Ageing: Its Health Implications
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- Title
- Ageing: Its Health Implications
- Creator
- Udaya Shankar Mishra
- Date
- 2000
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MFC 2000 Meet Background Papers
Ageing: Its Health Implications'
Udaya Shankar Mishra
Centre for Development Studies, Trivandrum
1. Ageing: An Overview
The phenomenon of ageing conceived in terms of chronological measurement has
become an area of demographic research and studies of ageing in human population
are of quite recent origin. Rapid social and economic changes are expected to have
serious implications for the circumstances under which the future elderly will
live. These socio-economic changes consist of family nucleation, average smaller
number of children per couple, greater longevity, physical separation of parents
from adult children as a result of rapid urbanisation and age selective rural-urban
migration and also the changing values of the younger generation against the older
one.
Population ageing is an obvious consequence of the process of demographic
transition.
Being ahead in the process, the developed regions of the world have
already been experiencing this situation and the developing world is well on its
way to face a similar scenario.
Though the proportion of elderly persons (defined
in terms of aged 60 and above in a population) is low in some of the developing
countries, the number of elderly persons in absolute numbers are more because of
the large population base.
Projected increase in both the absolute and relative size of the elderly
population in many third world countries is a subject of growing concern for social
policy (Treas and Logue, 1986; Grigsby 1993; World Bank 1994). These increases are
the result of changing fertility and mortality regimes over the last forty to fifty
years. The combination of high fertility and falling mortality during much of the
present century ensures that there will be large and rapid increases in elderly
population as successively larger cohorts enter the older ages. Further, the recent
sharp declines in fertility ensure an increasing share of future elderly. Given
that these demographic changes have been accompanied by rapid and profound socio
economic change, cohorts have differed in their experience as they have aged.
Despite growing awareness of recent and impending increases,
few empirical
assessments have been made of the accompanying compositional changes that might be
expected in these elderly populations or to the historical and dynamic aspects of
cohort succession which give rise to these changes.
With the background of transient fertility and mortality trends, it is
worthwhile to preface our discussion with an account of the structure and magnitude
of the elderly. The number of elderly in the developing countries has been growing
at a phenomenal rate to the extent that in 1990 the population 60 years old and
over in the developing countries exceeded that of the developed countries
(estimated world total of 490 million). By 2030, that number will triple to 1.4
billion. Most of this growth will take place in developing countries and over half
of it in Asia (World Bank 1994) . Obviously, the two major population giants of
Asia, namely India (Irudaya Rajan, Mishra and Sarma, 1999) and China contribute a
significant proportion of this growing elderly in future. A detailed account of
growing elderly population in India and its states (See Appendix Table Al) has been
included.
* A Major part of this paper has been extracted from the book India's Elderly:
Burden or Challenge, Sage Publications, 1999.
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MFC 2000 Meet Background Papers
Ageing and its Health Implications:
The changing age structure of the population results in different patterns of
ageing. Consequently, the pattern of death and disability due to ageing in a
population would also vary. This ageing pattern causes differential health risks in
a population as a result of the epidemiological transition process.
Secondly,
extended years of life unaccompanied with better physical well being during later
ages poses a greater demand for health services. Often,
a high price is paid for
ensuring disability free old age which is a resultant of postponing death with
improvement in mortality. The following table shows the trend in expected years of
life that an Indian will have beyond sixty years of age. Given that the expected
years of life beyond sixty years is increasing, it will be essential to make these
years free from disability. In fact, according to Murray and Lopez (1996) a quarter
of this extended life will be with disability of one kind or the other. Also
predictions are made with regard to these disabilities on account of noncommunicable diseases mainly cardio-vascular, neuro-psychiatric, sense organ and
respiratory related symptoms. Therefore, in order to make these additional years of
life more productive and healthy, there is a need to plan and provide for an
increasing burden of chronic disease morbidity, some of them rather debilitating
for the elderly.
Table 1: Expectation of life at ages 60 and 70 for India.
