Ageing Issues and Responses in India [1st ed.] 9789811551864, 9789811551871

Table of contents :
Front Matter ....Pages i-ix
Ageing Issues and Responses in India: A Synopsis (Mala Kapur Shankardass)....Pages 1-7
Addressing Marginalization Among the Elderly: A Social Work Perspective (Archana Kaushik)....Pages 9-23
Preventive Geriatrics—A Way Towards Active Ageing (Anand Ambali)....Pages 25-43
Age-Friendly Initiatives (Biju Mathew)....Pages 45-75
Ageing Policies and Programmes in India (K. R. Gangadharan)....Pages 77-96
Elder Care from a Distance: Emerging Trends and Challenges in the Contemporary India (Archana Kaushik)....Pages 97-113
Extent of Population Ageing and Intergenerational Support in the States of India (S. Anil Chandran)....Pages 115-127
Elderly Women in India: Concerns and Way Forward (Pamela Singla)....Pages 129-141
Institutional Care for Elderly (Sandhya Gupta)....Pages 143-155
Old Age Homes as a New Pattern of Life (Anupriyo Mallick)....Pages 157-169
Senior Citizens—Protections in Law, an Overview (Sarita Kapur)....Pages 171-184
Health Challenges and Responses to Ageing Women (Meena Yadav)....Pages 185-206
Examining the Lived Experiences of Ageing Among Older Adults Living Alone in India (Jagriti Gangopadhyay)....Pages 207-219
Revered or Abused: Exploring Reasons for Abuse Within Family from the Narratives of Three Elderly Women in Chennai (Asha Banu Soletti, P. V. Laavanya)....Pages 221-234
Role of Integrative Medicine in Management of Dementia (Vidya Shenoy)....Pages 235-253

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Mala Kapur Shankardass   Editor

Ageing Issues and Responses in India

Ageing Issues and Responses in India

Mala Kapur Shankardass Editor

Ageing Issues and Responses in India

123

Editor Mala Kapur Shankardass Maitreyi College University of Delhi New Delhi, Delhi, India

ISBN 978-981-15-5186-4 ISBN 978-981-15-5187-1 https://doi.org/10.1007/978-981-15-5187-1

(eBook)

© Springer Nature Singapore Pte Ltd. 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Acknowledgements

I as the editor of this very interesting and relevant volume wish to express my gratitude to all the authors of various chapters for their meaningful contributions by putting in their hard labour and giving their personal and professional time to complete this book. They, without any complaints, adhered to my pressures for writing and willingly agreed to write on different topics to make the book a comprehensive reader. I am grateful to Springer team in India for encouraging me to submit this manuscript and patiently go along my timeline in completing this assignment. I appreciate the efforts put in by Priya Vyas in putting everything together for publication of this timely volume. I take this opportunity to thank my husband Suman Shankardass for being my pillar of support in taking up professional work and calmly adjusting to my odd hours of working and compelling pressures whenever they arose. My toddler grandson Kirat provided all the relaxation when I needed and I thank him for keeping my spirits high. I was happy to bring this volume to completion and thank all those who in small and silent ways contributed to my achieving the goal of introducing this book to readers. Mala Kapur Shankardass, Ph.D.

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Contents

1

Ageing Issues and Responses in India: A Synopsis . . . . . . . . . . . . . Mala Kapur Shankardass

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Addressing Marginalization Among the Elderly: A Social Work Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Archana Kaushik

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Preventive Geriatrics—A Way Towards Active Ageing . . . . . . . . . Anand Ambali

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Age-Friendly Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Biju Mathew

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Ageing Policies and Programmes in India . . . . . . . . . . . . . . . . . . . . K. R. Gangadharan

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Elder Care from a Distance: Emerging Trends and Challenges in the Contemporary India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Archana Kaushik

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Extent of Population Ageing and Intergenerational Support in the States of India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 S. Anil Chandran

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Elderly Women in India: Concerns and Way Forward . . . . . . . . . 129 Pamela Singla

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Institutional Care for Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Sandhya Gupta

10 Old Age Homes as a New Pattern of Life . . . . . . . . . . . . . . . . . . . . 157 Anupriyo Mallick 11 Senior Citizens—Protections in Law, an Overview . . . . . . . . . . . . . 171 Sarita Kapur

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Contents

12 Health Challenges and Responses to Ageing Women . . . . . . . . . . . 185 Meena Yadav 13 Examining the Lived Experiences of Ageing Among Older Adults Living Alone in India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Jagriti Gangopadhyay 14 Revered or Abused: Exploring Reasons for Abuse Within Family from the Narratives of Three Elderly Women in Chennai . . . . . . . 221 Asha Banu Soletti and P. V. Laavanya 15 Role of Integrative Medicine in Management of Dementia . . . . . . . 235 Vidya Shenoy

About the Editor

Dr. Mala Kapur Shankardass is a sociologist, gerontologist, health and development social scientist. She is also a teacher, writer, researcher, consultant and activist. She has been involved with ageing studies since 1992, when she began pursuing postdoctoral work on ageing issues. She has held prestigious assignments with various United Nations agencies, and with national and international institutions. She has participated in panel discussions, delivered keynote addresses and chaired sessions on ageing concerns with reputed organizations both in India and abroad. She has been awarded Fellowships for her contributions to gerontology around the world.

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Chapter 1

Ageing Issues and Responses in India: A Synopsis Mala Kapur Shankardass

Abstract India is now described as an ageing society by many demographers. The changing age structure of Indian society calls for many policy and programme initiatives favouring older people in the field of health and social care for improving their status along with legal provisions to safeguard and protect them. The demographic transition resulting in ageing of the population also calls for changes in attitudes and thinking about lives of older people for their betterment. This chapter highlights some of the demographic features of ageing Indian society and discusses the vulnerabilities of older people as well as the societal responses seen in the country to the increasing strength of older people in society.

Introductory Comments India is an ageing society, with the percentage share of older population, 60 years and above being 10% in 2019 (United Nations 2019). The proportion of older people is increasing and the proportion of children gradually decreasing due to rise in longevity and declines in fertility and mortality along with attention to individual health. According to demographers by 2050, in another 30 years, the proportion of older people will exceed the share of those below 15 years of age, which has been consistently declining since 2015. This changing age structure becomes significant demographically and it also impacts the social context of increasing number of older people. The declines in fertility and mortality as well as the epidemiological transition taking place brings in consequent socio-economic changes that impact on various aspects related to quality of life of older people. The care of older people, support system and mechanisms available to them, the living arrangements, their livelihood characteristics, health care facilities, state responses in terms of policies M. K. Shankardass (B) Maitreyi College, South Campus, University of Delhi, New Delhi, India e-mail: [email protected] International Network for Prevention of Elder Abuse (INPEA), New York, USA Development, Welfare and Research Foundation, New Delhi, India © Springer Nature Singapore Pte Ltd. 2020 M. K. Shankardass (ed.), Ageing Issues and Responses in India, https://doi.org/10.1007/978-981-15-5187-1_1

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and programs, legal provisions—all undergo a change once ageing of the population takes place. It is true that old people have been part of Indian society for centuries but since the beginning of this century, their status, their characteristics in all respects, the impact of migration patterns, employment opportunities, economic and social security, educational facilities including mid-life career development options and available legislations and legal recourse are impacting in more ways than one. This becomes significant especially as the number of older people is increasing rapidly and will do so with more speed in the coming decades. As per certain demographic projections by 2025, in another five years, the share of older people in the total population would be 11%. This in some ways may not seem as a concern especially compared to many European countries, but for India, the emerging huge absolute numbers of older people in society would be quite large given the large population base since last many years. Over the last two decades, in particular after the formation of the National Policy on Older Persons in 1999, many new responses have emerged in the country related to ageing issues which have and are changing the complexion of the society, and much more also needs to be done with pertinent consequences for older people. This volume reflects on some of these ageing issues and concerns. It opens the reader through different chapters written by experts to various dimensions of ageing society in terms of their noticeable marginalization, health needs with the requirement for preventive geriatric services, developing age friendly initiatives, policies, programmes, elder care from distance especially because of migration of children, reviewing intergenerational support mechanisms, analyzing the status of older women, reflecting on gender differences, discussing the growing institutional care facilities and emergence of old age homes as new pattern of life. The book also reflects on legal protections available in the country for older people. This becomes particularly relevant with growing incidences of abuse against older people especially against older women by family members as the narratives presented in two of the chapters reveals. This volume makes note of special health concerns of ageing population with regard to postreproductive issues and management of dementia. Both issues not much discussed in other books on ageing are extremely important and need attention. All the chapters in this book provide an understanding of old and new forms of responses to older person’s needs and concerns from a development perspective. Underlying the contributions is a right-based approach which stresses on the need to give due attention to the dignity of older people and provide them respect, love and care in society. Clearly, an ageing society cannot ignore this aspect and we all as citizens of the country must ensure a good quality of life for older people. Thus, the book is a meaningful, relevant and noteworthy contribution in the ageing field.

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Understanding Some of the Demographic Facts Related to Ageing Issues The last census, conducted in 2011 in the country, revealed 8.6% of older people in the total population of India. Of this, 8.8% are residing in rural areas and 8.1% in urban areas, though there is steady increase in the proportion of older people residing in urban areas over the years. The census indicates state variation in the population of older people with Kerala having the highest proportion of 12.6%. Goa, Tamil Nadu, Punjab, Himachal Pradesh are the next four states in the country with higher proportion of older people being, 11.2%, 10.4%, 10.3% and 10.2%, respectively. Most of the states barring a few, mainly as part of north east region, as per 2011 census data have more than 7% of older people. This according to UN specifications is characteristic of ageing society and has implications for care, support, social, economic, health and development aspects in a society. Ageing in India also is meaningful as it is taking place at the rate of 3.5% per year and as per estimates considered one of the fastest in the world (Prasad and Goli 2019). Today, India is considered to have the second-largest older population, with China leading among the different countries. As few demographers and social scientists point out (Rajan and Balagopal 2017) since 1961 there is a consistent upward trend in the growth of elderly population in the country, and after 2001, it is increasing at a sharper pace. This clearly means there is need to develop services, programmes and policies for older people that enhance their quality of life and there be provisions in society that recognize the rights of older people. Interestingly, the proportion of oldest-old, 80 years and above is increasing steadily, from 34.8% in 1961 to 38.3% in 2011. From 1950 to 2100, the proportion of oldest-old will show a 20% increase as per projections (Prasad and Goli 2019). With increases in 80 plus population, health needs of older people require special attention. Also, higher proportion of older people is a cause of concern for developing economy like India. Not only there is need to think of employment and reemployment of older people besides adequate pensions, there is also need to prioritize developing geriatric services and make available long term care facilities. In contrast to old-old population, the proportion of young-old has decreased from 65.2% in 1961 to 61.7% in 2011. But nonetheless with growth in older population in the country as a whole and with epidemiological transition taking place with increases in chronic ailments and non-communicable diseases emphasis must be given to preventive aspects along with curative mechanisms in health care services as well as to the provision for institutional care and community care. Data from India indicates that like other countries, the female to male sex ratio increases in old age, though not to the extent as the differential is seen in developed countries. In 2015, UN data indicates 8.37% of aged 60 years and above males compared to 9.52% of females of the same age group (United Nations 2017). In another three decades, by 2050 males in 60 plus age group will consist of 17.72% and females 20.54%. The consequence of this is higher proportion of widows and also many aged women requiring social care for which the society has to be well

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prepared and equipped. Research evidence since long is indicating that differential mortality between the sexes (Dandekar 1996) has important health and social policy implications. While older women are living longer than older men, they are prone to more health problems and their health and social status in general is lower than that of older men. Experience of ageing is different for men and women and the latter as many narratives reveal (Shankardass 2004) lead more dependent, abusive lives. Older women compared to older men have higher illiteracy rates. 2011 census shows a difference of over 30% points with older women being low at 28.5% and older men being at 59.1%. The implication of this is that older women are less likely to be involved with formal workforce and consequently have fewer means of social and financial security. Older women also have limited ownership rights and assets. A large proportion of older women compared to older men are dependent on others for economic support. However as certain studies indicate older women are more resilient (ib.id) despite the hardships they face.

Vulnerabilities of Older People There is growing literature in the country which reflects on the vulnerabilities which older people face particularly due to financial, emotional and health insecurity (Sen, 2000) and this as is stated by certain studies is more compared to younger people. India has one of the poorest social security systems in the world. The government spends a meagre amount of 3 US dollars per month as pension (Pension Watch 2018). The expanding informal sector, poor social security, low paying work and unfriendly work environments are big challenges facing the country. Also, the rising old age dependency ratio is of concern and has tremendous implications for the health and social systems. Increased migration of younger family members along with urbanization and the fact of large numbers of older people residing in rural areas on their own, makes older people left behind at home vulnerable to many problems cutting across social, psychological, health and economic aspects. While the burden of caregiving is increasing with ageing of India for both the old and young segments of the population in the country, it is also leading to marginalization of older people. Various studies indicate that with weakening family support and inadequate social and financial security available to older people, the marginalization of old increases and also their chances of destitution are enhanced. Besides, data is also indicating that disease adjusted life expectancy in India is much lower than that of developed nations (United Nations 2017) and this has vital implications on the well-being of older people. A survey conducted by United Nations Population Fund (UNFPA) in 2011 shows almost 50% of older men in age bracket of 60–69 years as being economically productive. This proportion does reduce in age group 70–79 years, coming down to 27% but even at age 80 years and above nearly 13% of men continued to work. The percentage of older women working is low compared to older men, being 15% for age group 60–69 years and decreasing to 5 and 3% respectively for ages 70–79 years

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and for 80 plus population. While the trend of work participation of older women reflects the differential seen from a younger age not only in India but in most parts of the world, but in all, the work participation continuing at older ages is a reality of many due to economic compulsions as the survey highlights and is not a matter of personal choice as could be the reason at younger age. Recent Government of India data indicates that 47.1% of the total elderly in rural areas and 28.5% total elderly in urban areas work to earn their livelihood (GOI 2016). Poverty induced work participation is a cause seen from the UNFPA survey for older people being economically active though the earnings are often meager, enough to cope with daily life and at times insufficient to maintain a certain standard of living for appropriate quality of life. In addition since 66% of the total older population in urban India and 34.2% in rural areas as per 2011 census were illiterate, it means that employment opportunities for older people are not only limited but restricted to being casual labourers or working in the informal sector or engaged in home-based employment with low incomes, which may fluctuate and provide no job security. Interestingly as the survey reveals often older people use their earnings to make intergenerational transfers to children and grandchildren and the concept of retirement does not in particular apply to many among the older population in the country. Pensions and other social security benefits are also means used by older people to financially secure themselves even though in many cases, these are not enough to meet expenses of daily living, especially the health and social care costs. Nonetheless, as pointed out by experts with anguish that the pension policy is being availed by less than 10% of older people (James and Syamala 2016). Further, as UNFPA survey shows only 25% of below poverty line older people receive social security benefits. It is an important source of income for them, even though it is a small amount. Significantly, 66.4% of older women rely on funds outside their own source, mainly on families to support themselves. Thus, more than half of this segment is financially dependent. This adds to their vulnerability and often creates abusive environment for older men and women in families. Such existent situation of older people in society is a wakeup call for the government to pay attention to the reality of large majority of older people and take concrete steps to alleviate the conditions. The policy and programme response in the country to ageing issues must factor in the socioeconomic vulnerabilities experienced by older people.

A Brief Review of Some of the Responses to Ageing Issues Indian government, central and different state governments, various NGOs working on ageing issues and civil society members since last two decades or more are paying attention to concerns related to older people though not to the extent that it should be done given the range and gravity of problems being faced by older segments of the population. No doubt there is more being done for older women compared for older men in terms of specific initiatives but to a large extent older people in general are discriminated in society, face socioeconomic and resource deprivations, have low

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status in families and communities, are facing increasing levels of abuse and neglect, have limited age-friendly facilities and products, and lack adequate health and social care services. Multidimensional poverty is seen to be more pronounced among the older population as they experience ill health, emotional insecurity, exploitation, discrimination at various levels be it in the house, community, work place and social exclusion. Yet, many proactive steps have been taken, namely a National Policy for Older Persons, an initiative of the central government along with different state-level policies, health policy for the elderly, certain legislative measures such as the Maintenance and Welfare of Parents and Senior Citizens, Act as well as provisions in the law to safeguard the interests of older people, build age friendly buildings and environments, create certain safety nets and social security mechanisms, recognize their contributions to families, community and in development. The government also provides certain concessions and benefits to older people through its various ministries and departments, such as in terms of income tax, savings, travel by railways, airlines, public transport, giving priority to older people for health and social services, providing institutional care, building day care centres, and taking different steps for their wellbeing, looking after their dignity and respect in society. However, there is general consensus among experts, those concerned with ageing issues that much more is required to make life more comfortable for a large population of older people and government in the coming years needs to plan more systematically for an ageing society.

Concluding Remarks The different chapters in this book provide extensive understanding of what is happening in Indian society in addressing some of the emerging issues and reflecting appropriate responses in facing the upcoming challenges. The big question arises whether India is prepared to tackle the concern with ageing of its society and in what ways is it finding solutions to protect the rights of older persons and ensure for them a life of dignity and respect. As a country are we making appropriate choices for an ageing society to accommodate its younger and older populations simultaneously and can we take up the future demands of older people as we work for the interests of younger population. Are we well prepared to protect and safeguard the interests of older people as we are still defined by certain demographers and statistics as a young society along with ageing rapidly in this twenty-first century.

References Dandekar, D. (1996). The elderly in India. New Delhi: Sage.

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GOI. (2016). Ministry of Statistics Programme and Implementation, Elderly in India: Government of India. James, K. S., & Syamala, T. S. (2016). India’s support system for the elderly: Emerging challenges. In: K. Gayithri, & K. V. Raju (Eds.), State, governance and financing of India’s development. New Delhi: Cambridge University Press. Kasturi, S. (2000). Demographic ageing and social development. In Proceedings of International Conference ‘Health Systems and Social Development: An Alternative Paradigm in Health Systems Research, Maastricht. Pension Watch. (2018). Social Pensions Database, HelpAge International. Available at https://bit. ly/2ZVVIDQ Prasad, R. D., & Goli, S. (2019). Is South Asia prepared for ageing challenges? Geography and You, 19(19 & 20), 10–15 Rajan, S. I., Balagopal, G. (2017). Caring India: An introduction. In S. I. Rajan & G. Balagopal (Eds.), Elderly care in India—Societal and state responses. Springer Nature Singapore Pte Ltd. Shankardass, M. K. (2004). Growing old in India: Voices reveal and statistics speak. B R Publishing House. United Nations. (2017). United Nations Population Prospects. 2017 Revision. Department of Economic and Social Affairs, Population Division. New York: USA. United Nations. (2019). World Population Prospects. 2019 Revision, Department of Economic and Social Affairs, Population Division. New York: USA. Online Edition. Available at: https://bit.ly/ 322PA83.

Chapter 2

Addressing Marginalization Among the Elderly: A Social Work Perspective Archana Kaushik

Abstract Old age, in the present sociocultural milieu, is driving people to marginalization and social exclusion. The present paper briefly discusses the multilayered vulnerabilities elderly face at the health, social and economic levels and their implications. In old age, body strength deteriorates and several diseases crop up in the body. Mental health ailments too rise in old age. Informal support system in terms of joint families and community ties is waning away making elderly struggle for their status and security. Current social security measures initiated by the government are grossly inadequate to meet the demands of two-thirds of the elderly, who are economically impoverished. Several research studies have validated that strong, amicable relations with significant others act as antidote to loneliness, alienation, depression, anxiety, elder abuse, sense of insecurity and even marginalization. So, to address the challenges faced by elderly, the paper strongly advocates for the development and maintenance of cordial and amicable family and community relations. It highlights the scope of geriatric social work to promote well-being among the elderly. Keywords Population ageing · Health vulnerability · Economic vulnerability · Social vulnerability · Social support

Introduction It is quite ironical that the elderly, who have occupied an utmost position, reverence and unquestioned authority in the society in ancient and medieval times, are increasingly becoming alienated, marginalized and socially excluded. The elderly, who have once played a pivotal role in the societal growth and development, are more and more perceived as vulnerable, dependent and spent force. They are increasingly losing their traditional ascribed status, respect and authority in the family and society. Once an epitome of knowledge, power and authority, they are now viewed as one of the vulnerable and marginalized sections of the society. A. Kaushik (B) Department of Social Work, University of Delhi, New Delhi, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. K. Shankardass (ed.), Ageing Issues and Responses in India, https://doi.org/10.1007/978-981-15-5187-1_2

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Among other factors, demographic transition in terms of population ageing has indirectly contributed to the marginalization of the aged. Though old age is a natural and universal occurrence, population ageing is an unprecedented phenomenon in the history of humankind. With improved public health system and medical advancement, there is drastic reduction in death rate and increase in life expectancy. Now, more and more people are living long enough to experience ‘old age’. At the time of Independence of India in 1947, life expectancy was merely 35 years which now has become more than double (nearly 70 years). In 2017, globally, elderly population outnumbered 962 millions. It is projected to be doubled (nearly 2.1 billion in number) by 2050. It is projected that in next 50 years, there would be more grandparents than grandchildren, in these developed nations (see United Nations 2017). The phenomenon of ageing and the issues related to it are not primarily confined to developed countries alone. Over half (59% or 249 million people) of the world’s elderly live in developing nations, and by 2030, 71% (or 686 million) of the world’s elderly would be in developing countries. East and South-east Asia are fastest ageing regions. In this context, India is no exception. Its elderly constitute the fastest growing segment of the population and are expected to cross 200 million by 2025, and by 2050 this figure would almost double (324 million) as noted by Jeyalakmi et al. (2011). Population ageing, though taken as a triumph of human civilization, is also posing challenge for the state to ensure basic needs, security, dignity, protection, health care and similar others for its aged population. Panda (2005) quotes Ramachandran (1994) who has observed that, in developed countries, to one person eligible for social security, three persons are contributing through taxes. This ratio is reducing further, throwing additional burden on earning population of a country. Contrarily, developing countries, where the majority of the elderly population resides, are often characterized by poor economic conditions, inadequate healthcare and social welfare systems. So, for these countries maintaining elderly population is difficult as there are hardly enough resources to meet the needs of its young population. Cost of social insurance and social assistance for senior citizens can be quite taxing for nations with scarce resources. Consequently, the elderly are frequently viewed as a spent force and dependent. This situation is facilitating ageism and stereotyped perceptions. In any country, if a large segment of population is considered dependent and viewed negatively, then it would be a huge loss to the nation’s progress and development. Change in the structure, composition, functioning, pattern and dynamics of the family system has crucial implications on the society, and one of the vulnerable groups in this regard is ‘the elderly people’. In ancient times, orphans, children, disabled, elderly are well taken care of by the joint family. Only in rare cases, state had to intervene to provide care and support to the needy. In contemporary times, state has to adopt more proactive role as the rate of destitution has increased manifolds and preventive role of joint family system is diminishing. In addition, a high degree of variability is observed in the levels and magnitudes of vulnerabilities and problems faced by the elderly. Age, gender, hereditary endowment, socio-economic status, gender, occupation, educational status and such other

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socio-demographic factors influence the intensity of vulnerabilities among the aged people. Though it is not possible to cover all the vulnerabilities of the elderly in the present, prominent ones are delineated below:

Health Vulnerabilities Case 1 Kanto Devi is 79 years old lady living in rural Haryana. Her stooping gait, wrinkled face and haggard looks make her even much older. Her body has become a hub of ailments. She is suffering from urinary incontinency and high blood pressure. She is diabetic and her cataract operation is also being postponed. Kanto is dependent on others for getting up and sitting. Her medicine and treatment costs are increasing steadily. The daughter-in-law and grandchildren find it difficult to provide care and attention to the frail ageing lady. Though Kanto doesn’t have obvious financial constraints, increasing health problems are making her suffer in many ways. Her interactions with neighbours and relatives has decreased.

Increasing Dependence Deterioration in health condition and strength brings vulnerability in old age. With body becoming susceptible to several ailments and reduction in sensory capacities, the aged face increased dependence in activities of daily living. Elderly people are also prone to fractures, accidents and disabilities due to weakening of body’s balance and stamina and proneness to fall. Prevalence of disability is also higher as body’s capacity to heal is considerably reduced. Data show that the aged who become dependent on others for their activities of daily living are susceptible to elder abuse (see Kaushik 2016). Poverty Accentuates Health Vulnerability Though there is great deal of heterogeneity in health condition among the elderly, for those amidst poverty ageing process accelerates very fast. Due to chronic malnutrition, poor health and hygiene, and irking livelihood through physically strenuous jobs, invariably a forty-year-old person appears to be sixty years old. Gender and Health Vulnerability In addition, aged females are all the more at a disadvantageous position than their male counterparts. Apart from the age-related diseases, they also suffer from gynaecological problems. Moreover, their childhood and adulthood are invariably denoted by malnutrition, deficiency disorders, multiple pregnancies, which hamper their health in old age. Further, females are more prone to osteoporosis, particularly after menopause, which makes their bones quite fragile (Ganesh 1997). Thus, often feminization of old age is crippled with poor health and disability. Present Lifestyle Adds to Health Vulnerability Ageing in modern-day living is further complicated by faulty lifestyle. The World Health Organization (2007) maintains that aged people are prone to non-communicable diseases such as hypertension,

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heart diseases, stroke, diabetes, cancer, respiratory diseases, arthritis and mental problems. Presently, such non-communicable diseases account for about 56% of all deaths worldwide, and this proportion is expected to jump to 73% by the year 2020. Moreover, ageing and disability go hand in hand. Jeyalakmi et al. (2011) note that nearly 64 per thousand aged people in rural areas and 55 per thousand older individuals in urban areas are afflicted with one or more types of disabilities. Most frequently occurring disability among the elderly people was loco motor disability as 3% of them suffering from it, next being the hearing disability (for about 1.5%) and blindness (1.7% in rural areas and one per cent in urban areas). Rise in Mental Health Problems In addition, there is increase in mental health problems in old age, which are both organic (i.e. due to anatomical and physiological changes) as well as functional (due to environmental factors) in nature. Loneliness, alienation, sleeplessness, worry and tension and death fear are some of the common mental health challenges found among elderly people. Rigidity of behaviour and increasing introvert tendency make interaction of elderly with significant others less amicable. Further, in old age, chances of having Alzheimer’s disease and dementia increase manifolds. They are the progressive neural disorders or brain dysfunctions that gradually attack brain cells and strip people of their memory, personality and a sense of the self. Dementia not only affects sufferers, but also puts multiple burdens on their caregivers or family members. It is reflected in the case below of an old man suffering from Alzheimer’s disease. Case 2 Janhvi, a 37 year old married working woman lives in rented accommodation in Delhi. Apart from workplace and home management, Janhvi has to take care of her 77 years old father who is suffering from Alzheimer’s disease, which drains her out physically and emotionally. Her father can’t recognize her. He lives all alone in the nearby apartment with one domestic help as Janhvi’s in-laws refused to allow entry of a ‘mad’ man in their house. Janhvi finds herself clueless as every other day her father’s behaviour puts her into trouble. Without informing anyone he goes out of the household. He ‘forgets’ to use bathroom for nature’s call. Sometimes he shouts and abuses at others for no apparent reasons. Janhvi cries in frustration and utter confusion, as she neither can control or understand her father’s mental ailment nor can change the mindset of her relatives and neighbours who keep on blaming and targeting her for her father’s behaviour.

In India, there is lack of awareness about major mental health disorders including Alzheimer’s disease and dementia, and there is a stigma and labelling attached with it. There is a dire need of support services for families dealing with patients of Alzheimer’s and dementia otherwise soon, such situations can lead to elder abuse (see Kaushik 2016). Shooting Medical Expenses So, need for medical treatment increases manifolds. Getzen (1992) claims that in old age people require health services eight times more frequently than young persons in their thirties. Accessibility and affordability to

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healthcare services often influence health vulnerability of the general population, what to say of the aged. National Rural Health Mission (2005) observes that curative services favour the non-poor: for every Re. 1 spent on the poorest 20% population, Rs. 3 is spent on the richest quintile. Also, over 25% of hospitalized Indians fall below poverty line because of medical expenses. Over 40% of hospitalized Indians borrow heavily or sell assets to cover expenses. Seemingly, increased longevity hardly offers a cheering prospect due to poor geriatric healthcare and rising medical expenses. Helpage India (n.d.) notes that amidst inadequate healthcare facilities in general, geriatric care services are almost non-existent. This is all the more true with regard to mental health services. There is poor awareness as well as coverage of health insurance schemes. There is lack of palliative and home-based care for bedridden and terminally ill elderly. For the poor elderly, health vulnerability may result in loss of ability to earn leading to destitution.

Economic Vulnerabilities Poverty Fuels Elder Abuse Old age brings deterioration in earning capacities of the people. Compulsory retirement adds to the economic vulnerability among elderly. Further, nearly 93% of the Indian population works in the unorganized sector where there are hardly any retirement-related social security options. Thus, people in informal sector work till their physical capacities wane and then they are thrown out of the job market. Thus, they are rendered without any pension or provident funds. Case 3 Ramdeen, a 62 years old man looks somewhat 20 years older than his age. After his wife’s death, he was almost thrown out by his son and daughter-in-law who were staying in a resettlement colony in Delhi. His son, a rickshaw puller, was not able to earn enough to feed his ‘unproductive’ father. In the day time, Ramdeen drags himself to get some work as porter, carry load-trolley in Kirti Nagar furniture marker. In case, he doesn’t get any work, he starts begging. Late evening, he goes to a night shelter, where stray dogs, alcoholics and drug addicts barge in. Many times, his entire day’s earning and miniscule savings are snatched away or stolen in the night shelter. Ramdeen misses his family a lot. He is in perpetual state of destitution and desperately cries to be with his little eight-months old grandson who lovingly would call him, “dudu”.

Increased Physical Labour with Reduced Energy The National Policy on Older Persons (1999) brings out that one-third of elderly in India are living below the poverty line and another one-third of it are just above it. Thus, two-thirds of the aged population in the country are economically vulnerable and need social assistance. These older people encounter numerous challenges in making both ends meet. In terms of numbers, out of 81 million elderly, 51 million are poor. Moreover, 60% elderly men and 19% aged women are forced to work, despite failing health conditions in order to survive (Helpage India n.d.).

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Reducing Informal and Formal Support Systems There are many manifestations of aged in poverty—most often they push themselves hard to earn a source of survival. They may be seen as casual labourers at the construction sites, factories, agricultural lands, rickshaw pullers, security guards and so on. Aged women often take up the job of domestic help. Those who are able to arrange some finances may work as hawkers and venders. Physically strenuous activities may take a heavy toll of their health. Social systems like banks, credit societies often do not encourage lending loan to the aged. Selling of perishable goods has their own set of challenges due to non-availability of storage facilities. When the poor elderly become unproductive and lack family support, they are pushed towards destitution. They have to either engage in physically strenuous activities like causal labour or resort to begging. Increasing Gap Between Demand and Supply In the name of social assistance for the aged, the government provides old age pension (which ranges from Rs. 200 to 1500 per month) subjected to stringent qualifying conditions such as proof of destitution, age verification and domicile. Statewise variations in terms of conditions and amount of pension are high. Official data show that there are nearly 56 lakhs elderly getting OAP that constitutes 5.8% of the total elderly population and 8.75% of those in need of social assistance. Thus, the coverage of old age pension is very limited. The Government of India earmarks nearly two per cent financial resources of the GDP for social safety net covering subsidized food, employment guarantee and social pension (Weigand and Grosh 2008). Social pensions (for elderly, widows, disabled) make up less than four per cent of the total allocated money for social safety net (Dutta 2008). This gives the indication of availability of scanty resources for a huge section of needy population group of the elderly. If the state is not allocating funds for security and well-being of the senior citizens when their proportion to the general population is about ten per cent, what would be the situation when this proportion would rise to one-third or more?

Social Vulnerabilities In the agrarian society, the elderly enjoyed utmost respect and reverence in the family and community. Joint family system was considered safe haven for the aged where they were the head of the household. They would control the properties and resources and were the prime decision-makers. Their words were not less than a law. They had salient roles to perform in the functioning of family affairs—they acted as guides, mentors, educators, counsellors and mediators. Added Gendered Vulnerabilities However, in modern times, due to factors like commercialization, industrialization and urbanization, situation of elderly has changed drastically. Along with, modernization has profoundly influenced the values like interdependence, cooperation and self-sacrifice giving way to independence,

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personal mobility and personal achievement. All these factors have contributed to changes in the structure and functioning of the family system. Joint family system is giving way to nuclear families where the role and status of the aged have diminished. Added to this, women used to be the prime caregivers in the family. In modern times, women are increasingly entering into job market, and they are having much reduced time to do domestic chores including caregiving. On the contrary, elderly especially after eighty years need constant care which in nuclear family and alternate family patterns is difficult to provide. Migration and Widowhood Accentuate Vulnerability The situation is further complicated by the fact that the young seek jobs at places other than their own native places and even abroad. This often results in spending long years of old age with waning capacities in loneliness and alienation. Further, widowhood accentuates vulnerability manifolds especially with women. Consequently, elderly are becoming targets of abuse, violence, crime and destitution. Case 4 Raji, a 68 year old lady living in a Delhi village, never imagined in her nightmare even that her own son would slap, thrash and beat her up to abandon her at the time when she needed him the most. Her husband died eight months ago and since then her bad days began. Her daughter-in-law instigated him against her, cries Raji with unstoppable tears. Raji now stays in a thatched house, which some benevolent neighbours have built for her. If her health permits, she works as maid in some households. On some days, she gets porridge or some snacks from the Anganwadi centre in the village.

About a half (50%) of the elderly in India are facing abuse that includes neglect, disrespect, maltreatment, verbal, physical, violation of rights, deprivation of choices and basic needs and exclusion from social functioning of the family. Yet, the increasing reports of crime and violence against the elderly are a cause of concern because only one in every six crimes gets reported (Helpage 2015). The elderly refrain from reporting abuse against them because of fear, shame and reprisal. In the contemporary times, the image of the elderly has been distorted enough and apparently they are treated as spent force, passive, at times, rigid and nagging. Towards this, Telmon (1988) has observed that in a society that places high value to the ‘productivity’ or ‘usefulness’ of its members, elderly are taken as spent force and burden. In today’s society that is characterized by market-driven consumerist approach, ‘youth’ is celebrated while old age is negated and neglected. Social image is a contingent factor in role allocation and expectations vis-à-vis elderly. In this transition phase, their traditional roles and associated status are fading away and not being well replaced by newer roles. They are increasingly in a state of ‘rolelessness’. It leads to alienation, neglect, isolation, hostility, ageism, marginalization and social exclusion of the elderly.

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Implications Indeed, old age brings multiple vulnerabilities that are accelerating marginalization and social exclusion of the elderly. Population ageing at this scale is unprecedented, affecting nearly all the countries, and its impact is visible in all the facets of human life. Economically, population ageing will affect growth, labour markets, pensions, taxation, intergenerational transfers as well as consumption and savings patterns. Leading to increased dependency ratio, this is throwing up additional challenge, especially for developing countries, with scarce resources to provide for the social security and health services for their elderly population. Socially, increased proportion of elderly would mean that almost all the families would have to encounter the issues related to elderly caregiving, including the long-term health care. Moreover, spending a long life without any substantial role to play would add to loneliness, alienation, low self-esteem and many psychological ailments. At the macro level, if a sizable proportion of population (of older persons) is treated as unproductive, spent force and useless, it surely will have severe implications on the national economy. Increase in population of elderly would add to disease burden and treatment cost due to rise in physical and mental health ailments in old age. Then, what is the way out? Old age is the natural and the last phase of life. It is the duty of the society to provide support and care to the elderly who have contributed for the progress and development of the nation in their prime time. In their twilight years, if they are left unnoticed and treated as unproductive, it would be a blot to humanity.

Social Support: An Answer Several research studies have, beyond doubt, proved that amicable social relations and social support are antidote to varied psychosocial challenges faced by the aged in contemporary world, be it elder abuse, insecurity or destitution. Relationships have an extremely important place in the life of people. They are the source of joy and happiness. Love and belongingness are among the basic needs of human beings. These needs are fulfilled by social institutions like family and neighbourhood. Khan (1997) observes that those aged, who are amicable and forbearing, possess communication skills and have warmth towards family members, continue to be important to the family. There is a strong evidence amicable relation which provides a buffer between stressful event and emotional distress (House 1981). Panda (2005) finds that irrespective of their financial conditions, sense of security and well-being among elderly women in Delhi depends on their relationships with their family members. Thus, an aged lady in rugs is contented with amicable and loving family relationships while another elderly lady with crores of property feels insecure and grumpy, having incongruent relations with significant others. On the

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contrary, those individuals who exhibit negative communication pattern, often, get the same in response. This, in turn, affects their well-being (Ewart, et al. 1991). In fact, Cousins (1979) has shown that it is our attitude and our thinking process that influence our life. This is also true in the case of elderly people (Mishra 1996; Natrajan 1987; Ramamurti and Jamuna 1993). Further, Havighurst (1961) observes that feeling of happiness and satisfaction with one’s life, health, family, friends, work and finances, zest, positive self-concept and optimistic mood tone help in viable adjustment in old age. Formal or informal acceptance of significant others is crucial for the self-concept and well-being. Stevens (1992) claims that interactions with family members and significant others, involvement in community affairs, respect from youngsters bring a sense of acceptance and satisfaction among the aged. A longitudinal study from Bassuk et al. (1999) has found that elderly persons who had no social ties were at increased risk for cognitive decline, compared with those who had five or six social ties. Using frequency of contact with friends and colleagues as an indicator for social support, Boult et al. (1994) have found that social support was associated with a reduced risk of developing disability up to four years later. Research has also shown that social role involvement and personal control were factors not only in slowing age-related decline in physical health, but also in reducing levels of activities of daily living (ADL) disability. In a prospective cohort study that followed 1203 non-demented aged 75 and over for 3 years, Fratiglioni et al. (2000) found that a social network reduced the incidence of dementia. In the same wavelength, Chan and Lee (2006) observe that older persons with a larger network are happier and that social support plays a mediating role. Likewise, Lu and Argyle (1991), through series of experiments conclude that cooperativeness is one of the important determinants of happiness. Kim et al. (2008) note that social support is one of the most effective means by which people can cope with stressful events. Panda (2005) brings out that elderly women who share cordial relations with their family members have fewer ailments. Stoddart et al. (2000) bring out that social networks play crucial role in preventing dependency in old age. The bigger the social network size, the more active and productive is the elderly person. Kaushik (2016) asserts that incongruent relations between elderly and their caregivers are potent factor to elder abuse. Khan et al. (2013) have collected ample evidences of strong community support nullifying marginalization and destitution among elderly women in their study on nine states with sample size of more than 8000 women. Another major study by London School of Economics finds that failed relationship plays a far greater role in causing unhappiness than other factors like economic crunch, poverty, unemployment and ill health. In the light of the findings, Richard Layard, the famous economist and research team leader, has claimed that ‘this demands a new role for the State - not wealth creation but well-being creation’ (England 2016). Thus, social support and congruent relations are powerful factors that have the potential to deal with most of the challenges that are delineated above. Social support that is inclusive of congruent social relations has following salient benefits: • Rolelessness is a major challenge elderly are facing in the present times. When relations of the elderly are amicable with family members and in neighbourhood,

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they are able to take up newer roles and involve themselves in childcare activities like babysitting, dropping and receiving grandchildren at the school bus, caring them after school hours, helping in studies, sharing their experiences and problems, etc. They can facilitate tasks like getting electricity and telephone bills paid (if agencies located within convenient distance). Such an initiative in taking up new roles may greatly help the aged in better adjustment and active ageing. On the contrary, if the elderly have strained relations, they are more likely to feel lonely and alienated. Elderly are often labelled as spent force and unproductive. This has given rise to ageism remarks and negative stereotypes that become breeding ground of elder abuse. There is a general tendency to label everyone over 60 years as old, unproductive and incapable. However, old age is a huge age slot of 40+ years. There are young-old (60–70 years) who can be productive, provided opportunities. Moreover, we must recognize that all old people are not unproductive. Age and infirmity are not always directly proportional. With some financial and technical support, this category of active elders is able to irk their livelihood conveniently. Majority of the elderly in India are from unorganized sector and in the category of active elders. Seeing the existing gap between demand and supply, social security measures are grossly inadequate to meet the needs of the elderly. Assisting the elderly in income generation programme would help reduce their dependence on government as well as on informal support. Initiatives by Helpage India on elder self-help groups (ESHGs) are worth mentioning. This programme caters to about 75,600 elderly across 19 states in India, through 5400 groups. From agriculture to pisciculture (or fish farming), handicrafts to making pickles, chutneys, the members of ESHGs are ardently engaged in economically gainful activities, thereby defying the stereotype of being unproductive and useless. These ESHGs have pivoted on economic independence, denting on marginalization of the aged. With accentuated social and economic vulnerabilities, abuse and crime against older persons are on the rise. Helpage India, through its ESHGs programme, has validated that the elderly not only have the courage to stand up on their own for financial independence but also through cooperation and sharing their problems helped their fellow beings in coming out of various psychosocial and financial problems. With no longer dependent on their married children for financial support, the elderly also guard against abuse and marginalization. In addition, the aged, like most other vulnerable groups, are taken as passive receptors of care and services. On the flipside, they have not only shown resilience but also extended help to their needy fellow beings. Vridha Sangh, another programme initiated by Helpage, has created ‘pressure groups at village levels who do advocacy for securing the rights of their disadvantaged counterparts. Notable aspect of this programme is that rather than being the passive receive of care and services, the elderly themselves fight the battle for their fellow beings. Studies have shown that the elderly, who are socially well adjusted, have fewer ailments. So, if social workers in geriatric setting intervene to ensure amicable social relations of the elderly with their significant others, the cost of medical services and health security can be drastically reduced. For a nation like India, with resource

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crunch, reliance on informal support system can be a big advantage. Social workers can inculcate and refine social skills among elderly, organize sensitization sessions with family members especially youth and children to bridge intergenerational gaps. Help Unite Generations (HUG) programme of Helpage India is directed towards creating sensitivity among youth for intergenerational solidarity. Helpage’s another programme School Action for Value Education (SAVE) is geared towards sensitizing school kids about the importance and contributions of their grandparents. Older people contribute significantly in several ways, though it remains unnoticed and unrecognized. Efforts to bring the contribution and significance of the elderly in the limelight would reduce negative stereotypes against them and help building a society for all ages. • Among older persons, deterioration in strength, impairment and certain ailments are common that may affect their productivity. However, those elderly who are healthy and autonomous in carrying out their activities of daily living more frequently take up new roles and participate in family and community affairs. Therefore, healthy and active ageing through health promotion and disease prevention among the elderly is the goal of geriatric professionals. Awareness needs to be created about nutrition and balanced diet, disease prevention, active ageing lifestyle, light physical exercise and Yoga and meditation. • Mental health problems like anxiety, depression and dementia afflict quite a few older persons. On the other hand, our sociocultural milieu is not sensitive enough to deal with such problems. Social work professionals and psychologists need to come forward to fill in this gap. There is a wide scope for counselling services for the aged and their family groups on mental health issues. Social workers could also initiate measures to form self-help groups of older people at the neighbourhood level, which would go a long way in alleviating many of the psychosocial problems. Senior Citizen Associations (SCAs) formed in several metropolis like Delhi also act as pillar of strength for many elderly living alone or those who feel lonely, alienated and marginalized after retirement from their prime roles in life. Moreover, most of the Delhi neighbourhoods have Residents Welfare Associations. These have a major role to maximize the psychosocial satisfaction of the elderly. These institutions could assign elderly persons specific roles and responsibilities, paying due attention to their age and physical strength, for looking after the upkeep of the neighbourhood or for organizing recreational and cultural activities children, adolescents and others. People, including older persons, having roles and responsibilities tend to have positive self-regard and reduced mental and physical ailments. • Role of voluntary organization can be significant, and the elderly can act as volunteers or as advisors. Likewise, in old age homes, elderly inmates can work as care takers. This would develop a sense of ownership and control among them. Old age home can be work oriented. They would be made available, rather more attractive, to such elderly persons by providing them a life of purpose and fulfilment. They will constitute an important resource and form an integral part of the service centre.

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• It is possible to device aged-specific employment generating schemes reflecting the distinctive age and other consequential differentials in regard to kinds, hours and nature of work. Such schemes can be not only non-competitive but also employment generating for other groups. Economic utilization of this potential will have salutary repercussions on social welfare in various ways. It will make for better health and greater happiness of the aged themselves. It will bring down social expenditure on the sick, the infirm and the destitute. It will increase the proportion of economically independent among the aged and thus lower the dependency ratio and increase the usable income of the other age groups on themselves. The contribution of the aged will enhance the national domestic product of the country. Social support refers to positive exchanges with network members that help people stay healthy or cope with adverse events (Thoits 2011). It is a powerful predictor of living a healthy and long life. Several research studies have explained that older people who are embedded in social networks and have social support enjoy better mental and physical health. They also have ample opportunities for companionship and social engagements. Social support helps people cope with setbacks and serves as a protective barrier against threats to well-being. Contrarily, lack of social support is related to negative impacts on health and well-being, especially for older people. Having a variety of positive social supports can contribute to psychological and physical wellness of elderly individuals. Support from others can be important in reducing stress, increasing physical health and defeating psychological problems such as anxiety and depression. When considering who provides social support for an elderly individual, our first thoughts are of family members. While it is true that most support does come from family members, there are many circumstances in which family members cannot be supportive (stress due to responsibilities, illness, death, financial problems, job relocation). In the coming decades, most families would be having old people to care for. With changing structure and functioning of the family system, family’s role in elder care is fast diminishing. As a consequence, need for community-based services is more important now than ever before. Community-based elder care services can be useful for elderly individuals, thereby ensuring social support, senior citizen associations, religious affiliation groups, day care centres, etc. These services can provide positive social supports that can help older persons defeat loneliness and isolation. Information and advice giving, counselling, crisis intervention, basic social support, conflict management and mediation, bereavement counselling and advocacy are some of the prominent areas where social workers are intervening with and for the elderly. Caregiving stress often leads to elder abuse. Working with caregivers, be they family members or in formal set-up to deal with stress and burnout is an important aspect of social work. The tasks of social workers with older people are very varied and include working with their families and caregivers. Social work with older people focuses on the preservation or enhancement of functioning and of quality of life of aged clients. It aims at maximizing both opportunities and quality of life in the context

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of their social system, their needs and their rights, through the method of case work. Assessment is key to all the main roles and tasks of social workers. Social workers carry out social assessments that involve identifying practical and emotional needs and appropriate supports. This ensures planned intervention to assist older people and their family. Social workers employ the method of social group work with older people and their caregivers in many situations such as stress management, Yoga group, adopting healthy behaviours, the aged facing terminal illness, financial management in old age and palliative care. Other social work interventions include advocating on behalf of the aged to a range of services such as old age pension, health security and social welfare services. Social workers network and liaise with community resources provide elderly and families information on a range of topics including benefits and entitlements and support services. They assist the aged to empower themselves, encourage and support them to act on their own behalf by providing information and support. Social workers provide counselling to elderly clients and their families encompassing loss and bereavement, psychosocial adjustment, stress management or addiction. They focus on strengths and uniqueness of the elderly and promote resilience in them. Thus, social work with older people takes place in a wide variety of settings and encompasses a broad range of methods, approaches and areas. The recognition and promotion of active ageing and contributions of the older persons are becoming centre stage issues worldwide. In his message on the International Day of Older Persons, 1 October 2009, the Secretary General Ban Ki-Moon of the United Nations states, ‘Over the past decade, we intensified our efforts to build a “society for all ages” and to promote international commitment to the United Nations Principles for Older Persons. The Principles are founded on the need to build an inclusive society that emphasizes participation, self-fulfilment, independence, care and dignity for all. To transform them into deeds, we have campaigned for policies that will enable older persons to live in an environment that enhances their capabilities, fosters their independence and provides them with adequate support and care as they age’. In 2007, in his message, the Secretary General affirmed that older persons now have many more opportunities to keep contributing to society beyond any set retirement age. Our views on what it means to be old are changing all the time. Where older persons were sometimes seen as a burden on society, they are now increasingly recognized as an asset that can and should be tapped. Note As the author is supervising students placed in Helpage India for their concurrent fieldwork for over ten years, she got opportunity to closely observe the agency’s initiatives. This is the only reason of citing several examples of Helpage India’s work in the paper, though several other organizations are equally committed for the cause of elder well-being.

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References Bassuk, S. S., Glass, T. A., & Berkman, L. F. (1999). Social disengagement and incident cognitive decline in community dwelling elderly persons. Annals of Internal Medicine, 131, 165–173. Boult, C., Kane, R. L., Louis, T. A., Boult, L., & McCaffrey, D. (1994). Chronic conditions that lead to functional limitation in the elderly. Journal of Gerontology, 49, M28–M36. Chan, Y. K., & Lee, R. P. L. (2006). Network size, social support and happiness in later life: A comparative study of Beijing and Hong Kong. Journal of Happiness Studies, 7(1), 87–112. Cousins, N. (1979). Anatomy of an illness as perceived by the patient. New York: W.W. Norton and Co., Inc. Dutta, P. V. (2008). The performance of social pensions in India: The case of Rajasthan. Social Protection Discussion Paper No. 0834, World Bank. England, Charlotte. (2016). Love bigger cause of unhappiness than cash (p. 17, col. 1–6). Times of India, December 13, 2016 Tuesday. Ewart, C. K., Taylor, C. B., Kraemer, H. C., & Agras, W. S. (1991). High blood pressure and marital discord: Not being nasty matters more than being nice. Health Psychology, 10(1), 155–163. Fratiglioni, L., Wang, H. X., Ericsson, K., Maytan, M., & Winblad, B. (2000). Influence of social network on occurrence of dementia: A community-based longitudinal study. Lancet, 355, 1315– 1319. https://doi.org/10.1016/S0140-6736(00)02113-9. Ganesh, K. (1997). Common gynaecological morbidity pattern in elderly females. In K. Bagchi (Ed.), Elderly females in India (pp. 65–78). New Delhi: Society for Gerontological Research & Helpage India. Getzen, T. E. (1992). Population aging and the growth of health expenditures. Journal of Gerontology: Social Sciences, 47(3), S98–S104. Government of India. (1999). National policy on older persons. Shastri Bhawan, New Delhi: Ministry of Social Justice and Empowerment. Government of India. (2005). National rural health mission. Retrieved December 10, 2016 from http://nrhm.gov.in/nhm/nrhm.html. Havighurst, R. J. (1961). Successful aging. The Gerontologist, 1(2), 8–13. India, Helpage. (2015). A report on elder abuse and crime in India. New Delhi: Helpage India. Helpage India. (n.d.). Growing old in New India. New Delhi: Helpage India. House, J. S. (1981). Work stress and social support. Reading, MA: Addison-Wesley. Jeyalaxmi, S., Chakrabarti, S., & Gupta, N. (2011). Situational analysis of the elderly in India. Central Statistics Office, Ministry of Statistics and Programme Implementation, Government of India. Retrieved August 12, 2018 from http://mospi.nic.in/sites/default/files/publication_reports/ elderly_in_india.pdf. Kaushik, A. (2016). Elder abuse: A review of literature. Helpage India Research & Development Journal, 22(2), 3–28. Khan, M. Z. (1997). Elderly in metropolis. New Delhi: Inter-India Publications. Khan, M. Z., Yusuf, Mohd, & Kaushik, A. (2013). Elderly women: Vulnerabilities and support structures. New Delhi: Gyan Publishing House. Kim, H. S., Sherman, D. K., & Taylor, S. E. (2008). Culture and social support. American Psychologist, 63(6), 518–526. http://dx.doi.org/10.1037/0003-066X Lu, L., & Argyle, M. (1991). Happiness and cooperation. Journal of Personality and Individual Differences, 12(10), 1019–1030. Mishra, S. (1996). Coping with aging at individual and societal levels. In V. Kumar (Ed.), Aging: Indian perspective and global scenario (pp. 223–225). New Delhi: All India Institute of Medical Sciences. Natrajan, V. S. (1987). Geriatrics: A new discipline in India. Indian Journal of Community Guidance Service, 4(1), 63–70. Panda, A. K. (2005). Elderly women in megapolis. New Delhi: Concept Publications. Ramachandran, C. R. (1994). The emerging problem of old age. In: C. R. Ramachandran & B. Shah (Eds.), Public health implications of aging in India (p. 2). Division of Non-communicable

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Diseases, Indian Council of Medical Research. Cited in Panda, A. K. Elderly women in megapolis. New Delhi: Concept Publications. Ramamurti, P. V., Jamuna, D. (1993). Some predictors of satisfaction with present life in an Indian sample. Indian Journal of Gerontology, 3(3 and 4), 96–103. Stevens, E. S. (1992). Reciprocity in social support: An advantage for the aging female. Family in Society, 73(9), 533–541. Stoddart, H., Sharp, D., & Harvey, I. (2000). Social networks are important in preventing dependency in old age. BMJ: British Medical Journal, 320(7244), 1277–1278. Retrieved from http://www. jstor.org/stable/25224458. Telmon. (1988). Social aspects of ageing. In International encyclopaedia of social and behavioural sciences. US: Elsevier. Thoits, P. A. (2011). Mechanisms linking social ties and support to physical and mental health. Journal of Health and Social Behavior, 52, 145–161. https://doi.org/10.1177/0022146510395592. United Nations. (2017). World population ageing 2017—Highlights (ST/ESA/SER.A/397). Department of Economic and Social Affairs, Population Division. Retrieved August 1, 2018 from http:// www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2017_Highlights. pdf. Weigand, C., Grosh. M. (2008): Levels and patterns of safety net spending in developing and transition countries. Social Protection Discussion Paper No. 0817. World Bank. World Health Organization. (2007). Non-communicable diseases and development. Retrieved December 1, 2016 from http://www.who.int/nmh/publications/ncd_report_chapter2.pdf.

Chapter 3

Preventive Geriatrics—A Way Towards Active Ageing Anand Ambali

Abstract The elderly (>60 years) population in India is on rise and now constitutes 9% of total population. The population in India is greying at much faster rate while the health system is not yet completely prepared to face this silver tsunami. Unlike in west, the country became rich first and with adequate infrastructure while the population greyed later. Providing health care to the elderly as speciality is a biggest ever challenge our country is facing today. Few things that one needs to be aware regarding the elderly population are they fear disability more than death, blame the symptoms to ageing and delay in seeking medical attention. The preventive geriatrics shall aim at maintaining independent or near independent life, preserve the function so as to ensure good quality of life and active ageing. The primary, secondary and tertiary levels of preventive measures are very effective in preventing or delaying diseases in elderly age group. The priority for preventive measures should begin before the onset of diseases and or in preventing or delaying the complications of the existing chronic diseases. The preventive strategies will include modifiable, protective and screening measures. The modifiable measures aim at healthy lifestyle activities, good oral hygiene, cessation of smoking, tobacco chewing and alcohol consumption. Protective measures like immunization against pneumonia, herpes, hepatitis and tetanus will prevent communicable disease. The screening for diabetes mellitus, hypertension, vision disturbances, depression, dementia and risk for falls should be carried out on all elderly people at regular intervals. The main goal of the preventive geriatrics will be to keep the elderly population physically, mentally and socially active. The role of family support is also more effective tool in promoting good quality of life in older people. Keywords Prevention · Elderly · Quality of life · Active ageing

A. Ambali (B) Geriatric Clinic, Bijapur Lingayat Democratic Education Association, Deemed to Be University, Shri B M Patil Medical College Hospital and Research Centre, Vijayapura, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. K. Shankardass (ed.), Ageing Issues and Responses in India, https://doi.org/10.1007/978-981-15-5187-1_3

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Introduction The elderly (>60 years) population in India is on rise and now constitutes 9% of total population. The population in India is greying at much faster rate while the health system is not yet completely prepared to face this silver tsunami. Unlike in west, the country became rich first and with adequate infrastructure while the population greyed later. Providing health care to the elderly as speciality is a biggest ever challenge our country is facing today. Presently our health system is concentrating on child and maternal health. There are many challenges in providing health care to the older people in view of heterogenicity and multidisciplinary approach to diseases in older people unlike in children and pregnant women. Another important issue is that our medical curriculum did not had topics concerned to geriatric medicine and gerontology; hence, the practicing clinicians at present may not be aware of special issues in approach and management of health problems in elderly. The health status in elderly is measured by the functional ability during acute illness, living with chronic diseases and during disability and not by mere presence or absence of disease at a given time. The preventive geriatrics aims at healthy ageing which can be attained by various goals. The goals are to maintain functional ability, retard progress of chronic diseases, delay complications of chronic diseases, prevent communicable diseases, promote behavioural changes, create awareness and prevent untimely and premature deaths. These measures need to be applied in single or in multiple depending up on the health status of the older people. Preventive geriatrics does not prolong ageing process. The issues should also address how to avoid health-damaging behaviours and adapting a protective approach to remain healthy. Single disease models may not be effective in preventive interventions in older people; it should be rather for many diseases in a given older person (Mangin et al. 2007). The preventive measures to be successful should be financially, culturally and socially viable and also acceptable.

Historical Background The first probable scientific article published on preventive geriatrics is “The potentialities of preventive geriatrics” was by Stieclitz ET in the year 1941 (Stieglitz 1941). Ayurveda, the Indian traditional holistic health science, has got the potential for prevention of diseases by promotion of health and management of diseases occurring in older people. The principles of maintaining a proper well-being of the body and mind are incorporated in Ayurveda in form of Dinacharya, Ritucharya, balanced diet and the observance of personal, moral, seasonal and spiritual conduct (Burdak and Gupta 2015).

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Challenges for the Delivery of Preventive Health Care Services Promoting preventive measures is a challenge for the clinicians and gerontologists. The following factors need to be considered when applying preventive measures. 1.

The older people fear disability more than death, blame the symptoms to ageing and delay in seeking medical attention. 2. The priority changes with every decade of life. The health profile of older people in terms of seeking preventive health services changes with the different age groups. Majority of the young old (60–74 years) are active and have easy access to preventive measures, the old (75–84 years) will be less active, need frequent assistance and are not easily accessible to preventive services while the age group very old (>85 years) are isolated, bed ridden and needs frequent hospitalization. They are devoid of preventive services. 3. The older people will present challenges to the health care system given the fact that many comorbid conditions and associated disabilities become more common with age. An older person develops many medical, surgical, psychosocial and skeletal disorders over period of time for which they need medical assistance. This makes them the highest user of health services over a period of their life span. 4. The present generation of older people are not having health insurance cover; hence, they need to spend from their savings or depend on their children to take care of the expenses. 5. The diseases that have developed in their age of fifties will have complications in their sixties and seventies. This can be prevented by meticulous control of parameters of diseases and adapting healthy lifestyle changes. 6. The behaviours of elderly with health issues are both serious and casual. Many older people accept the diseases as they appear while some are apprehensive to accept them; the impact is sudden deterioration in quality of life in the latter group. 7. In India, the older people will be suffering from both the communicable and noncommunicable diseases unlike in west where only non-communicable disease are more common. 8. The diseases keep on adding over years in older people. For example, the diseases namely hypertension, myocardial infarction and stroke which all are related to circulation will follow each other in any order over years. 9. The diseases like Parkinson’s, Alzheimer’s, depression, heart failure make the older people not only socially isolated but also add burden on caregiver. 10. The older persons are not included in clinical trials of preventive strategies. 11. The prevalence of undetected, correctable conditions and comorbid diseases is high in older people because of the tendency to under-report the medical and social problems. The syndromes like fall, incontinence is commonly blamed to the ageing process. 12. There is delay in seeking medical attention either due to financial constraints, being lonely or being neglected.

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13. Most of the diseases are silent, have weak link or present with atypical features which leads to delay in identification of disease. This leads to older people presenting with complication rather than the primary disease per se. The preventive measures when practiced will be an actual holistic approach towards prevention of disorders or diseases in older people. The preventive measures shall be applicable to all the older people irrespective of health and social status.

Levels of Prevention All the three levels of prevention are found to be effective in prevention of the diseases or complications or disabilities. The primary prevention measures basically are meant to prevent occurrence a disease or disorder. The secondary prevention measures constitute timely diagnosis and treatment of diseases and thereby prevent occurrence of complications. The tertiary prevention measures are to prevent disabilities. This article discusses the various evidence based preventive strategies for falls, infections, malnutrition, depression and cognitive decline. The role of creating awareness and screening is also discussed. Clinically, all the conditions mentioned above merits considerable effort in prevention because of its contributions to disability, morbidity and mortality.

