, and
convergence with programmes of Ministry of Social Justice and
Empowerment in the field of geriatrics.
o Reorienting medical education to support geriatric issues.
National Policy on Senior Citizens 2011
The foundation of National Policy for Senior Citizens 2011 is based on several factors –
demographic explosion among the elderly, the changing economy and social milieu,
advancement in medical research, science and technology and high levels of destitution among
the elderly rural poor. In principle the policy values an age integrated society. It believes in the
development of a formal and informal social support system, so that the capacity of the family to
take care of senior citizens is strengthened and they continue to live in the family. All those of 60
yearsand above are senior citizens. This policy advocates issues related to senior citizens living
in urban and rural areas, special needs of the ‘oldest old’ and older women. It will endeavour to
strengthen integration between generations, facilitate interaction between the old and the young
as well as strengthen bonds between different age groups. It believes in the development of a
formal and informal social support system, so that the capacity to the family to take care of
senior citizens is strengthened and they continue to live in the family. The policy seeks to reach
out in particular to the bulk of senior citizens living in rural areas who are dependent on family
bonds and intergenerational understanding and support.
The focus of the new policy:
o Promote the concept of ‘Ageing in Place’ or ageing in own home, housing, income security
and homecare services, old age pension and access to healthcare insurance schemes and other
programmes and services to facilitate and sustain dignity in old
age. The thrust of the policy would be preventive rather than cure.
o Mainstream senior citizens, especially older women, and bring their concerns into the national
development debate with priority to implement mechanisms already set by governments and
supported by civil society and senior citizens’ associations. Support promotion and establishment
of senior citizens’ association, especially amongst women.
o The policy will consider institutional care as the last resort. It recognizes that care of senior
citizens institutional care as the last
resort. It recognises that care of senior citizens has to remain vested in the family which would
partner the community, government and the private sector.
o Long term savings instruments and credit activities will be promoted to reach both rural and
urban areas. It will be necessary
for the contributors to feel assured that the payments at the end of the stipulated period are
attractive enough to take care of the likely erosion in purchasing power.
o Being a signatory to the Madrid Plan of Action and Barrier Free Framework it will work
towards an inclusive, barrier-free and age friendly society.
o Recognise the senior citizens are a valuable resource for the country and create an environment
that provides them with equal
opportunities, protects their rights and enables their full participation in society. Towards
achievement of this directive, the
policy visualizes that the states will extend their support for senior citizens, living below the
poverty line in urban and rural areas and ensures their social security, healthcare, shelter and
welfare.
It will protect them from abuse and exploitation so that the quality of their lives improves.
o Employment in income generating activities after superannuation will be encouraged.
o States will be advised to implement the Maintenance and Welfare of Parents and Senior
Citizens Act, 2007 and set up Tribunals so that elderly parents unable to maintain themselves are
not abandoned and neglected.
o Support and assist organisations that provide counseling, career guidance and training services.
o States will set up homes with assisted living facilities for abandoned senior citizens in every
district of the country and there
will be adequate budgetary support.
IV SOME OTHER IMPORTANT ACTIVITIES
Some of other important activities regarding the welfare of elderly people are as follows:
International Day of Older Persons
The International Day of Older Persons is celebrated every year on 1 st October, 2009. On
01.10.2009, the Hon’ble Minister of Social Justice and Empowerment flagged off “Walkathon”
at Rajpath, India Gate, to promote inter-generational bonding. More than 3000 senior
citizens/elderly people from across Delhi, NGOs working in the field of elderly issues, and
school children from different schools participated in this.
Role of Non-Governmental and voluntary organisations:
While the government continues its efforts to introduce programmes for the welfare of
the elderly, it is the non-governmental organisations which have played a key role in bringing to
the forefront the problems of the older people to the society at large and through its various
services it has sown the seeds for a forum whereby the voice and the concerns of the elderly can
be addressed. Presently there are many non-governmental organisations working for the cause of
the elderly in India. In India most of the non governmental organizations have concentrated their
work among the lower income group and the disadvantaged sections of the society. This is
mainly because one- third of these people are defined as “capability poor” which means that they
do not have access to minimum levels of health care and education for earning a decent living.
However in the first few years of the growth of the NGO’s the emphasis was on the abuse of
women due to the gender discrimination prevalent in our Indian society. It is only in the last few
years when the demographers provided alarming statistics on the growth of the elderly
population that a need was felt to work in this area as it was always assumed that the elderly
were well taken care of and were safe in the custody of the well integrated joint family system in
India. Initial studies show that the elderly are taken care of by the family but the reality and
recent ethnographic cases studies also prove that the so called “joint family system” in India is a
myth and the elderly though they live with their sons and their families are neglected and
uncared for by them. This scenario led to the emergence and mushrooming of various NGO’s
working towards the concerns of the elderly.
In recent years several national level and state level voluntary organisations have been set
up for promoting the welfare of the elderly, for advocating a general national priority to their
problems and needs and for organising services. The Government describes the services they are
providing as residential care, day care, geriatric care, medical and psychiatric care, recreation,
financial assistance and counselling. These services are however primarily urban based. One of
the premier voluntary organisation which began work on the cause and care of the older people
of our country is Help Age India. It is a secular, a political, non profit, non governmental
organisation and is registered under the Societies’ Registration Act, 1960, in 1978. Help Age
India was formed in 1978 with the active help from Mr. Cecil Jackson Cole, founder member of
help the Aged, United Kingdom. In its newsletters and brochures one can clearly see it has
charted out its goals and objectives which are “To create an awareness and understanding of the
changing situation and the needs of the elderly in India and to promote the cause of the elderly.
To raise the funds for creation of infrastructure through the medium of voluntary social service
organisations for providing a range of facilities especially designed to benefit the elderly and
thus to improve the quality of their lives.” Help Age India is basically a funding organisation
which looks for partner agencies in the field that are able to implement the various projects and
programmes of the organisation. The head office of Help Age India is located in New Delhi and
it has around twenty-four regional and area offices located all over the country.
Old Age Homes and Day Care Centres:
Help Age India has sponsored the construction and maintenance of old age homes in
India. These homes cater to the needs of those elderly who are unable to live by themselves and
for those who have been abandoned by the family or are neglected and uncapped for by their
children. These old age homes provide and cater to the various needs of the elderly so that they
can spend the “evenings of their lives” with dignity and respect and not feel a burden to the
society. There are over 800 old age homes all over India and nearly half of them are being
sponsored and funded by Help Age India. Besides old age homes, Help Age India also supports
day care centres where the elderly come for a few hours every day or on certain days of the week
and spend some time together. These centres combat the loneliness they face and create a sense
of “we feeling” among them. In some of the centres being supported by Help Age India in rural
areas they are also places where the income generating activities are conducted.
SCHEMES OF OTHER MINISTRIES:
(i) Ministry of Railways
The Ministry of Railways provided the following facilities to senior citizens (elderly).
Separate ticket counters for the elderly people at various Passenger Reservation System
Centres.
Provision of Lower Berth Quota – provide in AC and Sleeper Classes.
Provision of 30 percent discount in all Mails/Express.
Provision of wheel chairs at stations for the disabled elderly passengers
Railway grant 75 percent concession to Senior Citizens undergoing major heart/cancer
operations from starting station to Hospital station for self and one companion.
(ii) Ministry of Health and Family Welfare:
Central Government Health Scheme provides pensioners of central government offices the
facility to obtain medicines for chronic ailments up to three months at a stretch. Ministry of
Health and Family Welfare provides the following facilities for
the elderly people:
Provision of separate queues for elderly people in governmental hospitals.
Set up of two National Institutes on Ageing at Delhi and Chennai.
Provision of Geriatric clinic in several government hospitals.
(iii) Ministry of Finance:
Some of the facilities for senior citizens provided by the Ministry of Finance are:
Exemption from Income Tax for senior citizens of 60 years and above up to Rs. 2.50 lakh per
annum.
Exemption from Income Tax for senior citizens of 80 years and above up to Rs. 5.00 lakh per
annum.
For an individual who pays medical insurance premium for his/her parents or parents who are
elderly or senior citizen,
deduction of Rs. 20,000 under section 80D is allowed.
An individual is eligible for a deduction of the amount spent or Rs. 60,000, whichever is less
for medical treatment of a dependent elderly or senior citizen.
(iv) Department of Pensions has set up a Pension Portal to enable senior citizens or elderly to get
information regarding the status of their application, the amount of pension, documents required
etc. The Portal also provides for lodging of grievances. The recommendation of the Sixth Pay
Commission on provision additional pension to older persons is given below:
Age Group Percentage Pension to be added
80 + 20
85 + 30
90 + 40
95 + 50
100 + 100
(v) Insurance Regulatory Development Authority (IRDA):
Insurance Regulatory Development Authority (IRDA) vide letter dated 25.05.2009 issued some
instructions on health insurance
for elderly or senior citizens to CEOs of all General Health Insurance Companies which inter-
alia includes:
Allowing entry into health insurance scheme till 65 years of age
Provision of transparency in the premium charged.
Reasons to be recorded for denial of any proposals on all health insurance products catering to
the needs of senior citizens.
(vi) Ministry of Civil Aviation:
Under the Ministry of Civil Aviation, the National Carrier, Air India provides concession in air
fare up to 50 percent for male
passengers aged 65 years and above and female passengers aged 63 years and above on
production of proof of age and
nationality on the date of commencement of journey.
(vii) Ministry of Road Transport:
The Ministry of Road Transport and Highways has provided reservation of two seats for elderly
or senior citizens in front row
of the buses of the State Road Transport Undertakings. Some States Governments are providing
fare concession to senior
citizens in the State Road Transport Undertaking buses for e.g. in Punjab Elderly women above
60 years enjoy free travel, Free
passes are provided to old people who are freedom fighters to travel in fast and express buses in
Kerala. Some State Governments also introducing the Bus models according to the convenience
of the elderly.
(viii) Miscellaneous:
Mumbai Police (1090), Dignity Foundation and many other organizations have given help
lines for senior citizens.
MTNL gives 25 percent concession in rent of land line telephone.
Postal Savings Schemes – Senior Citizens Saving Scheme (9 percent interest to elderly,
10,000 to 15 Lakhs), Monthly Income
Scheme (Return of 8 percent and a bonus of 10 percent on maturity)
Large number of association of senior citizens have come up in all areas, giving opportunities
to express and share one’s views, get knowledge about various facilities available, get
entertainment, group support etc.
(ix) Insurance schemes:
Several types of insurance schemes for the benefit of elderly people were introduced time to time
by several government and private insurance companies which are – Jeevan Dhara, Jeevan
Akshay, Jeevan Suraksha, Bima Nivesh, Senior Citizen Unit Plan and several other medical
insurance schemes like Group Medical Insurance Scheme, Jan Arogya etc. The schemes
Jeevan Dhara, Jeevan Akshay, Jeevan Suraksha and Bima Nivesh have been discontinued and
relaunched in the new version as New Jeevan Dhara, New Jeevan Akshay, New Jeevan Suraksha
and New Bima Nivesh respectively.
Senior Citizens Unit Plan (SCUP) - Senior Citizens Unit Plan is a Scheme under which one
has to make a one time investment depending on his/her age and have the benefit of medical
treatment for self and spouse at any of the selected hospitals on completion of 58 years of age.
SCUP have special arrangements with New India Assurance Co. Ltd. (NIAC) under an exclusive
medical insurance cover where by the bills from the hospitals in connection with all medical
treatment by you will be settled directly by NIAC up to the prescribed limit. Age group of 18-54
years can join this Scheme. The person may be a resident or a non-resident Indian. The person
will be entitled for a medical insurance cover of Rs 2.5 lakh after he/she attains the age of 58
years. This insurance cover is available for both the citizen and his/her spouse. After the age of
61 years both of them are eligible for a cover of Rs 5 lakh after adjusting any claims made
earlier. The citizen can avail medical treatment in any of the hospitals under this Scheme. The
Trust will call for all details about recent photograph, signature and address of the member and
the spouse as soon as the member attains the age of 54 years so as to prepare an identity card
cum log book, for the member and the spouse.

Medical Insurance Scheme - The Medical Insurance Scheme known as Mediclaim is

available to persons between the age of 5 years and 75 years. Earlier, the sum insured varies
from Rs 15,000 to Rs 300,000 and premium varies from Rs 175 to Rs 5,770 per person per
annum depending upon the different slabsof sum insured and different age groups. However,
with effect from 1 November 1999, these limits of benefits and the premium rates have since
been revised. The sum insured now varies from Rs 15,000 to Rs 500,000 and premium varies
from Rs 201 to Rs 16,185 per person per annum depending upon different slabs of sum insured
and different age groups. The policy is now available to persons between the age of 5 years and
80 years. The cover provides for reimbursement of medical expenses incurred by an individual
towards hospitalisation/ domiciliary, hospitalisation for any illness, injury or disease contracted
or sustained during the period of insurance.
Group Medical Insurance Scheme - The Group Medi-claim policy is available to any group/
association/ institution/ corporate body of more than 100 persons provided it has a central
administration point. The policy covers reimbursement of hospitalisation and/or domicillary
hospitalisation expenses only for illness/diseases contracted or injury sustained by the insured
person. The basic policy under this scheme is Mediclaim only. This policy is also available to
persons between the age of 5 years and 80 years. The sum insured varies from Rs 15,000 to Rs
500,000 and premium varies depending upon the different slabs of sum insured and different age
groups.
 Jan Arogya - This scheme is primarily meant for the larger segment of the population who
cannot afford the high cost of medical treatment. The limit of cover per person is Rs 5,000 per
annum. The cover provides for reimbursement of medical expenses incurred by an individual
towards hospitalisation/ domiciliary hospitalisation for any illness, injury or disease contracted or
sustained during the period of insurance.
(V) SPECIFIC MEASURES/SCHEMES IMPLEMENTED BY
PUNJAB GOVERNMENT
Some of the schemes and programmes of Punjab Government for elderly are as follows:
Pension Scheme for the Employees of Punjab Government
Punjab government is providing pension to the Punjab government employees, retiring in
accordance with Punjab Civil Services Rules Volume-II as amended from time to time and as
applicable to the pensioners/family pensioners. Pension amount constitutes 50 percent of basic
pay (plus NPA). It shall also to be calculated on the basis of last pay drawn or 10 months average
which ever is beneficial to the employees subject to a minimum of Rs. 3500/- per month. In
addition to this, additional quantum of pension is also provided to old pensioners/family
pensioners.
After careful consideration of the recommendations of the Fifth Punjab Pay Commission, the
Governor of Punjab revised various benefits available to the old pensioners/ family pensioners,
w.e.f. 1st December, 2011. The recommendation of the Fifth Punjab Pay Commission on
provision additional pension to older persons is given below:
Age of Pensioner/family pension
Additional quantum of Pension/ family
Pension
from 65 years to less than 70 years
5 percent of revised basic pension/ familypension
from 70 years to less than 75 years
10 percent of revised basic pension/ family pension from 75 years to less than 80 years
15 percent of revised basic pension/ family pension from 80 years to less than 85 years
25 percent of revised basic pension/ family pension from 85 years to less than 90 years
35 percent of revised basic pension/ family pension from 90 years to less than 95 years
45 percent of revised basic pension/ family pension from 95 years to less than 100 years
55 percent of revised basic pension/ family pension
100 years or more 100 percent of revised basic pension/ family pension
Old Age Pension Scheme of Punjab Government
This scheme was first started in the state of Punjab in the year 1964. The purpose of this Scheme
is to provide social security in the shape of financial assistance to old and infirm persons. Under
this scheme women who are 60 years old or above and 65 years or above in the case of men,
whose monthly income should not be more than Rs. 1000/- in case of individual and Rs. 1500/-
if husband wife both are alive will get the benefit of this scheme. The payment of old age
pension i.e. Rs. 250/- per month is provided through banks in the urban sector and through
sarpanchs in the Rural Sector.
Indira Gandhi National Old Age Pension Scheme
It was launched by Ministry of Rural Development. All persons of 60 years and above (before
2011 it was 65 years and above) and belonging to below the poverty line category according to
the criteria prescribed by the government of India time to time, are eligible to be a beneficiary of
this scheme. Punjab government has decided in principle to disburse pension to the old widowed
and destitute women and disabled persons regularly from 1st April, 2010.
Beneficiaries under this scheme are as follows:
Elderly males and females of 60 years of age who have no surviving sons/ widows/ disables
and who belongs to below the poverty line category get Rs. 200/- per month from Central
government if he or she is not getting the pension benefit of Rs. 250/- per month from Punjab
government.
Widowed females with age limit 40-64 years who belongs to below poverty line category get
Rs. 200/- per month.
The disabled person whose age is between 18-64 years, whose disability is more than 80
percent and who belongs to below poverty line category get Rs. 200/- per month.
Provision of Identity Cards for Senior Citizens
Under this scheme senior citizens (males and females of above 60 years of age) will get identity
cards issued by District Social
Security Officer. With the help of these cards they can get separate queues for them for payment
of water and electricity bills, in
hospitals, bus stands etc. Under this scheme, 44223 Identity Cards have been issued in the State.
Punjab Maintenance of Parents and Senior Citizens Act
Punjab chief minister, Parkash Singh Badal has given sanction for implementation of the
Punjab Maintenance of Parents and Senior Citizens Act in January, 2009. According to the Act,
parents and senior citizens above 60 years of age can now legally demand sustenance from their
wards. And to ensure the rule is followed, the Punjab government has notified setting up one-
member tribunals at the sub-divisional level throughout the state. Punjab has become fifth state
in the country where old parents can legally stake claim to financial aid from their grown up
children for their survival and a denial would invite a prison term.
Punjab government would also establish and maintain at least one old age home in each
district (with a minimum capacity of 150 inmates) and ensure provision of special beds for senior
citizens in all government hospitals. In Punjab elderly women above 60 years have free transport
facility in the public transport buses. On the whole we can conclude that the beneficiaries among
the older persons for various schemes and programmes initiated by the government are very
insignificant when compared to the very high size of population and the growth rate among
them. Further, given the level of urbanization and industrialization of India, economic factors
and diminishing value system are likely to make welfare of the elderly as the most critical area
for intervention. There is need to protect and strengthen the institution of the family and provide
such support services as would enable the family to cope with its responsibilities of taking care
of the elderly. Along with proper and effective professional welfare services that need to be
evolved to provide counseling services both to the elderly and their family members, it is also
important to provide financial support to low income family groups having one or more elderly
persons. A state specific health policy for elderly is the
basic pre-requisite for health planning in the state. For improving health services for elderly
pertain to easy, queue-less accessibility, provision of cheap medicines, mobile vans etc. are
required. Further, rising costs of treatment, in both public and private sector, warrant a viable
health insurance policy.

Focus of the policy

 Mainstream senior citizens, especially older women, and bring their concerns into the
national development debate with priority to implement mechanisms already set by
governments and supported by civil society and senior citizens associations. Support
promotion and establishment of senior citizens associations, especially amongst women.
  Promote the concept of “Ageing in Place? or ageing in own home, housing, income
security and homecare services, old age pension and access to healthcare insurance
schemes and other programmes and services to facilitate and sustain dignity in old age.
The thrust of the policy would be preventive rather than cure.
 The policy will consider institutional care as the last resort. It recognises that care of
senior citizens has to remain vested in the family which would partner the community,
government and the private sector.
 Being a signatory to the Madrid Plan of Action and Barrier Free Framework it will work
towards an inclusive, barrier - free and age -friendly society.
 Recognise that senior citizens are a valuable resource for the country and create an
environment that provides them with equal opportunities, protects their rights and enables
their full participation in society. Towards achievement of this directive, the policy
visualises that the states will extend their support for senior citizens living below the
poverty line in urban and rural areas and ensure their social security, healthcare, shelter
and welfare. It will protect them from abuse and exploitation so that the quality of their
lives improves.
 Long term savings instruments and credit activities will be promoted to reach both rural
and urban areas. It will be necessary for the contributors to feel assured that the payments
at the end of the stipulated period are attractive enough to take care of the likely erosion
in purchasing power.
 Employment in income generating activities after superannuation will be encouraged.
 Support and assist organisations that provide counselling, career guidance and training
services.
 States will be advised to implement the Maintenance and Welfare of Parents and Senior
Citizens Act, 2007 and set up Tribunals so that elderly parents unable to maintain
themselves are not abandoned and neglected.
 States will set up homes with assisted living facilities for abandoned senior citizens in
every district of the country and there will be adequate budgetary support.