Year
1971
1981
1991
2001
2011
2021
Male
Female
e60
e70
e60
e70
13.80
14.25
15.01
15.74
16.29
16.75
8.57
8.83
9.27
9.70
10.03
10.32
14.75
15.31
16.23
17.05
17.75
18.18
9.10
9.42
9.97
10.45
10.87
11.14
Demographic Transition and Epidemiological Transition:
The demographic transition described is accompanied by changes in the pattern
of disease- the epidemiological transition first defined by Omran(1971). In the
past, as nations underwent social and economic transformation, improvements were
gradually reflected in changing pattern of disease for instance through control of
infectious and parasitic diseases contributors to early mortality. However, the
experience of recent decades has shown that developing countries are now undergoing
changes in disease patterns, even in the absence of socio-economic development.
This is largely due to impact of medical technology. A patient with tuberculosis
for example would have died at a young age in the past is now likely to survive due
to availability of effective treatment. The same could be said of a child living in
a slum who will not experience infectious diseases such as measles or poliomyelitis
due to availability of vaccines. The control of infectious diseases in the
developing world has taken place more rapidly. For example the share of infectious
and parasitic diseases causing death has been replaced by deaths due to
cardiovascular diseases and neoplasm (Kalache,
1991). Though,
some of these
infectious diseases like pneumonia and dysentery remain widespread, they cause
fewer deaths.
On the contrary disease causing agents
like cardiovascular,
intestinal and respiratory infections are of greater importance in terms of
morbidity or potentials years of life lost.
Trends in the duration of life lived with disability that accompany the
epidemiological transition have been subject to extensive debate (Crimmins, 1990;
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MFC 2000 Meet Background Papers
Murray and Chen, 1992). There are three types of theories or postulates put forward
to explain the changes in disability that accompany mortality decline. Fries (1980,
1989) and colleagues (Fries et.al 1989, Leigh and Fries (1994) argue that with
improvement in survival, the prevalence of disability will decline and therefore
the proportion of life span lived in a disabled state will decrease. These theory
is often called 'compression of morbidity hypothesis' .
Conversely, an alternative set of theories have been proposed predicting that
the proportion of the life span lived in disability will increase as mortality
declines. Gruenberg (1977) suggest that as the survival of individuals with chronic
conditions such as Down syndrome improves, the prevalence of these conditions would
rise. Other authors
(Alter and Riley,
1989;
Feldman 1983 and Shepard and
Zeckhauser, 1980) also forecast an increase in the disability. According to them
medical interventions improve survival for more frail individuals who will
subsequently experience higher incidence rates of disability.
More recently
Olshansky et.al (1991) further refined the expansion of morbidity hypothesis. A
third theory (Manton, 1982) which shares element of both these view points,
predicts that the progression of chronic diseases to severe disability will be
slowed leading to a decline in the prevalence of severe disability but a rise in
the prevalence of mild disability; the later would occur due to decline in
mortality.
2 . Health Concerns of Elderly
Health problems are supposed to be the major concern of the elderly as older
people are more prone to suffer from ill health than the younger ones. It is often
claimed that ageing is accompanied with multiple illnesses and physical ailments.
Besides physical illnesses, aged are more likely to be victims of poor mental
health which arises from senility, neurosis and extent of life satisfaction. Health
therefore occupies prominence in any study of the elderly. In most of the primary
surveys, the Indian elderly in general and their rural counterparts in particular
are said to have some health problems.
Nandal, Khatri and Kadian (1987) found a majority of the elderly were
suffering from ailments like cough, poor eyesight, anaemia and dental problems. The
proportion that are ill among the elderly is found to be increasing with advancing
age and the major physical disability is in terms of blindness and deafness. Shah
(1993) in his study of urban elderly in Gujarat too finds deteriorating physical
conditions among two thirds of elderly in terms of poor vision, hearing handicap,
arthritis and loss of memory.
memory. An interesting observation made in this study was
regarding the proneness of sick elderly towards availing treatment from private
doctors.
Besides physical ailments, psychiatric morbidity is also prevalent among a
significant proportion of the Indian elderly,
elderly. An enquiry in this direction
indicates that mental illnesses starts beyond the age of sixty years. While
distinguishing between the functional disorders and organic disorders, it was noted
that functional disorders are more common compared to organic disorders which
occurs beyond 70 years of age. The National Sample Survey (1991) indicates that 45
per cent prevalence of chronic illness among the elderly and joint pain and cough
were reported to be the most common health problems. The other diseases among the
elderly found in the survey include blood pressure, heart disease, urinary problem
and diabetes. A major cause for mortality among the elderly was respiratory
disorders in 'rural areas and the disorders of circulatory system among the urban
elderly.