Prevention of Falls A fall is an unexpected event in which the older person comes to rest on the ground, floor or other lower level. It is the leading cause of fatal and nonfatal injuries leading to hospital admissions. Majority of older people who had fall will develop a fear of falling which makes them to limit their physical activity and social interactions, creating a “domino effect” that results in reduced mobility, physical weakness and decline, and feelings of isolation and depression. (National Council on Ageing). Falls are the main risk factor for fractures even more important than osteoporosis (Järvinen et al. 2008). The most common place to fall is a nursing home, external environment and home. In home, bathroom is the commonest place where older people fall. According to Chang et al. (2004), Cameron et al. (2012) and Karlsson et al. (2013), fall can be prevented by addressing the common risk factors. The factors are: 1. Health-related risk factors—postural hypotension, chronic osteoarthritis, polypharmacy, excessive alcohol use, low levels of physical activity and insufficient sleep. 2. The intrinsic capacity such as declines in physical, emotional and cognitive capacity.

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3. The difficulties with vision and balance. 4. The environmental factors like slippery flooring, dim lighting, obstacles and tripping hazards, poor stairway design, uneven footpaths, improper use of assistive devices, lack of social interaction and inappropriate footwear. Preventive measures Do’s and Dont’s in preventing a fall.

No

Things to do

1

If you are feeling dizzy or swaying while walking use stick or walking aid

2

Keep light “on” in bathroom daily during night

3

In case of vision disturbance, kindly consult ophthalmologist and get it corrected. Use hearing aids regularly, if you are advised

4

Keep soft bed by the side of the cot in night hours. In case even if you fall, you will not sustain injuries

5

Remove clutters like wires. The wires or toren rugs will lead to fall, hence avoid using low set electrical pins

Do’s

(continued)

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(continued) No

Things to do

6

Use bed rails. These rails are flexible and can be used only during sleep time

7

Spend time in sunlight. The exposure to sunlight preferable between 11 am and 2 pm for 15–30 min is ideal. It helps formation of Vitamin D in body

8

Walking and Yoga are the best exercises. Walk at least 30 min for five days a week. This gives strength to muscles and helps maintain balance

9

Drink at least one glass of milk daily and have foods rich in calcium

10

Get bar grabs fitted by side of commode. Keep bathroom dry. Use mattress on floor of bathroom to avoid slips

Do’s

b

(continued)

3 Preventive Geriatrics—A Way Towards Active Ageing (continued) No

Things to do

11

On staircase, mark the top and bottom steps with different colour. The handrail also should be of different colour

12

Medications—drugs meant for control of hypertension, diabetes should be taken regularly

13

Keep all the items of daily use preferably on the table of equal height which can be reached easily

14

Go for periodic blood pressure check-up and sugar levels. Look for orthostatic hypotension and hypoglycaemia and discuss with consultant

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Place a call bell near washbasin or toilet having easy access

Do’s

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No

Things not to do

1

Alcohol intake. It leads to falls

2

Benzodiazepine drugs (diazepam, alprazolam) and consuming more than five drugs (polypharmacy)

3

Do not walk on wet floors. Also be care full while walking on unequal pavement on the roadside

4

Do not use ladder. Avoid using stools or ladder to climb for getting items place at high level

5

Do not get down on stairs. Instead use escalator. Older people are more likely to fall while getting down the stairs

6

Do not use glasses with bi-focal lens. Make two different glass one each for short sight and another for far sight

Dont’s

(continued)

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(continued) No

Things not to do

7

Do not use loose and ill-fitting foot wears and foot wears of the other person

Dont’s

The external hip protectors are available for use to prevent hip fracture when a person falls (Lauritzen et al. 1993). The use of hip protectors in older people residing in nursing home is found to be beneficial in preventing fractures (Sawka et al. 2007). The older people in India do not prefer to use these protectors. A study by Lai et al. (2010) showed that the polypharmacy leads to hip fractures. The prevention of fall is of paramount importance. It helps reduce morbidity and mortality. Stevens (2008) in their report has stressed that the multifaceted interventions to address environmental, behavioural, and physical risk factors, implementation of exercise programs, hazard reductions and training and guidance to further reduce risk hold lot of importance in prevention of fall and recurrent falls.

Prevention of Infections The prevalence and severity of infectious diseases are • higher in the ageing population due to the decrease in the immune function (Weinberger et al. 2008). The older people having comorbid like diabetes further make them prone for pneumonia and herpes zoster. Pneumonia of viral and bacterial aetiology is common in the older people and leads to increased morbidity and mortality. The quality of life reduces drastically following recovery from pneumonia. The influenza and pneumococcal pneumonia can be prevented by immunization. There is rise in number of older people opting for replacement and transplant surgeries which predisposes them to hepatitis B infection. Various injuries are also common in them which predisposes them to tetanus. The large number of older people now are travelling and attending melas or yatras and the change in weather or exposure to cold makes them prone for developing infections. Vaccination boosts immunity and promotes healthy ageing. It is also a costeffective means to prevent most of the infections. The World Health Organization, Centre for Disease Control and Prevention (ACIP Report 2014), Geriatric Society of India (Sharma 2015) and Government of India (ICMR 2017) have laid guidelines

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for immunization in older people. In India, the guidelines for use of all vaccines are yet to be published by the government. The easy access to vaccines and awareness among public and clinicians is need of the hour at local level. The study by author on immunization status and awareness among elderly living with diabetes mellitus concluded that the awareness regarding immunization in older people and clinicians is less while the participants were not worried about the cost of vaccine (Divyasree et al. 2018). The geriatric clinic has been promoting preventive geriatrics by organizing immunization camps exclusively for senior citizens. Hundreds of senior citizens have been benefitted through this activity. The older people are immunized against hepatitis, tetanus, influenza and pneumococcal infections. The vaccines against influenza and pneumococci are supplied by main distributor at cost price and maintaining cold chain. Every year in month of October first week with the beginning of winter season, we organize immunization day where in vaccine against influenza is administered to the senior citizens. On November 12, every year, we organize immunization campaign against pneumococci to commemorate World Pneumonia Day, and in the month of April, we observe World Immunization Week again to immunize the senior citizens against tetanus, hepatitis and pneumococcal pneumonia. Till now, we have received very good response from the senior citizens for these camps. The recommended schedule for immunization in older people is as follows.

Disease against

Route

Frequency

Influenza

Subcutaneous

Annual (once every year), one month before onset of winter season

Pneumococcal

Intramuscular

One dose on attaining 60 years and repeat every five years in special situations

Hepatitis

Intramuscular

Three doses, one each in three consecutive months

Tetanus

Intramuscular

One dose every ten years

Herpes zoster

Subcutaneous

One dose on attaining 60 years (One time)

The adverse events following vaccination are rare and mild in older people. They not only provide protection to individuals but also to their community as well. Though the vaccines are costly but are very meagre compared to the cost of treatment of the disease when it occurs. The authors are of opinion that all the employees of the government, bank, private, military and medical sectors should be immunized against influenza and pneumococcal on their day of retirement on a mandatory basis. Also, all the doctors must immunize their older parents apart from creating awareness among their patients. Such practices will help vast coverage of older population being immunized and will prevent vaccine-preventable diseases which will benefit the family and the society at large. Awareness and motivation among the public and clinicians is essential to achieve high vaccination coverage.

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Prevention of Malnutrition Poor nutrition is a major problem for older people above 70 years of age. It results in increased hospitalization rates, length of stay, hospital readmission, and in-hospital mortality (Furman 2006). A reduction in appetite and food intake referred to as “anorexia of ageing” is common among seniors and affects even those who are in good health (Hays and Roberts 2006). This is caused by a physiological, psychological, social and environmental factor ranging from changes in taste and smell to feelings of loneliness and depression. The health-related problems due to under nutrition are nutrient deficiencies and weight loss, constipation, dehydration, (Mentes 2006), reduced muscle mass and strength, functional and cognitive limitations, poor recovery from illness, loss of energy and frailty (Johnson et al. 2008; Elia 2009) Eating food together with family members is found to improve the intake of food in older people. In my practice, I have found that the older people prefer to eat alone than with family members. The reason being that they can eat whatever they wish to eat, while with family members, they are restricted from using additional salt, sugar or prickles. The poor denture status prevents them from chewing the food properly and consuming fruits and semi-solid and hard food. This further aggravates undernutrition. Preventive measures 1. The older people should consume (a) Fruits and vegetables in small and multiple servings which provide micronutrients, minerals and fibres. (b) Proteins up to 1.2 g daily in form of ragi, pulses, sprouts and egg. (c) Fibre-rich food up to 25 g/day which prevents constipation (d) Fluid intake up to 2 litres a day. (e) Milk and milk products daily. 2. The older women in India practice rituals like fasting which should be avoided. 3. Taboos towards consumption of certain foods are very common in Indian scenario which needs to be addressed. For example, the person suffering from jaundice will restrict intake of food for two to three weeks which leads to severe anaemia and they consult doctor for blood transfusion. 4. The older people should use dentures to avoid under nutrition and need to change it at least once in two years as the gum size decreases causing discomfort. The Government of Karnataka has a unique project called “Danta Bhagya” for senior citizens where in dentures are provided free of cost through all dental colleges in Karnataka state. (Danta meaning teeth). The dental colleges will be reimbursed for every denture that is delivered. This project is appreciated by World Health Organization (Health systems 2015) 5. The use of chats and taste enhancers is now recommended so that the change in the taste of food will enhance its intake. The food when served in coloured plates also has positive impact on food intake.

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Prevention of Obesity Interventions to prevent or reduce weight are challenges in clinical scenario. The lifestyle modifications, physical exercises, diet counselling and healthy eating patterns will help reducing weight to some extent. Good nutrition allows us to prevent, delay and better manage normal ageing as well as chronic conditions. Discussing eating habits with older people will help know their food habits, food preferences and interventions can be planned accordingly. The importance of proper nutrition should be stressed.

Prevention of Depression Depression, sadness, and “feeling blue” are accepted as part of the normal ageing process by the older people. Denial of illness despite having many, decreased food intake suggest the older person is depressed. In India, the change in the family structure along with economic insecurity results in the elderly losing their relevance and significance in their own house and increasing feelings of loneliness. This has a detrimental influence on the psychological health of the elderly. World Health Organization World Health Day 2012—Ageing and health. [Accessed July 18, 2012]. Available from: http://www.who.int/world-healthday/en/. Depression has a tendency to be chronic or recurrent hence preventive measures play significant role. The impact of depression on older people is vast and are as follows. 1. It reduces quality of life for the affected individuals as well as their friends and families. (National Alliance on Mental Illness 2009) 2. It will lead to declines in physical, mental and social functioning. 3. The depressed older people visit hospitals more frequently, have longer lengths of stay and take more medications, all of which result in high health care costs (CDC 2008) Depression is the single greatest risk factor for suicide among older people. It is found that as many as 75% of older adults who commit suicide visit a physician within the month before their death; hence, the need for prevention, early diagnosis, and treatment of depression is very important (Conwell 2001). The common risk factors for depression are bereavement, disability, chronic comorbids, insomnia and low levels of physical activity (SAMHSA 2018).

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Preventive Measures Preventing depression will enhance both health and life span. 1. They should keep participating in all the social gatherings and family programs. 2. Involving the older people in spiritual practices prevents loneliness. 3. The positive mindset can be attained by practicing meditation and prayers. A feeling of wellbeing can also be achieved through this. 4. There is role of media campaign to reduce the stigma associated with depression. 5. Those undergoing treatment for depression should not stop medications. This prevents recurrence of depression. 6. Substance or alcohol abuse should be identified and rehabilitation measures should be applied. 7. Spirituality and religiosity are found to be protective against depression. The older people should be allowed to participate in all the religious activities happening in nearby location. 8. The strategies for better sleep may diminish affective reactivity and enhance cognitive flexibility on the part of both care recipients and caregivers (Germain et al. 2006). Teaching older people healthy sleep habits will prevent depression in people with insomnia. The problem-solving therapy (PST) has been used successfully in depression prevention studies (Veer-Tazelaar et al. 2009). PST is more easily learned than interpersonal psychotherapy and can be embedded within a clear service model (Baldwin 2010). PST is practicable, safe, cheap and is deliverable by general medical clinician, nurses and social workers. It is also acceptable to older adults.

Prevention of Cognitive Decline In India, the prevalence of dementia in older people is increasing. The screening for cognitive impairment is part of a comprehensive geriatric assessment and should be done at initial visits for patients in all categories. Preventive measures are 1. The fruits rich in phytochemicals like citrus fruits, apples and berries when consumed regularly have been found to prevent age-related cognitive decline (Spencer 2010). 2. Livingston et al. (2017) identified nine potentially modifiable lifestyle factors when addressed across the life span may prevent dementia. The nine factors are education, midlife hypertension, midlife obesity, hearing loss, late-life depression, diabetes, physical inactivity, smoking and social isolation. The authors are ambitious about prevention, as this offers the potential to delay or prevent one-third of dementia cases. 3. Mental exercise

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4. 5.

6. 7. 8.

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Willis et al. (2006) investigated the role of cognitive training in reasoning, speed or memory in 2802 healthy older adults. All three groups showed significant improvements in memory over the five-year follow-up period. Memory training involved teaching mnemonic strategies (organization, visualization, association) for remembering verbal material (e.g. word lists, texts), Reasoning training involved teaching strategies for finding the pattern in a letter or word series (e.g. a c e g i…) and identifying the next item in the series and the speed of processing training involved visual search and divided attention (Willis et al. 2006). The overall measures like blood pressure control, weight reduction, smoking cessation may help to reduce cognitive decline (Krystal et al. 2018). The stigma associated with cognitive decline as mad person in villages in India needs to be addressed through priests in temple and social networks. This helps person with mild cognition decline to seek help from medical team. Modifiable risk factors like high homocysteine levels and hypercholesterolaemia should be screened and treated accordingly. Ng et al. (2008) showed the regular intake of tea has been associated reduced risk of cognitive decline. The activities that maintain and strengthen cognitive abilities are solving crosswords puzzles, sudoku, Stroop test, learning a new skill especially computer or start using digital phone, gardening, listening to music and using left hand for brushing teeth instead of right and yoga.

Health Education The older people should be made aware of common diseases and the health-related issues. The role of health education is to provide information about the risks and benefits of a healthy lifestyle and practicing preventive measures. The author organizes awareness talks in local language on important diseases like diabetes, hypertension, Alzheimer’s, osteoporosis, elder abuse, depression, COPD for senior citizens regularly in the medical college hospital. Lectures are given by specialist in their field. These programmes help older people to know the disease in depth. Such programmes being held in medical college and addressed by a doctor will have more positive impact on the older people and it is found that the suggestions given in such programs are followed by older people. The older people participating in awareness lecture programs are also allowed to clear their doubts through question and answer session. It is observed that the question and answer session is longer than the duration of lecture. Older people should receive education regarding 1. Role of exercise in preventing many diseases 2. Medicine management which prevents interactions and iatrogenic diseases 3. Behaviour changes which leads to improved quality of life.

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1. Exercise It has a tremendous positive effect on health at all ages. The older people avoid doing exercises citing various reasons like “I feel weak”, “I have joint pain”, “I feel giddy”. The benefits of the exercise are (a) It prevents and controls various metabolic disturbances (b) It retards and reverses the age-related loss of muscle mass (Fiatarone and Evans 1993). (c) It prevents myocardial infarction in older people when compared to the elderly with sedentary lifestyle (Mittleman et al. 1993). 2. Medication management The use of many drugs and combination of systems of treatment should be avoided. In India, it is common practice to combine allopathic medicine with ayurvedic, homaeopathic and herbal medicines. Polypharmacy (use of >5 drugs) is risk factor for many diseases. The older people should avoid use of on the counter drugs, the drugs prescribed for others for the same disease. Adherence to prescribed medications will help prevent occurrence of many complications of chronic diseases. 3. Behaviour changes The older people need to stop smoking or chew tobacco and alcohol consumption. It is evident that stopping these habits will have beneficial effects even in older people. Emphasis is laid on periodic health check-up which is often neglected by older people. The role of practicing yoga, spirituality and social involvement has positive impact on overall health. The older people need to give more importance towards personal hygiene and oral care. The use of aids like spectacles, hearing aids, dentures, and walking stick when indicated has positive impact on health and wellbeing (Phelan et al. 2009).

Screening The screening for the detection of hidden diseases in older people residing in the community and effective interventions will help to prevent of postpone disability and premature death (Sackett 1987) Fletcher et al. (1966) defined screening as the identification of an unrecognized disease or risk factor by history taking, physical examination, laboratory test, or other procedure. Screening is often mentioned in the same context as prevention activities; however, it should not be considered as diagnostic.

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It separates people who are apparently well but may have a disease or risk factor for a disease from those who do not. Screening may also be a part of some primary and secondary prevention approaches. In Indian context screening for diabetes, hypertension and cancer in all older people should be carried out in OPD visits at least once a year. Our geriatric clinic along with National Programme for Health Care of Elderly (NPHCE) and the NonCommunicable Disease Cell (NCDC) of Government of India is screening all the middle-aged and older people for diabetes and hypertension through health check-up camps in rural and urban primary health centres at free of cost. Such programmes will help identification of silent non-communicable diseases so that the older people presenting with its complications like blindness, stroke, myocardial infarction and heart failure are prevented. The screening for cataract in older people residing in rural areas followed by corrective surgeries is carried out on large scale by government of India. This has prevented many cases of preventable blindness and falls in older people. Screening for depression by using depression scale in clinical practice needs to be done in older people who are having subtle symptoms and signs suggestive of depression. Depression screening should be carried out at initial visits for patients in all categories. The Geriatric Depression Scale (GDS) may be one of the easiest to administer (Yesavage et al. 1982). However, the GDS does not maintain its validity for patients with dementia and the Cornell scale (a 19-item clinician-administered instrument) is recommended (Alexopoulos et al. 1988)

Conclusion Preventive measures are the key to longevity among older people. Despite so many health, social and economic problems in older people, the fascinating thing about it is they accept it and learn to live with it happily. The training on prevention-focused geriatric care for health care professionals and creating awareness among the older people is need of the hour. The preventive services should have insurance coverage. These preventive measures will not replace medical care for acute diseases and do not relieve suffering directly but reduce the risk of future suffering. The preventive measures when applied in young old will help in control or eliminate the disease, while in old (>85 years), it is optimum. The denial of appropriate interventions based on age discrimination should be avoided in clinical practice (Ageism). Preventive geriatrics is the only intervention that is cost-effective and can be practiced universally. The best and cost-effective support for the older people in India is the family support which is taking care of the older people considering cultural, spiritual economic and social issues.

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The older people should take responsibility in accepting the preventive measures. We need to ensure that the older people have access to and receive recommended clinical preventive services. Preventive services may not provide 100% prevention but will definitely reduce the occurrence of disease, duration and cost of treatment. The preventive measures when applied need multidimensional approach and no single intervention will fit to all the diseases in all the older people. “Delaying onset of chronic disease, postponing disability and enhanced health status in the additional years of life”

References Alexopoulos, G. S., Abrams, R. C., Young, R. C., & Shamoian, C. A. (1988). Cornell scale for depression in dementia. PsycTESTS Dataset. https://doi.org/10.1037/t20968-000. Baldwin, R. C. (2010). Preventing late-life depression: A clinical update. International Psychogeriatrics, 22(08), 1216–1224. https://doi.org/10.1017/s1041610210000864. Burdak, S. L., Gupta, N. (2015). A review of preventive health care in geriatrics through Ayurveda. International Journal of Ayurvedic Medicine, 6(2):100–112. Cameron, I. D., Gillespie, L. D., Robertson, M. C., Murray, G. R., Hill, K. D., Cumming, R. G., et al. (2012). Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd005465.pub3. Centers for Disease Control and Prevention and National Association of Chronic Disease Directors. (2008). The state of mental health and aging in America. Issue brief no. 1. Atlanta, GA: National Association of Chronic Disease Directors. Retrieved from http://www.cdc.gov/aging/pdf/mental_ health.pdf. Chang, J. T., Morton, S. C., Rubenstein, L. Z., Mojica, W. A., Maglione, M., Suttorp, M. J., et al. (2004). Interventions for the prevention of falls in older adults: Systematic review and metaanalysis of randomised clinical trials. BMJ, 328(7441), 680. https://doi.org/10.1136/bmj.328. 7441.680. Conwell, Y. (2001). Suicide in later life: A review and recommendations for prevention. Suicide and Life-Threatening Behavior, 31(Supplement to I):32–47. https://doi.org/10.1521/suli.31.1.5. 32.24221. Divyasree, N., Ambali, A. P., Devaramani, S. S., Sai Krishnan, P. (2018). Immunization status and awareness among elderly living with diabetes mellitus. International Journal of Medical Science and Education, 5(2):161–166. Elia, M. (2009). The economics of malnutrition. The economic, medical/scientific and regulatory aspects of clinical nutrition practice: What impacts what? Nestlé Nutrition Institute Workshop Series: Clinical & Performance Program, 29–40. https://doi.org/10.1159/000235666. Fiatarone, M. A., & Evans, W. J. (1993). 11 The Etiology and Reversibility of Muscle Dysfunction in the Aged. Journal of Gerontology, 48(Special_Issue), 77–83. https://doi.org/10.1093/geronj/ 48.special_issue.77. Fletcher, R. H., Fletcher, S. W., Wagner, E. H. (1966). Clinical epidemiology—The essentials (pp. 166–168). Baltimore: Williams & Wilkins. Furman, E. F. (2006). Undernutrition in older adults across the continuum of care: nutritional assessment, barriers, and interventions. Journal of Gerontological Nursing, 32(1), 22–27. https:// doi.org/10.3928/0098-9134-20060101-11. Germain, A., Moul, D. E., & Franzen, P. L. (2006). Effects of a brief behavioral treatment for late-life insomnia: Preliminary findings. Journal of Clinical Sleep Medicine, 2, 403–406.

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Stevens, J., Sogolow, E. (2008). Preventing falls: What works. A CDC compendium of effective community-based interventions from around the world. Atlanta, GA: Centres for Disease Control and Prevention, National Centre for Injury Prevention and Control. Stieglitz, E. J. (1941). The potentialities of preventive geriatrics. New England Journal of Medicine, 225(7), 247–254. https://doi.org/10.1056/nejm194108142250701. Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine Among Adults Aged ≥65 Years: Recommendations of the Advisory Committee on Immunization Practices (ACIP). (2014, September 19). Retrieved from https://www.cdc.gov/ mmwr/preview/mmwrhtml/mm6337a4.htm. Veer-Tazelaar, P. J., Marwijk, H. W., Oppen, P. V., Hout, H. P., Horst, H. E., Cuijpers, P., et al. (2009). Stepped-care prevention of anxiety and depression in late life. Archives of General Psychiatry, 66(3), 297. https://doi.org/10.1001/archgenpsychiatry.2008.555. Weinberger, B., Herndler-Brandstetter, D., Schwanninger, A., Weiskopf, D., & GrubeckLoebenstein, B. (2008). Biology of immune responses to vaccines in elderly persons. Clinical Infectious Diseases, 46(7), 1078–1084. https://doi.org/10.1086/529197. Willis, S. L., Tennstedt, S. L., Marsiske, M., Ball, K., Elias, J., Koepke, K. M., et al. (2006). Longterm effects of cognitive training on everyday functional outcomes in older adults. Jama, 296(23), 2805. https://doi.org/10.1001/jama.296.23.2805. World Health Day 2012—Ageing and Health. Good health … (n.d.). Retrieved from http:// www.euro.who.int/__data/assets/pdf_file/0011/159977/WHD_toolkit_2012_EURO_Version. pdf?ua=1. Falls in the Elderly Statistics|NCOA. (n.d.). Retrieved from https://www.ncoa.org/news/resourcesfor-reporters/get-the-facts/falls-prevention-facts/. Yesavage, J. A., Brink, T., Rose, T. L., Lum, O., Huang, V., Adey, M., et al. (1982). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17(1), 37–49. https://doi.org/10.1016/0022-3956(82)90033-4.

Chapter 4

Age-Friendly Initiatives Biju Mathew

Abstract The greying of the global population has become a matter of concern for planners, scientists and the common man alike. In simple terms, the greatest challenge ahead is formulating appropriate and customized responses for the ‘needs of the elderly’. It is in this background that a study was commissioned by HelpAge India in 2016 to explore further strategies and pilot initiatives in the state of Kerala, which is much ahead of other states in India. Goal of the study was to develop informed frameworks and models for transforming Kerala to an ‘age-friendly’ state as a pilot age-friendly initiative in India. Kerala’s demographic transition from a state with high mortality and high fertility to one with a low count in both of these outpaces that of the rest of the country by 25 years according to Kerala Development Report of the Planning Commission in as early as 2008. Currently at 14% of the total population of Kerala, the number of those above 60 years is expected to reach 40% by the end of 2061. The declining birth rates and the migration of the young, coupled with the increase in life expectancy to an average of 72 years, Kerala is fast ageing with a greying population and increasing demands on the fiscal, health and social security mechanisms. Institutionalization of state government schemes/projects takes its own time. It may be noted that the age-friendly initiatives will lead to action in grassroots level for senior citizens through day centres. Ultimately, the day centres will be converted into Agecare Service Centres of Government where all actions related to senior citizens will be coordinated by the people, of the people, for the people (ESHGs in rural and SCAs in urban will lead the action). ‘Age-friendly initiatives’ will do groundbreaking work into making ‘ageing’ a wonderfully productive period of life. Keywords Ageing · Age-friendly · Senior citizens · Greying population · Day centres · Agecare · Sustainable agecare · Productive ageing The greying of the global population has become a matter of concern for planners, scientists and the common man alike. In simple terms, the greatest challenge ahead is formulating appropriate and customized responses for the ‘needs of the elderly’. B. Mathew (B) HelpAge India, 4th Cross Road, Panampilly Nagar, Ernakulam 682036, Kerala, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. K. Shankardass (ed.), Ageing Issues and Responses in India, https://doi.org/10.1007/978-981-15-5187-1_4

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It is in this background that a study was commissioned by HelpAge India in 2016 to explore further strategies and pilot initiatives in the state of Kerala, which is much ahead of other states in India. Goal of the study was to develop informed frameworks and models for transforming Kerala to an ‘age-friendly’ state as a pilot age-friendly initiative in India.

Age-Friendly Initiative by HelpAge India The study was spread across the districts of Ernakulam, Kottayam, Pathanamthitta, Thrissur, Kozhikode and Kollam and was done by BEDROC, Nagapattinam. It covered about 600 respondents belonging to the upper class, the upper-middle class, the middle class, the lower-middle class and the poor. Discussions were held with institutions like IEEE and Kerala Sasthra Sahithya Parishad (KSSP) for the designing of the study. The organizations that partnered the study team were—Nav Jeevan Trust; Magics; Department of Social Work, Sri Sankara University, Kalady; Archana Women’s Centre, Action for Social Development; Department of Social Work, St. Thomas College, Thrissur; Department of Social Work, Devagiri College, Kozhikode; and IEEE Student Chapter.

Age-Friendly Initiative by Government of Kerala Government of Kerala under the initiative of then Chief Secretary Mr. S. M. Vijayanand (retired) and guided by Mr. Mathew Cherian, CEO, HelpAge India; held a brainstorming session at IMG, Thiruvananthapuram on 20.12.2016. The session coordinated by Social Justice Department, Government of Kerala, was attended by Minister of Social Justice, Chief Secretary, Secretary of Social Justice, Director of Social Justice, various officials from Government, NGO sector, etc. Following it up, a smaller group led by Director Social Justice after few meetings chalked out ‘Sayamprabha’ Action Plan (Phase-I) for Age-Friendly Kerala project. Based on this action plan, government issued an order to help 70 local self-governments (LSGs), who will get support for a staff salary to run day centre for senior citizens. Government of Kerala also decided to run model Multi-Service Day Centres (MSDC) in association with NGOs at local self-government level. The first MSDC/Sayamprabha Home was inaugurated in June 2018 at Neyyattinkara Municipality under a tripartite agreement between Government of Kerala, Neyyattinkara Municipality and HelpAge India.

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Age-Friendly Initiative by Kerala Institute of Local Administration (KILA) Kerala Institute of Local Administration (KILA) is an autonomous institution functioning for the local governments in Kerala. KILA has the mandate of facilitating and accelerating the socio-economic development of the state through strengthening the local self-government (LSG) institutions. It is a Government of Kerala supported nodal agency for training, research and consultancy for LSGs. Faced with the situation of 182 LSGs submitting budgets in 2017–’18 for establishing 382 day centres for senior citizens in Kerala, KILA was happy to associate with HelpAge India in developing a way forward. Dr. Joy Elamon, Director of KILA, and Dr. Peter. M. Raj, Associate Professor of KILA, were enthused by the Vayojana Sevana Kendram (day centre) models run by HelpAge India in association with local self-governments. KILA initiative got its wings with elected representatives, and officials from 124 local self-governments (1st Phase) were given a two-day workshop cum training in 13 batches (October 2017 to February 2018) to develop age-friendly day centres/resource centres for senior citizens as per local needs. Local mobilization of senior citizens into Elder Self-Help Groups (ESHGs), Geriatric Clubs, Senior Citizen Associations (SCAs), etc., will form the backbone of the age-friendly LSG initiative. Ultimately, day centre will develop into a ‘age-friendly resource centre’ for senior citizens in that LSG. Essentially, the age-friendly initiative will be ‘of the people, by the people, for the people’.

Vayojana Sevana Kendram as ‘Age-Friendly Service Delivery Model’ HelpAge India based on its experience of four decades and survey findings has formulated a comprehensive list of problems of elderly termed as ‘10 + 1’, wherein an individual elder may face a combination of these factors. In the case of any individual elder, the number of factors listed below tends to increase with advancing age. Problems faced by older persons in India S. No.

Problem

Need

1

Failing health

Health

2

Economic insecurity

Economic security

3

Isolation

Inclusion

4

Neglect

Care

5

Abuse

Protection (continued)

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(continued) S. No.

Problem

6

Fear

Need Reassurance

7

Boredom (idleness)

Be usefully occupied

8

Lowered self-esteem

Self-confidence

9

Loss of control

Respect

10

Lack of preparedness for old age

Preparedness for old age

Equity issues are relevant to all the above

An effective response to identified needs of the elderly requires a broad spectrum of activities. HelpAge India’s Agecare Programme covers a broad range of activities mainly based on the perceived needs of the elderly as also insights gained from various projects and field studies. The programmatic vision can be seen in terms of agecare and social protection and health, and yet they are very much cross-cutting in nature. In fact, most activities are cross-cutting and attempt to reinforce each other.

Three pillars of Agecare explained with regard to Day Centre acvies

Parcipaon Senior Cizens ESHGs(Elders Self Help Groups) HUG / College Students SAVE / School Students Kudumbasree (SPEM) Village Level Federaons of elderly Police SCA/NGO's

Health Home Care Palliave care Assisve devices Medical Consultaon Physio care Demena/Alzheimer Care Eye Care Exercise

Security Social Psychological Financial Emoonal Legal

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Activities at Age-Friendly ‘Vayojana Sevana Kendram (Day Centres)’ as Per Needs Identified • Failing Health – – – – – – – –

Home care Palliative care Assistive devices Medical consultation Physiocare Dementia/Alzheimer care Eye care Exercise.

• Economic Insecurity – – – – – – –

Elder Self-Help Groups (ESHGs) Income generation activity Trainings for ESHGs in day care centres on IGP Skill development Employment exchange of elderly Consultancy Reverse mortgage.

• Neglect, Abuse, Loss of Control, Isolation, Boredom, Fear, Lowered Selfesteem, Lack of Preparedness – Helpline Counselling Legal assistance Survey Active and reflective listening Information provider Distress intervention Guidance in pension and other policies. – Day Care Facilities/Programmes Awareness talk Computer/smartphone literacy Library, books, newspapers and periodicals TV Picnics Recreation/games/park and garden Midday meal/nutrition Preretirement training.

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• Community Participation – – – – –

Help Unite Generations (HUG)/college students Student Action for Value Education (SAVE) Volunteers from NSS, NCC, SPC, etc. Janakeeya Samithi Kudumbashree liaising for paid services like washing clothes, food preparation, etc. – ESHGs and village-level federations of ESHGs – Police department.

Management System Options • Operation Directly by LSG – Staff by Panchayat – Support of Suhruth Samithi – Can apply for IPSrC funds. • Operation by LSG and NGO Partnership – – – –

Building, water and electricity by LSG Running cost by LSG NGO should mobilize more funds for the activity Can apply for IPSrC funds.

• Operation by LSG and SCA/ESHG’s Partnership – Mobilization of senior citizens into groups – Hand holding and technical support has to be given – Peoples’ ownership.

Fund Mobilization • 5% of compulsory plan fund of the Panchayat for the elderly • Skill development and other activities of the day centre can be associated with various Panchayat schemes and project • Integrated programme for Senior Citizens (IPSrC) of central government • CSR funds of the public/private sector companies • Donations from individuals/sponsoring/local fund raising.

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Elder Self-help Groups (ESHGs) as ‘Mobilization Model’ The unorganized sector is characterized by lack of financial, nutrition and social security. It is also characterized by lack of statutory safeguards in adversity, available in the organized sector. This means, to survive, a person has to work till the last day of his/her life. Erosion of traditional social support family and community structures and dwindling livelihood options makes the elderly one of the most vulnerable segments of the Indian population. HelpAge India over the years has pioneered and successfully implemented a model of sustainable agecare for elderly using a two-pronged approach of addressing vulnerability and preparedness encompassing welfare, development and rights. Some of the important elements which have proven to be successful are the self-help approach (elders for elders) and access to elder’s rights and entitlements. This was developed and successfully implemented pan India by Programmes Department of HelpAge India.

Categorization of Elderly

Mobilization of senior citizens at grass-roots level will only sustain the longterm process of empowering them through any service model. The success of HelpAge India guided District Level Federations of Senior Citizens in Kerala at Kollam (Kerala Punajani Vayojana Samithy); Wayanad (Vayoshakthi Samajam); Elders for

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Elders Foundation and ESHG groups at Ernakulam; Kottayam; Thiruvananthapuram reinforces the ESHG concept as the best senior citizen mobilisation model. The local backbone of the whole process will be built-up from grass-roots level by forming Elder Self-Help Groups (ESHGs)/Senior Citizen Associations (SCAs)/Geriatric Clubs/Gram Sabha of Senior Citizens, etc. These groups along with LSG will run the day centre/resource centre at local level.

Conclusion Kerala’s experience with local self-government has been distinct in three important ways. First, financial devolution is more important in Kerala than elsewhere. Secondly, the part played by local bodies in formulating and implementing plans is greater in Kerala than elsewhere. Thirdly, the extent of people’s participation in development planning is greater than elsewhere. Institutionalization of state government schemes/projects takes its own time. It may be noted that the whole exercise initiated by KILA will lead to age-friendly action in grass-roots level (LSG—local self-government) for senior citizens through day centres. Ultimately, the day centres will be converted into Agecare Service Centres of Government where all actions related to senior citizens will be coordinated by the people, of the people, for the people (ESHGs in rural and SCAs in urban can lead the action). Kerala is at a stage where it can do groundbreaking work into making ageing, a wonderful productive period of life. Thus, the successful age-friendly model being piloted through local self-governments can be replicated in other states of India with modifications as per local ground-level situations.

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Annexure II: Study on Age-Friendly Services (Foundation on which the age-friendly initiatives in Kerala is built-up) The study on age-friendly services was done in 2016 by HelpAge India in the state of Kerala on the elderly who are living alone or with their equally aged spouses. This study was to understand their needs and concerns and to develop appropriate models that will provide them with age-friendly services, either on payment or otherwise, with relatively better access and ease.

Goal of the Study Develop informed frameworks and models for transforming to an ‘age-friendly’ state.

Objectives 1. Assess the number of elderly singles or family units in the study area who require assistance to live their lives with dignity and support. 2. Develop a better understanding of the services currently available, the gaps, the issues and the changes required to make it more age-friendly. 3. Develop appropriate models, on payment basis or otherwise, that can help such elderly people living alone to live their lives more comfortably.

Scope and Time Frame The study was spread across the districts of Ernakulam, Kottayam, Pathanamthitta, Thrissur, Calicut and Kollam. Initially although only four districts of Ernakulam, Kottayam, Thrissur and Pathanamthitta were selected, Calicut was added as there was considerable migration from there also. The study covered about 600 respondents belonging to the upper class, the upper-middle class, the middle class, the lowermiddle class and the poor. While initially the study proposed to have different target groups for Objectives b and c, it was later decided that the Objective c was equally applicable to all categories, only the source of funding being different. The study was completed in three months. The time frame was extended as establishing contacts in the villages for FGDs took more time than expected.

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Methodology and Tools There were initial discussions held with institutions like IEEE and Kerala Sasthra Sahithya Parishad (KSSP) for the designing of the study. It was based on the outcome of these discussions that Calicut was also added. Kollam was added only for focus group discussions. As the study team did not have a direct presence in the districts selected, it was decided to work through partner organizations. The organizations that partnered the study team are: 1. 2. 3. 4. 5. 6. 7. 8.

Kollam—Nav Jeevan Trust Ernakulam Urban: Magics Ernakulam Rural: Department of Social Work, Sri Sankara University, Kalady Kottayam: Archana Women’s Centre Pathanamthitta: Action for Social Development Thrissur: Department of Social Work, St. Thomas College Calicut: Department of Social Work, Devagiri College All across the state: IEEE Student Chapter.

One-day training programmes were held at each of the centres to orient the field investigators on questionnaire-based data collection as well as the requirements through FGDs. There was a mid-course review as well, and the team was given feedback on the data collected. Revisits were recommended wherever the field data were seen to be insufficient. This study adopted a three-pronged approach: 1. Questionnaire-based 2. Focus group discussions 3. Discussions with caregivers and institutions providing support. Five hundred individuals were sampled through the questionnaire-based approach. The questionnaires were largely close-ended. The questionnaires were administered through the field investigators of partner organizations identified in the target districts. Additional 100 were accessed through the students of IEEE Student Chapter. Ten FGDs were held in all the selected districts, covering more than 200 participants. These FGDs were held in accessible spaces like Anganwadis, community centres, schools and, sometimes, even in their homes. There was a greatly enthusiastic acceptance among the participants, about both the concept and the need for intervention. The meetings were arranged through Pensioners’ Associations, Elderly Clubs, Pakal Veedu and Pensioners’ Union. Interestingly, the questionnaire-based approach was lesser successful than the personal FGD-based approach. The propensity to accept old age and all its difficulties stoically, and the presence of family members or the tendency to accept such negatives as a natural progression of age kept them from opening up or discussing their problems openly. However, when in a group, these barriers were broken and they spoke freely about the challenges they face in everyday life.

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The engagement with the caregivers was also two-pronged—through Web-based questionnaires and direct discussions. The Web-based questionnaire did not have as much response as expected.

Findings from the Study Profile of the Target Group A total of 529 people were interviewed using the structured questionnaire, and about 200 people were part of the FGDs. Of the 529 individuals interviewed, 299 were women and 230 men. The age-wise profile is as shown in the graph. Age-wise Profile

An analysis of the current place of stay of the interviewees showed that close to 50% of them stayed with their married children. But, 35% men and 26% women came in the most vulnerable category where they were either living alone or with their equally aged spouse. Additionally, 19% of the women were staying with relatives and 1% in old age homes.

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Current Status

Men

Women

Alone

2%

11%

With Spouse

33%

15%

With Married children 49%

47%

With Unmarried 14% Children

6%

Relaves

2%

19%

OAH

0%

1%

Total

100%

100%

Current Place of Stay

As this was not a purely random selection of samples, it may not be theoretically correct to say that this is a true reflection of the picture at the field level. Even so, the current estimation of 46% of the elderly women and 35% of the elderly men staying without strong or reliable support systems is a matter of concern. An age-wise break-up of the men and women living on their own is as shown: Age Group

Men Women

50-60

Men

Women

5

0%

16%

60-70

3

10

60%

31%

70-80

1

14

20%

44%

>80

1

3

20%

9%

5

32

100%

100%

Age Profile of those Staying Alone

Fifty-three percentage of the 32 women staying alone were above 70 years of age. This was 5% of the universal sample of women interviewed. They are the most vulnerable and require focused attention. The next most vulnerable group are those who are living with only their spouse who may be also equally aged. Thirty-one percentage of the total women interviewed and 65% of the total men interviewed stayed with just their spouse. Of this, 37% of the men and 24% of the women were above 70 years of age.

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Men

Women

Men

Women

50-60

14

30

9%

33%

60-70

80

40

53%

43%

70-80

38

14

25%

15%

>80

18

8

12%

9%

150

92

100%

100%

Staying with only Spouse

These numbers are a matter of concern to the state, as this will have an impact on the policies that impact social welfare and security, health and even livelihoods.

Availability and Accessibility of Services Health Services There are many justifications for devoting public resources to improving the health of older populations. The first is the human right that older people have to the highest attainable standard of health. Yet, people often experience stigma and discrimination, and violations of their rights at individual, community and institutional levels simply as a result of their age. Under the right to health, states are obligated to deliver, without discrimination of any kind, health facilities, goods and services that are available, accessible and acceptable and of good quality. The interviewees were asked a range of questions based on their health status, health-seeking behaviour, current ailments, issues and concerns and finally their recommendations. These questions were also discussed during the FGDs. 1. Current Practices: About 50% of the men and the women stated that they visited hospitals regularly on a monthly basis, and 20% each stated that they have had to visit hospitals regularly on a semi-annual basis. Six percentage of the women and 5% of the men had to visit on a weekly basis.

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Frequency of Hospital Visits

2. Reasons for the Hospital Visits: Forty-two percentage of the women and 46% of the men stated that they visited the hospital for controlling diabetes, 24% of women and 21% of men for treating hypertension and about 14% each for treating cardiac ailments. Thus, about 80% of the elders visiting the hospital were going for lifestyle diseases which required routine tests but needed consultations only if the tests showed abnormalities. In the normal course of events, these routine tests, like testing of blood for sugar levels and cholesterol, and checking of BP, could be partially or fully done from home. There is modern medical equipment that can do all these tests and display results immediately. However, almost 80% of the elderly have to visit hospitals every month for these tests.

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3. Issues Faced: Medical health is the most important service frequently accessed by the elders, and they face a lot of problems in accessing this service. (a) Transportation to Hospital: Of the 529, 26% used own vehicles as transportation for their trips to the hospital, 42% used private transportation facilities and 22% used public transportation facilities. Only about 10% walked. Of the 37 people staying on their own, 6 (16%) used own vehicles, 17 (46%) used private transportation, 10 (27%) used public transportation and 4 walked. During the FGDs, the participants clarified saying that they found it very difficult to use the public transportation system and that is why most of them depended on auto rickshaws to take them to the hospital. The frequently increasing auto fare was a matter of concern to most of them. If the quality of the services of the public transportation improved, it would benefit 73% of those living alone and 64% of the universal sample. (b) Long Queues: Although only 141 (27%) responded with a clear ‘no’ when asked about being satisfied with the services provided at the hospital, many more responded to the reasons for dissatisfaction. Of the universal sample, 5% said that the doctors were too busy and not as responsive to them as desired, 20% said that the waiting time was too long and they had to wait in long queues, and about 2% spoke about the procedures being too complicated requiring external support to navigate. However, there was a 100% dissatisfaction stated during the FGDs. The long wait and the unsympathetic response of the hospital staff were very vociferously conveyed during the FGDs. Although there were boards in some hospitals saying the elderly patients need not wait in the queue, there were many anecdotes of how rudely they were asked to get out when they jumped the queue. They spoke about the nurses telling them sarcastically that the board only meant that they need not ‘stand’ in a queue. They could mark their place and sit on the chairs till their turn came. However, there were never enough chairs also available, especially in the government hospitals. (c) Complex Procedures: The procedures followed in the hospital for registration, follow-up visits, payments, laboratory tests, etc., were difficult, and the elderly wanted some staff to guide them on it. Apart from the complexity of the procedures, they also felt that they were made to walk to too many windows for the different processes. New registrations, retrieving old registrations, making payments, going to the laboratory, then back to wait for the consultation with the doctors, all these involved a lot of moving up and down corridors or even floors. This tired them out as well as adding to the stress. (d) Scans and Invasive Testing Procedures: The participants also spoke about the increase in the number of tests that the hospitals insisted on. Most of them felt panicked at the thought of scans. They wanted to minimize the need for scans and invasive testing processes. Most of them demanded an

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age-friendly atmosphere in the hospital that minimized stress and helped them feel relaxed and cared for. (f) Not Getting Services of Senior Doctors: The elders felt that their cases were being passed on to house surgeons or senior medical students as they were just routine check-ups. But the students fumbled with injections, etc., making the process more painful. They also did not get adequate reassurance or advice from the students as they were not experienced enough. They felt they were being ignored in the larger scheme of things. (g) Queues at the Pharmacy: As most of them purchased their monthly requirement of medication after the visit to the hospital, they found even this difficult due to the long queues and crowds in the pharmacy section of the hospital. 4. Coping Mechanisms There were quite a few participants who spoke about voluntarily reducing the number of hospital visits, from once a month to once in two months or even once a quarter, because they did not want to face the long queues. This was specially the case with elders who were dependent on their children to accompany them to the hospitals. The care provider had to take a day or more off from work to take them to the hospital. This coping mechanism was mainly practised by the respondents who generally went for routine check-ups for diabetes and hypertension. Although Kerala Government does have palliative care facilities in some Panchayats, they are more focused on patients who are totally bedridden like terminal stage patients, accident victims, etc. The elderly, who cannot walk to the clinic, do not fall under this category. Some Panchayats also have doctors visiting the Panchayat once or twice a week. However, they do not do home visits and the participants said that they are not on call on the other days and hence unavailable for emergencies.

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Employment and Income

Of the 529 interviewed, one man and 112 women (21%) were unemployed even prior the generally accepted retirement age. Currently, this has increased to 143 men and 255 women (75%). Of the unemployed, 336 are solely dependent on pensions of some kind, own job-related pension, husband’s pension, old age pension, disability pension or widow pension. Seven, of the 529, were continuing with their MGNREGA employment. This has serious implications on the fiscal outflow from the government exchequer. With increasing number of people coming into the pensioners’ bracket coupled with the increase in the payout period per person due to the increase in life expectancy, the dependents on state-based incomes will increase exponentially, adding to the fiscal burden of the state. The government will have to seriously consider alternate methods of payments rather than making provisions for it in their normal budgetary allocations. Tax-funded minimum pensions may be an alternative to ensure the financial security of the older populations. This is particularly important for people who have been part of the informal workforce (e.g. women who have played a caregiving role throughout their life or agricultural workers) and who have not had the opportunity to accrue benefits such as pensions or health insurance. From the respondents’ point of view, their current incomes are insufficient to ensure their continued well-being. Increasing costs of health care, transportation, basic necessities, etc., are not in keeping with the paltry amounts they are getting, especially through the social welfare-based pensions, like the old age pension or the widow pension. While the study did not look at change in lifestyles due to reduced incomes, the participants of the FGDs were concerned about this. They requested the study team to explore possibilities of introducing and promoting age-friendly livelihood skills so that they could either ensure or augment their incomes, especially when they were incapable of physical labour.

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Age-Friendly Banking—Financial Transactions and Bank Services As almost all payments are now being routed through the banks, 437 (83%) of the respondents had bank accounts. However, the visits to the banks varied from monthly visits (48%) to annual (8.5%).

Status of Bank Accounts

Frequency of Bank Visits

Despite the large number of respondents holding bank accounts, they did not deem it to be ‘age-friendly’. Thirty-two percentage of the respondents had problems with banking. Their concerns ranged from the complex procedures to the difficulties in reaching the bank.

1. Complex Procedures: The procedures changed frequently and confused the respondents. They required support to understand and comply with the bank requirements. Although most banks have a very prominent help desk, it was either never staffed or the person was too busy to provide the respondents the time and hand holding help required. Even the paperwork required was not age-friendly with the font size being too small to read. The respondents had to invariably ask help to fill in these forms.

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2. Lack of Instructions/Information: Given the frequently changing procedures and processes involved in banking, the interest rates and the lack of staff who can guide them through their requirements, the respondents felt that this could have been ameliorated if the information/instructions were displayed prominently. Even what was displayed was usually in an A4 size sheet with small fonts, making it difficult for them to read. 3. Time Taken: The procedures took too much time, and the spaces were not agefriendly. Issues such as lack of adequate priority seating facilities, lack of easy access to drinking water or toilets, and crowds at the counters were not conducive for age-friendly banking practices. During FGDs, the participants very matter-of-factly stated that most of them had high blood sugar and it is a known fact that such people experience the need for frequent urination. However, no bank had toilet facilities that the public could access.

Means of Transportation to the Bank

4. Travel: Sixty-eight percentage of the respondents used either private or public transportation to reach the banks. Fifteen percentage depended on their children or other relatives to accompany them to the bank. Given that most of their children are working and banks can be accessed only during working days, the children have to take a day’s leave to accompany their parent to the bank. This has been stated as a problem by both the respondents and the caregivers. With the rising rates of crime, the FGD participants were fearful of being seen as coming out of a bank or even taking autos that they were not familiar with. As the social welfare/security pensions are not deposited regularly on a monthly basis, sometimes they have to make multiple visits to the banks to enquire about it. This was proving to be problematic, and the current move of the state government in reaching the social welfare pensions to their homes has been welcomed by the participants. 5. ATMs and Their Utility: Two hundred and seven (47%) of the respondents who had bank accounts had ATM facilities. Of those who did have ATM cards, 132 (64%) used it often or very often and 57 (28%) rarely. If this is analysed over the total number of respondents, only 39% had ATM facilities and only 25% used it frequently. Hence, this facility, although increasingly available and accessible, is not useful for the ageing population. The reasons given are:

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(a) Forgetting the pin or the operating instructions 30% (b) Did not apply due to the additional charges levied 5.5% (c) Unable to see the instructions 2.5%. This is a matter of concern as the card is normally given to their children/relatives to withdraw money, and the elders may be unaware of misappropriations. With some modifications, like enabling a fingerprint recognition system instead of pin numbers, increase in the font size of the instructions or enabling audio facility, this can be made more age-friendly so that the senior citizens can carry out their financial transactions with safety and dignity.

Outdoor Environment and Neighbourhoods Good neighbourhood enables older people to feel safe when going out for basic necessities such as shops and health services and for social and leisure purposes. It encourages exercise through walking, which benefits health (Traynor et al. 2013). However, reality, as based on responses that came in through the questionnaires as well as the FGDs, showed that the current conditions of neighbourhoods and roads inhibited free movement and often led to enforced seclusion of the elderly. Seventy-nine percentage of those interviewed said that they found the roads unsafe. Hundred percentage of those who attended the FGDs were very vocal in decrying the condition of the roads and the traffic. Heavy traffic not slowing at zebra crossings, pavements not usable due to vehicle parking, petty traders or extended shops were the often heard complaints.

Crossing the road is a nightmare for most of the participants. Unaccompanied outings are few due to these reasons, and they are dependent on their children or other well-wishers to take them out. As a result, they restrict their movement outside their homes as much as possible. Lack of safe roads coupled with lack of safe transportation is resulting in a voluntary withdrawal from the external world. Two hundred and thirty-four said that

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physical mobility is a problem, and 145 stated that their mobility was restricted due to this. This enforced seclusion is detrimental to the well-being of the elderly.

There are no public spaces that are available for a quiet outing or even a walk. The participants expressed the need for such green spaces where they could take walks and feel refreshed. Currently, they are house-bound most of their time and feel excluded from the outside world. Transportation In developing countries, the basic minimum standards would at least be:

• • • •

Public transportation is available and affordable. They are accessible with low floors and disabled—friendly features. They have priority seating which is respected. Staff are courteous and considerate.

The study showed that close to 50% of the women and 40% of the men depended on private transportation or their children for their visits. The people who preferred to walk outnumbered the people who used public transport. The reasons for not using public transportation facilities were: 1.

Difficulty in boarding the bus due to the height of the steps.

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2. 3.

The impatience of the drivers and the conductors. Crowded busses with no special features to help the elderly to maintain their balance. 4. Although priority seating is available, it is often not respected and the elderly are forced to stand. 5. Rash driving. 6. Long-distance travel by public transportation is completely ruled out due to lack of toilet facilities and very brief breaks that are not in keeping with their reduced mobility. 7. Even trains are not age-friendly as the steps are vertical. Climbing up is not a problem, but climbing down is a major problem, even for those without arthritis. 8. Railway stations do not have escalators or ramps. Climbing up and down the overhead bridge is difficult. 9. The train stops only for a brief time in the smaller stations. They have to fight the crowds to even get into the train. There is no priority seating in the train. Finding the right compartment, getting into the train at their slow pace, non-availability of sitting spaces are all deterrents to accessing this form of transportation. 10. Despite reservation rules that are age-friendly, more often than not, the participants say they have been allotted middle or upper berths. As they have to frequently visit the toilet, these berths pose a problem. Coping Mechanisms Reduce frequency of trips requiring transportation facilities. Only the unavoidable trips, mainly for health care and bank transactions, are usually undertaken. Increasingly, there is the tendency to reduce the hospital visits due to these reasons as they do not want to burden their children each time they have to visit the hospital.

Respect and Inclusion The most pressing matter of concern as expressed in the FGDs was the feeling of not being respected or of having lost one’s individuality and identity. Once the initial barriers were down, the participants of the FGDs became more open and emotional. Their outpourings were centred around their feelings of being excluded from daily life. They felt they were not being ‘respected’ and ‘valued’. According to them, there was a serious erosion of the value systems prevailing in the state. The fast changing technologies, globalization, impact of cellular phones and mobile technology, easy access to Internet, both parents being employed, all these according to them contributed to the deteriorating value systems. While this advent cannot be stemmed, the participants felt that it was time we accept it and find alternate ways of dealing with the possible fallouts and adverse impacts. They felt that an attempt has to be made right from school levels to inculcate respect for their elders. Retirement also led to a loss of their individual identity, and they feel unimportant, lost, invisible. Even the participants staying with their children felt lonely and cut

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away from the mainstream. The intergenerational dependencies that had earlier made them a cohesive unit no longer held true. Ageism, prejudice or discrimination on the grounds of a person’s age is seen in different forms in different walks of life even in a state like Kerala, which revered its seniors. The doctors say, ‘well, you are old, what more do you expect?’, the children say, ‘you are old, why don’t you just relax at home and leave the rest to us?’, the community says, ‘you are old, now its time for you to relax and take things easy at home…’, the prospective employers say, ‘you are old, do you think you will be able to deliver?’ This finally becomes the mantra that the seniors internalize. Some of the women participants had developed this into a ‘martyr complex’ saying ‘we should understand we are old and have to bravely face all the discomforts that come with it without complaining. Physical ailments, aches and pains are part of this’. One man gave the study team a small write-up which ended with the despondency of the dispirited, ‘….now all we do is wait for death…that is all we have to look forward to….’ Seniors are a valuable resource, and they can meaningfully contribute to the development of the society. They have workplace knowledge, skills, the wisdom of experience, the spirit of voluntarism and the time to spare. They can be effectively utilized, provided the society recognizes their capabilities, respects their inputs and gives them a chance to contribute. In short, healthy ageing requires an enabling environment that promotes intergenerational synergy.

Social Life and Entertainment

Women

Kerala has made great strides in recognizing the need for age-friendly social life and has introduced the concept of Pakal Veedu or daytime home for enabling the seniors to spend quality time with their peers. In some Panchayats, they have also been provided with a building through the MP funds or donations. However, the recurring costs for the maintenance of these buildings have not been taken into

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account and most of such buildings are left locked. One of the participants pointed out very sarcastically that they have provided a maternity home for the street dogs. Wherever NGOs have taken up this concept, it is running well with well planned activities. However, they are not sustainable due to the heavy dependence on grants. Hobbies According to the study, watching TV and periodic visits to the temples or the houses of the relatives seem to be the most common social activities indulged in.

Men

Apart from women also spending time in prayers, there does not seem to be much difference in the way men and women respondents spend their free time. Men also spend relatively less time in housework, which is understandable. Group activities are meeting friends and going for meetings, and solitary activities are reading and listening to music. More men than women seem to prefer to spend their time in such solitary pastimes. There does not seem to be any significant difference in this pattern among the people who are staying on their own or with just their spouse. There is a marginal shift seen in the pastimes of the respondents staying with married children from watching TV to housework. The category under ‘nothing/watching TV’ has reduced to 57% from 62%, and the category under ‘housework’ has increased to 17%. What is a matter of concern is the large percentage of respondents spending their time ‘doing nothing, just watching TV’, especially in the age group of 50–60, when they could have been extremely useful human resources for the community. Outings The responses to the question of ‘where all do you visit’, 22% said that they do not go anywhere. This is a fairly large number and a matter of concern. The reasons stated were lack of mobility, problems with transportation, lack of company, lack of finances and fear of going out into the roads. Interestingly, of the respondents who were staying with their married children, only 2% said that they do not go anywhere and they were all males. This seems more a matter of choice than lack of opportunity. However, respondents living with their married children had more chances of going out of their homes at least occasionally.

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This only proves that seclusion is not a matter of choice but of circumstances, which, if corrected, would result in a much more active life for the senior citizens. This was validated during the FGDs when all of them showed great interest in visiting places. The physical weaknesses did not seem to matter as much as their need for some diversion. Two hundred and seventeen (41%) of the respondents indicated that they would have liked to travel, go on pilgrimages, visit parks, go on picnics or even just visit relatives but were unable to do so due to reasons like: lack of companionship and finances. Sixteen percentage of the respondents above 80 also showed an interest in travelling.

Problems faced by Elders

Churches and NGOs have been active in arranging for day outings for the senior citizens. Companionship Loneliness was a major problem faced by most of the participants. Even those staying with their children faced this problem as everyone was too busy with their own schedules to spend much time talking to them. The grandchildren were too busy with their computers and mobiles to spare anytime for the grandparents. According to the participants, ‘the present generation did not even have time for their own parents; then how will grandparents come into their thoughts’.

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Meeting and spending time with peers, who understood their problems, are of great help, and the respondents were very keen to start networks of senior citizens to create such platforms. Although the Pakal Veedu concept was based on this, this need is not being met as the day houses are not functional. The respondents feel that the Panchayats are not giving their needs any priority. There is no stigma attached to the Pakal Veedu concept unlike the old age homes. Some of the participants did mention that they were teased in their own homes when they attended Pakal Veedu or attended any meetings of the senior citizens. During the FGDs, wherever such platforms were not available, the participants started making plans to meet somewhere, even in houses on a rotation basis, on a periodical basis. Wherever such platforms do exist, there is great enthusiasm in planning outings, competitions, community lunches during festivals and just getting together, even if it is only once a month.

Communication and Information While the study did not go into great detail on their channels of communication and sources of information, it did look into their access to and ease of operating computers and cell phones. Cell Phone Utilization Two hundred and eighty three (53%) of the total respondents used the cell phone frequently. Of those who used it frequently, 261 (92%) used it only for making and receiving calls. Five were also comfortable in sending and receiving messages, and 17 were even conversant with WhatsApp. Of those who were conversant with WhatsApp, 6 were women and the remaining men. An age break-up showed that 6 were from 50 to 60 age bracket, 8 were from 60 to 70 age group and 3 were from 70 to 80 age group.

The respondents who were uncomfortable with using cell phones said that it was because they were scared of pressing the wrong keys, found it too complicated, the keys and/or the screen were too small or that they preferred the landlines for

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communication. Interestingly, the respondents also spoke of finding the touchscreen models difficult to use as the screens were too sensitive and their fingers were not agile enough or steady enough to swipe correctly. Some also spoke about the audio level not in keeping with their diminished hearing capabilities. Computers and Internet Forty-six percentage (8.7%) respondents stated that they used the computer frequently, of which 19 were women and 27 were men. Among women, 2 were from the ‘above 80’ age group. Eighty-one (15%) said that they would like to learn to use the computer. Here again, 4 are from the ‘above 80’ age group. Fifty (9.5%) respondents said they use the Internet frequently. Seventy-five (14%) said they would like to learn to use the Internet. Of those who showed interest to learn, 7 were in the ‘above 80’ age group. HelpAge India is giving trainings for seniors to use computers and smartphones. A digital literacy training centre has been started for elderly at Vayojana Sevana Kendram. Through Senior Citizen Associations, HelpAge India implements the digital literacy programme all over Kerala and successfully completed hundreds of training sessions • Routine Requirements Respondents were asked about their routine practices of purchasing groceries, provisions, accessing their supplies from the PDS, cooking, washing and ironing. As expected, the role of children increases in keeping with the increase in age of the respondents.

