Overview of ageing - common related health and social problems and preventive, therapeutic and rehabilitative healthcare

1. Care of the Elderly
Kayode Afolabi
1

2. Outline
• Introduction
• Defining ‘Elderly’
• Epidemiology
• Rationale for Care of the Elderly
• Care of the Elderly (Stages of prevention and care of common health
problems)
• Care of financial problems of the elderly
• Conclusion
2

3. Introduction
• With improvement in health status of the populace,
increasing life expectancy and reducing fertility, countries
have started to get to a point where the population starts to
age and the problems of the age group have gained more
attention in recent decades.
• At the First World Assembly on Ageing in 1982, “Vienna
International Plan of Action on Ageing.” was developed
focusing on specific interventions for the elderly.
3

4. Introduction
• The UN General Assembly declared 1999 the International
Year of Older Persons. The International Day of Older
Persons is celebrated on 1 October every year.
• There has been continued interest and work on ageing,
however there is little evidence that elderly people today are
in better health than their parents(WHO).
4

5. Defining ‘Elderly’
5

6. Defining ‘Elderly’
• Aged, old, older, senior, venerable
• Ageing is defined as the process of progressive
changes in the biological, psychological and social
structure of an individual (Kirkwood, 1996)
6

7. Defining ‘Elderly’
1) CHRONOLOGY
• 50 – Friendly Societies Act 1875, MDS project 1999
• 60 – UN/WHO
• 65 – WHO
• 75 – Orimo et al, 2006
7

8. Defining ‘Elderly’
2) CHANGE IN SOCIAL ROLE
• change in work patterns
• retirement from work/becoming pensionary
• adult status of children – marriage/independence
• becoming dependent on children
• death of Spouse
• menopause
8

9. Defining ‘Elderly’
3) CHANGE IN CAPABILITIES
• Loss of motor control/mobility loss
• Visual impairment and hearing loss
• Cognitive impairment especially memory loss
• Becoming in need of nursing care
9

10. Why do we age?
10

11. Aetiology
• Programmed Theories: fixed biological timeline
towards old age and death
• Genetics, Hormones, Immune system
• Error Theories: accumulated environmental damage
to our body's systems
• Wear and Tear, free radicals, Cross-linked proteins,
Genetic mutations
11

12. Epidemiology
Figures pooled from WHO’s Bulletin of the World Health Organization (1999),
Policy Framework on Active Ageing (2002) and Fact sheet on Ageing and health (2018)
0
500
1000
1500
2000
2500
1970 1999 2015 2025 2050
Global population over 60 years (in million)
Global population over 60 years
12

13. Epidemiology
• Demographic Revolution
• Not just young people!
• Improvements in public health and medicine
• The rate of growth is increasing and is likely to continue to increase
• Worldwide, the proportion of people age 60 and over is growing faster
than any other age group.
• The proportion of the elderly is going to nearly double between 2015 and
2050 (12% - 22%)
• By next year, people aged 60 years and older will outnumber children
younger than 5 years.
13

14. 14

15. Epidemiology
• By next year, approximately 70% of the elderly population will be
living in developing countries.
• And in SubSaharan Africa, which has the world’s youngest population,
the number of people over 60 years of age is expected to increase
over threefold, from 46 million in 2015 to 147 million in 2050
• In Nigeria, the absolute number is on the rise although proportion is
dropping (NDHS 2008, 2013, 2018)
15

16. NDHS 2008, 2013, 2018
8.5
9
9.5
10
10.5
11
11.5
Population of over 60s (in millions)
Trend in population of the elderly in Nigeria
2008 2013 2018
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17. Why must we care?
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18. Rationale for Care of the Elderly
• The old-age dependency ratio (i.e., the total population age 60 and
divided by the population age 15 to 60) is increasing
• Concerns about whether or not a shrinking labour force will be able
to support the “dependent” groups
• However, most of the older people can continue to be a vital resource
to their families and communities: working, teaching/mentoring and
performing civil duties.
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19. Rationale for Care of the Elderly
• Yet the extent of these opportunities and contributions
depends heavily on one factor: HEALTH.
• As stated in the WHO Brasilia Declaration on Ageing (1996),
healthy older persons are a resource for their families, their
communities and the economy. The more active they are,
the more they can contribute to society.
19

20. Rationale for Care of the Elderly
• However, the elderly still face poor health conditions
especially in LMICs. Many elderly still come down with
preventable chronic conditions that lead to disability and
death.
• In the coming decades, many countries are likely to face
economic and developmental pressures if work is not done
to prevent chronic diseases, and provide proper
management and delay disabilities.
20

