Thursday, July 7, 2016


 When does a person become ‘old’ and when does ageing begin?
There is no universally accepted definition of when an adult crosses a threshold and becomes "old". In the western, developed countries old age is synonymous with the time of retirement and eligibility to receive pensions. This corresponds to the ages of either 60 or 65 years and is, of course, based on chronological time. But chronological time may not have much meaning in certain parts of the developing world where functional ability is the criterion for old age. In Africa, for instance, a person is often considered old at 50 or 55 years of age (Ref). 

Ageing is not the same as being old. Ageing is a process that starts from birth and continues throughout life. Some of the changes of ageing seen in cells and tissues are genetically determined while others are determined by environment, nutrition and lifestyle. Ageing is also not a uniform process for everyone as some show the effects of ageing more than others of the same chronological age. 

The elderly population in Malaysia and in different parts of the world
The population of people above the age of 60 years in Malaysia in the year 2020 is expected to be about 10 percent of the population (approximately 3.3 million people will be considered old in 2020 - Ref.) The percentage of people above the age of 60 years in the world in 2017 is about 13% of the global population and it is Europe that has the highest percentage of those above 60 years (about 25% of Europe's population is above the age of 60 years). The United Nations has projected statistics which say that most regions of the world except Africa will have one-quarter of its population above the age of 60 years in the year 2050 (Ref.) Most of the currently developed countries in the world have become rich before their population becomes old while countries that are still developing appear to be becoming old before they become rich. 

Life expectancy in Malaysia and in other countries. 
The life expectancy in Malaysia according to statistics in 2015 was 73 years for males and 77 years for females. Some of the statistics for other countries can be found from this link (Ref.). Some examples are: 
Singapore 80 years and 86 years respectively. 
USA 77 years and 82 years respectively. 
India 67 years and 70 years respectively.
Kenya 61 years and 66 years respectively

The life expectancy of a population gives information about longevity but does not contain any information about the quality of life. A long life is only appreciated if it is lived without functional restrictions caused by diseases and disabilities. The impact on the quality of life caused by diseases can be captured by a parameter called disability adjusted life years (DALY). When comparing people with the same lifespan, those with greater DALY can be considered to have more disease-span than health-span. Lifespan = Health span + Disease span.

Socioeconomic conditions play an important role in determining the health status of a population as they grow older. There are statistical calculations that try to determine how many years of healthy life (health-span) can be expected from the age of 65 years onward. This is called the Healthy Life Expectancy (HALY) and data from 2016 show that the HALY after age 65 differs between countries and according to income (Reference.). The HALY for a few countries are given here:
Singapore: 18 years and 15 years for males and females respectively
USA: 15 years and 13 years respectively.
Malaysia: 13 years and 12 years respectively
India: 11 years and 10 years respectively.

Globally, those who live in higher income countries have increased HALY compared to those who live in low income countries (Females have additional 7 years of healthy life after 65 years while males have 4 years of healthy life after after 65 years of age).

Illnesses or disabilities that the elderly are more prone to. Economic / financial concerns for an elderly person.
In many parts of the world, the non-communicable diseases like diabetes, hypertension, coronary artery disease and cancers are increasingly responsible for disability and illness in the elderly. Depression and dementia are also a concern in the elderly. There are real financial concerns for the elderly related to loss of employment income. Financial weakness leads to the elderly being dependent on others.

Whatever the situation they are in, people should be aware that they have the ability to create in their own minds the kind of future they want.  They have the cognitive power to choose the narratives of what their lives will be in the future as they age. These mental constructs can be safety nets that allow them to move bravely towards an uncertain and potentially fearful future. 

Ageing and suffering. Can people be happy as they grow old? Concerns of the children as their parents grow older.
As people grow older, one of the things that they may fear is the inability to make their own choices about how they want their lives to be. Well being is a subjective feeling of being in good health and is not always depended on the objective parameters of good health. Well being can be adversely affected when ageing is viewed as a disease or disorder by itself. When elderly people begin to chase a normality defined by younger people, there is bound to be distress and a potential for growing old unhappily. Well being is lost when self-image is adversely affected by one’s beliefs.  