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As is seen, the major procurers are either self or the children. There are no other local support systems available. This is a matter of concern for those who are living on their own. Twenty-five of the respondents had to travel more than 4 kms to buy their rations, and of them, 7 were in the ‘70-80’ age group and 4 were in the ‘above 80’ age group. To make matters worse, they were using the public transportation system to make these purchases on a monthly basis, sometimes even more. This same group had to also travel more than 4 kms to also access health facilities and the bank. Of the 4, in the ‘above 80 group’, two are staying on their own. Given the fact that they are only about 6% of the respondents above 80 and 0.7% of the total sample size, they may tend to get missed out in the final reckoning, due to the costs involved in reaching out to small pockets of vulnerable populations. To make matters worse for the elderly, they have to visit the ration shops more than once as about 20% state that all materials were not sold to them at one go, either due to shortage or due to non-receipt of the material. Sixteen percentage of the respondents stated that they have problems accessing goods from the ration shop. Apart from the long wait and the rude behaviour of some

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of the shop keepers, they also spoke about physical weakness, forgetfulness and poor transportation facilities. Ensuring timely information on the arrival of goods, age priority and providing basic amenities at the ration shops would greatly benefit the senior ration cardholders. The fierce independence of the respondents is further evidenced in 74% of them washing their own clothes (self or spouse) and 51% doing the ironing themselves. Interestingly, 23% do not iron their clothes. The questionnaire did not look at earlier practices, and hence it is not clear if this is a change in practice due to age-related issues.

Services They Are Willing to Pay for Interestingly, apart from 95, all other respondents wanted services at home. The help ranged from cleaning premises and washing clothes to supporting in purchases, financial transactions and even routine blood tests. However, only 27% said that they would be willing to pay for the services. Forty-two percentage of those willing to pay required routine tests at home or health care. The amounts they were willing to pay ranged from 87 willing to pay up to 1500, 25 willing to pay up to Rs. 5000 and 3 willing to pay even up to Rs. 10,000/- for the services. About 50% preferred a package deal, whereas the rest preferred to pay based on services rendered. Business Model for Age-Friendly Care Wherever the study team had an opportunity to interact with groups of senior citizens, they have been surprised by the vitality and positive energy created by the participants. The participants used the meeting itself to formalize their association and, in Pathanamthitta, would not let the team leave till they had helped them chalk out a plan of action. Plan of Action as described by Pathanamthitta Groups 1. The groups are willing to take over the responsibility of the Pakal Veedu, wherever available. They will charge nominal registration and membership fees. They are also willing to approach local business houses for monthly donations to keep the club operational. 2. They will conduct a survey along with the Panchayat and the local Kudumbashree groups to map the senior citizens and understand their current status. They will take special care to map those living on their own, those who are immobile or incapacitated to reach the centre. 3. They will identify interested educated youngsters to be trained as paramedicals and provide services on a paid basis. They will cross-subsidize those who cannot pay. 4. They will procure necessary tools like sphygmomanometer, blood drawing implements, adult diapers, walking sticks or other assistive devices based on the services they will be offering.

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5. They will draw up a list of medical practitioners who are willing to provide their services on a periodical basis. 6. They will also explore possibilities of linking up with Kudumbashree to provide home-based support like meals, washing, etc., on a paid basis.

Chapter 5

Ageing Policies and Programmes in India K. R. Gangadharan

Founder, India’s premier private geriatric health care facility, Heritage Medical Centre (1974) and Co Founder Kshetra Assisted Living facility (2013)

Abstract The first ever document to be announced by the Government of India on ageing was the National Policy on Older Persons in 1999 to commemorate the international year of older persons declared by the United Nations which articulates what the government in India would be doing to ensure that the senior citizens remain a national asset and the welfare measures needed to ensure their income and safety are protected by the governments. Few states have their own policies. The Government of India announced Vayoshreshtha awards to eminent senior citizens and institutions in recognition of their service to elderly persons. In 2007, a landmark legislation, the Maintenance and Welfare of Parents and Senior Citizens Act 2007 was enacted by the Indian Parliament and over the past decades many crucial judgements were awarded in favour of senior citizens, thereby cautioning the children that neglecting their parents would attract penal actions for neglect and abuse. Old age pension of Rs. 200/- for those over 60 years and Rs. 500/- for those over 80 years is given by the central government expecting the states to offer an equal amount. The coverage needs to be increased as it is targeted towards those living below poverty line. There are schemes such as Annapurna, widow pension, distribution of assistive devices and so on. Training of manpower in old age homes, particularly those funded by the Government of India, is being carried out by the Regional Resource and Training Centres and other collaborating agencies. The National Programme for Health Care of the Elderly since 2013 is making a steady progress; the regional centres have been established; during the next few years, these institutes would be making available postgraduate geriatric medical professionals. The National Institute of Social Justice is a central agency involved in coordinating the education, research and training that benefits the Indian senior citizen community. The Government of India is involved in the Human Rights of Older Persons, and they present the India government’s stand on K. R. Gangadharan (B) Heritage Foundation, Hyderabad, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. K. Shankardass (ed.), Ageing Issues and Responses in India, https://doi.org/10.1007/978-981-15-5187-1_5

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the rights of senior citizens in the Open-Ended Working Group meetings convened by the United Nations at New York. The senior citizens are getting empowered by several efforts of the NGOs and state- and district-level programmes, especially on 1 October commemorating the International Day of Senior Citizens, and several people receive awards and are honoured by the governments. Keywords Policy · Health care · Award · Care · Elderly self-help groups · Assistive living devices

Demography of Ageing Indian Population India is ageing much faster than previously thought and may have nearly 20% population of 60 years and above by 2050. The government recently stated in Parliament that India will have 34 crore people above 60 years of age by 2050 that would be more than the total population of the USA. As per 2011 census, there were 104 million elderly persons (60+) in India, as compared to 70.6 million in 2001 and they are expected to cross 173 million by 2026. Out of 104 million elderly persons in 2011, 64 million are young-old, i.e. in the age group 60–69, 28.4 million in the old-old age group 70–80, while 11.4 million are oldest-old, i.e. above 80, of which 0.6 million are 100+.1 Rapid ageing is the result of expected increase in the life expectancy from 1996 to 2021–25 (from 61.6 years to 69.8 years for males and from 62.2 years to 72.3 years for females) and drop in fertility from total fertility rate (TFR) of 3.2 per woman in 2001 to the replacement level by 2021–25. The numbers indicate that India may lose demographic dividend and stare at a situation where a large number of population will be dependent including old age, widowed and highly dependent women. The twin challenges of rising population and old age dependents will only add to India’s troubles of providing jobs, education, health along with geriatric care. During 2000–2050, the overall population of India is expected to grow by 56%, while the 60-plus population will increase by a whopping 326 and 700% in 80-plus age group. Continuously declining intergenerational support within families makes it imperative to have a well-developed, self-sustaining pension system in the country.2 The pursuit of affordable, adequate, efficient and sustainable pension system will involve a great deal of interministerial, interstate, inter-regional and interinstitutional decisions and coordination. Almost 90% of the population was below the age of 60 years, and the working age population proportion stood at 44% in 2015. Having personal finance and retirement planning a part of the formal education curriculum can aid in achieving the overall objective of financial literacy.

1 Registrar 2 CRISIL

General, Government of India, 2013. Research, Financial Security for India’s Elderly, The imperatives April 2017.

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Policies and Programmes/Schemes on Ageing Population The first ever document to be announced by the Government of India on ageing was the National Policy on Older Persons in 1999 to commemorate the International Year of Older Persons declared by the United Nations which articulates what the government in India would be doing to ensure that the senior citizens remain a national asset and the welfare measures needed to ensure their income and safety are protected by the governments. Few states have their own policies. The National Policy on Older Persons (NPOP), 1999, envisages state support to ensure financial and food security, health care, shelter and other needs of older persons, equitable share in development, protection against abuse and exploitation and availability of services to improve the quality of their lives. The policy also covers issues like social security, intergenerational bonding, family as the primary caretaker, role of non-governmental organizations, training of manpower, research and training. The National Council of Older Persons was constituted in 1999 to monitor the implementation of the policy and advise the government on issues related to the welfare of senior citizens. The council has been reconstituted few times thereafter with the latest one being in 2012 as National Council of Senior Citizens with wider national impact. Similar councils have been constituted at the states. The Ministry of Rural Development has been implementing Indira Gandhi National Old Age Pension Scheme (IGNOAPS) since 1995 with the aim to provide financial security to senior citizens living below the poverty line. Under the scheme, central assistance is given towards pension @ Rs. 200/- per month to persons above 60 years and @ Rs. 500/- per month to persons above 80 years of age. According to the Minister of State for Rural Development, the Government of India has adopted the Direct Benefit Transfer (DBT) Scheme for direct transfer of benefit into the bank/post office accounts of beneficiaries of schemes under National Social Assistance Programme (NSAP). Instructions have been issued to the states for getting the due consent for seeding the Aadhaar details. Instructions also mention that disbursement of pension of any beneficiary could not be affected due to nonavailability of Aadhaar number. Further, NSAP guidelines provide that given their physical, social and economic vulnerability, states should ensure that an infirm/old beneficiary will not have to travel far distance to access his/her pension account. As far as possible, for people who cannot cover distance physically, the objective is to provide doorstep delivery. Several banks in many states are using the services of Bank Sakhi, coming from self-help groups to provide cost-effective solutions for delivery of pensions at home.

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Benefits Directly Offered by the Government of India The Government of India directly offers these benefits to the senior citizens. 1. The Government of India offers a subsidy of Rs. 200/- and Rs. 500/- to those over the age of 60 years and 75 years, respectively. The coverage is limited to those living below poverty line. 2. Lower income tax for those in the age group 60–79 years and much lower for those over 80 year of age. 3. Tax deduction under Section 80D of Income Tax Act 1961 for premiums paid for coverage under health insurance. 4. Air travel discounts are offered by the public sector Air India up to 50% of basic fare, while private airlines offer different discounts. 5. Indian Railways being the Government of India undertaking offers discounts up to 50%. The states in India offer their senior citizens monthly pension in varying amount. For instance, Telangana offers Rs. 2014/- per month to those above the age of 57 years living below poverty line, Andhra Pradesh Rs. 2000/- and Tamil Nadu Rs. 1000/- for those above 60 years. Bus travel concessions are available though the discounts vary from state to state.

The Maintenance and Welfare of Parents and Senior Citizens Act 2007 In 2007, a landmark legislation, the Maintenance and Welfare of Parents and Senior Citizens Act 2007 was enacted by the Indian Parliament. Over the past decade, many crucial judgements were awarded in favour of senior citizens, thereby cautioning the children that neglecting their parents would attract penal actions. The act enables providing need-based maintenance to the parents/grandparents from their children. Tribunals will be set up for the purpose of settling the maintenance claims of the parents in a time-bound manner. Lawyers are barred from participating in the proceedings of the tribunals at any stage. The act contains enabling provisions like protection of life and property of senior citizens, better medical facilities, setting up of old age homes in every district, etc. The tribunal may, during the pendency of the proceeding regarding monthly allowance for the maintenance under this section, order such children or relative to make a monthly allowance for the interim maintenance of such senior citizens or parents.3

3 http://socialjustice.nic.in/writereaddata/Uploadfile/Annexure-X635996104030434742.pdf.

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National Programme for Health Care of the Elderly (NPHCE)4 Keeping in view the recommendations made in the ‘National Policy on Older Persons’ as well as the state’s obligation under the ‘Maintenance and Welfare of Parents and Senior Citizens Act 2007’, the Ministry of Health and Family Welfare—MoHFW— launched the NPHCE during the year 2010–11 to address various health-related problems of elderly people. The scheme offers for all elderly people (above 60 years) in the country free, specialized healthcare facilities through the state health delivery system. The centre bears 75% of the total budget, and the state governments are expected to contribute 25% of the budget. The responsibility of running the programme is handed over to the state governments. Following Strategies are Adopted to Achieve the Objectives of the Scheme 1. Preventive and Promotive Care: The preventive and promotive healthcare services such as regular physical exercise, balanced diet, vegetarianism, stress management, avoidance of smoking or tobacco products and prevention of fall are provided by expanding access to health practices through domiciliary visits by trained health workers. They will impart health education to old persons as well as their family members on care of older persons. Besides, regular monitoring and assessment of old persons are carried out for any infirmity or illness by organizing weekly clinic at PHCs. 2. Management of Illness: Dedicated outdoor and indoor patients’ services are being developed at PHCs, CHCs, district hospitals and regional geriatric centres for management of chronic and disabling diseases by providing central assistance to the state governments. 3. Health Manpower Development for Geriatric Services: To overcome the shortage of trained medical and paramedical professionals in geriatric care, in service training are being imparted to the health manpower, using standard training modules prepared with the help of medical colleges and regional institutions. The postgraduate courses in geriatric medicine will be introduced in regional geriatric centres for which additional teaching and supportive faculties are provided to them. 4. Medical Rehabilitation and Therapeutic Intervention: By arranging therapeutic modalities like therapeutic exercises, training in activities of daily life (ADL) and treatment of pain and inflammation through physiotherapy unit at CHC, district hospital and regional geriatric centres. Necessary infrastructure, medicine and equipment are provided to them. 5. Information, Education and Communication (IEC): Health education programmes using mass media, folk media and other communication channels are 4 https://mohfw.gov.in/major-programmes/other-national-health-programmes/national-

programme-health-care-elderlynphce.

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being promoted to reach out to the target community for promoting the concept of healthy ageing, importance of physical exercise, healthy habits and reduction of stress. Camps for regular medical check-up are being organized at various levels where IEC activities are also specifically promoted. The NPHCE since 2011 is making a steady progress; the regional centres have been established; during the next few years, these institutes would be making available postgraduate geriatric medical professionals.

Ayushman Bharat5 a Large Government-Funded Healthcare Scheme Ayushman Bharat aims to provide healthcare facilities to over 100 million families covering urban and rural poor. The scheme offers an insurance cover of Rs. 500,000, which will cover almost 500 million citizens. The scheme would initially cover 100 million poor families as per the socio-economic census of 2011, and it will in the coming days also benefit the lower-middle class, middle class and upper-middle class by way of jobs in the medical sector as new hospitals will open in Tier-2 and Tier-3 cities. The scheme is targeted at poor, deprived rural families and identified occupational categories of urban workers’ families. So, if we were to go by the Socio-Economic Caste Census (SECC) 2011 data, 8.03 crore families in rural and 2.33 crore in urban areas will be entitled to be covered under these schemes; i.e. it will cover around 50 crore people. To ensure that nobody is left out (especially women, children and the elderly), there will be no cap on the family size and age. States would need to have State Health Agency (SHA) to implement the scheme. To ensure that the funds reach SHA on time, the transfer of funds from central government through Ayushman Bharat—National Health Protection Mission to State Health Agencies may be done through an escrow account directly. In partnership with NITI Aayog, a robust, modular, scalable and interoperable IT platform will be made operational which will entail a paperless and cashless transaction.

Rashtriya Swasthya Bima Yojana (RSBY)6 In the past, the government had tried to provide a health insurance cover to selected beneficiaries either at the state level or national level. However, most of these schemes were not able to achieve their intended objectives. Often, there were issues with either the design and/or implementation of these schemes. Keeping this background in mind, Government of India decided to design a health insurance scheme which 5 Ayushman

Bharat: A National Health Protection Scheme, https://www.india.gov.in/spotlight/ ayushman-bharat-national-health-protection-mission. 6 https://www.india.gov.in/spotlight/rashtriya-swasthya-bima-yojana.

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not only avoids the pitfalls of the earlier schemes but goes a step beyond and provides a world-class model. After taking all this into account and also reviewing other successful models of health insurance in the world in similar settings, RSBY was designed. It has started rolling from 1 April 2008. RSBY has been launched by Ministry of Labour and Employment, Government of India, to provide health insurance coverage for below poverty line (BPL) families. The objective of RSBY is to provide protection to BPL households from financial liabilities arising out of health shocks that involve hospitalization. Unorganized sector workers belonging to BPL category and their family members (a family unit of five) shall be the beneficiaries under the scheme. It will be the responsibility of the implementing agencies to verify the eligibility of the unorganized sector workers and his family members who are proposed to be benefited under the scheme. The beneficiaries will be issued smart cards for the purpose of identification. There has been a concern in respect of senior citizens, as often the families did not cover the senior citizens when the number of members covered increased five—spouses and children were covered. Government of India contributes 75% of the estimated annual premium of Rs. 750, subjected to a maximum of Rs. 565 per family per annum. The cost of smart card will be borne by the central government. State governments contribute 25% of the annual premium, as well as any additional premium. The beneficiary would pay Rs. 30 per annum as registration/renewal fee. The administrative and other related cost of administering the scheme would be borne by the respective state governments.

Standing Committee on Social Justice and Empowerment The Standing Committee on Social Justice and Empowerment in its report on the implementation of schemes for the welfare of senior citizens recommended the following new policies and laws7 : • A comprehensive law for the social security. • An integrated action plan involving various stakeholders and departments of the government. • A new National Policy on Older Persons as the one launched in 1999 has not been implemented effectively. A draft National Policy on Senior Citizens was published in 2011 but has not been finalized and implemented either. • An expert committee must be constituted to formulate specialized healthcare policies for the population above 80 years. • The Department of Disability Affairs in the Ministry of Social Justice and Empowerment, Government of India, to be renamed Department of Disability Affairs and Senior Citizens and to work towards implementing schemes for senior citizens.

7 https://www.prsindia.org/report-summaries/implementation-schemes-welfare-senior-citizens.

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• More old age homes be constructed, to ensure an old age home in every district as per the Maintenance and Welfare of Parents and Senior Citizens Act 2007. Standardized norms and guidelines must be formulated for old age homes, especially related to design of buildings and expertise required to manage these homes. • Pension be increased to a minimum of Rs. 1000 per month and that it be made available to those above the poverty line as well. • A health insurance scheme be formulated for senior citizens. Alternatively, the Rashtriya Swasthya Bima Yojana, which provides health insurance to BPL families to be universalized. • Tax exemptions for people above 60 years and 80 years, respectively, should be raised periodically.

Integrated Programme for Senior Citizens8 Integrated Programme for Senior Citizens is a scheme to improve the quality of life of the senior citizens introduced by the Ministry of Social Justice and Empowerment, Government of India. The main objective of the scheme is to improve the quality of life of the senior citizens by providing basic amenities like shelter, food, medical care and entertainment by encouraging productive and active ageing through providing support for capacity building of state/Union Territory Governments/nongovernmental organizations (NGOs)/Panchayat Raj Institutions (PRIs)/local bodies and the community at large. Assistance under the scheme is given to them for conducting programmes catering to the basic needs of senior citizens particularly food, shelter and health care to the destitute elderly, programmes to build and strengthen intergenerational relationships through Regional Resource and Training Centres (RRTCs), programmes for encouraging active and productive ageing, through RRTCs, programmes for proving institutional as well as non-institutional care/services to senior citizens, research, advocacy and awareness building programmes in the field of ageing.

8 Press

Information Bureau, Government of India, Ministry of Social Justice and Empowerment 24 July 2018 Implementation of Central Sector Scheme of Integrated Programme for Senior Citizens (IPSRC).

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National Human Rights Commission (NHRC) The Government of India is involved in the Human Rights of Older Persons, and they present the India government’s stand on the rights of senior citizens in the Open-Ended Working Group meetings convened by the United Nations at New York. NHRC has Listed Out Few Specific Challenges Faced by Older Persons9 Such as facing far higher risk of a range of ailments, poverty resulting in homelessness, malnutrition, unattended chronic diseases, lack of access to safe drinking water and sanitation, unaffordable medicines and treatments and income insecurity, violence and abuse including physical, emotional, mental, sexual and financial exploitation, lack of specific measures and services as being old, they do not have enough resources and facilities to cope with the growing demand, particularly for specialized services such as residential centres, and long-term home care programmes or geriatric services, necessary to guarantee Human Rights of Older Persons and discrimination in all aspects of life including employment and access to housing, health care and social services. NHRC India has constituted a core group on protection and welfare of the elderly persons to review existing government policies, laws/rules/orders, etc., and other matters from human rights perspective and make an assessment of current status of enforcement of the rights of the elderly in different parts of India, to identify voids and gaps in the policy framework for implementation and to suggest measures to fill the same, to identify important human rights issues concerning the elderly and to suggest measures as appropriate for better protection of their rights, to suggest plan of action for enforcement of rights of elderly persons, to examine best practices in India and abroad dealing with the care of elderly and any other issue which is considered relevant to the subject by the group. Employment After Retirement or During Old Age: Mahatma Gandhi National Rural Employment Guarantee Act and Senior Citizens The Government of India introduced the National Rural Employment Guarantee Act in 2005 which was later renamed to Mahatma Gandhi National Rural Employment Guarantee Act. This act is a social security scheme that aims to provide livelihood, sustenance and employment to the rural communities and labourers in India. The NREGA assures income security to rural families and provides a minimum of 100 days of definite wage employment in one year. This wage employment is applicable for adults who have volunteered for unskilled manual labour. The NREGA was passed as an Indian labour law and was implemented in 200 districts across India on 2 February 2006. More districts were covered across the country later from 1 April 2008. This scheme has been implemented on a very large scale, and the World Bank even mentioned the NREGA as an excellent example of rural development in the 9 Comments of NHRC, India, on the Questionnaire for the focus areas of the IX Session of the Open-

Ended Working Group on Ageing. Ref: https://social.un.org/ageing-working-group/documents/ ninth/Inputs%20NHRIs/India.pdf.

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World Development Report of 2014. Under the MGNREGA, any rural adult nonskilled worker can get a minimum 100-day job guarantee, every financial year. Every Indian rural citizen is entitled to receive employment within 15 days of registering under this scheme. Once the registration has been done, the worker is eligible for an unemployment allowance from the government as well if employment has not been found within the stipulated period. The Gram Panchayats were nominated to implement the MGNREGA across India. Initially, the minimum wages that were to be given to labourers were Rs. 100 per day. The Government of India revised the wages on a later date in accordance with state labour employment conventions. Currently, the minimum wages are being determined by the state government, with the Rs. 163 being the minimum in Bihar and Rs. 500 being the minimum in Kerala. Any senior citizens who have not been taken care by their families can also enrol under MGNREGA for support.10 Senior citizens can be included into the special category of workers. Gram Panchayats can form special senior citizen groups and ensure that the work allocated to them requires less physical strain.

Social Security and Income Social security is defined by the International Labour Organization (ILO) as ‘the protection which society provides for its members, through a series of public measures to prevent the social and economic distress that would otherwise be caused by the stoppage or substantial reduction in earnings resulting from sickness, maternity, employment injury, unemployment, invalidity, old age and death, the provision of medical care and the provision of subsidies for families with children (ILO 1942). Social security is a basic human right, which was recognized in the United Nations Declaration of Human Rights in 1948. The right to life, recognized as a fundamental right by Article 21 of the Constitution of India, implies the right to live with human dignity. It encompasses not only the security regarding the basic human needs of food, clothing and shelter, but also health security. Social security schemes usually give priority to income security because, generally, the basic needs of the vulnerable sections may be satisfied if people have an adequate income. A high percentage of population live below the poverty line, work in the informal sector, have inadequate earnings and leave giving little scope to save for a majority of households. As per the 2011 census, nearly 54% of the workforce is engaged in agriculture. With nearly 60% rural households not having bank accounts, a large majority of the elderly will continue to rely on their children and family members for old age security. • Successive rounds of National Social Survey (NSS) (1987, 1996, 2004) indicate that out-of-pocket expenditure for the elderly was four times as high as that among 10 Mahatma Gandhi National Rural Employment Guarantee Act, 2005, Comprehensive Modules July 2015 developed by the Department of Rural Development, Ministry of Rural Development, Government of India.

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the working age group members and out-of-pocket expenses for hospitalization have been increasing sharply among the poor sections. • Due to the increased longevity of women, at higher ages they become more vulnerable due to widowhood. The percentage of Indian women who are widowed increases from 44.5 in the age group 60–64 years to 86.8 for women aged 80 and older. In contrast, one in ten men in the age group of 60–64 years and one-third of men above 80 are widowers (United Nations Population Fund (UNFPA) 2012). As women are at a disadvantage in terms of ownership of assets, lower work participation and lower wages, they are more likely to be at the mercy of the male family members and more so once they are widowed. Central schemes (not specifically targeted at the elderly): The elderly, if eligible, can avail: • Mahatma Gandhi National Rural Employment Guarantee (MGNREGA) scheme guarantees 100 days of employment. All the districts in India are in its ambit since 2008. • Indira Gandhi National Disability Pension Scheme (funding shared by the central government and state government) provides for pension of Rs.300 per month to destitute with severe or multiple disabilities and who do not receive other pension. The eligible age group is 18–79 years. • National Family Benefit Scheme provides the dependent family a lump sum of Rs. 10,000 if the breadwinner dies between ages 18 and 64 years. • Rashtriya Swasthya Bima Yojana (RSBY), which was launched in 2008 by the Ministry of Labour and Employment, provides insurance cover to five members (including the elderly) in BPL families, and they are entitled to hospitalization expenses up to Rs. 30,000. They have to pay only the registration fee of thirty rupees. The premium is paid by the central government and respective state government. • Indira Awas Yojana (IAA) of the Ministry of Rural Development gives grants for the construction of dwelling units for BPL households. Central: state ratio for funding is 75:25. Elderly persons belonging to the below poverty line households, if in need of a dwelling unit, can avail of this scheme. • National Old Age Pension Scheme (renamed as Indira Gandhi National Old Age Pension Scheme (IGNOAPS) in 2007), targeted at the destitute elderly, was launched by the central government on 15 August 1995. This was seen as a big step towards fulfilment of Article 41 and 42 of the constitution. From April 2011, the eligibility age for this scheme was reduced from 65 to 60 and the pension amount was raised from Rs. 75 to Rs. 200 per month for elderly persons in the age group 60–79 years and Rs. 500 for those above 80. The entire funding for this is disbursed by the central government to the states, and cover is limited to 50% of the BPL population above age 65 (now 60). • The selection of beneficiaries is done by Gram Panchayats on the basis of targets communicated by the state government. It was made explicit that the central assistance is not a substitute for state governments’ expenditure on pensions for the elderly, but is intended to ensure that a uniform minimum amount is paid. State

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governments, however, may expand coverage or increase the pension amount per person. It is also specified that the benefits of the scheme should be disbursed in not less than two instalments in a year. The ceiling on numbers and qualifying financial entitlements for the states are worked out by the following formula: • Numerical ceiling = 1/2 of population in the state aged 65 and above multiplied by the poverty ratio of the state. • A survey in two districts of Jharkhand and Chhattisgarh also revealed that beneficiaries have difficulties in accessing the banking system and face inordinate delays in receiving their meagre pensions (Gupta 2013). • Frauds and fake cases: Many people with influential political connections manage to get assistance from more than one scheme or even multiple times, while genuine claimants could be excluded (Irudaya Rajan 2001). • This formula, used to work out the financial entitlement, implies that only half of the BPL elderly population in each state are considered worthy of receiving pension benefits (Alam 2004) but as pointed by Irudaya Rajan (2001), the actual allocation is lower than the financial entitlement. It was found that many states could not utilize the amount allotted to them, a pointer to their failure to identify the potential beneficiaries. Rajan also observed that utilization improved from 74% in 1995–96 to 95% in 1999–2000. Senior Citizens’ Welfare Fund Rules, 201611 This fund was established promoting the welfare of the senior citizens and for such other purposes as specified in Chapter VII of the Finance Act, 2015. It shall be an interest-bearing account in the public account of the Union of India and shall be administered by the committee. Every institution shall transfer the unclaimed amounts from small savings and other savings schemes of the central government including the Post Office Savings Accounts, Post Office Recurring Deposit Accounts, Post Office Time Deposit Accounts, Post Office Monthly Income Accounts, Senior Citizens’ Savings Scheme Accounts, Kisan Vikas Patras, National Savings Certificates (all issues), Sukanya Samriddhi Accounts and discontinued Small Savings Schemes, Accounts of Public Provident Funds under the Public Provident Fund Scheme, 1968, maintained by the institutions concerned and Accounts of Employees’ Provident Fund under the Employees’ Provident Funds and Miscellaneous Provisions Act, 1952. The nodal ministry for the administration of the fund shall be the Ministry of Social Justice and Empowerment. The fund shall be utilized for such schemes for the promotion of the welfare of senior citizens in line with the National Policy on Older Persons and the National Policy on Senior Citizens. The schemes for promoting financial security of senior citizens, including but not limited to, old age pensions, long term saving instruments and employment in income generating activities. Schemes for promoting healthcare and nutrition of senior citizens, including but 11 Government of India, Ministry of Finance Department of Economic Affairs, New Delhi, 18 March

2016.

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not limited to, affordable health care programs, mental health services, health insurance schemes, nutrition education programs and training and orientation in health care of senior citizens, schemes for promoting welfare of elderly widows, schemes related to old age homes, short stay homes and day care of senior citizens, schemes related to education training and information needs of senior citizens, schemes related to research activity on ageing and information systems on senior citizens and any other scheme, with the approval of the Committee. Distribution of Physical Aids and Assistive Living Devices—Rashtriya Vayoshri Yojana12 A new scheme, viz. Rashtriya Vayoshri Yojana (RVY), was launched on 1 April 2017 which aims at providing physical aids and assistive living devices, viz. wheelchairs, hearing aids, spectacles, support sticks, etc., to the older persons of below poverty line category. Till end of 2018, more than 53,000 senior citizens were benefitted under this scheme. Initially 305 districts were though its implementation has started in 55 districts. Re-employment of Those Retired: National Policy on Senior Citizens 201113 National Policy on Senior Citizens 2011 submitted to the MSJE provided for productive ageing by stating that the government will promote measures to create avenues for continuity in employment and/or postretirement opportunities and a directorate of employment would be created to enable seniors find re-employment. However, a part of its recommendations was implemented while the rest of the document is under consideration. Provision of social security by the state is an intrinsic part of the living standards in more developed countries (MDCs). In the less developed countries (LDCs), however, due to chronic unemployment and extreme deprivation that is inherent in the social structures, the extent of vulnerability is well beyond the risks that are normally covered by the social security systems that exist in the MDCs.14 The economic feasibility of social security at a comparable level is a vital constraint in LDCs. Until recently, family and adult children took on the responsibility of looking after their elderly and were considered to be a reliable source for providing old age security. However, these traditional sources of old age security have come under great strain due to the increased longevity of the elderly, and other widespread demographic and socioeconomic and sociocultural changes taking place in these transitional societies. The problem is more acute among the poor elderly who, with their deteriorating health conditions, are unable to work for earning and have hardly, if ever, any savings to fall back upon. Marginalization of the poor—an unforeseen consequence of globalization—and increasing feminization of poverty have further underscored the need 12 Annual Report 2017–18, Department of Social Justice and Empowerment, Ministry of Social Justice and Empowerment, Government of India. 13 http://socialjustice.nic.in/writereaddata/UploadFile/dnpsc.pdf. 14 Sumati Kulkarni, Siva Raju & Smita Bammidi, Social Security for the Elderly in India, Thematic Paper 1, Building Knowledge Base on Ageing in India: Increased Awareness, Access and Quality of Elderly Services.

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to adopt suitably targeted measures that provide social security to the elderly. Like a few other developing countries, the Government of India as well as the state governments have undertaken some initiatives in this direction. Presently, the debate on provision of social security to the elderly revolves around the eligibility, coverage, pension amount, appropriate form of assistance to the elderly (food or physical assistance or monetary help, etc.), delivery mechanisms, their suitability and the economic implications of such measures. Self-help Groups of Elderly Ageing, for instance, causes livelihood insecurity for many, on account of no or inadequate resource transfers to the elderly. Public and family interest in the livelihood of elderly persons wanes with growing age, leading to a seemingly hapless situation for them. The problems of the elderly become intolerable in the event of a natural disaster—flood, earthquake, tsunami, etc.,—as their health and other vulnerabilities make them liable to greater harm. In such circumstances, emerging evidence shows that community intervention is a useful tool to improve the livelihood security of the elderly. Elderly self-help groups (ESHGs) were initiated for the first time in Tamil Nadu, in 2005, after a devastating tsunami caused suffering across the state, in particular, for the elderly.15 ESHGs have played a significant role in tackling the complex socio-economic issues that arise with age-related vulnerabilities. ESHGs have been formed in many parts of the country including Bihar—an eastern state with a long history of devastating floods. ESHGs were designed to connect the elderly with financial provisioning by forming groups of 10–20 members to generate thrift and extend credit to the needy elders. A recent experiment that involved the forming of thrift and credit-enabled elderly self-help groups (ESHGs) that would help the elderly to undertake small incomegenerating activities is an example that deserves attention, further emulation and public support. The underlying discussion is drawn to serve this objective. ESHGs and economic well-being—participation improves income security in old age. ESHGs foster a sense of mutual belonging—participation keeps elders active and happy. Participation in ESGH improves income security in old age. It fosters a sense of belonging—participation keeps elderly healthy and happy. Respondents painted a picture of moving towards a sense of total well-being in their lives after joining ESHGs. When Panchayats are sensitized, they can show interest in extending support to ESHGs by way of an office space, fixtures and other support needed. In the bargain, Gram Panchayats are sensitized to the specific needs of elderly who live in villages. The governments must recognize ESHGs as one of the best options.

15 Alam,

Moneer and Khan, Khalid and Patil, Shruti, Working to Build Livelihood Opportunities for the Elderly: A Qualitative Study of Elderly Self-Help Groups in Bihar 2017.

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Care Family members have long provided care for ageing and older adults at home, especially in low- and middle-income countries. However, many of the deep-rooted cultural cornerstones of caregiving have not been explored in the context of India’s current myriad rapid demographic and epidemiological transitions. Cultural gender norms remained important, but not sole motivators of care expectations.16 A key reward for care providers was the hope that providing their loved one care would result in this being their last rebirth or offer them a better birth or life in the next life.17 The Indian state of Kerala leads the demographic transition and characteristically showcases emigration of predominantly male adult children, leaving behind parents, spouses and children.18 When men emigrate, gendered contexts burden women, especially spouses and daughters-in-law, with caregiving duties including elder care. Employing the social exchange perspective and drawing on in-depth interviews of left-behind caregivers to older adults in emigrant households, we explore reciprocal motives, expectations and perceptions of burden. Findings resonate gendered expectations of care and social sanction that ensure women do much of the caregiving. Daughters-in-law sacrificed careers and endured separation from husbands to transition into caregiving roles, costs borne to effectuate their husband’s filial role. Perceived non-reciprocity, unbalanced exchanges and unmet expectations increased perceptions of burden for caregivers. Temporary financial autonomy could hardly alleviate perceptions of burden among women caregivers who perceived emotional and functional support exchanges from husbands, older adults themselves or other family members as supportive.19 Caring for the aged or elderly or senior citizens is the fulfilment of needs and requirements that are unique to senior citizens. Caring for the aged encompasses services such as assisted living, old age homes, adult day care, long-term care, nursing homes (often referred to as residential care) and home care. Because of such wide variety of elderly care services found nationally, which is often influenced by different cultural perspectives on elderly citizens, care for the aged cannot to be limited to any one practice. For example, many countries in Asia, including India, use governmentestablished elderly care quite infrequently, preferring the traditional methods of being cared for by younger generations of family members.20 Elderly care emphasizes the 16 Culture and Caregiving for Older Adults in India: A Qualitative Study, The Gerontologist, Volume 55, Issue Suppl_2, 1 November 2015, Pages 112, https://doi.org/10.1093/geront/gnv504.06. 17 See Footnote 16. 18 Allen Prabhaker Ugargol & Ajay Bailey (2018) Family caregiving for older adults: gendered roles and caregiver burden in emigrant households of Kerala, India, Asian Population Studies, 14:2, 194–210, https://doi.org/10.1080/17441730.2017.1412593. 19 Allen Prabhakar Ugargol, Family Caregiving for Older Adults: Gendered Roles and Caregiver Burden in emigrant households of Kerala, India. 20 Policy for the Aged: Opportunities and Challenges, National Institute of Rural Development and Panchayati Raj.

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social and personal requirements of senior citizens who not only need financial assistance but also need some assistance with daily activities and health care, but who desire to age with dignity. It is an important distinction, in that the design of housing, services, activities, employee training and such should be truly customercantered. Working couples find the presence of old parents emotionally bonding and of great help in managing the household and caring for children. However, due to the operation of several forces, the position of a large number of older persons has become vulnerable due to which they cannot take for granted that their children will be able to look after them when they need care in old age, especially in view of the longer lifespan implying an extended period of dependency and higher costs to meet health and other needs. The financial planning for taking care of old needs has to start quite early in ones working life. Educating the need for such financial planning is not given enough scope in the national policies.21 The proposal for rating of the organizations providing home care services to elderly was one of the recommendations of the Group of Secretaries on Education and Social Development constituted by the government. It is proposed to prescribe standards in respect of various services to be provided by the home care service providers to the senior citizens and to rate them according to the facilities being provided, through suitable amendment to the Maintenance and Welfare of Parents and Senior Citizens (MWPSC) Act 2007.22 Certification courses for training geriatric caregivers are conducted by NISD and other collaborating institutes. All Regional Resource and Training Centres and other collaborating agencies providing training to develop geriatric caregivers have been directed to apply for accreditation as Training Centre for Home Health Aide Qualification Pack and get affiliated to Healthcare Sector Skill Council (SSC) under National Skill Development Corporation (NSDC). Healthcare SSC has also been requested to develop separate module for geriatric caregivers as the existing qualification pack of home health aide is not exclusive for the senior citizens. National Skill Development Corporation (NSDC) is offering training courses in elderly home care services through two of its Sector Skill Councils. These are National Skill Qualifications Framework (NSQF)-aligned courses under the Ministry of Sill Development and Entrepreneurship (MSDE).23 There is adequate evidence to show that the living arrangements of the elderly have shifted significantly over the decades in India. In the west, although daughters and spouses continued to remain the primary caregivers of older adults, the division of labour by gender along with different family and kinship structures brought about by divorce, remarriage and stepfamily formation increased the complexity of who

21 See

Footnote 20.

22 Government of India, Ministry of Social Justice and Empowerment Lok Sabha, Starred Question

No. *239 Answered on 01.08.2017. 23 See Footnote 22.

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would take on the caregiving role.24 In contrast, intergeneration family continues to be the site for elder care in India. Historically, the joint family structure was never part of the Western European family structure. A joint family household could have grandparents, aunts, uncles, nephews and nieces, all living under the same roof. This family structure has historically served as a safety net for the elderly irrespective of their health status. Although the original form of joint family structure has changed, an intergenerational household arrangement that is living with only adult children, preferably the son, continues to be the dominant living arrangement for majority elderly Indians above the age of 60 though such a situation is changing very quickly. India, a society steeped in filial piety, family is still considered to be the ideal setting for elder care.25 However, traditional structures, such as the joint family that had been responsible for elder care, have changed or are fast changing. Further, laws and policies often get framed to support the elderly and not much to protect their caregivers, who are primarily women. These raise questions and speak to the extent to which cultural and moral visions around elder care dominate public and academic discourse, and raise pertinent questions on where the future of elder care is to be located and who would be responsible for their care: the family or the state. For example, the Maintenance and Welfare of Parents and Senior Citizens Act in India, implemented by the Ministry of Social Justice and Empowerment, India, in 2007 made it legally obligatory for children and heirs to provide maintenance to senior citizens and parents, by providing them with monthly allowance. The primary goal of this act was to protect the lives and ensure financial security of the elderly in India by making it legally binding for families to care for them. Arguments provided by activists, bureaucrats, academics and demographers for the creation of the act centre on the breakdown of family, brought about by forces of development, such as modernization, migration, urbanization and the like. Thus, there was an implicit belief that the breakdown of the intergenerational family was the root of the old age depravity and a need for state intervention.26 Vayoshreshtha Awards The Government of India announced Vayoshreshtha awards to recognize senior citizens and institutions in recognition of their service to elderly in 2005 which was upgraded to the status of National Awards in 2013. The awards are given away for institutions involved in rendering distinguished service for the cause of elderly persons, especially indigent senior citizens and to eminent citizens in recognition of their service/achievements. These awards are presented as part of the celebration of the International Day of Older Persons (IDOP) on 1 October. The National Awards 24 Who

Will Care for the Elder Caregiver? Outlining Theoretical Approaches and Future Research Questions: Subharati Ghosh, Benjamin Capistrant and Greta FriedemannSánchez. 25 Tannistha Samanta, Cross-Cultural and Cross-Disciplinary Perspectives in Social Gerontology. 26 Ghosh Subhashree, Capistrant Benjamin & Friedmann Greta, Who will Care for the Elderly Caregivers? Outlining Theoretical Approaches and Future Research Questions.

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are intended to showcase the government’s concern for senior citizens and its commitment towards them with the aim of strengthening their legitimate place in the society. It is also intended to provide an opportunity to the younger generation to understand the contribution of the elderly in building of the society and the nation and conferred on eminent senior citizens involved in rendering distinguished services for the cause of elderly persons. Nominations are invited from governmental and non-governmental agencies. U3A-India27 U3A-India is a self-help group of like-minded people who have retired or about to retire from professional careers and have fulfilled their commitments towards their families. The members in the age group of 50 plus years have ample time to enrich their knowledge, acquire new skills, rediscover the ambitions of their younger years through new friendships and use their experiences to create a new vibrant community of elders. The movement has substantially varied approaches in different countries. It is aimed at helping the elders to face their day-to-day needs in the areas of health, finance, social security, guarding against elder abuse from within and outside the family, fighting loneliness and familiarizing them with the benefits that are extended by the government agencies. Its activities focus on awareness programmes on health of body, mind and soul, besides lifestyle, finance, security and safety leaving the rest to be shared and cared by the government. It organizes conferences and seminars and conducts workshops on relevant topics to educate and benefit the senior citizens at state and national levels. Elderly Housing: Retirement Homes The Government of India has issued model guidelines for development and regulation of retirement homes in March 2019.28 Salient features include elderly friendly design, gas leak detection systems, power backup facilities in corridors, lobby, lifts and apartments, compliance with green building principles and use of non-polluting and renewable energy, 24 × 7 water and electricity supply, hygiene, indoor and outdoor recreation facilities, security and housekeeping, single window facilities and helpdesk, transportation assistance, yoga and fitness facilities, caregiving facilities, etc., 24 × 7 on-site ambulance service, mandatory tie up with nearest hospitals and pharmacy, medical emergency room, regular medical check-up of residents, customized services over and above basic common services also prescribed and retirement homes to be friendly for differently abled provision of lifts, signage and signalling systems mandatory. The model guidelines address the special needs and protect the rights of senior citizens and retirees living in retirement homes who aspire to spend their retired life independently in a safe, secure and dignified environment. The guidelines provide option to senior citizens and family members, who are willing and can afford to purchase a living space for their parents. 27 http://u3aindia.com/about.php. 28 Press

Information Bureau, Government of India, Ministry of Housing and Urban Affairs dated 06 Mar 2019.

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The Future of Indian Elderly From approximately 7.6 crore in 2001, the number of senior citizens in India has increased to 10.4 crore in 2011. This number is expected to grow to 17.3 crore by 2025 and about 24 crores by 2050. By the end of the century, senior citizens will constitute nearly 34% of the total population of the country. The policies, programmes and services must start focusing on addressing every single issue of senior citizens, particularly those living in rural India, women and eighty years and over whose number will be sizeable. Elderly people are the conscious keepers of our society, and it is everybody’s responsibility to respect them. Avoid the use of the word ‘old’, and replace it with ‘senior’; replace ‘old age homes’ with ‘homes for the elderly’; extend all affordable healthcare programmes to the elderly.29 The quality of services provided under these government schemes must be ensured, and coverage should be expanded. The Maintenance and Welfare of Parents and Senior Citizens Act 2007 provides for establishment of one old age home in every district to accommodate up to 150 infirm senior citizens. This has not been done till now, while the legislation is being reviewed and a draft amendment bill has been announced in the public domain seeking suggestions. The current grant in aid scheme can be enlarged to reach out to senior citizens in old age homes with clearer objectives, goals and implementation mechanism to ensure well-being of those seeking asylum into such homes. The processes of availing the benefits of such government schemes should be easy. We cannot expect our elderly citizens to run around the office at that age, to avail the benefits. The coverage under the old age pension is far from reaching out to senior citizens who deserve them. The Government of India and other governments must provide higher budgetary allocation so they are able to get a respectable monthly pension so the families do not consider them a burden and send them to institutional care. Ministry of Health and Family Welfare has issued Short Term Training Curriculum Handbook on Home Health Aide in 2017. As is observed all over the world, senior citizens prefer to live at their own homes and if possible with families. Therefore, dependence on institutional care may not be attractive though those not having families may not hesitate seeking such care. However, at least 90% of senior citizens would prefer living at homes and manpower must be trained to make them available to render essential care at homes. Since this curriculum is developed by the government, the National Skill Development Corporation, Ministry of Social Justice and Empowerment, Government of India, can encourage human resources pursuing such career as they have a huge potential for very large size enrolment. The senior citizens are getting empowered by several efforts of the NGOs and state- and district-level programmes, especially on 1 October commemorating the 29 Press Information Bureau, Government of India, Vice President of India’s Secretariat, 01 October

2018.

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International Day of Senior Citizens, and several people receive awards and are honoured by the governments. The Government of India and the state governments have in place policies, programmes and schemes for the senior citizens. Their implementation with transparency will go a long way in ensuring quality of care to our growing number of senior citizens.

Chapter 6

Elder Care from a Distance: Emerging Trends and Challenges in the Contemporary India Archana Kaushik

Abstract Forces of social change have, among others, altered the structure and functioning of the family system, which has brought eldercare at the crossroads. Caring for their elderly relatives that used to be the duty of young family members no longer is discharged by many families in contemporary times. In today’s world, migration because of work needs has become a stark reality. At times, it is not possible to take the aged parents along. Migration for education and career options, women’s work participation, inflation, competition, and so on, are some of the reasons that have affected the traditional ways of caregiving to the elderly. Distance care is one such newer system of caregiving that has emerged in the recent times in those cases where children are not staying with their aged parents but trying to maintain close ties and making efforts for providing care and support, though miles apart. This study looks into eldercare issues from a distance. Its objective is to explore how distance care is operationalized in everyday living in the context of the elderly who are living alone. The study is qualitative with descriptive research design with a sample size of 60 (30 elderly and 30 children), conducted in the National Capital Region. It focuses on the challenges and constraints faced by the elderly living alone and strategies and approaches developed by their children as caring responses. Findings of the study have implications for geriatric care initiatives by the government and civil society, other than the family members. Keywords Elder care · Distance care · Migration · Caregiving · Health vulnerability · Support

Introduction Population ageing has become a reality due to declining birth and death rates across the globe, though in varying degrees. Increased number and proportion of older persons in the world population have made the care of the elderly an international concern. This apart, forces of social change such as industrialization, urbanization, A. Kaushik (B) Department of Social Work, University of Delhi, New Delhi, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. K. Shankardass (ed.), Ageing Issues and Responses in India, https://doi.org/10.1007/978-981-15-5187-1_6

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modernization and now globalization, has altered the structural and functional aspects of the family system, which has traditionally assumed the responsibility of elder care. There has been a gradual shift from the exclusive responsibility of families to care for their elderly relatives to the state taking up the role of elderly care. While developed countries are facing challenges related to providing social security to rapidly increasing population of older persons, developing countries are witnessing a tussle between the withering role of informal support systems like family and community and emerging role of formal support systems like government institutions and non-governmental organizations. However, this does not imply that elderly people are becoming marginalized and left uncared for, rather every society and country is responding in unique ways to ensure care and security of the older persons. Old age has been a universal and natural phase of human life cycle and since ages, across the globe, individuals grow old and require support of their family, kith, kin, community and the government to handle age-related changing mental and physical capabilities. However, since life expectancy was quite low and fewer individuals used to live up to old age, resources and services were enough to meet the demands of the ageing population. Conversely, advances in medical sciences have, among others, resulted in increasing longevity and, in turn, greying of the nations. The United Nations (2017) projects, that by 2050, the elderly population in the world would be two billion people. And people aged eighty years or more are the fastest growing segment of global elderly population. Further, centenarians are projected to increase fourteen times from 265,000 people in 2005 to 3.7 million by 2050. By 2050, India too would be having more grandparents than grandchildren with projected population of elderly more than 340 millions, accounting for 20% of the total population (Helpage India 2015). It is important to note that this increasing population of elderly in India and in the world is not a homogeneous category but has differential needs and problems including caregiving issues. Elderly in their sixties have a different set of capabilities and needs than their octogenarian and centenarian counterparts. However, among the elderly, along with other factors such as ailments and disability, with increasing age, caregiving needs increase due to increasing dependence for activities of daily living. Migration is yet another exigency that has challenged caregiving issues among the elderly. In contemporary times, especially in rural areas, children (or young caregivers) have migrated for better career options or due to marriage, leaving behind their elderly relatives to fend for themselves. This phenomenon is also visible in urban areas where children either go to abroad or other cities within the country due to job requirements or marriage obligations. This has given rise to a new system of elderly care—distance care or caring from a distance. The present paper focuses on distance care as a newer modality of elderly care, looking at its operationalization in reality, associated challenges and problems.

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Changing Patterns of Elder Care: Reviewing Literature Since ancient and medieval times, elder care has been the role of the family system. The social institution of family has been given the utmost importance in the social fabric, without which the existence of societies would have not been possible in the present form. Philosophers have considered family as the bastion of human civilization. Social scientists have seen the family as the basic building block of society. One of the primary reasons for the evolution of the institution of family is to provide protection and nurturance to infant and children who are perhaps the most helpless creatures at the time of birth and also to the elderly who biologically are at the downslope of life (Kaushik, 2012). Family, among many of its crucial functions, provides safety, security, love and affection to its members including the elderly. In the context of elder care, traditionally, certain norms and practices in the Indian family system not only ensured safety and security of the older relatives but also provided them with utmost respect and reverence. In agrarian societies, joint family system was the normative family structure where the eldest male would be the head or karta of the household. He would control the family property and make all the necessary decisions (Ramamurthi & Jamuna, 2004). With industrialization and urbanization, people started migrating to urban centres and joint family gave way to the nuclear family system. There was a change in the composition of the family, and accordingly roles, power and status of the family members changed to a large extent. In modern era, even younger earning males are enjoying headship and females, in greater number and proportion, are stepping out of the four walls of household for becoming economically self-reliant. Migration of children is taken as one of the crucial factors that lead to inability of family to care for its elderly, which is forcing elderly parents to live alone (Paltasingh & Tyagi, 2015). Studying the situation of the elderly in rural Karnataka, Sivamurthy (2005) reports that, during crisis situation, 94.3% elderly women from lower socio-economic strata received support from their family, whereas this proportion was only 75% for those from upper socio-economic strata. Khan et al. (2013), however, in their study on over 8000 elderly women from eight states of North and North-eastern India, note that 71% of aged ladies are dependent on others and hence vulnerable, economically and socially. Nonetheless, gerontologists have claimed that unlike the Western countries, where due to domination of modernization and globalization, family systems are increasingly becoming unable to care for their elderly, the situation in developing countries like India is in favour of the older persons as families, particularly younger generations are, more often than not, looking after their elderly relatives, despite several economic and social problems (see Siva Raju, 2002; Siva Raju & Anand, 2000). However, modes and qualities of care are varying with the changing times. Chan (2005) has studied changes in formal and informal support structures for elders in South and Southeast Asia in the light of modernization. Findings show that the majority of older adults in South and Southeast Asia coreside with at least one of their adult

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children. She notes that although traditional Asian family structure and intergenerational support for elders are breaking down in countries like China, Thailand, Hong Kong, Malaysia and India, families are trying to find ways and means to care for their elderly in their attempt to strike balance between their job responsibilities and traditional roles of caring for their aged relatives. However, there are several forms and modes of elderly care visible in postmodern era; elder abuse and destitution are on rise, old age homes are becoming popular, and at the same time, many youth are found leaving no stone unturned to care for their aged parents. Chan further finds that many Asian governments are fearing that if informal systems, like family, fail to look after the increasing population of the elderly, burden would fall on formal systems, and hence on the public exchequer. In some Asian countries, like Malaysia and Singapore governments have initiated programmes such as offering tax concession incentives for children of the elderly, while other countries like India have allowed older parents to sue their children for elder abuse, including economic neglect. Just as family as an institution is coping to the changing demands of the society by changing its forms and functions, newer forms of elderly care are also emerging. Kaushik (2012) asserts that among these newer systems, distance care is gaining prominence. Often times, it is assumed that younger generation does not care for their elderly relatives and older people are left to fend for themselves. This is not always true. There are circumstantial reasons like job constraints, space constraints, nobody to take care of immovable property back at village, inability of older parents to adjust to fast pace of urban life. According to the Family Caregiver Alliance (2010), between five and seven million Americans are caring for the elderly from afar (defined as living at least one hour away from an older relative). These numbers are increasing every day. Against this backdrop, a newer system of caring for the elderly is emerging— distance care or caring through long distance. It implies that children are making efforts to provide care to their aged parents though they are not staying with them but are miles away. Technological advancements like telephone, mobile phones and the Internet are providing the opportunity for interactions to the aged and their children, greater than ever before. Distance care has become a reality in today’s times. This study aims to look into this area, which is almost untouched by the researchers, especially in Indian setting. It may be put on record that despite rigorous review of literature, in terms of research studies, both in India and abroad, nothing noteworthy could be gathered on distance care with regard to the elderly.

Research Methodology Forces of social change have not left family as a social institution unchanged. Families are changing structurally and functionally. Elderly care that used to be the duty of young family members no longer is assumed by many families in contemporary times. In the present society, youth is straightaway blamed for not being able to discharge

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their duties of caring for their elderly parents as they give more importance to their career achievement. People often perceive youth as irresponsible, self-centred as they are not staying with their parents and generally daughters-in-law are blamed for intergenerational conflicts. In today’s world, migration because of work needs has become a stark reality. At times, it is not possible to take the aged parents along. Space constraint, fast pace of life and impersonality are some of the characteristics of urban life that go against the well-being of the elderly. Also, with women’s involvement in economic roles outside the household, caregiving issues are affected. Migration for education and career options, women’s work participation, inflation, competition, and so on, are some of the reasons that have affected the traditional ways of caregiving to the elderly. Distance care is one such newer system of caregiving that has emerged in the recent times in those cases where children are not staying with their aged parents but trying to maintain close ties and making efforts for providing care and support, though miles apart. This study aims to look into caregiving issues with regard to the elderly from a distance. Its objective is to explore how distance care is operationalized in everyday living in the context of the elderly who are living alone. It also intends to record the frequency of contacts and conversations and visits in the process of caregiving to the elderly and the modes of care (financial, emotional, social, ensuring medical attention and the like). The study with descriptive research design was conducted in the National Capital Region, that is, the National Capital Territory of Delhi, Gurgaon, Noida and Faridabad. There were two types of units for data collection—one, elderly parents with children not staying with them for reasons other than conflicts and adjustment problems and second, married children having elderly parents away from them. The sample size is 60 (30 elderly and 30 children).

FINDINGS: Needs and Problems of Elderly Living Alone Age Thirty elderly were interviewed in the study, out of them 17 were in the age bracket of 60–69 years, ten were in the age group of 70–79 years and three were 80 years and above. Though individual differences exist, advancing age often increases health vulnerability and also brings deterioration in health and consequently increased dependence on significant others. In that context, 13 elderly in the study may be requiring help of others in performing their activities of daily living. Gender In the study, 18 respondents were males and 12 females. Further, 20 elderly respondents were married and ten widowed (six men and four women). In the gendered context, marital status influences men and women differentially especially in old age. Demographically, women tend to live longer than men, and hence, gerontologists maintain that ageing is getting feminized. However, socioculturally, it is easier for

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men to live alone as the patriarchal structure does not, generally, encourage women to be independent—socially, economically and psychologically. Women are socialized to learn to be dependent, always, on male family members. For women, living alone in old age can be psychologically and socially much more devastating. Religion In the study, 28 respondents are Hindu; one is Christian and one Sikh. Educational Status Among the 18 male respondents, four are postgraduate, ten are graduates and four are studied up to 12th standard. Among the 12 females, seven are eighth pass and two are studied up to 12th and three are graduates. It seems that for educated elderly staying alone, managing helm of affairs independently is easier than those who are illiterate or have basic educational qualifications. By this notion, gender disparity is visible in the educational status of elderly respondents, making aged women vulnerable owing to patriarchal social reality. Occupational Status Among the 30 elderly respondents, seven retired from government job, eight retired from private jobs, 11 female respondents were housewives, and only one aged lady was a teacher in her prime time. Three respondents were into business. Coming to present occupation, 12 aged respondents are getting pension, and only four are engaged in some gainful employment. Rest of the respondents are in the category of non-workers. Occupational status of the elderly respondents too reflects the sociocultural norms guided by patriarchy. Whether in their prime time or in old age, males have enjoyed the clear-cut distinction of being the bread earners, while females largely have remained housewives. Family Details In traditional societies, especially the patriarchal social structure, having sons means social security in old age. People would pray for sons so that they can have somebody to care for them in old age. In the study, among the respondents, six have only one son, seven have one son and one daughter. Further, eight have two sons, and nine have three or more sons. It may be noted that inclusion criteria for selecting aged respondents for the study were those staying ‘alone’ and having married sons living separately in their respective neo-local families. Only in three cases, the son of elderly respondents is living in Delhi or NCR. In ten cases, children are abroad and in rest of 17 cases children are in different cities of India. Reasons for Staying Away From Children An ideal situation, especially in Indian sociocultural context, is elderly parents staying with their sons and receiving care, reverence and support from their sons, daughters-in-law and grandchildren. However, forces of social change like urbanization, globalization, migration, etc., have seriously influenced this trend of elderly care commonly visible in joint family system. Nowadays, more and more children are opting for neo-local family set-up after their marriage, where elderly parents hardly find place. The reasons for this are

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many—job prospects available in metropolis/abroad, intergenerational conflicts, no scope for raising living standards in the native place, educational opportunities and the like. In the study, the most common cited reason of children living separately was job requirement of the children. Several others regarded higher education as an important factor that pushed many young boys and girls to cities/metropolis/abroad. Those, staying in Delhi/NCR, distance from the office or convenience is claimed as the reasons for staying away from their elderly parents. In the case of girl children, marriage was the most prominent reason for not staying with parents. Period of Staying Alone Since how long an elderly person is staying alone or away from his/her children may have an association with coming to terms with the reality and looking forward to make the best out of the situation. Hypothetically, a few months after children leave home can be very difficult for elderly parents, commonly termed as ‘empty nest syndrome’. This period is associated with depression, tension, loneliness, feeling of void, restlessness, meaninglessness and so on. With the passage of time, elderly may ‘adjust’ to the reality and try to make the most of the situation. Findings of the study show that the range of staying alone is from 6 months to 32 years. Mean time is 18 years. Among the 30 respondents, seven have been staying alone since the past 20 years or more, 15 are staying alone for the past 10– 19 years, and rest of the 8 respondents are staying away from their children for the past 6 months to 9 years. So, apparently, most of the respondents have adjusted to their ‘staying alone and without children’. Frequency of Contact with Children Results of the study bring out that though children are staying away from their elderly parents but regular contact has been maintained. Findings show that out of 30 respondents, four meet their children once in 2–3 years. Maximum of the respondents (22) meet their children 1–3 times in a year. Rest of the aged respondents (4) meet 4–6 times a year with their children. Regular contact seems to be an important component of providing care from a distance. Mode of Contact Table 6.1 provides the details of the mode of contact between elderly respondents and their children. Table 6.1 Mode and frequency of contact between elderly parents and children Mode of contact

Almost daily

1–3 times a week

>4 times a week

1–2 times a month

Talk over telephone

2

12

12

4

Emails

–

–

–

4

Letters

–

–

–

–

Any other (video conferencing)

4

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Table 6.1 brings out that telephonic conversation is the most preferred and frequently used mode of contact between elderly parents and children. The electronic gadgets—mobile phones and landlines—have truly boosted the contact between relations miles apart. Hearing voice of loved ones as and when desired has been a big boon that paved way of caring from a distance. Emails have been confined to professional families where computer literacy, a pre-requisite, is fulfilled. Writing letters and posting them seemingly have become outdated. Video conferencing is confined to those cases where children are abroad. Thus, technological advancement has helped in initiating and sustaining long-distance relations, including that of elderly parents and married children. Problems in Living Alone There are several practical problems faced by elderly living alone in their daily dealings. Panda (2005) finds that with increasing age, there is reduction in activities of daily living. Apparently, elderly people living alone have to meet their basic needs like food, clothing, daily/weekly and monthly shopping, taking medicines, taking care of the household, dealing with security concerns and so on. Findings in this regard are documented below: 1. Food: Preparing food daily can be highly taxing for elderly living along, especially when sick, but it is a necessary task for survival. Some elderly have hired cook for this purpose, but for many it can be financially straining. Added to this, daily newspaper reports of domestic help killing/murdering elderly for property also raises stir. Study results show that out of 18 elderly males, seven cook food on their own, which in patriarchal social set-up is not expected. Among 12 females, seven cook on their own while others are dependent on maid servants. Thus, majority of the aged respondents are cooking for themselves. 2. Household chores: Though there are variations, decreasing health and strength is a common feature of old age. Doing household chores requires much of stamina and energy. Out of the 12 elderly women, seven do all the household chores themselves. All the males are either dependent on their spouse or domestic help for most household chores like cleaning, sweeping, washing, etc. Most of the market work is carried out by the respondents themselves either alone or with their spouses. When ailing, then the aged respondents, more often than not, request neighbours or other relatives in the same city for the necessary market work. 3. Health vulnerability and care: The elderly respondents try to maintain a healthy living so as to avoid chances of falling sick. They tend to stick to healthy and restricted diet as prescribed by their doctor. Still, out of 30 respondents, 17 maintain that their chronic ailments like diabetes, arthritis, heart problems, reduced eyesight, etc., have reduced their independence in activities of daily living, thereby increasing their risk of health deterioration. Visiting doctors and accessing medical services, too, become challenging when they are sick.