21. Rationale for Care of the Elderly
• The greatest causes of disability are sensory impairments,
back and neck pain, COPD, depressive disorders, falls,
diabetes, dementia and osteoarthritis.
• The biggest killers of older people are heart disease, stroke
and chronic lung diseases.
• Financial difficulty is also bothersome to the elderly and has
implications on dependency, their health and the economy.
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22. Care of the elderly
22

23. Care of the elderly: Primary Prevention
• Life course approach to prevention of diseases particularly
NCDs via counselling and promotion of healthy lifestyle
• Nutrition
• Exercise/Physical activity
• Alcohol restrictions
• Tobacco avoidance
• Recreation and Social activities
• Other established risk factors
23

24. 24

25. Care of the elderly: Secondary Prevention
• Periodic Medical Check-ups
• Early detection and evidence-based treatment
• Common conditions in the elderly that have been found to be strong
predictors of care dependency, morbidity and mortality include
• mobility loss
• Malnutrition
• visual impairment
• hearing impairment
• cognitive impairment
• depressive symptoms
• urinary incontinence
• falls (WHO).
25

26. Mobility Loss
• From loss of muscle mass and muscle strength, decreased flexibility
and problems with balance.
• Mobility impairment is found in 39% of people over 65 years of age, 3
times higher than among those within 15 and 65 years
• Manage underlying conditions
• Involve physiotherapist
• Encourage multimodal exercise, including progressive strength
resistance training and other exercise components (balance, flexibility
and aerobic training)
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27. Malnutrition
• Sensory impairments, poor oral health, isolation, loneliness and
depression, diminished cognitive function, diminished ability to care
for oneself –individually or in combination – all increase the risk of
malnutrition in older age.
• Malnutrition represents a major problem that affects 22% of older
adults
• Manage underlying conditions/refer appropriately
• Dietary Counselling
• Recommend oral supplementation/special foods for the elderly,
mealtime interventions
27

28. Visual impairment
• Mostly from cataract – the single-most important cause of vision loss
• Cataract affects 79% of people over 60 years of age and 90% of
people over 70
• Other common causes: presbyopia, glaucoma, diabetic retinopathy
and age-related macular degeneration
• Visual screening with Snellen’s chart at PHC
• Manage underlying conditions and refer appropriately
• Cataract Surgery
28

29. Hearing Impairments
• Worldwide, more than 180 million people over 65 years of age have
hearing loss that interferes with understanding normal conversational
speech.
• Routine screening for the elderly: asking about hearing problems,
audiological examinations, otoscopic examinations, whisper test at
PHC.
• Manage underlying conditions & exclude ototoxic drugs
• Refer to ENT
• Provision of hearing aids
29

30. Cognitive impairment
• Problems with memory, orientation, speech and language,
and difficulties in performing key roles and activities.
• Ranges from mild cognitive impairment to dementia. It is a
chronic condition and a third of the cases progress to
dementia.
• Worldwide, 46.8 million older people are living with
dementia. This number is expected to double every 20 years.
30

31. Cognitive impairment
• Standard or Local assessment of cognitive functions
• Encourage family members and caregivers to provide older
people with regular orientation information (day, date, time,
weather, names of people, and so on) and use materials such
as newspapers, radio and television programmes, family
albums e.t.c.
• Refer appropriately/Cognitive stimulation
31

32. Depression/depressive symptoms
• Increased risk of Subthreshold depression in elderly due to increased
risk of adverse life events. It is major risk factor for a depressive
disorder
• Affects nearly 1 in 10 older adults
• Refer appropriately for structured psychological/mental health
interventions
• Physical exercise as an adjunct
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33. Urinary Incontinence
• From loss of sphincteric functions, and also mobility loss, cognition
impairment and lack of motivation.
• Affects about a third of older people worldwide
• Manage underlying conditions and refer appropriately
• Exclude drug-induced diuresis or retention
• Bladder training: scheduled intermittent voiding
• Pelvic floor muscle training (PFMT)
33

34. Falls
• Majorly related to declining physical capacity
• Extrinsic factors that increase risk of include environmental hazards
such as loose rugs, clutter, poor lighting and improper foot wear such
as ill-fitting, floppy slippers.
• A third of people over 65 years of age and living in the community
have a fall each year
• Falls are the leading cause of hospitalization and injury-related death
• Management of injuries/Refer as appropriate
• Multimodal exercises
• Home/Environmental modifications
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35. Care of the elderly: Tertiary Prevention
• Rehabilitation
• Creation of age-friendly environments:
• overcoming ageist attitudes and policies such as mandatory
retirement
• Family presence/visit, home help, old age homes/clubs
• strengthening the links between older people and younger
generations
• creating physical environments that allow people with disability to
participate
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36. REHABILITATION
36