Areas of intervention

The concerned ministries at central and state level as mentioned in the “Implementation Section?
would implement the policy and take necessary steps for senior citizens as under:

Income security in old age

A major intervention required in old age relates to financial in security as more than two third of
the elderly live below the poverty line.

It would increase with age uniformly across the country.

Indira Gandhi National Old Age Pension Scheme

Principal Areas of Intervention and Action Strategies

 Old age pension scheme would cover all senior citizens living below the poverty line.
  Rate of monthly pension would be raised to Rs.1000 per month per person and revised at
intervals to prevent its deflation due to higher cost of purchasing.
 The “oldest old? would be covered under Indira Gandhi National Old Age Pension
Scheme (IGNOAPS). They would be provided additional pension in case of disability,
loss of adult children and concomitant responsibility for grandchildren and women. This
would be reviewed every five years.

Public Distribution System

 The public distribution system would reach out to cover all senior citizens living below
the poverty line.

Income Tax

 Taxation policies would reflect sensitivity to the financial problems of senior citizens
which accelerate due to very high costs of medical and nursing care, transportation and
support services needed at homes.

Microfinance

 Loans at reasonable rates of Interest would be offered to senior citizens to start small
businesses. Microfinance for senior citizens would be supported through suitable
guidelines issued by the Reserve Bank of India

Health care

With advancing age, senior citizens have to cope with health and associated problems some of
which may be chronic, of a multiple nature, require constant attention and carry the risk of
disability and consequent loss of autonomy. Some health problems, especially when
accompanied by impaired functional capacity require long term management of illness and
nursing care.

1. Healthcare needs of senior citizens will be given high priority. The goal would be good,
affordable health service, heavily subsidized for the poor and a graded system of user
charges for others. It would have a judicious mix of public health services, health
insurance, health services provided by not – for - profit organizations including trusts and
charities, and private medical care. While the first of these will need to be promoted by
the State, the third category given some assistance, concessions and relief and the fourth
encouraged and subjected to some degree of regulation, preferably by an association of
providers of private care.
2. The basic structure of public healthcare would be through primary healthcare. It would be
strengthened and oriented to meet the health needs of senior citizens. Preventive,
curative, restorative and rehabilitative services will be expanded and strengthened and
geriatric care facilities provided at secondary and tertiary levels. This will imply much
larger public sector outlays, proper distribution of services in rural and urban areas, and
much better health administration and delivery systems. Geriatric services for all age
 groups above 60 ---preventive, curative, rehabilitative health care will be provided. The
policy will strive to create a tiered national level geriatric healthcare with focus on
outpatient day care, palliative care, rehabilitation care and respite care.
3. Twice in a year the PHC nurse or the ASHA will conduct a special screening of the 80+
population of villages and urban areas and public/ private partnerships will be worked out
for geriatric and palliative health care in rural areas recognizing the increase of non –
communicable diseases (NCD) in the country.
4. Efforts would be made to strengthen the family system so that it continues to play the role
of primary care giver in old age. This would be done by sensitizing younger generations
and by providing tax incentives for those taking care of the older members.
5. Development of health insurance will be given priority to cater to the needs of different
income segments of the population with provision for varying contributions and benefits.
Packages catering to the lower income groups will be entitled to state subsidy.
Concessions and relief will be given to health insurance to enlarge the coverage base and
make it affordable. Universal application of health insurance – RSBY (Rashtriya
Swasthya Bima Yojana) will be promoted in all districts and senior citizens will be
included in the coverage. Specific policies will be worked out for healthcare insurance of
senior citizens.
6. From an early age citizens will be encouraged to contribute to a government created
healthcare fund that will help in meeting the increased expenses on health care after
retirement. It will also pay for the health insurance premium in higher socio economic
segments.
7. Special programmes will be developed to increase awareness on mental health and for
early detection and care of those with Dementia and Alzheimer‟s disease.
8. Restoration of vision and eyesight of senior citizens will be an integral part of the
National Programme for Control of Blindness (NPCB).
9. Use of science and technology such as web based services and devices for the wellbeing
and safety of Senior citizens will be encouraged and expanded to under - serviced areas.
10. National and regional institutes of ageing will be set up to promote geriatric health care.
Adequate budgetary support will be provided to these institutes and a cadre of geriatric
health care specialists created including professionally trained caregivers to provide care
to the elderly at affordable prices.
11. The current National Programme for Health Care of the Elderly (NPHCE) being
implemented in would be expanded immediately and, in partnership with civil society
organizations, scaled up to all districts of the country.
12. Public private partnership models will be developed wherever possible to implement
health care of the elderly.
13. Services of mobile health clinics would be made available through PHCs or a subsidy
would be granted to NGOs who offer such services.
14. Health Insurance cover would be provided to all senior citizens through public funded
schemes, especially those over 80 years who do not pay income tax.
15. Recognize gender based attitudes towards health and develop programmes for regular
health checkups especially for older women who tend to neglect their problems

Safety and Security

Provision would be made for stringent punishment for abuse of the elderly.

 Abuse of the elderly and crimes against senior citizens especially widows and those
living alone and disabled would be tackled by community awareness and policing.
 Police would be directed to keep a friendly vigil and monitor programmes which will
include a comprehensive plan for security of senior citizens whether living alone or as
couples. They would also promote mechanisms for interaction of the elderly with
neighborhood associations and enrolment in special programmes in urban and rural areas.
 Protective services would be established and linked to help lines , legal aid and other
measures

Housing

Shelter is a basic human need. The stock of housing for different income segments will be
increased. Ten percent of housing schemes for urban and rural lower income segments will be
earmarked for senior citizens. This will include the Indira Awas Yojana and other schemes of the
government.

 Age friendly, barrier - free access will be created in buses and bus stations, railways and
railway stations, airports and bus transportation within the airports, banks, hospitals,
parks, places of worship, cinema halls, shopping malls and other public places that senior
citizens and the disabled frequent.
 Develop housing complexes for single older men and women, and for those with need for
specialized care in cities, towns and rural areas.
 Promote age friendly facilities and standards of universal design by Bureau of Indian
Standards.
 Since a multi - purpose centre is a necessity for social interaction of senior citizens,
housing colonies would reserve sites for establishing such centres. Segregation of senior
citizens in housing colonies would be discouraged and their integration into the
community supported.
 Senior citizens will be given loans for purchase of houses as well as for major repairs,
with easy repayment schedules

Productive Ageing

 The policy will promote measures to create avenues for continuity in employment and/or
post retirement opportunities.
 Directorate of Employment would be created to enable seniors find re-employment.
 The age of retirement would be reviewed by the Ministry due to increasing longevity

Welfare

A welfare fund for senior citizens will be set up by the government and revenue generated
through asocial security cess. The revenue generated from this would be allocated to the states in
proportion to their share of senior citizens. States may also create similar funds.
  Non-institutional services by voluntary organizations will be promoted and assisted to
strengthen the capacity of senior citizens and their families to deal with problems of the
ageing.
 All senior citizens, especially widows, single women and the oldest old would be eligible
for all schemes of government. They would be provided universal identity under the
Aadhar scheme on priority.
 Larger budgetary allocations would be earmarked to pay attention to the special needs of
rural and urban senior citizens living below the poverty line.

Establishment of National Council for Senior Citizens

A National Council for Senior Citizens, headed by the Minister for Social Justice and
Empowerment will be constituted by the Ministry. With tenure of five years, the Council will
monitor the implementation of the policy and advise the government on concerns of senior
citizens. A similar body would be established in every state with the concerned minister heading
the State Council for Senior Citizens.

 The Council would include representatives of relevant central ministries, the Planning
Commission and ten states by rotation.
 Representatives of senior citizens associations from every state and Union Territory.
 Representatives of NGOs, academia, media and experts on ageing. The council would
meet once in six months.

Responsibility for Implementation

 The Ministries of Home Affairs, Health & Family Welfare, Rural Development, Urban
Development, Youth Affairs & Sports, Railways, Science & Technology, Statistics &
Programme Implementation, Labour, Panchayat Raj and Departments of Elementary
Education & Literacy, Secondary & Higher Education, Road Transport & Highways,
Public Enterprises, Revenue, Women & Child Development, Information Technology
and Personnel & Training will setup necessary mechanism for implementation of the
policy. A five - year perspective Plan and annual plans setting targets and financial
allocations will be prepared by each Ministry/ Department. The annual report of these
Ministries/ Departments will indicate progress achieved during the year. This will enable
monitoring by the designated authority

International Plan of Action on Ageing: report on implementation

Report by the Secretariat
1. The United Nations Second World Assembly on Ageing (Madrid, 8-12 April 2002)
unanimously adopted the Madrid Political Declaration and International Plan of Action on
Ageing, 2002. WHO’s contributions to the Assembly included the submission of a policy
framework,1 and the
formulation of regional action plans for implementing the International Plan, notably by the
United Nations Economic Commission for Europe, the United Nations Economic and Social
Commission for Asia and the Pacific, and the United Nations Economic Commission for Latin
America and the Caribbean. Reports on the content of the policy framework and the outcomes of
the Second World Assembly were submitted to the Fifty-fifth World Health Assembly.
2 The present report summarizes WHO’s contributions to the implementation of the International
Plan of Action since 2002 and the results of disseminating the active ageing policy framework.
2. WHO defines active ageing as “the process of optimizing opportunities for health,
participation and security in order to enhance quality of life as people age”. The policy
framework takes into account the determinants of health throughout the life course, and has
helped to shape ageing policies at national and regional levels and to direct academic research on
ageing; it has also influenced the practical application of policies at community level. Policy-
makers at various levels have adopted the framework’s conceptual approaches. Basic indicators
for monitoring the implementation of active ageing policies are now being formulated and
should be ready in 2005.
3. A series of international conferences on ageing, such as the International Federation on
Ageing’s Sixth and Seventh Global Conferences (Perth, Australia, 27-30 October 2002 and
Singapore, 4-7 September 2004, respectively) and the forthcoming XVIII World Congress of
Gerontology
(Rio de Janeiro, Brazil, 26-30 June 2005), have adopted the active ageing conceptual approach
with its three pillars of health, participation and security in their respective agendas. WHO has
taken an advisory role in international as well as in national research projects on active ageing,
such as those sponsored by the European Commission.

FOCUS ON PRIMARY HEALTH CARE

4. Good health is imperative for older people to remain independent and continue to contribute to
their families and communities. The Madrid International Plan of Action prioritizes access to
primary health care and, accordingly, that has become WHO’s focus in order to provide the
regular, continuing contacts and care that older people need to prevent or delay the onset of
chronic, often disabling diseases and to enable them to be vital resources to their families,
societies and the economy. Consequently, WHO has launched a series of complementary
projects focusing on the provision of integrated care that aims to be available, accessible,
comprehensive, efficient, and responsive to both gender and age.
5. The objective of WHO’s project to formulate an integrated response of health-care systems to
rapid population ageing in developing countries is to create a knowledge base to support
countries in reorienting policies towards integrated health and social care systems serving older
populations. The first two phases (now completed) of the project, conducted in 12 developing
countries (Botswana, Chile, China, Ghana, Jamaica, Republic of Korea, Lebanon, Peru, Sri
Lanka, Suriname, Syrian Arab Republic and Thailand), consisted of quantitative and qualitative
research on the care-seeking behaviours of older people at primary health-care level; the roles,
needs and attitudes of their service providers; and the types of services provided. Governments,
academic institutions, and nongovernmental organizations contributed to this interdisciplinary
research project, which resulted in the sharing of information and models of good practice
among the participating countries and a series of specific policy recommendations. The next
phase, being implemented in collaboration with the WHO Centre for Health Development, Kobe,
Japan, brings in six additional countries (Bolivia, India, Kenya, Malaysia, Pakistan, and Trinidad
and Tobago) and focuses on older people who do not use primary health care. The project will
lead to comprehensive policy recommendations on developing a continuum of care within the
primary health-care sector aiming towards integrated old-age care. Thereafter, work will focus
on step-wise implementation of the recommendations. The project was conceived as a model to
stimulate exchanges of knowledge, experience and models of good practice between developing
countries with rapidly ageing populations, and with the aim of building relevant
research capabilities in developing countries.
6. In 2002, WHO initiated the related age-friendly primary health care project in order to
sensitize and educate primary health-care workers and build capacity in primary health-care
centres to provide for the specific needs of their older users. Despite the vital role of such centres
in older people’s health and well-being, there are many barriers to care that may result in older
people not changing behaviours detrimental to health or becoming discouraged from seeking or
continuing treatment. The project provides a set of age-friendly principles for primary health-
care centres1 and training and information materials for primary health-care workers on how to
overcome such barriers. Implementation of the principles will be piloted in at least four
developing countries with the aid of a set of training and information materials, including a
protocol for evaluating the impact of the project. Once finalized, that package will be made
widely available in electronic and other formats to health and social care providers.
7. Recognizing the importance of relevant training for future health workers, WHO has partnered
with the International Federation of Medical Students’ Associations in a continuing effort to put
ageing in the mainstream of medical curricula and to strengthen the teaching of geriatric
medicine in 42 countries. The WHO Centre for Health Development, Kobe, is standardizing
terminology and definitions for a glossary on community-based health care for older people. The
first of several case studies on model practices in delivery of primary health care to ageing
populations in mega-cities will focus on Shanghai, China. A research advisory meeting
organized by the Centre outlined a proposal for exploring the effects or urbanization,
environmental change and technological innovations on ageing populations.
9. In 2003 the World Health Survey collected information in 71 countries on population health
status and health services coverage, including data on older age groups. This information should
lead to a better understanding of the determinants of health and causes of morbidity at older ages.
A longitudinal study on health and ageing, which builds on the Survey, is being conducted in six
countries.

EMERGING ISSUES
10. The International Plan of Action on Ageing, 2002 identified two emerging areas requiring
urgent action: older persons and HIV/AIDS; and abuse of older people. Worldwide, particularly
in sub-Saharan Africa, older people (mostly women) absorb enormous additional burdens placed
on the family by the HIV/AIDS pandemic. In response, WHO has developed a method to asses
the needs of older carers through pilot research in Zimbabwe. The project is intended to be
replicated in other countries in order to provide evidence-based data for interventions.
11. In work towards the prevention of abuse of older people, WHO is conducting research in
collaboration with the University of Geneva on reliable tools to facilitate detection of such abuse
at the primary health-care level. Following a large study in Canada that validated one such tool,
WHO will pilot the application in four other countries. The project builds on a qualitative study
jointly conducted by WHO, the International Network for the Prevention of Elder Abuse, and
HelpAge International. That study’s resulting publication on the views of older people on elder
abuse has been widely disseminated.1 WHO was one of the parties to the Toronto Declaration on
the Global Prevention of Elder Abuse launched at the Ontario Elder Abuse Conference (Ontario,
Canada, 18-20 November 2002).
REGIONAL WORK
12. Work at regional level is largely focused on how to provide community-based primary health
care to growing numbers of older people. In September 2002, the 26th Pan American Sanitary
Conference adopted resolution CSP26.R20 urging Member States to implement the International
Plan of Action on Ageing, 2002 and to provide adequate support for implementation of priority
areas, such as access to health care, essential drugs and vaccinations for older people. The
Regional Office for the Americas has developed a training manual for primary health-care
providers on old-age care. It collaborated with six Member States (Chile, Costa Rica, El
Salvador, Mexico, Panama and Uruguay) to implement training programmes for primary health-
care professionals and is monitoring the improvement of quality of care. It collaborates with
health system reform projects in Bolivia, Ecuador and El Salvador to ensure provision of health
services to older persons. It has established a network of
trainers in geriatric care. In the area of research, PAHO conducted a study on health, well-being
and ageing in collaboration with ministries of health and universities in 10 countries.
13. In 2003, the Regional Committee for the Eastern Mediterranean at its Fiftieth Session
adopted resolution EM/RC50/R.10 on health care for the elderly, which emphasizes the need to
establish and improve the integration and coordination of health, welfare and other sectors in
order to develop comprehensive services and programmes. Eight countries have included healthy
ageing in collaborative programmes with the Regional Office for the eastern Mediterranean
during the current biennium. An in-depth study on the current state of community-based care for
older people has been conducted in Bahrain, Egypt, Islamic Republic of Iran and Lebanon.
14. The Regional Office for the Western Pacific works with five Member States in the Region
(China, Mongolia, Philippines, Republic of Korea and Viet Nam) to support community-based
programmes for older people. Its recent document on a health promotion approach to ageing and
health for developing countries provides guidance to countries on how to improve health
promotion, disease prevention and health services delivery for older people. Other publications
with practical information on old-age care are being prepared.
15. In the South-East Asia Region, the focus has been primarily on old-age care at the primary
health-care level. The Regional Office prepared both a manual for primary health-care workers
and a regional model for comprehensive community and home-based health care, which was
pilot-tested in Bhutan, Myanmar, Nepal, Sri Lanka and Thailand. A recent document on health of
the elderly in South-East Asia has been widely disseminated.
16. The African Union has adopted a regional implementation plan for the Madrid International
Plan of Action on Ageing, 2002. While still assessing the implementation plan, the WHO
Regional Office for Africa aims to promote health care for older people in addition to its
continuing
collaboration with HelpAge International in selected countries on supporting older carers of
people living with HIV/AIDS and their children.
17. The Regional Office for Europe continues its work on ageing within the Healthy Cities
programme, of which healthy ageing is one of the three core themes. The Regional Office
recently published two documents on how to provide better palliative care for older persons.

COLLABORATION WITHIN THE UNITED NATIONS SYSTEM

18. The Madrid International Plan of Action on Ageing, 2002 and subsequent United Nations
resolutions asked for a strengthening of the functions of the focal points on ageing throughout
the United Nations system in order to put work on ageing at the heart of all United Nations
system activities and to improve communications and intersectoral information on the
implementation of the International Plan. WHO designated a focal point on ageing for the
Second World Assembly on ageing and its follow-up implementation activities.
19. UNFPA and WHO recently agreed to conduct a study on the factors that determine the health
status of older women and their access to care as a joint contribution to the tenth anniversary of
the adoption in 1995 of the Beijing Platform for Action. The project will emphasize best
practices worldwide and policy recommendations. Other collaborative activities within the
United Nations system include the production of
informational materials for the annual International Day of Older Persons.
21. Although the Millennium Development Goals do not specifically mention the roles and
contributions of older persons to development, rapid population ageing has many far-reaching
societal and economic implications. WHO consistently draws attention to the importance of a
holistic lifecourse approach to ageing, including consideration of determinants of health and
emphasis on a continuum of health and social care services that enable older people to remain
healthy and productive within their families and communities. Through the United Nations Focal
Point on Ageing and other United Nations agencies, WHO seeks to ensure the integration of
ageing issues into policies and programmes for attaining the Millennium Development Goals and
to provide continued overall commitment on population ageing issues.