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Loneliness is yet another critical problem that most respondents reported. They told that loneliness coupled with anxiety related to their children’s well-being negatively impacts their health. Reminisce is the most frequently reported mental engagement for most of the elderly respondents, especially among women. The present study brings out three interesting trends as follows: 1. Women are more frequently exhibiting the void after their children leave home. 2. There is an inverse and strong relationship between the time duration of separation from the children and feelings associated with empty nest syndrome. 3. Health security is something that preoccupies the minds of most elderly people. Most aged respondents told that they are conscious of their health status and put in lot of effort in preventive health care so as to avoid any crisis situation, particularly knowing that their children are away from them and would take some time to come in times of need. 4. One of the most haunting fears that reportedly elderly people face is failing health, need for hospitalization and lack of support system. This one factor is also a big concern among children too. Findings of the study bring out different coping patterns among elderly respondents with regard to ill health and hospitalization. More than a half of the elderly have shown foresight in choosing a place of residence quite close to any healthcare institution. Likewise, two-thirds of elderly have maintained ties with distant relatives and friends in the same city so that in the time of health crisis, support can be sought. In some situations, they rent out a portion of their house to persons who can be helpful in times of need, say, doctors or students as paying guests. Most elderly respondents understand that situations in the present times are markedly different from the past, and now due to career requirements, it becomes necessary for children to leave their parents and establish neo-local families. They understand their children’s constraints and recognize that despite all odds, their emotional attachment with their children is supreme. For elderly parents, their happiness lies in their children’s happiness. The senior citizens have trust that whenever the need be, their children would extend support. Response to Child Staying Away In situations, where young children step out of the household to establish their own household unit or for their career development, old parents are left alone in the family. They started their family unit together, and in this stage again the two are left alone. This is called ‘empty nest’. They may have enough time resource, but energy resource and money resource decrease considerably. A lot of health problems like high/low blood pressure, asthma, diabetes, cataract, etc., creep in which influences their daily life activities. Socially also, elderly parents do not have significant roles to perform and feel disengaged. This results in feelings of alienation, worthlessness and neglect. It is termed as ‘empty nest syndrome’ that denotes the anxieties, loneliness and feeling of emptiness, the old couple are left with, when their children leave, as seen in the case study of Mrs. Gurinder.

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Gurinder’s Unending Loneliness Eighty-one years old Gurinder’s life has been a long struggle, full of suffering and pain. During Indo-Pak partition in 1947, her family migrated from Multan, they left behind a transport business. Her husband took out one of the buses, loaded the family and drove all the way to Delhi. Afterwards the dilapidated bus also provided subsistence. Hardly had the family settled, when her husband passed away. Those were doubtless hard days. Gurinder sold the bus as well as her jewelry to start a money-lending business. It turned out to be quite profitable. She could get her sons complete education and take up jobs at decent places, get her daughter married off and even bought a 500-yard piece of land in a posh locality of Delhi. Few years later, her one son settled in Goa and the other works in Gurgaon. Children motivated the mother to rent out a portion of their house, which she did. Gurinder, by now, has become very weak and frail. She developed ulcers and underwent surgery. Her eye-sight weakened and rheumatism limited her mobility. Her sons keep on visiting her, especially the younger one who stays in Gurgaon. Gurinder is still financially sound and her three children regularly talk to her over phone and visit her but loneliness is an unending agony for her. To cope with it, her younger son has bought her a 14-inch TV. But rarely does she have anybody to talk to. Sons do care for her health needs but the vastness of her loneliness remains untouched. Would her isolation ever end?

Coping with Empty Nest Syndrome In the study, most of the aged respondents had perpetual feeling of sadness for many days when their son left the home. However, out of thirty, seven told that their son has moved out of the house much before his marriage as he went to study abroad or in other city. Sadness is always a common perception in mothers at the beginning of their child’s departure. Many would worry a lot and have anxieties as without mother’s care, how their sons would manage. Gradually, the aged parents started recouping and engaged themselves in varied activities and hobbies. Educational status of elderly parents and expectations related to elderly care show no significant correlation. So, irrespective of educational status, it is the adaptation and flexibility, reduced expectations and understanding perspective of younger generation that help in dealing with empty nest syndrome. Children’s Efforts in Elderly Care In the study, all the respondents were in regular touch with their children over telephone. Frequency was a little less in the case of children residing abroad. However, there is difference in perceptions and experiences of old parents towards their children’s care efforts. ‘My son takes care of me in every possible way under the Sun even sitting so far’, says an elderly father proudly. Another aged couple lamented, ‘our son used to send money regularly and that was a great help but after his children were born, he even stopped that minimal help’.

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In 14 cases, children were regularly sending money to their elderly parents. In seven cases, money sending was stopped once grandchildren are born. In rest of the cases, the aged parents have sufficient financial resources to meet the regular and unforeseen needs. Children, who are staying at affordable distance, do visit their parents whenever they are unwell. All elderly parents mentioned that their children do keep track of their health status through regular phone calls.

Children’s Efforts in Caring for Elderly Parents from a Distance Socio-Demographic Profile In the study, thirty children were interviewed whose elderly parents are staying away from them. Among them, 24 were males and six females. Though, at the planning stage, it was decided that only sons would be interviewed as daughters after marriage, as per the social expectation of patriarchal society, are not encouraged to care for their elderly parents. In the study, six females (or married daughters) are included as they are the only children (they do not have brothers) and onus of caring for their parents lie on them. Married daughters were, traditionally and culturally, not allowed and encouraged to take up any proactive engagement/role in their family of orientation. However, aged couples and individuals have to rely on their daughters for caregiving in situations where they do not have sons or their sons are not in position to fulfil their caregiving duties. Even the social legislations (Maintenance of Parents and Senior Citizens Act, 2007; Criminal Procedure Code, sec. 125) make it obligatory on both sons and daughters equally to care for their elderly parents. All the respondents are married, and 18 have children. In the study, among the 30 respondents, 16 are graduates, ten post graduates and rest have some professional degree like B.E., etc. Distance Data bring out that in only five cases, parents are staying in the same city or in the National Capital Region. In two cases, parents are in Kerala, five in Bihar, four in Uttar Pradesh, seven in Rajasthan, three in Gujarat, two in Andhra Pradesh and two in Tamil Nadu. Thus, in case of any crisis encountered by aged parents, 25 children would be having problems in immediately reaching to their parents. Distance in ‘distance care’ matters a lot. Reasons of Staying Away from Parents Among the respondents, 17 mentioned ‘job’, 6 regarded ‘marriage’, 6 told ‘education’ and one informed ‘job as well as conflict between wife and parents’ as a ground for staying away from aged parents. All the female respondents are staying away from their family of orientation due to ‘marriage’ reason. Duration of Separation Findings show that the range of duration of staying away from aged parents is between 6 months and 14 years. The mean is nine years. Among

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Table 6.2 Mode and frequency of contact between children with their aged parents Mode of contact

Almost daily

1–3 times a week

>4 times a week

1–2 times a month

Talk over telephone

6

13

6

5

Emails

–

–

–

3

Letters

–

–

–

–

Any other (video conferencing)

1

the 30 respondents, eight have been staying away from parents since the past 12 years or more, 11 are staying away for the past 6–12 years and rest of the 11 respondents are staying away from their parents for the past 6 months to 6 years. So, apparently, most of the respondents have adjusted to the care giving through a distance. Frequency of Visit Regular contact is an important component of providing care from a distance. Results of the study show that out of 30 respondents, five children meet their children once in 2–3 years. Maximum of the respondents (21) meet their parents 1–3 times in a year. Rest of the four respondents meet 4–6 times a year with their parents. Modes of Contact Newer and faster modes of communication in terms of telephones, mobile cells, emails, video conferencing have added flesh and blood to newer ‘means of distance care’. Table 6.2 provides the details of the contact between the children and their elderly parents. It depicts that telephonic conversation is the most preferred and frequently used mode of contact between elderly parents and children. Emails are used only by three children and video conferencing just by one child as a mean for contacting their elderly parents. Here also, letters are not used by anyone for maintaining contacts. Guilt Feeling Study findings show that children staying away from their elderly parents perpetually are in tension about their health status and well-being. ‘There is constant fear at the back of my mind that something wrong may not happen to my mom, I should be there to provide care and support whenever she needs me’, says a respondent. Health of old parents was a major concern most respondents face. ‘Parents should not be left uncared for; we are not there with our parents in the time when they need us the most; I am failing in my duty as son; I feel hopeless and dejected that due to my job I am away from my parents…how they would be managing on their own with failing health; when I needed my mom, she left her job and cared for me…she sacrificed her career, her dreams, everything for me…now she is all alone fending for herself and I am here for my own career and achievement’, these were some of the versions of children staying away from their parents and they indeed reflect some kind of ‘guilt feeling’ that they failed their parents as children. Concerns Regarding Parents’ Health The children respondents were asked to tell about the health condition of their aged parents staying away from them that

6 Elder Care from a Distance: Emerging Trends and Challenges …

109

hamper their day-to-day functioning. Three respondents reported that their parents are not facing any health problem and are hale and hearty. Seven respondents told that their either parents are having high/low blood pressure, ten are having diabetes, five are suffering from arthritis and two have heart and respiratory problems. All the respondents, except three, are worried about the health status of their parents. Coping with Guilt Feeling It may be reiterated that children staying away from elderly parents suffer from certain kind of guilt feeling for not being able to do much about their aged parents. Related to its coping, six respondents told that they rationalize that it was the need of the hour that aided them take this decision. Four respondents told that they become withdrawn or aggressive as they fail to deal with their inability to care for their aged parents. Twelve children told that initially they used to feel bad about their parents not living with them, but now they have overcome it. Three women cry a lot, at times, realizing the pain and loneliness their aged parents are undergoing. Five children feel helpless and curse themselves. Respondents were again asked about their coping with such negative feelings regarding their inability to care for their parents in person. Most children (27) told that they try to take some proactive steps like visiting, calling them up, requesting neighbours/kin living in the same city as their parents for visiting them, arranging for bringing parents to them and the like. Three children told that they tend to divert their mind and engage themselves in some work. Modalities of Distance Care Table 6.3 depicts the modes and efforts made by children respondents as part of their distance care. It highlights that regular telephone calls followed by visits are the most frequent initiatives. Sending money is not a preferred mode of ensuring care. Caregiver children staying away from their old parents face a host of issues. They must balance the needs of their aged parents with those of their immediate family and job, in terms of financial and time management. Visiting their parents, keeping Table 6.3 Initiatives for care of elderly parents

Initiatives for care Financial support (sending money on regular basis)

Number* 5

Talking over phone regularly

30

Regular visits

18

Making their payments electronically

7

Requesting friends/kin in the same city to care for parents

6

Sending items of their requirement through friends

4

Arranging for grocery/daily need items on regular visits

7

Arranging for regular health check-ups of parents

5

* Multiple

choice

110

A. Kaushik

in mind the demands of their job and other responsibilities add to their burden, as depicted in the case study below: Distance Care: A Demanding and Draining Experience Ajit, a software engineer, works in a multinational company in Gurgaon and his wife Durga is a lecturer in a private college, his two children are studying in a reputed private school. Ajit’s parents, after their retirement started living in their ancestral house in Kerala about 15 years ago. His parents were living a disciplined yet happy and comfortable life. Ajit and Durga were in their early forties and have a busy, professional life as they hardly had time to relax with their children. Retired parents would visit Ajit only for 3–4 days a couple of times in a year. All of them shared cordial relations among themselves. A few weeks before Ajit’s father’s 71st birthday, he received call from his mother informing that his father is hospitalized. He flew to Kerala immediately and found his father in intensive care. Durga’s father suffering from cancer, was terminally ill and was cared by Ajit and Durga. Within 48 hours, Ajit had to rush back as his father-in-law died. A week later, after discharging all funeral rites, Ajit flew back to Kerala. It was the beginning of an exhaustive process of providing care to his ailing and ageing parents. Every two or three weeks, Ajit would catch an early Friday morning plane to Kerala, joined by Durga in every other trip. On Sunday afternoon, he would catch the 4 p.m. flight back to Delhi. On his every visit, Ajit would help his mother with tasks like medical insurance, doctors, medication, car repair, payment of bills, etc. Hospital bills were high, the solace was they had health insurance. Meanwhile Ajit’s father got discharged after 18 days of hospitalization but still was bedridden. Consuming fistful of medicines made his dad very cranky and sicker. Tendering ailing father was quite challenging for Ajit. One week had passed and health condition of Ajit’s dad worsened and he again was hospitalized. Doctors could not predict when he would be discharged but told that he would not live more than a few months. Ajit was receiving phone calls from his office again and again; his every application of leave was frowned upon by his seniors. When once Ajit was on an official tour to Mumbai, his mother frantically called him saying that the insurance company would no longer pay for his dad’s hospitalization, who is otherwise ready for discharge. Angry and helpless Ajit, spent hours over the phone in finding ways to pay bills and ensuring secured discharge of his father from the hospital. He got the next plane to Kerala. Ajit’s father never got out of bed unassisted again. Ajit arranged for a nurse to take care of his father who took total charge of taking care of him. Though

6 Elder Care from a Distance: Emerging Trends and Challenges …

111

exhausting and financially depleting, Ajit continued his weekend visits to his aged and ailing parents for another nine months. Though dad’s death was painful, Ajit also had some sigh of relief that as an only child, he could do whatever was within his means. Now, his mother spends several months with Ajit and his family in Gurgaon and they keep on visiting their ancestral house every vacation.

Conclusions To sum up, elder care is emerging as a matter of concern for the youth and families today, which in near future would become a greater challenge owing to rise in number and proportion of elderly in India. Distance care or caring for the aged parents from a distance is emerging as a newer mode of elder care. Being a recent phenomenon, there are hardly any empirical evidences of its effectiveness, especially in the Indian setting. Migration is a reality and so is distance care of elderly parents. The study shows that elderly people try their best to cope with age-related changes in terms of health and mental health all by themselves, trying not to be a burden on their children. They adopt several measures to keep themselves healthy and fit, revive and maintain contacts with relatives staying in the same city so that at the time of need, help can be sought from them. Those having their own house and enough space provide rented accommodation to healthcare practitioners or youth so as to seek help when needed. Empty nest syndrome is another challenge elderly parents, especially mothers, face. Engaging in hobbies, and creative pursuits, revival of friendly ties in the neighbourhood, attending religious and spiritual discourses have helped the elderly living alone in dealing with empty nest syndrome. On the other hand, children do have guilt feeling of not being able to care for their aged parents because of job compulsions. Married daughters without any brother too leave no stone unturned to care for their parents. They try their best to pay visits, talk over phone and other modes of communication more frequently. They admitted that parents’ health is a major anxiety they face. Children take measures to ensure security of their elderly parents by keeping a close check on their health parameters, paying bills online and sending money as and when required.

Intervention Plan Based on the findings of the study, an intervention plan is chalked out as follows that may be taken as practical tips to care from a distance:

112

A. Kaushik

For Health Dimension Ensure that aged relatives parents have insurance policy. Children should have all the details of the medical history of their parents, drugs they are allergic to, their health card, policy numbers, contact details of the family doctors as well as other doctors in the nearby vicinity, contact details of nearest hospitals, chemist shops, emergency taxi and ambulatory service, contact details of neighbours, local NGOs, etc. Children should have bank details so that money in emergency can be transferred. For Social Support A list of all important phone numbers should be stuck at a convenient point, say, telephone, television, refrigerator such as those of nearby grocery shop, medicine shop, police station, essential services like payment of electricity/telephone/mobile bills, neighbours, etc. If possible, then one or two rooms of the house should be given on rent so that in case of emergency there are some persons around. In many places, such elderly people living alone give rooms to students as paying guest that can have symbiotic association. It is important to encourage elderly parents to engage in community work, for instance, hold some position in the management of Resident Welfare Association, Mahila Mandals, NGO functionaries, etc. This would help not only in creative engagement of free time but also people would be around to take care of them. Socialization with neighbours and relatives in the same city/town/locality would be important. Occasional gifts to these people may become handy in case of the need. Make your parents learn basics of computer handling and email services, alert signs of cardiac attack and any other health vulnerability. Important phone numbers in bold and big font size available at easily accessible place. One emergency bell in the home of a neighbour should be installed. Meeting Emotional Needs Encourage the aged parents to develop/regain interest in hobbies or pursue their prime time interests. This would help them in coping with the empty nest syndrome. Music and books are the best company. A good collection of classical movies and songs can be presented to elderly parents, which they can relish. Frequent and regular calls should be made to aged parents living alone to make them feel that distance is only physical and not psychological. If affordable, video conferencing would go a long way to fill in the gap created by the distance. Economic Needs Children should be aware of the financial position of your parents and as and when required should contribute monetarily. Though value-loaded, accumulation of money gives psychological boosting to elderly who otherwise face depletion of energy and body vigour. Economic security is significantly related to subjective well-being among the elderly. Children should be aware of the financial expenses their aged parents are meeting regularly. Roles of social work professionals in this stage include preretirement counselling, preparing late middle aged for old age, preventive interventions to avoid health problems, advice on financial management, dealing with death of spouse, relatives and friends, intergenerational relation building, active ageing, maintaining physical and financial autonomy in old age. Parent–child relationship if the most fundamental of human life, though with time, it has seen changes in its expressions, modes and means, still children, most often

6 Elder Care from a Distance: Emerging Trends and Challenges …

113

than not, realize their parents’ sacrifice for them and do their best to provide care, love and attention. Mode of distance care shows that both parents and children are adjusting to the changing societal demands and at the same time keeping their love, affection and care intact.

References Chan, A. (2005). Formal and informal intergenerational support transfers in south-eastern Asia. Retrieved August 15, 2018, from http://www.un.org/esa/population/meetings/EGMPopAge/ EGMPopAge_AChan_19.pdf. Family Caregivers Alliance. (2010). Family care-giving 2010: Year in review. Retrieved August 19, 2018, from https://www.caregiver.org/sites/caregiver.org/files/pdfs/2010-Caregiver-Guide.pdf. Helpage India. (2015). 20% of population to be elderly by 2050: HelpAge India report. Retrieved August 21, 2018, from https://www.livemint.com/Politics/z6BacVOwf5SvmpD9P1BcaK/20-ofpopulation-to-be-elderly-by-2050-HelpAge-India-repor.html. Kaushik, A. (2012). Elderly care through a distance in India. Saarbrücken, Germany: Lambert Publications. Khan, M. Z., Yusuf, M., & Kaushik, A. (2013). Elderly women: Vulnerability and support structures. New Delhi: Gyan Publications. Paltasingh, T., & Tyagi, R. (2015). Caring for the elderly: Social gerontology in Indian context. New Delhi: Sage. Panda, A. K. (2005). Elderly women in megapolis. New Delhi: Concept Publications. Ramamurthi, P. V., & Jamuna, D. (2004). Handbook of Indian gerontology. New Delhi: Serial Publication. Siva Raju, S. (2002). Health status of the urban elderly—A medico social study (pp. 160–170). New Delhi: B.R. Publishing Corporation. Siva Raju, S., & Anand, S. C. (2000). Physical health of older persons: Differentials and determinants. In M. Desai & S. Siva Raju (Eds.), Gerontological social work in India: Some issues and perspectives (pp. 157–183). New Delhi: B.R. Publishing Corporation. Sivamurthy, M. (2005). Care and support for the elderly population in India: Results of a survey rural North Karnataka. Available: http://www.iussp.org/Brazil2001/s50/S55_P04_Sivamurthy. pdf. United Nations. (2017). World population prospects: The 2017 revision. Retrieved August 21, 2018, from www.un.org/en/sections/issues-depth/ageing/index.html.

Chapter 7

Extent of Population Ageing and Intergenerational Support in the States of India S. Anil Chandran

Abstract Age structural transition, the progressive shift from young to old age structure, occurs as populations undergo shift from high mortality and fertility to a situation of low mortality and fertility. During the process of age structural transition, initially there will be a period during which child dependency ratio declines due to decline in fertility as well as increase in the working age population. But later on, as the population continues to have low fertility, the higher proportion of working population move to older age groups making it an older population with higher proportion of elderly. With declining fertility rate, India is also undergoing transitions in its age structure and the proportion of older population is also increasing. Some states like Kerala, Goa, Tamil Nadu, etc., are already experiencing larger proportions of old age population. The purpose of this paper is to analyse the age structure of population in the states of India and find out the extent of population ageing and rank the states according to the level of intergenerational support available in the states. Census data for 2001 and 2011 and projected figures for the period 2011–2026 are used for the analysis. The paper used both static and dynamic indicators for the analysis, viz. Kii’s index, demographic ageing index, index of demographic longevity, intergenerational support index and potential support index. Finally, a categorization of states is made by arranging the states in India according to the selected indicators. The study found that the states of Kerala, Tamil Nadu, Orissa, Karnataka, Andhra Pradesh, Gujarat and West Bengal are at a greater risk of population ageing with lower intergenerational support. Keywords Population ageing · Intergenerational support · Longevity · Age structure transition

Introduction Population ageing was one of the most distinctive demographic events of the twentieth century and will remain more important during the twenty-first century as well S. Anil Chandran (B) Department of Demography, University of Kerala, Thiruvananthapuram, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. K. Shankardass (ed.), Ageing Issues and Responses in India, https://doi.org/10.1007/978-981-15-5187-1_7

115

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(United Nations 2013). As demographic transition advances, populations will experience reductions in mortality and fertility rates, and as a consequence the proportion of child population declines and proportion of population in the working age group increases. This may result in a demographic window of opportunity, which if harnessed effectively can bring in economic prosperity to the country. Further transitions in the age structure of the population will result in increasing the proportion of older people. Population ageing has profound implications on the economic, social, political, cultural and public health dimensions. World population has witnessed higher growth of older population during the past few decades. According World Population Prospects: the 2017 Revision (United Nations 2017a), population aged 60 years and above has increased substantially in recent years in most countries and regions. There were 962 million older persons in 2017, which is more than twice as large as in 1980 (382 million). Aged population is expected to double again by 2050, when it is projected to reach nearly 2.1 billion (United Nations 2017b). About two-thirds of the elderly population of the world live in developing countries. The growth rate of elderly population is higher than that in the developed regions. In 2050, it is expected that nearly eight in ten of the world’s elderly will be living in developing countries. Like in many other developing countries, population ageing has emerged as an issue for research during the recent decades. The country has witnessed an increasing rate of growth of elderly in recent years. The proportion of elderly in India is expected to increase from 8% in 2015 to 19% in 2050 and 34% by the end of the century. Population ageing has implications on the economic, social and public health arenas. The social environment in which elderly people live is changing rapidly. Perceptions of society and family towards elderly are changing and because of this elderly people are becoming more and more amenable to problems in life. Social exclusion, isolation, poverty, deteriorating intergenerational relationships, etc., are various sources of risk experienced by elderly. Increasing prevalence of non-communicable diseases also pose threats to an active ageing process. The purpose of this study is to assess the demographic aspects of population ageing by considering various measures.

Objectives and Data The objective of this study is to make a comprehensive analysis of the levels and trends of population ageing and related indicators in the states of India and to categorize the states of India according to levels of population ageing and familial support by using several indicators related to population ageing. Data for the study are taken from the Census of India and from the report ‘Population projections for India and states 2001–2026’ published by RGI in 2006. Population ageing is accelerated due to decline in fertility rates and/or increase in life expectancy at birth. India has achieved remarkable progress in life expectancy over the last few decades (see Table 7.1). The life expectancy at birth was 49.7 years

49.7

45.7

Odisha

India

53.8

Maharashtra

57.4

47.2

Madhya Pradesh

43.0

62.0

Kerala

West Bengal

55.2

Karnataka

Uttar Pradesh

56.1

Jammu and Kashmir

49.6

52.6

Himachal Pradesh

Tamil Nadu

57.5

Haryana

57.9

48.8

Gujarat

48.4

52.9

Bihar (1981–85)

Rajasthan

45.5

Assam

Punjab

48.8

Andhra Pradesh

50.5

56.8

45.4

49.6

49.2

59.0

46.0

53.3

47.6

60.8

55.4

56.9

54.8

59.0

48.8

54.2

46.2

48.4

49.0

58.0

40.5

49.6

47.5

56.8

453

54.5

46.3

63.3

55.1

55.2

50.9

55.6

48.8

51.5

44.8

49.3

68.7

70.8

64.8

71.4

68.3

72.5

67.6

72.2

65.4

75.1

69.1

73.5

72.3

69.4

69.5

68.7

65.5

69.6

Total

Female

Total

Male

2012–16

1971–75

Table 7.1 Expectation of life at birth in India and major states

67.4

69.8

63.9

69.5

66.1

71.0

66.2

70.8

63.7

72.2

67.6

71.6

69.4

67.2

67.4

68.9

64.4

68.0

Male

70.2

71.9

65.6

73.4

70.7

74.2

69.1

73.7

67.2

77.9

70.7

76.2

75.5

72.0

71.8

68.5

66.8

71.4

Female

19.0

13.4

21.8

21.8

19.9

14.6

21.9

18.4

18.2

13.1

13.9

17.4

19.7

11.9

20.7

15.8

20.0

20.8

Total

16.9

13.0

18.5

19.9

16.9

12.0

20.2

17.5

16.1

11.4

12.2

14.7

14.6

8.2

18.6

14.7

18.2

19.6

Male

21.2

13.9

25.1

23.8

23.2

17.4

23.8

19.2

20.9

14.6

15.6

21.0

24.6

16.4

23.0

17.0

22.0

22.1

Female

Gain in life expectancy during 1971–2016

7 Extent of Population Ageing and Intergenerational Support … 117

118

S. Anil Chandran

during the period 1971–75 which has increased to 68.7 years in 2012–16. Females had a slightly lower life expectancy at birth than that of males (49 years against 50.5 years) during 1971–75. But remarkable increase in female life expectancy was observed after 1975, and the gain in life expectancy for females was 21.2 years between 1971–75 and 2012–16 compared to 16.9 years for males. Eleven of the 17 major states in India including Uttar Pradesh, Bihar, Haryana, etc., also had life expectancy favourable to females. Only four states, viz. Kerala, Maharashtra, Andhra Pradesh and West Bengal had life expectancy figures favourable to females. But life expectancy figures during the period 2012–16 show that females have an edge by about 2.8 years over males (70.2 years against 67.4 years). Among states, Kerala recorded the highest life expectancy figures (75.1 years, 72.2 years and 77.9 years, respectively, for overall, male and female populations) followed by Jammu and Kashmir and Punjab. By this time, all states except Bihar have achieved higher life expectancy at birth for females, except Bihar. Uttar Pradesh (25.1 years), Himachal Pradesh (24.6 years), Tamil Nadu and Odisha (23.8 years) have recorded more gains in female life expectancy, whereas maximum gains in male life expectancy were recorded in the states of Odisha (20.2 years), Tamil Nadu (19.9 years) and Andhra Pradesh (19.6 years). Though Kerala has the highest life expectancy, gain during the period mentioned was lower as Kerala’s progress in life expectancy started much earlier than 1971 and gains in life expectancy will be lower as states approach higher life expectancy figures. Fertility rates also have come down drastically in India and states. India had a TFR of 5.2 in 1971, which has come down by about 55% to reach 2.3 (see Table 7.2). Though India is yet to achieve replacement level fertility, the decline in TFR during the period is noteworthy. While the southern states and states like Maharashtra, West Bengal, Punjab, Himachal Pradesh and West Bengal have achieved major strides is TFR, many of the Empowered Action Group (EAG) states are still lagging behind. In the states where fertility rates are higher and life expectancy at birth is lower, the population ageing is still low. But from the trends in life expectancy and TFR, it can be seen that all states in India will experience population ageing sooner or later. Table 7.3 shows the proportion of elderly in the overall population in India and states for the period from 2001 to 2026 using the projected data on age composition (Registrar General of India 2006). In 2001, India had only 6.9% of aged people in its population, which is expected to increase to 12.4% by 2026. The state of Kerala, with about one in five elderly persons in 2026, is currently going through a faster ageing process. States like Tamil Nadu, Himachal Pradesh, Punjab and Karnataka will also have more than 14% elderly population in 2026. The ageing index refers to the number of elders per 100 persons 0–14 years old in a specific population. This index increases as population ages and a figure above 100 indicates that older population outnumber younger population and vice versa. For India, the ageing index was 19.4 in 2001 and is expected to increase to 53% in 2026 (refer to Table 7.4). Kerala with the highest proportion of elderly population will have an ageing index of 97.4%, closely followed by 91% for Tamil Nadu. States like Rajasthan, Uttar Pradesh, Assam, Bihar and Jharkhand have low ageing index figures indicating that these states are predominantly younger.

5.2

4.7

Odisha

India

4.6

Maharashtra

NA

5.6

Madhya Pradesh

6.6

4.1

Kerala

West Bengal

4.4

Karnataka

Uttar Pradesh

NA

Jammu and Kashmir

3.9

NA

Himachal Pradesh

Tamil Nadu

6.7

Haryana

5.2

5.6

Gujarat

NA

NA

Bihar

Rajasthan

5.7

Assam

Punjab

4.6

Andhra Pradesh

1971

4.7

NA

5.9

3.8

4.9

4.8

4.7

3.9

5.8

3.4

3.8

NA

NA

5.2

5.2

NA

4.5

4.4

1976

4.5

4.2

5.8

3.4

5.2

4.0

4.3

3.6

5.2

2.8

3.6

NA

NA

5.0

4.3

5.7

4.1

4.0

1981

Table 7.2 Total fertility rate in India and major states

4.2

3.6

5.4

2.7

5.0

3.4

4.2

3.6

4.9

2.3

3.5

NA

NA

4.4

3.8

5.2

4.0

3.8

1986

3.6

3.2

5.1

2.2

4.6

3.1

3.3

3.0

4.6

1.8

3.1

NA

3.0

4.0

3.1

4.4

3.5

3.0

1991

3.4

2.6

4.9

2.1

4.2

2.8

3.1

2.8

4.1

1.8

2.6

NA

2.5

3.5

3.0

4.5

3.2

2.5

1996

3.1

2.4

4.5

2.0

4.0

2.4

2.6

2.4

3.9

1.8

2.4

NA

2.2

3.1

2.9

4.4

3.0

2.3

2001

2.8

2.0

4.2

1.7

3.5

2.1

2.5

2.1

3.5

1.7

2.1

2.3

2.0

2.7

2.7

4.2

2.7

2.0

2006

2.4

1.7

3.4

1.7

3.0

1.8

2.2

1.8

3.1

1.8

1.9

1.9

1.8

2.3

2.4

3.6

2.4

1.8

2011

2.3

1.6

3.1

1.6

2.7

1.7

2

1.8

2.8

1.8

1.8

1.7

1.7

2.3

2.2

3.3

2.3

1.7

2016

55.8

61.9

53.0

59.0

44.9

67.3

57.4

60.9

50.0

56.1

59.1

25.7

43.3

65.7

60.7

42.1

59.6

63.0

% Change 1971–16

7 Extent of Population Ageing and Intergenerational Support … 119

120

S. Anil Chandran

Table 7.3 Proportion of population in the 60 years and above age category in India and states 2001

2006

2011

2016

2021

2026

10.6

11.2

12.3

14.0

16.0

18.3

Tamil Nadu

9.0

10.0

11.2

12.9

14.8

17.1

Himachal Pradesh

8.8

9.4

10.3

11.5

12.9

14.7

Punjab

8.7

9.1

9.7

10.9

12.6

14.5

Maharashtra

8.3

8.6

9.0

9.9

11.2

12.9

Orissa

7.8

8.3

9.0

10.1

11.8

13.8

Karnataka

7.3

8.1

9.2

10.7

12.5

14.5

Kerala

Uttarakhand

7.3

7.9

8.5

9.3

10.4

11.7

Andhra Pradesh

7.2

8.0

9.1

10.5

12.2

14.2

Haryana

7.0

7.2

7.6

8.4

9.8

11.4

Gujarat

6.7

7.4

8.4

9.8

11.6

13.7

West Bengal

6.6

7.5

8.5

10.0

11.9

14.2

Chhattisgarh

6.5

7.2

7.9

8.8

10.0

11.6

Madhya Pradesh

6.2

6.7

7.1

7.8

8.9

10.4

Jammu and Kashmir

6.2

6.9

7.7

8.9

10.5

12.4

Uttar Pradesh

6.1

6.6

7.1

7.8

8.7

9.8

Rajasthan

6.0

6.7

7.3

8.2

9.4

10.8

Bihar

5.5

6.3

7.2

8.2

9.5

11.0

Assam

5.2

5.8

6.5

7.6

9.1

11.0

Delhi

5.0

5.7

6.5

7.5

8.7

10.0

Jharkhand

5.0

6.0

7.1

8.3

9.7

11.3

India

6.9

7.5

8.3

9.3

10.7

12.4

Though ageing index and proportion of elderly are widely used as measures of population ageing, these measure only take into account two broad age groups 0–14 and 60 years and above. They do not take into account changes in the middle-aged population, i.e. 15–59 years. Kii (1982) observed that there were difficulties in using the proportion of elderly population as an index of population ageing as this measure did not take into account the variations in population in specific age or age groups. It also ignores the age variations within each category that changes over the years. He also pointed out the arbitrariness involved in creating the ‘old’ age category. He also observed that both ageing index and proportion of elderly exaggerated the degree and trend of the ageing process. Kii proposed a new measure using a regression index assuming linear relationship between age and proportion of persons in that age. Kii’s index is the slope of the regression line between age and proportion of population in the age group. Kii’s index calculated for India and states for the period 2001–2026 is presented in Table 7.5. According to this, the states of Kerala, Tamil Nadu, Karnataka, Gujarat and Orissa are ahead in the ageing process, whereas Delhi, Uttar Pradesh, Bihar and Haryana have slower ageing process.

7 Extent of Population Ageing and Intergenerational Support …

121

Table 7.4 Ageing index in India and states during 2001–2026 Kerala

2001

2006

2011

2016

2021

2026

40.5

46.6

54.2

65.6

79.7

97.4

Tamil Nadu

33.5

40.7

49.7

60.3

74.4

91.3

Himachal Pradesh

28.2

34.2

41.4

50.4

61.0

74.4

Punjab

27.7

32.9

38.9

46.9

58.7

74.7

Maharashtra

25.7

29.6

33.8

40.1

48.6

60.7

Orissa

23.4

27.9

33.9

42.1

52.2

65.8

Karnataka

22.7

28.7

36.2

45.5

56.9

70.7

Andhra Pradesh

22.3

28.4

36.3

45.5

56.5

70.4

Gujarat

20.4

24.9

31.1

39.6

51.4

65.2

Uttarakhand

19.9

23.9

28.0

32.6

39.1

48.2

West Bengal

19.9

25.6

33.7

44.5

55.9

69.3

Haryana

19.3

22.6

26.6

32.5

41.0

52.9

Chhattisgarh

17.5

21.0

25.1

30.3

37.1

46.4

Jammu and Kashmir

17.3

22.0

27.3

33.6

43.1

56.8

Madhya Pradesh

16.1

18.7

21.6

25.6

31.6

40.2

Delhi

15.5

20.4

26.4

32.8

38.4

44.9

Rajasthan

14.9

18.3

22.3

27.9

34.5

44.2

Uttar Pradesh

14.8

17.5

20.3

23.5

27.8

34.1

Assam

13.9

17.1

21.6

27.6

35.1

45.8

Bihar

13.0

16.5

21.1

27.5

34.8

44.1

Jharkhand

12.5

16.8

22.6

29.8

37.1

45.9

India

19.4

23.4

28.4

34.7

42.5

53.0

Index of demographic ageing (I DA ) is another measure proposed by Dlugosz in 1998 (Dlugosz 2013). It calculates the changes in the proportion of population for two time periods in the 0–14 and 60+ age groups and is calculated using the formula     IDA = P(0−14)t − P(0−14)t+n − P(60+)t+n − P(60+)t This provides a measure of ageing by computing changes in the proportion of young and old age groups during two time points. As we see from Table 7.6, index of demographic ageing was positive for all the states during 2001–06, but by 2021–26 most of the states will have negative figures for the index. This indicates that the change in the population of 60+ years age group during 2021–26 (and during many other time periods) will be higher than the change in population in the 0–14 years age group. States with higher levels of population ageing, namely Kerala, Tamil Nadu, etc., have negative or near to zero figures for IDA.

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Table 7.5 Kii’s index for India and states 2001

2006

2011

2016

2021

2026

Kerala

8.2

8.8

9.2

9.7

10.2

10.5

Tamil Nadu

7.6

8.1

8.6

9.0

9.3

9.4

Karnataka

6.8

7.3

7.8

8.3

8.9

9.3

Gujarat

6.5

7.1

7.6

8.2

8.7

9.3

Orissa

6.8

7.2

7.7

8.2

8.8

9.3

Himachal Pradesh

7.1

7.6

8.0

8.5

8.9

9.1

Andhra Pradesh

6.7

7.2

7.7

8.2

8.6

9.0

Maharashtra

6.9

7.3

7.7

8.1

8.6

9.0

Chhattisgarh

6.1

6.6

7.1

7.6

8.2

8.9

West Bengal

6.5

7.0

7.5

7.9

8.4

8.8

Uttarakhand

6.1

6.6

7.1

7.6

8.2

8.8

Punjab

6.9

7.4

7.8

8.2

8.5

8.7

Assam

5.8

6.2

6.7

7.3

7.9

8.6

Jammu and Kashmir

5.9

6.4

7.0

7.5

8.1

8.4

Jharkhand

5.6

6.1

6.6

7.1

7.7

8.3

Madhya Pradesh

5.7

6.2

6.6

7.1

7.7

8.3

Rajasthan

5.5

6.0

6.5

7.1

7.6

8.2

Haryana

6.0

6.4

6.9

7.3

7.7

8.0

Bihar

5.2

5.7

6.2

6.8

7.4

8.0

Uttar Pradesh

5.4

5.8

6.2

6.6

7.2

7.8

Delhi

6.0

6.2

6.3

6.5

6.9

7.5

India

6.3

6.8

7.3

7.9

8.5

9.2

Intergenerational Support in Population Ageing The shift from a younger population structure to an older one will not only affect the economic situation of populations, but also impact the attitude of younger generation towards elderly. It is presumed that younger generations take care of older ones. The age structure of population will have a lot to do with the support provided to elderly population. This issue is analysed using two measures, namely index of intergenerational support (I IS ) and index of potential support (I PS ) (Dlugosz 2013). Index of intergenerational support is defined as IIS =

Population 80 years and above × 100 Population 45 − 59 years

The index of intergenerational support (see Table 7.7) for 2001 varied across states with Jharkhand (0.9) and Bihar (1.1) showing the lowest figures and Kerala (6.3) and Punjab (5.6) recording the highest figures while the national average was 2.8. The

7 Extent of Population Ageing and Intergenerational Support …

123

Table 7.6 Index of demographic ageing for India and states during 2001–2026 2001–06

2006–11

2011–16

2016–21

2021–26

Average

Kerala

1.4

0.3

−0.2

−0.7

−1.1

−0.06

Tamil Nadu

1.5

0.6

−0.4

−0.5

−1.1

0.02

Karnataka

2.8

1.7

0.5

−0.3

−0.6

0.82

Andhra Pradesh

2.9

2.2

0.7

−0.3

−0.7

0.96

Gujarat

2.3

1.8

0.9

0.3

−0.4

0.98

Delhi

4.1

2.5

0.7

−1.1

Himachal Pradesh

2.9

1.8

0.9

West Bengal

3.3

2.8

Punjab

3.4

2

Orissa

2.9

Maharashtra Chhattisgarh Assam

−1

1.04

0

−0.4

1.04

1.3

−0.7

−1.4

1.06

0.6

0.1

2.6

1.3

−0.1

2.9

1.9

1.1

0.2

0

1.22

2.1

2.2

1.5

0.8

0.4

1.40

3.2

2.9

1.6

0.1

−0.2

1.52

0

1.22

−0.6

1.22

Uttarakhand

2.9

2

0.8

0.9

1

1.52

Jammu and Kashmir

3.7

2.3

0.5

0.7

0.7

1.58

Uttar Pradesh

2.6

2.4

1.3

0.9

1.3

1.70

Madhya Pradesh

2.5

2.5

1.7

1.1

0.8

1.72

Jharkhand

3.2

3.3

2.1

0.3

0

1.78

Haryana

3.9

3

1.7

0.8

0.5

1.98

Rajasthan

3

3.1

2.5

1.1

1.1

2.16

Bihar

2.8

3.6

3.1

1.3

0.8

2.32

India

2.7

2.3

1.2

0.3

0.1

1.32

index measures the number of individuals 80 years and above per 100 individuals in the 45–59 years age group who could theoretically be their children and could potentially take care of them in their old age. As population ageing happens faster in Indian states, it may be assumed that government provided social service measures will not be able to take care of the increase in the number of elderly. I IS will increase for all the states in India, as all the states in India are on the road to population ageing and Kerala will have the highest figure of I IS 11 in 2026, followed by 10.6 in Himachal Pradesh. When we look at the increase in the I IS , it can be seen that while Kerala had an increase of 75% in the I IS figure between 2001 and 2026, some of the states that are younger currently like Uttar Pradesh, Bihar, Jharkhand, etc., will have about 500–700% increase. This is significant for policy as many of these younger states will have major stress on intergenerational support by 2026 and beyond. The whole support systems for elderly depend on the relationship between working age population, namely the 15–59 years age group and elderly population. An approximation of this relationship is provided by index of potential support (I PS ), which is defined as

124

S. Anil Chandran

Table 7.7 Index of intergenerational support for India and states Kerala

2001

2006

2011

6.3

7.9

9.2

2016

2021

2026

9.7

10.3

11.0

Change 2001–26 75

Punjab

5.6

7.3

9.5

10.3

10.6

10.4

86

Himachal Pradesh

5.6

7.7

9.8

10.1

10.4

10.6

89

Tamil Nadu

4.7

6.0

7.1

7.8

8.8

9.8

109

Haryana

4.1

5.2

7.7

8.5

8.6

8.3

102

Maharashtra

3.6

4.4

6.8

8.0

8.4

8.5

136

Karnataka

3.5

4.4

6.4

7.3

8.3

9.0

157

Gujarat

3.5

4.3

5.7

6.6

7.5

8.3

137

Uttarakhand

3.5

4.7

7.3

8.6

9.5

10.0

186

Orissa

3.4

4.1

6.2

7.1

8.0

8.9

162

Jammu and Kashmir

3.0

3.8

5.9

6.8

7.8

8.6

187

Andhra Pradesh

2.8

3.5

5.5

6.7

7.7

8.6

207

West Bengal

2.8

3.4

5.3

6.1

6.8

7.7

175

Delhi

2.6

3.1

4.3

4.6

5.0

5.4

108

Rajasthan

1.9

2.5

5.9

7.4

8.4

9.0

374

Madhya Pradesh

1.7

2.1

5.1

6.3

7.2

7.9

365

Assam

1.7

2.0

4.1

4.9

5.7

6.4

276

Chhattisgarh

1.5

1.8

4.6

6.0

7.3

8.4

460

Uttar Pradesh

1.4

1.8

5.4

7.1

8.3

9.1

550

Bihar

1.1

1.4

4.0

6.2

7.8

9.1

727

Jharkhand

0.9

1.1

3.2

5.0

6.5

7.9

778

India

2.8

3.5

5.9

7.1

8.0

8.7

211

IPS =

Population in the 15 − 59 years age group Population in the 60 + years age group

As populations grow older, the index of potential support will tend to decline. Index for potential support for the major states of India is provided in Table 7.8. While Kerala had the lowest figures of I PS , Delhi showed the highest figures. The higher figures of Delhi may be because of the presence of larger numbers of migrant workers. As expected, I PS shows a decline over the period and the figure for Kerala in 2026 will be 3.4, a decline of 43% over the period 2001–26. I PS for India will decline by 38% from 8.4 in 2001 to 5.2 in 2026. The various measures of population ageing and intergenerational support for major Indian states indicate a complex picture with no sign of a specific pattern. So an attempt is made to categorize the states into four types and four subtypes based on ageing index at 2001 level, averaged index of demographic ageing (I DA ) from 2001– 05 to 2021–26, rate of change in the potential support index and rate of change in the index of intergenerational support. Index values were compared to the average for

7 Extent of Population Ageing and Intergenerational Support …

125

Table 7.8 Index of potential support (I PS ) for Indian states Kerala

2001

2006

2011

6.0

5.8

5.3

2016

2021

2026

% Decline 2001–26

4.6

4.0

3.4

43

Tamil Nadu

7.1

6.6

5.9

5.1

4.4

3.8

46

Himachal Pradesh

6.9

6.7

6.3

5.7

5.1

4.4

36

Karnataka

8.4

7.9

7.1

6.2

5.3

4.5

46

Punjab

6.9

7.0

6.7

6.0

5.2

4.5

35

Andhra Pradesh

8.5

7.9

7.3

6.4

5.4

4.6

46

West Bengal

9.1

8.5

7.8

6.8

5.6

4.6

49

Orissa

7.6

7.4

7.2

6.5

5.6

4.7

38

Gujarat

9.0

8.4

7.7

6.7

5.7

4.8

47

Maharashtra

7.2

7.3

7.2

6.6

5.9

5.1

29

Jammu and Kashmir

9.4

8.9

8.3

7.2

6.2

5.3

44

Uttarakhand

7.8

7.5

7.2

6.7

6.0

5.5

29

Chhattisgarh

8.7

8.2

7.7

7.1

6.3

5.5

37

Jharkhand

11.1

9.8

8.8

7.7

6.6

5.7

49

Bihar

9.6

8.7

8.2

7.6

6.7

5.8

40

Haryana

8.2

8.5

8.4

7.8

6.8

5.9

28 46

Assam

11.0

10.5

9.8

8.6

7.2

5.9

Rajasthan

9.0

8.5

8.2

7.6

6.8

6.0

33

Madhya Pradesh

8.9

8.6

8.5

8.0

7.1

6.1

31

Uttar Pradesh

8.7

8.4

8.2

7.6

6.9

6.2

29

Delhi

12.4

11.7

10.7

9.3

7.9

6.8

45

India

8.4

8.0

7.6

6.9

6.0

5.2

38

India. States are classified into ones that have an older age structure and that have younger age structure using ageing index. States that are above the national average are taken as the ones having older age structure and those with ageing index lower than national average are considered as having younger age structure. Each of these two categories is then categorized into two—states that are ageing faster and ageing slower using index of demographic ageing (I DA ). In each of the four subcategories, four divisions are made according to the change over the period 2001–26 in the two indices, index of potential support and index of intergenerational support (see Table 7.9). The categorization of states as given in Table 7.9 indicates that states in the category A1, namely Kerala, Tamil Nadu, Orissa, Karnataka, Andhra Pradesh, Gujarat and West Bengal will be facing most difficult challenges by 2026 and beyond. These states have a faster ageing process and less of support for older people from their younger counterparts. Governments in these states need to have adequate programmes and policies for tackling the challenges of population ageing. States in the

126

S. Anil Chandran

Table 7.9 States by different categories based on selected measures of population ageing Population structure

Type

Subtype

Rates of change

States

Older population structure Ageing index > X

Ageing faster (A) I DA ≥ X

1

I PS ≤ X and I IS ≥X

Kerala, Tamil Nadu, Orissa, Karnataka, Andhra Pradesh, Gujarat, West Bengal

2

I PS ≤ X and I IS ≤X

3

I PS ≥ X and I IS ≥X

4

I IS ≥ X and I PS ≤X

1

I PS ≤ X and I IS ≥X

2

I PS ≤ X and I IS ≤X

3

I PS ≥ X and I IS ≥X

4

I IS ≥ X and I PS ≤X

Uttarakhand

1

I PS ≤ X and I IS ≥X

Delhi

2

I PS ≤ X and I IS ≤X

3

I PS ≥ X and I IS ≥X

4

I IS ≥ X and I PS ≤X

1

I PS ≤ X and I IS ≥X

Jammu and Kashmir

2

I PS ≤ X and I IS ≤X

Assam, Bihar, Jharkhand

3

I PS ≥ X and I IS ≥X

Chhattisgarh, Madhya Pradesh, Rajasthan, Uttar Pradesh

4

I IS ≥ X and I PS ≤X

Haryana

Ageing slower (B) I DA ≤ X

Younger population structure Ageing index < X

Ageing faster (C) I DA ≥ X

Ageing slower (D) I DA ≤ X

Himachal Pradesh, Punjab, Maharashtra

7 Extent of Population Ageing and Intergenerational Support …

127

categories of D1 to D4 will have lesser problems in the near future as these states are having a slower ageing process and better intergenerational support.

Conclusion The results clearly provide some clear messages to the policy makers of the category A1 states. With increasing life expectancy and lower fertility, older population is increasing in proportion. Along with this, studies indicate that epidemiological transition in these states is also faster (India State-Level Disease Burden Initiative CVD Collaborators 2018; Anjana et al. 2017). The health system in these states will be under stress to provide services to the ailing older populations. Though life expectancy increases, people will be living longer with some form of disability as shown by a study from Kerala that of the total life expectancy of 67 years, people would be living about 11 years of their life with some disease or disability (Chandran and Nair 2013). Health systems and social security systems need to be revamped for taking care of elderly population in these states. The states which are ageing faster will have to consider improving general economic and social conditions and issues such as livelihood, housing and health care for the elderly.

References Anjana, R. M., Deepa, M., Pradeepa, R., Mahanta, J., Narain, K., Das, H. K., et al. (2017). Prevalence of diabetes and prediabetes in 15 states of India: Results from the ICMR–INDIAB populationbased cross-sectional study. The Lancet Diabetes & Endocrinology, 5(8), 585–596. Chandran, A., & Nair, M. (2013). Life expectancy and active life expectancy: Study from Kerala, India. Lambert Academic Publishing. Dlugosz, Z. (2013). Risk of population aging in Asia. Procedia Social and Behavioral Sciences, 120, 36–45. India State-Level Disease Burden Initiative CVD Collaborators. (2018). The changing patterns of cardiovascular diseases and their risk factors in the states of India: The Global Burden of Disease Study 1990–2016. Lancet Global Health, 6, e1339–e1351. Kii, T. (1982). A new index for measuring demographic aging. The Gerontologist, 22(4), 438–442. United Nations, Department of Economic and Social Affairs, Population Division. (2013). World population ageing 2013. ST/ESA/SER.A/348. United Nations, Department of Economic and Social Affairs, Population Division. (2017a). World population prospects: The 2017 revision, volume I: Comprehensive tables (ST/ESA/SER.A/399). United Nations, Department of Economic and Social Affairs, Population Division. (2017b). World population ageing 2017 (ST/ESA/SER.A/408).

Chapter 8

Elderly Women in India: Concerns and Way Forward Pamela Singla

Abstract The Indian joint family was a well-developed system to take care of the needy in the family. The social fabric has changed with globalization leading to migration and breaking up of joint families into nuclear families. The women of the family are among the worst to be impacted. As the nurturer before she realizes she is already past her prime and unlike the west where the parents are left alone by their children quite early in their life thus leaving them with sufficient time and energy to decide the route of their life, in India, it is yet not so. The paper proposes to trace the problems faced by the elderly especially the women in the Indian society. The paper shares with its readers some of the practices adopted within India and abroad to engage the elderly women actively so that they become productive citizens of the society. Keywords Senior citizens · Development · Challenges · Active-ageing · Age-well · Model · Success stories

Introduction Social work with the elderly is an extremely relevant area for social workers both as academicians and as practioners. As per the available data, by 2050, there will be 2.03 billion people aged 60 years and above. As per the report by UNFPA and Help Age International (2012) globally, the older population, i.e. 60 years and above, is expected to increase substantially by 2050 representing an increase from 12% to 22% of the total population during that period. Japan is currently the only country with 30% of the population in the age group of 60 years and above, and by 2050, 64 countries are likely to fall in that category. In India while the proportion of elderly in the population is nearly 7% as per the situational analysis of elderly in India, 2011, it is projected to rise to 12.4% of the country’s population by 2026. According to NISD, the total population of elderly presently in India is 10.4 crore. Hence, the urgent need to address the needs of this growing population. The question gets to P. Singla (B) Department of Social Work, University of Delhi (DU), Delhi, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. K. Shankardass (ed.), Ageing Issues and Responses in India, https://doi.org/10.1007/978-981-15-5187-1_8

129

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P. Singla

be why does the situation require an urgent attention; what is so serious about it? The point is that ageing which is a universal phenomenon cutting across temporal boundaries and a phase of life is marked with “fear”. Fear of illness, immobility, declining looks, dependency, isolation and many more aspects which make each one of us entering the phase of 50s fear for old age. The fear being more in case of women who face aggravated problem of health and limited mobility. Those of us born in the 1960s and before have been an eye witness to the joint family system which we visited during our summer vacations from school. These joint families were both at the maternal and paternal family and comprised of members from new born to the elderly. The elderly men and women enjoyed a space of respect and were in command. The elderly had a good life till their end and their death was seen as a very personal loss for the family to the extent that the grownups would wail and remark that they were now “orphan”. In other words, the Indian joint family was a well-developed system to take care of the needy in the family. The social fabric has changed with globalization leading to migration and breaking up of joint families into nuclear families. The elderly hence face a challenge in the newly developed social system and mostly the women.

Elderly Women Need Special Attention Life is lived differently by men and women that is to say that men and women age differently. Both have their own concerns, their own narratives which tell their life stories, their priorities and their experiences. The elderly women definitely face more hardship due to the lifetime of gender-based discrimination faced by them emerging from deep-rooted cultural and social bias. This is compounded by others forms of discrimination which is based on class, caste, illiteracy, unemployment, disability and marital status. As per the available data, over 50% of women over the age 80 are widows. And in the backdrop that women in India are deprived of property rights and are occupied with their household chores for most part of their lives thus resulting in isolation and dependency in later years. The following section looks into the theoretical component of the elderly women.

The Case of Elderly Women Across Sociological Theory and Literature Old age, as quoted in Beavoir (1972) is “a process of unfavourable, progressive change, usually correlated with the passing of time becoming apparent after maturity and terminating invariably in death of the individual”. The theory of age stratification outlined by Riley Johnson and Anne Fonner (1972) treats age as a centrally important characteristic like class, sex or ethnicity, influencing individual behaviour and social

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structure. Age is thus a basis for structured social “inequality”. The status of old people in society and family depends upon group membership and power. Power means power in the micro-level in the environment of the family because the old owned and controlled property and had the final word on the disposition of wealth. According to Hindu philosophy, the fourth stage of life is the stage of “Sanyasa”. The aim of the “Sanyasin” is not to free oneself from the cares and shares of life, but to attain a stage of spiritual bliss when she is not tempted by worldly pleasures. They are solitary souls who are detached completely from the material world (Kasthoori, 1996). Old age is seen by Manu as a period of gradual disengagement from the fullness of life that was. This view would appear to go against the western view of active ageing or the “activity theory” of resolving (postponing) old age by countering ageing (Ramamurti and Jamuna, 2004). In understanding sexist and ageist relations in the household and as manifestation of these relations, the visibility of domestic violence at various levels and in different forms draws attention to notions of power. Power is exercised in manifold ways by socially structured and culturally patterned behaviour of groups and institutions. It is because of power relations that persons in specific roles operate within structurally determined limits, accepting their role in the existing order of things, either because they can see or imagine no alternative to it or because they see it as natural and unchangeable as divinely ordained and beneficial. Violence against females of older generations is not of the same variety and the same kind as that which is perpetrated on women of younger age. Elderly women’s subjection to domestic violence culminates in her rejection by the family and by the community at large. Singh has stated that the nuclear family has steadily surfaced as the dominant form of residential unit in India, especially in urban areas. He countered the views of Desai (1955); Kapadia (1958); Madan (1999) and Shah (1998) by referring to census data. Urbanization, industrialization, migration and partition of parental property weakened family ties and put the family care of the elderly in jeopardy. Cumming and Henry (1961) developed a theoretical model of ageing (similar to Manu) called the “Theory of Disengagement”. The theory envisages a mutual withdrawal of the individual and his society, a sort of mutual disengagement. Ageing in India is to be seen against the background of Manu’s prescription, though in recent times modernization and social change have changed the lifestyles and attitudes (Ramamurti and Jamuna 2004). Within sociology of ageing, two competing theoretical perspectives exist, the normative perspective and the interpretive perspective. The normative perspective focuses upon social order, which is viewed as desirable, and the mechanisms of social control that are created to maintain order. For instance, the age-stratification theory (Riley et al. 1972), a macro-theory, and disengagement theory (Cumming and Henry 1961), a micro-theory. These find space within the larger trajectory of a structural-functionalist/normative perspective that views the loss of roles in later life as important for the maintenance of the equilibrium of the wider society. The interpretive perspective embodies (within the larger trajectory of conflict theories) the symbolic interactionist standpoint and focuses on how older individuals interpret and give meaning to events and situations in their lives, e.g. residence in nursing homes

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and age-segregated housing, terminal illness and societal definitions of uselessness (Gee and Kimball 1987). Foucauldian approach demonstrates the role played by cultural norms in regulating how we embody or perform our gender identities. According to Butler, gender identity is simply “a set of repeated acts within a highly rigid regulatory frame that congeal over time to produce the appearance of substance, of a natural sort of being’” (Butler 1990, p 33). The regulatory power of the norms that govern our performances of gender is both disguised and strengthened by the assumption that gendered identities are natural and essential. Thus, for Butler, one of the most important feminist aims should be to challenge dominant gender norms by exposing the contingent acts that produce the appearance of an underlying “natural” gender identity (Armstrong 2005). Critical gerontology alerts us to some of the ways in which society continues to oppress us as we age. It argues that ageing issues and older people have been marginalized and ignored and it prompts us to question long-held and taken-forgranted assumptions and beliefs about old age. It is about making the voices of the oppressed heard such as those of the marginalized older women in spaces wherein injustices occur. Such ideas resonate much with the feminist perspectives which according to Minkler (1996) and Achenbaum (1997) have invigorated critical gerontology by stressing upon the gendered nature of ageing by getting us to look critically at the “social construction of women’s marginality in old age” (Bernard, Chambers & Granville 2000). Essentially, feminist perspectives divide into the “traditional” ones, which date from the beginning of the second wave of feminism in the 1960s and 1970s and include liberal, radical and Marxist/socialist schools, and the “contemporary” perspectives which developed in the 1980s and 1990s and have their origins in psychoanalytical and postmodernist/poststructuralist discourses. According to Arber and Ginn (1995, p.5) as quoted in Granville (2000), an adequate sociological theory of age needs to distinguish between at least three different meanings—chronological age, social age and physiological age—and how they interrelate. Social age refers to the social attitudes and behaviour seen as appropriate for a particular chronological age, which itself is crosscut by gender…

Postmodernists are seeking to understand the meaning of menopause in terms of a physiological transition that all women will experience, but with a great deal of individual variation. Emily Martin (1993) suggests that through menstruation, menopause and childbirth a woman’s body in medical texts is organized as a hierarchical system. Inherent in this concept is the mind controlling the body. She claims that, by separating the body and mind, it is possible to move away from the negative aspects of biological materialism (Granville 2000). Menopause has been the subject of an intense public debate throughout the 1990s and has had an impact on the cohort of women known as the “baby boomers”, who are currently in mid-life. Two polarized discourses concerning the menopause experience have dominated debates: one located in a biomedical model and the other within a radical feminist framework. The medical response has been to construct menopause as a deficiency disease, requiring treatment in order to prevent illnesses in old age such

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as osteoporosis and Alzheimer’s disease. The opposing radical feminist response has been to critique the biomedical model, suggesting that it is part of a conspiracy by men- and male-dominated institutions to control women’s ageing at mid-life (Greer, 1991; Coney, 1995). Foucault (1977) theorized that institutions discipline the body, and feminist scholars, examining his theories, have argued that the media discipline women’s bodies through images and texts that privilege youth and present old age as unattractive (Bartky 1998). Through mass media, women learn that their value lies in their physical appearance (i.e. their attractiveness to men), and they learn that old age diminishes their worth. For older women, the standards of youthful beauty are impractical to meet, ensuring insecurity and subordination to patriarchal authority (Barnett 2006).

