Geriatric Health

Dr Nik Nor Ronaidi bin Nik Mahdi

Outlines

• Definition• Demographic changes• Common health (including sexual health), social

& economic problems/ implications• National policy for older person• Health care programme for elderly in Malaysia

(objective, strategies, medical, health & institutional care, agencies involved)

• Social & economic supportive program• Programs for older person in other countries

Definitions

Definition

• GeriatricsGeriatricsA branch of medicine that deals with the A branch of medicine that deals with the

problems of aging and the diseases of the problems of aging and the diseases of the elderlyelderly

• GerontologyGerontologyA branch of study that look into the social A branch of study that look into the social

aspect of ageing including its related aspect of ageing including its related policypolicy

• What is ageing?What is ageing?A progressive state beginning from A progressive state beginning from

conception and ending with death.conception and ending with death. Associated with it are certain Associated with it are certain physicalphysical, , socialsocial and and psychologicalpsychological changes. changes.

• TerminologyTerminology– ElderlyElderly– The agedThe aged– Older peopleOlder people– Senior citizenSenior citizen– ‘‘Wargatua’Wargatua’– ‘‘Orang tua’Orang tua’– ‘‘Warga emas’Warga emas’

• Elderly:

- WHO defines old age as those who are ≥60 years ( developing countries) or ≥65 years (developed countries).

Demographic Changes

Why older people?Why older people?

Ageing population:Ageing population:Global phenomenonA phenomenon occurring both in developed and

developing countriesChallenge of increase longevity but compressed

morbidity Major sources of population ageing include:

• declining fertility and mortality rate • improved health and life expectancy

Ageing populationAgeing population

• Today, there are 600 million people in the world aged 60 years and over.

• This figure is expected to double by 2025 and to reach 2 billion by 2050.

• Population ageing is characteristically accompanied by an increase in the burden of chronic noncommunicable diseases (NCDs) such as cardiovascular diseases, diabetes, Alzheimer's disease and other ageing-associated mental health conditions, cancers, chronic obstructive pulmonary disease and musculoskeletal problems.

Ageing Population in Malaysia

Source: Department of statistics, Malaysia (2003)

Piramid Kependudukan Malaysia Tahun 2000 Dan 2050

Piramid Kependudukan Malaysia Tahun 2000 Dan 2050

Malaysia Population 2000

1500 1000 500 0 500 1000 1500

0-4

10-14

20-24

30-34

40-44

50-54

60-64

70-74

80-84

90-94

100+

Ag

e G

rou

p

Number (Thousands)

Male Female

Malaysia Population 2050 (Medium Variant)

1500 1000 500 0 500 1000 1500

0-4

10-14

20-24

30-34

40-44

50-54

60-64

70-74

80-84

90-94

100+

Ag

e G

rou

p

Number (Thousands)

Male Female

Total Fertility Rate by ethnic group, Malaysia, 1991-1998Total Fertility Rate by ethnic group, Malaysia, 1991-1998Source: Vital Statistics Time Series, Malaysia, 1963-1998Source: Vital Statistics Time Series, Malaysia, 1963-1998

YearYear TotalTotal MalayMalay ChineseChinese IndianIndian

19911991 3.43.4 4.24.2 2.52.5 2.82.8

19921992 3.53.5 4.24.2 2.52.5 2.82.8

19931993 3.53.5 4.14.1 2.62.6 2.82.8

19941994 3.43.4 4.04.0 2.62.6 2.72.7

19951995 3.43.4 3.93.9 2.52.5 2.72.7

19961996 3.33.3 3.93.9 2.62.6 2.72.7

19971997 3.33.3 3.83.8 2.52.5 2.72.7

19981998 3.13.1 3.73.7 2.22.2 2.62.6

Life Expectancy at birth, Peninsular Malaysia,1966-1995Source: Vital statistics time series, 1963-1998

YearYear MaleMale FemaleFemale

19661966 63.163.1 66.066.0

19701970 61.661.6 65.665.6

19751975 64.364.3 68.768.7

19801980 66.466.4 70.570.5

19851985 67.767.7 72.472.4

19901990 68.968.9 73.573.5

19951995 69.169.1 74.474.4

20042004 7272 7676

Illness and Older PeopleIllness and Older People

Illness and Older PeopleIllness and Older People

• Growing old is a life long process– Does not occur suddenly

• Involves physiological, psychological changes and physical changes

• Involves senses and all the systems– Skin – less elastic and wrinkles– Eyes, hearing, taste, smell – less sensitive– Physical – loss height, stooping walk