Principal Areas of Intervention and Action Strategies

Strategies to implement the national policy intent are described below.
i) Financial Security
Old age pension scheme
1. It would cover all senior citizens living below the poverty line.
2. Rate of monthly pension would be raised to Rs.1000 per month per person and
revised at intervals to prevent its deflation due to higher cost of purchasing.
3. The "oldest old" would be covered under Indira Gandhi National Old Age
Pension Scheme (IGNOAPS). They would be provided additional pension in case
of disability, loss of adult children and concomitant responsibility for grand
children and women. This would be reviewed every five years.
Public distribution system (PDS)
The PDS would reach out to cover all senior citizens living below the poverty line.
Income Tax
Taxation policies would reflect sensitivity to the financial problems of senior ci tizens which
accelerate due to very high costs of medical and nursing care, transportation and support services
needed at homes.
Microfinance
Loans at reasonable rates of Interest would be offered to senior citizens to start small businesses.
Microfinance for senior citizens would be supported through suitable guidelines issued by the
Reserve Bank of India.
Settlement of Retirement Benefits

Prompt settlement of all retirement benefits like pension, gratuity PF, etc. Widows will be given
special consideration in the matter of settlement of benefits accruing to them on the demise of
husband.
Pension Schemes
 1. To facilitate the establishment of pension schemes in nongovernmental
employment, with provision for employers also to contribute. Pension Funds will
function under the watchful eye of a strong regulatory authority.
2. To consider much higher annual rebate for medical treatment, whether
domiciliary or hospital based, in cases where superannuated persons do not get
medical coverage from their erstwhile employers.
ii) Health Care and Nutrition
The 2011 national health policy recognizes that with advancing age, senior citizens have
to cope with health and associated problems some of which may be chronic, of a multiple nature,
require constant attention and carry the risk of disability and consequent loss of autonomy. Some
health problems, especially when accompanied by impaired functional capacity require long term
management of illness and nursing care.
Health care needs of older persons will be given high priority to ensure good affordable health
services which will be very heavily subsidised for the poor and a graded system of user charges
for others.
The primary health care system will be the basic structure of public health care. It will be
strengthened by larger budgetary support to provide geriatric care facilities and curative,
restorative and rehabilitative services at secondary and tertiary levels.
Twice in a year the PHC nurse or the ASHA will conduct a special screening of the 80+
population of villages Private organizations and not for profit organizations will be
encouraged to provide health services, and health insurance services for the aged by offering
grants, tax relief and land at subsidized rates to provide free beds, medicines and treatment to the
very poor
Public hospitals will be directed to ensure that elderly patients are not subjected to long waits
and visits to different counters for medical tests and treatment. Geriatric wards will be set up.
Medical and paramedical personnel in primary, secondary and tertiary health care facilities
will be given training and orientation in health care of the elderly. Facilities for specialization in
geriatric medicine will be provided in the medical colleges. Training in nursing care will include
geriatric care.
Difficulties in reaching a public health care facility will be addressed through mobile health
services, special camps and ambulance services by charitable institutions and not for profit health
care organizations.
Older persons and their families will be given access to educational material on nutritional
needs in old age.
Mental health services will be expanded and strengthened. Families will be provided
counseling facilities and information on the care and treatment of older persons having mental
health problems.

iii) Shelter / Housing

Housing schemes for urban and rural lower income segments will earmark 10 per cent of the
houses/house sites for allotment to older persons. This will include Indira Awas Yojana and
other schemes of government.
Layouts of housing colonies will have to respond to the life styles of the elderly. It will have to
be ensured that there are no physical barriers to mobility, and accessibility to shopping
complexes, community centres, parks and other services is safe and easy.
 Group housing of older persons comprising flat lets with common service facilities for meals,
laundry, cultural activities, common room and rest rooms will be encouraged.
Payment of civic dues will be facilitated. Older persons will be given special consideration in
promptly dealing with matters relating to transfer of property, mutation, property tax and other
matters.
iv) Education
Information and educational material specially relevant to the lives of older people will be
developed and widely disseminated using mass media and non-formal communication
channels.
Access of older persons to libraries of universities, research institutions and cultural centres
will be facilitated.
Educational curriculum at all stages of formal education as well as non-formal education
programmes will incorporate material to strengthen intergenerational bonds and mutually
supporting relationships.
Interactions of older persons with educational institutions will be facilitated
v) Welfare
The policy will be to consider institutional care as the last resort when personal circumstances
are such that stay in old age homes becomes absolutely necessary. The main thrust of welfare
will be to identify the move vulnerable among the older persons such as the poor, the disabled,
the infirm, the chronically sick and those without family support, and provide welfare services to
them on a priority basis.
Services by voluntary organizations will be promoted and assisted to strengthen the coping
capacity of older persons and their families.
Assistance will be provided to voluntary organizations by way of grants-in-aid for
construction and maintenance of old age homes’ day care, multiservice citizen's centres, reach-
out services, and supply of disability related aids and appliances
Voluntary organizations will be supported to provide helpline and telephone assurance
services to help in maintaining contacts with friends, relatives and neighbours and escorting
older persons to hospitals, shopping complexes and other places
Senior citizen's forums and centres formed for a group of neighbourhoods / villages.
A Welfare Fund for older persons will be set up. It will obtain funding support from
government, corporate sector, trusts, charities, individual donors and others. Contributions to the
Fund will be given tax relief. States will be expected to establish similar Funds.
vi) Protection of Life and Property
Safety and security is given much less importance in 2011 national policy with just three items.
The 1999 policy was more elaborate and hence it is reviewed here.
Old persons have become soft targets for criminal elements. They also become victims of
fraudulent dealings and of physical and emotional abuse within the household by family
members to force them to part with their ownership rights. Widow's rights of inheritance,
occupancy and disposal are at times violated by their own children and relatives. It is important
that protection is available to older persons.
o The introduction of special provisions in IPC to protect older persons from domestic violence
will be considered and machinery provided to attend all such cases promptly.
o Tenancy legislation will be reviewed so that the rights of occupancy of older persons are
restored speedily.
o Voluntary organizations and associations of older persons will be assisted to provide protective
services and help to senior citizens through helpline services, legal aid and other measures.
o Police will be directed to keep a friendly vigil on older couples or old single persons living
alone
vii) Other Areas of Action

There are various other areas which would need affirmative action of the State to ensure that
policies and programmes reflect sensitivity to older persons. Machinery for achieving this
objective will be put in place.
Issue of identity cards by the administration;
Fare concessions in all modes of travel;
Preference in reservation of seats and earmarking of seats in local public transport;
Modifications in designs of public transport vehicles for easy entry and exit;
Priority in gas and telephone connections and in fault repairs;
Concessions in entrance fees in leisure and entertainment facilities, art and cultural centers and
places of tourist interest.
Speedy disposal of complaints of older persons relating to fraudulent dealings, cheating and
other matters
The year 2000 will be declared as the National Year for Older Persons.
Facilities, concessions and relief given to older persons by the Central and State governments
and the agencies will be complied, updated at regular intervals and made available to
associations of older persons for wide dissemination.

Non-Governmental Organizations
The State alone cannot provide all the services needed by older persons. Private sector
agencies cater to a rather small paying segment of the population. The National Policy
recognizes the NGO sector as a very important institutional mechanism to complement the
endeavours of the State in providing services to the aged.
Trusts, charities, religious and other endowments will be encouraged to and supported in a big
way
Networking, exchange of information and interactions among NGOs will be facilitated.
Opportunities will be provided for orientation and training of
The grant-in-aid policy will provide incentives to encourage NGOs to raise their own
resources and not become dependent only on government funding for providing services on a
sustainable basis.
ix) Realizing the Potential
The National Policy recognizes that 60+ phase of life is a huge untapped resource. Facilities
will be made available so that this potential is realized and individuals are enabled to make the
appropriate choices.
x) Family

Family is the most cherished social institution in India and the most vital non-formal social
security for the old. Most older persons stay with one or more of their children. It is the most
preferred most emotionally satisfying living arrangement for them. It is important that the
familial support system continues to be functional and the ability of the family to discharge its
caring responsibilities is strengthened through support services.
 Programmes will be developed to promote family values, sensitise the young on the necessity
and desirability of intergenerational bonding and continuity and the desirability of meeting filial
obligations.
State policies will encourage children to co-reside with their parents by providing tax relief,
allowing rebates for medical expenses and giving preference in the allotment of houses,
xi) Research
The importance of a good data base on older persons is recognised. Research activity on ageing
will require to be strengthened.
Universities, medical colleges and research institutions will be assisted to set up centres for
gerontological studies
Funding support will be provided to academic bodies for research projects on ageing.
Superannuated scientists will be assisted so that their professional knowledge can be utilized.
An interdisciplinary coordinating body on research will be set up.
Professional associations of gerontologists will be assisted to strengthen research activity,
disseminate research findings and provide a platform for dialogue, discussion, debate and
exchange of information.
The necessity of a national institute of research, training and documentation is recognised.
Assistance will be given for setting up resource centres in different part of the country.
xii) Training of Manpower
The policy recognizes the importance of trained manpower.
Medical colleges will be assisted to offer specialization in geriatrics.
Training institutions for nurses and for the paramedical personnel need to introduce specific
courses on geriatric care in their educational and training curriculum.
In service training centres will be strengthened to take up orientation courses on geriatric care.
Facilities will be provided and assistance given for training and orientation of personnel of
NGOs providing services to older persons.
xiii) Media
The National Policy recognizes that media have a very important role to play in highlighting the
changing situation of older persons and in identifying emerging issues and areas of action.
Creative use of media can
The Policy aims to involve mass media as well as informal and traditional communication
channels on ageing issues.
Opportunities will be extended for greater interaction between media personnel and persons
active in the field of ageing.

Implementation Mechanisms
The Policy will make a change in the lives of senior citizens only if it is implemented.
The 2011 policy states that: "there will be efforts to provide an identity for senior citizens across
the country and the ADHAAR Unique identity number will be offered to them so that
implementation of assistance
schemes of Government of India and concessions can be offered to them. As part of the policy
implementation the Government will strive for:
Establishment of Department of Senior Citizens under the Ministry of Social Justice and
Empowerment
o The Ministry of Social Justice and Empowerment will establish a “Department of Senior
Citizens” which will be the nodal agency for implementing programmes and services for senior
citizens and the NPSC 2011. An inter-ministerial committee will pursue matters relating to
implementation of the national policy and monitor its progress. Coordination will be by the nodal
ministry. Each ministry will prepare action plans to implement aspects that concern them and
submit regular reviews.
Establishment of Directorates of Senior Citizens in states and union territoriesStates and union
territories will set up separate Directorates of Senior Citizens for implementing programmes and
services for senior citizens and the NPSC 2011.

National/State Commission for Senior Citizens

A National Commission for Senior Citizens at the centre and similar commissions at the state
level will be constituted. The Commissions would be set up under an Act of the Parliament with
powers of Civil Courts to deal with cases pertaining to violations of rights of senior citizens.
Establishment of National Council for Senior Citizens

A National Council for Senior Citizens, headed by the Minister for Social Justice and
Empowerment will be constituted by the Ministry. With tenure of five years, the Council will
monitor the implementation of the policy and advise the government on concerns of senior
citizens. A similar body would be established in every state with the concerned minister heading
the State Council for Senior Citizens.
o The Council would include representatives of relevant central ministries, the Planning
Commission and ten states by rotation.
o Representatives of senior citizens associations from every state and Union Territory.
o Representatives of NGOs, academia, media and experts on ageing.
o The council would meet once in six months.
National Association of Older Persons
An autonomous registered National Association of Older Persons (NAOPS) was sought to be
established in 1999 policy but is absent in 2011 policy. The NAOPS is expected to mobilize
senior citizens, articulate their interests, promote and undertake programmes and activities for
their well being and to advise the Government on all matters relating to the Older Persons. The
Associationwill have National, State and District level offices and will choose its own bearers.
The Governmentwill provide financial support to establish the National and State level offices
while the District level offices will be established by the Association from its own resources
which may be raised through Membership, subscriptions, donations and other admissible means.
The Government will also provide financial assistance to the National and State level offices to
cover both recurring as well as nonrecurring administrative costs for a period of 15 years
Responsibility for Implementation
The Ministries of Home Affairs, Health & Family Welfare, Rural Development, Urban
Development, Youth Affairs & Sports, Railways, Science & Technology, Statistics &
Programme Implementation, Labour, Panchayati Raj and Departments of Elementary Education
& Literacy, Secondary & Higher Education, Road Transport & Highways, Public Enterprises,
Revenue, Women & Child Development, Information Technology and Personnel & Training
will setup necessary mechanism for implementation of the policy. A five-year perspective Plan
and annual plans setting targets and financial allocations will be prepared by each Ministry/
Department. The annual report of these Ministries/ Departments will indicate progress achieved
during the year. This will enable monitoring by the designated authority.
 Role of Block Development Offices, Panchayat Raj Institutions and Tribal Councils/Gram
Sabhas
o Block Development offices would appoint nodal officers to serve as a one point contact
forsenior citizens to ease access to pensions and handle documentation and physical
presencerequirements, especially by the elderly women.
o Panchayat Raj Institutions would be directed to implement the NPSC 2011 and address local
issues and needs of the ageing population.
 SCHOOL OF SCIENCE AND HUMANITIES

DEPARTMENT OF PSYCHOLOGY

UNIT – IV - OLD AGE CARE -GERONTOLOGY PSYCHOLOGY-SPSY1401

 Crisis Intervention-medical (skilled care) versus non medical(social care)
Gerontological social workers, also known as geriatric social workers, coordinate the care
of elderly patients in a wide variety of settings, including hospitals, community health clinics,
long-term and residential health care facilities, hospice settings, and outpatient/daytime health
care centers. In outpatient settings, gerontological social workers serve as advocates for elderly
individuals, helping to ensure they receive the mental, emotional, social, and familial support
they need, while also connecting them to resources in the community that can provide additional
support. In inpatient and residential care settings, gerontological social workers conduct intake
assessments to determine patients’ mental, emotional, and social needs; collaborate with a larger
team of physicians, nurses, psychologists, case managers, and other health care staff to develop
and regularly update patient treatment plans; discuss treatment plan options with patients and
their families; and manage patient discharges.
Elderly individuals can grapple with isolation, depression, financial instability, dementia,
anxiety, and other psychological, emotional, and social challenges. They may also experience
declining health and increased reliance on medical care and family support, and this shift in
independence can prove difficult for both them and their families. Gerontological social workers
help their clients manage these and other challenges by providing counseling and therapy,
advising clients’ families about how to best support aging loved ones, serving as the bridge of
communication between clients and the rest of the care team, and ensuring that clients receive
the services they need if or when they move between inpatient and outpatient treatment
programs, in-home care, day treatment programs, etc.Geriatric social workers encounter
numerous challenges on the job, including having to contend with complicated medical and
mental health care systems, managing the different interests of various parties involved in a
client’s care, shouldering the emotional burdens of clients and family members, and general
overwork and overwhelm. However, social workers who care for the elderly note the unique
rewards of the profession, which include making deep and meaningful connections with clients
and their families, opportunities to change problematic systems within medical and mental health
care for the elderly at both the individual and community levels, and the knowledge that their
daily work has a direct positive impact on individuals in need.

Where Gerontological Social Workers Work

Social workers can work with elderly populations in many different settings; in general,
at any organization that serves the physical, mental, emotional, and/or social needs of senior
citizens, social workers may play a crucial role in providing direct care (counseling and advising,
resource navigation services, etc.), as well as care coordination services (contacting different
departments, care providers, and organizations to ensure clients get the inpatient or outpatient
support they require). Common work environments that employ gerontological social workers
include but are not limited to medical settings, adult day health programs, programs for all-
inclusive care for the elderly, hospices, nursing homes and residential care facilities.

Hospitals and Medical Centers

 Hospitals and medical centers typically have inpatient and outpatient divisions devoted
specifically to supporting elderly patients who suffer from either chronic or acute health
conditions. For example, hospitals may have geriatric acute and emergency care units, fracture
care centers, palliative care, and a geriatric oncology unit. Gerontological social workers can
work in the geriatric departments of hospitals and medical centers, either as part of a specific
unit, or across multiple units.
Gerontological social workers who work at hospitals and medical centers collaborate
with a larger medical team of physicians, nurses, medical assistants, psychologists, and other
staff to evaluate patients’ needs, develop a treatment plan, coordinate geriatric patients’ care
according to their needs and circumstances, and maintain and submit patient records and
documentation. They also provide counseling, advising, and resource navigation services to
patients and their families. Some medical centers also have adult day health programs that
provide daily activities, counseling, and social support services to senior citizens, with the goal
of supporting patients so that they can remain at home instead of transitioning to a nursing home.
Social workers in these settings can coordinate activities, programs, and other services for their
clients, provide counseling services as necessary, and connect senior citizens and their families
to resources within or outside of the program.

Programs of All-Inclusive Care for the Elderly

Programs of All-Inclusive Care for the Elderly (PACE) provide comprehensive medical,
mental health, and behavioral health care to elderly individuals who are eligible for Medicaid
and/or Medicare. These programs employ an interdisciplinary team of medical, mental health,
behavioral, and social service specialists that provide patients with care in their homes, and/or at
day treatment centers. Laura Burns, MSW is a Medical Social Worker at On Lok Lifeways,
which is a PACE program located in San Jose, CA. In an interview with
OnlineMSWPrograms.com, she described the different services that On Lok provides. “We have
a day health center (DHC) where participants come to receive different types of activities,
socialization, and cognitive stimulation including pet therapy and bingo,” she explained,
“There’s also a clinic on site with three doctors and one nurse practitioner and several nurses. All
of our participants are given a full physical exam before they are enrolled and they are evaluated
every 6 months, or as health conditions occur. We also have a rehab team, which includes
occupational therapists and physical therapists. […] We have a home care team of nurses and
aids who provide people with showers, assist them with meals, provide medication reminders,
and assist them with chores and laundry in their home.”
Ms. Burns also explained how social workers are an important part of PACE programs’
interdisciplinary team, in that they serve as patient advocates and as the bridge of communication
between patients and caregivers, as well as between different health providers and teams. “Social
workers are connected to all of the aforementioned teams. It is our job to connect our patients
with the services that these teams provide, and to connect the teams with one another as
necessary to ensure proper emotional, mental, and physical care for our participants,” she said,
“We also are the primary point of contact for our participants’ family members. Social workers
at On Lok also play an important role in the initial assessment of patients, and in the
development of their care plan.”
 Social workers who work at PACE programs have similar work settings and
responsibilities as social workers who work in geriatric departments of hospitals and medical
centers; however, as PACE programs provide a more comprehensive set of services (because
they combine medical, mental, and behavioral health care), and serve clients who are eligible for
Medicare and/or Medicaid, social workers at PACE programs may connect with more
organizations, provide a wider range of care coordination services, and travel across different
settings. For example, they may also conduct home visits, help patients and their families
navigate the process of applying for medical benefits, and communicate with medical, mental
health and behavioral, and social services departments within their program.

Specialized Senior Assistance Programs

Gerontological social workers may work for specialized programs that support senior
citizens with a certain area of their life, such as financial literacy, community engagement,
housing coordination, and low-income support services. For example, social workers may work
for a community service organization that serves low-income senior citizens and helps them find
stable housing, health care, and/or disability assistance, or they might work for an organization
that provides financial advising, subsidized nutrition programs, or home care services to the
elderly. Some larger organizations, such as San Francisco’s Institute on Aging External link ,
fund a wide range of programs that serve elderly individuals, and also conduct research on how
society and local, state, and federal governments can better support elderly populations. Social
workers may work for these larger organizations, within one or more programs.

Hospices

Hospice settings provide palliative and end-of-life care to individuals who are suffering
from terminal illnesses or conditions. Gerontological social workers in hospice settings work
with elderly patients and their families, providing them with emotional support, grief and
bereavement counseling, resource navigation services, and care coordination services. Hospices
typically provide patients with services such as symptom and pain management (palliative care),
as well as assistance in end-of-life planning. Hospice social workers engage in all of the non-
medical aspects of a patient’s care, including coordinating community resources, answering
patients’ and family members’ questions, helping family members cope with the loss of a loved
one, and assisting clients in managing their family and social relationships during their time in
hospice care.

Nursing Homes and Residential Care Facilities

 Nursing homes provide residential support to elderly individuals who cannot live
independently due to mental or physical conditions such as dementia or disability. The transition
to a nursing home or a residential care facility can be challenging psychologically, emotionally,
and financially for elderly individuals and their families. Gerontological social workers in these
settings help clients during this transition and ensure that they receive the services that they
require both during their admission and throughout their stay. They can also participate in the
development and review of nursing home policies and procedures to ensure that residents receive
the care and attention they need.

What Gerontological Social Workers Do

Gerontological social workers support clients and their families through a combination of
psychosocial assessments, care coordination services, counseling and therapeutic work, crisis
management and interventions, and discharge planning.

Psychosocial Assessments

Gerontological social workers conduct psychosocial assessments to determine their

clients’ mental, emotional, and social needs, and to understand how these needs connect with
their physical health and medical conditions. Mental and physical health are closely linked, and
by gaining a holistic picture of clients’ mental, emotional, and social circumstances, social
workers help clients’ medical care providers and their families better understand how to develop
a care plan that is as comprehensive and compassionate as possible.
Psychosocial assessments gather information on a client’s:
 Mental and emotional health, including past and/or present psychological conditions (ex.
depression, dementia, anxiety, bipolar disorder, etc.)
 Behavioral health challenges, such as substance abuse, anger management issues, social
anxiety and/or isolation, suicidal desires, etc.
 Social, financial, familial, educational, and occupational history and current situation,
including available support systems (community, family, friends, colleagues, etc.)
 Medical and mental health treatment history
 Current medications and adherence to treatment schedules/plans
Gerontological social workers complete psychosocial assessments at the time of a client’s
admission into a given care program (this type of psychosocial assessment is called an intake
assessment), and also conduct regular assessments throughout a client’s time in the program.
Ms. Burns explained to OnlineMSWPrograms.com how social workers evaluate multiple facets
of clients’ cognitive, emotional, and behavioral health. “The social workers’ intake of a
candidate is focused on the person as a whole and explores their support systems, psychosocial
risks, cognition and mood,” she said, “The three main things that we assess for are changes in
mood, behavior and cognition. We test for changes in cognition and mood every six months.”
Ms. Burns also noted that interacting closely with clients and connecting with them regularly
allows her to evaluate their emotional and cognitive health at any point in time, and to convey
any concerning changes to the larger treatment team. “[E]ach time I’m checking in on someone,
even if it seems just like a social visit, I’m also checking in on their emotional well-being,” she
said, “As social workers we don’t just do formal screenings; we also do informal check-ins with
the participants all the time. Also we don’t have to wait until a participant is due for a formal
assessment to make an adjustment in their care plan; we are able to modify it at any time.”
In addition to being essential for the development and improvement of a client’s care plan,
psychosocial assessments help social workers determine if a client is at risk of experiencing
certain adverse mental, physical, and/or behavioral health outcomes (for example, if a client
shows signs of severe depression, has suicidal tendencies, or is neglecting his/her medication).
These evaluations of risk to clients, also known as risk assessments, help social workers and
other members of a client’s care team determine the appropriate courses of action to address
factors that may seriously compromise a client’s well-being.