Old Age and Women: An Insight Over the past three decades. the topic of women and ageing has received considerable attention across the world (Subaiya et al. 2012). As per the mentioned report (p. 1) out of the few challenges faced by an ageing population, feminization of ageing is one, as women live longer than men. Women it is said constitute 55% of the ageing population and as high as 58% of them live in the developing countries. By 2025, nearly 75% of the world’s older women are expected to reside in what is today’s developing world. The challenges of ageing for women are many. Referring to Mary Wollstonecraft, women in India and across the world are seen as the second sex. Implying that women are subjugated and are deprived of some of the basic fundamental rights by way of control over resources. With age, this deprivation gets of further concern and more so when the woman loses her husband and becomes the victim of increased dependency. To add, the large number of older women outliving their spouse is bound to impact their living arrangements at a very late stage of life which is of much concern as by that time they would carry additional burden of ill health and various kinds of disabilities. Due to the gendered nature of our societies, women are dependent on their spouses and their families and living without the spouse further puts them in a high state of dependency on their families. Further, widowhood is associated with social orthodoxy and cultural practices which does not put the widow in a comfortable state. The UN acknowledges the problem and has announced various important events and days in mark of the elderly. The last International Conference on Women in Beijing urged UN Members to formulate effective policies for the elderly especially for the elderly women. As per the study by Agewell Foundation based on sample of 6000 older women from rural and urban areas as respondents from five different states, older women have limited earning opportunities and several medical complications. They have limited knowledge on legal awareness and face emotional isolation even from their own children. 75% were found living in nuclear families and as high as 75% were found isolated in old age wherein old age has been defined as age of 60plus. Due to the social upbringing, the elderly women find it difficult to take financial decisions.

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They have difficult relations with their daughters-in-law, limited interaction with their children and grandchildren. Most of them are homebound and have no other outlets. With age, they get further conscious of their looks due to spectacles, grey hair, wrinkles. Most of them turn to religion more so after losing their life partner or any other family member. The study definitely gives a glimpse of the condition of the elderly women in India and is a point of concern. Certain concerns of the elder women which emerge from the review of literature can be enumerated as follows: 1. Isolation: Due to the patriarchal set-up of our society, women spend their life as dependents on their male counterpart which makes them highly dependent and vulnerable in the old age. They suffer from emotional alienation which is more than their male counterparts due to limited mobility. Differences in opinion and thought processes with the families, busy schedule of the young members staying with them or away further results in isolation of the elderly women. This is concern with the women as they are the ones who sacrifice their careers and devote their entire life to their families only to find isolation and deprivation at the end of the day. 2. Women in difficult circumstances: “Elderly women” is not a unified category as they differ on various grounds. The elderly women face multiple challenges such as widowhood, poverty, various diseases arising out of old age and emotional isolation, physical disabilities, abuse, neglect and vulnerabilities. 3. Ignorance: Large number of women in our country lack awareness on financial management, government schemes and programmes related to them, on laws related to property rights to name a few which along with lack of education complicates things as they age resulting in abuse and vulnerability. 4. Limited financial control: Finances in majority of the cases in our country have been the male prerogative which leaves women with limited workable knowledge. This further creates dependency on their children in old age and resulted in deprivation of their assets and savings. 5. Health Issues: Women tend to neglect their health in our society and their health issues are negated by their family and seen as part of their cynicism and old age. Ignorance on the health issues further results in women ignoring serious symptoms of illness/disease thus complicating the illness. 6. Resort to religious sects and divine powers: With time in hand, emotional insecurity and isolation many women turn to religion for peace and calmness. Visit to places of pilgrimage, membership of religious groups, belief in power of the divine tend to catch the attention of the women in the old age. The elderly particularly women should be seen as integral part of the social and economic development and a treasured resource, discussed as below.

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Elderly as an Integral Part of Development In view of their knowledge, experience and skills, the older persons are a valuable resource for the society’s development. This is as enumerated below: 1. Unpaid care work: Elderly women in particular provide a lot of unpaid care by way of addressing the needs of their spouses, their grandchildren or children and other persons with disabilities. With growing industrialization and changes in the social structure including shift from joint to nuclear families, the elderly women seem to be an indispensable part of economic growth as the young married children venture out for economic gains leaving the small children in the hands of their old mothers, in the absence of adequate support systems like creches. 2. With time in their hand, the elderly tend to vote in larger numbers and hence play an important role in the political life of the country. 3. The elderly women and men are also the guardians of social values, traditions and culture which are transmitted to the younger generation in form of narratives, old grandma stories and folklores. However, it is sad that despite their strong contribution to the society as senior citizens, they have been overlooked by the government policies and discourses. For instance, discourses and policymaking tend to ignore the nature of violence faced by the elderly women who is a major source of support for the working couple but also becomes a victim of violence in many cases particularly after her husband’s death.

Way Forward The image created in our minds of elderly particularly elderly women is of a vulnerable, weak, ill, cynical and dependent person. Most of us grow up with this image and hence despise the age factor. As teachers and as humanitarians, it is our responsibility to see that such images are broken and, in their place, new images of healthy elderly who are in touch with themselves and the surroundings are created. The pictures should show that old age is not bad but mark of knowledge and experience after having given to this society one’s best years of life. In other words, the concept of “active ageing” needs to be introduced in our social system and in our policies and programs. Active ageing and the paradigm shift The World Health Organization (WHO) defines active ageing as the process of optimizing the opportunities for health, participation and security in order to enhance quality of life as people age. The concept of active ageing helps people to realize the importance of physical, social and mental well-being throughout their life and the significance of continuing participation in society according to one’s capacities, desires while providing for adequate protection and assistance to the elderly as and

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when they need it. In other words, active ageing can be seen as a paradigm shift from the “need-based approach” of the elderly towards the “right-based approach” which recognizes the right of the elderly to human dignity, respect and opportunities. This as a concept is important to be imparted to the senior citizens of the country particularly the women who belong to the even more vulnerable group among the elderly. The active ageing approach should become a part of the national policies and programmes which enable the elderly to contribute to the country’s development in their own way. The underlined idea is that the elderly should not be dismissed after they retire from productive life but should be considered as agents of change and development. Our labour, employment, health, education policies need to be changed to mainstream issues and concerns of elderly with the approach of active ageing in backdrop. The difference is of mindset that needs to be changed to incorporate active ageing in people’s minds. The European Commitment on Active and Healthy Ageing, 2012, gives certain recommendations for active ageing and healthy life. These recommendations are very important for successful ageing and include social participation, healthy diet, physical work, control of alcohol consumption, proper use of drugs to name a few. It is hence important that with the full realization that ageing is a necessary and inevitable part of life, it is important that actions are taken at both individual and community level and at the level of the government. Some of these are enumerated as below: 1.

2.

3.

4.

Keep pace with information and technology: The elderly women can be trained into using technology for better socialization and contact with their family who are not staying near to them. Skype, Facebook and other social media are useful for maintain contact with friends and relatives about which the elderly women can be told. Community Care: Presence of a single lonely elderly woman in the neighbourhood should be taken seriously by the residents. There should be a laid down rule to visit her in turns depending upon her convenience. My doctorate guide who recently passed away as an elderly widow was well cared for by the family with the best support at her disposal. During my last visit before her death, she shared about her accommodation which was in the best location of the city basically due to the community feeling as neighbours would drop in at all hours to check for her health and even children would come and read out poems for her. Women would sing devotee songs (bhajans) which she loved. Internship: Compulsory placement of young girls and boys as part of community service to be placed in Home for the Elderly Women or visit senior citizens for specific number of hours in a week to ensure also their well-being. This can also be made part of the course curriculum of school or graduation as per the policy decisions of the government. Multipurpose senior citizens services: This can include services such as meals, health care from a recognized health care centre/hospital, medicines; reading

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6.

7.

8. 9. 10.

11.

12. 13.

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books or newspaper or simply talk so as to give a vent to the feelings of the elderly particularly the elderly women. Prior planning: Expecting the state to do everything might not be a suitable idea. Hence, it is important that the families and more so the women realize that their children will have to go for careers and jobs to other places. It is important hence to plan one’s life accordingly and in advance. Like-minded families can book houses together in a housing society as this would help in providing each other with the required support system. Facilities: It is important that the Resident Welfare Associations (RWAs) keep the data base of the elderly seniors and a sex-wise breakup of the data. Facilities like intercoms, readily available helpline numbers and numbers of neighbours should be made available to the elderly to access during time of crisis. Role of social workers needs visibility in India: Goes without saying that social workers have a very important here. One of the models of fieldwork can be that the Schools of Social Work prepare a list of the elderly couple in respective areas and place at least 30% of the students to work for the elderly with modalities worked out by the field work unit of the social work departments. They can be placed at the Old Age Home for Elderly and for Women or the placement can be in a specific geographical area where the students ensure that the government provisions by way of the legislations are implemented; talk to them; read to them so that their well-being is ensured. Elderly women would definitely benefit. Wherever facilities permit the students can stay with them. Let every person in their prime age take out time to be with their elderly mother, aunts, elderly women in neighbourhood. Religious institutions like church, temples, Gurudwaras should be asked to run old age homes for women specifically. A viable suggestion I received was of generating employment under NREGA for caregivers to take care of elderly women and also men. They can be trained for the same. This policy decision by the government can be made an important clause under the Act. Incentives play an important role in motivation. Hence, a data base can be created to check the longevity and health of the senior citizens and accordingly the families and the RWAs can be honoured for taking good initiatives and care of their senior women. Cases of 80-year-old lady going to gym every day should be publicized for others to follow the suit rather than think that their life is over. RWAs with intercoms, facilities, helplines for the elderly women and men should be recognized and acknowledged. Have women beat constables to regularly visit the elderly women to check for genuine cases of discomfort and abuse and for general interactions. More research on the needs and challenges faced by the elderly women need to be conducted. Impact of various schemes for elderly women should be found through impact or evaluation studies. Also research on elderly women is much desired to understand the nature of gender discrimination faced by them in old age so that adequate policy interventions can be made.

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14. Women tend to neglect their health and this is more in case of elder women. The local PHCs and the health centres can keep a data base of the elderlies in their area and ensure a monthly checkup. 15. Elderly women should enhance their socialization by setting up their clubs or meeting groups which are apart from the religious gatherings. The objectives of such groups would be to enhance the quality of life through positive exchange of thoughts, productive involvement in activities. Rural Areas: 16. The Panchayati Raj Institutions need to play a prominent and active role in ensuring that schemes meant for the elderly women reach out to them. This is because there are larger chances of the elderly women not in know how of the schemes and ignorant of the procedure to avail them. 17. The elderly women can get involved with the self-help groups (SHGs). This would also help them in getting better oriented about the government programmes and schemes for them and also in general.

Success Stories The elderly must be recognized as persons with repository of knowledge and as active agents of social development. Some of the following initiatives have been taken across the world for the benefit of the elderly population: 1. In India, Sulabh International is doing creditable work with the widows of Vrindavan. Similarly, SEWA Bank Gujarat provides financial assistance to elderly women belonging to lower economic strata of society. HelpAge India’s Vidharba project deals with reducing financial burden of elderly women who were victims of farmer suicides in Maharashtra. 2. Unpaid Care Work: Older women play a vital role in providing unpaid care for families especially in the case of disabled, working parents, ill members of family. In many countries, older persons vote in larger numbers and have formed their own associations and political parties. 3. Social Capital: Many elderly persons get actively involved in the community and civic life through volunteering and active participation. Government initiatives 1. Increased the age of retirement of the employees so as to give them more productive years. 2. Introduced universities for them which are called universities for third age. 3. Flexible working schemes.

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4. In USA, contributions of older persons through taxation, consumer spending, and other economically viable activities such as social care provision and volunteering were estimated to be even higher than the government expenditure on them through pensions, welfare and health services combined and the number is expected to further rise. In sub-Saharan African countries, the elderly constitute a substantial portion of the smallholder farmers which makes them essential for food security. 5. Due to the elderly persons expertise in rural farming, their expertise has been used to develop farming practices and know how to cope with various kinds of natural calamities and food shortages. 6. The elderly provide a good support system to take care of the grandchildren as seen in many countries. For instance, Bolivian migrants, migrants from rural China and from Colombia left their children at home with their grandparents when they shifted to cities or to other countries for work.

A Suggestive Model for Ageing Well Elderly women need to have a holistic lifestyle to age successfully. This would require them to have a high self-esteem and be a part of certain senior citizens groups, religious groups, or community groups which facilitate social resilience through mutual bonding. It is important that they talk to each other so that there is space to vent out feelings. In other words, it is imperative that the women elderly are a part of active social network. It is important that they are visited by the women police constables to check on their well being. In the Indian setting, abroad structure for their well being would comprise of: Spiritual health, networking groups, linking with the RWAs of their society and with the women police constables/men constables, have savings and financial stability strong, be mobile and positive to name a few.

Conclusion Moen (2013) quotes as to how age and gender are not simply characteristics of individuals shaping their preferences; rather, they are themselves social institutions, key axes organizing social life and “channelling” social choices, such that women and men of different ages and life stages are both allocated to and socialized to expect distinctive roles, resources, and relationships. Ageing is an unavoidable part of our lives. Hence, it gets important that both women and men develop a positive outlook towards it and the preparation for the same should start in good time with successful ageing. Acknowledgement I am thankful to Risha and Arpan for their inputs.

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References Achenbaum, W. A. (1997). Critical gerontology. In A. Jamieson, S. Harper, & C. Victor (Eds.), Critical approaches to ageing and later life. Buckingham: Open University Press. Arber, S., & Ginn, J. (1995). Connecting gender and ageing: A sociological approach. Buckingham: Oxford University Press. Armstrong, A. (2005). Foucault and feminism. Internet encyclopedia of philosophy. Retrieved from https://www.academia.edu. Barnett, B. (2006). Focussing on the next picture: Feminist scholarship as a foundation for teaching about ageism in the academy. NWSA Journal, 18(1), 85–98. Bartky, S. L. (1998). Foucault, femininity, and the modernization of patriarchal power. In J. Kourany, J. P. Sterba, & R. Tong (Eds.), Feminist philosophies: Problems, theories and applications (pp. 119–134). Upper Saddle River, NJ: Prentice Hall. Bernard, M., Chambers, P. & Granville, G. (2000). Women ageing—Changing identities, challenging myths. In M. Bernard, J. Phillips, L. Machin & V. H. Davies (Eds.), Women ageing—Changing identities, challenging myths. Routledge. Butler, J. (1990). Gender Trouble. New York: Routledge. Coney, S. (1995). The menopause industry. London: The Women’s Press. Cumming, E., & Henry, W. E. (1961). Growing old. New York: Basic book. De Beavoir, S. (1972). Old age. London: Cox and Wyman Limited. Desai, I. P. (1955). Symposium on caste and joint family: An analysis. Sociological Bulletin, 4(97), 117. Fonner, A. (1972). Age and politics, age stratification and the age conflict in political life. American Sociological Review, 39(2). Foucault, M. (1977). Discipline and punish: Birth of the Prison. Harmondsworth: Penguin. Gee, E. M., & Kimball, M. M. (1987). Women and aging—Perspectives on individual and population aging. Canada: The Butterwoth Group of Companies. Government of India (2011), National policy for senior citizens. Granville, G. (2000). Menopause: A time of private change to a mature identity. In M. Bernard, J. Phillips, L. Machin & V. H. Davies (Eds.), Women ageing—Changing identities, challenging myths. Routledge. Greer, G. (1991). The change: Women, ageing and the menopause. London: Hamish Hamilton. Helpage India International (2001), Gender and aging briefs, London. Helpage International and AARP, Aging, older persons and the 2030 agenda for sustainable development. Kapadia, K. M. (1958). Marriage and family in India. Bombay: Oxford University Press. Kasthoori, R. (1996). The problems of the aged—A sociological study. New Delhi: Uppal Publishing House. Madan, T. N. (1999). The hindu family and development. In P. Uberoi (Ed.), Family, kinship and marriage in India, (pp. 416–435). Martin, E. (1993). The woman in the body: A cultural analysis of reproduction. Buckingham: Open University Press. Minkler, M. (1996). Critical perspectives on ageing: New challenges for gerontology. Ageing and Society, (pp. 467–487). Moen, P. (2013). New directions in the sociology of ageing. Retrieved from https://www.nap.edu. Ramamurti, P. V. (2004). Psychological and social aspects of ageing in India. In P. V. Ramamurti & D. Jamuna (Eds.), Handbook of Indian gerontology. Delhi: Serials Publications. Riley, M., Johnson, M., & Fonner, A. (Eds.). (1972). Aging and society. (Vol. III). New York: Russel-Sage Foundation. Shah, A. M. (1998). The family in India: Critical essays. New Delhi: Orient Longman.

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Shankardas, M. K. (1997). The plight of older women: Victims of domestic violence. In K. Bagchi (Ed.), Elderly females in India. New Delhi: Society for Gerontological Research and HelpAge India. Subaiya, L., Verma, S., & Giridhar, G. (2012). Older women in India: Economic. UNFPA: Social and Health Concerns.

Chapter 9

Institutional Care for Elderly Sandhya Gupta

Abstract Institutionalization of elderly care in India is still in the beginning stage. In the west, where they call these places as ‘retirement homes’ make sense that soon after one retires he/she as a couple or single can shift their life completely. The elderly can enjoy similar lifestyle outside of their homes in addition to taking care of household services and medical emergencies. As age increases, persons are more likely to experience physical disabilities and limitations in their functional abilities. First and foremost step in this direction should be aimed at expanding the comfort zone that can be enjoyed by each one of the older generation. The result should be a well-furnished plan for institutionalized care for the elderly. It also favours seniors with an option to spend the rest of their lives with like-minded people from the same age group and income group. Old age homes and long-term care services help people live as independently and safely as possible when they can no longer perform everyday activities on their own. These days, in India, we see a lot of these facilities. The residents are happy to live and realize that retirement is the time to hang up ones boots and relax. Mostly the elderly are left in a standalone mode of care from middle- and upper-middle-class family.

Introduction The calendar age and biological age are synonymous traditionally, age set at 60 years, that varies from country to country reflecting cultural and social class differences and other criteria related to the degree of biological decline. Senior citizen: at what age should a person be known as older person/senior citizen in a country? The answer to this question today is not one and uniform thus different countries have different answers to the query. The Ministry of Social Justice and Empowerment, the nodal agency at the central level responsible for the welfare of senior citizens, has also stressed upon various other ministries and departments for adopting the age of 60 for extending facilities/concessions at the Inter-Ministerial Committee meeting (NPOP S. Gupta (B) Department of Mental Health Nursing, AIIMS, New Delhi, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. K. Shankardass (ed.), Ageing Issues and Responses in India, https://doi.org/10.1007/978-981-15-5187-1_9

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2001). Moreover, due to improved life expectancy and quality of life of the older persons, it has created crucial policy challenges on several fronts. With the increase in the elderly population due to significant changes in the life span leading to high life expectancy, the concept of old age needs to be appropriately defined. The figure used for the maximum span of human life, which is usually defined as the maximum biologically possible duration of life, changed from around 85 years in the early 1700s to the current figure of around 120 years around the world (Irudaya Rajan et al. 1999). Furthermore, the notion of long life expectancy does not give expression to the quality of life of the elderly population. This has called for the introduction of the concept of good health expectancy or disabilityfree life expectancy. This idea, then, directs the attention to the definition of disability and related concepts such as handicap, injury, impairment and morbidity and to the need to have internationally accepted definitions for comparative purposes. Selfassessment of disability and the quality of personal life will also incorporate the fact that the perception of disability and quality of life is an outcome of public attitudes and cultural wisdom (Jamuna 1997). These issues add to the financial burden and conflicts of governments already facing needs of other age groups and having to deal with new health and social problems. Hence, the issues in front of the policymakers and planners are to collect adequate data, concepts and methodologies to understand these new developments, to find out the future course of mortality for the elderly and whether the increased length of life can be accompanied by sufficiency of quality of life of the elderly (Dandekar 1996).

Ageing: The Global Scenario Among older people, the number of the oldest-old, i.e. those aged 80 years and over will increase more rapidly in the time to come. According to the above projections, the number of those aged 80 years and over will get multiply seventeen times between the year 1995 and year 2150, i.e. from 61 million in the year 1995 to 320 million by the year 2050 and to 1054 million by the year 2150 (United Nations Population Division 2003). Further, in developing countries, one in every 12 is now an older person and the number is expected to grow to one in five by the year 2050. In developed countries, the ratio is already one in five now and it is projected to go up to one in three by the year 2050 (National Programme for the Health Care of the Elderly 2011).

Ageing: The Asian Scenario The Asian scenario is presently the opposite to that of the European Continent, while Eastern Asia led the continent with 11 per cent older persons in the year 2000, the corresponding figure for other regions was only 7 per cent. By 2050, whereas,

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presently seven countries in Asia have crossed the 10 per cent mark and one country, i.e. Japan in Eastern Asia has already reached the mark of 23 per cent of the elderly population. It is estimated that by the year 2050, the proportion of elderly persons in 33 countries of Asian Continent, except Afghanistan, Oman and Yemen is projected to be above 10 per cent. The two most populous countries of the world, i.e. China and India will share the major proportion of the world’s elderly population. Currently, one in ten Chinese is an elderly person and this ratio is expected to reach one in four by the year 2050; similarly, one in 12 Indians is an elderly and this ratio is likely to be one in five by the year 2050.

Ageing: Indian Scenario In absolute terms, India’s elderly population is expected to increase from 76 million in the year 2000 to 327 million by the year 2050. Though the proportion of the aged population for the whole country was only around 7 per cent in the year 1991, yet it has the highest number of elderly persons in South Central Asia. Moreover, the ageing process is intensified owing to higher survival of elderly persons beyond age of 60 and 70 years (Nalini 1996). In India, the elderly are fast-growing segment which is projected to grow at more than double the growth rate of general population. Further, on disaggregating elderly into young-old (i.e. 60 to 74 years) and oldest-old (i.e. 75 years plus), the young-old who were growing at rate of 4.7 per cent and 5.3 per cent in the year 1981, respectively, are projected to grow at 5.6 per cent by the year 2021. Thus, young-old have been increasing at much faster pace than oldestold in India, whereas global maximal growth is recorded in later not in the former category of the elderly.

Need for Special Facilities for Older Persons As age increases, persons are more likely to experience physical disabilities and limitations in their functional abilities. The disability and impairment slowly reach a stage of dependency requiring biosocial and psychological support from the kith and kin, especially from the members of family, as it increases the role of family in providing assistance to frail elderly. Other than family members, kin, neighbours, friends and other voluntary and non-voluntary organizations at institutional level are required to provide care services to needy aged people. The need for care varies from person to person based on age, physical capabilities and socio-psychological conditions especially, for the elderly the biosocial factors like senility, morbidity, physical disability, impairment and societal compulsions and norms make them dependent on kin network. For them, the care services areas can be broadly categorized into physical, social and psychological.

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Social Sensibilities for the Aged In 1990, the General Assembly of UN designated 1st October of every year as International Day of Older Persons, which has been regularly celebrated ever since. The General Assembly adopted the UN’s ‘Principles for Older Persons’ in the year 1991. These 18 principles provide a broad framework for providing course of action for the older persons. These principles have been organized into five clusters, namely independence, participation, care, self-fulfilment and dignity of older persons. In the year 1992, the General Assembly of UN adopted the proclamation which called for the observance of the year 1999 as International Year of Older Persons and all the member countries of the United Nation follow the same. The Government of India approved the National Policy for Older Persons (NPOP) for accelerating welfare measures and empowering the elderly in ways beneficial to them. A National Council for Older Persons (NCOP) was set up to look into the problems of the older persons. In India, the new policy for such persons provides for setting up of a pension fund for ensuring financial security with empowerment of those in unorganized sector and construction of OAHs.

Institutionalized Care of Older Persons The traditional extended family system is eroding faster and faster. Today’s techsavvy generation may find their parents as boring. However, one must become fully aware of the fact that the so-called older generations are rich sources of new ideas. Those extra years of experience itself are answers to almost all your queries. We must find a way to fully utilize this treasure. First and foremost step in this direction should be aimed at expanding the comfort zone that can be enjoyed by each one of the older generations. The result should be a well-furnished plan for institutionalized care for the elderly. It should be made in such a way that they feel at home and must tackle almost all their needs of old age. Such a movement should be much different from the services provided by the traditional old age homes that run for charity. A new leash of life in a much better place should happen automatically when they approach the evening of their life. This will never create trauma of separation (Central Statistics Office 2011).

Institutionalization Institutionalization of elderly care in India is still in the beginning stage. In the west, where they call these places as ‘retirement homes’ make sense that soon after one retires he/she as a couple or single can shift their life completely.

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These days, in India, we see a lot of these facilities. The residents are happy to live and realize that retirement is the time to hang up one’s boots and relax. The entire perspective of the senior care as confined to old age homes has now changed. They are no more for the destitute and run for charity. Mostly the elderly are left in a standalone mode of care from middle- and upper-middle-class family. This means they have the financial stability to opt for a better stay. This has led to a new direction of thoughts of setting a retirement community which will be homelike and elderly friendly. In fact several investors are putting in their time and money into making this into reality. The concept of ‘retirement communities’ first came up in the South India, states of Kerala, Tamil Nadu and Andhra Pradesh from where most of the migrants hailed from. It has now moved all over India with its branches spread to Pune and Greater Noida. The elderly can enjoy a similar lifestyle outside of their homes in addition to taking care of household services and medical emergencies. It also favours seniors with an option to spend the rest of their lives with like-minded people from the same age group and income group. The needs of the senior citizens are met maximally while designing. They are maintained with the special requirements of senior citizens—grab rails, anti-skid tiles, wheelchair-friendly premises and many more. Also, facilities like social and spiritual events, restaurants, libraries and club area add icing to the cake. The inmates are kept busy and active with regular activities, cultural events and festivals. For emergency purpose, each unit is equipped with emergency switches and there are medical personnel in the complex.

Concept of Homes for Older Persons in India In the times to come when the family values are shifting from favourable to unfavourable for the older persons in the society, more of older persons will be in need of care services, as they may be left single and unable to care for themselves due to failing physical faculties. Ancient society divided the human life into four stages called Ashramas of life namely, Brahmacharya, Grihastha, Vanprastha and Sanyasa. Before the aged persons left the house as Sanyasis, they were expected to fulfil their responsibilities as parents before entering Vanaparastha. It must not be forgotten that old age homes did exist in the Indian system of life, they were called Vriddhaashramas and were present at all places, more so, in pilgrim centres. However, due to urbanization, westernization and modernization, family value systems are changing, at a very fast rate accompanied with the economic compulsions, which are forcing children to migrate to another city and place, resulting in a large number of older people being left out without family care. The age old Indian system, thus, has a new shape, name and the context because of the shift in the family structure in the present times. This shows that changing values are putting at risk the most vulnerable group of the society. It is now our primary focus and need to provide space for elders in the ideal OAHs and crèches for

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the children in the same premises so that the young and old can enjoy each other’s company. There is a common tendency to foist responsibility on the government for actions that should have been tackled on a community and family levels. The issue of older persons’ care cannot be addressed by the government only nor can it be left solely for families to solve on their own. So, there is a need to develop an integrated approach where the government and the family share the responsibility to create a space for the elderly that is natural, comfortable and enriching, of course Non-Governmental Organizations (NGOs) can play pivotal role in this regard (Sreevals and Nair 2001). The Government of India has framed policy (NPOP) in the year 2001 to meet its commitment to take proper and due care of its elderly population in India. Any policy stands tall if it is implemented in a manner to achieve the underlined objectives of the policy. Explicitly, the policy of Government of India hits to achieve the twin objectives, i.e. to better the management of these OAHs and ensure the quality of life (QOL) by way of satisfying the elderly people by meeting their basic needs to investigate into the underlying success of these twin objective, the researcher has made an attempt through the review of literature pertaining to these areas.

Types of Institutionalized Care in India A-Old Age Homes Old age homes are meant for senior citizens who are unable to stay with their families or are destitute. States in India such as Delhi, Kerala, Maharashtra and West Bengal have developed good quality old age homes. These old age homes have special medical facilities for senior citizens such as mobile healthcare systems, ambulances, nurses and provision of well-balanced meals. There are more than a thousand old age homes in India. Some of them offer free accommodation. Some homes work on a payment basis depending on the type and quality of services offered. Apart from food, shelter and medical amenities, old age homes also provide yoga classes to senior citizens. Old age homes also provide access to telephones and other forms of communication so that residents may keep in touch with their loved ones. Some old age homes have day care centres. These centres only take care of senior citizens during the day. For older people who have nowhere to go and no one to support them, old age homes provide a safe haven. These homes also create a family-like atmosphere among the residents. Senior citizens experience a sense of security and friendship when they share their joys and sorrows with each other. The Ministry of Social Justice and Empowerment, Government of India, has recommended and prescribed what is to be done for the welfare of older persons in policy document, i.e. NPOP for old age care, i.e. to examine implementation of the policy for older people. For this, one of the processes is initiation of development of

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newer activities and other is efficient execution of OAHs. An ideal OAH is a homely and comfortable one, which is able to provide a barrier-free environment to older persons is functional and is able to cater to the needs of older persons. It should lend itself to the participation, involvement, independence and dignity of the residents in OAHs (NPOP 2001). The OAHs should ensure that all the five principles enunciated by the United Nations are respected and are operated for the good of the older persons. These principles being: (i) care, (ii) participation, (iii) self-fulfilment, (iv) independence and (v) dignity (National Family Health Survey 1998). The needs of elderly persons, which should primarily be borne in mind for maintaining an OAH, are: • Physiological needs: sleep, rest, food, hygiene, sex, light, air and sun; • Safety needs: general house safety, avoidance of pollution, noise, accidents, traffic safety and; • Psychological needs: contact, experience, privacy, activity, play, structuring, identification and aesthetics.

OAHs—Provisions Therein In the OAHs, usually older persons live in a congregate residential setting that generally provides personal services, 24-hour supervision and assistance, activities and health-related services, which are specifically designed to: minimize the need to relocate, accommodate individual residents changing needs and preferences, maximize residents’ dignity, autonomy, privacy, independence, choice, safety and encourage family and community involvement. Care of the residents (Dandekar 1996) staying in OAHs must give a feeling of a home, and hence, it is pertinent that the care for residents is given utmost importance by its management. It is of paramount importance for the management and staff of the OAHs to understand the ageing process and the needs of older people. The OAHs can achieve their objectives of providing a homely environment to the older people only when the staff ensures that residents of OAHs are quite satisfied with the services (Shankardass et al. 2000). At present, if any society is providing any services to older persons be it residential or any other is mandatory to register itself with the Ministry of Empowerment and Social Justice for receiving one-time financial grant. Presently, it may be noted here that the long-term institutions and old age homes are not governed under any regulatory authority. Therefore, it is essential to establish such system of registration, which may initiate enforcement of the regulations of such services and domiciliary care. There is a need to develop residential care standards in India in order to ensure that managements of such institutions adhere to those standards and run them in more effective and efficient manner.

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A Guide for OAHs, published by HelpAge-India, is an attempt to provide insight in all aspects of any OAHs from its building plan to its management, which are crucial to its smooth functioning. It also provides guidelines to evaluate the facilities and functioning of OAHs (Help-Age India and Book 2000). In India, various types of old age homes are functioning, but there are no provisions to evaluate their functioning as well as to ensure that they are following any guidelines or giving satisfactory services to the older persons. There are two basic queries which need to be addressed as far long care institutions are concerned, one is whether the basic facilities for the older persons exist and the other is whether the needs of the older persons are met to their satisfaction.

B-Long Stay Homes Long-term care homes are places where adults can live and receive help with most or all daily activities and access to 24-hour nursing and personal care. Residents can expect much more nursing and personal care here than one would typically receive in a retirement home or supportive housing (https://www.seniorliving.org/lifestyles/ long-term). Long-term care homes for elderly: Definition: Long-term care includes a wide range of medical and support services provided over an extended period of time. Long-term care is not limited to the elderly; in fact, 43% of individuals requiring long-term care are younger than the age of 65. The vast majority of long-term care recipients are older, however, with a projected seven out of ten people over the age of 65 requiring some form of long-term care services in their lifetime. By the time an individual reaches the age of 75, there is a 50% chance they all need long-term care.

Types of Long-Term Care Long-term care may be temporary or permanent. It all depends upon the underlying reason for the care. Reasons for temporary long-term care (weeks or months) can include: rehabilitation after a hospital stay, rehabilitation after a surgical procedure, recovery from an injury or illness and end-of-life medical services. Reason for permanent (ongoing) long-term care (months and years) can include: permanent disabilities, chronic severe pain, chronic medical conditions, need for supervision, need for assistance with activities of daily living, cognitive impairment such as that caused by brain injury, Alzheimer’s or dementia. The need for long-term care can be instantaneous, such as after a car accident, a stroke or heart attack. Generally, however, it develops gradually, as individuals age and become frailer or as an illness or disability worsens. Although it is difficult to predict who will need long-term care and for how long the care will be required,

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several factors increase the risk of the needing long-term care: as individuals age, they become frailer. Women live longer and often require long-term care for a period extending twice as long as that of men. Marital status affects the need for care. Single individuals are more likely to need a paid care provider. Lifestyle and habits, including poor diet and lack of exercise, increase an individual’s risk. Health and family history also come into play. Most long-term care is provided by family members, friends and volunteers, all generally unpaid. In fact, it is estimated that 80–90% of all long-term care provided in the home is done so without compensation.

Categories and Levels of Long-Term Care Long-term care services fall into two categories: personal care and skilled care. Most long-term care falls into the category of personal or custodial care, rather than medical or skilled care. Personal care provides assistance with what is generally referred to as activities of daily living and/or provides for the supervision of an individual who is cognitively impaired. Activities of daily living (ADLS) include the normal activities necessary to live at home. These personal care activities generally fall into four category types: Meal preparation includes the planning and preparation of meals. Household chores include routine tasks necessary for the upkeep of a home such as cleaning, laundry and yard maintenance. Personal hygiene includes bathing, grooming, dressing and toileting. Errands and transportation include driving and shopping assistance. It is easy to take being able to perform activities of daily living (adls) for granted until one or the family member experiences a chronic or degenerative condition and can no longer accomplish these tasks alone.

Skilled Care The second category of care is skilled care, which includes nursing, physical therapy, occupational therapy and medication management. These services are provided by a licensed professional. Nursing care providers monitor health and vital signs. Physical therapy provides therapy sessions generally centred around the need to increase mobility and strength. Occupational therapy’s primary focus is to improve the skills necessary to perform ADLS. Medication management monitors prescription medications and their daily dosing. Levels or frequency of care: Long-term care falls into four different levels or frequency of care: • Occasional assistance occurs a few times a month • Minimal assistance may only be needed two to three times per week

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• Significant assistance may be required as often as five times per week • Maximum assistance might be needed every single day

C-Long-Term Care Living Options Different types of long-term care are available within community-based care organizations and care communities1 . a. In-home care Long-term care in the home is often provided by a family member, but care providers may be enlisted to provide housekeeping, personal care, home health aide and skilled nursing services. Rehabilitative services may be performed in the home or at a community-based service location depending upon circumstances. In-home care may not be feasible if care needs are extensive or medically intensive. b. Assisted living Long-term care in an assisted living community provides assistance with activities of daily living, basic health care, housekeeping, meals and medication management in a home-like setting. Assisted living communities promote self-sufficiency and strive to offer residents a high level of independence. Assisted living is the intermediate step between independent living and skilled nursing. c. Adult day health care Adult day health care provides a break to caregivers during the day. Health services, therapeutic services, social activities and meals are provided at a community— or facility-based location during the day as a part—or full-time service during the day for adults who need assistance or supervision, with the care recipient returning to their home in the evening. This type of service allows the primary caregiver to continue working, to run errands and take care of other business or to take a break from the demanding activity of caregiving (National Programme for Health Care of the Elderly 2011). d. Memory care Although a community may have both assisted living and memory care, the two are not synonymous. Memory care communities provide the vigilant care required for the care recipient dealing with Alzheimer’s and dementia. This care includes a structured environment with set schedules and routines, plus round-the-clock supervised care in a secure, locked-down facility. e. Skilled Nursing Care Centres 1 https://www.seniorliving.org/lifestyles/long-term-care/e/onnect

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In a skilled nursing centre, round-the-clock skilled nursing care is provided by licensed and trained nursing professionals. Residents generally have high care needs and complex medical conditions. Licensed nurses are onsite 24/7 and a doctor is on call at all times. Ambulances remain available to transport patients to hospitals in the need for an emergency. Skilled nursing care centres offer services ranging from short-term care for a rehabilitative stay to long-term extended stays. Rehabilitative services, treatments assisting patients in regaining recently lost abilities, are offered onsite and help individuals recovering from disease, illness, injury or surgery.

Costs of Long-Term Care Long-term care due to its nature, often requires 24-hour care or supervision, and long-term care can be expensive. It may be provided by a family member or friend, a paid caregiver, a staff member within a care community or a combination of these. It can be provided in a broad range of locations, as well, ranging anywhere from an individual’s home to a skilled nursing facility the need for long-term care, costs are expected to continue to rise, several factors impact the cost of this care including location and type of care needed. Location of care has an obvious impact on cost: The recipient’s home with personal care and skilled care services brought in community organizations, such as providing rehabilitative services. This would also include an adult day healthcare program where care is provided for a portion of the day enabling the primary caregiver to continue working or to take a break from their caregiving duties during the day. The average cost of care in a care community varies from city to city and state to state. Other options available are: Self-pay often requires a substantial amount of savings be available for use. Long-term care insurance requires prior planning, and the longer you wait the more cost-prohibitive it becomes. Just like any insurance policy you get, you pay for it hoping to never use it. More options are available such as life insurance policies, some have coverage of long-term care services, permit a certain percentage of the life insurance policy’s face-value to be used for their chosen specified care locations.

D-Palliative Care The Indian Association of Palliative Care was set up on 16 March 1994 in consultation with the World Health Organization and the Government of India as a national forum to connect, support and motivate individuals and institutions involved in palliative care. Mostly home-based palliative care is promoted in India at very few palliative services are institution-based. Less than 1% of India’s 1.2 billion population has access to palliative care. The efforts by pioneers over the last quarter of a century have resulted in progress, some of which may hold lessons for the rest of the developing

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world. In recent years, a few of the major barriers have begun to be overcome. The South Indian state of Kerala, which has 3% of India’s population, stands out in terms of achieving coverage of palliative care. This has been achieved initially by non-government charitable activity, which catalysed the creation of a government palliative care policy. The non-government action by involving the community serves to strive for quality of care as the government system improves coverage. On the national level, recent years saw several improvements, including the creation of a national program for palliative care (NPPC) by the Government of India in 2012. The year 2014 saw the landmark action by the Indian Parliament, which amended India’s infamous narcotic drugs and psychotropic substances act, thus overcoming many of the legal barriers to opioid access. Education of professionals and public awareness are now seen to be the greatest needs for improving access to palliative care in India.

E-Hospice Care Hospice care is end-of-life care. A team of health care professionals and volunteers provides it. They give medical, psychological and spiritual support. The goal of the care is to help people who are dying have peace, comfort and dignity. The caregivers try to control pain and other symptoms so a person can remain as alert and comfortable as possible. Hospice programs also provide services to support a patient’s family. Usually, a hospice patient is expected to live 6 months or less. Hospice care can take place at home, a hospice centre, a hospital or in a skilled nursing facility. Not many hospice are available in India at present.

Conclusion Old age homes and long-term care services help people live as independently and safely as possible when they can no longer perform everyday activities on their own. Long-term care facilities utilize an interdisciplinary team to focus on preventing and relieving suffering. Older persons often live with and die from chronic illnesses that are preceded by long periods of physical decline and functional impairment. Long-term care in the geriatric population requires an accurate and comprehensive geriatric assessment although elderly patients often have significant impairments that make such assessment difficult. There are important issues in management of old age homes (OAHs): There are no regulations or licensure for OAHs in India, OAHs are ill-equipped and understaffed. Untrained staff is working to take care of the most sensitive segment of society, and poor healthcare facilities exist in OAHs. Often there is poor connectivity between older person, their family and OAH staff. The families are not participating in functioning of OAH. There are no reports of evaluation of performance of OAHs is done so far in India.

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References Central Statistics Office. (2011). New Delhi: Central statistics office ministry of statistics and programme implementation, Government of India. Situation analysis of the elderly in India Dandekar, K. (1996). Elderly in India (pp. 10–12). New Delhi: Sage Publications. Help-Age India. (2000). Old age homes a guide book. https://www.seniorliving.org/lifestyles/long-term-care/e/onnect with nia. Jamuna, D. (1997). Correlates of quality of lie among Indian elderly men and women. New Delhi: Report of ICMR. Nalini, B. (1996). Institutional care for the Aged—The issues and implications. Ageing and society, 6(3–4), 69–90. National Family Health Survey (NFHS-2), 1998–99: Kerala. (2001). Report of international institute for population sciences (IIPS) and ORC Macro. National Programme for Health Care of the Elderly. (2011). India current affairs. A leading resource of online information of India. [Last Accessed on 20 Oct 2012]. Available from: http://www. indiacurrentaffairs.org/. National Programme for the Health Care of the Elderly (NPHCE) (2011). An approach towards active and healthy ageing. Directorate general of health services, Ministry of health and family welfare, Government of India. [Last accessed on 2012 Oct 17]. Available from: http://www.health. bih.nic.in/Docs/Guidelines-NPHCE.pdf. NPOP. (2001). National Policy on Older Persons, Government of India: Ministry of social justice and empowerment-policy paper. NPOP. (2001). National policy on older persons. Government of India: Ministry of social justice and empowerment, A Policy Paper, 2001. Rajan, I., & Mishra, U. S. (1999). India’s Elderly burden or challenge (pp. 232–250). New Delhi: Sage Publications. Shankardass, M. K. (April 2000). Societal responses, Seminar 488: Ageing (pp. 44–47). Sreevals., & Nair P. S. (2001). Elderly and old age homes in Kerala. Research and Development Journal-Help Age India, 7(3), 11–21. United Nations Population Division. (2003). India demographic profile-world population prospects: The 2002 revision population database. http://esa.un.org/unpp/p2k0data.asp. September 24, 2003.

Chapter 10

Old Age Homes as a New Pattern of Life Anupriyo Mallick

Abstract Old age homes are coming in existence as a newer occupancy for elderly and becoming the need of present Indian society. The recent data collected from several studies show that there are more than 1000 old age homes in India and most of them are located in the south India. There are of two types of old age homes: free and paid. The “free” type care homes are for the destitute old people who have no family to care and support for them. In such old age homes shelter, food, clothing and medical care, etc. are being provided free of cost. In the paid type, all types of services are available for a price. However, hardly studies explored the factors responsible to compel elderly to reside in old age homes. Therefore, an attempt was made through this paper to explore factors responsible to force elderly to reside in old age homes leaving their own homes. There have been many transformations in recent years that have had an impact on society in different sectors—societal, financial and personal. Lifestyles have drastically changed, some for the better and a few with negative consequences. The population in general has been reaping the benefits, and mostly, those from the younger generation have been able to realize many of their dreams and develop their careers in a better fashion than was possible earlier. However, the senior citizens, referred to as elders, face certain problems as a consequence of the social transformation. This is reflected in the transition from the traditional ways of life to modern patterns, which require many compromises and adjustments. One of these involves old age homes. What is the genesis of old age homes and how have they changed life patterns for the elders? These questions need to be examined dispassionately. Keywords Old age homes · Transformation · Changed life patterns

A. Mallick (B) Eastern Institute for Integrated Learning in Management (EIILM), Affiliated to Vidyasagar University, Kolkata, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. K. Shankardass (ed.), Ageing Issues and Responses in India, https://doi.org/10.1007/978-981-15-5187-1_10

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Introduction In ancient India, a person’s activities were harmoniously regulated according to his or her stage of life. Each stage had its own dharma, or duties, to be undertaken. These stages, called ashramas, were four in number—Brahmacharya, Grihastha, Vanaprastha, and Sannyasa—and were to be strictly followed. The ashrama system was fundamental to maintaining discipline, peace, and harmony in the family and society. In family as well as social and public arenas, virtuous living, guided by noble character, high values, and a sense of duty, was the norm, resulting in all round happiness, peace and harmony. But with the passage of time, the meaning, interpretation and practical application of the ashrama system changed, and gradually the whole system fell into disuse.

The Ashrama System The guidelines for an ideal arya-jivana, or life of an Arya, have been delineated in Manu Samhita, Bhrigu’s codification in verse of rules laid down by the ancient Indian lawgiver Manu. Manu clearly explains the significance of and duties pertaining to the four ashramas. Though Manu and the Manu Samhita have not escaped modern controversy, still, his work is a foundational Dharmashastra, and forms the basis of Hindu law even today. The four ashramas are described below: The Brahmacharya Ashrama was meant for the all-round development of the child, including formal, informal and secular education. One was to receive training in various areas to enable one to stand on one’s own feet in later life. Ethics and values were imbibed in each and every area of learning. Manu set forth the many basic traits which were to be developed from student days. For example, the following two shlokas from Manu Samhita illustrate the most important virtues to developed in young age: Indriyanamvicaratamvisayesvapaharisu; Samyame yatnam-atisthed-vidvanyanteva vajinam. The wise person (brahmacharin) should strive to restrain his senses which run wild among alluring sense objects, just as a charioteer controls his horses (2.88). Vasekrtvendriyagramamsamyamyacamanastatha; arthan-aksinvan-yogatastanum.

Sarvan-samsadhayed-

Having subdued the (ten) organs and controlled the mind, one (brahmacharin) should achieve all one’s aims without weakening the body through yoga (excessive austerity) (2.100). In the Grihastha Ashrama, the householder was to discharge all his duties and debts according to dharma. Artha, wealth, was to be obtained for satisfying kama, desire, but only in a righteous manner, according to dharma. Enjoying worldly life, earning

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money, having children, taking care of the family and its welfare, and performing various duties required by family and society: these belong to this stage of life. Manu called the Grihastha Ashrama the key to the other three: Yathavayumsamasrityavartantesarvajantavah; Tatha grhastham-asritya vartante sarva asramah. As all creatures depend on air for life, in the same way (the members of) all ashramas subsist on the support of the grihastha (3.77). It is important to note here that if a grihastha does not live in the prescribed way, the other three ashramas are affected. Manu continues: Yaman-sevetasatatamnanityamniyaman-kevalan-bhajan. Yaman-pataty-akurvano-niyaman-kevalan-bhajan. A wise man should constantly discharge the paramount duties (called yama), but not always the minor ones (called niyama); for he who does not discharge the former, while he obeys the latter alone (surely) falls (4.204). In other words, first the yamas, then the niyamas. What are they? These shlokas explain: Anrsamisyainksamasatyam-ahimsadamam-asprha; Dhayanam prasado madhuryam-arjavam cayama dasa. Mercy, forgiveness, truth, non-violence, control over the senses, non-attachment, concentration, joyousness, sweetness, and straightforwardness are the ten yamas. Saucam-ijya-tapo-danamsvadhyayopasthanigrahah; Vratopavasau maunam ca snanam ca niyamadasa. Purity, sacrifice, austerity, charity, study, chastity, pious observances, fasting, control of speech are then niyasmas. The Vanaprastha Ashrama was to be entered household duties completed, and one’s settled. One was to hand the household over to one’s successor, leave the worldly life and all its luxuries and enjoyments and go to the vana, the forest, to lead a sattvic, godward life in solitude. The Manu Samhita says: Grhasthastuyadapasyedvalipalitamatmanah; tadaranyam samasrayet.

Apatyasyaiva

capatyam

When a householder gets to see wrinkles on his body, white hair on his head, and his grandchildren, he should resort to the forest (6.2) Svadhyayenityayuktahsyaddantomaitrahsamahitah; Dattaityam-anadata sarvabhutanukampakah. He should be engaged in regular study, control his senses, keep friendly behaviour with everyone, and have a tranquil mind. He must always give in charity, not accept gifts from others, and have mercy on all living beings (6.8).

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The Sannyasa Ashrama was the final stage of life, in which one was to give up everything and strive solely for liberation through intense sadhana. The aim was to reach the final goal of human life, moksha or liberation from samsara-or Godrealization. Vanesu tu vihrtyaivam trtiyam bhagam-ayusah; Caturtham-ayuso bjagam tyaktva sangan-parivrajet. After spending the third portion of one’s life in the forest, the fourth portion of life should be spent as a sannyasin, renouncing all attachment (for the world) (6.33). Adhyatma-ratir-asino nirapekso nir-amisah; Atmanaiva sahayena sukharthi vicared-iha. Delighting in meditation on the supreme, independence of others, giving up all desires, with only the self as companion, seeking supreme bliss, shall (the sanyasin) live (6.49). At the present time, these ideals as given by Manu are not practical or applicable in toto. However, they embody certain basic truths and values which are not only applicable but also very much wanted to re-establish the glory of India.

Current State of the Elderly Nowadays, most people live a very hectic life. Their lifestyle, priorities, need for luxury and enjoyment, and often, lack of values, leave no room for the concept of ashramas. Some strive for great wealth, name and fame. The majority, perhaps, are just trying to earn their bread, trying to live the best possible life. And there are many unfortunate people whose condition is so miserable that they cannot think beyond having two meals per day. For these last, the four ashramas have absolutely no meaning at all. When those who have striven for wealth, name, and fame, and those who have lived a life of relative comfort, retire from active life, they—some of them at least— feel emptiness. Their worldly achievements no longer seem attractive. They feel a strong craving for peace and true joy. Most of these people have enjoyed enough worldly life and public life; they have fulfilled their duties towards family and society. However, they feel emptiness within. How do they address this emptiness? Those having spiritual aspiration from their youth may try to get involved in activities with their chosen organization, where their spiritual quest can flourish. When such activities are performed without attachment the aspirant will gain true joy and fulfilment. Some try to use their knowledge and experience in activities benefiting society at large, without seeking personal gain. Such selfless work will give them inner joy and fulfilment. Those who are well-todo, having adequate finances and shelter and good health, have the freedom to live their life in their own way, and may try to find joy and peace by engaging themselves

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in activities of their choice, like travelling, socializing with their friends, or spending occasional quality time in solitude. Such people will also find inner joy and fulfilment. Yet others will choose to spend lots of time in reading, writing, researching, creating new things, painting, music, dancing, and other art-related activities and find joy and fulfilment in those things. There are many families in which the retired members are well-respected, welltreated, and very lovingly taken care of as long as they live. Such families have strong family bonds. Moreover, their family legacy is carried forward from generation to generation. In such cases, there is nothing to worry about. But the avenues of expression and seeking fulfilment we have mentioned are not available to all; a large number of people are stymied in their search for inner joy and happiness in their retired life. A typical family set-up, which has naturally many distractions, makes such a search difficult. Again, many may be unable to live in solitude because of poor health, financial constraints, or the fear of social stigma. Most elderly people are dependent upon others—either children or someone close. Very few people have the freedom and provisions to live independently in their own way. Even if they do, it may not be safe for them to do so. Elderly persons living alone are easy targets for criminals, and cases of such people being robbed and even murdered in their own homes are increasing, particularly in the metropolises. Under such circumstances, most elderly people compromise with the conditions they are confronted with. Some end up living in old age homes; some with severe health problems are kept in nursing homes. Again, there are old people who are so much attached to their family life—even in old age—that they cannot imagine living in any other way but with the family. Some are attached to their wealth; some are attached to their children and grandchildren. Even if there are problems and an unhappy environment in the family, they try to adjust, and try to feel contented living in the same old ruts. Nobody can help such people suffering and living an unhappy life. This is certainly not the way to live in one’s old age! Population ageing is one of the most discussed global phenomena in the present century. Countries with a large population like India have a large number of people now aged 60 years or more. The population over the age of 60 years has tripled in last 50 years in India and will relentlessly increase in the near future. According to census 2001, older people were 7.7% of the total population, which increased to 8.14% in census 2011. The projections for population over 60 years in next four censuses are: 133.32 million (2021), 178.59 (2031), 236.01 million (2041) and 300.96 million (2051). The increases in the elderly population are the result of changing fertility and mortality regimes over the last 40–50 years (Ministry of Health and Family Welfare 2011; Central Statistics Office, New Delhi 2011). With the rapidly increasing number of aged, the care of elderly has emerged as an important issue in India. Providing care for the aged has never been a problem in India where a value-based joint family system was dominant. This family structure has been the socio-economic backbone of the average Indian (Shah 1998). During ill health or emergency or any critical position, family members were taking the responsibilities and sharing the burden to help each other. The families also were sharing the responsibility to look after their elderly by giving them all kind of support including emotional, psychological,

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behavioural or economic. They were getting full respect and value. Their advices were also being received by younger generation and were revered and honoured. They were living in the family till the end of their life. With the increasing influence of modernization and new lifestyles resulting in transitional changes in value system in recent times, the “joint family” is breaking down into several scattered nuclear families (Shah 1998). Change in family structure and contemporary changes in the psycho-social matrix and values often compel the elderly to live alone or to shift from their own homes to some institutions or old age homes (Dotty 1992; Hegde et al. 2012; Kumar et al. 2012; Mishra 2008; Mudey et al. 2011). OAHs are coming in existence as a newer occupancy for elderly and becoming the need of present Indian society. The recent data show that there are more than 1000 old age homes in India and most of them are located in the south India. There are of two types of old age homes: free and paid. The “free” type care homes are for the destitute old people who have no family to care and support for them. In such OAHs shelter, food, clothing and medical care, etc. are being provided free of cost. In the paid type, all types of services are available for a price. However, hardly studies explored the factors responsible to compel elderly to reside in OAHs. Therefore, an attempt was made to explore factors responsible to force elderly to reside in OAHs leaving their own homes. There have been many transformations in recent years that have had an impact on society in different sectors—societal, financial and personal. Lifestyles have drastically changed, some for the better and a few with negative consequences. The population in general has been reaping the benefits, and mostly, those from the younger generation have been able to realize many of their dreams and develop their careers in a better fashion than was possible earlier. However, the senior citizens, referred to as elders, face certain problems as a consequence of the social transformation. This is reflected in the transition from the traditional ways of life to modern patterns, which require many compromises and adjustments. One of these involves old age homes. What is the genesis of old age homes and how have they changed life patterns for the elders? These questions need to be examined dispassionately. Quite noticeable is the tendency among grown-up children today to view their aged parents with callous disregard and to neglect them, especially if the parents are not without means. Elderly people if they are penniless generally become burdens and objects of ridicule. Some youngsters, hen-pecked husbands, disgrace themselves by putting their parents in old age homes. Some elders, it must be admitted, are also capable of being a bit of a nuisance to their children, provoking disrespect. India is steeped in tradition. In what came to be called a “combined family system”, parents, children, and grandparents all lived together under one roof, united by love and mutual concern. Grandparents, though, in many cases with no source of financial support, did share the burden of raising the small children. The reciprocal love and esteem between the generations held the joint family together.

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A Burden and a Liability But the times have changed. Today, many parents are viewed as a burden, a liability. Young fathers and mothers go to work to make money. Their babies have their crèches. The aged grandparents are no longer needed and therefore are dispensable. Such a state of affairs ushered in the new “fashion” of lodging elderly parents in senior homes. Commercially run old age homes have mushroomed, especially around the larger cities. Parents forsaken by their children and put in such homes, often ascribe this unsympathetic situation to the newcomer in the family—the daughter-in-law. The young woman certainly likes to assume the reins of the family. Some men assume they are superior to women. But when it comes to matters of conjugal bliss, even such male chauvinists know they are weak. For, men love in haste and detest at leisure. They try, albeit unsuccessfully, to defeat this ridiculous penchant. Young women exploit this weakness and cast them to their knees. Once the prince is captivated, the queen is captured.