• Bones – brittle and prone to fractureBones – brittle and prone to fracture

• Muscle – loss bulkMuscle – loss bulk

• Immune function - compromisedImmune function - compromised

• Nutrition - Nutrition - malnutrition and under nutrition malnutrition and under nutrition are commonare common

• SexualitySexuality– Studies show that 74% of married men and Studies show that 74% of married men and

56% of married women over 60 years of age 56% of married women over 60 years of age remain sexually active. (Diokno AC et al)remain sexually active. (Diokno AC et al)

– Common problems : arthritis, diabetes, fatigue, Common problems : arthritis, diabetes, fatigue, fear of precipitating a MI and side effects from fear of precipitating a MI and side effects from prescription drugs prescription drugs

• Brain function Brain function – cognitive decline and depression.cognitive decline and depression.

GIANTS OF GERIATRIC (Bernard Isaacs, 1975)

• Bernard Isaacs described the "giants" of geriatrics: incontinence, immobility, impaired cognitive function and instability.

• He asserted that if we look closely enough, all common problems with older people relate back to one of these giants.

• The GIANTS are disabilities that lower the quality of living.

• In common: multiple causes, chronic nature, reduced independence, no simple cure.

• The ‘final pathway’ that affect elderly with diminished ability to recover, make them DEPENDANT on others.

1. Incontinence

- Urinary & Fecal

2. Instability/Immobility

- Risk of fall & Osteoporotic fracture

3. Impaired cognitive function

- Dementia/depression

•A study by the Public Health Institute, Malaysia in 1995 showed:-

- 81.4% suffered from at least from one chronic medical illness.

- 12.7% had 3 or more chronic diseases.

•The commonest medical illness:-

- joint paint 50.1% - eyesight problem 40%- hearing problem 21%- hypertension 26%- heart diseases 16.3%- diabetes 11.6%

Socio- economic implications

1. Social security

• In Malaysia, the social security covers only employees in the formal sector.• Pension scheme for civil servants while the EPF

for private sector employees.

• Only 61.8% of total employed persons covered by these two schemes leaving the remaining 38.2 per cent without known source of coverage. (Labor Force Survey Report, 1998)

2. Growing Burden of Non communicable Diseases

– In the next 10 to 15 years, the loss of health and life in every region of the world, including Africa, will be greater from noncommunicable or chronic diseases, such as heart disease, cancer, and diabetes, than from infectious and parasitic diseases.

3. Changing Family Structure

• As people live longer and have fewer children, family structures are transformed.

• People will have less familial care and support as they age.

4. Financing for Health Care

• Increase health care expenditures• On the average, Malaysian’s visit to the

public and private primary care service sector is about 2.3 visits per year. The elderly made an average of 6 visits per year (Chin 1996)

National policy for older person in Malaysia

• Approved in October 1995

• Malaysia one of the earliest countries in the Asia Pacific region to have policy for older person.

The policy statementThe policy statement……

““To ensure the social status, dignity and To ensure the social status, dignity and well-being of older persons as well-being of older persons as

members of family, society and nation members of family, society and nation by enabling them to optimize their self by enabling them to optimize their self

potential, have access to all potential, have access to all opportunities and have provision for opportunities and have provision for

care and protection”care and protection”

ObjectivesObjectives

• To establish and develop the dignity and respect for the elderly in the family, community and country.

• To develop the potential among the elderly to maintain their activeness and productivity in the process of developing the country.

• Encouraging to create facilities to ensure care and protection for the elderly towards a better living.

StrategiesStrategies

• Respect and dignity– Enable older people to live with respect and self

worth, safe and free from exploitation and abuse– Ensure older people are given fair and equal

treatment irrespective of age, sex, ethnicity, religion, disability or their ability to contribute

– Enable older people to optimize their potential– Enable older people to have access to

educational, cultural, spiritual and recreational resources in society..

StrategiesStrategies

• Self reliance– Able to fulfill their basic needs through income

sources, family and societal support and self effort.– Have access to opportunities to continue to serve and

contribute.– Enjoy an environment that is safe and conducive in

accordance to their needs and changing capacities– Able to reside within their community without having to

resort to institutional care– Able to make early preparation to plan their

continuous contributions towards national development based on their expertise and capabilities.