Care Coordination

One of the most important responsibilities that gerontological social workers have is care
coordination, which is defined as the purposeful organization of different teams and services in
order to effectively address a client’s overall health care needs (physical, cognitive, emotional,
and social). Care coordination involves not only completing psychosocial assessments to inform
the larger treatment team of a client’s needs, but also participating in or facilitating meetings
between different providers to discuss patient treatment and health outcomes; conveying the
concerns and desires of the patient and his/her family to the teams involved in their care; and
connecting clients and their caretakers with resources within the larger community that can
provide additional support.

Counseling and Therapy

Gerontological social workers provide counseling and therapy to clients to help them
cope with the psychological, emotional, social, and financial challenges that come with aging.
They also provide therapy and advising as necessary to clients’ families and loved ones. During
their sessions with elderly clients, social workers can employ a variety of different
psychotherapeutic techniques to help their clients manage negative emotions, set objectives for
life improvement, address behavioral problems or psychological barriers to meeting certain
goals, and (where applicable) make end-of-life preparations.
When working with the families of their clients, gerontological social workers may help
them manage the various difficulties they can encounter around caring for an aging loved one,
including strains on financial resources and familial relationships, and processing grief and other
emotions around loss.
Specific therapeutic techniques that gerontological social workers may use in their work
with clients and families include but are not limited to cognitive behavioral therapy and
dialectical behavioral therapy, problem solving therapy, motivational interviewing, and
mindfulness based stress reduction. (For more information about these and other therapeutic
modalities that social workers can use when providing clinical therapy to clients, please refer to
our Guide to Clinical Social Work.)
Crisis Management and Interventions

Depending on their role and work setting, gerontological social workers may encounter a
variety of client crisis situations. For example, some clients may struggle with severe depression
and/or suicidal desires, acute dementia that renders them unable to care for themselves, family
conflicts about treatment decisions, traumatic experiences that require immediate support, or
mental or emotional disorders that pose a danger to themselves or others. In other instances,
elderly clients may be the victims of neglect, domestic abuse, exploitation, and other crimes. In
these instances, gerontological social workers may have to intervene through a number of
measures to ensure client safety and well-being; such measures may include providing emotional
support and counseling to clients and their family members as needed; managing difficult
conversations between client, family, and care providers as necessary; contacting relevant
organizations and/or the authorities (in the case of elder abuse), and developing a short and long-
term support plan for clients and their loved ones.
Ms. Burns explained some of the crisis intervention services that she provides at On Lok
Lifeways, Inc. “Since we screen for changes in mood, if someone is doing fine emotionally and
then all of a sudden they’re severely depressed or suicidal or homicidal, that’s obviously
something to communicate immediately to the medical team and the participant’s family,” she
said, “We consult with Adult Protective Services to report cases of abuse or neglect. We let their
doctor know to see if they need to have a medication adjustment, and we’ll usually also
recommend meetings with the chaplain or the mental health counselor who works on site as
well.”
Gerontological social workers can also provide crisis support and interventions in non-
medical settings. Charis Stiles, MSW, who is a Friendship Line Manager at the Institute on
Aging (IoA) in San Francisco, CA, also helps elderly individuals during crisis situations by
coordinating volunteer services for the IoA’s suicide prevention and grief support hotline. “The
Friendship Line at the Institute on Aging provides suicide prevention and trauma grief support to
older adults and adults with disabilities. It’s a 24-hour hotline that operates from 8am to 8pm in
the office and after hours remotely,” she explained to OnlineMSWPrograms.com, “Callers are
primarily over the age of 60 and are dealing with isolation, loneliness, depression, grief, and
illness. Many have mental health conditions, some treated and some untreated, and many also
have a history of trauma. We have between 50-70 volunteers who are the primary hotline
counselors.”

Resource Navigation and Benefits Application Guidance

Gerontological social workers also help clients and their families understand and apply
for health care benefits, as well as other financial or social assistance at the federal, state, and
local community levels. Clients and their loved ones may have a hard time navigating health
insurance benefits, applying for Medicare and/or Medicaid benefits, and making use of
community support systems. Social workers can guide clients through these steps and connect
them with local support systems, such as senior centers, discounted or pro bono counseling, free
community clinics, and subsidized food and housing if necessary.

Discharge Services

Consistent with their role as care coordinators, gerontological social workers are often
responsible for developing and coordinating a discharge plan for clients when the time comes for
them to transition from one care setting to another–for example, from inpatient to outpatient care,
or from residential care to home care. When coordinating a client’s discharge from a care setting,
social workers typically contact the relevant parties involved in the transition and organize
logistics such as as transportation, health insurance and medical financial aid, and paperwork and
documentation. They may also consult with the client and his/her family in order to prepare them
for the change.
The Challenges and Rewards of Gerontological Social Work
Gerontological social work provides the opportunity to connect deeply with individuals in need
who are often deeply appreciative of the support, and who have a wealth of life experiences and
perspectives to share. Serving as an advocate for elderly clients who would not otherwise have a
voice in their care can also be gratifying and empowering. In addition, this field of social work
involves working with clients’ families and loved ones, which can form unique and rewarding
connections as well.
“One of the most rewarding experiences are the long-term relationships I have with my
participants and knowing that I am able to make a difference in their lives, Ms. Burns said, “I
find it very rewarding to build relationships with my participants and know that part of my
treatment plan is to check in with them. I feel really blessed that I get paid to do this work, to
connect and learn about people who have lived very interesting lives–very different, often, from
the life that I have led.”
She also noted how her role as a geriatric social worker enables her to share more about herself
with her patients, relative to other types of medical settings, which at times allows for deeper and
more rewarding connections. “I think one thing that I’ve noticed in geriatric social work is
because I have such long-term relationships with people, [I’m] able to share a little bit more of
[myself],” she explained, “In hospitals you’re working with someone for a short amount of time,
and you just need to focus on them, and they don’t get as much of an opportunity to also learn a
little about you.”
In addition to her work at the Institute on Aging, Ms. Stiles worked as a Medical Social
Worker, Bereavement Coordinator, and Bereavement and Volunteer Manager at Odyssey
Healthcare, a hospice setting in which she served a number of geriatric patients and their
families. In both her past and current roles, she has found the positive impact she has had on
patients’ well-being and relationships, and her preservation of their comfort and dignity as they
manage difficult health conditions, to be deeply fulfilling. “I have had so many rewarding
experiences with clients–so many frail, dying individuals I’ve had the honor of working with and
being present for, so many people I’ve been privileged to advocate for when they were not able
to speak for themselves, so many grieving families I’ve been able to comfort and counsel,” she
said, “It’s been really incredible how many clients have really touched me.”
Some of the primary challenges of gerontological social work include the complexity and
severity of some clients’ challenges (which at times necessitate difficult conversations about end-
of-life care and planning), instances of elder abuse or neglect, age-based discrimination, family
conflicts that interfere with appropriate or sufficient care, and the challenges and limitations
within the health care system that can prevent elderly patients from receiving the medical
attention and resources they need.
Ms. Stiles described how prejudice against aging and the elderly, senior citizens’
changing occupational and/or financial status, and the physical and mental declines that often
come with aging can all combine to make the difficulties that elderly individuals face particularly
challenging. “Older adults face many of the same concerns and issues as any adult–limited
resources, mental health issues, substance abuse, history of trauma, systemic racism,
homophobia, classism, etc.,” she said, “What makes older adults ‘unique’ is that they are dealing
with these concerns with the added pressure of ageism (discrimination against people based on
their age) and ableism (discrimination against individuals with disabilities), as well as potential
physical health changes and accumulated losses.”
Managing family members’ concerns (or their lack of concern) can also prove
challenging. “While many families are wonderful to work with, other families are very difficult
to work with,” Ms. Burns noted, “Families often are at one end or the other of the spectrum,
very, very involved and high maintenance and then there are other families that you call and call
and cannot get them to call you back. It is important to have strong relationships and build trust
with all families that you work with.”
Encountering systemic injustices that particularly hurt the elderly can also be a challenge
that gerontological social workers encounter on the job. “Many of the challenges I’ve faced with
clients are primarily due to longstanding, often untreated mental illness that clients have been
dealing with for decades,” Ms. Stiles noted, “Often there are systematic issues like generational
poverty, lack of services in the community, and a general lack of concern for older adults unless
in a medicalized setting.”
To manage the challenges of the work, the social workers whom we interviewed suggested that
social work students manage their expectations around what they are able to do to help clients,
and to appreciate their successes while learning from their mistakes. “For new social workers, I
recommend keeping perspective and understanding the limitations placed on people in this
profession,” Ms. Stiles advised, “Many issues an older client is dealing with are issues they’ve
been dealing with for decades; we cannot solve family discord, we cannot solve poverty, we
cannot solve regrets or mental illness or a lack of services. This is incredibly difficult and takes
years of practice and self-reflection.”
Ms. Burns explained how she remains optimistic and turns the challenges she encounters into
opportunities to connect with her clients and their families, and to better meet their needs and
concerns. “It’s very rewarding when you are able to build trust with a family that is hard to reach
or get them to agree to provide care that they have been resistant to provide,” she noted.

INTRODUCTION
"Sarah, an older lady with a walker, was waiting for me with her outdoor clothes on in
her studio apartment. The stairs and the heavy front door keep her indoors as she is unable to
maneuver them with her walker. My job was to help her go outdoors once a week. We met for
the first time last week when we were introduced to each other after I enrolled in a voluntary
work program. She was really delighted go out. It was early spring and trees were just beginning
to turn green. We walked around the block very slowly and did lotto in the kiosk and came back
home. She said that the previous time she went outdoors was six months ago."
Most people wish that they could live a long, productive, and autonomous life without
debilitating disability. However, in old age, progressing diseases and the consequent impairments
and functional limitations increase the risk of mobility decline, potentially resulting in a situation
where the person becomes practically home confined. Participation in meaningful activities and
running daily errands, both of which are key elements for life satisfaction, require the ability to
access the outdoors. Outdoor physical activity, particularly walking, plays a key role in the
maintenance of functional independence in old age [1]. With populations aging worldwide, there
is an increasing need for knowledge and evidence-based policy to promote independence in older
people to ensure the sustainability of societies while also ensuring good quality of life for older
people. Understanding different factors affecting outdoor mobility in older adults helps identify
approaches to planning accessible and safe environments and to motivating older adults to move
about outdoors and thus prevent the development of disabilities.

Promoting independence in old age and improving mobility

MOBILITY
Outdoor mobility refers to the physical ability to move. It refers to all types of trips
outside home, either by foot or by other means of transportation [2]. Mobility is necessary for
accessing commodities, making use of neighborhood facilities, and participation in meaningful
social, cultural, and physical activities. Mobility also promotes healthy aging as it relates to the
basic human need for physical movement. Unmet physical activity need, defined as inability to
increase physical activity despite being willing to do so, is common among community-living
older people who have mobility problems and who report negative environmental features in
their neighborhood [3]. Commuting and transportation systems influence mobility; however, the
focus here is on walking. Walking is an integral part of mobility and may be considered a
prerequisite for unassisted use of other forms of transportation.
Assessment of Mobility
Walking as a physical ability is often assessed by asking people whether they experience
difficulties walking given distances. Another option is to use standardized tests of walking.
Typically, for gait speed calculation, a person is asked to walk a specific distance, which is
timed. The advantage of self-reports is that they provide us with subjective evaluation of one's
mobility in one's everyday environment and thus carry immediate relevance to people's lives.
However, they also reflect the challenges in the environment and may not be comparable across
localities or countries. In addition, most existing self-report instruments primarily assess
difficulty, inability, or degree of assistance required to perform specific tasks of mobility. Thus,
these measures may not be sensitive enough to identify early stages in the course of mobility
decline.
The advantage of performance-based assessments, such as gait speed, is that they may be
administered in a standardized environment and provide information that is universally
comparable. However, it may be difficult to interpret changes in walking speed in terms of how
big an improvement is clinically significant. Recently, estimates of small meaningful change in
gait speed (approximately 0.05 m/s) have been suggested by contrasting walking speed against
perceived walking difficulties .
Mobility Decline
The first signs of declining mobility are typically observed for more demanding mobility
tasks, such as walking longer distances or running. Perceived running difficulties are already
common in midlife [5]. In the early stages of functional decline prior to the onset of task
difficulty, older persons may be able to compensate for underlying disease by modifying their
task performance and thereby maintain their function without the perception of difficulty. This
stage of functional decline, that is, changes in method, frequency, or time used in task
performance or increased tiredness has been proposed as preclinical disability [6-8].
In our study among more than 600 community-dwelling people aged 75 to 81 years, participants
with preclinical mobility limitation showed intermediate levels of walking speed and muscle
power, compared with those with no limitation or manifest mobility limitation. Participants
reporting baseline preclinical mobility limitation had a 3- to 6-fold higher ageand sex-adjusted
risk of progressing to major manifest mobility limitation during the 2-year follow-up compared
with participants with no limitation at baseline . These results suggest that it is also possible to
identify people in the early phases of mobility decline by relatively simple self-report tools.
Those in the early phases of mobility decline will benefit most from preventive interventions
because their own physical resources will still allow them to increase their physical activity and
training on their own without intensive support from other people. We studied physical activity
counseling as a way to promote the mobility of older people. The intervention included one face-
to-face counseling session with a physiotherapist and follow-up phone contacts every four
months for two years. The aim of the counseling was to increase the physical activity of the
participant. This intervention increased physical activity and slowed down progression of
mobility decline. We concluded that physical activity counseling was efficacious in preventing
mobility decline, especially among people who were still in the early phase of mobility decline.

Physiological requirements for Walking

From the physiological point of view, walking is an integrated result of the functioning of
musculoskeletal, cardio-respiratory, sensory and neural systems. Two of the most immediate
prerequisites for walking are lower extremity strength and postural balance. These are needed to
generate movement and to maintain a balanced upright position while moving. Consequently,
progressive resistance training and balance training may help maintain or rehabilitate walking
ability among older people at risk of accelerated mobility decline.
In particular among older people, immobility while being ill may result in critical
mobility decline. Among older people, mobility may not spontaneously recover to its pre-illness
level. In an American study, it was observed that in the year during which severe disability
developed, hospitalizations were documented for 72% of those developing sudden, catastrophic
disability and for 49% of those developing progressive disability, while only 15% of those who
were stable with no disability and 22% of those with some disability were hospitalized .
We studied the effects of progressive resistance and functional training among older frail
patients discharged from a hospital ward after an acute illness. Maximal voluntary isometric
strength of knee extension and hip abduction, dynamic balance, and maximal walking speed
were measured before and after the 10-week training period, and 3 and 9 months after the end of
the intervention. After the intervention, significant improvements were observed in the training
group compared to the control group in the maximal voluntary isometric knee extension strength
(20.8% vs. 5.1%, p=0.009), balance scale (+4.4 vs. -1.3 points, p=0.001), and walking speed
(+0.12 vs. -0.05 m/s, p=0.022). Effects on knee extension and hip abduction strength, balance,
and walking speed were observed 3 months later, and some effects on hip abduction strength
(9.0% vs. -11.8%, p=0.004) and mobility were still apparent even 9 months after the intervention
. These results suggest that the negative consequences of acute diseases and hospitalizations may
be counteracted among older people by intensive physical training.
A recent meta-analysis of the effects of strength training included 121 trials with 6700
participants. In most of the trials, progressive resistance training was performed two to three
times per week and at a high intensity. Progressive resistance training had a large positive effect
on muscle strength (73 trials; 3059 participants; standardized mean difference, 0.84; 95%
confidence interval [CI], 0.67 to 1.00) and a modest but positive effect on gait speed (24 trials;
1179 participants; mean difference, 0.08 m/s; 95% CI, 0.04 to 0.12). This review provided
evidence that progressive resistance training is an effective intervention for improving physical
functioning in older people, including improving strength and the performance of some simple
and complex activities.

Sensory factors, Falls, And Walking

Adequate sensory functioning, that is, receiving accurate information about potential
environmental risks through different sensory channels, plays an important role in safe walking.
We observed that hearing and vision impairments correlated with increased fall risk and that the
risk of falls was particularly high among people who had multiple sensory impairments. Falls
may accelerate the worsening of walking difficulties even further. We observed in a prospective
study that even non-injurious falls increased the risk of walking difficulties at least partly due to
reduction of walking activity among those who sustained falls. We also found that women with
hearing or vision impairments had slower maximal walking speed and poorer balance than
people without these impairments . It is possible that people may adjust to a gradually declining
function of a single sensory modality and learn to compensate for the deficiency by utilizing
information from the other sensory modalities. However, when multiple sensory difficulties are
present, it becomes more and more difficult for the person to receive accurate information about
the environment, which may eventually lead to increased fall risk, avoidance of walking, and
finally to increased risk of walking difficulty. It is important to rehabilitate vision and hearing,
because they provide us with feedback about the environment needed for safe mobility.
Rehabilitation of sensory impairments may also improve mobility and reduce fall risk.

Environmental Barriers And Walking

Older people with mobility limitations often report more barriers in their outdoor
environment than people with intact mobility. Need for assistive walking devices makes people
especially vulnerable to environmental barriers. However, it is uncertain whether older people
perceive their environment as problematic because of their mobility limitations or whether the
environmental barriers precede incident mobility limitation and consequently contribute to the
progression of mobility decline. We observed in a prospective study that the presence of specific
environmental barriers (long distances, lack of resting places, high hills, poor street conditions,
and busy traffic) in a person's living environment increased the risk for developing new walking
difficulties by up to almost three-fold. Differences in socio-demographics, health, and physical
activity explained part of the increased risk, but not all of it [20]. It is possible that environmental
barriers, by reducing physical activity, lead to accelerated mobility decline. We observed that
environmental barriers correlate with fear of moving outdoors, which typically manifests in
avoidance of outdoor activities that are within a person's health capacity. Fear of moving
outdoors was found to increase the risk of mobility decline and may be one of the underlying
factors in the association between environmental barriers and mobility decline .
Decreasing mobility barriers in the environment will have an immediate effect on mobility by
improving accessibility. However, removing barriers may also slow down progression of
mobility decline by helping to maintain adequate activity levels.

Promoting Mobility
"Use it or lose it" is definitely true for mobility in old age. Consequently, it is important
to find ways to increase or maintain the active mobility of older people. Promoting mobility
should happen at the community level as well as at an individual level. Community planning
strategies and community amenities are important to minimize environmental and social barriers
and also to ensure equal opportunities for mobility among those with functional limitations. In
addition, older people should have opportunities to participate in physical activities. Physical
exercise classes should be adapted to the possible special needs of older people, the classes
should be inexpensive, and exercise facilities should be accessible, so that all have an equal
opportunity to participate. It is also important to promote positive attitudes toward physical
exercise among older people and avoid stereotypic images and negative messages. For example,
we found that many older people recalled that their doctor had advised them to avoid physical
exertion . Such a message may have been intended for a limited time; however, older people may
consider it to be definitive.
Even though older people may have many problems related to mobility, sometimes
solving just one of them may critically improve the opportunities to solve the other problems.
Health care providers, engineers, community planners and decision makers, leisure service
providers, civil society, as well as family members and other loved ones of older people should
work together to optimize opportunities for older people to maintain independent mobility as
long as possible.