Formula for Trouble Some mothers-in-law, however, become adamant and refuse to abdicate, as it would dent their ego. Peace and serenity that characterize a combined family give way to persecution and belligerence between the women. The young lady then quietly persuades her husband either to live separately with her or to convince his parents in feigned innocence and love to accept the old age home option. The foundation of the family develops cracks. But it is unfair to impute blame on the daughter-in-law alone. Women as mothers are most loving humans, but as mothers-in-law some of them transform themselves into incorrigible termagants. Until his marriage, the young son focused all his love and adoration on his mother. Now, another woman has entered the arena, determined to make her own a major share of his love and indulgence. This feeling that dwells in her subconscious racks her. Many girls have committed suicide, unable to bear dowry torture at the hands of their mothers-in-law. To understand the concept of old age homes, one has to go back in time five to six decades to see the life pattern of elders and chronologically trace the developments that led to the slow yet steady changes that were necessitated by circumstances. There was the much-acclaimed joint family or extended family system wherein elders lived with not only their children but also with their brothers, sisters or uncles and aunts in nearby houses, mostly in villages or in small towns. They all used to live close by, helping each other for many purposes, be it happy small events or big occasions like marriages. Everyone was close at hand for any emergencies such as health problems or deaths. Thus, the social fabric was well-woven and due respect was given to elders. This system enabled elders to lead reasonably happy lives with hardly any tension,

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as they had the confidence that someone would take care of them when needed. Whenever there were some health issues for an elder, the whole family would run around to attend to all needs, rendering medical to personal assistance. With perfect understanding on caring and sharing the duties, the elders did not feel let down or lonely. Another major blessing in those days was the system of a “family doctor”: each family would have a friendly physician who would be ready to visit houses whenever someone was unwell. Besides medical attention, the doctor would instil confidence with pleasant words of encouragement, which would in itself often cure the illness. Thus, a close, well-knit family system served wonderfully the elders in particular and all others in times of need. In those days when most of the deliveries used to be at home, the doctor was easily available to attend to the woman members of the family. The scenario changed slowly and steadily with the decline or disappearance of the joint family system, which was replaced by the nuclear family system. A 50year analysis would reveal the great transformation. Many reasons may be attributed for this change, which reflected not only the whole family set-up but also the life pattern of elders, who became dependent, partially or totally. The major factor was the disintegration of families, necessitated by the migration of sons and daughters, as also relatives from their places of birth to towns and cities in search of greener pastures. This was for education, jobs, career enhancement, marriage, amenities and improved lifestyles. While the younger generation had no difficulty in moving out of the house and adjusting themselves to new environs and adapting to new ways of life, the elderly population found the change to be a hardship. For them, to move away from their own places with attached sentiments, comforts and property holdings, and a fairly happy life, to new environs in the cities was tough. But they had to sacrifice and compromise for the sake of their children and for their own security—financial, health and social. So, the stage was set for new life pattern of life for elders. Are they all in the same life system with their children? What are the variations and problems they face? There are five patterns that elders today face generally, which are situationdependent. In one, elders stay with children in the same house in the city, which ensures financial and health security. In another situation, they live alone in a separate house with children living elsewhere in the city, considering proximity to places of work or the educational needs of children. Here, the family members visit the parents once a week or when any health problems necessitate their presence. In a third scenario, elders stay alone in a town or city while the children live in faraway cities for employment; the children visit once in a few months for occasions or emergencies of health. In a fourth pattern, elders live all alone in the city, the children having migrated to foreign countries or for higher education, jobs and so on. The children will be living settled and comfortable lives with family and children, with all material comforts. They will visit the elders once in two or three years; this situation causes health-related and emotional insecurities, though the elders will be financially sound thanks to foreign remittances. In another pattern, elders live with relatives or in old age homes,

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either with spouse or alone, with financial, health and emotional insecurity. Elders, both men and women, who remained single without marriage, invariably landed in old age homes. Each of these situations has its own advantages and disadvantages. While many elders accept the change, others are unable to adjust, and start grumbling and sulking, which is understandable considering the age and exposure to circumstances. Among the estimated population of over 10 crore in the country in the age range of 65 and above, at least 10–20% will be above 75 who face health problems to different degrees. Due to personal compulsions, many have emigrated and stay with children mostly in the USA. But some are unable to travel owing to health reasons such as immobility or other personal reasons, and go in search of old age homes. Each family has its own problems, with a single child or two or many sons and daughters to look after parents. As they give priority to their own lives with a bright future, many children face the embarrassment of taking care of their parents. Here comes the question of whether to stay back in the country to provide a comfortable life for parents in their advanced age or to migrate to other countries. Attracted by advanced technologies that provide opportunities to prosper in life and by materialistic benefits, many youngsters migrate to greener pastures, leaving behind parents to take care of themselves or with relatives. In the absence of either option, the choice is to leave the elders in old age homes under the care of others who manage the system. Thus, old age homes were born to help chiefly the non-resident Indians (NRIs), to relieve them of the tension of leaving behind parents under the care of someone outside the family system. So, the old age homes were a concomitant of the emergence of the nuclear family system. Having said that, it must be admitted that there are sons and daughters in some families who do not want to leave their aged parents and prefer to take care of them until their last breath, by opting to remain in the country with the satisfaction of whatever employment and other benefits they have commensurate with their education and qualifications. Thus, the mindset of children varies widely and parents have learnt to compromise with the given situation. Just as in the case of systems in other sectors, old age homes have also become highly commercialized. There has been a virtual mushrooming of old age homes in recent years. It has become a lucrative business, thanks to the NRIs who are prepared to shell out huge deposits to admit their helpless parents in old age homes. The cost of providing accommodation, food, comforts and medical help is high. A cursory glance at the number of old age homes in the country reveals that there are different categories of them to cater to the needs of elders, depending on the payment capacity. While some old age homes seem to provide good facilities, others lack such comforts. It is not that all elders are taken care of well by the managements. Some of them impose restrictions. The food served is reported to be of low quality and deficient in quantity in many of them. A recent newspaper report spoke of how a poor elder in old age homes was beaten for asking for more food. So also their bedrooms and toilets are often poorly maintained. Some of the managements do not utilize payments made to them by children in India and abroad, leaving the helpless and hapless parents in the lurch. Such abuse and misuse of old age homes come to

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the limelight often, but seldom is action taken to rectify the situation. There are some well-managed old age homes too, though they are very costly. Thus, most of the elders in old age homes are not very happy, confined as they are to isolation. Unfortunately, children are unable to come on time when parents fall sick or even die in old age homes. But there are some elders who feel comfortable in old age homes for the freedom and friendly atmosphere with other elders who keep them company, enjoying the time with TV, games and gossip. They show some detachment from family members and feel more secure in old age homes and avoid a restricted life with their children. The life of elders in the present age is full of problems, both for themselves and for the children. The fortunate few depart with satisfaction and peace of mind, while others leave with an unhappy state of mind. Meanwhile, the old age homes have come to be a part of our social system.

Taking Care of Elderly With about 50% of the elderly being financially dependent on others, it is affordable housing, healthcare, and the psychological and social manifestations of ageing that we will struggle to respond to as a country with no social security and dismal elderly care facilities. What will be the combined impact of this trend on small, nuclear families, along with an improvement in lifestyle and an increase in degenerative diseases and life spans, especially for women? Where are we going to live as we grow old and who is going to take care of us? Clearly, Parliament had some of these issues in mind when it passed the Maintenance and Welfare of Parents and Senior Citizens Act in 2007. The model Act makes it obligatory for children or relatives to provide maintenance to senior citizens and parents. It also provides for the setting up of old age homes by state governments. Despite this, however, it is a fact that most people in India would rather suffer than have the family name sullied by taking their own children to court for not providing for them. This need to maintain a façade is combined with a lack of knowledge of rights, the inherent inability of the elderly to approach a tribunal for recourse under the law, and poor implementation of the Act by various state governments. So what happens to those who have been turned out from their homes, or have lost a partner, or just can’t manage to live on their own anymore, especially since the number of old age homes the Centre supports under the Integrated Programme for Older Persons (IPOP) has seen a decline from 269 homes in 2012–2013 to a dismal 137 in 2014–2015? The Centre has asked state governments to ensure that there are old age homes whose functioning can be supported under IPOP, but since it is optional for the State governments to do so, the total number of old age homes remains abysmally low.

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Need for a Pragmatic Approach While we hope that the Indian family continues to be stronger than in most countries and provides a caring environment for the elderly, it cannot be the basis for our ability to support the elderly. India needs to take a serious look at the needs of the elderly in a more pragmatic and holistic manner. For starters, it could focus on the three key aspects of health, housing and dignity. Each of these is a large issue on its own, but it is important to first strengthen the health care system. If 18 percent of the population is going to be over 60 years of age by 2050, then it becomes almost crucial to encourage research in geriatric diseases, and push for building capacity in the geriatric departments across the primary and tertiary health care systems. There also seems to be a growing informal industry of home care providers, which urgently needs regulation and mandated guidelines so that a large pool of certified and affordable trained home caregivers can help provide basic support, prevent unnecessary hospital admissions, and keep the elderly in the familiar environs of their homes as far as possible. Next, there needs to be a network of old age homes, both in the private and public sector. While the private sector has taken the lead in setting up some state-of-the-art facilities, most of these are priced well out of the reach of ordinary citizens. State governments must be mandated to set up quality, affordable homes. As traditionally supportive social structures are changing and the elderly are increasingly losing their “status” as the family patriarchs, it is also time that we did our bit to help address the indignities and loneliness that this change is bringing. Businesses could look at harnessing the talent of elders by retaining or hiring older workers and offering flexible working hours for those who want to continue working after retirement. Industry will benefit by retaining their knowledge and experience and the elderly will continue to be financially independent and retain their sense of self-worth. At the community level, we also need to increase the avenues for older people to participate in local issues, in resident associations, set-up and manage spaces for community interaction, to leverage their experience as a resource, give them an opportunity to share their concerns, and to help them feel that they contribute socially and have a purpose in life. The one big issue that does not get enough attention today is that old people deserve dignity. Apart from ensuring appropriate medical help, there needs to be more awareness about common degenerative diseases like dementia so that family members, caregivers, and society at large are sensitized to incontinence, the momentary lack of comprehension, the hallucinations—all the painful behavioural, physical, emotional and mental struggles of those who suffer from these diseases.

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Conclusion The rapid growth of the elderly population highlights elder care as an important issue in India (HelpAge India 2013). The issues of elder security and well-being are becoming a matter of concern. There is a need to take care of older adults, with a focus on social and mental well-being, economic and social security and elder abuse. Considering all these factors, there seems to be a need to understand the experiences of older adults in order to adopt effective mechanisms by which they will be cared for and respected and will be able to live a life with dignity (Kumar et al. 2012). However, though there is a need to create an awareness among older adults and their families; and caregivers of old age homes, about the needs, experiences and coping styles of older adults; it would be more beneficial to empower older adults to be emotionally vibrant about living positive and fulfilling lives. This will help to reduce the stress and difficulties of living in a home and also enable older adults to experience the joys of living in their twilight years. A large fraction of older adults are living either in a home for the elderly or alone at home without the support of immediate family. It would be interesting to explore the life experiences and the coping styles of these older adults. Research could also explore if living with family has more meaning for older adults than when living in a community. We need to admit that residing in an old age home is challenging and stressful. In India today, the “old age home” is no longer a western concept. There are old age homes in India that are making an effort to uphold the needs, desires and values of older adults, while also creating and fulfilling new ones (Lamb 2007). In order to facilitate a more meaningful, fulfilling and satisfying life in older adults, they can be helped to be more positive and hopeful. To enable this, special emphasis can be laid on Psychological Capital (PsyCap) of the elderly. It focuses on the individual’s positive mental power and positive ageing and offers a new perspective on how to help older adults live a fulfilling, happy and vibrant life (Yongmei 2015). For those older adults who live in old age homes and are lonely and have almost nothing to look forward to, PsyCap will give then renewed confidence and faith in themselves as it focuses on enhancing mental health by instilling a sense of hope, optimism, self-efficacy, well-being and resilience.

A Tale from Japan Ancient Japan had a strange tradition. After retirement from active service, people lived on for several barren years of “no worth”. They were no help either to themselves or to anyone around. Some non-agenarian parents were such an impossible millstone around their children’s neck that they were constrained to disencumber themselves of their parental burden. Young men carried their disenchanted parents to a godforsaken hilltop far from home and abandoned them there. With no food or water, the frail body soon withered and the breath of life departed.

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A robust young son threw his aged mother on his shoulder and tramped away. Mother knew her sole beloved son was taking her out to her Golgotha. And, the journey was long through thick jungles. They brushed through the whole snaky distance of thickets and bushes and tall trees. It was a footman’s pathway. All the way, neither mother nor son opened their mouth even once in conversation. The old mother, precariously hanging truss-shaped over her son’s shoulder, was wide awake. From their entry into the forest, the mother was doing something that her son initially ignored. Every now and then she plucked some twigs and sprigs or whatever her swinging hands could reach and littered their path with them. The son became rather curious. At one stage, he asked her what she was doing, scattering stuff along the way. She answered that she was securing a safe trail for him through the forest, so he would find his way back home. This changed the son’s mind. Tears rolled down his cheeks. He turned around and went back home, of course with his mother. The son had finally perceived the mother’s love! Love, the noblest frailty of the mind, conquers all things. Yet, old age homes increase in number because soft and supple is the heart of parents, while hard as flint is that of their children.

References Central Statistics Office, Ministry of Statistics and Programme Implementation. (2011). Situation analysis of the elderly in India. New Delhi: Government of India. Director General of Health Services, Ministry of Health and Family Welfare. (2011). National program for health care of the elderly. New Delhi: Government of India. Dotty, P. J. (1992). The oldest old and the use of institutional long term care from an international perspective. In R. Suzman, D. P. Willis, & K. G. Manton (Eds.), The oldest old (pp. 250–259). New York: Oxford University Press. Hegde, V. N., Kosgi, S., Rao, S., Pai, N., & Mudgal, S. M. (2012). A study of psychiatric and physical morbidity among residents of old age home. International Journal of Health Sciences & Research, 2(1), 57–74. HelpAge India. (2013) HelpAge India marks world elder abuse awareness day. HelpAge News, 4. Kumar, P., Das, A., & Rautela, U. (2012). Mental and physical morbidity in old age homes of Lucknow, India. Delhi Psychiatry Journal, 15(1), 111–117. Lamb, S. (2007). Lives outside the family: Gender and the rise of elderly residences in India. International Journal of Sociology of the Family, 33(1), 43–61. Mishra, J. A. (2008). A study of the family linkage of the old age home residents in Orissa. Indian Journal of Gerontology, 22(2), 196–212. Mudey, A., Ambekar, S., Goyal, R. C., Agarekar, S., & Wagh, V. V. (2011). Assessment of quality of life among rural and urban elderly population of Wardha district, Maharashtra, India. Ethno Medicine, 5(2), 89–93. Shah, A. M. (1998). The family in India: Critical essays. New Delhi: Orient Longman Limited. Yongmei, W. (2015). Review on psychological capital of the elderly. Scientific Research on Aging, 3(1), 59.

Chapter 11

Senior Citizens—Protections in Law, an Overview Sarita Kapur

Abstract India is increasingly seeing a changing social reality whereby joint families are giving way to nuclear families. This naturally leads to an increasing number of senior citizens, who are being left to fend for themselves, without the support of the immediate family. This reality is coupled with the prediction that the population of senior citizens in India is likely to increase to more than 19% of the total population, by the year 2050. It is imperative that we protect the life of our senior citizens, as well as their property during their lifetime. The role of the government in the protection of the senior citizens has now essentially increased. By this article, I will discuss the legislation, protection and programmes that are currently available (as they exist on 15 May 2020) to protect the senior citizens in India. I will also briefly discuss the global position of the legislation and protection for the senior citizens that exist in some countries like USA and UK; to identify certain lacunae in our system that need to be addressed. I will conclude with some suggestions for changes that must be made in our system to ensure that the senior citizens are not only protected, but are also comfortable in the final years of their lives.

The traditional family system in India was a joint family. The elders, the ailing and the children in the family were looked after—even when some of its members went away for employment and economic reasons. The earners would send money home and the remaining members of the joint family would handle the shared responsibilities such as tilling the earth, upbringing of children and caregiving of the elders. Like rest of the world, we have embraced the social reality of the post-industrial revolution world order. The norm of “joint family” has given way to “nuclear family”. The care and safety net of the joint family is vanishing with an increasing number of senior citizen being left to fend for themselves—often without the financial means and support system to secure to them a right to live with dignity. According to the Census of 2011, the total population of senior citizens [people aged 60 years and above] was 10.38 crores in a total population of about 121.05 crores [that is around S. Kapur (B) Legal Professional, New Delhi, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. K. Shankardass (ed.), Ageing Issues and Responses in India, https://doi.org/10.1007/978-981-15-5187-1_11

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8% of the total population].1 The number of senior citizens was projected to rise from 11.81 crores in a total population of about 126.99 crores in the year 2016 [that is 9.3% of the total population] to 17.32 crores in a total population of about 139.68 crores in the year 2026 [that is 12.4% of the total population].2 The need to build an alternate formal mechanism for care of the elders to fill the void created by the fast-vanishing informal mechanism of the joint family in context of this demographic reality has acquired gravity and urgency. The role of the “state” has increased in filling up the ‘caregiver vacuum’ in the present social structure. This is imperative to protect the life, property and well-being of our senior citizens, who have earned it by their contribution to society during their productive years. In this backdrop, I discuss the legal and policy framework in place today in India, enshrining the protection and programs available for the care of its senior citizens. I conclude with some suggestions and changes that may be required to be made in our system to ensure that senior citizens are not only protected, but are also cared for and made comfortable in their final years. This will remain be a dynamic reality, with each generation deciding how to balance the intergenerational equities, i.e. how to cater for the seniors in balance with care for the young.

International Developments Before looking at the domestic laws of India, let us examine some international developments. The first instrument on ageing was drafted by the World Assembly on Ageing held in Vienna on 26 July to 6 August 1982, called the Vienna International Action Plan on Ageing.3 This was endorsed by the General Assembly by its resolution 37/51 of 3 December 1982. On 14 December 1990, the United Nations General Assembly passed resolution 45/106 to designate 1 October as “the International Day of Older Persons”.4 Subsequently, the United Nations General Assembly adopted Principles for Older Persons by resolution 46/91 of 16 December 1991.5 The parties to the resolution agreed, with commitment of various signatory national governments, to secure a set of rights and privileges to older people, to ensure their independence, participation, care, self-fulfilment and dignity. It was resolved that they must have access to (i) adequate food, water, shelter, clothing and health care; (ii) opportunity 1 Annual

Report 2015–16 (pp. 93–94, Rep.). (n.d.).Government of India. Retrieved from http:// socialjustice.nic.in/writereaddata/UploadFile/SOCIALJUSTICEENGLISH15_16.pdf. 2 Annual Report 2015–16 (p. 94, Rep.). (n.d.). Government of India. Retrieved from http:// socialjustice.nic.in/writereaddata/UploadFile/SOCIALJUSTICEENGLISH15_16.pdf. 3 Vienna International Plan of Action on Aging (Rep.). (n.d.). Retrieved http://www.un.org/en/ events/elderabuse/pdf/vipaa.pdf. 4 International Day of older persons—Homepage (Publication). (n.d.).United Nations.Retrieved from https://www.un.org/development/desa/ageing/international-day-of-older-persons-homepage. html. 5 OHCHR|United Nations Principles for Older Persons. (n.d.). Retrieved from https://www.ohchr. org/en/professionalinterest/pages/olderpersons.aspx.

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to work or other income-generating opportunities; (iii) appropriate educational and training programmes; (iv) remain integrated in society, to benefit from family and community care and protection in accordance with each society’s system of cultural values; (v) enjoy human rights and fundamental freedoms when residing in any shelter, care or treatment facility, including full respect for their dignity, beliefs, needs and privacy and for the right to make decisions about their care and the quality of their lives; (vi) live in dignity and security and be free of exploitation and physical or mental abuse; (vii) be treated fairly regardless of age, gender, racial or ethnic background, disability or other status; and (viii) be valued independently of their economic contribution. The Second World Assembly on Ageing took place two decades later in Madrid, from 8 to 12 April 2002. The participating countries adopted two key documents, a Political Declaration and the Madrid International Plan of Action on Ageing, 2002.6 Both documents included commitments from governments to devise and implement measures to address the challenges posed by the phenomenon of ageing. They put forward over 100 recommendations for action based on three priority themes centered around older people—development, health and well-being; and ensuring enabling and supportive environment. The United Nations regional commissions were made responsible for translating the International Plan of Action on Ageing into regional action plans reflecting, inter alia, the demographic, economic and cultural specificities of each region and serving as a basis for implementing the recommendations.7 India is a signatory to these plans of action and hence has taken up these commitments as a matter of its governance decisions. As recently noted by the United Nations General Assembly Resolution no. 72/144 dated 19 December 2017,8 several resolutions in the past, between 2005 and 2016, endorsed the Madrid International Plan of Action on Ageing. It was noted in the Resolution 58/134 of 22 December 2003 [at page 2/8] that, “between 2017 and 2030, the number of persons aged 60 years or over is projected to grow by 46 percent, from 962 million to 1.4 billion, globally outnumbering youth, as well as children under the age of 10 and that this increase will be the greatest and the most rapid in the developing world, and recognizing that greater attention needs to be paid to the specific challenges affecting older persons, including in the field of human rights”. This UN Resolution call upon the member states to take active steps, adopting of policies and legislation that would ensure that older persons fully realized their human rights and fundamental freedoms.

6 Political

declaration and Madrid Action Plan of Action on Ageing(Rep.). (n.d.). Retrieved http:// www.un.org/esa/socdev/documents/ageing/MIPAA/political-declaration-en.pdf. 7 Outcomes on Ageing. (n.d.). Retrieved from http://www.un.org/en/development/devagenda/ ageing.shtml. 8 United Nations Official Document. (n.d.). Retrieved from http://www.un.org/en/ga/search/view_ doc.asp?symbol=A/RES/72/144.

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Indian Laws and Policies The Constitution of India enshrines provisions for the protection of the rights and dignity of aged persons in India. To begin with, the Preamble of the Constitution of India resolves to secure to all its citizens, amongst others, “Fraternity assuring the dignity of the individual”. The fundamental rights of all citizens of this country, including the senior citizens, are enshrined in Part III of the Constitution of India, being, Article 12 to Article 35. These core fundamental rights that are available to all citizens in India are, (i) (ii) (iii) (iv) (v)

Right to Equality [Articles 14 to 18 of the Constitution of India]; Right to Freedom [Articles 19 to 22 of the Constitution of India]; Right Against Exploitation [Articles 23 and 24 of the Constitution of India]; Right to Freedom of Religion [Articles 25 to 28 of the Constitution of India]; Cultural and Educational Rights [Articles 29 to 30 and 31A to C of the Constitution of India]; (vi) Right to Constitutional Remedies [Articles 32 to 35 of the Constitution of India].

Part IV of the Constitution of India enshrines the Directive Principles of State Policy—provisions not enforceable by any court, but are the fundamental guiding principles in the governance of the country. It is the duty of the State to apply these principles in making laws [Article 37, Constitution of India], including: (i)

Article 38 directs that the state must “secure a social order for the promotion of welfare of the people”. The state is required to “(1) strive to promote the welfare of the people by securing and protecting as effectively as it may a social order in which justice, social, economic and political, shall inform all the institutions of the national life; and (2) in particular, strive to minimize the inequalities in income, and endeavor to eliminate inequalities in status, facilities and opportunities, not only amongst individuals but also amongst groups of people residing in different areas or engaged in different vocations”. (ii) Article 39 provides that the state shall, in particular, direct its policy towards securing inter alia the following, each of which constructively would include the aged— (a) that the citizens, men and women equally, have the right to an adequate means to livelihood; (b) that the ownership and control of the material resources of the community are so distributed as best to subserve the common good; (c) that the health and strength of workers, men and women, and the tender age of children are not abused and that citizens are not forced by economic necessity to enter avocations unsuited to their age or strength; (iii) Article 39-A warrants that the state shall secure that the operation of the legal system promotes justice, on a basis of equal opportunity, and shall, in particular, provide free legal aid, by suitable legislation or schemes or in any other way,

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to ensure that opportunities for securing justice are not denied to any citizen by reason of economic or other disabilities. (iv) Article 41 directs the state to, 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. (v) Article 46 directs the state to promote with special care the educational and economic interests of the weaker sections of the people, and, in particular, of the Scheduled Castes and the Scheduled Tribes, and shall protect them from social injustice and all forms of exploitation. It is now a settled position of Indian Constitutional Law as laid down by the Hon’ble Supreme Court of India in the case of Minerva Mills Ltd. v. Union of India, [cited in (1980) 3 SCC 625] that “The significance of the perception that Parts III and IV together constitute the core of commitment to social revolution and they, together, are the conscience of the Constitution is to be traced to a deep understanding of the scheme of the Indian Constitution. Granville Austin’s observation brings out the true position that Parts III and IV are like two wheels of a chariot, one no less important than the other. You snap one and the other will lose its efficacy. They are like a twin formula for achieving the social revolution, which is the ideal which the visionary founders of the Constitution set before themselves. In other words, the Indian Constitution is founded on the bedrock of the balance between Parts III and IV. To give absolute primacy to one over the other is to disturb the harmony of the Constitution. This harmony and balance between fundamental rights and directive principles is an essential feature of the basic structure of the Constitution. The goals set out in Part IV have, therefore, to be achieved without the abrogation of the means provided for by Part III. It is in this sense that Parts III and IV together constitute the core of our Constitution, and combine to form its conscience. Anything that destroys the balance between the two parts will ipso facto destroy an essential element of the basic structure of our Constitution.” To give effect to the constitutional protections and safeguards provided, a set of legislative provisions have been enacted in India that provide for elderly care. A short description of each of these legislations is enumerated below. The Hindu Adoption and Maintenance Act, 1956 [Act 78 of 1956, amended up to Act 30 of 2010], inter alia, casts a duty upon a Hindu to maintain his or her aged or infirm parents. Section 20 of this Act provides as follows: 20. Maintenance of children and aged parents.—(1) Subject to the provisions of this section a Hindu is bound, during his or her lifetime, to maintain his or her legitimate or illegitimate children and his or her aged or infirm parents. … (3) The obligation of a person to maintain his or her aged or infirm parent or daughter who is unmarried extends insofar as the parent or the unmarried daughter, as the case may be, is unable to maintain himself or herself out of his or her own earnings or other property. Explanation.—In this section “parent” includes a childless stepmother.

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This obligation was succinctly explained by the Hon’ble Supreme Court of India in the case of Kirtikant D. Vadodaria v. State of Gujarat [cited in (1996) 4 SCC 479, at page 485], “According to the Law of the Land with regard to maintenance, there is an obligation of the husband to maintain his wife which does not arise by reason of any contract — express or implied — but out of jural relationship of husband and wife consequent to the performance of marriage. Such an obligation of the husband to maintain his wife arises irrespective of the fact whether he has or has no property, as it is considered an imperative duty and a solemn obligation of the husband to maintain his wife. The husband cannot be heard saying that he is unable to maintain due to financial constraints so long as he is capable of earning. Similarly, it is obligatory on the part of a son to maintain his aged father and mother by reason of personal obligation. Under the old Hindu law, this obligation was imposed on the son alone, but now the present-day Hindu law extends this obligation both on sons and daughters. …Under the present law, as said earlier, both son and daughter are liable to maintain aged or infirm parents including childless stepmother, when the latter is unable to maintain herself. It is well settled that a son has to maintain his mother irrespective of the fact whether he inherits any property or not from his father, as on the basis of the relationship alone he owes a duty and an obligation, legal and moral, to maintain his mother who has given birth to him. Further, according to Section 20 of the Hindu Adoptions and Maintenance Act, 1956, a Hindu is under a legal obligation to maintain his wife, minor sons, unmarried daughters and aged or infirm parents. The obligation to maintain them is personal, legal and absolute in character and arises from the very existence of the relationship between the parties …” [Emphasis supplied] The Code of Criminal Procedure, 1973 (Act 2 of 1974 as amended up to Act 1 of 2014), in Chapter IX provides as follows 125. Order for maintenance of wives, children and parents.— (1) If any person having sufficient means neglects or refuses to maintain— (a) … (b) … (c) … (d) his father or mother, unable to maintain himself or herself, a Magistrate of the first class may, upon proof of such neglect or refusal, order such person to make a monthly allowance for the maintenance of his wife or such child, father or mother, at such monthly rate, as such Magistrate thinks fit, and to pay the same to such person as the Magistrate may from time to time direct…

This section gives an enforceable right to any aged parent, unable to maintain himself or herself, to approach a Magistrate of the First Class, seeking an order to direct his or her son or daughter to give a monthly allowance. Chapter IX of the Code of Criminal Procedure, also provides for the procedure [Section 126] that has to be followed for a case under Section 125; Cases in which an aged father or mother may seek an alteration in allowance [Section 127] that he is already receiving under Section 125; and, Procedure for Enforcement of order of maintenance [Section 128].

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Personal Laws. Apart from the Criminal Procedure Code, which gives a right of maintenance to all senior citizens in India irrespective of the personal law that they follow, under Mahomedan Law, children are bound to maintain their parents. According to the Mulla Principles of Mahomedan Law,9 children in easy circumstances are bound to maintain their poor parents, although the latter may be able to earn something for themselves. The Maintenance and Welfare of Parents and Senior Citizens Act, 2007 [Act 56 of 2007; hereafter “MWPSC Act”] was enacted by the Union Parliament, inter alia, to provide for more effective provisions for the maintenance and welfare of parents and senior citizens guaranteed and recognized under the constitution. The Statement of Objects and Reasons of the MWPSC Act notes as under “Traditional norms and values of the Indian society laid stress on providing care for the elderly. However, due to withering of the joint family system, a large number of elderly are not being looked after by their family. Consequently, many older persons, particularly widowed women, are now forced to spend their twilight years all alone and are exposed to emotional neglect and to lack of physical and financial support. This clearly reveals that ageing has become a major social challenge and there is a need to give more attention to the care and protection for the older persons. Though the parents can claim maintenance under the Code of Criminal Procedure, 1973, the procedure is both time-consuming as well as expensive. Hence, there is a need to have simple, inexpensive and speedy provisions to claim maintenance for parents”. [Emphasis supplied] It is instructive to evaluate the scheme of the MWPSC Act and its efficacy. Chapters I & II is titled “Provisions relating to maintenance of senior citizen by Children and Relatives” which is summarized below: (i)

Section 2 defines • “senior citizen” to mean “any person, being a citizen of India, who has attained the age of sixty years or above”. [Section 2(h)] • “Children” have been defined to include son, daughter, grandson and granddaughter, but not a minor. [Section 2(a)] • A “relative” has been defined to mean “any legal heir of the childless senior citizen who is not a minor and is in possession of or would inherit his property after his death”. [Section 2(g)]

(ii)

9 Mulla,

Sections 4 and 5 of the MWPSC Act secure an enforceable right of maintenance in the hands of a parent or a senior citizen [as defined by the Act] who is unable to maintain herself/himself from her/his own earning or out of the property owned by her/him. Such parent or senior citizen may seek maintenance from her/his children or a relative. This obligation of the children or relative, extends to meeting the needs of such senior citizen to lead a normal life, as held by the courts [see Nasir v. Govt. of NCT of Delhi; cited in: 2015 SCC OnLine Del 13060] to “certainly include a right to peacefully live in D. F. (2015). Mulla principles of Mahomedan law. Gurgaon: LexisNexis.§371, p457.

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one’s own property and being not prevented from use thereof and recovering rent thereof …” (iii) An application of maintenance maybe moved before the Maintenance Tribunal [constituted under Section 7, MWPSC Act] either (i) by the senior citizen, or (ii) if he is incapable, by any other person or organization [as defined under the MWPSC Act]. The Tribunal is empowered to take suo moto cognizance of such a condition of a parent or a senior citizen to initiate proceedings for maintenance. [Section 5(1)] (iv) The Tribunal may direct the payment of a monthly allowance, which shall not exceed 10,000.00. [Section 9(2)] (v) Failure to comply with an order of maintenance passed by a Tribunal can attract fines and even imprisonment for a term that may extend up to one month or until payment, whichever is earlier. [Section 5(8)] (vi) Chapter III provides for setting up of Old Age homes by state governments. [Section 19] (vii) Chapter IV casts an obligation on state governments to ensure that senior citizens get medical support.[Section 20] (viii) Chapter V requires state governments to take all measures to ensure publicity and awareness for welfare of senior citizens. In this context, state governments are required to put in place an action plan for providing protection of life and property of senior citizens [Section 22(2)]. As a legislative deterrent to fraudulent conduct, the MWPSC Act envisages that the Tribunal may for failure of consideration cancel a transfer of property made by a senior citizen after the commencement of the MWPSC Act subject to the condition that the transferee will provide the basic amenities and physical needs of such senior citizen, if the transferee fails to provide such amenities or needs. [Section 23] The Ministry of Social Justice and Empowerment, Government of India, has in March 2018 published for consultation a draft Bill for the amendment of the MWPSC Act.10 The Bill has been drafted, amongst other things, to expand the definitions of “children” to include daughters-in-law and sons-in-law; and “maintenance” to include, food, clothing, housing, medical attendance, treatment, safety and security. The Maintenance and Welfare of Parents and Senior Citizens (Amendment) Bill, 2019, was introduced in the Lok Sabha by the Minister of Social Justice and Empowerment on 11 December 2019. On 23 December 2019, the Bill has been referred to a Standing Committee awaiting its comments; which Committee has been granted an extension upto the last week of June 2020 for filing of its report. Progressive judicial pronouncements which are relevant for senior citizens. In recent years, there has been a set of progressive judicial pronouncements by the Supreme Court of India on issues which impact senior citizen like “Passive Euthanasia” and “Advance Medical directive” (or what is termed as a “Living Will”). In the case of Common Cause V. Union of India [cited in: (2018) 5 SCC 1], a 5Judge Bench of the Supreme Court of India, considered a Public Interest Litigation 10 (n.d.). Retrieved September 13, 2018, from http://socialjustice.nic.in/writereaddata/UploadFile/ MWPSCAct,2018l636580082691025377.pdf.

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filed by a registered society relating to the serious problem of violation of fundamental right to life, liberty, privacy and the right to die with dignity of the people, guaranteed to them under Article 21 of the Constitution of India. It was submitted that such citizens, suffering from chronic diseases and/or are at the end of their natural lifespan, i.e. senior citizens, are likely to go into a state of terminal illness or permanent vegetative state and are deprived of their rights to refuse cruel and unwanted medical treatment, to artificially prolong their natural lifespan; leading to extended physical and mental pain and agony. Such citizens seek to end their life by making an informed choice and clearly expressing their wishes in advance, [by way of a living will] before it becomes impossible for them to express their wishes. The Supreme Court discussed the law on euthanasia to observe as follows: “E. Legislation in reference to euthanasia 552. The only statutory provision in our country which refers to euthanasia is statutory regulations framed under the Indian Medical Council Act, 1956, namely, the Indian Medical Council (Professional Conduct, Etiquette & Ethics) Regulations, 2002. Chapter VI of the Regulations deals with “Unethical Acts”. Regulation 6 is to the following effect: “6. Unethical Acts. —A physician shall not aid or abet or commit any of the following acts which shall be construed as unethical— ∗ ∗ ∗ 6.7. Euthanasia. —Practising euthanasia shall constitute unethical conduct. However, on specific occasion, the question of withdrawing supporting devices to sustain cardiopulmonary function even after brain death, shall be decided only by a team of doctors and not merely by the treating physician alone. A team of doctors shall declare withdrawal of support system. Such team shall consist of the doctor in charge of the patient, Chief Medical Officer/Medical Officer in charge of the hospital and a doctor nominated by the in charge of the hospital from the hospital staff or in accordance with the provisions of the Transplantation of Human Organs Act, 1994….” [At page 277] 553. The Law Commission of India had stated and submitted a detailed report on the subject in 196th Report on “Medical Treatment to Terminally-Ill Patients (Protection of Patients and Medical Practitioners)”. …. The draft Bill, namely, Medical Treatment of Terminally-Ill Patients (Protection of Patients and Medical Practitioners) Bill, 2006, was made part of the Report as an Annexure. 554. Chapter 8 of the Report contains summary of recommendations. It is not necessary to reproduce all the recommendations. It is sufficient to refer to Paras 1 and 2 of the recommendations: In the previous chapters, we have considered various important issues on the subject of withholding or withdrawing medical treatment (including artificial nutrition and hydration) from terminally ill patients. In Chapter VII, we have considered what is suitable for our country. Various aspects arise for consideration, namely as to who are competent and incompetent patients, as to what is meant by “informed decision”, what is meant by “best interests” of a patient, whether patients, their relations or doctors or hospitals can move a court of law seeking a declaration that an act or omission or a proposed act or omission of a doctor is lawful, if so, whether such decisions will be binding on the parties and doctors, in future civil and criminal proceedings, etc. Questions have arisen whether a patient who refuses treatment is guilty of attempt to commit suicide or whether the doctors are guilty of abetment of suicide or culpable homicide not amounting to murder, etc. On these issues, we have given our views in Chapter VII on a consideration of law and vast comparative literature.

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In this chapter, we propose to give a summary of our recommendations and the corresponding sections of the proposed Bill which deal with each of the recommendations. (The draft of the Bill is annexed to this Report). We shall now refer to our recommendations: (1) There is need to have a law to protect patients who are terminally ill, when they take decisions to refuse medical treatment, including artificial nutrition and hydration, so that they may not be considered guilty of the offence of “attempt to commit suicide” under Sect. 309 of the Indian Penal Code, 1860. It is also necessary to protect doctors (and those who act under their directions) who obey the competent patient’s informed decision or who, in the case of (i) incompetent patients or (ii) competent patients whose decisions are not informed decisions, and decide that in the best interests of such patients, the medical treatment needs to be withheld or withdrawn as it is not likely to serve any purpose. Such actions of doctors must be declared by statute to be “lawful” in order to protect doctors and those who act under their directions if they are hauled up for the offence of “abetment of suicide” under Sects. 305, 306 of the Indian Penal Code, 1860, or for the offence of culpable homicide not amounting to murder under Sect. 299 read with Sect. 304 of the Penal Code, 1860 or in actions under civil law. (2) Parliament is competent to make such a law under Schedule VII List III Entry 26 of the Constitution of India in regard to patients and medical practitioners. The proposed law, in our view, should be called “the Medical Treatment of Terminally-Ill Patients (Protection of Patients and Medical Practitioners) Act….”[At page 277] 557. The withdrawal of medical treatment of terminally ill persons is a complex ethical, moral and social issue with which many countries have wrestled with their attempt to introduce a legal framework for end of life decision-making. In absence of a comprehensive legal framework on the subject the issue has to be dealt with great caution.[At page 278] ….614. The concept of Advance Medical Directive is also called living will is of recent origin, which gained recognition in latter part of 20th century. The Advance Medical Directive has been recognised first by the Statute in United States of America when in the year 1976, State of California passed “Natural Death Act”. It is claimed that 48 States out of 50 in the United States of America have enacted their own laws regarding patient’s rights and Advance Medical Directives. Advance Medical Directive is a mechanism through which individual autonomy can be safeguarded in order to provide dignity in dying. As noted above, the Constitution Bench of this Court in Gian Kaur [Gian Kaur v. State of Punjab; (1996) 2 SCC 648] has laid down that right to die with dignity is enshrined in Article 21 of the Constitution. 629.4. Thus, the law of the land as existing today is that no one is permitted to cause death of another person including a physician by administering any lethal drug even if the objective is to relieve the patient from pain and suffering. 629.5. An adult human being of conscious mind is fully entitled to refuse medical treatment or to decide not to take medical treatment and may decide to embrace the death in natural way. 629.6. Euthanasia as the meaning of word suggests is an act which leads to a good death. Some positive act is necessary to characterise the action as euthanasia. Euthanasia is also commonly called “assisted suicide” due to the above reasons. 629.7. We are thus of the opinion that the right not to take a life saving treatment by a person, who is competent to take an informed decision is not covered by the concept of euthanasia as it is commonly understood but a decision to withdraw life saving treatment by a patient who is competent to take decision as well as with regard to a patient who is not competent to take decision can be termed as passive euthanasia, which is lawful and legally permissible in this country. 629.8. The right of patient who is incompetent to express his view cannot be outside the fold of Article 21 of the Constitution of India.

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629.9. We are also of the opinion that in cases of incompetent patients who are unable to take an informed decision, “the best interests principle” be applied and such decision be taken by specified competent medical experts and be implemented after providing a cooling period to enable aggrieved person to approach the court of law. 629.10. An Advance Medical Directive is an individual’s advance exercise of his autonomy on the subject of extent of medical intervention that he wishes to allow upon his own body at a future date, when he may not be in a position to specify his wishes. The purpose and object of Advance Medical Directive is to express the choice of a person regarding medical treatment in an event when he loses capacity to take a decision. The right to execute an Advance Medical Directive is nothing but a step towards protection of the aforesaid right by an individual. 629.11. Right of execution of an Advance Medical Directive by an individual does not depend on any recognition or legislation by a State and we are of the considered opinion that such rights can be exercised by an individual in recognition and in affirmation of his right of bodily integrity and self -determination. 630. In view of our conclusions as noted above the writ petition is allowed in the following manner: 630.1. The right to die with dignity as fundamental right has already been declared by the Constitution Bench judgment of this Court in Gian Kaur case [Gian Kaur v. State of Punjab, (1996) 2 SCC 648] which we reiterate. 630.2. We declare that an adult human being having mental capacity to take an informed decision has right to refuse medical treatment including withdrawal from life saving devices. 630.3. A person of competent mental faculty is entitled to execute an Advance Medical Directive in accordance with safeguards as referred to above”. [At pages 309–310;” Emphasis supplied]

Till the Medical Treatment of Terminally-Ill Patients (Protection of Patients and Medical Practitioners) Bill is enacted and brought into effect, the following directions of the Supreme Court are binding: “203. We have laid down the principles relating to the procedure for execution of Advance Directive and provided the guidelines to give effect to passive euthanasia in both circumstances, namely, where there are Advance Directives and where there are none, in exercise of the power under Article 142 of the Constitution and the law stated in Vishaka v. State of Rajasthan…” [Vishaka v. State of Rajasthan; cited in (1997) 6 SCC 241] “…The directive and guidelines shall remain in force till Parliament brings a legislation in the field”. [At page 136] Government Schemes and Policies. In exercise of its executive powers, certain policies and schemes have been put in place by the Government to ensure care of the elderly. The Ministry of Rural Development has, since the year 1995, been implementing the Indira Gandhi National Old Age Pension Scheme. This Scheme was launched to provide financial security to senior citizens living below the poverty line. Under the Scheme, assistance is given towards pension @ Rs. 200/- per month to persons above 60 years and @ Rs. 500/- per month to persons above 80 years of age. In terms of the Government of India (Allocation of Business) Rules, 1951 [as amended from time to time], the Ministry of Social Justice and Empowerment is the administrative ministry responsible for 5 focus social groups, one of which is the senior citizen. Pursuant to its responsibility to evolve and implement programs for senior citizen, as also international conventions, the ministry launched the National

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Policy on Older Persons, 1999,11 which envisages state support to ensure financial and food security, health care, shelter and other needs of older persons, equitable share in development, protection against abuse and exploitation, and availability of services to improve the quality of their lives. The policy also covers issues like social security, intergenerational bonding, family as the primary caretaker, role of Non-Governmental Organizations, training of manpower, research and training. A National Council of Older Persons was constituted in 1999 to monitor the implementation of the policy and to advise the government on issues related to the welfare of senior citizens. Though, interestingly there is no mention about this council or work done by it in the Annual Report of the Union Ministry of Social Justice and Empowerment for 2017–18. This policy was replaced by the National Policy for Senior Citizens 201112 which tackles within its fold the changes like the 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 [51 million elderly live below the poverty line]. A higher proportion of elderly women than men experience loneliness and are dependent on children. Social deprivations and exclusion, privatization of health services and changing pattern of morbidity affect the elderly. All those of 60 years and above are senior citizens. This policy addresses issues concerning senior citizens living in urban and rural areas, special needs of the “oldest old” and older women. The National Council of Older Persons was reconstituted in 2012 as the National Council of Senior Citizens, with wider national impact. Similar councils have been constituted at the state level too. A Central Sector Scheme of Integrated Programme for Older Persons13 has also been launched. Under the Scheme, financial assistance up to 90% of the project cost is provided to government/Non-Governmental Organizations/Panchayati Raj Institutions/local bodies etc., for establishing and maintaining old-age homes, daycare centres and mobile medicare units. The Scheme was revised with effect from 01 April 2008 to increase the amount of financial assistance under the Scheme. Some of these are: (i) Maintenance of Respite Care Homes and Continuous Care Homes; (ii) Running of Daycare Centres for Alzheimer’s Disease/Dementia Patients; (iii) Physiotherapy Clinics for older persons; Helplines and Counselling Centres for older persons; (iv) Sensitizing programmes for children particularly in schools and colleges; (v) Regional Resource and Training Centres; (vi) Awareness Generation Programmes for Older Persons and Care Givers; (vii) Formation of Senior Citizens Associations, etc. 11 Annual

Report 2015–16 (p. 95, Rep.). (n.d.). Government of India. Retrieved from http:// socialjustice.nic.in/writereaddata/UploadFile/SOCIALJUSTICEENGLISH15_16.pdf. 12 (n.d.). Retrieved September 13, 2018, from http://socialjustice.nic.in/writereaddata/UploadFile/ dnpsc.pdf. 13 Annual Report 2015–16 (pp. 98–99, Rep.). (n.d.).Government of India. Retrieved from http:// socialjustice.nic.in/writereaddata/UploadFile/SOCIALJUSTICEENGLISH15_16.pdf.

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Some of the important activities/projects supported under the Scheme are: (i) Old Age Homes—for destitute older persons; (ii) Mobile Medicare Units—for older persons living in slums, rural and inaccessible areas where proper health facilities are not available; (iii) Respite Care Homes and Continuous Care Homes—for older persons seriously ill requiring continuous nursing care and respite. The Ministry of Social Justice and Empowerment also launched the Central Sector Scheme to improve the quality of life of the Senior Citizens [Revised as on 01 April 2018].14 The main objective of the Scheme is to improve the quality of life of senior citizens by providing basic amenities such as shelter, food, medical care and entertainment opportunities and by encouraging productive and active ageing through providing support for capacity building of state/UT Governments/NonGovernmental Organizations (NGOs)/Panchayati Raj Institutions (PRIs)/local bodies and the community at large. Assistance under the scheme will be given to implementing agencies such as state/UT Governments/Panchayati Raj Institutions/local bodies and eligible Non-Governmental/Voluntary Organizations, etc. for the following purposes: (i) (ii)

(iii) (iv) (v) (vi)

Programmes catering to the basic needs of senior citizens, particularly food, shelter and health care to the destitute elderly; Programmes to build and strengthen intergenerational relationships, particularly between children/youth and senior citizens, through Regional Resource and Training Centres (RRTCs); Programmes for encouraging active and productive ageing, through RRTCs; Programmes for proving institutional as well as non-institutional care/services to senior citizens; Research, advocacy and awareness-building programmes in the field of ageing through RRTCs; and Any other programmes in the best interest of senior citizens.

Thus, the Government of India and the state governments have taken some very concrete legislative and policy measures to build mechanisms to provide care as also safeguards to protect the senior citizens in our country from abuse and neglect. As keepers of our elders, we need to ensure that they live their lives with dignity and enjoyment. No one suffers and no one takes advantage of any helpless or hapless senior citizen. Whether our elderly get timely and effective access to such care and protection will depend significantly on the actual implementation of such legislative and policy measure. The success or failure of all such ameliorative measures and reform initiatives is also dependent upon the timely and effective establishment of agencies to implement the initiatives. Such agencies must be duly empowered with proper staffing of people with relevant experience and education. As appears from the organogram on the site 14 (n.d.).

Retrieved September 13, 2018, from http://socialjustice.nic.in/writereaddata/UploadFile/ Revised_IPSrC_Bilingual_14618.pdf.

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of the ministry, the direct responsibility of the “senior citizen branch” rests with a Deputy Secretary reporting to the Joint Secretary (Social Defence, Media and Rehabilitation & resettlement of Narmada Project), while three of the other groups are the direct responsibilities of Joint Secretaries. The contact details of the National Council of Senior Citizens is conspicuous in its absence. There is an urgent need for a periodic review and audit of implementation of this senior citizen care. Further, in this age of medical advancement, it may well be time to reconsider whether 60 years is too soon to declare a person as a senior citizen, or at least exceptions be carved out for people in service or employment, since they would get the necessary facilities as a part of their emoluments and perquisites. This is particularly relevant now that several public sector and private sector employment goes well beyond 60 years of age. We need to take active steps to avail of our current demographic dividend/profile where there are many more young earning hands to share the burden of creating the caregiving safety net for our elders and ensure that the senior citizens in our country are taken care of before the situation gets out of hand. I can do no better than end with the meaningful words of John F Kennedy “The time to repair the roof is when the sun is shining”.

Bio-Sarita Kapur commenced her practice 32 years ago with a focus on dispute resolution (courts and arbitrations—domestic and international) besides advising/representing corporates and high commissions. Her practice has primarily focused on contractual and commercial matters; issues of public and private international laws including aspects like diplomatic immunity, immigration, refugee rights, etc.; employment laws; personal laws; succession and trusts. In her advisory mandates for various High Commissions and Consulates included issues relating to various aspects of immigration, personal laws (matrimony, succession, adoption, property, etc.) and social issues. She is a Certified Mediator. Sarita has served on the Editorial Board of the “Indian Advocate”, the journal of the Bar Association of India for over 15 years.

Chapter 12

Health Challenges and Responses to Ageing Women Meena Yadav

Abstract The issue of postreproductive health care in women demands recognition and priority in India as the number of women in this age group is increasing due to higher life expectancy as a result of better healthcare facilities. Menopause marks the transition to postreproductive life in women. The physical, physiological and psychological symptoms accompany menopause which affect the women’s health and well-being. Perimenopausal and postmenopausal women have to bear the results of these developments in their bodies. Women experience these symptoms around and after menopause which remain uncared for due to lack of awareness. The biological age of women is usually different from their chronological age and may depend on several factors like diet, environment, lifestyle changes, menopause, etc. The women, who experience menopause early in their lives, tend to age faster than women of similar age who have late menopause. Thus, menopause hastens the process of ageing in women. In India, there is not much awareness about the problems and needs of women in their postreproductive stage of life, especially menopause. Like menstruation, women do not feel free to discuss the problems they face during menopause and thus majority of the women bear the consequences of the developments of midlife in silence. There is a strong need to address the problems faced by women in their postreproductive life and to spread the awareness about this crucial phase as it is a transition from reproductive to non-reproductive phase of life which is accompanied by several health issues. Keywords Menopause · Midlife · Postreproductive health · Perimenopause · Postmenopause

Introduction Ageing is a complex and inevitable process, for both men and women, and is influenced by several factors like genetics, environmental factors, diet, pollutants, exercise, etc. In most of the developed countries, women live longer than men suggesting M. Yadav (B) Department of Zoology, Maitreyi College, University of Delhi, New Delhi, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. K. Shankardass (ed.), Ageing Issues and Responses in India, https://doi.org/10.1007/978-981-15-5187-1_12

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that ageing is faster in men than in women. Ageing is accompanied by the slowing down of the functions of organ systems and tissues which is due to the changes at the physiological level. The physiological changes that occur with progressing age can be grouped into three categories: first, alterations in the cellular homeostasis mechanisms; second, reduction in organ mass; and third, decline in the functions of the organ systems (Nigam et al. 2012). Ageing is strongly influenced by body’s metabolism; thus, the factors such as nutrition, hormones and lifestyle play important roles in the process of ageing (van Beek et al. 2016). Menopause is the permanent cessation of menstrual cycles due to loss of ovarian follicles and is confirmed when there is no menstruation for a period of one year. Thus, the period of menopause starts from the last menstrual cycle which is followed by a year of amenorrhoea. In women who undergo hysterectomy or oophorectomy, the age of menopause starts from the date of the procedure. In case of women who undergo unilateral oophorectomy, menopause starts at an early age as compared to women who do not undergo such procedure (Ceylan and Özerdoˇgan 2015). It is considered that menopause marks the transition from reproductive age to nonreproductive or old age in women. Menopause is inextricably associated with ageing and is actually marked by an endocrinological transition that strongly affects the health and physiology of middle-aged and elderly women (Auro et al. 2014). In women, ovary is the only source of oocytes or eggs which are produced inside the ovarian follicles, and a chief source of oestrogen, progesterone and androgens. After 35 years of age, the production of follicle-stimulating hormone (FSH) in women increases and as a result there is reduction in the levels of effective estradiol and inhibin B, the two hormones involved in menstrual cycle. There is also a sharp decline in the number of primordial follicles in ovaries after the age of 37 years due to which there is less production of oestrogen leading to several problems arising due to oestrogen deficiency such as decline in serotonin synthesis in brain leading to insomnia (Crowley 1982); vasomotor symptoms such as hot flushes and night sweats; urogenital ageing including thinning of vaginal epithelium, a decrease in cervical mucus leading to vaginal dryness; retaining collagen but thinning of dermis leading to development of wrinkles and lines; and higher osteoclastic activity leading to bone weakness and conditions like osteoporosis as well as cardiovascular diseases (AlAzzawi 2001). Thus, due to these physiological changes, the postmenopausal years of a woman’s life are associated with several health problems such as hypertension, heart problems and osteoporosis which lead to decline in the overall quality of life (Pallikadavath et al. 2016). The onset of menopause as well as postmenopausal life is associated with health consequences like changes in the lipid and glucose metabolism, psychological stress, etc. (Auro et al. 2014). Menopause is not a sudden event. It takes few years of physical and physiological changes, influenced by several factors that culminate in menopause. Perimenopause is the duration when the ovaries start to produce less oestrogen due to lesser number of follicles, and it ends with menopause when ovaries stop releasing the eggs. The average duration of perimenopause is around 4 years (Fuh et al. 2006). Perimenopause is characterized by irregular menstrual cycles, prolonged and heavy menstrual cycles that are intermixed with periods of amenorrhoea, low

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fertility, vasomotor symptoms and even insomnia (Dalal and Agarwal 2015). Further, premenopause is a period when there are no signs of perimenopause or menopause but some hormonal changes might be there which are not noticeable. The mean age at menopause in Indian women is 46.2 years (Ahuja 2016), and it ranges between 41.9 and 49.4 years (Kriplani and Banerjee 2005). The onset of menopause is accompanied by several health issues for the women due to cessation of secretion of oestrogen by the ovaries.

Menopause and Ageing Menopause and ageing are so correlated with each other that they share their progression and many of the symptoms. Weight gain is the most common problem of ageing. Several factors promote weight gain like decline in oestrogen levels, mood disorders, lifestyle changes and insomnia. There is a common belief that weight gain in midlife women is due to ageing and lifestyle changes and menopause as such does not account for the weight gain. This can be explained as follows: there is lack of oestrogen after menopause which results in increase in total body mass, but it also decreases lean body mass; thus, there is no significant weight gain due to menopause. Thus, it can be said that women have a tendency to gain weight due to ageing and lifestyle changes and not due to menopause alone (Kapoor et al. 2017). With the onset of menopause, there is deterioration of musculoskeletal system due to the lack of oestrogen which is required for remodelling of bones and soft tissues (Amarya et al. 2018) and thus causes muscle and joint pains. Thus, we can say that menopause enhances the rate of ageing. As per Indian National Family Health Survey (NFHS-3 survey 2005–2006), about 18% women in the age group of 30–49 reached menopause and these observations are similar to NFHS-2 survey (1998–99) where 17.7% reached menopause in the same age group. The results of the surveys pose serious concern as in India the cases of premature menopause are rising and especially in certain sections of the society. Thus, many women in India spend approximately half of their life in postmenopausal phase due to early menopause. A decline in the fertility and early adoption of sterilization by women shorten the span of their reproductive life and may account for early menopause. Since the onset of menopause accelerates ageing in women, an early menopause further reduces the life span.

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Postreproductive Life: Manifestation of Health General Symptoms The symptoms of menopause in women vary from individual to individual and are dependent on several factors like biological ageing, cultures, menopausal fluctuations or society in general. In developed countries, women usually experience vasomotor symptoms like hot flushes, insomnia, vaginal dryness, joint pain and fatigue to name a few (Santoro et al. 2015) while women in developing countries experience hot flushes, joint pain, insomnia, anxiety, fatigue, urogenital problems, tiredness, sleeplessness, palpitations, weight gain, irritability as observed in African countries (Anolue et al. 2012). In Ethiopia, the predominant menopausal symptoms as reported are vasomotor symptoms like hot flushes and night sweats, sleep disturbances, depression, irritability and anxiety. However, the most severe menopausal symptoms are psychological symptoms which leave deep impacts on women (Yisma et al. 2017). The menopausal symptoms observed in Indian women include joint and muscular discomfort, insomnia, physical and mental exhaustion, anxiety, irritability, hot flushes and night sweats, vaginal dryness, depression, etc. The perimenopausal women experience more psychological symptoms than premenopausal and postmenopausal women. However, postmenopausal women experience more urogenital problems (Agarwal et al. 2018). It has been observed that women with higher body mass index (BMI) show higher vasomotor symptoms during and after menopause. In such cases, exercise or other physical activity can reduce the vasomotor symptoms. In a study involving urban women in India, the major menopausal symptoms observed in symptomatic women were: musculoskeletal complaints (80%), gastrointestinal problems (78%), weight gain (70%), urogenital complaints (50%), vasomotor symptoms (44%), mood swings (46%), sleep disturbances (58%) and loss of libido (40%) (Malla and Tuteja 2014). The symptoms vary between individuals because of different socio-economic, psychological, biological and other factors that lead to variable decline in the oestrogen levels. The various types of menopausal symptoms experienced by women in different regions of the world and different parts of India have been summarized in Tables 1 and 2.

Menopausal Age and Biological Age There is a significant correlation between menopausal age and the biological ageing rate. The menopausal age is inheritable. After 35–40 years, women’s body starts showing physiological disturbances or slowing down of the processes which become the reason of several health issues which we can call as ‘ageing’. DNA methylation, an epigenetic biomarker, is a promising biomarker to describe ageing and monitor life expectancy. Ageing is directly correlated with changes in DNA methylation

Country

Australia

Thailand

Ethiopia

Nepal

S. No.

1

2

3

4

Somatic symptoms: Hot flushes, night sweats, weight gain, muscle and joint pain, insomnia Psychological symptoms: Mood swings, irritability, anxiety, depression, panic attacks, easy tearfulness Urogenital symptoms: Decreased libido, vaginal dryness, difficulty in urination

Somatic symptoms: Hot flushes, heart discomfort, insomnia, musculoskeletal problems Psychological symptoms: Depression, irritability, anxiety Urogenital symptoms: Dryness of vagina, bladder problems, sexual problems

Somatic symptoms: Vasomotor symptoms, tiredness, poor appetite, joint pain Psychological symptoms: Dizziness, palpitation, irritability, headache, insomnia, depression, poor concentration, forgetfulness, nervousness Urogenital symptoms: Increased micturition, no sexual desire, uterine prolapse and/or vaginal relaxation

Somatic symptoms: Hot flushes, night sweats, insomnia, heart discomfort, musculoskeletal problems Psychological symptoms: Depressive mood, irritability, anxiety

Symptoms

Table 1 Menopausal symptoms in different regions of the world

Shrestha and Pandey (2017)

Yisma et al. (2017)

Melby et al. (2005)

Jones et al. (2012)

References

(continued)

12 Health Challenges and Responses to Ageing Women 189

Country

England

China

Five European countries (France, Germany, Italy, Spain and UK)

Saudi Arabia

S. No.

5

6

7

8

Table 1 (continued)

Somatic symptoms: Joint and muscle pain, physical and mental exhaustion, hot flushes and sweating Psychological symptoms: Anxiety, irritability The overall symptoms were mild and were more prevalent in perimenopausal women than in premenopausal and postmenopausal women

The symptoms were comparatively lower in France. Night sweating is reported highest in UK, while it is almost similar in other European countries (57–67%). Other symptoms were sleep disturbances, hot flushes, vaginal dryness and sexual dysfunction. Hot flushes are more common in European and American women than in Asian women

Somatic symptoms: Insomnia, joint and muscle pain, dizziness, hot flushes There are overall low symptoms in Chinese women

Somatic symptoms: Hot flushes, night sweats, fatigue, weight gain, joint pain, headache, joint pain Psychological symptoms: Mood swings, depression, anxiety, loss of concentration Urogenital symptoms: Loss of libido, vaginal dryness, vaginal discharge and itchiness, change in sexual activity

Symptoms

AlDughaither et al (2015); Al-Musa et al (2017)

Constantine et al (2016); Mahajan et al (2012)

Yang et al (2008)

Moon et al (2016)

References

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State

Delhi (rural)

Kerala

Puducherry

West Bengal

S. no.

1

2

3

4

Somatic symptoms: Hot flushes, night sweats, depression, poor memory, lowered physical strength and stamina, low backache Psychological symptoms: Dissatisfaction with personal life Urogenital symptoms: Painful and frequent urination, inability to hold urine, urine leakage, vaginal dryness, vaginal discharge and itching, bad smell

Somatic symptoms: Hot flushes, night sweats, musculoskeletal problems, insomnia, lowered physical strength and stamina, weight gain, feeling bloated Psychological symptoms: Dissatisfaction with personal life, anxiety, poor memory, depression Urogenital symptoms: Frequent urination, involuntary urination with laughing or coughing, changes in sexual desire, vaginal dryness

Somatic symptoms: Headaches, lethargy, burning micturition, musculoskeletal problems Psychological symptoms: Depression, irritability, forgetfulness, lethargy Urogenital symptoms: Dysuria, sexual problems like decreased libido and dyspareunia, vaginal dryness and itching

Somatic symptoms: Hot flushes, night sweats, muscle or joint pain, tiredness, palpitations, headache Psychological symptoms: Sleep disturbances, irritability Urogenital symptoms: Urinary problems, decreased libido More than 90% women suffered from one or more postmenopausal symptoms

Symptoms

Table 2 Menopausal symptoms in different parts of India References

(continued)

Dasgupta et al (2015); Karmakar et al (2017)

Poomalar and Arounassalame (2013)

Borker et al (2013)

Singh and Pradhan (2014)

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State

Tamil Nadu

Odisha

North Central India

Uttar Pradesh

S. no.

5

6

7

8

Table 2 (continued)

Urogenital symptoms: Vaginal dryness, vaginal discharge, dysuria, sexual problems. Presence of urogenital problems was not related significantly to menopause; these problems were present more in illiterate and lean women than in educated and obese women. Obese women have more problems in later years of menopause. Also, the symptoms were more severe in the initial years of menopause Somatic symptoms: Joint and muscular discomfort, heat discomfort, insomnia, hot flushes Psychological symptoms: Mental exhaustion, depression, irritability, anxiety The menopausal symptoms were more in women of lower socio-economic strata and less educated and/or illiterate women

Somatic symptoms: Joint and muscular pain, physical and mental exhaustion, insomnia, hot flushes, sweating, heart discomfort Psychological symptoms: Anxiety, irritability, depression Urogenital symptoms: vaginal dryness, frequent urination Perimenopausal women experienced greater somatic and psychological symptoms than premenopausal and postmenopausal women

Somatic symptoms: Hot flushes, joint pains, sleep disturbances, headache, increased heartbeat, weight gain Psychological symptoms: Irritability, forgetful, loosing over emotions, anxiety, poor concentration Urogenital symptoms: Vaginal dryness, difficulty in intercourse

Somatic symptoms: Hot flushes, sweating, backache, muscle pain, insomnia Psychological symptoms: Lack of energy, forgetfulness, lowered concentration, low self-esteem, poor judgement, frustration Urogenital symptoms: Changes in sexual desires, difficulty in urination

Symptoms

References

Gupta et al. (2018), Khatoon et al. (2018)

Agarwal et al.(2018)

Satpathy (2016)

Jayabharathi and Judie (2016)

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patterns. The more recent ‘epigenetic clock’ method (Unnikrishnan et al. 2019) to understand the process of ageing is based on measuring the methylation changes in 353 CpGs in DNA. This method can be applied to majority of cell types of the body that contain DNA, except sperms, to determine cellular age. There were other old methods that relied only on the saliva and blood to determine the biological age (Horvath 2013). Information from the epigenetic clock method can be retrieved as follows: if a woman shows changes in the DNA methylation in CpGs in her DNA, either hypermethylation or hypomethylation, then she is ageing faster than her chronological age. In such a scenario, she might experience menopause earlier than the other women of similar age. Thus, it can be ascertained that the hormonal changes that accompany menopause accelerate the biological age in women (Levine et al. 2016). Further, the women who experience menopause early in their lives have higher risks of age-related diseases and even early death.