Another rural survey reported around 5 percent of the elderly as bed
ridden and another 18.5 per cent as having limited mobility.
Given the background of the prevalence of ill health and disability among the
elderly Vijay Kumar (1991) reports a feeling of dissatisfaction among the elderly
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MFC 2000 Meet Background Papers
with regard to the provision of medical aid. This report also mentions that the
sick elderly lack proper familial care and at the same time public health services
are insufficient to meet the health needs of the elderly.
We have made an attempt to assess the health situation among Indian elderly
with data from the National Sample Survey (1991) and the Ageing Survey (1993),
carried out by us in four major states as a part of the study on elderly in India
(more details, see Irudaya Rajan, Mishra and Sarma, 1999: Irudaya Rajan, 1993). The
two major health concerns among the elderly are their disability/impairments and
chronic disease prevalence. Also, their lifetime habits along with preference for
type of treatment have also been analysed. These parameters are also examined with
respect to three basic characteristics e.g. age, sex and marital status to
understand the differential therein according to such characteristics.
The National Sample Survey (NSS) provides information specifically on the
physical mobility as well as chronic disease prevalence. It is found that 44-47
aged males per thousand reported physical immobility as against 67-68 aged females
per thousand at the all India level (Table 2) . The male-female disparity in the
proportion of persons with physical immobility observed at an all India level is
also reflected both in rural and urban sectors. Physical immobility seems to be a
function of age. Further, it is found that around 60 per cent of physically
immobile among the elderly are in the old-old (70+) category.
Table 2: Proportion (per 000)
residential Background, India.
Physically
Residence
Male
Female
Total
Rural
Urban
44
47
68
67
54
55
Immobile
Aged
persons
by
sex
and
Source: National Sample Survey, 1991.
Table 3: Percentage Distribution of Physically Immobile Elderly by Age,
Residential Background, India.
Rural
Sex and
Urban
Age
Male
Female
Total
Male
Female
Total
60-64
65-69
70 +
22.71
20.88
56.41
19.93
19.88
60.19
21.30
20.37
58.33
19.10
24.66
56.24
18.07
19.83
62.10
18.59
22.34
59.17
Source: National Sample Survey, 1991.
As can be seen from the Table 4, the proportion of aged persons with chronic
disease varied between 443 to 455 per thousand persons at the all India level. This
proportion among the aged males and females were of the same order in most of the
states. With regard to the prevalence of chronic disease among the elderly, the
problems of joints (46.96 per cent) followed by cough or Asthma related complaints
(34.37 per cent) were found to be prominent. Though there remains no wide
difference with regard to prevalence of chronic illness between rural and urban
areas, the pattern of disease prevalence shows some differential (Table 5). For
instance, heart disease, diabetes and blood pressure are more common among urban
elderly compared to their rural counterparts. Such differential pattern of chronic
disease between sexes does not seem significant except the female elderly sharing a
little greater risk of being chronically ill.
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MFC 2000 Meet Background Papers
Table 4: Proportion (per ’000)
Residential Background, India.
of Aged Persons having Chronic disease by Sex and
Residence
Male
Female
Total
Rural
Urban
451
443
448
455
450
448
Source: National Sample Survey. 1991.
Table 5: Percentage Distribution of Type
Elderly by Age and Residential Background.
of
Chronic
Diseases
among
the
Indian
Type of Chronic Disease
Age
Cough
Piles
Problem
Blood
Heart
Urinary Diabetes
of jointsi Pressure disease problems
60-64
65-69
70 +
60 +
35.6
33.78
33.69
34.37
3.37
2.98
3.35
3.25
46.07
48.50
46.65
46.96
60-64
65-69
70 +
60 +
24.16
24.25
24.95
24.52
3.65
3.80
3.38
3.58
38.37
38.70
39.16
38.79
Rural
6.47
6.22
6.52
6.42
Urban
18.53
17.65
16.60
17.48
3.26
3.53
4.33
3.74
3.20
3.21
4.05
3.53
2.04
1.78
1.41
1.73
6.44
6.88
5.93
6.34
3.20
3.10
5.23
4.02
5.65
5.62
4.76
5.27
Source: National Sample Survey 1991.