Assessing and planning health care surgery

Older people attending the emergency department (ED) or acute medical units (AMU)
often have more complex needs due to multiple co-morbidities, physical limitations, increased
functional dependence and complex psychosocial issues. Thus, they are more vulnerable and
could easily decompensate with minor stressors, resulting in increased frailty. There are
established detrimental effects of hospitalisation on older adults and about 17% of older medical
patients who were independently mobile 2 weeks prior to hospital admission required assistance
to walk at hospital discharge. Therefore, to improve outcomes for frail older people with multiple
co-morbidities and an acute illness, admission should be to an Emergency Frailty Unit (EFU), a
separate unit within an AMU but led by a geriatrician and the multidisciplinary team (MDT) to
provide comprehensive person-centred care.
The clinical assessment of frail older people is challenging, as they often have multiple
co-morbidities and diminished functional and physiological reserves. In addition, the physical
illness or adverse effects of drugs are more pronounced resulting in atypical presentation,
cognitive decline, delirium or inability to manage routine activities of daily living (ADLs).
Among the potential adverse outcomes for frail older inpatients, are the risks of continued
deterioration as a consequence of medical complications such as pressure sores, hospital-
acquired infections or functional decline. This can also lead to long-term increased dependency,
institutionalisation and death.

Impact of ageing on hospitals

Hospitals face a rising demand from an increasing number of acute emergency

admissions of people aged 65 years and above with multiple co-morbidities and psychosocial
problems. The admission rates for people over 65 years are three times higher than for people
aged 16–64 years. Older patients cannot always be transferred quickly from the hospital after
acute illness and on average hospital length of stay (LoS) is significantly higher than for under
65 years [6]. The older people occupy around two-thirds of acute hospital beds and emergency
admissions have been rising for several years [7]. The healthcare cost and the proportion of
hospital bed days used by older people are likely to increase further due to ageing population [8].

1.2. Physiological changes of ageing

The normal physiological changes occur with ageing in all organ systems (Table 1) and this has
implications for the clinical assessment of older people [9–11]. Therefore, it is essential to be
aware of these changes as these have an impact on drug metabolism and pharmacodynamics. In
addition to comprehensive geriatric assessment (CGA), these changes can be delayed or reversed
with appropriate diet, exercise and medical intervention.
Change in
Impact on health
physiology
↓ Heart rate and
cardiac output
↓ Arterial
Easy fatigability and loss of stamina for physical work
compliance
Peripheral oedema
Cardiovascular ↑ Systolic blood Isolated systolic hypertension
pressure
Dysrhythmias
↑ Myocardial
Cold sensitivity in the hands/feet
irritability
↓ Tissue perfusion
↑ Circulation time
↓ Normal reflexes
↓ Proprioception
↓ Baroreceptor
Nervous Impaired cognition
response
Falls
system ↓ Sympathetic
Postural hypotension
response
↑ Sensitivity to
anticholinergics
↓ Salivation and Aspiration
taste Dehydration
Sensory
↓ Thirst Falls
↓ Response to Increased isolation and depression
 Change in
Impact on health
physiology
pain
↓ Visual acuity
and
peripheral vision
↓ Hearing
↓ Tidal volume
↓ Vital and total
lung
capacity
Lungs ↓ Lung Low oxygen saturations
compliance
↓ Response to
hypoxemia
↑ Residual
volume
↓ Glomerular
filtration Higher chance of drug side effects due to reduced renal clearance
Kidneys rate (serum creatinine level remains relatively constant due to reduced
↓ Renal flow and
muscle mass and reduced creatinine production)
kidney
size
Smaller voided
volume
↓Bladder capacity
Urinary incontinence
Bladder ↑ Involuntary
Urgency
detrusor
Overactive bladder symptoms
contractions
↑ Residual
volume
↓ Gastric
emptying
↓ Bowel
movements
Weight loss
↓ Transit time and
Constipation
Gastrointestinal absorption Slower drug metabolism and reduced hepatic first-pass effect, thus
↓ Liver mass
increased bioavailability
(by 30-40%)
Dehydration
↓ Sense of thirst
↓ Capacity to
conserve
water.
Endocrine ↓ Insulin Hyperglycaemia during acute illness
sensitivity Risk of hypothermia
 Change in
Impact on health
physiology
Thyroid Osteopenia/fragility fractures
impairment
↓ Metabolic rate
↓ Temperature
regulation
↓ Bone mineral
density
Atrophy of skin
epidermis
↓ Subcutaneous
Easy bruising
fat
Pressure ulcers
Body ↓ Sweat glands
Dry skin
composition Atrophy of
Sarcopenia
muscle cells
Falls
Degenerative
changes in
many joints
Immune ↓ Neurohumoral
Higher infection rate
response
system Higher probability of infection
↓ T-cell response
Normal physiological changes of ageing.
2. Assessments of older people in hospital
The holistic assessment of older people is best achieved by the MDT. The MDT members
include doctors, nurses, physiotherapist (PT), occupational therapist (OT), dietician, clinical
pharmacist, social worker (SW), specialist nurses (e.g. tissue viability nurse and Parkinson’s
disease nurse specialist), hospital discharge liaison team and carers. Input from a clinical
psychologist or old age psychiatrist may be needed depending on individual patients’ needs. All
members engage with patients and carers to complete their assessments and intervention,
followed by multidisciplinary meeting (MDM) to formulate ongoing care plan and follow-up.

2.1. Medical assessment

The medical assessment begins at the time of admission to an AMU or an EFU with the
appropriate investigations and thus establishing the relevant diagnosis. In addition to treating
acute illness, there must be an attempt to optimise the symptoms and treatment of chronic
diseases [12]. The common medical diseases among older people are listed in Table 2. A carer or
a relative usually accompanies an older patient to the hospital, and a short conversation with
them can rapidly reveal the diagnosis and direct ongoing management.
Alzheimer’s disease
Normal pressure hydrocephalus
Mostly seen in older people Temporal arteritis (giant cell arteritis)
Diastolic heart failure
Inclusion body myositis
 Atrophic urethritis and vaginitis
Shingles (herpes zoster)
Benign prostatic hyperplasia
Aortic aneurysm
Polymyalgia rheumatic
Degenerative osteoarthritis
Overactive bladder with urinary incontinence
Diabetic hyperosmolar nonketotic coma
Falls and fragility hip fracture
Osteoporosis
Parkinsonism
Common in older age group
Accidental hypothermia
Pressure ulcers
Prostate cancer
Stroke
Glaucoma and cataract
Monoclonal gammopathies
Common medical diseases among older people.
2.1.1. Acute medical illness
Older people admitted to the hospital with an acute illness often a non-specific presentation,
which can obscure the serious underlying pathology or medical diagnosis. For example, acute
bowel infarction in older people may not present with typical abdominal pain or tenderness or
lack of typical signs on meningism in bacterial meningitis. The atypical presentation in older
people could be one or combination of ‘feeling unwell’, ‘inability to cope’, ‘off-legs’, ‘fall’,
‘confusion’, ‘dizziness’, ‘incontinence’, ‘weight loss’, etc. The atypical presentation with
possible background sensory impairment, lack of collateral history, polypharmacy and high
prevalence of cognitive deficits limits good clinical assessment.
‘Feeling unwell’ or ‘inability to cope’ could be a presentation of an acute infection, exacerbation
of underlying chronic disease (e.g. chronic heart failure), drug side effect (e.g. constipation) or
dehydration. However, this could be due to underlying malignancy; therefore, such a
presentation warrants good clinical examination and appropriate investigations.
Worldwide, falls are the second most common cause of unintentional injury and death. A non-
accidental fall is a complex system failure in the human organ system, where a person comes to
rest on the ground from a standing or a sitting height, unintentionally with no associated loss of
consciousness [13]. The prevalence of falls increases with age, and oldest old is at highest risk.
One-third of older adults over 65 years and half of older people above 80 years could experience
one fall in a year [14, 15].
Falls are most common in institutionalised older people [16] and half of the fallers will fall again
within a year [17]. Older people with high risk of falls are sometimes admitted to the hospital to
avoid future falls but in reality, hospitals are associated with a higher risk of falling due to
several new risk factors such as unfamiliar environment, increased risk of delirium, high beds,
single rooms and so on [18, 19]. Falls are associated with a threefold increased risk of future
falls, fear of falling, prolonged hospital stay, functional decline, increased dependency,
institutionalisation, increased expenditure, morbidity and mortality . Falls result in injury (4%)
and fragility hip fracture (1%), following which up to 10% of people will die within a month, a
third dying during the following year after [.
The evaluation of falls begins by distinguishing it from brief sudden loss of consciousness
(syncope). However, it could be challenging to do so in certain cases but every effort should be
made. Falls cannot only be simply related to underlying medical or neurological disorder as falls
are usually multifactorial including a wide range of intrinsic and extrinsic factors. The most
common factors leading to falls in neurological patients are the disorder of gait and balance
(55%), epileptic seizures (12%), syncope (10%), stroke (7%) and dementia. Falls have
particularly being linked to Parkinson’s disease (62%), polyneuropathy (48%), epilepsy (41%),
spinal disorders (41%), motor neuron disease (33%), multiple sclerosis (31%), psychogenic
disorders (29%), stroke (22%) and patients with a pain syndrome (21%) [16]. Dementia is
associated with impaired mobility and is an independent risk factor for falling [23]. People who
present with a fall or report recurrent falls in the past year or demonstrate abnormalities of gait
and/or balance should have multifactorial, multidisciplinary assessment for falls, risk factors,
perceived functional abilities and fear of falling. In addition, bone health and history of previous
fragility fractures should be explored [24].
‘Delirium’ is a common syndrome affecting older people admitted to AMU or EFU. It is a
serious acute problem which has been best understood as an ‘acute brain dysfunction’ or an
‘acute confusional state’ characterised by a rapid onset of symptoms, fluctuating course and an
altered level of consciousness, global disturbance of cognition or perceptual abnormalities. The
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) defines delirium as ‘a
disturbance of consciousness that is accompanied by a change in cognition that cannot be better
accounted for by a pre-existing or evolving dementia’ [25].
The diagnosis of delirium is based on clinical observations, cognitive assessment, physical and
neurological examination. Despite the common problem, delirium remains a major challenge and
often under-diagnosed and poorly managed. Clinically, delirium can be divided into hyperactive,
hypoactive or mixed forms, based on psychomotor behaviour. The Confusion Assessment
Method (CAM) supports a diagnosis of delirium if there is a history of acute onset of confusion
with a fluctuating course and inattention in the presence of either disorganised thinking and/or
altered level of consciousness [26]. Collateral history from the family member or carers is
helpful to detect a recent change in cognition.
Delirium usually occurs as a result of complex interactions among multiple risk factors such as
cognitive impairment, Parkinson’s disease, stroke, poor mobility, history of previous delirium,
hearing or visual impairment, malnutrition or depression. It is often precipitated in the hospital
setting due to acute medical illnesses including infection, acute coronary syndrome, bowel
ischaemia, surgical disorder, polypharmacy, pain, dehydration, electrolyte imbalance, new
environment, sleep deprivation, constipation, hypoxia, use of restraints or indwelling catheters.
Delirium, if not recognised early and managed appropriately, can result in poor outcomes,
including prolonged hospital stay, increased functional dependence, institutionalisation, a risk of
developing dementia, increased inpatient and post-discharge mortality [27–29]. Therefore, an
older person admitted to hospital with confusion should be promptly assessed for delirium to
improve clinical outcomes. The optimal assessment should be completed to identify underlying
modifiable risk factors and treating precipitating factors, followed by reorientation and
restoration of cognitive functions using non-pharmacological strategies including carer support
and education, good communication among MDT and appropriate follow-up. The
pharmacological drugs including haloperidol or risperidone should be used to manage severe
agitation or behavioural disturbance.
 ‘Dementia’ is often recognised for the first time as an incidental condition when people
are admitted to an acute hospital for another reason. More than one-third of acute medical
admissions (42.4%) for over 70s have been reported to have dementia and only half of which
were diagnosed prior to admission [30]. However, dementia can be misdiagnosed as an acute
illness and can be accompanied by reversible cognitive decline. In addition, older people with
known dementia who present with an altered mental state can be mislabelled as having
progressed to another stage of dementia missing undiagnosed delirium. Older people with
cognitive impairment are at increased risk of falls [31] and are also more likely to die during
hospitalisation, and increased severity of cognitive impairment is associated with higher odds of
mortality (from 2.7 in those with moderate impairment to 4.2 in those with severe impairment)
[32]. Therefore, older people in hospital settings should be carefully assessed for underlying
cognition. Dementia is a chronic progressive brain disorder marked by a disturbance of more
than two domains of brain functions for more than 6 months. The various cognitive deficits may
include short-term memory loss, language- or word-finding difficulties, mood and personality
changes, impaired reasoning, learning new skills, inability to concentrate, plan or solve
problems, difficulty in taking decisions or completing a task, disorientation, visuospatial
difficulties or problems with calculations. Dementia is the most appropriate diagnosis when two
or more cognitive deficits have an impact on ADLs or social interaction, often associated with
behavioural and psychological symptoms of dementia (BPSD) [33].
‘Frailty’ is defined variably and there is no single generally accepted definition. Fried et
al. [34] reported a clinical definition of frailty based on the presence of three or more frailty
indicators: unintentional weight loss, slow walking speed, subjective exhaustion, low grip
strength and low levels of physical activity. Frailty, based on these criteria, was predictive of
poor outcome including institutionalisation and death [34]. Whereas Rockwood and Mitnitski
[35] had advocated an alternative approach to frailty by considering frailty in relation to the
accumulation of deficits with age, including medical, physical, functional, cognitive and
nutritional problems. The frailty index expresses the number of deficits identified in an
individual as a proportion of the total number of deficits considered. Higher values indicated a
greater number of problems and hence greater frailty. For example, if 40 potential deficits were
considered, and 10 were present in a given person, their frailty index would be 10/40 = 0.25 [36].
A valid index can be derived from the routine information collected on CGA [37–39]. Therefore,
the presence of frailty on clinical judgement should prompt consideration to holistic assessment
by MDT.
2.1.2. Chronic co-morbidities
Older people usually have more than five medical conditions and one pathological
disorder in an organ, which can weaken another system. This results in increased disability,
physical dependence, functional deterioration, isolation or even death. Long-term conditions in
older people require very careful assessment and monitoring particularly whilst undergoing acute
medical treatment in the hospital. Every older person admitted to MAU or EFU should have
assessment of underlying chronic medical conditions, including ischaemic heart disease, heart
failure, chronic respiratory diseases, chronic inflammatory and autoimmune problems.
Modifiable cardiovascular risk factors such as diabetes mellitus, hypercholesterolemia,
hypertension, obesity, excessive smoking or alcohol consumption should be reviewed and
optimally addressed.

2.2. Mental health assessment

 Many people with long-term physical health conditions also have mental health problems
[40]. Mental health problems are common in older people, and 8–32% of patients admitted to
acute hospitals were found to be depressed . Depression is not a natural part of ageing but can be
easily missed in older patients, thus resulting in adverse outcome including delayed recovery and
suicide. It is often reversible with early recognition and prompt intervention. Delirium has been
reported in 27% of older patients above 70 years . The prevalence of dementia in acute hospitals
was reported as 48% in men and 75% in women older than 90 years .
The current service models for the provision of mental health input in general medical care
wards are variable. The prevailing view in the United Kingdom is that old age psychiatrists have
the main responsibility for the diagnosis and management of dementia and other mental health
problems. In many hospitals, both psychiatric and medical notes are not easily accessible and are
mostly kept separately .
The National Service Framework (UK) for older people was published in 2001—standard
seven aims to promote good mental health in older people and to treat and support those older
people with dementia [44]. The liaison mental health services have not only shown improved
clinical outcomes as measured by the length of hospital stay or discharge to original residence
but also suggested cost effective models. However, concerns have been raised about the
reliability and validity of the various studies included in this systematic review [45]. The hospital
liaison multidisciplinary mental health team is the model advised in the United Kingdom to offer
a general hospital a complete service.
The Rapid Assessment Interface and Discharge (RAID) service model is an example in
the United Kingdom where a psychiatry liaison service provides MDT input to acutely unwell
older people with existing mental health admitted to hospital [46]. The RAID service has shown
to be an effective, enhanced service model for older people who are at risk for dementia or other
mental health problems and has shown good outcomes with quality improvements in the care of
older people .
Collateral history from the family or carers remains the key feature for initial assessment.
If dementia is suspected in a person, a full medical assessment must be completed, an example
being the British Geriatrics Society’s guidance on CGA of the frail older people [12]. Older
people in the hospitals should be assessed for mood, anxiety and depression. The hospital anxiety
and depression scale (HADS) is a simple, valid and reliable tool for use in hospital practice [47].
It is a self-assessment screening tool, which warrants further assessment based on abnormal
scores. The score for the entire scale for emotional distress can range from 0 to 42, with higher
scores indicating more distress. Score for each subscale (anxiety and depression) can range from
0 to 21 (normal 0–7, mild 8–10, moderate 11–14, severe 15–21). A short-form Geriatric
Depression Scale (GDS) consisting of 15 questions can be used for depression [49]. Any positive
score above 5 on the GDS short form should prompt a detailed assessment and evaluation.
Generalised anxiety disorder (GAD) is the most common mental disorder encountered in older
patients and is often accompanied by depression. It could be helpful to assess older person’s
emotional state and sense of well-being as they may report psychological burden of the disease,
for example, fear of falling or fear of being in the hospital which is associated with loss of
independence by older people. History of delusions and hallucinations or previous use of
psychotropic drugs may suggest a mental health problem. Patient’s permission should be sought
before interviewing their relatives or carers for collateral history.
Following initial suspicion or diagnosis of a mental health problem in older people, a more
collaborative work between physicians and old age psychiatrists for the prompt diagnosis and
management of mental health problems will improve outcome [46].

2.3. Drugs
Drug prescribing increases with both age and incidence of co-morbidities [50, 51].
Polypharmacy is defined as use of either five or more concurrent medications or, at least, one
potentially inappropriate drug. Half of older people aged between 65 and 74 years and two-thirds
of those aged 75 years and over are affected by polypharmacy including conventional and
complementary medicines. Polypharmacy is associated with adverse outcomes including hospital
admissions, falls, delirium, cognitive impairment and mortality. Although drugs have an
important role in managing co-morbidities, it is not without harm and adverse outcomes.
There is conflicting evidence that psychotropic medications are associated with higher falls in
people with dementia though there is clear evidence that there is associated increased fall risk in
cognitively intact people]. Other classes of drugs including Parkinson’s disease drugs,
anticonvulsants, steroids and fluoroquinolone can result in acute confusion [59]. Drug
interactions could impair electrolytes, cause postural hypotension, hypothermia, gait disorder or
gastrointestinal disturbance, resulting in prolonged hospital admission.
Therefore, all older inpatients should have drug review and withdrawal of any possible
offending agent if practical would be logical. This can be based on screening tool of older
persons’ prescriptions (STOPP), and a tool to alert doctors to commence appropriate treatment
(START) criteria should be used [60]. Patients should also be assessed for their ability to manage
their drugs, understanding of drug, dexterity and vision. At the same time, appropriate new
medications if deemed necessary and evidence-based should be commenced. Older people with
cognitive impairment should be prescribed with greater care, adhering to the principle of‚
‘starting low and going slow’.

2.4. Physical performance

Gait and balance are regulated by both central and peripheral nervous system; thus,
various neurological disorders can result in postural instability and poor mobility. Balance
system can be affected by the impact of neurological disease on postural responses, postural
tone, sensory feedback, visuospatial disorder, executive dysfunction or delayed latencies. Gait
disorders have been classified into lower (e.g. peripheral), middle (e.g. spinal, basal ganglia) and
higher level gait disorders (e.g. frontal or psychogenic) [62]. The more pragmatic approach could
be used to describe gait disorders including hypokinetic gait disorders, dystonic, hemi- or
paraparetic gait, ataxia, vestibular, neuromuscular and psychogenic gait [62]. All components of
gait including initiation of walking, step length, coordination, walking speed, symmetry, stride
width, rhythm and posture should be assessed. Various tools/scales can be used for further
assessment of gait and balance (Table 3). Most physicians work closely with PT and rely on their
assessment of patient’s needs in relation to mobility, balance and posture. Multidimensional
assessment and multiagency management of mobility in older people lead to better outcomes.
Technique Normal values
Turn 180° A measure of dynamic postural stability, asking a patient to take Five or less steps
 Technique Normal values
[63] few steps and then turn around by 180° to face opposite direction.
Count the number of steps taken to complete a 180° turn
A measurement of mobility. A person is asked to stand up from 12 or fewer seconds,
3-m TUG
seated position, walk for 3 m, turn and walk back to a chair and sit can vary with age
test [64]
down. Measure the time taken in seconds by 2–4 s
A measure of balance and ankle strength. A person is asked to stand
in a
Near
near tandem position with their bare feet separated laterally by 2.5 Able to stand >30 s
tandem
cm with the heel of the front foot 2.5 cm anterior to the great toe of with eyes closed
stand [65]
the back with their eyes closed. A person can hold arms out or move
the body to help keep the balance but do not move the feet
A measure of strength, balance, coordination and stair climbing. It
Alternate 10 or fewer seconds,
provides a measure of mediolateral stability. A person should be
step test can vary with age
asked to place alternate whole left and right bare foot onto a 19-cm
[66] by 2–4 s
high stepper for a total of eight times
A measurement of functional mobility, balance and lower limb
11.4 s (60–69
strength.
Sit-to-stand years); 12.6 s (70–
A person should be able to stand up and sit down five times with
test [67] 79 years); 14.8 s
crossed
(80–89 years)
arms from a 45-cm straight-backed chair
Gait and balance assessment tools.
Physical activity interventions for people with an intact cognition are well documented
and shown to be effective in improving balance and reducing falls. People with dementia are two
to three times more likely to fall [16] and risk is further increased in people with Lewy body
dementia (LBD) and Parkinson’s disease dementia (PDD) [23, 68]. There is limited evidence
showing significant gait and balance improvement following the targeted exercise programme in
the community-dwelling older people with dementia [69]. More recently, it has been shown that
supervise exercise training in people with dementia living in community could improve muscle
strength and physical activity [70]. There is dearth of similar studies in the hospital setting and
further research is required. A simple flexible home-based muscle strengthening and balance-
training exercise programme along with medication could improve the physical performance in
the older people.