Menopause and Cognitive Status of Women In the premenopausal women, the circulating oestrogen protects them from cognitive ageing (Henderson 2011). However, in midlife, women experience cognitive ageing as is evident from the decline in processing speed and verbal memory (Karlamangla et al. 2017). The cognitive symptoms are more prevalent during the early menopause phase. Cognitive ageing does not mean decline in other domains of physiology as it varies from individual to individual and can be compensated by mechanisms that improve the decline in cognitive ageing and overall well-being (Hahn and Lachman 2015). The menopausal symptoms such as hot flushes have direct relation with the vascular system which is influenced by the changes in the levels of oestrogen during and after menopause (Maki 2015). There are an abundance of oestrogen receptors (ERs) at several locations associated with cognition in central nervous system (CNS) like verbal memory, working memory, control of attention, etc. (Pompili et al. 2012). The influence of oestrogen on the nervous system has been seen and confirmed in animals, but in case of humans it can be ascertained only during and after menopause. It is widely known that women are at increased risk of developing cognitive decline and Alzheimer’s dementia (AD) which might be due to the decline in the neuroprotective actions of oestrogens during and after menopause (Navarro-Pardo et al. 2017). Many women, especially in Western countries, take hormone replacement therapy (HRT) to cope up with the perimenopausal and menopausal symptoms. Generally, HRT consists of predominantly oestrogen supplements as there is decline in the levels of oestrogen around and after menopause but the guidelines recommend that women who have uterus should be given oestrogen and progesterone in the HRT formulations, in different combinations, as progesterone protects the endometrium (Fuh et al. 2006). Ageing affects the ERs and other ER co-activators like growth factors, neurotransmitters and neuromodulators (Fuh et al. 2006). Thus, even in the presence of oestrogen, as provided by HRT in ageing and menopausal women, in the

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absence of proper ERs and co-activators, the oestrogen is not able to exert its effects to the fullest and may show signs of cognitive complications. It has been observed that women who start taking any type of HRT before their last menstrual cycle perform better in memory testing than women who start HRT after menopause has started. The decline in cognitive abilities in the early menopausal duration does not imply that the same is not likely to worsen in the postmenopause other than as expected from ageing. Some cognitive changes called as mild cognitive impairment (MCI) may be signals of an early dementia. Alzheimer’s disease (AD) is the most common type of dementia in old people. Medications are not effective in treating cognitive problems. However, lifestyle modifications such as exercise, nutritious diet and regular social activities can lower the risk of dementia and cognitive decline (Santoro et al. 2015).

Mood Swings Perimenopausal women are prone to depression. There are increased chances of mood swings during menopause, especially in the perimenopause, as in this duration women usually undergo depression due to physical changes in their bodies. In some women, anxiety may precede the episodes of depression in midlife (Kravitz et al. 2014). Some factors such as poor sleep, stressful life, higher BMI and smoking may cause more depression in menopausal women. The race of women also affects depression levels as has been observed that African American women are twice prone to depressive symptoms than other Americans. For treating mood swings and/or depression, selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), escitalopram (Lexapro), citalopram (Celexa), sertraline (Zoloft) and paroxetine (Paxil) can be used as first-line medications (Santoro et al. 2015).

Metabolic Disorders Menopause has been linked to cardiovascular disease (CVD) which is a leading cause of mortality worldwide. The premenopausal women have low incidences of CVD as compared with men of the same age indicating a protective role of endogenous oestrogen (Mikkola et al. 2013). Loss of function of ovary, due to natural or artificial menopause, increases the risk of CVD. Postmenopausal women have lower highdensity lipoprotein (HDL) cholesterol levels and high levels of low-density lipoprotein (LDL) cholesterol, triglycerides (TGs) and total cholesterol (TC) as compared to premenopausal women of same age. Thus, after menopause HDL loses its protective role against CVD. Menopause also stimulates atherosclerosis, higher body fat particularly abdominal fat leading to higher incidences of CVD and other metabolic dangers (Auro et al. 2014). Other common metabolic disorders in menopausal women

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include dyslipidemia, impaired glucose tolerance, insulin resistance, type II diabetes and hyperinsulinemia (Stachowiak et al. 2018).

Factors Affecting Menopause Menopause holds a significant importance in a woman’s life as it is the transition from reproductive age to a non-reproductive age where they are no longer able to reproduce. The age of onset of menopause varies in different women. Some women experience early menopause, i.e. before 40 years, while some experience late menopause, i.e. after 55 years, and the mean age of menopause in Asian women is 42.1–49.5 years (Palacios et al. 2010). Some of the significant factors influencing the postreproductive life of women are as follows:

Genetics The biological and epidemiological studies have shown that reproductive performance, age of menopause and life expectancy are interrelated through common genetic factors that are associated with DNA repair and maintenance. The family history is responsible for approximately 50% of the variation in the age of menopause (Laven 2015). The parents pass the characteristic features like number of oocytes and/or rate of follicle maturation and ovulation to their daughters. The behaviour of a mother during pregnancy influences the number of follicles in the ovary of her daughter at birth. Further, the age of onset of menopause and/or the ovarian reserve is affected by the environment and the behaviour of the individual woman from birth to menopause (Leidy 1994). A woman whose first-degree relatives have history of early menopause will also experience early menopause. In the process, this woman will start becoming less fertile and will become completely infertile at an early age (de Bruin et al. 2001). Thus, she may remain childless if she does not conceive early and delays her childbearing as is happening more in the present world where people are delaying child birth due to various socio-economic reasons.

Reproductive Factors Various factors contribute to the age of menopause and its symptomatology. Reproductive factors and behaviour play a role in the attainment of menopausal age. The earlier age of menarche is positively correlated with early natural menopause. Multiple parity leads to early menopause, while birth of less children is associated with late menopause (Ahuja 2016). Also, women who had their first child at older age experience premature menopause (Wang et al. 2018).

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Women who breastfeed their children for short duration have less number of live births or are nulliparous left with less number of ovarian follicles. This implies that they attain menopause earlier as their menstruation stops due to lack of ova. The faster depletion of ovarian follicles also results in depletion of oestrogen levels and various problems associated with oestrogen deficiency like vaginal problems. Also, women who have a history of low menstrual discharge suffer from vaginal problems during menopause (Dasgupta and Ray 2015). Women who use less oral contraceptives experience early menopause as compared to women who have been using oral contraceptives for a long time (Jones et al. 2012).

Body Mass Index (BMI) Weight also influences the age of menopause. Lower BMI is associated with early onset of menopause (Ahuja 2016) as has been found in a study in China that underweight women are more likely to experience early menopause as compared to healthy women with normal BMI. Diet plays an important role in the attainment of natural menopausal age. Consumption of meat has been associated with late menopause. A diet rich in vitamins is related to lower incidences of premature menopause (Wang et al. 2018), while higher polyunsaturated fat acids in diet hasten the menopause. Women having hypertension and low exposure to sunlight throughout their life experience early menopause (Ceylan and Özerdoˇgan 2015). Further, it is observed that women who have normal BMI have lesser vasomotor symptoms and better quality of life whereas women who are overweight and have higher BMI have increased vasomotor symptoms but they are protected against osteoporosis and related fracture. Women who have high BMI produce more estradiol (E1) and oestrone (E2), and thus their menopause is delayed (McTiernan et al. 2006). Postmenopausal women produce oestrone, an endogenous oestrogen from adrenal glands. The higher production of oestrone in obese women leads to delay in the menopausal age. However, high weight negatively influences the quality of life in postmenopausal women from all ethnic backgrounds (Kothiyal and Sharma 2013).

Lifestyle Lifestyle factors like smoking and use of alcohol lower the menopausal age and are associated with hot flushes, and reproductive factors like women having no children or less children, less breastfeeding and low use of contraceptives also trigger early onset of menopause (Jones et al. 2012). Smoking is the most significant factor that influences the age of menopause. Smoking reduces the age of attainment of menopause by approximately three years and also increases the menopausal symptoms (Jones et al. 2012). It has been observed in a study in Himachal Pradesh in

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India that the women who smoke attain menopause at 43 years while non-smokers experience menopause at a mean age of 44.7 years (Mahajan et al. 2012).

Physical Activity Physical activity enhances the quality of life of postmenopausal women and even reduces the severity of hot flushes. An active life that includes regular physical activity reduces the menopausal symptoms, whereas low physical activity can result in climacteric symptoms (Kothiyal and Sharma 2013). Heavy physical activity is associated with early menopause, whereas moderate and light physical activity delays the menopausal age (Ceylan and Özerdoˇgan 2015). Thus, women should maintain an active lifestyle with regular walks and other exercises to improve their fitness which in turn will reduce symptomatology of menopause.

Social Factors The social factors that affect the quality of life of postmenopausal women include marital status, education, economic and social status, as well as number of children staying with the family. Marital status and the satisfaction in marriage are associated with the quality of life in postmenopausal women. Divorce is a psychological experience and is associated with early onset of menopause. The language of a region largely influences the perceptions. In Western worlds, menopause is generally described by words such as ‘reproductive failure or ovarian failure’. Use of such language makes it appear as if menopause is a disease or some kind of deficiency that makes a woman’s body incomplete. In Arab world, the word used for menopause means ‘desperate age’ that signifies a pessimistic attitude towards menopause. The native American women do not have any word for menopause, and the Japanese women also do not have any word for hot flushes. These observations signify that the symptoms of menopause do not hold much importance to them (Jones et al. 2012).

Psychological Factors The attitude of women towards menopause has large influence on the overall experience of menopause. Women who have negative opinions about menopause and/or ageing tend to report a large number of menopausal symptoms. The attitudes of women towards menopause are influenced by their family members and friends and especially their mothers. Postmenopausal women are seen to have more positive attitude towards menopause than premenopausal women. Many women see menopause

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as a relief from menstruation, no worries about contraception and increased sexual freedom. Women who reach menopause before they can have desired number of children have more negative approach towards menopause. In Western societies, more importance is given to youthfulness than procreation. Hence, attainment of menopause is seen as a sign of ageing and loss of youth and sexual activity and thus they develop negative attitude towards menopause (Jones et al. 2012).

Culture The sociocultural structure of a given region profoundly influences the understanding and experiences of menopause. The choice of diet and its preparation is a cultural concept and is one of the major factors that influences the health of a person. Phytoestrogens present in diets have protective role for the reproductive system and are associated with low incidences of cancers related to reproductive system and menopausal symptoms. Although phytoestrogens are weak oestrogens, their consumption can partly compensate for the absence of oestrogens after menopause (Melby et al. 2005). Soy food provides isoflavins which have preventive role in perimenopausal symptoms. In postmenopausal women, the levels of total cholesterol, low-density lipoproteins, triglycerides and high-density lipoproteins fluctuate and are important markers of cardiovascular diseases. The soy foods or other diets rich in phytoestrogens, consumed mostly in Asian countries, reduce the menopausal symptoms, regulate the plasma lipid concentrations and thus may reduce cardiovascular diseases (Melby et al. 2005; Kothiyal and Sharma 2013). Let us take an example to understand the impact of culture on reproductive system: Japanese women experience lower menopausal symptoms and lower risks of breast, ovarian and endometrial cancer as compared to women in Western countries and Japanese women living in Hawaii. This suggests that it is not just the genetic factors and lifestyle but the culture and environmental factors also that affect the menopausal age and symptoms of menopause (Tham et al. 1998). Further, the vasomotor symptoms like hot flushes and sweats are more pronounced in Japanese Americans during perimenopause than the Japanese living in Japan but still they are less than the Caucasian Americans (Gold et al. 2004). These observations suggest that the cultural differences may arise due to local cultural and environmental influences and may affect the reproductive senescence.

Education Education influences the age of menopause. More educated women experience late menopause as compared to illiterate women who have early menopause. Also, women belonging to higher economic status have higher menopausal age (Gold 2011; Ahuja 2016). These observations could be explained due to the better nutritional status,

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differences in reproductive choices and stress levels between the groups. Education also plays a role in understanding the various ailments and the health issues in women. Doctors spend less time in treating a less educated woman as they do not discuss much about the health issue that is being treated and thus there is low awareness among such women (Kothiyal and Sharma 2013). The same holds true for menopause. The more educated is the woman, the more she is aware about the menopause and its symptoms.

Marital Status There exists a strong and positive correlation between menopausal age and marital status. Unmarried women experience early menopause as compared to married or widowed women (Ahuja 2016). This observation is more significant in countries with conservative cultures as the marital status is an important factor in the sexual life of women in these countries. Simply being married and having less or no sexual activity during pre- and perimenopause might not delay onset of menopause. But, in women who are sexually active there is less risk of experiencing early menopause (Arnot and Mace 2020) and less severity of the climacteric symptoms and their ageing also slows down.

Management of Menopause There are several coping strategies which the women can adopt based on the symptoms experienced by them. Women can take calcium supplements or change their lifestyle and include exercise as a necessary activity (Malla and Tuteja 2014). The social, economic and emotional support may provide relief for the menopausal women and reduce the severity of the symptoms. For treating vasomotor symptoms and insomnia during perimenopause or menopause, women can take oestrogen therapy. It brings some relief from the symptoms as it reverses the calcium metabolism and improves metabolism of lipoproteins. However, the oral administration of oestrogens can produce side effects such as nausea, gastric irritation, breast tenderness and headaches. Healthy women in perimenopause can take oral contraceptives to get relief from severe hot flushes. Women can also take low doses of oral esterified and conjugated oestrogens or transdermal estradiol which is affective in lessening the symptoms and has minimal side effects. Women can also go for progestin-only therapy to relieve them from vasomotor symptoms. Other drugs that can provide relief from hot flushes include medroxyprogesterone acetate, megestrol acetate, clonidine and selective serotonin reuptake inhibitors (SSRIs) (Dalal and Agarwal 2015). Tibolone is a synthetic steroid which has activities similar to weak oestrogen, weak progesterone and weak androgens and is used by the postmenopausal women

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to reduce vasomotor symptoms and bone loss (Al-Azzawi 2001). Taking oestrogen and progesterone as HRT reduces the incidences of cardiovascular diseases. However, taking progesterone has its disadvantages as well. It has been observed that HRT causes withdrawal bleeding which can be irregular or heavy. But the type and dose of HRT can be manipulated to suit the individual. Hence, continuous HRT with oestrogen and progesterone has been recommended with lower frequency of bleeding.

Postreproductive Health of Women: Challenges It is a general perception that menopause marks the initiation of old age in women. Even before menopause is attained, women experience several symptoms for 4– 5 years. In addition to the symptoms, women who experience early menopause are at risk of developing cardiovascular diseases, osteoporosis and rheumatoid arthritis while women who experience late menopause are at higher risk of breast and endometrial cancer (Dasgupta et al. 2015). The perception of women about menopause also varies in various cultures, regions and societies. The women in eastern countries consider menopause as the natural process and hold a positive attitude towards it, whereas Nigerian women show negative attitude towards it (Mahajan et al. 2012). In general, it has been witnessed that perimenopause and early postmenopause exert more negative influence on the quality of life of women (Ceylan and Özerdoˇgan 2015). Generally, women in large part of the globe are less aware about the symptomatology of menopause and thus do not adopt methods to cope with the symptoms. For example, postmenopausal women are not aware about osteoporosis accompanying menopause and the ways to prevent it. In women above 65 years, osteoporosis may cause complications like fragility fractures. Thus, there is deficit of awareness in women about the factors that predispose them to osteoporosis (Gopinathan et al. 2016; Senthilraja et al 2019). Further, a large number of working women transition to menopause while still employed. These women report lesser symptoms than unemployed women fearing their colleagues’ perception about the decline in their performance due to premenopausal and postmenopausal symptoms. The vasomotor symptoms affect the work life of the women, but psychological and somatic symptoms of menopause leave still greater negative impacts. These symptoms affect the relationships of the employee with colleagues and management. This stresses the need for suitable mechanisms, such as psychological and emotional support, that ensure proper care of perimenopausal and postmenopausal women at workplace which will help them in lessening the severity of the symptoms and improve the work output (Jack et al. 2016). In India, there is an increasing trend of early menopause and thus women spend several decades in postmenopausal phase due to higher life expectancies. Women in India do not generally report the perimenopausal or menopausal symptoms. The symptoms vary with cultures and socio-demographic status. Different ethnic and

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local groups practise different cultures, social traditions and reproductive habits such as endogamy. Thus, due to varied social and cultural practices, the reproductive health of the women is influenced resulting in variable reproductive ageing and menopause. The women should be made aware about the symptoms they encounter from perimenopause to postmenopause phase, and the simple and feasible methods to reduce these symptoms should be communicated to them. It is also a fact that in India the term menopause as well as menstruation is not heard of in social circles or public life. Menstruation has several taboos associated with it, and thus women do not feel free to talk about the problems faced by them during their reproductive years, although the trend is now changing at least in big cities like Delhi (Yadav 2018). Menopause is the second phase of women’s life following the end of menstruation and marks a transition from reproductive to postreproductive life. Women’s health has been largely ignored in the past, especially the postmenopausal phase. Indian postmenopausal women lead poor quality life and are dissatisfied about their health status. Postmenopausal women have to cope with the physical and psychological changes during menopause and accept their new roles in the family and society. But they need to be made aware of the changes in their bodies so that they accept them as normal phenomenon and adopt some coping methods to lessen the severity of symptoms. The family members and the society also should be sensitized regarding this issue so that women get social acceptance and emotional support from family and friends. We all understand that menstruation and menopause are the two key events in a woman’s life that change her perception about her body and expose her to physical, social and psychological turbulences. The awareness about reproductive health of women is now gaining momentum in India. Awareness about menstruation is now imparted in schools so that girls are aware about the process before they encounter menarche. It is also included in the school curriculum. Girls and young adults in urban areas are now breaking the taboos and are more open about it in social circles. They discuss the process with their family members and even male friends. These developments are helping reproductively active women to handle menstruation more confidently and lead a healthy and quality life (Yadav et al. 2018). However, similar awareness and approach are not observed for problems faced by women in their postreproductive life. There are no programmes by the government which address the problems associated with menopause. Talking about menopause is still out of question for a majority of women in India as a very large number of women still live in villages and small cities fastened by social and cultural practices. There is need for organizing awareness camps for spreading awareness about various symptoms experienced by postmenopausal women so that the understanding about various symptoms among women increases and the women are able to lead a healthy and quality postreproductive life.

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Conclusion Postmenopausal women undergo substantial physical, physiological and psychological changes which influence their postreproductive life. Women need to adopt coping strategies to deal with the symptoms during crucial transition to menopause. However, a majority of women around the globe are not aware about their needs and means to manage menopausal symptoms. The health issues of postmenopausal women can be addressed by spreading awareness about the problems they face during postreproductive life and including them in the Primary Health Care Programs by the government. Increasing the education level of the women can go a long way in the understanding of the process and its symptomatology and adoption of better coping strategies.

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Chapter 13

Examining the Lived Experiences of Ageing Among Older Adults Living Alone in India Jagriti Gangopadhyay

Abstract In the postliberalization era, a large number of older adults are choosing to live alone in urban India. With the rise of the nuclear family system, older adults residing with their adult children are gradually on the decline in the urban areas of the country. Despite losing their spouse, older adults in urban India intend to stay alone and not shift in with their adult children. Instead, older adults with financial security in urban India prefer to rely on assisted living for physical support and network ties outside the family system for emotional sustenance. To retain their own individual agency, these older adults do not favour institutional caregiving arrangements either. However, in their course of staying alone these older adults continue to face several challenges in their regular existence. Drawing from the sociological theories of modernization and everyday life, the present study highlights how majority of the middle-class older adults in urban India are opting to lead an independent existence and in the process dealing with everyday issues. Specifically, findings from this study suggest that filial ties are also changing as in their course of chartering a self-sufficient lifestyle, older adults are depending more on domestic servants, drivers and shopkeepers for their daily needs as opposed to their own adult children. In particular, this study indicates how mobility, food preferences and access determine lived experiences of ageing. By focusing on the regular concerns of older adults living alone, this study aims to shed light on the micro-issues of ageing in India. Keywords Lived experiences · Everyday life · Individual agency · Independent existence · Filial ties

Introduction In the postliberalization era and digital age, most of the older population in urban India are opting to lead independent lives. With the disintegration of the joint family system and rise of different caregiving services, a considerable number of elderly in India are choosing to stay alone. As per the Census of India (2011), the total elderly population J. Gangopadhyay (B) Manipal Center for Humanities, Manipal Academy of Higher Education (MAHE), Manipal, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. K. Shankardass (ed.), Ageing Issues and Responses in India, https://doi.org/10.1007/978-981-15-5187-1_13

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of India is 8.6% out of which 5.2% live alone. Previous studies on older adults in India have focused on filial ties, loneliness concerns, abuse, rise of institutional support and availability of social security measures. In most of these studies, the older adults either lived with their adult children or spouse or had shifted to an old age home (Jamuna 2003; Rajan and Kumar 2003; Vera-Sanso 2004; Shankardass 2008; Giridhar et al. 2014; Gangopadhyay and Samanta 2017). Very few studies have examined the issues faced by older adults living alone in India. Notable exceptions include Lamb (2005) whose study on the Bengali middle-class older adults highlights how loneliness becomes a major challenge for elderly living alone. These older adults become members of several clubs and organizations to avoid isolation and seclusion. Another study by Bhatia et al. (2007) on elderly in Chandigarh found that rates of loneliness were highest among older adults living alone, particularly elderly women. Corroborating similar findings, Agrawal (2012) in her research based on the National Family Health Survey (1998–1999) indicated that elderly living alone are more likely to suffer from chronic ailments such as asthma, tuberculosis, jaundice and malaria. In a more recent study, Samanta et al. (2015) suggested that living alone is associated with the highest possibility of short-term morbidity. To summarize, these studies advocated that while older adults are preferring to live alone, nonetheless this choice results in severe emotional and health outcomes. Despite these negative connotations associated with living alone, a lot of older adults continue to opt for independent living. In fact, while studies in India depict the adversities of staying alone, a detailed study by sociologist Klinenberg (2012) found that ‘solo dwellers’ in USA displayed more commitment towards their social and civic life. Drawing from a large number of in-depth interviews across classes, Klinenberg (2012) showed that solo living results in better mental health status and sustainable lifestyles. Drawing from Klinenberg’s work and based on empirical findings, the present chapter demonstrates how solo living is gradually becoming popular among older adults in urban India. In the process, this chapter also indicates some of the everyday problems faced by older adults staying alone in India. Specifically, this chapter highlights how individual agency trumps the regular challenges faced by these older adults. Finally, this chapter attempts to suggest policy implications for the growing number of elderly residing alone in India.

Theoretical Approaches Gerontology as a discipline has often been criticized for being ‘data rich and theory poor’ (Achenbaum and Bengtson 1994; Bengtson et al. 1997, 1999; Alkema and Alley 2006; Bass 2009; Alley et al. 2010). In particular, gerontological studies in India are data-oriented and lack theoretical underpinnings. Hence, the present chapter draws from the modernization theory of Giddens (1991) to understand the rise of independent living among older adults in urban India. Giddens (1991: 70) in his theory of modernization suggested that the ‘microaspects of society such as self and identity cannot be isolated from macro aspects such as the state, globalization and

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capitalism’. He further elaborated on this theoretical approach through the example of changing marital relationships. For instance, he suggested that with the decline of religious forces and rise of rationality, there is an increase in divorce rates (Giddens 1991). Drawing from Giddens’s modernization theory, this chapter proposes that with the weakening of family ties and influence of Western culture, older adults in urban India with financial stability are preferring to live alone. Apart from the modernization theory, this chapter also relies on the sociological theory of everyday life (Cicourel 1964; Garfinkel 1967; Denzin 1970; Douglas 1970, 1976) to understand the daily challenges faced by older adults living alone in urban India. The sociology of everyday life as a theoretical model locates human interactions in their natural context. This theoretical paradigm stresses on the natural occurrence of interactions. In particular, this perspective suggests that perceptions, feelings and emotions experienced by individuals give shape to a micro-structure (Adler et al. 1987). Building on the theory of everyday life, this study highlights how daily interactions determine lived experiences of ageing. Specifically, this study draws from the theory of everyday life to indicate how in the process of retaining their individual agency, older adults develop a new form of dependence on members outside the family system. By utilizing both the modernization theory and the theory of everyday life, this study aims to shed light on the changing filial ties, emergence of new forms of reciprocity and how older adults residing alone negotiate with their routine challenges and in their course of growing old bank on support mechanisms outside the family system.

Living Alone and the Role of Choice in Later Lives Previous studies on living arrangements in urban India have found that older adults either prefer multigenerational living or opt for institutional caregiving services in their later lives (Shah 1999; Rajan and Kumar 2003; Vera-Sanso 2004; Lamb 2009; Kalavar and Jamuna 2011; Samanta et al. 2015; Gangopadhyay and Samanta 2017). Traditionally, it was the moral responsibility of the son and the daughter and law to provide financial, physical and emotional care to their parents in later lives. Since daughters would be married into another family, older parents received all forms of support from their son/sons and their spouses (Shah 1999; Rajan and Kumar 2003; Vera-Sanso 2004; Lamb 2009; Gangopadhyay and Samanta 2017). However, with the rise of urbanization and adult children migrating to other cities and countries for employment and educational opportunities, older adults relied on external agencies outside the family system for mental and physical maintenance. As a result, India witnessed the growth of institutional arrangements, also known as old age homes, as alternate caregiving arrangements (Lamb 2009; Kalavar and Jamuna 2011; Samanta and Gangopadhyay 2016). However, recently, older adults with financial stability in urban India are gradually choosing to live alone and not relocate with their adult children or move to old age homes. These older adults are economically independent and depend upon hired help for their everyday needs. In some cases, the elderly

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are physically frail, yet they opt to live alone and rely on employed assistants for the irregular requirements (Kaul and Bhattacharya 2016; Bora 2018). Against this backdrop, the present study draws from the author’s research and adopts a sociogerontological lens to analyse the growing prominence of independent living in urban India. Most of these older adults do not want to move in with their adult children and their families because they want to live in a city they are familiar with in their later lives. Shifting to a new city requires them to get acquainted with new routes and locations, and most of these older adults are anxious that they will lose their way. Alternatively, they have to depend on their adult children or their families for going out. This limits their mobility and results in clashes with their adult children. Postretirement, most of the older men find it difficult to stay at home for the whole day. Hence, they prefer to live in a city where they have their colleagues and friends whom they can meet from time to time and remain engaged in their lives. However, relocating to a new city limits their network ties and they are forced to remain at home. Additionally, often language also acts as a barrier for these older people. For instance, a considerable number of information technology (IT) professionals regularly migrate from Kolkata to Bengaluru. However, their older parents do not want to move to Bengaluru due to language constraints and food habits. In Bengaluru, Kannada is the most widely spoken language and Bengali older adults find it challenging to extend their social capital due to their inability in understanding or speaking Kannada. Consequently, due to the dominance of Hindi in North Indian cities such as New Delhi, Agra and others, South Indian elderly face similar language barriers. In addition to language, food habits also act as a constraint for these older adults. Most of the older adults from North Indian cities such as New Delhi, Chandigarh and Agra find it hard to adjust in South Indian cities. For instance, North Indian older adults favour rotis (flatbread native to the Indian subcontinent) as opposed to the preference of rice in South India. Similarly, older adults from the eastern zone find it challenging in other parts of the country due to the limited choice of fish. Most of the older adults indicated that in their later lives they would prefer to not have too many dietary restrictions and are not willing to accommodate new food items in their regular meals. Mobility, access and cultural needs act as some of the major factors for older adults to grow old in cities of their own choice. Despite, being widows or widowers, these older adults opt to live alone because they want to retain their individual agency. The fact that these older adults are financially independent due to pension or personal savings acts as a safety net and aids their choice of independent living. Additionally, due to the rise of different agencies which provide assisted living, it has become easier for these older adults to live alone. Even in cases, where the older adult is frail and not physically fit, they chose to stay alone to retain their individual entity. Drawing from the modernization theory of Giddens (1991), it could be suggested that older adults are choosing to remain independent and self-sufficient in their process of ageing. Specifically, most of the cities in India are witnessing the rise of private agencies which offer caregiving services and assist older adults in leading an autonomous lifestyle. In particular, these capitalist ventures are enabling older adults

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to inflict their own choice and preventing them from becoming dependents on their adult children. Additionally, by living in cities of their own choice, these older adults are able to fulfil their emotional needs as well. Since they are familiar with the city, they are able to easily access grocery stores, movie theatres, cafes, restaurants, book shops and other destinations catering to their individual requirements. As a result, older adults are enabled to rely on their own selves in the course of growing old. Building on Klinenberg’s study, the present study suggests that solo living enables older adults to have a more active and independent social life. This approach to ageing also ensures harmonious relations with their adult children. Adult children are constantly worried for their older parents, hence offer personalized care through phone or visit them more often to ensure their health and emotional well-being. Hence, it could be suggested that older adults are transitioning to a new course of ageing which allows them to maintain their individual agency, choice and identity.

Regular Constraints and New Forms of Dependence Several studies have noted that due to the disintegration of the joint family system, old age homes have increased in India as alternate caregiving arrangements. Most of these homes provide accommodation, regular meals and health facilities against monthly payments (Dandekar 1996; Ara 1997; Patel and Prince 2001; Lamb 2005, 2009, 2013; Kalavar and Jamuna 2011; Kumar et al. 2012; Samanta and Gangopadhyay 2016). Despite the rise of these homes which are considered to be secure options, many older adults in urban India chose to live alone. The major reason cited by older adults for avoiding old age homes is constant surveillance. In these homes, they are under dietary restrictions and their mobility is also curbed. They are expected to follow certain rules and regulations and also adhere to the timings of the institution. Hence, most of the older adults through their narratives suggested that these homes appeared as constricted spaces and they would prefer more freedom in their later lives. As indicated, these older adults are financially independent and rely on external agencies to provide them with regular help at home. These agencies require older adults, or in case of disability, their adult children have to sign contracts and avail of their services. These contracts have certain clauses: the help will have to be retained at least for a month; an advance payment for a month will have to be made; in case the help is required to stay for 24 × 7, the older adult will have to offer three meals per day; in case of any conflict, the agency will not be held responsible. The services provided by these domestic help range from cooking to cleaning to washing to buying grocery to giving medicines on time to the older adult. In case the older adult is bedridden or paralyzed, the domestic help bathes, cleans and feeds them as well. The cost of these hired helps is determined as per the standard of living in every city. For instance, while a hired help in Delhi would charge Rs. 30,000 per month, in Kolkata for the same service, the help would charge Rs. 10,000. This distinction is simply due to the variation in wealth accumulation and quality of life in the different cities of India. Some of these older adults also hire a driver from these agencies for

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daily travelling purposes. In spite of receiving 24 × 7 caregiving services, the lives of older adults are laid with constraints. In their narratives, the older adults indicated that they had an argument with their hired help on an everyday basis. Mostly, they are not satisfied with the cooking or the way in which their house is cleaned or their clothes are washed and their grocery shopping is often incomplete. Additionally, these older adults also complained that their hired help consumes too much of food and that added to the irregular expense. Some of them also had disagreements with their drivers over rash driving and the routes taken to reach a destination. In particular, these older adults also mentioned that daily challenges such as fixing the drain or a leaking pipe or a fused tube light or a broken door knob also required them to rely on their plumbers, electricians and carpenters. This constant form of dependence resulted in annoyance and irritation among most of these older adults. In spite of their exasperation with their help, these older adults had to maintain some form of mutual understanding with their maids and drivers. This relation was established through gifts on occasions, special food and personal tips.1 Most of the older adults indicated that it was important to maintain this sort of an association with their appointed help for their own well-being. The other concern which was expressed by most of the older adults who live alone was the issue of safety. Given the rising crime rates against older adults in urban India, a considerable number of the respondents feared for their safety. As a result, many of the older adults have sold their ancestral homes and shifted to flats which are located in gated communities for better security and protection. The other important concern that these older adults shared through their narratives was their constant fear of death. The older respondents indicated that while they were not nervous of death but they were worried about their bodies after their demise. In particular, they were concerned that their bodies might decay till the time their adult children arrive. Hence, the older respondents mentioned that they hoped that at least their employed personal will inform the neighbours and make arrangements to take care of their dead body. Though living alone requires older adults to become dependent on their hired help, involves the hassle of taking safety measures and invokes anxiety over their body after death, nonetheless this form of living arrangement is becoming popular. Drawing from the theory of everyday life (Cicourel 1964; Garfinkel 1967; Denzin 1970; Douglas 1970, 1976; Lofland 1971, 1976), it may be suggested that irrespective of the daily conflicts, older adults in urban India prefer to live alone as they can keep their self-respect intact. Most of these older adults chose to have clashes with their employed help as opposed to their own adult children to avoid feeling emotionally drained. In fact, in most cases staying apart from their adult children leads to improved and strengthened intergenerational ties. The adult children are constantly worried 1 These

tips were given in the form of cash to the hired individual and were additional to the lump sum amount paid to the agency. Most of the older adults practised giving tips because the agencies did not pay the full amount to these individuals. The agencies would keep their cut from the amount received and then pay the rest of it to the hired personal. As a result, the employed help usually has a constant grievance that while they do all the work, these agencies reduce their payments through their own commissions.

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and frequently offer their support through phone and monthly visits. In particular, these changing family ties pave the path for a new kind of maya (affection) (Lamb 1999) among the older parent and the adult children. Lamb (1999) in her extensive anthropological work in Mangaldihi (village near West Bengal) demonstrated that despite conflicts, older adults find it increasingly difficult to reduce their maya over their adult children and other family members. Hence, they are troubled that ‘their soul will be bound to their body, surroundings and relationships even after death’ (Lamb 1999: 121). Corroborating similar findings, the present study suggests that living apart reduces tensions and creates greater attachment between the adult child and the older parent. Thus, based on the theory of everyday life, it could be suggested that in their day-to-day interactions, these older adults might construct reciprocal relations with their domestic help; however, in this process, their emotional bonds with their own adult children were also reinforced.

Social Constructions, Gender Roles and Ageing Majority of the gerontological studies have portrayed older Indian women as fragile and dependent and as an advocate of values and traditions. In most of these studies, the older women either live with the families of their adult children or have shifted to old age homes. These studies highlight that older women have become religious, accepted their immobility and are waiting for death (Lamb 1999, 2002, 2009; Kalavar and Jamuna 2011; Samanta and Gangopadhyay 2016; Gangopadhyay and Samanta 2017). However, gradually with economic stability older women in urban areas of India are choosing to lead independent lives. As per the Census of India (2011), around 8.2 lakh older women in urban India live alone. Findings from the present study demonstrate that older women in urban India are going against the normative order of coresiding and adjusting with their adult children. Instead, they prefer to live alone and focus on their individual needs. Most of the older women interviewed asserted that elderly females in India are perceived as weak with no mind of their own. Specifically, older widows are expected to live with their adult children and perform their household chores and grand parenting responsibilities. Prewidowhood, they are expected to follow their husband’s orders, and postwidowhood they have to listen to the dictates of their adult children. In this process over the life course, their own individual choice recedes into the background and hardly receives any attention. These older women also indicated that they had no intention of cohabiting with their adult children and their families because at every conflict usually they are projected as the dominating mother-in-law. However, this does not mean that they did not miss their adult children or grandchildren. Nonetheless, they intended to visit them depending upon their own convenience. Most of the older respondents were homemakers, and their financial incomes were either widow pensions or savings made by their late husbands. Neither of the older respondents relied on their adult children to send them monthly remittances. The older respondents did acknowledge that they were worried about their safety issues and as a result most of them relied on

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assisted living or had shifted to familiar neighbourhoods. By living on their own, these older women are maintaining their dignity and also coming across as self-sufficient beings. Specifically, these older women intended to fulfil their own desires in their later lives. They emphasized that over the life course they have fulfilled their duties as a responsible wife, daughter-in-law and mother. In their later life, they planned to devote time to their personal requirements. In particular, a large number of the older women respondents mentioned that they spent their time travelling through package tours and that gave them immense satisfaction. Some of the older women respondents mentioned that they were postholders of different charity organizations and through these positions they were able to add meaning to their later lives. In fact, postwidowhood these new forms of responsibilities and roles helped them to overcome their grief and attain inner peace. In addition to remaining engaged, these women through their narratives emphasized that they are also changing the general perception of growing old associated with older widows. Several studies have suggested that women give more importance to their bodies as opposed to men. Specifically, these studies have demonstrated that larger external forces such as capitalism and consumer culture also induce women to focus on their bodies (Diprose 1994; Weitz and Kahn 1998; Frost 2001; Tiggemann and Lynch 2001; Hofmeier et al. 2017; Cameron et al. 2018). Subsequently, a few studies have also highlighted that with age, older widows are expected to accept their bodily decline and also reduce their regular social life. In particular, these studies have indicated that older widows are more vulnerable and are financially at a disadvantageous position (Chen and Dreze 1995; Agarwal 1997; Lamb 1999; Reddy 2004; Agrawal and Keshri 2014). However, this notion of older widows is gradually changing in urban India. The older widows who were part of the study mentioned that they relied on various beauty products, diets and exercises to appear as fit and active. Most of these older widows have also transitioned to Western outfits and ditched the traditional Indian sari for comfort and convenience. In fact, most of the female respondents had become widows at the age of 60–65 and as a result they did not change their lifestyles. These respondents highlighted that they cannot change their ways of dressing, eating or having a social life because of certain norms attached with widows in Indian society. Based on the overall findings, it could be suggested that older widows in urban India are transforming the process of growing old. Drawing from the modernization theory of Giddens (1991), it could be indicated that due to globalization and the influence of Western culture, it has become easier for older women to focus on their selves. Specifically, these larger macro-forces have played an important role in changing the traditional kin keeper image of older women in India. For instance, the emergence of various agencies which provide hired help to the elderly has enabled most of these older women to lead an independent existence. Hence, backed by financial stability, these women are able to retain their individual agency and have a gratifying old age. By choosing to remain self-reliant, these older women are blurring gender ideologies in later lives. Additionally, these women are aware of their everyday challenges and as a result they take various preventive measures to ensure their own safety,

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mobility and convenience. Acknowledging the transition of older women in urban India, the older male respondents also believed that both older men and women should have access to equal opportunities and in order to have a satisfying old age. In particular, both older men and women urged that while gender norms are changing in their later lives, nonetheless, it is important to eradicate age-related discrimination in the country.

Policy Implications With the rising number of elderly living alone in urban India, it is important for the state to take note of this demographic shift and design effective policies accordingly. At present, one of the biggest challenges faced by older adults choosing to live alone is the issue of safety. Most of these older adults have had to sell their ancestral property and move to gated communities for better security reasons. Since they are relocating to a new society at such a late stage in their lives, it takes considerable amount of time for them to develop reliable network ties. This problem of safety has become extremely acute in metropolitan cities of India, where older adults living alone have emerged as the most vulnerable group. As a policy measure, it is important for the Government of India to create emergency helpline numbers which can be reached out at times of a crisis. Additionally, the state also has to plan awareness campaigns among older adults living alone to ensure that they avail these helpline numbers. In addition to creating helpline numbers, the central government can request the individual state governments to tie up with the police station of every locality to make routine checks in those particular houses and societies which are the abodes of older adults living alone. These regular checks will reinstate confidence among older adults and also provide considerable protection. The other major concern that older adults who have opted for independent living have to deal with is the dependence over hired help from different external agencies. Most of these employed staff display rude behaviour towards the older adult, and majority of them lack training in providing caregiving services. Majority of these agencies provide poverty-stricken urban migrants as domestic help and charge exorbitant rates for their services. As a result, most of these staff are non-professional and are not able to perform their expected responsibilities. In fact, in case the older adult living alone has some of disability it is also risky to rely on such untrained personal. Hence, it is important for the Central Government of India to intervene and regulate these agencies. The government should stress on the background and qualification of the domestic help who is being sent to the older adult’s residence. Most of these agencies do not have any proper license, and often the client has to pay the full amount in advance. In particular, the government needs to put in place a structure for these agencies and also set up committees which can regularly check on their functionalities and their enrolled staff. In fact, given the demand of such staff for older adults, the state should arrange training camps and opportunities for these agencies where they can train their employees in palliative care and then send them

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to their clients. Proper guidance will certify to a large extent that the hired help has some form of qualification to serve the older adult. It is important for the government to realize the importance of these forms of agencies and their employees in the lives of older adults living alone and cater to their needs subsequently. Older adults in India have to deal with a number of issues. These concerns range from abuse to ageism to safety to intergenerational dispute. However, there are very few civil societies or bodies to address these problems. The major non-governmental organization that deals with older adults and their challenges is HelpAge India. The HelpAge has several offices all over the country, and they provide mental and physical health support to older adults all over India. For instance to reduce feelings of loneliness, the HelpAge across India organizes several events which involves the participation of older adults. They also provide constant counselling services to older people dealing with abuse and property disputes with their adult children (HelpAge India Website). The other major civil body that focuses on the issues of older adults in India is the Agewell Foundation. This organization conducts surveys in different regions of India and understands the major challenges encountered by older people. Their surveys focus on abuse, abandonment, health and well-being, loneliness and ageism. They also have helpline numbers, and their volunteers interact with older adults regularly to enhance their overall welfare. They also provide various training programmes for different stakeholders such as the Delhi Police to create awareness regarding the rights of older people (Agewell Foundation Website 2018). However, apart from these two NGOs, there are no major civil bodies which are dedicated to the problems of older adults in India. Hence, from a policy perspective, it is important for the Government of India to open some state-funded NGOs which will be committed to work for the needs of older adults in India. Finally, while many older adults are selecting to live alone in urban India, the situation is different in rural India. The number of older adults living alone in rural India is also increasing. These older adults are devoid of financial security and are poverty-stricken. The Government of India could launch the ‘Adopt a Grandparent Scheme’ and urge families without older parents but with monetary stability to adopt an abandoned and poverty-stricken older person. This will help to condense the number of older adults who have been left alone by their family members and also lessen the burden of poverty among elderly in rural India. It is important for the Central Government of India to understand and examine the problems of the older adults from the policy level because as per the reports of the Census of India (2011) and the United Nations Fund for Population Activities (UNFPA) (2017), the major statistics indicate that there is a rise in the older adult population. Gradually, with medical advancement, India is bound to witness the growth in the elderly population and will have to deal with their financial and emotional challenges as well. Specifically, in the urban areas, the older adults with economic stability will encounter other issues such as safety, access and mobility. Thus, the Government of India needs to acknowledge this demographic transition and frame its policies accordingly.

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Concluding Observations This chapter began by examining the sociological causes for the rise of independent living among older adults in urban India. In the process, the chapter also focused on the everyday challenges encountered by these older adults. Additionally, the chapter also highlighted how gender equations are changing in later lives among older adults with financial stability in an urban setting. To bridge the gap between data and theory in Indian gerontology, the chapter also drew from major theoretical frameworks to substantiate the findings of the study. Finally, to improve the overall well-being of older adults living alone in urban India, the chapter suggested some policies which could be considered by the Central Government of India. In closing, the chapter will draw from the main findings of the study and shed light on some of the major themes which emerged from the study. The narratives of the older adults indicated that retaining of dignity and individual agency gets precedence over cohabiting with adult children. Specifically, to avoid regular clashes, adjustment issues and emotional turmoil, older adults in urban India are preferring to live alone and rely on their own selves in the course of growing old. In particular, their financial security is acting as a safety net which enables these older adults to forge an independent lifestyle. In fact, staying apart from their adult children and their families has strengthened intergenerational bonds. However, this form of living arrangement has created a new form of dependence among these older adults. In their course of living alone, the older adults have to rely on several external agencies for domestic help to satisfy their everyday needs. Hence, it could be suggested that older adults choosing to live independently is giving rise to new kinds of filial ties and changing the family system in India. Despite, living apart adult children are fulfilling their reciprocal roles through emotional support. They are relying on phone calls and monthly visits to look after their parents. On the other hand, the older parents are moving away from the traditional support system of adult children and banking on external resources for caregiving services. Against the backdrop of the modernization theory and the theoretical framework of everyday life, it could be suggested that older adults with monetary stability in urban India are becoming self-sufficient and in the process are also willing to deal with daily challenges in their later lives. By examining the experiences of growing old among older adults living alone in urban India, the present study hopes to expand the intellectual scope of family sociology and social gerontology in the South Asian context.

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Jamuna, D. (2003). Issues of elder care and elder abuse in the Indian context. Journal of Aging and Social Policy, 15(2–3), 125–142. Kalavar, J. M., & Jamuna, D. (2011). Aging of Indian women in India: The experience of older women informal care homes. Journal of Women & Aging, 23(3), 203–215. Kaul, R., & Bhattacharya, S. (2016). Alone and ageing in India: Here’s how to reach out and help our elders. Hindustan Times. Accessed at https://www.hindustantimes.com/healthand-fitness/alone-and-ageing-in-india-here-s-how-to-reach-out-and-help-our-elders/storyTYezRIkIhcTTJ4qYSYCiOJ.html. Klinenberg, E. (2012). Going solo: The extraordinary rise and surprising appeal of living alone. New York: Penguin Books. Kumar, S. G., Roy, G., & Kar, S. S. (2012). Disability and rehabilitation services in India: Issues and challenges. Journal of Family Medicine and Primary Care, 1(1), 69–73. Lamb, S. (1999). Aging, gender and widowhood: Perspectives from rural West Bengal. Contributions to Indian Sociology, 33(3), 541–570. Lamb, S. (2002). White saris and sweet mangoes: Aging, gender and body in North India. Berkeley: University of California Press. Lamb, S. (2005). Cultural and moral values surrounding care and (in)dependence in late life: Reflections from India in an era of global modernity. Care Management Journals, 6(2), 80–89. Lamb, S. (2009). Aging and the Indian diaspora: Cosmopolitan families in India and abroad. Bloomington: Indiana University Press. Lamb, S. (2013). In/dependence, intergenerational uncertainty, and the ambivalent state: Perceptions of old age security in India, South Asia. Journal of South Asian Studies, 36(1), 65–78. Patel, V., & Prince, M. (2001). Ageing and mental health in a developing country: Who cares? Qualitative studies from Goa, India. Psychological Medicine, 31(1), 29–38. Rajan, S. I., & Kumar, S. (2003). Living arrangements among Indian elderly: New evidence from national family health survey. Economic and Political Weekly, 38(1), 75–80. Reddy, P. A. (2004). Problems of widows in India. New Delhi: Sarup. Samanta, T., & Gangopadhyay, J. (2016). Social capital, interrupted: Sociological reflections from old age homes in Ahmedabad, India. In T. Samanta (Ed.), Cross-cultural and cross-disciplinary perspectives in social gerontology (pp. 109–124). New Delhi: Springer India. Samanta, T., Feinian, C., & Vanneman, R. (2015). Living arrangements and health of older adults in India. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 70(6), 937–947. Shah, A. M. (1999). Changes in the family and the elderly. Economic and Political Weekly, 34(20), 1179–1182. Shankardass, M. K. (2008). Critical understanding of prevalence of elder abuse and the combating strategies with specific reference to India. Indian Journal of Gerontology, 22(3–4), 422–446. Tiggemann, M., & Lynch, J. E. (2001). Body image across the life span in adult women: The role of self-objectification. Developmental Psychology, 37(2), 243–253. United Nations Fund for Population Activities (UNFPA). (2017). India ageing report. Accessed at https://india.unfpa.org/sites/default/files/pub-pdf/India%20Ageing%20Report%20%202017%20%28Final%20Version%29.pdf. Vera-Sanso, P. (2004). “They don’t need it, and i can’t give it”: Filial support in South India. In P. Kreager & E. Schröder-Butterfill (Eds.), Ageing without children: European and Asian perspectives on elderly access to support networks (pp. 77–105). New York and Oxford: Berghahn Books. Weitz, R., & Kahn, S. (1998). The politics of women’s bodies: Sexuality, appearance, and behavior. Oxford: Oxford University Press.

Chapter 14

Revered or Abused: Exploring Reasons for Abuse Within Family from the Narratives of Three Elderly Women in Chennai Asha Banu Soletti and P. V. Laavanya Abstract Though elder abuse is evident and documented in Indian context, the understanding of abuse revolves around specific themes or prevalence, types of abuse, the perpetrators and the interventions. This paper attempts to move beyond the definitions and types and intends to document older women’s experiences of abuse. The study borrows from the narratives of older women living in Chennai, and the themes are derived from the narratives. The themes indicate that the instance of abuse happens because of many social processes—both micro and macro. The micro-processes involving individuals and families had been attentively studied; however, the macroprocesses such as migration, globalization and privatization of health care have been overlooked and its relationship with elder abuse still needs further exploration and investigation. Keywords Elder abuse · Women · Families · Narratives · Qualitative study

Introduction Population ageing was never perceived as a concern in India till recently. Filial piety is considered as a key virtue of Indian culture. This phenomenon was seen across the cities and states in India as most of the families believed in the values of joint family system and community living. However with the advent of globalization, Indian society started experiencing socio-economic, cultural and technological transformation through education, modernization and industrialization. Since the 1990s, India is moving towards global markets and rapid urbanization. In this context, the aspiration of the younger generation and their migration to different cities due to employment has gradually marginalized elderly members in the family. We can see the transition in the family structure and also changing roles of members within the family. A. B. Soletti (B) School of Social Work, Centre for Health and Mental Health, TISS, Mumbai, India e-mail: [email protected] P. V. Laavanya Mumbai, India © Springer Nature Singapore Pte Ltd. 2020 M. K. Shankardass (ed.), Ageing Issues and Responses in India, https://doi.org/10.1007/978-981-15-5187-1_14

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Globalization and urbanization have demonstrated India to be a fast growing economy. However, such societal transformations have an effect on the families in India. It is affecting the status of elderly in India (Jamuna 2000). Apart from the transitions mentioned above, demographic transition in India is directly challenging the policymakers to draw plans to handle issues of growing elderly population. It is also observed that ageing in India is not a uniform phenomenon. According to the Census (2011), the population ageing is rapidly growing in the southern part of the country compared to the northern region. These regional differences of demographic variation make it more difficult to draw universal programmes or schemes for senior citizens. Also, there is such diversity among the elderly and the problems they face, in terms of age, gender, health, class and caste. In the absence of a sound policy framework that captures the whole gamut of diversity, elderly in India face numerous challenges such as economic insecurity, isolation, neglect and abuse. Among the numerous issues, elder abuse is least explored and least talked about. The existing work does not capture the context in which the abuse occurs and thus the complexities associated. The paper is an attempt to capture the phenomenon of elder abuse within the larger milieu and social science literature and to provide an explanation to the existing reasoning about elder abuse.

Defining ‘Elderly’ Ageing can be understood from biological, psychological, cultural, social, legal and social policy perspectives. From a biological perspective, chronological time assumes key part. On the other hand, from the cultural and social perspective age is a social construct and is related to the roles assigned to older people. As far as legal and social policy perspective is concerned, a cut-off year that is 60+ years is referred to as older population (Gorman 1993). However, there is no general agreement on the age at which a person becomes old. Nevertheless, for practical reasons the social policy/pension perspective is taken into account. Hence, the chronological age of 60 and above is defined as ‘elderly’ or older person.

Ageing in India Population ageing in India is of recent origin. It is a result of a demographic transition. The demographic transition has occurred as a consequence of decline in fertility rate and mortality rate over a period of time (Alam and Mukherjee 2005). A glance at the national census over the past three decades (Census 1991, 2001, 2011) will show that the elderly population (aged 60 and above) in India has increased from 56.5 million to 103.2 million, an increase of 46.7 million people between the age group of 60 and 99 years over a period of 30 years. The demographic transition in India has brought an inevitable challenge of caring for our elderly.

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The increasing population of elderly in India is perceived as a ‘challenge’ rather a ‘celebration’. This might be because of an increase in the age dependency ratio, where the relatively younger adult, i.e. working population, has to bear the responsibility of the larger group of older people. Secondly, the heterogeneous nature of the Indian population largely stratified by class, caste, geographical location, gender, regions and culture has posed the questions of care, social security, safety and overall wellbeing of elderly population. The joint family system that existed in India valued and respected elders. But with the advent of the modern nuclear family arrangements, with small and clogged spaces in urban areas, the elders are more often perceived by their children as a burden. The changing family structure as well as the forces of modernization has negatively impacted the lives of the elderly population, making them susceptible to loneliness, negligence and less importance, illness due to ageing and lack of treatment options (Kumar and Bhargava 2014). Envisaging elderly people as a homogenous group and their experience of ageing as uniform is a serious methodological problem. Vincent (2003) has written on how elderly people have heterogeneous experiences owed to social stratification—a key social process in the Indian subcontinent. Social stratification plays an important role in adverse social exclusion of elderly in various spheres of life. Hence, it is important to understand social stratification in order to capture the challenges and issues of the ageing population in India. Elderly women’s experiences are not the same as those of elderly men. In fact, even amidst women from different social positions, they perceive and experience ageing differently in our country. The demographic transition, on the other hand, has also brought the crucial issue of ‘feminization’ of ageing. According to the UNFPA (2012), the percentage of widowhood (59%) is high among elderly women and they face multiple layers of discrimination of being old, being women and being poor (WHO 1998). They are also imposed with multidimensional resistance in their social location and lack of gender-sensitive social securities. Indian feminists argue that achieved social position has not given women equal status with men, even within their own social location. Patriarchy is cross-cutting across the stratification, thereby giving women in India a dependent and subordinated position. As a consequence, older women from various social positions have to make negotiations and are faced with challenges when they insist on being treated equal to men in their own community. Elderly women experience domestic violence, prejudice in terms of income, food, meaningful work, health care, inheritances, social security and political power (WHO 2002). Action on Elder Abuse (1995: 11) defines elder abuse as a ‘single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person’. WHO defines elder abuse as ‘a single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person’ (2002: 3).

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Elder abuse has been described as intentional actions that cause harm or a risk of harm or as a caregiver’s failure to satisfy the basic needs and safe living conditions of elderly. It includes physical abuse, psychological abuse, negligence, material exploitation and sexual abuse (Cohen et al. 2006).

Towards Research Question This paper attempts to move beyond the definitions and intends to document older women’s experiences. The understanding of abuse revolves around specific themes or prevalence, types of abuse, the perpetrators and the interventions. Abuse often is defined and articulated as an act or an instance. But this paper wants to infer the emerging themes on abuse from the narratives of older women, and also the factors that lead to the abuse of older women.

Research Methodology In social science research, there are diverse viewpoints of social reality, and social scientists take different standpoints while examining this social reality (Chapman and McNeil 2005). Hence, choosing the appropriate methodology and research methods is a matter of choice and logic. Phenomenology (a stream in qualitative research) is adopted in this study as the research engages in understanding elder abuse. Phenomenological research emphasizes on subjectivity and discovery of the essences of experiences. It provides a systematic and disciplined methodology for derivation of knowledge. The purpose of the phenomenological approach is to illuminate the specific and to identify phenomena and how they are perceived by the actors in a situation. In the human sphere, this normally translates into gathering ‘deep’ information and perceptions through inductive, qualitative methods such as interviews, discussions and participant observation, and representing it from the perspective of the research participant (Lester 1999). The research study is conducted in Chennai. The researchers had three rationales for conducting the study in Chennai. Firstly, Chennai is situated in Tamil Nadu, which is experiencing population ageing (Census 2011). Secondly, Chennai being a metropolitan city, the probability of interviewing elderly from diverse social positions in the same geographical location can be comparably advantageous. Thirdly, in qualitative studies, especially in phenomenological studies, language has a vital role in articulating descriptive narratives. Both the researchers are comfortable with Tamil which is their native language. Hence, the phenomenological research had all the three aspects that benefit the study. Information-rich case sampling, a form of purposive sampling, was used in the study. Patton (1990) says that the logic for purposive sampling is selecting

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information-rich cases for the study. According to him, information cases are those cases that give rich information about the issue of importance understudied. In this study, the elderly women of above 60 years, who have experienced abuse of some form and are from one social position or other (characterized by caste, marital status, employment and educational background), were taken as sample frame. Three samples were finally taken for the study after obtaining permission from them.

Phenomenological Narratives Narrative 1: Ms. Kasturi Kasturi belongs to a Marwari family from Rajasthan. Her husband runs a pawnbroking shop in South Chennai. Their shop is part of her three-storeyed house. She has four children. Her elder son lives with them on the first floor. Kasturi’s day begins at 5 a.m. She says her prayers for two hours and performs all the rituals on an empty stomach. She religiously follows all the prayers and makes sure that her husband’s needs are met. She goes to the market every day and buys fresh vegetables for lunch. She manages her husband’s shop in the afternoon, when he takes a nap. She starts: I was married at the age 16. Now, if I think, it is too early for a girl to be married. It was my step-mother who insisted that I should get married. I had just completed my tenth standard in Chidambaram (a town and municipality in Cuddalore district of Tamil Nadu). My father had a gold jewellery shop. My mother died when I was in the second standard. I had two elder brothers and one elder sister. My father got married in the next few years. I had two step-brothers and one step-sister. My step-mother took care of me well. She insisted that I get married soon because I had dark skin compared to most of the women in my community. My step-mother was afraid that I might not get a suitable partner in my community. So I was asked to discontinue schooling after tenth standard and got married to this person.

Kasturi and her husband have a cup of tea around 4 p.m., and then she gets herself ready to take evening tuitions. She cleans the living hall for tutoring children for Hindi. Her Hindi classes begin around 5.30 p.m., and it goes up to 7 p.m. Nearly 10 students attend her Hindi tutorials on alternative days. She charges them 1500 rupees per month. She feels encouraged and motivated with the tutorial classes as it has reduced her stress over income and how to meet the day-to-day expenses of her family. She recollects: I always wanted to study. But because of my colour, I had to get married. I am glad that I expressed my interest to study further to my husband. He understood my desire to study and suggested that I continue my education through distance education. I completed my predegree course, graduation, post-graduation and pre-doctoral degree course in Hindi. During the process of my education, I also delivered four children. My mother-in-law, who died a decade ago, was not aware that I have so many degrees. All this was possible because of my husband’s effort. My own brother, who retired recently, was a college professor, but he

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did not encourage me or his wife to get educated. I am fortunate to have a life partner who encouraged my desire for education.

Kasturi manages her household chores and medical expenses from the income she receives through the tutorial classes. The income from her husband’s business has now reduced. Moreover, her sons are not interested in joining their father’s business. Since all her children have completed postgraduation and are into their own businesses and consultancy firms, they want their father to close the shop. Kasturi is currently recovering from poor health due to her surgery. She and her husband have used most of their savings in the hospitalization and recovery process. They are now worried because there is no guarantee that their children will take care of them in future if such an emergency arises. This makes Kasturi a little worried about the future. She shares: I had undergone a hysterectomy surgery a year ago. My husband had to sell few gold ornaments of mine that my parents gave me during my marriage. My children couldn’t help us, as they had their own family commitments. It was my younger son who supported us by paying the hospitalization fees partially.

She continues: I was a little upset that there was no one to take care for us. My daughter-in-law is working and my daughter lives abroad. My son and his family visited me. My elder daughter- inlaw prepared food for me and for my husband. The hospital expense was high and we couldn’t negotiate and we didn’t have any insurance. I was not aware that I will get such health problems. We didn’t save any money for ourselves. We spend all our earnings on our children’s education and for their marriage. We only have a house to stay now.