3. Health Status : Some survey results from selected states
This section makes an attempt to assess the physical health and mental health
of the elderly together with their preference in use of medical services (more
details, see Irudaya Rajan, Mishra and Sarma, 1999) . For this we have used the
results of the Ageing Survey conducted by us as a part of the larger study on
ageing sponsored by Economic and Social Commission for the Asia and Pacific, Social
Development Section, Bangkok. This Survey covered four Indian states namely Tamil
Nadu, Kerala, Gujarat and Karnataka.
This exercise has been carried out using the demographic terms of reference.
Therefore, its precision from epidemiological/medical perspective may not be high.
However, I present these findings as indicative of the well being experience of the
elderly in parts of India. The self rating of the health status of elderly is
presented against their individual characteristics (Table 6) . Though such a biased
assessment based on self rating may be subjective or relative, it has been
considered as an assessment of health status of the elderly. This self assessment
of health status was in three categories namely healthy, fairly alright and
unhealthy and it was found that around two third of the elderly reported to be
fairly alright as against ten percent who reported as unhealthy. The frequency of
declaring themselves unhealthy increases with age and by the age of ninety, fifty
percent of them reported themselves as unhealthy. Also, there appears no striking
difference on the rating of health status by sex.
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MFC 2000 Meet Background Papers
Table 6: Percentage Distribution of Elderly by Self Assessment of
Health Status and individual characteristics.
Individual
Characteristics
Healthy
Fairly Alright
Age 60-64
65-69
70-74
75-79
80-84
85-90
90 +
Total
28.6
22.9
21.8
21.5
11.7
3.3
6.7
24.4
65.5
70.6
64.7
59.9
66.2
53.3
46.7
66.1
Sex
Male
Female
Marital Status
NM
CM
W/D/S
24.7
24.0
26.0
28.1
18.0
Unhealthy
5.9
6.5
13.5
18.6
22.1
43.4
46.7
9.5
66.6
65.4
60.0
64.4
69.5
8.7
10.6
14.0
7.5
12.4
Source: Ageing Survey
In order to identifying health problems faced by the elderly they were asked
'were you sick at any time during the last one week/one month/one year?1 . In
addition they were also asked if they had a problem that they suffered from
continuously. This information was analysed with respect to the age and sex of the
respondent. In this regard, 35 per cent of the surveyed elderly reported having
some or the other perennial health problem which seems to increase in proportion
with increase in the age of the respondent (see Table 7) . This phenomenon is not
found significantly different between sexes except in the young-old category where
females seem to be having an advantage over the males. Based on the information on
sickness during last one week, one month and one year, the sickness prevalence with
a week reference period is measured at 11.3 per cent and the same with reference of
one month and one year is found to be 28.5 and 26.8 per cent respectively.
With
regard to the incidence of being bed ridden during last one year, around fifty
percent of the male elderly and 60 percent of the female elderly have positive
responses. This indicates the state of health among the elderly and the severe
morbidity which sometimes affect them. Instances of being bed ridden are more
frequently reported by old-old category.
Table 7: Age-Sex Distribution of the Elderly by perennial health problems and being
bed ridden during last one year.
Perennial health Problems
Reported to be bed ridden during last one year
Age
Male
Female
Male
Female
60-64
65-69
70-74
75-79
30.4
36.7
34.9
50.5
26.6
35.5
45.9
36.0
42.9
53.1
48.3
57.1
55.7
56.2
62.1
61.4
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MFC 2000 Meet Background Papers
80-84
“54.1
'
85-89
90 +
All ages
60.0
33.3
35.2
42.5
60.0
55.6
34.6
69.6
72.7
50.0
49.3
70.4
62.5
83.3
58.7
Source: Ageing Survey
Disability/Impairments:
Certain disabilities like impairment in vision, hearing and movement are
common consequences of deterioration of muscles and senses in old age. For
evaluation of the prevalent extent of disability/handicap among elderly, the three
aspects enquired were regarding the problems with vision, hearing and walking. The
reported number of cases having problems on these counts are tabulated by age and
sex. Following a listing of disability conditions the extent of use of aid to
overcome such deficiencies and their effectiveness was also enquired into.
Table 8: Percentage Distribution of Elderly by different Handicaps.