2.5. Functional status

It is not uncommon for older people to be admitted to the hospital with functional
deterioration or increased dependence, thus unable to cope. Older people admitted to the hospital
with an acute medical problem, ‘geriatric giants’ [71, 72], incontinence, immobility, postural
instability (falls) and intellectual impairment (dementia) or who are frail with one or more
disability should get an appropriate functional assessment. A typical geriatric assessment for
such people should begin with a review of their functional status. This is usually captured in two
commonly used functional status measurement—basic ADL and instrumental ADL (IADL). The
ADL that is initially affected includes complex or IADLs such as shopping, handling finances,
driving, cooking or using the telephone followed by basic ADL including bathing, dressing,
toileting, transferring, continence or feeding. Whether patients can function independently or
need some help is usually determined by OT, as part of the comprehensive geriatric assessment.
OTs work closely with the physiotherapists to assess patient’s own environmental and home
status with the identification of appropriate equipment and its delivery before discharge. In
addition to optimising functional independence, OT intervention also enhances home comfort,
safe use of available facilities, safe access to transport or potential use of telehealth technology
and local resources.
The assessment of functional limitations is best completed by an interview with the
person and caregiver with open-ended questions about their ability to perform activities. They
can further be assessed by direct observation either in their usual place of residence or whilst
performing a routine activity, for example, toilet use. The functional status can also be assessed
using a standardised assessment instrument with questions about specific ADLs and IADLs.
There are more than 15 validated scales to complete functional assessments including Katz index
of independence in activities of daily living [73], the modified Blessed dementia scale [74], the
instrumental activities of daily living scale [75], the Functional Assessment Questionnaire [76],
Functional Assessment Staging Test [77], Barthel Activities of Daily Living Index Scale [78],
Alzheimer’s Disease Co-operative Study-Activities of Daily Living Inventory [79], Disability
Assessment for Dementia [80] and Bristol activities of daily living [81].
The functional scales can detect early functional impairment and often help discriminate mild
dementia in comparison to those with no cognitive impairment. The scales that assess complex
social functional activities are better in detecting dementia compared to those scales that involve
basic ADLs [82]. A good timely recognition of functional difficulties may arrest further decline,
postponing the need for care-home placement. The functional assessment scales can only provide
a guidance and these scales are commonly used to assess the treatment efficacy in scientific
research studies.

2.6. Continence assessment

Urinary incontinence (UI) is defined by the International Continence Society as ‘the

complaint of any involuntary leakage of urine’. Older people may assume that UI is a normal
consequence of ageing and often may not be reported. UI is a common problem and older people
may feel embarrassed to discuss the problem and avoid evaluation. Incontinence is associated
with social isolation, institutionalisation and medical complication including skin irritation,
pressure sores, recurrent infections and falls. The prevalence of urinary incontinence depends on
the age and gender; for older women, the estimated prevalence of urinary incontinence ranges
from 17 to 55% (median = 35%, mean = 34%). In comparison, incontinence prevalence for older
men ranges from 11 to 34% (median = 17%, mean = 22%) [83].
There is a strong association of faecal incontinence (FI) with age; FI increases from 2.6% in 20–
29-year-old up to 15.3% in 70 years or above [84]. In hospital settings, UI can be an atypical
presentation and is a risk factor for adverse outcomes. The aetiology of incontinence in older
people is often multifactorial. People with cognitive impairment usually encounter UI and later
FI. Older people often find it difficult and challenging to express the need of regular toilet use,
and as dementia progresses, it could be difficult to identify toilet or use it appropriately.
Incontinence and inability to use toilet independently can be frustrating and distressing, which
may lead to psychological burden, isolation, immobility or institutionalisation.
Therefore, a good continence assessment should be an essential component for any older
people admitted to hospital to ensure good-quality person-centred care, promoting independent
living. Assessment of precipitating factors and identification of treatable, potentially reversible
conditions are essential steps. Continence problems can be secondary to drug side effects,
constipation, impaired mobility, arthritic pain, inappropriate clothing or dexterity.
A good clinical history could categorise UI as stress UI (involuntary urine leakage on exertion),
urgency UI (a sudden compelling desire to urinate) or mixed UI (involuntary urine leakage
associated with both urgency and exertion). Overactive bladder (OAB) is defined as urgency that
occurs with or without incontinence and usually with frequency and nocturia. Bladder diary (72-
h urine frequency volume chart) and pre- and post-void bladder scan support clinical diagnosis.
Vaginal inspection is helpful to exclude vaginal atrophy, prolapse or infections. Older people
with FI should have an anorectal examination to exclude faecal loading, lower gastrointestinal
cancer, rectal prolapse, anal sphincter problems or haemorrhoids. Neurological causes of cauda
equina syndrome, frontal lobe tumours, neurodegenerative disorders or stroke could also result in
UI or FI.
The continence problems can be minimised by promoting regular toilet use, appropriate
toilet adaptations and providing walking aids to improve accessibility to toilet. Nocturnal
incontinence remains a challenging situation but can be managed using various containment
methods or limiting fluid intake in the evening. Drug treatment after specialist continence
assessment is usually the next step if non-drug measures failed to provide symptomatic benefits.
The aim should be to treat the underlying cause but people who continue to have episodes of UI
or FI after initial management should be considered for specialised management.

2.7. Nutritional assessment

Older people admitted with an acute illness are at increased risk of weight loss and this
remains a challenge for the teams in the hospital setting. Acute illness can result in loss of
appetite, and management of an acute illness may take priority, therefore making older people
more vulnerable in the hospitals, particularly those with cognitive impairment or those who
cannot communicate their needs. The National UK Dementia Audit Report in 2013 showed that
nutritional assessments were undertaken in less than 10% of patients in some hospitals [85].
A detailed nutritional assessment should be undertaken on admission to hospital and should
include any recent weight loss, dietary intake and habits. The risk factors including dry mouth,
poor oral hygiene, problems with dexterity, reduced vision, acute or chronic confusion,
constipation or pain should be explored and actively managed to avoid poor nutrition. Regular
nutritional assessments using Malnutrition Universal Screening Tool (MUST) can be helpful and
this has been validated to be used by any health professional in the hospital. It is a five-step
screening tool, which can identify those who are at risk of weight loss or are malnourished [86].
A collective and simple approach with involvement of family and carers can prevent
malnutrition during hospitalisation. Patients should be offered small frequent meals and regular
snacks or preferred food is often helpful. Protected meal times and regular prompting or
assistance for those with cognitive impairment can lead to improved food intake [87].

Communicable Diseases
Most Common Infections in the Elderly
Common infections like influenza and UTIs can happen to anyone, but for adults over the
age of 65, these illnesses may be much harder to diagnose — leading to chronic poor health,
ongoing discomfort and a higher risk of hospitalization.
In fact, one-third of all deaths in seniors over 65 results from infectious diseases, according to
the American Academy of Family Physicians (AAFP). Though seniors are more susceptible to
infection overall, seniors with dementia or those who are in long-term care may be at even
greater risk.
For caregivers, it’s critical to learn about the most common infections in the elderly and
their often-elusive signs and symptoms: “Nonspecific symptoms, such as decline in functioning,
incontinence, loss of appetite and mental status changes may be the presenting signs of
infection,” according to an article in Infectious Disease Clinics of North America.
If we stay alert to any changes in senior health and take steps to ward off any infections that
might be preventable, we can help promote greater wellness and quality of life for our loved ones
in their golden years.
Here are the five most common infections in the elderly:

1. Bacterial pneumonia.

More than 60% of seniors over 65 get admitted to hospitals due to pneumonia (AAFP). Seniors
are at greater risk for pneumonia for a variety of reasons, including changes in lung capacity,
increased exposure to disease in community settings and increased susceptibility due to other
conditions like cardiopulmonary disease or diabetes.
Classic symptoms like chills, cough and fever are less frequent in the elderly, says the Infectious
Disease Clinics of North America; instead, keep an eye out for nonrespiratory symptoms like
confusion or delirium. Doctors usually prescribe antibiotic treatment for bacterial pneumonia.
Some types of pneumonia can be effectively prevented using a pneumococcal vaccine, and this
is highly recommended for nursing home residents.

2. Elderly influenza.

Influenza and pneumonia combined add up to the sixth leading cause of death in America —
90% of which occur in senior adults (AAFP). Weakened immunity in the elderly, along with
other chronic conditions, increases the risk of developing severe complications from influenza,
such as pneumonia. Because influenza is easily transmitted by coughing and sneezing, the risk of
infection increases in a closed environment like a nursing home.
Chills, cough and fever are the common symptoms, though again, influenza may present
different signs in older adults. Annual flu vaccinations are usually recommended for seniors in
order to prevent infection, but for those already infected, a physician may prescribe antiviral
medications to reduce symptoms.

3. Elderly skin infections.

 Changes to aging skin and its ability to heal and resist disease mean that skin infections get much
more common as we get older. These include:
 Bacterial or fungal foot infections (which can be more common in those with diabetes)
 Cellulitis
 Drug-resistant infections like Methicillin-resistant Staphylococcus aureus (MRSA)
 Viral infections like herpes zoster (shingles) and pressure ulcers
Stay alert to any unusual itching, lesions or pain, and seek treatment if your loved one is in
discomfort. Most skin infections are treatable and shingles is preventable with a simple vaccine.
Ward off other skin infections by practicing good hygiene such as proper hand washing,
particularly if your loved one lives in a senior care community.

4. Gastrointestinal infections.

Age-related changes to digestion and gastrointestinal flora put seniors at increased risk of
developing gastrointestinal infections. Two of the most common are Helicobacter pylori, which
may cause fever, nausea and upper abdominal pain as well as leading to long-term illness such as
gastritis; and Clostridium difficile, an increasingly common diarrhea-causing infection, which
usually occurs due to antibiotic treatments that suppress healthy gastrointestinal flora.
Both illnesses are more common in long-term care facilities. While H. pylori is treated using a
combination of drug therapies, C. difficile treatment involves halting the use of the antibiotic
causing the problem.

5. Urinary tract infections.

Urinary tract infections, or UTIs, are the most common bacterial infection in older adults, reports
the AAFP. The use of catheters or the presence of diabetes can increase the risk of UTIs in
elderly people. Sudden changes in behavior, such as confusion or worsening of dementia, or the
onset of urinary incontinence, are common warning signs — discomfort and pain don’t
necessarily happen with UTIs in seniors.
If you suspect a UTI, a physician can perform a urinalysis or other testing to confirm the
diagnosis and then prescribe antibiotics if needed. Caregivers should make sure their loved ones
drink plenty of water, as this can help prevent UTIs.
Keeping senior loved ones healthy is an ongoing process, but caregivers who stay alert and
informed are already one step ahead. Share how you help prevent infections in the elderly in the
comments below.
 SCHOOL OF SCIENCE AND HUMANITIES

DEPARTMENT OF PSYCHOLOGY

UNIT – V - RESEARCH AND DEVELOPMENT IN GERONTOLOGY -

GERONTOLOGY PSYCHOLOGY-SPSY1401
 RESEARCH AND DEVELOPMENT IN GERONTOLOGY

India derives its name from the Indus River that flows from the Himalayan Mountains. A
country of myriad subcultures that constitute a unity in diversity, its ancient past reaches back to
2000 B.C. As the world’s largest democracy, India based its parliamentary system of government
on that of the United Kingdom, from which gained its independence in 1947. As a federal union,
it includes 29 states and 7 Union Territories (UTs).

India’s constitution officially recognizes 23 of the many languages spoken by its citizens.
Hindi and English are the primary languages used in academia and in conducting business.
Eighty percent are Hindus, 13% are Muslims, and 3% are Christians. Sikhs, Jains, and Buddhists
comprise the rest. Although India’s industrial sector and technical prowess have grown rapidly,
agriculture continues to be the mainstay of the Indian economy ( Registrar General of India
[hereafter, Registrar], 2011 ).

Average per capita income is 54,000 Indian rupees or about US$1,000 annually; nearly one third
of its population lives below the poverty line, on less than $1.50 a day. The Gross Domestic
Product in 2011 was $1.85 trillion. The overall literacy rate is 74%: 82% for men and 66% for
women ( Registrar, 2011 ). This brief background sets the stage for examining issues concerning
India’s growing elderly population.

Demographics of Aging

Two national data sets, the Registrar’s Census of India and reports from the National Sample
Survey Organization (NSSO), provide most of the information about India’s senior citizens.
Statistics about the elderly population are drawn from the most recent NSSO survey of 2005 and
published in 2006; the next review will be conducted in 2015. The 2011 national census projects
that the current total Indian population of 1.22 billion—second only to China—will exceed 1.4
billion by 2030. The elderly population of 90 million may reach 130 million by 2030 ( Registrar,
1996 , 2011 ). India’s fertility rate of 2.5 live births may drop further, increasing the current
dependency ratio: 125 aged per 1,000 of the general population ages 14–59. Average life
expectancy at birth is 69.8 years: 68 years for men and 72 years for women. Life expectancy at
age 60 is 18 years for women and 16 for men. About 3.5% of the total population is more than 80
years of age, with women in the majority ( Registrar, 2011 ).

India’s rural population constitutes two thirds of its total population; three fourths of
Indian elders live in rural areas ( NSSO, 2006 ). Rural/urban differences are important for
examining elders’ income, support, and health issues.

Table 1 shows that most Indian elders reside with their adult children, a traditional practice. A
majority of rural (66%) and urban (63%) dwellers are dependent on their children, who are
expected to provide financial and social support and personal care ( NSSO, 2006 ). In 2007, the
Maintenance and Welfare Act of Parents and Senior Citizens was enacted to enforce family elder
care and prevent elder abuse.

Table 1.
Selected Social and Economic Indicators and Health Status of the Aged (60+) Population in
India (2001–2005)

Percent

Indicators Rural Urban

Living arrangements

Living alone 5.3 4.3

Living with spouse only 12.5 10.4

Living with spouse and family 44.2 44.0

Living with adult children 32.0 32.0

Living with others 4.2 4.9

Economic dependency on children

Not dependent 32.8 35.9

Partly dependent (supplemented by personal

sources) 13.9 11.4

Fully dependent (no self-income) 51.9 51.6

Education status

No formal education 74 40

Male Female Male Female

 Percent

Indicators Rural Urban

Health status

Reporting ailments 29 28 25 26

Immobile/confined to
home/bed 6.7 8.8 6.8 10.0

Source: NSSO (2006).

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In terms of education and health status, 74% of rural and 40% of urban elders lacked formal
schooling in their younger years, with implications for accessing and addressing their health care
needs. Reported ailments are somewhat higher in rural areas where health services are often in
short supply. However, urban older women are more likely to be immobile, with implications for
greater familial care responsibility. The absence of universal social security and health programs
contribute to the dependency of India’s elderly population ( NSSO, 2006 ).

Morbidity data are not available in the NSSO 2006 report. However, in the 1996 report, arthritis
was reported by 34% of the elderly population; vision problems by 26%; high blood pressure by
10%; diabetes by 9%; heart disease by 3%; and other conditions by 2% ( NSSO, 1996 ). A recent
comparison of elder health status in 91 nations ranked Indian seniors near the bottom, at 85
( Global Age Watch Index, 2013 ).

Developments in Research, Education, and Training

Research

Since the earliest studies in the late 1950s and early 1960s that concentrated on the
behavioral and social sciences (see Amesur, 1959 ; Ramamurti, 1956 ; Ramamurti &
Parameswaran, 1963, 1964 ), the pace and breadth of research on aging in India increased during
the 1980s and continues today. Approximately 3,000 articles on various aspects of aging in India
have appeared in a variety of Indian and international journals (see Karkal,
1999 , 2000 ; Ramamurti & Jamuna, 2010a , 2010b ; Ruprail, 2002 ). Research output now falls
into several major categories: medical, biological, behavioral, and the social investigations
( Ramamurti & Jamuna, 2010b ), as shown in Figure 1 .
Medical/Geriatric Research

Initially, medical research on morbidity in the elderly population was hospital-based,

beginning with the work of Pathak (1978) at Bombay Hospitals. Followed by the sustained work
of Venkoba Rao ( Rao, 1979 , 1987 , 1991 ; Rao & Madhavan, 1983 ) of Rajaji Hospital in
Madurai, research focused on physical and psychological morbidity, especially mental health,
depression, and suicide in the aged. During this pioneering period, Rao also directed the first
Task Force on Aging of the Indian Council of Medical Research (ICMR; Rao, 1987 ). In 1988, a
separate in-patient ward for elders was created by Natarajan at the Government General Hospital
in Madras. An outpatient clinic for the aged was established in 1996 by Vinod Kumar at the All
India Institute of Medical Sciences, New Delhi, to conduct a series of morbidity studies ( Kumar,
1996 , 2003 ).

A 1997 landmark issue of the Indian Journal of Medical Research focused on the
prevalence of chronic conditions and their management, including diabetes, hypertension, and
arthritis, as well as disabilities. These issues have continued to be addressed by Sharma
(1999) , Rosenblatt and Natarajan (2002) , Dey (2003) , and Rao (2004) . Since 2009–2010,
increased ICMR funding for individual research projects in geriatrics and geropsychology has
expanded these areas of inquiry. Nutrition also has become another significant area of research.
Recommended Daily Allowances of nutrients for Indian elders have been compiled by the
National Institute of Nutrition at Hyderabad. Research programs conducted by Bagchi
(2000) , Natarajan (1995) , Puri and Khanna (1999) , Shah (2004) , and Sujatha (2004) have
identified the nutritional status of different groups of the elderly population and the effect of
specific supplements on their health status.

Biological Gerontology

Biological research in aging was initiated in the late 1960s by Kanungo and associates at
Banaras Hindu University (BHU) in Varanasi. This work centered on enzymes as modulators of
the aging process and on the role of chromosomal histones and genetic interventions in
modulating gene expressions and their impact on aging ( Kanungo, 2004a , 2004b ). Dr.
Kanungo also founded the nationwide Association of Gerontology (India) in 1981.

This research emphasis has been continued by Thakur and associates, at BHU, by
developing an amnesic mouse model and examining the effects of Aswagandha plant leaf extract
and the role of estrogen coregulator molecules on brain function, including memory ( Thakur,
2003 , 2004 ). Other researchers across India, notably Subbarao (1997) , conduct studies in
several areas, such as telomere repair in brain cells.

Social and Behavioral Gerontology

 Gerontological research in this area has expanded since its beginning to include welfare,
economics, and demography. An extended description of these developments, especially in the
behavioral sciences, was conducted by Ramamurti and Jamuna (2010b) . A major development
was the founding, in 1983, of the first research center on aging in India. The Centre for Research
on Ageing (CEFRA) was established in the Department of Psychology of Sri Venkateswara
University (S.V. University) and has been supported by the University Grants Commission’s
Departmental Special Assistance Program (UGC/SAP) since 1990 ( CEFRA, 2014 ).

More than 20 major research projects conducted by Ramamurti, Jamuna, and associates
have covered a variety of topics including: markers of successful aging; disability assessment
and coping; characteristics of centenarians; and development of a conceptual model of aging
( Ramamurti & Jamuna, 2010a , 2010b ). The current focus is on a prospective cross-sequential
study of health and aging. Besides its teaching, training, and research, outreach activities include
distributing useful handouts for seniors and their families, for example, fall prevention,
improving memory, and nutritional tips for healthy aging.