After her surgery, Kasturi started paying for her own and her husband’s health insurance. Kasturi always had the desire to work, but her husband was not cooperative. Although he supported her to get educated, he expected her to perform her role as wife, daughter-in-law and a caring mother. He was particular that she does not deviate from these roles. She elucidates: I am an educated mother. But I never moved from the role of a dutiful daughter-in-law. I feel that I am not respected. I agree that times are changing, but I believe that respect for elders does not change with time.

Kasturi thinks that her health has started deteriorating after the surgery. She was advised to take rest and not to lift heavy things, not even a bucket of water. She has hired a maid for her house, referred to her by a friend from the community temple. She has to pay her 2000 rupees for cleaning and sweeping the house, and washing the vessels. Her youngest son supports her by paying the maid’s salary. Kasturi regularly visits her community temple. The temple is the place where she feels more connected and respected. She attends all the poojas and sings with the group. She believes her presence is felt more in the temple than at home.

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She elucidates: I feel it more meaningful when I visit the temple than when I’m at home. I am happy to meet my friends in the temple. We share our thoughts and read religious books together. I feel more accepted and respected in the temple.

Kasturi usually sleeps around 10 p.m. Of late, she gets disturbing thoughts about the future and is also haunted by the responsibility of finding a bride for her younger son. She wakes up in the middle of the night and drinks water. Apart from these issues, her major concern is about her husband’s health and her two sons’ constant pressure on her to sell the house. She narrates: Now-a-days, I don’t get peaceful sleep. The thought of my younger son keeps coming repeatedly. I feel responsible as a mother to find a suitable bride for him. I am worried about who will take care of my husband after my death. I could see my children, especially my two elder children, wanting that we sell the property and divide the share. My husband recently changed the property in my name and my elder son was upset that we didn’t sell the property. He also demands for financial assistance for his business. I feel children mustn’t depend on older parents for financial assistance as we have spent a lot of money on their education. I feel hurt when they keep pestering me for money. I work hard and saved some money for my husband’s health. Children have to treat their elderly parents with respect, seek their guidance and not ignore their presence, when they become old.

She is apprehensive about her children’s constant compulsion to sell the property to a builder. Kasturi is promised that she will get a single-bedroom flat in the same place if the property is sold to the builder. Nevertheless, she does not want to sell the property till she is alive. She feels secure when her husband is around her, much more secure than she feels about the single-bedroom flat. In this case, abuse cannot be seen as a stand-alone instance or categorize it as financial abuse or physical abuse, but we have to see how abuse is experienced by the women and embedded influencing many facets of their lives.

Narrative 2: Ms. Karpagam Karpagaamma works as a cleaner in Government General Hospital, Chennai. All the ward staff is very fond of her work. She has been working as a cleaner for the past five years. She sleeps in the same ward. She sleeps on a blanket at one corner of the ward, wakes up early in the morning to clean the toilet and bathroom and sweeps the ward. She drinks tea in the staff canteen and also brings tea for the nurses in the ward. She begins: Ward number 233 has become my house for the past five years. It will continue to be the same till I die. I am lucky to have good people around me. All the nurses and doctors treat me with respect. I realised only hard-work provides food and shelter. The doctors and nurses have become my family members in the past five years. When my sister asked me to leave her house, I was shocked and didn’t know what to do. It was one of my relatives who asked me to join the hospital as cleaner. When I started working at the hospital, I was scared about

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the doctors and nurses as I have never worked in a hospital setting. They assigned me the duty of cleaning up the toilet, bathroom and sweeping the ward twice a day and whenever necessary. They started liking me from the second month of my job. I decided to continue the work. I used to sleep in the corridor outside the hospital. Once my ward’s staff nurse saw me and asked about my family. I said that I don’t have a place to stay. The staff nurse requested me to sleep inside the ward from that day onwards.

Karpagaamma has studied up to the fifth standard. She had seven siblings, of which only four survived and Karpagaamma is the seventh child. Her father was a tailor, and mother was a housewife. She discontinued school as she found it difficult to study English in the school. She and her siblings helped her father in the tailoring work. Her father owned a tailoring shop. When Karpagaamma was about to get married, she lost her father during the week of her marriage. She recounts: After my father’s death, my family had no guidance or support. My marriage didn’t take place, and my brother was very young to take up the responsibility of arranging for dowry, which my father had promised them. I started working in a manufacturing company that packs soft drinks; I used to stick labels on nearly 100 soft drink bottles in a day. My mother saved money from my salary for my wedding. Later, I was married to one of my brotherin-law’s relative. My husband collected milk from the dairies and distributed it in the city every day. He earned 700 rupees per month.

She continues: I didn’t go for work after the marriage as I had three children. I have two sons and one daughter. My husband got into a habit of drinking, and spent most of the money on alcohol. I started working again to feed my children. I used to drop my children at my mother’s house and worked in an aluminum workshop nearby. I got my children admitted in a good school. As I was not educated, I wanted my children to be educated so that their life would be secured. Unfortunately, one day I saw my two sons playing in the park rather than attending school. I was really upset and didn’t know what to do. I punished them, but still they repeated the same. I asked them to come with me to the iron smith and work, so that they would realise the hard work I put in. They started helping me and told me that they like working rather than getting educated. They felt like they were not motivated much in the school. I started taking them for iron smith work. As they grew up, my elder son learned driving and became a driver in the market and my younger son began working in a packaging company.

Karpagaamma’s children are married. They live in different places. Her daughter lives in another district of Tamil Nadu. After Karpagaamma husband’s death, she decided to stay alone as her sons showed little interest in accommodating her. It was her elder sister who asked her to stay with her. She elucidates: I lived with my elder sister after my husband’s death. I lived with her for eight years. I use to wake up at 4.30 am, wash the utensils and help my sister with cooking. I didn’t live like a guest in her house. I went to work from her house. She asked me to move out of the house as I was not helpful in taking care of her grand-daughter. She asked me to pay her 50,000 rupees before I leave her house, claiming that it was the amount that she had spent on me while I stayed at her house. I was really upset. I didn’t know what to do. I gave all the money I had saved to my sister, which was around 40,000 rupees. I shared this with another relative who worked at the hospital. She told me to apply for the housekeeping job at the hospital. I went and registered at the agency. I got the job in the hospital for a salary of 3,500 rupees per month and took shelter at the hospital ground.

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She continues: Once I fell sick. I didn’t have anyone to take care for me. The hospital official asked me to call my daughter. Unfortunately, my daughter was the bread winner of her family, and she had one daughter and one son. Her husband had become a paralytic because of his alcoholic behaviour. Her daughter worked as a daily wage worker in a construction company. If she did not go to work, she had to borrow money on interest. After hearing my life story, the staff nurse took care of me like her mother.

Karpagaamma felt proud to take responsibility of the ward. She is appreciated by the doctors who visit the ward. She is not transferred to another ward because the staff wants her to be in the same ward. The hospital staff has not received any complaint from the patients. She visits each bed in the ward and gives the patients hope that they will recover soon. The staff likes her so much that she does not have to worry about her daily meals. She gets her breakfast and lunch from the staff. She is so overwhelmed by their care. She pours out: I don’t think even my parents and husband has shown the kind of care shown by the hospital staff. I am thankful to God. Once upon a time, when my sons refused to accommodate me in their house, I started believing that God didn’t exist. But I believe now. God gave me the work and health so that I don’t have to depend on anyone. I have now started praying that I should die in the same ward.

She continues: I save my salary to give my children money whenever they need it. I visit my sons once in a month. I support them with whatever savings I have. Today evening, I am going to visit my elder son to give him 50,000 rupees as he needs the money to repay the borrowed money. I trust him. Anyway, he is the one who is going to set fire to my pyre on the day of my funeral. I didn’t tell this to my younger son and daughter. But I do give them money whenever they need it as well. I want my son to do the last rituals. I do not want to be thrown as an orphan on the road. This is what I expect from my children. I pray that my health should be fine. I can’t read properly now-a-days. I have shared this with the nurse in the ward. I am planning to go for an eye check-up in the hospital

Narrative 3: Ms. Lakshmi Lakshmi works as an honorary doctor in a non-governmental organization. In the evening, she visits her own clinic at home. Lakshmi retired as a chief doctor from ESI hospital. She loves attending to her patients’ needs. She wakes up around 6 a.m. and starts her day with short prayers. She prepares breakfast for her mother and for her elder sister. She attends to her sister and mother’s needs and leaves to work in an auto rickshaw around 10 a.m. She begins: I like my profession so much that I just can’t sleep without seeing at least one patient a day. It gives me more satisfaction and adds meaning to my existence. When my father wanted me to learn shorthand, I refused and expressed my interest for medicine. As I was adamant, he

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agreed, and I joined a medical course. My elder sister joined in a central government office and I joined the ESI hospital after my studies. My two younger brothers are engineers and my younger sister is not as educated like us. We felt it was good for her to get married and have a happy life than to be single.

Lakshmi’s father had his own business of hardware. He used to travel very often. It was her mother who took care of the family independently and managed household chores and the children. It was a breakdown for her and for the family when they heard about their father’s relationship with another woman. She elucidates: I had a lot of respect for my father. He always told us to be proud of our caste because I used to feel isolated sometimes in college because of the caste I belonged to. But my father wanted me to work hard, and focus on our studies. As my father had his own business, he didn’t have any financial problems; we used to wear decent dresses to college.

She continues: All the respect I had for my father vanished when I heard that he has another family. I didn’t want to trust any man anymore in my life, when my father disclosed his relationship with another woman. My mother was willing to forgive my father as he took care of the family well. I started hating him more when my sister’s marriage proposal was rejected because of my father’s affair. We had our own house and some properties, but my relatives started suspecting our behaviour. At one stage, my mother felt that it was my sister’s fate for not getting married and not because of my father’s affair. As days went, my sister showed less interest in marriage and we both decided to remain single, thinking of our two younger brothers’ and our younger sister’s future. My sister and I took up the responsibility of nurturing our brothers and sisters, as my father decided to stay with his second wife.

Rani and her siblings live in the same compound. She lives in a house with her mother and elder sister. Her brothers and sister live with their families in the row houses built inside the compound. Her younger sister solely depends on her for financial assistance. She recounts: We wanted our younger sister to get married at a young age because my mother wanted to see her married before she died. As per the wish of my mother, she got married once she completed her higher secondary school education. Unfortunately, our brother-in-law turned out to be a alcoholic. He tortured my sister for money. She blames us for the situation. I never thought of this situation in her life. Her husband denies her money for managing the house. She is dependant on us for her needs and for her schooling son’s needs. My sisters-in-law don’t want to live in the same compound. There is pressure on us from our brothers to sell the property. I am really upset with my family circumstances.

She continues: After my retirement from active service, my confidence of handling family issues has reduced. I want to run away from the family commitments. I have started to feel that my family members perceive me as an ATM machine.

Lakshmi is upset that her brothers are not willing to care for her elder sister and her mother, who is often falling sick. Although Lakshmi is 62 years old, still she

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cares for her elder sister, who is 66 years old, and her mother, who is 82 years old. She has to take up a job in order to meet the needs of their medical expenses. She pours out her heart: I don’t depend on my family members for financial needs. I expect only care and concern. I could see my younger sister in a helpless situation. On the other hand, my brothers have taken me for granted and my nephew and niece turn to me for pocket money. I can’t say no to them. If I say no to them, they don’t talk to me. I have faith in them that they will take care of us once they get a job. Sometimes, my half-brother visits us. They are caring towards my mother. My mother wanted me to care for my half-brothers too.

Lakshmi feels that her family members perceive her as a motherly figure. They all turn to her for help, both financially and emotionally, but she associated herself with the identity of a doctor. She makes sure that her health is in good shape. She never communicated to her family members that they are demanding, but expressed it through irritation and anger. Her family members take decisions without her consultation. But if expenses are involved in those decisions, Lakshmi is asked to contribute. This adds to her irritations. Thus, it is Lakshmi who provides for the family. Her life after retirement is stressful. She manages the stress by taking a walk every day. Her central position in the joint family gives her joy and happiness even though it is demanding most of the time. She worries about whether she will be respected if she does not support her family through her income. She has these doubts especially when her nephew and niece get angry with her if she fails to give them pocket money.

Discussion (a) Basic Necessities The narratives of three elderly women suggest that their families give less care about ensuring basic necessities in their old age. Ms. Kasturi’s sons are unable to support their parents financially for their day-to-day expenses; instead, they expect support from their parents. Kasturi and her husband realized late that they have no savings to care for themselves in old age and she decided to take up her first job in late years. Still her children fail to understand the responsibility towards them because they themselves find it difficult to manage their life demands in the social context with respect to work and to their own family. Her children are more concerned about maintaining the social status and are pushing the needs of their elderly parents as least in their priority list of their family. In case of Karpagaamma, her family itself is in poverty. Her children are unable to handle their own issues. In this scenario, they give preference in fulfilling the needs of their nuclear family members. Her children find it difficult to accommodate their dependent mother with their family as they live in cramped place in the suburbs of the Chennai city. Karpagaamma decided to fight her own poverty and chose not to be a burden for her sons and understood that poverty has strained the relationship between her children and herself.

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In contrast, Lakshmi’s financial status makes her vulnerable. Her siblings demand and depend on her financially, and she had to bend to their needs because of the fear of losing shelter and safety. Being a spinster, she is dependent on her brothers for safety and security and losing joint family arrangement can make her vulnerable. She accepts the demands of their brother’s family even after knowing their abusive behaviour. (b) Material Resources Lakshmi and Kasturi had a privilege to live a life away from poverty and never worried about it in their earlier days. However in their ageing days, both have shared experiences of conflict within the family because they have property in their names. Their siblings and sons often engage in argument, and sometimes it leads to abusive behaviour when they do not yield to their financial demands. Though both have a different sociocultural and linguistic background, in their old age both are forced or complied to sell their property to real estate consultancy for better market price. Their families’ members feel it is a golden opportunity for them as they can be benefitted by a new flat and money. However, both Lakshmi and Kasturi are against the idea of selling their property as they feel their property reminds them about their tradition and values. In case of Karpagaamma, though she does not have any property still she is exploited by her children. Her children depends on her for financial gains, though she is paid Rs. 3500 per month as a salary in the hospital. She saves it for her children, ignoring her own needs. Her children feel it is a duty of a mother to help her children, and Karpagaamma also feels that she has to think of her children rather being self-centred in the old age. If Karpagaamma fails to keep up her promise, she is verbally abused by her children and sometimes emotionally too. (c) Intergenerational In all the three narratives, elder women do time and again get into conflict of interest with their family members irrespective of their social context with respect to their day-to-day affairs. The women felt that their family members do not respect them and if they respect it is because of resources. They feel that today’s generation is failing to accommodate the needs of the elderly. They perceive that younger generation in the family consider them to non-productive and ignore their presence in the family. However, they are aware that younger people have to keep up with demands of global culture as it puts pressure on the young people for better performance, consumerism and rise in the price of basic commodities, and lifespan deprivation. However, elder women feel that irrespective of the different processes, they have to be respected and believe that time should not change their relationship. It can be understood from their narratives that child care is seen as a right and an expected one, provision for basic needs for children is an essential tenet, and however when it comes to provision of care for parents, it seemed as a duty and not as a right. Despite the age, culturally also it seems appropriate for the adult children to seek for property and economic resources as a right; however, it seems that parental care is perceived as not obligatory. The elderly also do not articulate parental care as a

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right; they also perceive that they are an additional burden. Also, they never saved any money for their future and spent their resources in upbringing children. Common concern for most of the elderly is the lack of formal support mechanisms—shelter, day care, legal, health care and dwindling informal support that was available earlier. Health care has become almost an unaffordable option and an inaccessible one for majority of the elderly. There are also older women like Karpagaamma, despite having children are roofless. She works at this age, but does not have a place to call it as her home. It is important to locate and understand elder abuse outside the familial context. Locating the same within families limits the understanding of the contextual factors influencing the same. To evolve mechanisms to combat elder abuse, it is critical to understand the macro-factors affecting abuse and create supportive mechanism to support elderly live with dignity. Right versus Duty: Educating the children and taking care of them have always been viewed as a right and the parents take care of them, whereas children taking care of their parents is always viewed as a duty and not a right. This discrepancy in terms of caregiving really compromises on the quality of care and support available for the elderly within the family. Irrespective of the age, the children even as adults demand financial support while not providing any guarantee for the parent’s healthcare expenses and other needs. The adult children’s continual pressure on their older parents and the associated emotional upheaval is a definite form of abuse. Pressurizing the older parents to sell the property is increasing, and the children cite many reasons for the same. Culturally, letting go (renunciation) is a norm, and thus the adult children do not see any remorse and see it as a rightful thing; even in some cases, the older parents also feel obliged to support their children. This causes distress and conflicts in the family relationship. To conclude, from the three narratives, we can clearly see the macro- and microlinkages, as captured in the following diagram.

Conclusion The case of three elderly women in Chennai reveals that there are three contexts in the modern life which causes problems for elderly women, namely lack of basic necessities such as spacious house; ownership over material resources such as land, building and jewels; and intergenerational issues. Interestingly, both lack of basic necessary things in life and ownership of material resources, and both are a challenge. The study shows that the context of elder abuse is a result of many processes. It is influenced by both micro- and macro-social processes. The micro-processes involving individuals and families had been attentively studied, but macro-processes such as lack of provisions in the form of healthcare support and legal support are increasing the dependency on the children. Gender also plays a major role, and the current baby boomer generation never had the privilege of education and continued to be very subdued in all walks of life. The paper concludes that the abuse can be

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traced on everyday interactions and dynamics in the family system and in the care provision context. Until we connect it to the paucity of service provisions, we will fail in addressing the concern. The paucity of mechanisms to support elderly as well as the adult children in caregiving has been overlooked, and its relationship with elder abuse has be to explored and investigated. From the policy perspective, it is important to strengthen job security, income security for the elderly, to assure a reasonable standard of living and to provide decent housing and appropriate recreation spaces, so that the elderly have a choice to choose a life of dignity. Acknowledgements The phenomenological narratives presented in the article are based on the Ph.D. data of the second author.

References Action on Elder Abuse Bulletin. (1995). What is elder abuse? May–June 11, 1995. Alam, M., & Mukherjee, M. (2005). Ageing, activities of daily living disabilities and the need for public health initiatives: Some evidence from a household survey in Delhi. Asia Pacific Population Journal, 20(2), 47. Chapman, S., & McNeil, P. (2005). Research methods (3rd ed.). London: Routledge. Cohen, M., Levin, S., Gagin, R., & Friedman, G. (2006). Development of a screening tool for identifying elderly people at risk of abuse by their caregiver. Journal of Aging and Health, 18(5), 660–685. Gorman, M. (1993). Development and the rights of older people. In J. Randel, et al. (Eds.), The ageing and development report: Poverty, independence and the world’s older people (pp. 3–21). London: Earthscan Publications Ltd. Jamuna, D. (2000). Ageing in India: Some key issues. Ageing International, 25(4), 16–31. Kumar, Y., & Bhargava, A. (2014). Elder abuse in Indian families: Problems and preventive actions. International Journal of Scientific and Research Publications, 4(10), 1–8. Lester, S. (1999). An introduction to phenomenological research. Patton, M. Q. (1990). Qualitative evaluation and research methods. SAGE Publications, Inc. UNFPA. (2012). UNFPA working paper series 7. New Delhi: UNFPA. Vincent, J. A. (2003). Inequality and old age. Routledge. World Health Organization. (1998). Women, ageing and health: Achieving health across life span. Geneva: World Health Organisation. World Health Organization. (2002). Missing voices: Views of older persons on elder abuse.

Chapter 15

Role of Integrative Medicine in Management of Dementia Vidya Shenoy

Abstract ‘Health is a dynamic state of complete physical, mental, spiritual and social well-being and not merely the absence of disease or infirmity’, ‘determinants’ of which are ‘behavioural, biological, socio-economic and environmental factors’ according to WHO, for which, integrative medicine is a great complementary for the care of persons and management of diseases. Slow but an effective holistic therapeutic route that can play a supportive role in the treatment of Alzheimer’s, the most common form of dementia. Volunteering and counselling many, I have found these therapies person-centrically effective for those affected by disease, their caregivers and their family. Plausible option of using therapies like Yoga, stretch Pilates, music, dance, laughter, pet and creative arts as a tool to reduce psychological and social impact of diseases at individual and community levels are valuable. Today, Yoga has permeated not only into people’s daily lives but also field of medicine. Research confirms that Yoga is safe and an inexpensive therapy to avail of. Music knows no language and is a medium that expresses that which cannot be spoken and cannot stay unexpressed. It serves as a conduit for emotional and psychological ‘ventilation’ that all need in various moments in one’s lives. At diagnosis of or in early stages of dementia, I find Yoga and music to be an excellent combination to bring positive changes within one’s lives. Keywords Integrative medicine · Complementary · Effective holistic therapy in management of Alzheimer’s · Person-centric · Inexpensive therapy that brings positive changes Herman Melville said, ‘We cannot live only for ourselves. A thousand fibers connect us with our fellow men; and among those fibers, as sympathetic threads, our actions run as causes, and they come back to us as effects’. How true! This can be done only

V. Shenoy (B) Alzheimer’s & Related Disorders Society of India (ARDSI), Kochi, India e-mail: [email protected] ARDSI Mumbai Chapter, Mumbai, India Maharashtra State Mental Health Authority (MSMHA), Mumbai, India © Springer Nature Singapore Pte Ltd. 2020 M. K. Shankardass (ed.), Ageing Issues and Responses in India, https://doi.org/10.1007/978-981-15-5187-1_15

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when we can work towards this goal together, at a personal and social level. So let us make it a dementia-friendly existence. I am indebted to my ‘family’ of Smriti Vishvam—Universe of Memory, Specialized Dementia Daycare Centre, ARDSI, Mumbai, comprising those affected by dementia. For they nurture me everyday as I professionally volunteer at this centre. My immense gratitude to this extended ‘family’ that includes their families for trusting me and caregivers at their homes from whom I am learning the nuances of integrative medicine and fine-tuning my skills as a ‘carer’, too. With utter humility, I wholeheartedly dedicate this chapter to them. Thank you! Every 3 seconds someone in the world develops dementia…

Handling the onus of the most common form of dementia, Alzheimer’s disease, has been thrust upon us that needs to be attended to on high priority. After China and America, India has excruciating figures of over 4.4 m lives being affected by dementia in 2015, almost doubling by 2030 and reaching 14.3 m by 2050. Presently, with lack of a firm national dementia policy in place in India, low accessibility of services for diagnosis, early intervention and treatment, one cannot think of risk reduction measures or delay of the onset of the disease itself. So it becomes imperative for us to address this grave concern on a war footing. In general, Alzheimer’s disease causes problems with memory, thinking and behaviour and has only four drugs that have been approved and made available in the last 20 years. This tells us the gross truth of the situation. We also need to make society aware and bring a positive change in the mindset of the community to let them know that dementia is a disease not due to old age or witchcraft. It is a disease of the brain like any other diseases of other organs of the body. Fortunately, attitudes are slowly changing, and Alzheimer’s and dementia are now being discussed about openly which has never happened in the past due to social stigma. Also, people are becoming more health conscious, more vigilant and concerned about brain disorders. This is because their numbers are rising and some are more apparent in society. More visibility like Parkinson’s that is commonly noticed through 3‘S’-es: slowness, stiffness and shaking. People are familiar with epilepsy that which is seen through flash episodes and some other brain diseases that disrupt normal brain functions. Unlike all these, Alzheimer’s is not noticeable in the early stages at all. When signs become evident, alas, it is considered to be a part of normal ageing process. When diagnosed, more often than not it is too late. It is like a ‘thief’ that sneaks into people’s lives and robs them of their memory. Initially, it affects memory, and when it has taken its toll and personality of the individual has changed drastically that diagnosis confirms dementia. By then, the damage has already been done. Hence, it is very important that when there is a slight memory loss and diagnosis confirmed that early intervention and treatment is started. It is shocking that less than 10% of persons with dementia actually get diagnosed, and if they do, they cannot access treatment easily. Dementia has been proclaimed as a public health priority and a ‘global crisis of the twenty-first century’ by WHO. Truly, this is a global crisis lurking large round the corner. Unfortunately, dementia is nowhere present in the health priorities of India, while diseases with lesser numbers

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have been prioritized as high-risk diseases and elaborate strategies and action plans are in place with large funds allocated and infrastructure created for their treatment, management and research. However, World Alzheimer’s Month, September 2018 has shown a light at the end of the tunnel! Alzheimer’s and Related Disorders Society of India (ARDSI) has handed the ARDSI National Dementia Strategy Report to the government. This is being considered while drafting a national dementia policy by the Ministry of Health and Family Welfare. Average life expectancy of age is now deemed at 68.3 years, thanks to scientific research and advances in medicine. Of course, what matters is quality of life, keeping in mind age-related diseases and chronic non-communicable diseases due to faulty and inactive lifestyle. Of the multidiseases, this neurodegenerative disease, Alzheimer’s, has a crippling impact on the person affected by dementia, mentally, physically and emotionally. But what often goes unnoticed is that the actual onus of having a member in the family affected by dementia is more on the family members or the caregivers. To begin with, the diagnosis itself is a rude shock to the person affected by dementia and the stark reality of crisis on hand. Thereafter, there is a huge transformation in their daily lives, where this member becomes the fulcrum of the entire family’s existence itself. Added to this, socio-economic burden, horrendous costs leave a dire effect on their fast depleting finances too. It is here that one sees the need of a national dementia policy to be in place on a high priority basis. This would enable costs and the burdens to be shared by both, the government and families. Public–private partnerships can be considered along with corporate social responsibility (CSR) projects for the community especially in rural areas. Ageing is a definite arc in the circle of life and there is a looming problem of an increasing ageing population all over the world. Alzheimer’s accounts for 60–80% of cases of dementia accompanied by impairment of activities of daily living (ADLs), mental and physical weakness. Added to these concerns are age-related diseases that are factored by family medical history, environment and sedentary lifestyle leading to a frail ageing body and the possibilities of facing injuries due to imbalance or failing eyesight, concussion, trauma, etc. All these problems increase the risks of developing dementia. Thereafter, their mental matrix contains parameters of low self-esteem, loss of dignity, feeling unwanted, a sense of dependence due to lack of financial or working capacity. Thereby, negativity and pessimism get embedded in their persona. How does one age gracefully? How does one stay ‘young’ though the chronological age is much more? George Carlin’s views on ageing are worth a serious thought. To begin with, he feels age, weight and height do not matter, but to keep only the friends that cheer you up and (perhaps add spice to your life?) encourage you and give positivity in your life, to keep on learning, enjoy the small moments, laugh as much as you can are the bests bets to ‘stay young’. Thankfully, not all get dementia. And yet, how can we reduce the risk or delay onset of the disease if it is meant to be? Dementia, a cluster of symptoms, is not a consequence of ageing alone. It is also caused by non-modifiable factors like heredity or genetic history. Sedentary lifestyle, obesity, tobacco, diabetes, hypertension, depression and low brain activity are factors that are definitely modifiable.

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Can Alzheimer’s be prevented? Can there be something called ‘risk reduction’? We all know what is good for the heart is good for the brain. In the Mayo Clinic Health Letter November 2015, mention has been made how one can reduce the possibility of cognitive decline. In their study published in Neurology, they found certain resilience building factors in which lifestyle approach has been mentioned. How health issues like heart disease, diabetes blood pressure, etc., must be addressed through healthy diet, exercise, no smoking or else chances of cognitive decline is higher. Serge Gauthier, Director of the Alzheimer’s Disease Research Unit at McGill Centre for Studies in Ageing in Canada with more than 30 years of experience, has worked on significant international observational studies. One of which is Alzheimer’s Disease Neuroimaging Initiative—ADNI—where he feels that it is worth trying ‘to change strategy to multimodal or combination therapy’. Prof. Miia Kivipelto, of the Karolinska University, Stockholm, was one of the first to relate lifestyle and dementia and strongly believes that if lifestyle is managed well, then there could be 50% improvement. As Alzheimer’s has multirisk factors, a ‘multidomain intervention’ is necessary. Those who improved their lifestyle, whether in midlife or later, engaged in social activities in groups or as family, pursued hobbies like music, art, painting drawing or any crafts saw great risk reduction in cognitive decline. We observe that anything mentally stimulating is great for all, especially for those affected by dementia. In the last many years, only a few medicines have been made available to counter or cure Alzheimer’s and the best option would be the practice of integrative medicine or complementary therapies. What are these therapies and how do they work on the practitioner? Are they effective and how do they help? Changes in dementia are progressive, treatment of which is seen as a long drawn one. It has been documented in research that adverse effects of medications include sedation and quality of life being strongly affected leading to possibility of further cognitive decline. However, since a decade and over, non-pharmacological approaches for intervention and management of dementia are being used more frequently and, in fact, as first line of treatment as this is safer mode with no side effects. And, these therapies are used in conjunction with one or many others. They do not have any negative impact and are as effective on both the carers and family members enabling them to better manage persons affected by Alzheimer’s and dementia. It is very important to try non-pharmacological methods besides pharmacological treatment of dementia even if as a complementary use to avoid or lessen side effects of drugs. Where family history, social life and environment play an important role, the aim of management of dementia is to rehabilitate those affected by dementia on all planes: physical, mental, cognitive, pyschosocial and sensory. This holistic approach can work wonders falling in line with the WHO definition of health as that which ‘is a dynamic state of complete physical, mental, spiritual and social well-being and not merely the absence of disease or infirmity’. WHO also believes in ‘the resource of

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living a full life’ and the ‘ability to recover and bounce back from illness and other problems’. at our specialised dementia daycare centre SMRITI VISHVAM - UNIVERSE OF MEMORY We do all of this and MORE

DIET

MUSIC & DANCE HUGS & LAUGHTER CREATIVE ARTS REMINISCENCE

EXERCISE THERAPIES GAMES OUTING JOGGING SOCIAL GROUPS CELEBRATIONS

SUDOKU PUZZLES MATHS DAILY CHORES

YOGA

FAMILY, FRIENDS SUPPORT GROUPS COUNSELLING PET THERAPY,

SPIRITUAL GUIDE PRAYER GROUPS PLACES OF WORSHIP

EVENTS

OUTDOOR ACTIVITIES CHILD THERAPY

What does this imply? For this definition of health, let us see what these complementary therapies are. Naming a few of these therapies that help persons with dementia: Reality orientation includes that which is done on a one-to-one basis where the person affected by dementia is made aware of reality: circumstances, themselves and their families. It may or may not be received well by the individual due to moodswings. However, its benefits are slow and subtle. Validation therapy betters communication skills and allows them to accept realities and the truth of their experiences. For which, one needs to win the trust of the person affected by dementia to be able to have them open up enough to share. These communications help the individual get attention with a more personal touch. Behaviour therapy is practised with the help of a caregiver who will note the likes and dislikes of activity of the person affected by dementia. This can be used for daily activity to comfort them. As this is a familiar form often used, the person affected by dementia becomes more calm and can relate doing these activities without reservation. Reminisce therapy or stimulated benefit therapy (SBT) involves discussion and sharing of past events with carers or and with family with assisted aids of photos, familiar items, sound/clips or video recordings of family occasions. This invariably reduces symptoms of depression and leads to improvement in behaviour and cognitive functions. Henry Brodaty, Scientia Professor of Ageing and Mental Health and Director of the Dementia Collaborative Research Centre at the University of South Wales, believes that ‘psychosocial interventions are doing a lot better than drug taking for

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people with the behavioural and psychological symptoms of dementia, which people sometimes call BPSD’.

Other Complementary Therapies Some of the many other therapies are art therapy, music therapy, activity therapy, aromatherapy, colour therapy, multi-sensory approaches, education, occupational therapy, etc.

Spiritual Therapy This therapy basically helps one ‘connect’ to the higher power one believes in. It could include sessions of prayer, chanting, singing hymns or spiritual songs, affirmations, reading of religious books, meditations, etc. • Observations noted at our Dementia DayCare Centre: Smriti Vishvam: Universe of Memory We observed that sessions of spiritual therapy calm those affected by dementia. Relief is seen on their faces as though a load of negativity has been removed. Taken jointly with carers or their family members, such sessions have a profound effect on all. There is more connectivity between the affected person and carers leading to handling them more easily.

Colour Therapy Colour therapy is that whose effects are seen through use of colours. Bright colours, viz. red, orange, yellow are seen to energize the person with dementia. Sky blue, green, light grey or even light mauve or violet has a calming effect on the individual. • Observations noted at our Dementia DayCare Centre: Smriti Vishvam: Universe of Memory Whenever we have a painting or colouring session, we have seen the use of the abovementioned colours they choose are the ones that reflect their moods of that day. Dark colours trigger off other emotions. However, brown, an earthy colour, reflects them being grounded that particular day. They seem more calm and manageable at the centre, and thereafter, at home. Happy bright colours chosen tell us they are happy.

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Art Therapy Art therapy is rather special. It allows the person to choose what to draw or doodle and how to colour. A clean drawing reflects that they are not confused and close to being normal in temperament. It also shows the hidden meanings in their thought process. It also reflects on their frame of mind and what they want to communicate to others. • Observations noted at our Dementia DayCare Centre: Smriti Vishvam: Universe of Memory We notice that they do not resist a session of art and drawing. In fact, they love it! They do draw simple pictures, perhaps a tree or a house or just a bird. Remember, their state of brain function allows them to go down memory lane as reflex. But as they draw, they remain focused and enjoy their moment even if it is just doodling. However, when it is colouring time for what they have drawn, they choose with much ‘thought’. It gives them a sense of ‘HEart’ achievement! We ask them later to tell a story on their artwork. We encourage them by framing their artistic expressions and hanging it on the wall. Oh! And do not they feel good when their efforts are being appreciated and acknowledged. Visitors to the centre are reminded that these frames have been created by them!

Cognitive Behaviour Therapy Martin Knapp, Professor of Social Policy at the London School of Economics, feels that cognitive behaviour therapy through stimulation and remediation helps those until they reach moderate stage of dementia. There are some which can be done only in the early stages of dementia that aims to restore cognitive deficits and enhance daily functioning in day-to-day life. Cognitive behaviour therapy leads to a therapeutic mindfulness that deals with stress, depression and isolation too. So we have conducted support sessions for those with dementia. Some sessions have their family or caregiver present. These sessions eventually lead to better understanding of the person affected by dementia and eventually improved caregiving. • Observations noted at our Dementia DayCare Centre: Smriti Vishvam:Universe of Memory Whenever we have singular sessions, there is confidence in expression and a sense of trust between the therapist and the person. In joint sessions, we have found that there is a wall between them, lesser level of confidence and lesser expression of feelings or experiences in their daily lives.

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Activity Therapy Any activity like art, singing, dancing and painting are some of them done individually or groups. These have their own expressions depending upon the mental state of the person affected by dementia. So, our principle is ‘go with their emotional flow’. • Observations noted at our Dementia DayCare Centre: Smriti Vishvam:Universe of Memory There are good days when group sessions help. Some days they prefer to do it on their own with personalized one-to-one attention. We observe and do accordingly. After all, our purpose is to support their need of being happy and their life, fulfilling!

Physical Exercise This is beneficial to overall health and well-being. It also uplifts the mood of the person affected by dementia. Stretches and pulls also refresh them. • Observations noted at our Dementia DayCare Centre: Smriti Vishvam:Universe of Memory Initially, they did not want this exercise session at all. But we ‘accommodate’ our session depending on the average mood and plan accordingly. Sometimes, we use a prop for their convenience. They love carrying something in their hands for the ‘weight’ exercise. When they do so, perhaps a feeling of playing with a toy comes to their minds and they ‘play’ the exercise. For example, if they are asked to do stretches, stand on their toes and walk one behind the other, they feel it is a kind of game, perhaps like ‘bogey-train-train’, that they may have once played at school. Singing as they play–exercise makes it more fun.

Touch and Hug Therapy This is one of the most impressionable therapies that can be used for all and by all. From the carer to the person affected by dementia, this non-verbal form of communication helps both. What a thousand words cannot express, just a hug can say it all. It is a silent, though a potent a communicator. For example, a simple hand-clasp can convey a message and much more. The affected person can hold an old item, a family heirloom and reminisce of the good times. Of course, only those objects that convey a positive memory must be given to them.

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• Observations noted at our Dementia DayCare Centre: Smriti Vishvam: Universe of Memory Each member has brought something that revives good, positive and fond memories. We have a photo gallery where they are often taken for revisiting their past. We have story sessions during which time we encourage them to speak. Though they often speak incoherently, they speak very fondly of their happy moments.

Pet and Child Therapy They are two therapies very synonymous in effects. Both relieve agitation in persons affected with dementia and eventually calm them. It also instils confidence to reach out and, thereby, leads to increased social interaction. After all, both children and pets can absorb a lot of pain of others and are the ‘most confidential therapists’ for children do not relay and animals cannot speak! • Observations noted at our Dementia DayCare Centre: Smriti Vishvam: Universe of Memory Whenever we have child therapy, they forget themselves and become children once again. They get so involved playing with them that they forget that just prior to the onset of the session, they were feeling low or were unnecessarily ranting some trivial matter. Child therapy has a soothing effect, and the quality of moments spent with pets or children is very rejuvenating and energizing too. Cuddles are a form of patronizing the loving, loved child. Cuddles given to both children and pets lend a touch of propriety and possession for them. Of course, pets used for therapy must be trained and one must keep in mind of allergies that could affect persons with dementia.

Games Therapy Many different indoor games: carrom, ludo or as a matter of fact, any board games, and in initial stages sudoku, crosswords, card games, solitaire etc. • Observations noted at our Dementia DayCare Centre: Smriti Vishvam: Universe of Memory It depends on their mood. They are allowed to choose to play games in a group or by themselves. Does it not seem literally a second innings?

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Nature/Gardening Therapy Who can say how effective nature can be and is? Going to the park, listening to the birds or sitting by the seaside is immensely therapeutic to the person affected by dementia, their family and caregivers. Gardening refreshes them. They love to see their plants grow: just like any child marvels at a plant they have potted or a new leaf or a bud in bloom. • Observations noted at our Dementia DayCare Centre: Smriti Vishvam: Universe of Memory They just love it. An outing anywhere, be it the gardens, aquarium or the zoo, is most welcome. Do not we remember schooldays when outings meant no classes at school? As for potting plants, they love to play with soil. However, they wear gloves when doing gardening sessions.

Occupational Therapy • Observations noted at our Dementia DayCare Centre: Smriti Vishvam: Universe of Memory Once again, these depend entirely on the frame of mind all our members are in. They could just be happy folding paper or tapping their feet listening to music or doing a form of exercise thereafter. Keeping them occupied is the focus.

Group Therapy • Observations noted at our Dementia DayCare Centre: Smriti Vishvam:Universe of Memory A group therapy session offers an environment of warmth and acceptance wherein the individual has a platform to ventilate in the presence of others who understand him/her. This in turn builds up self-esteem, and hence, confidence to express any thought, experience or story without reservation. A group session for carers together with affected persons in turn helps them cope stress of work better. Each family therapy session gives an opportunity for a closed meeting to handle one problem at a time in complete confidentiality.

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Therapy Through Puppetry This ancient art form dates to more than 3000 years and is one of the 64 arts referred to in ancient literature. However, this art has not yet been given due recognition in India as it deserves, unlike countries like UK, Japan, USA and Europe. In fact, though I use this art form as often as I can, it is not used in India as therapy at all. We know of how inanimate puppets can build a relationship between the audience and the puppeteer who ‘brings them all to life’, to tell a story or teach morals to children. Most importantly, this art can convey what normal human communication cannot do due to social stigma or even when words that cannot be spoken due to sensitivity of the topic. These puppets become ‘stars of the show’ that create an illusion through animation along with the tone and language used by the puppeteer, and yet, conveys the message that leaves an indelible mark those affected by dementia, too. Puppetry puts ideas into action and uses visual arts to give them form. Puppet actors are created actors to fit a specific role and designed to bring to the fore and make believe the audience that its characters are real. The mastery of the puppeteer can bring to life inanimate puppets through human intervention. ‘Breathing life into puppets’ is a fantastic therapy where language is a barrier or to those who cannot express. An ancient art that is so applicable in modern times. And, instantly depending upon the mood of the group, a story can be carved out to soothe their troubled minds. These puppets are figures and powerful tools to help us ‘see’ and understand those who cannot find words or speak thoughts or cannot express verbally. In fact, puppetry is a simple, imaginary bridge that connects diverse cultures and languages and has a universal language to convey a message in visual form for those who are less abled or those who need special attention like persons affected by dementia. Elements of theatre, visual and performing arts are actively used to make a fine expression with the help of puppets that also includes painting, sculpture, text, music, movement and use of technology to enliven the art of expression through the visual medium of puppetry. Most importantly, puppets allow focus of those affected by dementia. • Observations noted at our Dementia DayCare Centre: Smriti Vishvam: Universe of Memory When we have had puppetry sessions at our DayCare, our experiences have been amazing. It is always a ‘back-to-school’ fun experience. Not only for our ‘family’ that also includes their families and carers but all our guests who have been invited for these sessions too. Themes chosen are simple and child-like conveying simple memories of childhood. They could be simple messages of caregiving conveyed to families and carers. It was amazing to see how they respond to visual stimuli. We saw them shed the veil of self-consciousness by looking at the puppets. Actually, each of them responded to these shows in their own way. Some of them tried to copy gestures of the puppets, and some tried mimicking them. They are absolute fun sessions that bring about a sense of togetherness. Now we have these sessions more often!

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We notice that their chuckles and laughter improve their mood. This happens not only at our centre but everywhere the puppetry sessions are conducted, viz. children with special needs. Even when performed in assisted living homes, this art of puppetry goes a longer way by bringing them camaraderie and, perhaps, giving them some temporary relief. It also helps them overcome their diffidence, grief, hurt or physical pain. By identifying with the puppets, it definitely helps bring miles of smiles into their lives. Art of puppetry can be also be used as reminiscence therapy enabling them to recall their good, old times in a light hearted way, simple yet an effective and an alternative medium of counselling, too. • Anecdote This is when we made a puppet presentation of a love story to seniors in old age homes. They were so emotionally overcome that we needed to follow-up this session on another day with ‘ventilation therapy’. We had a lady came up and say, ‘I am feeling lighter now as though I have a load removed from my chest’. Perhaps she had no one to talk to. Who better than a stranger or talking to a puppet? Many experiences reflect that their negative behaviourial extremes came to the fore, expressed and flushed out. These moments have purged them of memories that were difficult to expel or keep it far into the recesses of their mind and heart, thereafter, making them lighter. These are ways to enable the families and their caregivers to manage those with dementia too. So puppetry can be used in many, many areas with super effective results! Why cannot this ancient and simple art be used more often on a regular basis?

Dance and Movement Therapy Who does not like to shake a leg and swerve their hips? Whether for actual dancing or just for the fun of it. Dance and movement are a natural rhythm innate to each of us. We sway and swerve the very moment we hear tunes or songs. So what and how does this innate rhythm work as therapy? As Yoga discipline unites the mind with the body, music helps you move. When you move at whatever pace, there is some kinetic energy released. In turn, increasing endorphins that ‘season’ you for facing trials in life makes you feel better and sleep better too. It is a ‘movement therapy’ which helps you become stronger emotionally and helps flexibility of the body. It is very therapeutic for those with Parkinson’s or special needs. It allows the mind to let go off stress through gentle and graceful movements like the waves in the sea. Even though the sea is rough, eventually, the waves froth calmly as they touch the shores. So is dance and movement therapy, DMT as it is popularly referred to. • Observations noted at our Dementia DayCare Centre: Smriti Vishvam:Universe of Memory

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We wholeheartedly agree with Martha Graham when she says, ‘Dance is the hidden language of the soul of the body’. Actually, they just let their hair down. Love to ‘swing it’. When they are hyper, they actually ask for peppy music to be played so they can enjoy rhythmic movement.

Music and Singing Music as therapy not only helps the performer but the audience too. It creates a bond between the singer and those affected by dementia. It is that which has no boundaries, language, creed or religion. It is free for all: it is a cultural and social resource. It is blessed therapy that mesmerizes those with Alzheimer’s and dementia, effect of which stays on to the very end for those who listen. It enriches the listener and singer with a sense of well-being. Music is that which enfolds any activity one is doing, be it a chore that is onerous as in the case of caregiving or even soothing the person affected by sharp moodswings. Music is a good ‘lung organizer’ as it makes the singer take deep breaths and exercise vocal chords. When singing is practised as fun, therapy or learning, it builds up pulmonary function to a larger extent. Singing as well as swimming is good for those with difficulty in sustaining breaths. Of course, where swimming by those affected by dementia is concerned, one can do so only after taking the family physician’s advice and considering physical security of the person with dementia. As extensive research done by Dr. Hanne Mette Ridder, Aalborg University and Brynjulf Stige, University of Bergen, resulted in saying, ‘Music as a health promoting agent in dementia care’. How true, music helps stimulation of the mind, increases energy levels and you can multitask too. Jeffery Thompson, Founder of Centre for Neuroacoustic Research, believes that as frequencies slow down, one is able to feel it in the muscles, joints and bones. Differential effects of fast rhythmic music vis-à-vis light, slow instrumental music have been experienced by all. • Observations noted at our Dementia DayCare Centre: Smriti Vishvam: Universe of Memory Any time is music time. They just love it. Initially, our ‘family’ with dementia was reticent to sing. However, when they saw others make efforts in spite of being short of breath or out of tune, all shed their reservations and just sang aloud. Many a times they cannot recall the words, so they just hum or shake their heads and some even tune in with a la la la la. We have all heard of singing bowls. This is an ancient art, a technology if you can call it so, which is being popularly used. In this, there are bowls made of seven metals, viz. gold, silver, quicksilver, copper, iron, tin and lead. As these metals have individual sound, together they put forth an ‘orchestra’ performance of the bowls when struck with a mallet. Thereby, through vibrations and echoes of the sound produced, they affect the central nervous system (CNS) that is supposed to have a

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calming, de-stressing effect. Though no research data are available quantifying its effects, yet it is pleasing to the ears and effective on the mind and mood. Just as there are gyms for physical training and body building, likewise where those things that ‘tease’ and activate the brain, can be performed in the concept called ‘brain gym’. Crossword puzzles, playing solitaire or as a matter of fact, any card game, reading newspaper or books, story telling, etc.

Yoga Jennifer D’Angelo Friedman says ‘While there is no cure for Alzheimer’s, research suggests yoga and meditation may play a role in prevention and improve symptoms and quality of life for patients and their caregivers alike’. Medical Yoga, part of integrative medicine, is a holistic lifestyle that is not only an exact experiential science but a disciplined practice of which leaves a positive and lasting effect on its practitioners. It also hones them on mental, physical and spiritual planes to make them cope with and manage life well. Management and therapy for dementia through the ancient science of Yoga, slowly but surely, afford a compact package and now is recommended by doctors as therapy for their patients. Of course, plan of Yoga practice for those affected by Alzheimer’s needs to be tailored as per the individual requirements and taking into consideration various health parameters. Yoga is now considered strongly as part of integrated medicine and as therapy to persons affected by dementia, their families and caregivers. ‘Yogah cittavritti nirodhaha’ (Verse 2 in the Yoga Sutras) meaning a Yoga practitioner will be able to calm the ‘butterfly-mind’ bringing about improved focus and concentration. Yoga has positive and considerable effects through practice of certain kriyaslike KirtanKriya, mudras, mantras and breathing techniques especially where the nervous system is concerned. Sound that travels through any medium is proven to affect all energy equilibrium in the Universe, base of which is ‘AUM’. This cosmic sound, discussed in detail in the Upanishads and scriptures, resonates in the brain through external vibrations. Sage Patanjali said ‘AUM’ is omnipresent, probably the reason why it is chanted at the start of each mantra or prayer. It can alter brainwaves and the state of consciousness to help manage stress better. This ancient technique of ‘AUM’ chanting is a powerful tool that has proved that when heard or recited, its sound vibrations activate the spinal cord and brain. Therefore, one experiences harmony within. Many scientists have proved that exercises, especially Yoga, alter the biology of the brain in ways that it can make it more malleable and receptive to new information, referred as ‘plasticity’. Besides boosting the immune system, it converges and aligns the focus of purpose. Science of Yoga explains that the nerve centre at the mid-brow called Adnya Chakra (‘The Third Eye’) is directly in line with the centre of the brain. The sound of ‘AUM’ directly stimulates the brain, invigorating the entire body at all Chakras

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(power or neural centres) along the spinal cord. Thereby, the mind gets more calm, enables management of stress better leading to maintenance of good health. Neuroscientists believe that ‘neurons that fire together stay together’. Yoga does just this! Various studies have reflected through MRIs, scans etc., that meditation increases grey matter and can prevent Alzheimer’s, a leading cause of dementia. Studies have shown that stretch exercises, meditation and Yoga also have positive effects on verbal and visuospatial cognition of memory. However, all those affected with dementia cannot practise Yoga. They should be at an early stage of Alzheimer’s or at a mild cognitive impairment (MCI) stage. Called risk reduction, Yoga can prevent or defer the onset of dementia and cognitive decline during middle age as there is a chance that it is then that the brain starts slowing down. Meditation techniques help in early stages of dementia or as a risk reduction technique. It also helps improve memory and cognition as cerebral blood flow increases to the parietal and frontal lobes involved in retrieving memories. This technique is a good manager of pain which I refer to as ‘ventilation therapy’ as it is a great stress buster! Mood enhancement is another boon reflected in MRIs which show the brain cells connecting with each other more in those practising Yoga. Besides, general health and immunity getting better, Yoga helps in getting a good undisturbed sleep. In fact, there are some Asanasto induce sleep too! Alzheimer’s, the most common type of dementia, as Prof. Alarik Arenander put it, is ‘nothing more than a disorder of progressive disconnection’, and practice of Yoga does ‘create coherence and connection’. Management of dementia involves two types of people: the person affected by dementia and other category, caregivers. What is the price the family and caregiver, family member or hired, pay? We all know that it is not easy at all to handle the person affected by Alzheimer’s and dementia. Their families and caregivers are highly prone to stress and fatigue, both of mind and body. Due to time constraints and focus being totally for the care of the affected member, they sacrifice themselves, their personal needs, desires, etc., to keep their focus on care of the person with dementia. This could be that they are not able meet friends, socialize or just simply relax. This in turn leads to distress caused by isolation and depression of the caregiver. Better expressed is that they do not have any ‘me-time’ for themselves. Here, Yoga helps to de-stress. It actually synchronizes mind and body and also is a good pain manager for them too. It then allows them to take better care of the affected person or anyone needing palliative care. For those affected by dementia, Yoga physically improves their balance, agility, neuromuscular activity and mentally, their level of confidence, increasing social interactions as it frees the mind and relaxes the body. Yoga is also known to decrease mood swings, lower anxiety and stress levels. It helps boost the immune system, too. As memory is affected and persons affected by dementia cannot interact with comfort very easily, Yoga helps them to experience and enjoy ‘the moment’ and further motivates them to live ‘in the now moment’. Thus, the quality of their life is substantially improved.

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Yoga can be done in one’s own time, pace and place. Therapies practised in groups are of great help as they offer easy social interaction with each one to experience boons at different personal levels. For seeing people with similar problems of discomfort and diffidence, it conditions their minds in believing that they are not alone in their journey and they can make it on their own too. They experience the freedom to be themselves and without being looked down upon with critical looks or judgemental expressions. After all, they, too, feel and understand body language even if they cannot find the words to express and convey their feelings to others. They are still alive within. Truly, YOGA is Your Opportuned Gateway to All-round well-being! • Kirtan Kriya Technique Sometimes referred to as the chanting or singing exercise, Kirtan Kriya by Dr. Dharma Singh Khalsa, Alzheimer’s Research and Prevention Foundation, Tucson, Arizona. This is practised with mudras (repetitive finger movements) and singing of Saa Taa Naa Maa meaning infinity, life, death and rebirth. Thanks to research studies by the Foundation with Amen Foundation, Newport Beach, California in 2003 and at University of Pennsylvania in 2006 have shown that there was stimulation in the hippocampus and hypothalamus which happens to be a memory storehouse and an area that gives concentration and focus. Subjects in this study included those with mild cognitive impairment or those in the early stages of dementia. Research continues in this area. • Meditation Actually to be at peace with oneself is an art and learning this today has become a commercial commodity. ‘Calmsutra’ coined by orthopaedic surgeon, Dr Dilip Nadkarni, Lilavati Hospital, Mumbai says ‘taking a calm pause or a mini break during the course of the working day, be in a particular moment and enjoy it’. In today’s times, this ‘pause’ is required as a speed breaker in the fast pace of daily life. Meditation, like Yoga, is an inexpensive discipline that should be made an intrinsic part of one’s life. Including nature, various mediums connect one to the higher self. By sieving thoughts, it makes one go deep into the subconscious levels where our true energies exist and allow for the experience of serene moments. These energies need to be channelized. Easier said than done, this initially needs a conscious effort to control the butterfly-mind. This calls for respecting the mind by leaving it be, thereby transmitting energies to the heart. Eventually, that which will endow benefits on the physical, mental, emotional, intellectual and spiritual health that coincides with the WHO definition of good health. It also provides the propensity to do unconditional, selfless service to the community that in turn propels the practitioner on the spiritual path. Mindfulness comes out of practice of Yoga for paving the way for easier meditation. Mind-based stress reduction technique (MBSR) developed by Jon Kabat-Zinn in 1979 is used as a complementary treatment, a catharsis to reduce pain, depression

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and is found to be effective in palliative care. This is and can be done while you do normal routine activities by converging the focus on the activity itself. Both Yoga and meditation give a lot of positive energy to the body and mind. With various Asanas, Mudras and Pranayam, the body gets flexible and aligned to the mind. With practice of meditation, flow of nutrients, oxygen and energy supplied to the brain increases, reaching to the maximum number of capillaries making the brain ‘neuroplastic’, bettering cognitive functions and communication. Many research studies have proved that meditation by concentrating on a particular spot or subject improves the mental faculties. It betters focus and sharpens the mind. People who have been into practice of Yoga and meditation have been found to be in better health and placidity. Their acuity, recall and cognitive functions are shown to be higher than those who have not practised Yoga. In fact, quite a few corporate houses encourage Yoga breaks as it has been found that those that do have these pauses are able to perform better at work. Paul Wilson considered as the Guru of Calm says, ‘There’s a bigger need for learning about the science of being calm today than ever before’. Yoga and meditation do just this: bringing about a serenity within.

Yoga and Music: My Personal Take This is an excellent combination. However, what I find most rewarding is that both music and the ancient science of Yoga, in a way, ‘remodel’ the brain allowing to learn new things. The old sages (Rishis) formulated this simple, disciplined science of Yoga using the body as a ‘machine’ to improve the plasticity of the body in turn that of the brain, too. Yoga has been proved to be therapeutic through scientific methodology confirming that the brain undergoes positive changes reflected through neuroimaging and markers that there is a visible improvement in neurotransmitters leading to better concentration and focus. Yoga is safe and an inexpensive therapy to avail of. No need of expensive gym memberships, as the body is the ‘machine’, so worry of portability of other machines is out of the question! We also know that music knows no language and is a medium that expresses that which cannot be spoken and that which cannot stay unexpressed. It serves as a conduit for emotional and psychological ‘ventilation’ that all need in various moments of one’s lives. At diagnosis of or in early stages of dementia, I find Yoga and music to be an excellent combination to bring positive changes within the family environment and social behaviour of the affected person. The burden of dementia is aggravated by nuclear family systems, social stigma, lack of awareness, low human capital in the form of manpower to spread awareness and most importantly, lack of a national strategy, financial resources for research and very few public–private partnerships in the area of dementia for early diagnosis, intervention leading to risk reduction or hopefully, prevention. There is very low awareness of dementia throughout India especially in rural areas. To make it worse, there is little access for people to get to specialists, mainly in towns,

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mini metros or metros for a simple diagnosis. There is no proper infrastructure for memory clinics, for diagnosis, specially trained medical staff: doctors and nurses for Alzheimer’s and dementia and public healthcare centres (PHCs) where consultation and care can be offered as soon as the diagnosis is completed. Thus, there is high physical and psychological toll on the caregiver (usually spouse or child). With limited funding for dementia research and training in the country, Alzheimer’s and dementia will continue to be a dire problem leading to a grave crisis. Moreover, there is a social stigma attached to the disease. As this is a major issue, more Anganwadi workers are required and necessary for creating awareness and remove social stigma in villages. It is shocking to note that less than 10% are diagnosed in about 2500 new cases each day. The mounting societal costs were estimated to be Rs. 14,700 crores in 2010 are approximately Rs. 16,300 crores today. Numbers shot up to 4.1 m in 2015 from 3.7 m in 2010. So, there is a dire need of daycares, special hospital wards and 24-h homes for those with dementia. The dementia caregivers have little support from outside nor any counsellors to approach for getting guidance. More social support systems, dementia-friendly communities need to be in place. Vociferous in the commitment to the cause of dementia, in September 2018 ARDSI handed the national dementia strategy to the Hon. Union Minister for Health and Family Welfare and we have been assured of support, services and facilities to those affected by Alzheimer’s and dementia. With the Mental Health Act 2017 in force, Mental Health Authorities have been set up in all states of India with lot of work in progress. This will lead to more awareness, memory clinics to be set up and hospitals giving more inpatient and outpatient facilities to those affected by dementia. We need to have dementia as a national health and social care priority along with information management systems that will have a databank of those with dementia. Only then, we will have the actual figures of those affected by dementia in the country.

My Personal View Integrative medicine or complementary therapies best work in a matrix where parameters of the mind are allowed to be free. Freed by negative emotions, energies and frustrations to be released from within would allow for all positive energies to be received in the void created, sustained, harnessed and well channelized. It would further lead to increased social interaction, help those affected by dementia to develop and better coping mechanisms, achieve dignity and self-confidence, and most importantly, enable them to love life and enable them to live positively in the moment. It will reduce loneliness, isolation, negative emotions like anger, depression and better interpersonal relationships. This will also improve physical health and strengthening of emotional balance improving the cognitive reserve that requires to be replenished from time to time. This would also mean that they will be capable of finding alternative routes to the same task or function. As mentioned earlier, the brain is a ‘motor’ that needs ‘oiling’ through challenging activities for the brain to be toned. These ‘computers’ also need continuous ‘upgrading’. What normal exercise is to the

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body, challenging mind games are for the brain. To reiterate my view that integrative medicine or complementary therapies help dwell on positive traits, hobbies and interests that will eventually benefit those affected with dementia, their families and caregivers creating a dementia-friendly environment conducive to active ageing and a life of contentment for all. Acknowledgements Special thanks to: Herman Melville, George Carlin, Serge Gauthier, Director of the Alzheimer’s Disease Research Unit at McGill Centre for Studies in Ageing in Canada, Prof. Miia Kivipelto, of the Karolinska University, Stockholm, Henry Brodaty, Scientia Professor of Ageing and Mental Health and Director of the Dementia Collaborative Research Centre at the University of South Wales, Martin Knapp, Professor of Social Policy at the London School of Economics, Martha Graham, Dr. Hanne Mette Ridder, Aalborg University and Brynjulf Stige, University of Bergen, Jeffery Thompson, Founder of Centre for Neuroacoustic Research, Jennifer D’Angelo Friedman, Prof. Alarik Arenander, Dr. Dharma Singh Khalsa, Alzheimer’s Research and Prevention Foundation, Tucson, Arizona, Amen Foundation, Newport Beach California, Dr. Dilip Nadkarni, Lilavati Hospital, Mumbai, Jon Kabat-Zinn, Paul Wilson. My immense and humble gratitude to: Shri Ambika Yoga Kutir, Thane, my Alma Mater, and all the selfless teachers who enabled me to professionally qualify in the science of Yoga and Pranayama. Various books, Internet websites that update my learning of those affected by dementia. Research scientists, medical fraternity who have honed and scientifically confirmed my experiences and quenched my thirst of knowledge and who will continue to inspire me and solve some more mysteries of the brain and its functions in the future, too. Most importantly, my ‘family’ of Smriti Vishvam-Universe of Memory, Specialized Dementia Daycare Centre, ARDSI Mumbai. This includes their families and caregivers at home from whom I am continuously learning nuances of effects of integrative medicine practically on a daily basis.

References Mayo Clinic Health Letter November 2015 WHO The Global Burden of Disease. World Alzheimer Reports, Alzheimer’s Disease International. ARDSI Dementia India Strategy Report 2018