Age
Vision
Type of Handicap
Hearing
Walking
60-64
65-69
70-74
75-79
80-84
85-90
90 +
28.9
32.8
35.6
45.3
54.5
66.7
60.0
7.8
8.9
12.0
19.8
31.2
33.3
66.7
11.9
15.7
19.9
29.7
44.2
43.3
73.3
All Ages
33.7
11.1
17.4
Sex Male
Female
35.4
31.4
11.3
10.9
17.6
17.1
Source: Ageing Survey
Among the three major handicap faced by the elderly, handicap in vision seems
to be prominent with one third of the elderly (see Table 8) having poor eyesight.
Following this, mobility and hearing handicap account for 17.6 percent and 11.1 per
cent of the surveyed elderly. These handicaps become more and more frequent with
increasing age. A sex specific description of handicap prevalence puts females
better compared to the male elderly. With regard to the extent of use of aid to
overcome these handicaps, it is found that 27 per cent of those having vision
handicap use spectacles and the same for those with hearing and walking handicap is
2.3 per cent and 8.6 per cent respectively. Further the effectiveness of the aids
used is pretty high (i.e. 67.2 per cent) in case of vision handicap, whereas aids
used are reported to be least effective in case of hearing impairment followed by
walking. To assess the individual's physical ability, opinion was sought with
regard to their travelling without depending on somebody. And in this context,
males' physical ability seem to be more compared to the females, but this could
also be reflective of gendered norms regarding appropriate female behaviour.
Lifetime Habits:
Individual health condition ought to have some bearing on ones personal
habits and practices in relation to diet, exercise, occupation, sleep, smoking,
drinking and chewing etc. Among the personal habits enquired use of tobacco in any
form seems to be prominent.
Some of these habits have a linkage with traditional
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MFC 2000 Meet Background Papers
practice. Also there remains a subjective differential in these
sexes which perhaps can be attributed to the social acceptability.
habits
between
As regard the frequency of eating, the surveyed elderly are reported to be
eating on an average three times a day which is more or less same for both the
sexes. Also the extent of appetite reported by the respondents reveals that 40 per
cent of them do not have proper appetite. In addition, 36 per cent of the female
elderly were found in the vegetarian category against the same being around 22 per
cent for their male counterparts. Preference for vegetarian status seems to be
increasing with increase in age as more than sixty per cent of the elderly in later
ages are reported to be vegetarian. No doubt, the
tne eating frequency per day shows a
decline over age of the elderly. Similarly, the average number of sleeping hours
reported comes between 7 to 8 hours a day. This too is not very different between
males and females.
Use of health services:
The extent of use of health services is an indirect determinant of their
care. The frequent health problems among the aged calls for a
access to health care.
regular utilisation of health services. Hence our interest lies in answering
questions of the kind e.g. How do they cope with their health problems? Do they get
adequate treatment?, Which system of treatment do they prefer? and who pays for
their medical expenses? etc. In case of sickness, ninety per cent of the
respondents irrespective of sex stated that they had consulted a doctor. And the
most popular system of treatment preferred by the Indian elderly is the Allopathic
system which is adopted by nearly ninety per cent of them. The rest ten per cent of
the elderly adopt either Ayurvedic or Homeopathic system of medicine. Further the
most common source of health service utilisation is reported to be from the
Government followed by the private clinics and hospitals.
4.Summing up
Assessment of health status among the aged is commonly in terms of self
rating, though it is considered subjective to evaluate an individual's health in
terms of his/her self assessment. It is suggested in literature that self rating of
health is an excellent choice for measuring health status especially in surveys.
The elderly population in India is growing and these increasing numbers need
to be provided with adequate health care. There is a preponderance of chronic
morbidity conditions
among the elderly,
with
joint/arthritic problems
and
respiratory ailments among a majority of them. There is an urban-rural difference
in this proportion of elderly having circulatory disorders like hypertension (BP)
and heart disease. While most of them seek health care, it has been observed that
for most common impairments associated with ageing like vision, hearing and
mobility, only about two thirds used effective aids to overcome vision impairment.
In the case of hearing and mobility, aids were used minimally by the elderly and
their effectiveness were also limited. There is a need to make provisions not only
for health needs but also for aids required to improve vision and hearing, that
would improve the quality of life of the elderly.