A major surge of social and behavioral research has occurred since 1990, including major
contributions on gender aging, mental health, and empowerment of women ( Prakash,
2003 , 2004 ); on health and aging of urban elders ( Sivaraju, 2002a , 2002b ); advocacy and
rights of the elderly population ( Nayar, 2003 ); and sociological perspectives on and awareness
of elder abuse ( Shankardas, 2003 ).

Other major areas of inquiry have included rural aging, loneliness ( Prafulla, 2009 );
anthropometry of the elderly population, female aging, and health ( Bagga, 1994 , 2013 );
pensions, old age homes, and coping with disasters ( Anupama & Sonali, 2012 ); and the
demographics of aging and social security (Rajan & Matthew, 2008).

Much of this research has been published in major Indian journals dedicated to aging.
They include the Indian Journal of Gerontology (Indian Gerontological Society); Research and
Development Journal (HelpAge India); Aging and Society: The Journal of Gerontology (Calcutta
Metropolitan Institute of Gerontology); and the Indian Journal of Geriatrics (Indian Association
of Geriatrics). Research findings also appear in periodical reviews and annotated bibliographies
(see Karkal, 1999 , 2000 ; Ramamurti & Jamuna, 2010a , 2010b ; Ruprail, 2002 ).

Education and Training

Higher Education Roles

In contrast to the development of research, the trajectory of gerontological education has

been less robust. The first graduate course in gerontology was introduced in 1976 by the
Department of Psychology, S.V. University, as an applied branch of psychology at the master’s
and doctoral levels. It was followed by a master’s specialization and a multiyear diploma course
in 1990, supported by the UGC/SAP.

The Centre for Molecular Biology of Aging at BHU has offered doctoral programs in
molecular biology of aging since 1980. A postgraduate course in geriatrics was initiated by the
Madras Medical College in 1996.

Despite these initial developments, gerontology as a special course of study in higher education
has grown slowly. In 2000, the Government of India (GOI) recommended that universities and
other educational institutions introduce courses in aging as part of implementing the National
Policy on Older Persons (NPOP). Several institutions now offer courses as part of master’s and
doctoral-level programs in psychology, social work, anthropology, and home science.

Other Organizations Engaged in Research and Professional Training

The National Institute of Social Defence, as part of the GOI’s aging initiatives,
collaborates with nongovernmental organizations (NGOs) and educational institutions to train
individuals in geriatric and other elder care services and to raise public awareness about aging.
The gradual expansion of biomedical research has led to development of training modules in
geriatric clinical care for a variety of health professionals. At the National Institute of Health and
Family Welfare of the Ministry of Health, Khan has initiated programs on training health care
professionals in aging and promoting doctoral research ( Khan, 2011 ).

In 2011, the National Programme for Health Care of the Elderly (NPHCE) was
established to develop a multilevel, intergovernmental structure that delivers care dedicated to
specific needs of seniors. It also builds the capacity of medical and paramedical providers
through training programs.

Other Resources for Aging

National Data Sets

The NSSO reports and the national census data are important resources for both Indian
and international researchers. Beginning in 1985–1987, the NSSO undertook a nationwide
sample survey on rural and urban elders to assess their socioeconomic status. Similar surveys
were conducted in 1995 and 2005, with results published in subsequent years ( NSSO,
1996 , 2006 ).

Census data of the general population are collected every 10 years, followed by reports
from the Registrar. However, these surveys lack detailed information about persons aged 80+.
Efforts are under way to generate separate data on this age group from the 2011 census.
 A new resource, the Longitudinal Aging Study in India (LASI), was created in 2009 by
the International Institute of Population Science of Mumbai, the Harvard School of Public
Health; the School of Medical Sciences, University of California, Los Angeles; and the RAND
Corporation. Its objective is to provide reliable information on the health, health care, and social
and economic aspects of the Indian population, aged 45 and older. Its first phase (2013–2015)
will cover two waves of data and be made accessible to all, including other researchers and
policy makers ( http://www.iipsindia.org/research_lasi.htm ).

Nongovernmental Organizations

With GOI and other funding, NGOs have played major roles in implementing national
policy by conducting studies and offering various services to seniors. The largest—HelpAge
India—established in 1978 ( www.helpageindia.org ). With branches nationwide, it collects data
and offers different kinds of programs (e.g., old age homes, day care centers, health clinics) and
education. Information about research and its programs is published in its Research and
Development Journal .

The Alzheimer’s and Related Disorders Society of India ( ARDSI, 2013 ), founded in
1991, now include many local chapters. ARDSI has focused on various aspects of dementia
awareness and care ( www.alzheimerindia.org ) and provides data on the prevalence of dementia
in India. A recent study reported that one in every 20 Indian elders aged 60+ and one in five aged
80+ suffers from this disease ( Roy, 2010 ).

Other NGOs providing education and care are located in several major cities. They
include the Centre for Gerontological Studies in Trivandrum that organizes seminars and
conferences on aging and rights of the elderly population ( www.cgsindia.org ). The Calcutta
Metropolitan Institute of Gerontology, established in 1988, provides research, training, and care
services ( www.cmig.org.in ). The Heritage Hospitals and Foundation, established in 1994 at
Hyderabad, was India’s first private sector geriatric care service
( www.heritagehealthcareindia.com ). In 2004, the International Longevity Center at Pune was
created to conduct research and training and advocate for the aged ( www.ilcindia.org ).

Several NGOs are advocacy organizations. The All India Senior Citizens Confederation
( www.aisccon.org ) represents seniors nationwide. It publishes a newsletter and a magazine, The
Twilight Years . The SSS-Global is a leading web-based discussion group of senior citizens
( sss-global@yahoogroups.com ). Some foundations in Mumbai provide services and advocate
for the elderly population. They include the Dignity Foundation (1995); the Harmony
Foundation (2004); and the Silver Inning Foundation (2008). Each publishes a magazine for
seniors. Additionally, a large number of local NGOs serve elders by organizing programs on
their rights, health care, and legal aid. None of these organizations, however, has achieved the
same levels of influence on public policy as the AARP in the United States, the Senior Citizen’s
Forum in Canada, or the United Kingdom’s Age Concern ( Nayar, 2003 ).

Government Policy

The GOI, after extended deliberations and consultations with aging experts, established
India’s first national aging policy—the NPOP—in 1999. The Ministry of Social Justice and
Empowerment (hereafter, MOSJE), charged with implementing this policy, had no budget for
this new responsibility. Instead, it was expected to coordinate implementation through budgets of
other ministries identified as relevant to NPOP goals. Major goals include: provide financial
security through savings plans, pensions for the needy and workers in the nonindustrial sector,
special tax deductions, and discounts in travel and hospital services; promote affordable shelter
and subsidize basic necessities (e.g., food); advance and improve primary health care and health
insurance for elders; accentuate research and training in geriatrics and gerontology; strengthen
the family as the primary eldercare provider; and value seniors as human resource partners in
national economic development. The MOSJE disseminates information about senior programs.

NPOP goals and objectives often raise implementation issues. For example, to hold adult
children legally responsible for their aging parents, Parliament enacted the Maintenance and
Welfare of Parents and Senior Citizens Act in 2007. Although the law required state and UT
help, their involvement has been uneven. Their ability to implement national policies is often
dependent on their priorities and budget capacity (Rajan & Matthew, 2008). Six years later, only
15 states and 6 UTs had initiated enforcement ( http://socialjustice.nic.in/oldageact.php ).

This issue and other NPOP problems led to proposals for amending the national policy.
An advisory committee was convened in 2010 that subsequently issued its recommendations in
2011. Various stakeholders have continued providing input. The 2014 elections brought in a new
government that immediately appointed a new MOSJE minister, who is expected to provide
leadership for the new policy on aging.

Emerging Issues on Aging in India

Today, India is challenged by several major transitions (demographic, health,

sociotechnological) since it achieved its independence. As a developing nation, these changes
have been quite rapid, compared with experiences of more developed nations undergoing similar
changes in their past ( Hendricks & Yoon, 2006 ). These circumstances have put considerable
stresses and strains on India’s economy.

A basic issue for current and future Indian elders centers on government versus family
responsibility for their support. Given a trend toward nuclear families ( Khan, 2004 ), to what
extent can the traditional multigenerational family be expected to provide necessary care and
support for seniors, two thirds of whom live below the poverty line? Viable public–private
options are needed for management and maintenance of huge numbers of elders, particularly the
oldest old.

A second issue centers on adequate health care for escalating numbers of elders, many
with chronic diseases that can exacerbate dependency and lead to considerable expenditures.
Current national health programs, as well as proposed expansions in health and mental health
policies, cover all citizens, including seniors, but they rarely address geriatric care needs.

However, important changes are under way. Recently, states have received NPHCE
funding to develop regional geriatric centers and local clinics. Implementation will probably take
some time before it is widespread (K. R. Gangadharan, personal communication, April 18,
2014). Additionally, two National Institutes on Aging, to be funded by the GOI, have been
designated, one in the north (Delhi), the other in the south (Chennai). NGOs also play important
roles, as exemplified by a recent telemedicine/hospital-based dementia care management system
in Bangalore ( www.nightingaleseldercare.com ).

Finally, the LASI study is expected to generate significant data on health issues of
middle-aged and older adults as a basis for future health care provision. Policy makers and
NGOs at all levels also must familiarize themselves with effective policies and programs within
India and elsewhere.

A third issue concerns income security of the elderly population. National means-tested
monthly old age pensions are paid to poor, widowed, or single elders aged 60+, lacking family
support. States administer this program and can opt to provide monthly supplements, ranging
from 50 to 1,000 rupees, depending on the extent of their welfare budgets and other concerns.

Currently, there are two other kinds of pensions: a lifetime monthly retirement benefit,
predominantly for government workers, and lump-sum “provident funds” for some private sector
retirees. Critical long-range solutions involve expanding the availability of lifetime savings and
pension plans for those who work in nonindustrial and casual occupations, and developing a
universal social security program, particularly for the oldest old.

Developing national programs for India’s elders will increase the demand for more
research and education about aging, including effective social policies for the growing numbers
of seniors ( Birren, 2006 ). Strategies for enhancing gerontological education programs include
increased research funding; faculty development and continuing education of existing faculty;
widespread professional education, training and certification; expanded graduate and
undergraduate degree education; and practical education for elders and their families, especially
those who live in rural areas ( Liebig & Kunkel, 2014 ).
 In recent years, population aging has been recognized as an emerging social challenge in
many parts of the world. Some clear evidence of population aging is observed; for example, the
share of the aged 60-plus population in the world increased from eight percent in 1950 to 12
percent in 2014, and it is predicted to be 21 percent by 2050 [1]. The global life expectancy also
increased from 47 years in 1950 to 70 years in 2014, and a further increase to 75 years is
expected by 2050 [2,3,4]. Only a few decades ago, the major concern regarding world
demography was its rapid growth and increasing pressure on the ecosystem and food security
[5,6]. While population growth will continue in some fast-growing countries in Sub-Saharan
Africa and South Asia [7], the population aging phenomenon will have profound impacts on
various dimensions of society, and this aging trend will be intensified in the coming decades
[8,9].
Although there is an accumulation of studies about population aging covering diverse
topics, existing literature concentrates on population aging mainly in developed countries.
Population aging is largely seen as a threat to: (i) sustainable economic growth due to the
possible shrinkage of the labor force [10,11]; and (ii) social security systems to support the
elderly, such as pension plans, healthcare schemes and long-term care insurance [12,13,14,15].
In contrast to these alarmist views, some call attention to the emerging “silver market” to
illustrate a positive economic outlook ([16], pp. 22–23; [17,18]). Moreover, possible mitigation
of economic decline is suggested by way of increasing female labor participation and policy
reforms regarding the legal retirement age [19].
Despite the wide coverage of the earlier literature, these issues may represent only part of
the entire picture of population aging because they are limited to macro-scale changes derived
from population estimations. Furthermore, compared to the volume of knowledge on the cases of
developed countries, little is known about the actual changes that people, both elderly and young
population groups, are and will be experiencing in developing countries.
With the increase of life expectancies and the actual size of the older population defining an
era of aging societies, in which increasing proportions of older populations will continue in the
coming decades, what kinds of challenges should we expect? Given the expected impacts of
population aging in the coming decades, aims to: (i) describe population aging trends in the
world and the regional demography; (ii) provide a structural review of population aging
challenges at three levels, namely the national, the communal and the individual levels; and (iii)
elaborate future research topics on population aging that particularly emphasize the situation of
developing countries. For the third objective, this study briefly introduces the current state of
rural Japan, which is possibly the most aged region in the world. The case of rural Japan is
presented to illustrate the emerging population aging challenges in rural areas where the aging
phenomenon is happening rapidly.

2. The Era of Aging Societies

2.1. Population Aging in the World and the Regional Demography
 As was briefly mentioned in the previous section, the world demography is shifting to an
era of population aging. Figure 1 presents the demographic changes of the world and three sub-
regions1 with four age groups, and the share of older populations (aged 60-plus) from 1950–
2100. As the figure of the “World” clearly shows, aging will emerge as a strong trend in the
world demography. At the same time, Figure 1 also illustrates different patterns of population
aging in three sub-groups.

Figure 1. Population trends of the world and three sub-groups with four age groups and the
shares of the aged 60-plus population. Note: Created from population estimations for 1950–2010
and population projections with a medium fertility rate for 2015–2100 by the United Nations.

In the world demography, the older population group remained below 10 percent from
1950–2010 (“World” in Figure 1). The predictions suggest a steady increase of this age group
from 2015 onward. The share of the older population is predicted to reach 21.5 percent by 2050
and 28.3 percent by 2100. Although some scholars suggest that the world population may
stabilize at around 10 billion people after 2050 [20], aging will remain as a clear trend in the
world demography in the coming decades.
In the case of more developed regions, population aging was already present in the late
1970s as the share of the older population exceeded 15 percent by 1975, and it further increased
to 21.9 percent by 2010 (“More developed regions” in Figure 1). One key demographic feature
of developed regions is that the total population will be stabilized at around 1.28 billion from
2030 onward. At the same time, the size of the older-old (age 80-plus) group is expected to
increase steadily. This demographic pattern will create a further increase in the share of the older
population to 32.8 percent by 2050 and to 34.6 percent by 2100.
 In the less developed regions, population aging will quickly evolve from 2020–2060 as the
share of the older population is predicted to double from 11.9 percent to 21.8 percent (“Less
developed regions” in Figure 1). Although the acceleration of population aging will be slower,
the aging trend will continue to be on the rise, with an increase to 27.5 percent by 2100.
In contrast to the other two sub-regions, the least developed countries will experience rather
gradual population aging. As Figure 1 shows, the share of the older population is predicted to
increase gradually from 5.3 percent in 2010 to 9.8 percent by 2050 (“Least developed countries”
in Figure 1). From 2050 onward, aging will be accelerated in these countries, with the
proportion of the older population expected to reach 20.5 percent by 2100.
Along with its share, the actual size of the older population is also important. Figure
2 presents the projection of the aged 60-plus population in six regions of the world. Among
them, Asia will be home to 1.3 billion of the elderly by 2050 and 1.6 billion by 2100. Africa will
be the region with the second largest population of older people by 2100, with 844.4 million
people. Latin America will also experience a drastic increase of the older population from 70
million in 2015 to 200 million by 2050, and a further increase to 269.9 million by 2100. In
contrast, in Europe, Northern America and Oceania, the pace of older population increase will
not be as significant as the other regions (Figure 2).

Figure 2. Trends of the aged 60-plus population in six regions of the world. Note: Created from
population estimations for 1950–2010 and population projections with medium fertility rate for
2015–2100 by the United Nations.

2.2. Demographic Causes of Population Aging

Population aging is mainly caused by two demographic changes: (i) decline in fertility rates;
and (ii) increase in life expectancy ([7,21,22]; [23], pp. 13–20; [24,25]). These two demographic
changes are long-lasting and largely irreversible as countries achieve social and economic
development [26].
 As Figure 3 shows, the decline in the fertility rate has been a long-term trend in both the
world and regional demography. The total fertility rate in 1950 at the global level was 4.9 births
per woman. The figure dropped to 2.6 births by 2010, and a further decline to 2.0 births is
expected by 2050. At the regional level, the decline in fertility rate has been particularly
noticeable in Europe and Asia. In Europe, the figure dropped from 2.7 births per woman in 1950
to 1.5 in 2010, and an additional slight decline to 1.5 births by 2050 is predicted. As for Asia, the
figure was 5.8 births per woman in 1950, but it dropped to 2.3 by 2010 and is projected to be 1.9
by 2050. Although Africa still has as high as 4.8 births per woman today, the region is on a long-
term declining trend. The projection suggests that the fertility rate of Africa will decline to 3.1
births per woman by 2050. As Figure 3 illustrates clearly, low fertility rates are common across
all regions, and this trend will be accelerated in the coming decades [27].

Figure 3. Trends in the total fertility rate in the world and six regions. Note: Created from total
fertility estimations for 1950–2010 and projections with a medium fertility variant for 2015–
2050 by the United Nations.

The second demographic cause of population aging, the increase of life expectancy,
increased significantly both in the world and regional demography. Figure 4 depicts a long-term
trend of life expectancies for the world and six regions. The world average was 46.8 years in
1950, and it increased to 68.8 years by 2010 (22-year increase). Asia and Africa were two
regions with lower life expectancies than the world average in 1950 at 42.1 years and 37.3 years,
respectively. By 2010, Asia surpassed the world average at 71.6 years, although Africa still
remained much lower than the world average at 56.5 years. Latin America had about a five-year
longer life expectancy than the world average in 1950 at 51.2 years, and it increased to 74.5
years by 2010. Northern America was the region with the longest life expectancy at 68.6 years in
1950. This region already surpassed 70 years by 1970 and further increased to 79.2 years by
2010. Europe and Oceania regions also had about 15–18-year longer life expectancies than the
world average in 1950. These regions also experienced an increase, to 77.5 years by 2010.
Towards 2050, the life expectancies in Asia, Northern America, Latin America, Europe and
Oceania are projected to increase further. Asia is expected to reach 78.0 years, and the remaining
four regions are expected to reach somewhere between 81.0 and 84.0 years. Although Africa will
continue to have lower life expectancy than the world average, the region’s figure is expected to
increase sharply to 66 years by 2030 and nearly 70 years by 2050. Overall, as Figure 4 also
presents, the world average life expectancy increase will be a 30-year increase from 1950–2050.

Figure 4. Trends in life expectancy at birth in the world and six regions. Note: Created from life
expectation estimations at birth from 1950–2010 and projections with medium fertility variant
for 2015–2050 by the United Nations.

In addition to the increase in life expectancy at birth, the increase of life expectancy at older
ages is also a major contributor to population aging. Shrestha (2000) [28] states that population
aging is defined by demographers as “an increasing median age of a population or an alteration
in the age structure of a population, so that elderly persons are increasingly represented within a
country’s overall age structure”. However, population aging is also about people living longer
lives than they did in the past, as life expectancies, particularly at older ages, have improved
[29]. Table 1 shows the trends of life expectancy at age 60 in the world and six regions for males
and females. In the world population, a 60-year-old male could expect a remaining 13.1 years in
1950, while this increased to 17.8 years by 2000 and is predicted to reach 21.7 years by 2050. As
for a 60-year-old female, it was 15.3 years in 1950, 20.8 years in 2000, and it is expected to be
24.3 years by 2050. In each region, in general, there is an increasing trend in life expectancy of
about 6–10 years from 1950–2050. Females, throughout this time, have about a two- to three-
year longer life expectancies than males.
Table 1. Life expectancy at age 60 in the world and six regions.