StrategiesStrategies

• Participation– Enable OP to play a role in society and be actively

involved in the formulation and implementation of policies relating to their well-being and to pass on their knowledge and skills to younger generations

– Provide opportunities to OP to voluntarily contribute to society in accordance with their abilities and interest

– Encourage OP to establish associations and organizations that conduct activities for their own well-being.

StrategiesStrategies

• Care and protection– Establish facilities for care and protection within the

family and society in line with local socio-cultural systems

– Enable OP to have access to health care to enable them to maintain or restore their optimum physical, mental and emotional health and prevention of ailment.

– Access to services of institutions that provide care, protection and social and mental stimulation in a safe and comfortable environment

• Access to social and legal services towards advancement of their individual rights, protection and care

• Enjoy the basic rights of individuals while in care and under treatment by taking into consideration their self-respect, beliefs and needs

• Establish a comprehensive Social Security System to ensure the financial security and welfare of OP.

Research and development• Encourage research on OP for the

purposes of compiling information for use in planning programs for their development

• Establish a National Advisory and Consultative Council for OP to identify and coordinate the programs and activities for OP

Health care programme for elderly in Malaysia

Health Care Program for the Elderly

• Introduced in 1995 - aimed at improving and maintaining the health and functional outcome of the elderly with the ultimate objective of promoting quality of life as well as forging productive ageing among the elderly.

• Specific objectives:– To improve the health of the elderly to enable

them to lead and enjoy full and active life through promotive and preventive health care;

– To establish Geriatric Specialist Services at the regional and state levels

– To develop a comprehensive plan of action on training and research needs in the care of the elderly

– To provide quality health care for the elderly using community-based approaches to enable them to live as independently as possible within the community

Strategies 1. Promotive and preventive health care

• information dissemination regarding the pathologies and disabilities related to age.

• Screening programs

2. Medical and rehabilitative care• strengthening of care to the elderly at primary,

secondary and tertiary level • provide holistic specialized medical, psychological,

social and rehabilitative geriatric services in selected hospitals using a multidisciplinary team approach.

• Private Hospital Act, 1971 and Private Hospital Regulations, 1973, will be enforced to ensure quality care to the elderly.

Strategies3. Training and research

• to formulate and strengthen the existing curricula on care of the elderly for basic, post-basic and continuing medical education.

• Training in specialized areas relating to health care of the elderly is planned.

4. Program planning, monitoring, coordination and evaluation

• proper data collection in hospitals and health centers in order to obtain more accurate information about the elderly people.

• setting up a special Unit on Health Care for the Elderly in the Family Health Development Division of the Ministry of Health.

• Among the activities carried out are:

1. The National Mental Health Policy was approved in 1998 and 58 health clinics have been identified to implement the program.

2. Healthy lifestyle campaign aimed at preventing and controlling chronic diseases such as diabetes mellitus and cardiovascular disease.

3. Setting up of special health clinics for the diabetic and hypertension within the health clinics in rural areas.

4. Rehabilitative programs – physiotherapy and occupational therapy are provided to older people as a supportive service to the medical care or in-patient care in hospitals.

5. Health center or community-based activities. They include: home visits, health screening for high risk groups, referral to geriatricians, counseling on exercise, nutrition, diabetics and social support needs, home mobility and rehabilitative facilities, special care management such as incontinence, day care nursing, and community education on issues associated with health of the elderly.

• The main agencies involved in these activities and programs are:– Ministry of Health– Ministry of Women, Family and Community

Development – Ministry of Education– Department of Social Welfare– NGOs

Social & Economic Supportive Program

SOCIAL WELFARE DEPARTMENT

• The care and protection for older persons through institutional service provides health care, guidance, counseling, recreation and religious teachings.

• Other programmes included:– Financial Assistance– Day Care Centre for Older Persons– Homes for Older Persons Without Next of Kin– Programs and activities undertaken by NGOs– National Celebration Day For Older Persons

Homes for the Older Persons

• The objective is to provide a proper care and protection for the needy elderly to ensure their security, treatment and getting better quality of life.

PROCESS OF ADMISSION:• All application will be investigated and will be

considered base on the following criteria:– Needy elderly, aged 60 years and above– Not suffering from contagious diseases– Not having relatives or guardians– No permanent shelter– Able to look after him/herself

• The Old Persons’ Home provides various services or facilities as follow:– Care and protection– Counseling and Guidance– Occupational Therapy– Religious Facilities– Recreation– Medical Care

THE ROLE OF NGOs

• NGOs play a complementary role in helping the Government to meet the social needs of older persons

• Based on data from the Registrar of Societies, there were 30,907 NGOs registered in May 2000, of which 3,218 were welfare related.