Appendix
Table Al: Demographic Profile of the Aged, 1991-2021
States
Andhra Pradesh
Year
1991
2021
Population(0001s)
(60 + )
(70 + )
4306
11469
1425
4475
Percentage
Sex ratio
to total population
(60 + )
(60 + )
(70 + )
(70 + )
6.47
11.63
11
2.14
4.54
102
104
106
110
MFC 2000 Meet Background Papers
Arunchal Pradesh 1991
2021
Assam
1991
2021
Bihar
1991
2021
Goa
1991
2021
Gujarat
1991
2021
Haryana
1991
2021
Himachal Pradesh 1991
2021
Jammu & Kashmir 1991
2021
Karnataka
1991
2021
Kerala
1991
2021
Madhya Pradesh
1991
2021
Maharashtra
1991
2021
Manipur
1991
2021
Meghalaya
1991
2021
Mizoram
1991
2021
Nagaland
1991
2021
Orissa
1991
2021
Punj ab
1991
2021
Raj asthan
1991
2021
Sikkim
1991
2021
Tamil Nadu
1991
2021
Tripura
1991
2021
Uttar Pradesh
1991
2021
West Bengal
1991
2021
Andaman & Nicho- 1991
bar Islands
2021
Chandigarh
1991
2021
Dadra Nagar
1991
Haveli
2021
Daman & Diu
1991
2021
Delhi
1991
2021
Lakshadweep
1991
37
134
1186
3355
5227
13451
74
217
2540
6791
1230
2511
402
744
432
1111
3041
7770
2549
5771
4254
9704
5453
14019
109
310
82
264
34
108
65
190
2217
5026
1532
3558
2666
6488
19
63
4073
10261
192
422
9250
19083
4087
11495
10
53
29
136
6
23
6
17
444
1764
3
12
49
448
1153
1803
5123
27
88
966
2515
528
905
164
286
163
430
1149
3020
1006
2324
1583
3594
1934
5427
40
116
29
92
12
38
28
73
794
1935
625
1410
917
2422
6
22
1408
4195
87
146
3403
7256
1500
4176
3
19
11
48
2
8
2
6
154
606
1
4.23
7.02
5.29
9.34
6.05
8.11
6.34
14.51
6.15
10.33
7.47
8.72
7.79
9.58
5.78
8.15
6.76
11.18
8.77
15.63
6.43
7.75
6.91
11.72
5.94
10.16
4.62
6.73
4.93
8.61
5.40
8.32
6.98
10.60
7.56
11.11
6.06
7.59
4.59
7.98
7.29
14.30
6.96
8.59
6.65
7.10
6.00
11.62
3.55
12.13
4.52
15.71
4.40
8.35
6.32
11.41
4.71
11.29
5.22
12
1.42
2.57
2.00
3.21
2.09
3.09
2.27
5.90
2.34
3 . 83
3.21
3.14
3.18
3.69
2.18
3.15
2.56
4.34
3.46
6.30
2.39
2.87
2.45
4.54
2.19
3.80
1.64
2.35
1.77
3.01
2.31
3.19
2.51
4.08
3.08
4.40
2.08
2.83
1.51
2.82
2.52
5.85
3.17
2.98
2.45
2.70
2.20
4.22
1.18
4.32
1.73
5.53
1.24
2.95
2.43
4.30
1.63
3.88
1.68
83
86
81
90
86
100
131
109
107
99
93
90
89
114
77
99
101
101
115
117
98
98
101
100
88
100
83
101
96
95
71
95
99
99
83
95
98
99
75
85
92
106
97
97
81
97
96
91
67
79
83
81
122
103
150
107
85
81
92
90
85
76
89
85
99
141
117
113
105
81
91
87
120
75
104
105
102
121
130
100
105
105
106
92
102
86
102
105
99
69
93
98
104
78
99
103
105
78
84
90
110
100
103
77
97
96
96
78
68
87
79
140
115
168
123
86
82
93
MFC 2000 Meet Background Papers
Pondicherry
All India
2021
1991
2021
1991
2021
8
56
144
5560.6
136459
3
21
56
20252
52018
10.19
6.90
12.60
6.58
9.87
110
108
104
94
99
4.00
2.55
4.88
2.40
3.75
116
105
112
93
103
Source: Irudaya Rajan, Mishra and Sarma, 1999
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(ed)
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