3. Pervasiveness and Acceleration of Population Aging

As previous sections illustrate, one key characteristic of the population aging phenomenon
is its pervasiveness both in developed and developing countries. In terms of geographical
expansion, those areas with more than 20 percent of their population being age 60-plus are
concentrated in Europe, North America, Oceania and Japan in 2014. However, by 2050,
countries with the same proportion of elderly people will expand to both North and South
America, the entirety of the Eurasian continent and a wide area of the Asia and Pacific region,
even in some countries in Northern Africa and the Middle East [30,31,32].
In developing countries, the expansion of population aging is happening at a much faster
pace than developed countries. Another common indicator to measure the degree of population
aging is to examine the time (number of years) elapsed for the increase in the share of the aged
65-plus population or the elderly dependency ratio (EDR) from 7–14 percent [22,33,34,35].
Furthermore, some scholars have put forward 21 percent (or 20 percent or higher) as another
figure to illustrate a super- or hyper-aging society [10,36,37,38]. Reflecting these possible
benchmark figures, Figure 5 presents the number of years taken or predicted to take for three
aging transitions at the societal level. Each phase of transition is in multiples of 7–28 percent. As
for the first transition, from 7–14 percent, European and North American countries took a half to
one century to achieve this transition. For example, France, Norway and Sweden took more than
80 years; Australia, Canada and the United States needed more than 60 years; and even the
shortest cases—Germany, Spain and the United Kingdom—took more than 40 years. In contrast,
the first transition took place or is predicted to happen within 30 years in Asian and South
American countries. It will be particularly short, less than 20 years, in Brazil, Colombia, South
Korea and Vietnam.
Figure 5. Number of years taken or predicted to take for three aging transitions in selected
countries. Note: Created from the Organisation for Economic Co-Operation and Development
(OECD) and UN demographic database. Years in parentheses are the periods during which each
aging transition occurred or is predicted to occur.

The second and third aging transitions are predicted to happen within a much shorter
amount of time in developed countries. The second transition, from 14–21 percent, is expected to
happen in less than 60 years for Europe, less than 20 years for Canada and the United States and
in around 10–15 years for Asia and South American countries. All countries listed in Figure
5 will complete the second aging transition by 2050. Although the third aging transition may take
a longer time for some European countries, it is also expected to occur as rapidly as the second
transition in the majority of countries (Figure 5). Currently, only Japan, Germany and Italy have
reached the second aging transition, and among these three countries, Japan is the most rapidly
aging country, as it will reach the third transition by 2019. In general, the number of years taken
or predicted to take for these three aging transitions are expected to be lower as these countries
move to later transitions in the future.
As Figure 5 illustrates, population aging will be greatly accelerated in the coming decades
and have profound impacts both in developed and developing countries. This phenomenal
acceleration of population aging would particularly be a peril for developing countries, as they
have to face the emerging demands for medical treatment, long-term care and financial support
for aging societies before they fully benefit from their economic development ([39], pp. 30–47;
[40,41]; [42], pp. 86–95). Responses to population aging and related social challenges must be
developed according to the speed of population aging in developing countries.

4. Population Aging at Three Different Levels

As numerous profound impacts of population aging are anticipated, it is important to
structurally analyze the expected challenges at different levels. This point is also supported by
Bloom et al. (2011) [43], as they propose adaptation strategies to population aging at three
different levels: (i) societal; (ii) organizational; and (iii) individual levels. Employing a set of
analytical levels will greatly help, particularly developing countries, to foresee possible
challenges. In this paper, the authors propose using (i) national; (ii) communal; and (iii)
individual levels to delineate the emerging population aging challenges.
4.1. Population Aging Challenges at the National Level
At the national level, in developed countries, population aging is often framed as an
imminent issue for social welfare systems, which are based on the balance between the older
population who receives services and the younger population who supports the system’s
operation ([12,44]; [45], pp. 9–28; [46,47]). In 2010, there were four persons of working
population age (age 15–64) to support one older person (aged 65-plus) in developed countries;
however, this ratio is predicted to decline to three working age persons to one older person by
2025 [7]. This change in the balance between the older population and the younger population is
caused by the rapid increase of the older-old population (aged 80-plus) in the coming decades
[2]. Since public insurance for medical and geriatric services is covered almost universally in
developed countries [48] and the older-old persons have a higher risk of suffering from chronic
diseases and developing disabilities [49,50], there will be considerable pressure on welfare
budgetary schemes. For example, Japan, the most aged country in the world where the aged 65-
plus population accounts for 25.1 percent of the population, the share of social security
expenditure of the country’s total national income increased from 5.8 percent in 1970 to 29.6
percent in 2010. In actual terms, 70.5 trillion yen (equivalent to 579.5 billion US dollars) was
spent on elderly care, which is equivalent to 68.1 percent of total social security expenditure.
This figure was the largest ever, yet continual increases are expected [51].
In the context of developing countries, where social welfare schemes are not yet well
established, the main challenge is to adequately respond to the escalating medical and other
needs of the elderly. Among these countries, the impact of aging will be felt most drastically in
China, as the country has the largest aging population, which is 160 million aged 60-plus people
[52]. Considering the country’s shortage of nursing centers, the difficulty in constructing care
facilities fast enough to catch up with the growing aging population and the relatively expensive
medical costs for low and middle-income people in China, it will be important to train geriatric
care workers, to prepare a policy to cover uninsured and underinsured elderly and to build a
strategy to cope with the expected increase of elderly with disabilities [53,54]. Although there is
a considerable difference in terms of the speed and scale of aging transitions in each country, the
development of socioeconomic systems to provide economic security for the growing older
population will be a shared concern among developing countries [22].
4.2. Population Aging at the Communal Level
The definition of the communal level needs to be flexible, since this level includes all units
of society between the national and the individual levels. In a practical sense, the communal
level includes all administrative units below the national government, such as provincial and
municipal areas, and those smaller units of social groups, such as neighborhood communities or
voluntary groups of residents. In addition, the focus of the communal level is not limited to the
well-being of the elderly. The core challenge at this level is about securing adequate living
conditions for all generations and maintaining the livelihood of societies while facing population
aging challenges.
As for developed countries, topics discussed at the communal level in earlier literature have
varied across urban and rural areas. The issues of shrinking cities and abandonment of facilities,
such as complex housing, are discussed in relation to the living environment of elderly residents
in urban areas [55,56]. Recent urban, community-based initiatives, such as Groundwork in the
United Kingdom [57,58] or Machizukuri (participatory planning process) in Japan [59], are
exemplary communal initiatives that aim to create social ties by enhancing citizens’ participation
in city and neighborhood planning [60]. These bottom-up and autonomous approaches in
community design enable the community members to address the demands of older residents.
These local initiatives encourage residents’ collective actions to build an inclusive society for all
generations in urban communities.
In rural areas, the proportion of the older population tends to be higher than in urban areas,
often as a result of youth migration to cities [23]. Such out-migration of rural young population
is increasingly common in developed countries, and older residents are often left behind in rural
towns [61,62,63,64]. In the case of Japan, the United Kingdom and Ireland, rural residents are
experiencing critical declines in access to basic services, such as grocery stores, post office
services and gas stations, due to gradual withdrawal of service providers from remote areas
[65,66,67,68,69,70]. Closures of basic services primarily affect local living conditions,
particularly of elderly households, and decrease chances for interaction among community
members, which often becomes a driver of social isolation for older residents.
In the case of developing countries, the types of challenges at the communal level are more
diverse and particular to social contexts. Although the literature is limited, Rittirong et al. (2014)
[71] reported the importance of support by community organizations, such as Buddhist temples
or local healthcare centers, in Thailand. They also pointed out that religion has an important role
for the elderly in Thailand, as they participate in ceremonies at temples on holy days every
month and interact with other participants. Cases of community care are also reported in Taiwan
where neighborhood-based communities in cities may be critical in providing geriatric care for
the urban elderly [72]. As social welfare schemes for the elderly are either not available or may
not be fully established, structural responses at the communal level will be a key approach for
community-based care for elderly residents. In addition, the notion of sustainable development
will be particularly useful in analyzing diverse and unpredictable population aging challenges in
developing countries. The application of the sustainable development concept allows a holistic
view to investigate hidden challenges, as it explores the economic, environmental and social
dimensions of the target system [73].
4.3. Population Aging at the Individual Level
Aging is a life course process of individuals. During this process, every person experiences
gradual changes in physical and psychological conditions. The main challenge of population
aging at this level is how to ensure the fulfillment of living conditions for older individuals.
Regardless of the differences between developed and developing countries, older people
tend to be at higher risk on various occasions in their day-to-day lives. Earlier studies suggest
that older people have higher health risks and a greater possibility of being victims of severe
climate events, such as heat waves [74,75,76] and hurricanes [77,78]; especially those with
chronic diseases are more vulnerable to these events. In addition, older people are also exposed
to greater risks by being trapped in a state of social exclusion or relative poverty [79,80,81].
In terms of the psychological conditions of older people, loneliness and social isolation are
two important concepts that enable better understanding of the state of older people in a society.
To begin with, loneliness is a subjective notion and describes the state of individuals
experiencing the loss or absence of an intimate or needed relationship [80,82], yet it does not
necessarily imply the state of an individual being alone per se. Drennan et al. (2008) [83]
concludes that people with a higher degree of loneliness tend to be: (i) males at the low income
level; (ii) those who infrequently communicate with their children or other family members; and
(iii) often those who provide home care for their spouse or relatives. In contrast, social isolation
is an objective notion that describes the actual degree of connectedness to other individuals or
social groups. The condition of being socially isolated is explained as “the objective state of
having minimal contact with other people” [84]. Poor physical health, low morale and
experiencing difficulties in communication and mobility are considered as the causes of social
isolation [85]. As individuals go through different stages of life, they experience various patterns
of losing social relationships that they have built. For example, retirement is a representative
occasion of losing connections that can increase one’s vulnerability not only in financial terms,
but also in social relationships. Deaths of partners, friends and family members are also symbolic
moments that may become a trigger for a greater degree of social isolation.
Along with general life events, gender appears as the second trigger for social isolation.
Older women often receive a double jeopardy that positions them first as “elderly” and second as
“woman”. In fact, older women tend to be subjected to discrimination in employment, access to
daily needs, ownership of property and even participation in leisure activities [86,87]. Such
inequalities in older woman tend to appear in a rural setting more so due to the required travel
distance to services; recent price increases in energy and food are placing additional pressure on
household budgets, and such situations are generally more difficult to manage for older female
residents [66,88]. In addition, in developing countries, older women tend to have lower
educational levels and economic independence; hence, they tend to be economically dependent
on either their husbands or relatives [89,90].
One major challenge regarding loneliness and social isolation of older people exists in the
social perception towards older people. General perceptions of the elderly often have negative
connotations, and they set a strong assumption that “older people are inevitably dependent and a
burden on society” [91]. Such stereotypes classify the older population as welfare beneficiaries
and underestimate their contributions to society. In reality, older residents, especially those in
their pre-retirement, are often found as major contributors in caregiving and volunteering and
also as active entrepreneurs in local communities [92,93,94]. In a society with higher proportions
of the elderly, it will be critical to build an inclusive atmosphere not only for older residents, but
also for all generations, recognizing older residents as active members of society and actively
working to prevent loneliness and social isolation.

5. Topics for Future Research

5.1. Population Aging and Sustainable Development
As discussed in the previous sections, population aging is increasingly becoming a global
phenomenon, and various challenges are predicted across the national, communal and individual
levels. Particularly in developing countries, where both physical infrastructure and social
systems are rapidly evolving, what will be the unique challenges related to aging? More
specifically, along with the challenge in establishing social security systems and ensuring further
economic growth at the national level, what should be the focus of studies on population aging at
the communal and individual levels in the social and cultural contexts of developing countries?
To answer these questions, discussing population aging in line with the concept of sustainable
development, which incorporates intergenerational equity, environmental concerns and social
equality dimensions while pursuing economic development [95,96,97], would be very helpful, as
it provides a holistic view to address different dimensions of the aging phenomenon.
To start with, the current development scheme of developing countries does not necessarily
address the demands of the elderly. This is clearly pointed out by Shetty (2012) [98] who argues
that there has been “a massive disconnect between the Millennium Development Goals
(MDGs) and aging”. Highlighting the looming threat of aging in the coming decades, some
international organizations are calling for global attention to include population aging on
the sustainable development agenda [99,100]; however, aging is not included in post-MDG
discussions. This may be because of the still very young population of developing countries.
Shetty (2012) [98] pointed out that many developing countries have made their efforts in dealing
with diseases in youth and middle-aged people intensively, which has led them to achieve longer
life expectancies. However, such prioritization of the younger population has caused a situation
that many developing countries are unprepared to meet the needs of the emerging elderly
population [98]. Developing countries need to incorporate aging in their development agendas,
and strategic responses at all levels are required. Moreover, it is critically important to implement
such responses today, as any measures addressing demographic issues require a long time to
observe their effects fully [101].
Secondly, these responses to population aging should not be limited to policy level
discussions on such topics, such as the sustainability of social security systems; aging in every
dimension of society must be addressed. This is particularly the case for developing countries
where the impacts of environmental issues are more acute and the general living conditions of
elderly residents are more affected by rapid social changes [102]. Although there is a great
degree of heterogeneity among developing countries, a few studies reported unsafe living
conditions for the elderly. Although the higher chance of older residents to be crime victims is
not confined to developing countries, Veras (2009) [103] documented that elderly Brazilians
have to live with the fear of violence, which reflects the high crime rate of the country.
Somrongthong et al. (2014) [104] report possible dangers related to housing environments in
rural Thailand, such as “lighting and unsafe wires”. Accordingly, social infrastructure, such as
public facilities, transportation and public housing, needs to be designed to be accessible for all
generations, including older residents.
Thirdly, population aging needs to be examined in relation to other development challenges,
because aging populations will be a predominant condition in most countries in the coming
decades. For example, urbanization is another universal phenomenon; by 2030, more than 60
percent of the global population will be living in cities, and about 25 percent of them will be
aged 60-plus [105]. The combination of population aging and urbanization is considered as a
major demographic challenge of this century [106]. Despite the abundant studies on population
aging and urbanization, respectively, not much research has examined these two challenges
together. A review paper by Phillipson (2004) [107] listed: (i) elucidating the urban context; (ii)
examining the impact of globalization on definitions and perceptions of place; and (iii) urban
ethnography to comprehend the experience of aging within cities, as agendas for urban aging
research. Regarding the urban context, Smith (2009) [108] identified three factors that prevent
older residents from aging well, which are: (i) neighborhood problems, such as overcrowding,
noise and air pollution; (ii) living environment problems; and (iii) perceived city environment,
such as fear of crime and access to high-quality services. Particularly, living environment
problems include practical fears in the daily lives of older people, such as “negotiating hilly
and/or uneven terrain, and worries about being able to sit down whilst out shopping” [109], and
access to public toilets in the city centers [106]. These earlier studies are limited to the case of
developed countries.
As for developing countries, one such challenge related to urbanization pertains to the types
of urban residences. A large-scale migration from rural areas to cities has been taking place due
to rapid urbanization, and significant numbers of these migrants first settle in residential areas
with low-income level households or informal settlements in an urban area. Some of them
eventually move to other parts of the city, whereas the others continue to live in the same areas
and become permanent residents. As those permanent residents become aged, their experiences
in an urban settlement would differ greatly from those of older residents in developed countries.
Furthermore, urbanization often holds diverse environmental challenges in such areas, as water
quality, air pollution and waste management. As urbanization with all its complexities is
expected to expand rapidly in developing countries, further studies are required to examine how
environmental challenges affect older people and the local responses needed.
5.2. Community-Function Decline in Rural Areas:
Emerging Topic from the Experience of Japan
The other expected challenge related to population aging in developing countries is rural
declines induced by the recent rapid urbanization trend. This is because urbanization is largely
driven by the migration of young populations, which affects the “age distribution in both sending
and receiving areas” [110].
In developed countries, rural areas are hollowing out due to the continual out-migration of
young populations, and rural areas are experiencing diverse declines not only in their
demographics, but also in local economies, living environments and social vitality [61,111].
Among those countries that are experiencing such rural declines, Japan’s experience is
particularly drastic.
In Japan, a large-scale migration of young population to major cities occurred between the
late 1950s and the early 1970s during a period of rapid economic growth [112]. Figure
6 illustrates the changing flow of in-migration of three major city areas in Japan. The peak time
for this large-scale migration was the period of 1955–1960, when about 588,000 people moved
to these three metropolitan areas. Although the size is much smaller, the migration trend to the
Tokyo area is still present today, with around 65,000 people migrating there in 2010 (Figure 6).

Figure 6. In-migration of three major city areas in Japan from 1955–2010. Note: Created from
the report on Internal Migration in Japan by the Ministry of Internal Affairs and
Communications. Counted numbers show only Japanese nationality. Area definitions are as
follows: the Tokyo area includes Chiba, Kanagawa, Tokyo and Saitama prefectures; the Nagoya
area includes Aichi, Gifu and Mie prefectures; the Osaka area includes Hyogo, Kyoto, Nara and
Osaka prefectures.

Between two National Censuses of 2005 and 2010, 38 out of the country’s 47 prefectures
experienced negative population growth [113]. Especially, five prefectures with the greatest
degree of depopulation (Aomori, Akita, Iwate, Yamagata, Kochi) experienced a four–five
percent population decline annually during this five-year period. As of 2013, the share of older
people (aged 65-plus) in these five prefectures was between 27 and 32 percent, while the national
average was at 25.1 percent. Among them, Akita had the highest share of older people at 31.6
percent. Rural Japan is one of the areas in the world where the most rapid population aging has
happened; therefore, its experience can provide significant insights for rural areas of developing
countries where similar patterns of rural decline are predicted due to the rapid urbanization
experience.
One clear impact of population aging can be found in the declining community vitality in
rural areas. Though it is a relatively new concept and does not have a universal definition,
community vitality is seen as “the ability of a community to sustain itself into the future as well
as provide opportunities for its residents to pursue their own life goals and the ability of residents
to experience positive life outcomes” [114]. This concept is close to the notion of ‘community-
function’ developed by Japanese scholars in rural studies. In rural Japan, residents form
neighborhood-based social relationships for the activities that are essential for maintaining their
livelihood and local environment. These collective actions are recognized as a set of functions,
called “community-function” (originally “shurakukino” in Japanese), that each rural community
has ([115], pp. 73–76; [116,117,118,119,120]). Although there is no established set of indicators
for its measurement, earlier studies suggest that the collective actions of residents are critical for
sustaining community-function. For example, collective actions of residents in farming and
forestry, maintenance of living environments and local events, such as seasonal festivals and
traditional performing arts, are considered as key activities to determine the quality of
community-function.
Community-function is a useful notion for understanding the self-managing capacity of a
rural community, and its decline implies the weakening of community vitality. As a result of
continued outflow of young people and the aging of residents, rural communities are
experiencing drastic declines in community-function, and further declines are seen as possible
threats to the sustainability of rural communities [121].
Rural studies in Japan examined the actual changes that residents experience during the
declining process of community-function. They claim residents face a wide range of challenges
in their living conditions in such aspects as transportation and access to basic services [69,122],
management of vacant houses and community facilities [56,123,124] and abandonment of
farmlands and communal forests due to aging of farmers and lack of successors [125,126].
 The succession of traditional knowledge is another concern during the rural decline process,
as it has been the main body of knowledge about the interaction between nature and society
based on the regular observation of the local environment, which looks at patterns of natural
cycles including crises [127,128]. Traditional knowledge is also linked to local beliefs and
understanding of place that are critical to the identity formation of local people. The case of rural
Japan illustrates a severe situation regarding traditional knowledge transfer over generations as
older residents practically cannot transfer their knowledge to younger generations since there are
fewer young people in their communities. Additionally, even if some young people remain in
rural communities, many of them are not engaged with farming, which is a key intermediary
between nature and society. This situation makes learning specific types of traditional
knowledge, which they can only acquire through direct observations and experiences with
nature, much more difficult.
The main challenge for rural decline is to find a sustainable approach to reinvigorating the
declining community-function and to create new functions to respond to emerging challenges.
Fulfillment of declining functions may be achieved by merging a number of rural communities to
keep the critical mass for maintaining the minimum size and quality of community-function.
This initial phase of response aims at securing the living conditions of rural residents. Yet, at the
same time, it would be critical for rural communities to be open to the external infusion of
knowledge. New knowledge from outside may revitalize the traditional knowledge to preserve
declining community-function or add novel functions addressing new local challenges. In fact,
the demands of residents are likely to change, as there is a higher share of older residents in a
community. Further case studies are required to identify the role of traditional and new
knowledge during the process of population aging in rural communities.
Considering the larger scale of urbanization and population aging, a faster pace of rural
decline is expected in developing countries. For example, Gautam (2008) [129] reported the
living conditions of elderly residents in Nepal, noting that they are largely left alone in rural
villages and feel helplessness, loneliness and frustration even though they receive financial
support from their out-migrated children who are making their own livings in cities. Flahety et
al. (2007) [54] also claim that the recent trend of rural-to-urban migration may interfere with the
traditional networks of children to provide care for the elderly, as they are physically distant
from their home. Although the same degree of population aging as Japan may not be observed,
studies on rural decline, especially in terms of community-function and traditional knowledge,
will be critical for developing countries.