• The majority of NGOs provide institutional care and shelter for older persons in need.

Employees Provident Fund (KWSP)

• Government-sanctioned statutory body founded in 1951• Act as a social protection• Compulsory savings scheme in Malaysia for the formal

sector: monthly contributions from employers and employees - (Employers:12%, Employees: 11%)

• Contributions from self-employed are on voluntary basis

• The contributions are cumulative; annual dividend paid (Dividends of a minimum 2.5% per annum guaranteed on savings)

• EPF savings can be withdrawn upon retirement (age 55 yrs and above)

• EPF funds used for investments in sectors like equity, securities, property and currency as well as financing of large-scale government projects

• Objectives of the EPF:– Provide a measure of security for retired

elderly– Provide retirement benefits– Provide an easy and efficient system for

employers to fulfill legal and moral obligation to contribute to the EPF of their employees

– Contribute to the country’s socio-economic development through careful investments

• Limitations of EPF:– Provide coverage only for employees from the formal

sector• Many of the elderly are in the informal sector where contribution

are not mandatory

– Contributions from self-employed are on voluntary basis

– Rising cost associated with longer life expectancy and the effect of inflation will diminish the size of savings from EPF

– The lump sum nature of withdrawals tends to have high exposure to improper management or investment that does not provide the insurance needed for old age

Public Sector Pension Scheme

• Non-contributory social security scheme for civil servants

• Pensions expenditure is fully borne by the Government via annual allocation from the Federal Budget

• Provide security for old age and financial assistance to the dependents of those in the Government service if government employee passes away while in service or after retirement

• In 2005, the scheme covers only 9% of the workforce

Recommendation to improve our current services

1. Census-type information will have to be gathered to facilitate the formulation and implementation of policies and programs.

2. Continuous monitoring of activities as guided by the National Policy for the Elderly

3. Training of manpower in the health sector

4. Education and retraining for the elderly• Education to prepare the elderly to face the

challenges of ageing can be introduced as a pre-retirement course.  Retraining should be introduced to promote productive ageing.

Programs for older person in other countries

Programs for older person in other countries – Mississippi, USA

Division of Aging and Adult Services Programs:

– Senior transportation programs • Continued independence of older adults in the state is

facilitated by transportation services offered in their communities.

• Senior transportation programs make it possible for individuals who do not drive and cannot use public transportation to obtain rides for essential trips, such as medical appointments.

• Nearly 300 vehicles (from vans to mini-buses) provide transportation service to older riders

– Elderly Nutrition Program (ENP)• The ENP provides funding for two senior nutrition programs:

congregate meals and home-delivered meals.• Congregate meals

– They are offered at social and community centers such as senior centers, and churches

– provide seniors with social interaction and stimulation, and the chance to get involved in the community.

• Home-delivered meals– meals are delivered to homebound seniors who are unable to travel

to a congregate meal site.– during a meal delivery the volunteers are able to monitor the health

of the homebound seniors and make sure that they are getting the help they need.

• Both of these services are offered to seniors at no cost.• The meals must provide recipients with at least one third of their

daily recommended dietary allowances, and are cooked to take into account special senior nutrition considerations (such as low-fat, low-sodium diets).

• ENP volunteers also provide nutrition screening, nutrition education, and meal-planning counseling.

– Legal services programs • Legal advice, consultation or representation, legal

assistance may be obtained from lawyers or paralegals who have agreed to provide services to the state's elderly

• Many of the services are available without charge or reduced fees for referred elderly clients.

– Senior Community Service Employment Program (SCSEP)

• The program identifies employment opportunities for older persons whose incomes place them at or below the federal poverty level; who are unemployed or underemployed; or who have difficulty finding a job.

• Adults in the program generally work an average of 20 hours a week, receiving at least minimum wage.

– The Homemaker program• The program gives older citizens the option of having

homemakers perform the housekeeping tasks they can no longer do or need assistance in doing.

• Homemakers perform routine household tasks such as cooking, cleaning, grocery shopping, laundry, consumer education, bathing, dressing, safety education and oral hygiene assistance.

• This service is provided at no cost to the older person

– Adult Day Care• Adult day care centers specialize in supervised care

for functionally impaired elderly adults. • Their programs focus on health maintenance,

prevention/intervention and rehabilitation needs of older adults capable of only limited self-care.