The impact of ageing on the well being of individuals also depends on culture and society. The social construct of ageing – how the elderly are viewed by the members of a cultural group – has a significant impact on how the elderly view themselves. The commonly held view that old age is invariably a period of decay and decline of mental and physical functions is not based on facts (Doidge, 2007). There are very old people who have gone to college and earned undergraduate degrees. The architect Frank Lloyd Wright designed the Guggenheim Museum at the age of 90 years and Benjamin Franklin was 78 years old when he invented bifocal spectacles. 

The reality of growing older has been explored in the writings of many authors. In the book ‘Tuesdays with Morrie’ (Albom, 1998), an important theme is the acceptance of the physical and mental changes that aging brings in its wake. To experience old age without regret, we have to find a purpose for living while we are still young. Being aware of our own mortality on a daily basis can help us do that. Grief comes easily to many older people because of the losses they experience. In the book 'Lapping’ (Halligan, 2001) the author compares the movement of the mind to the rise and fall of waves on the seashore with some memories becoming prominent and others fading away over time. Loss, and the grief that comes with aging, is also discussed in the article ‘A poetic life’ (Leser, 2005). We are reminded here that loss can sometimes be a time to learn valuable lessons. In old age there are many lessons that can be learnt about the strength of the spirit and those who find this inner strength can triumph over all kinds of physical limitations. Finding new directions in our lives after retirement is important and is the theme in the story ‘Not to yield’ (McDonald, 2000) where we are reminded that growing older need not be an excuse to stop learning or following our passions. Memories represent unique aspects of our personalities. In ‘Saying Goodbye’ (McInnes, 2005), we learn about what happens when Alzheimer’s disease robs people of their memories and they become strangers to themselves and to their loved ones. Sometimes we wonder if knowing the diagnosis of an incurable and progressive illness like Alzheimer’s serves any purpose. In ‘The right to self-determination’ (Pieters-Hawke & Flynn, 2004) this question is explored and the authors feel that early awareness of incurable diseases can enable people to plan ahead and to ensure that what happens to them in the future is according to their wish.

Children may struggle with feelings of guilt for not doing enough for their parents and with anger for being in circumstances where they are forced to choose between being caregivers for their parents and living their own lives in the way they want. They can face burnout from being caregivers as they struggle with conflicting emotions and societal expectations. 

Institutional care (nursing homes or managed residential facilities) versus domiciliary care for the elderly. The concept of “respite care” in the context of caring for the elderly.
Institutional care, in this context, is different from admitting a patient in a hospital because of a medical problem. It refers to the provision of long term care and is a choice made for ensuring a safe and comfortable environment for the person towards the end of life. It is a choice that caregivers make hoping to achieve a 'good death' for the elderly person. Long term care, whether in institutions or at home, can be of two types - assistance in activities of daily living and assistance in other aspects of daily living. Assistance in bathing, using the toilet, getting up from bed are examples of the former while assistance in shopping, cooking and using transportation are examples of the latter.

While most people wish to experience 'a good death' at home, statistics from the UK indicate that the majority of deaths in the elderly happen in hospitals. When people say that they wish to have a good death, it implies that they wish to feel in control of what is happening to them; they wish to be free of pain and unpleasant symptoms; they wish to die in a place of their choosing with privacy and dignity, and they have the time to resolve personal conflicts, unfinished business and the knowledge that their wishes will be respected.

Statistics from USA in 2016 suggest that about 5% of the population above the age of 65 years live in nursing homes or assisted living facilities (Ref.). The common reasons for admitting the elderly in managed care facilities will be inability to provide care at home and the need for constant medical attention. People from Asia, because of their family oriented culture, tend to hesitate before admitting their aged parents in institutions for long term care. Mobile domiciliary care might be a solution. A service called 'Love on Wheels' was started in Malaysia for providing nursing care to the elderly in their homes (Reference).

Respite care refers to the use of services designed to give family caregivers a break from their jobs of looking after their elderly dependents at home. Such periods of respite care can rejuvenate the caregivers and prevent burnout (Ref.).


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