37. Rehabilitation for the elderly
Mostly for retraining of mobility and self-care
1) COMMUNITY BASED INTERVENTIONS
a) Outpatient clinics
b) Domiciliary visits
c) Day care
2) RESIDENTIAL CARE AND NURSING CARE
a) Short term care - a few days to less than a month
b) Long term care - a month or more
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38. Rehabilitation for the elderly
3) HOSPITAL CARE
• This can be either acute or a long term care.
• Prompt discharge because of the risk of nosocomial infections.
4) INFORMAL CARE
• often provided by spouses, children, and other family members
• accounts for most of the care the elderly currently receive in
developing countries.
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39. Rehabilitation – assessing needs
• For physical (and emotional) assessment some of the
common measures used are
• 'activities of daily living' or ADL
• Katz scale (assesses bathing, dressing, toileting, transferring,
continence, and feeding)
• Barthel scale (feeding, personal toileting, bathing, dressing and
undressing, getting on and off a toilet, controlling bladder,
controlling bowel, moving from wheelchair to bed and returning,
walking on level surface (or propelling a wheelchair if unable to
walk) and ascending and descending stairs.)
• PULSES scale (i.e. Physical condition, Upper limbs (self-care), Lower
limbs (ambulation), Sensory abilities, Excretory, Mental and
Emotional Status)
39

40. Rehabilitation – assessing needs
• A further modified scale that covers finances and social
participation is the "instrumental activities of daily living" or
IADL – handling, personal finances, meal preparation,
shopping, traveling, doing housework, using the telephone
and taking medications.
• for cognitive assessment some of the common scales used
are
• Short Portable Mental Status Questionnaire (SPMSQ)
• MMSE (mini mental status examination)
40

41. 41

42. Bowels 0 = Incontinent (or needs to be given enema)
1 = occasional accident (once/week)
2 = continent
Bladder 0 = incontinent, or catheterized and unable to manage
1 = occasional accident (max. once per 24 hours)
2 = continent (for over 7 days)
Grooming 0 = needs help with personal care
1 = independent face/hair/teeth/shaving (implements provided)
Toilet use 0 = dependent
1 = needs some help, but can do something alone
2 = independent (on and off, dressing, wiping)
Feeding 0 = unable
1 = needs help cutting, spreading butter, etc.
2 = independent (food provided within reach)
Transfer 0 = unable – no sitting balance
1 = major help (one or two people, physical), can sit
2 = minor help (verbal or physical)
3 = independent
Mobility 0 = immobile
1 = wheelchair independent, including corners, etc
2 = walks with help of one person (verbal or physical)
3 = independent (but may use any aid)
Dressing 0 = dependent
1 = needs help, but can do about half unaided
2 = independent (including buttons, zips, laces etc)
Stairs 0 = unable
1 = needs help (verbal, physical, carrying aid)
2 = independent up and down
Bathing 0 = dependent,
1 = independent (or in shower)
Barthel
Scale
42

43. PULSES SCALE
43

44. 44

45. 45

46. Rehabilitation – services
1) Activities of daily living
2) Neuropsychological rehabilitation
a) Reality orientation - repeatedly telling or showing certain
reminders
b) Cognitive retraining – helping improve memory, organization,
problem solving, decision making and executive skills
c) Compensatory memory aids
3) Physical exercises e.g Walking, jogging, swimming, yoga
46

47. Care of the elderly: Data, Research and Policy
• Standard indicators and analytical approaches are needed to be able
to measure and ensure Healthy Ageing
• Trends documenting Healthy Ageing trajectories across the life
course, including variation across and within countries; and
• More researches need to be done to understand how to improve
intrinsic capacity and functional ability across the life course and
gather evidence to influence policy-making.
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48. Care for financial problems of the elderly
• Health care
• Insurance measures from early adulthood
• Regular financial assistance from family members
• Provision of adequate, realistic and regular pension
• Provision of free/subsidised feeding, transportation, healthcare and
other essential services
• Provision of micro economic schemes for the active aged who can still
be involved in small scale business or farming
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49. Overview of elderly care in Nigeria
Research title, location and date Author(s) Finding(s)
Profile and correlates of functional status in elderly
patients presenting at a primary care clinic in
Nigeria.
Ibadan.
2015
Ajayi SA et al 88.3% of elderly have functional disability
in at least one area of BADL
Prevalence estimates of major neurocognitive
disorders in a rural Nigerian community.
Lalupon, Oyo state.
2016.
Ogunniyi et al 18.1% of the elderly had Mild cognitive
impairment and 2.8% had dementia
Characteristics of critically ill elderly patients
admitted to a tertiary ICU in Nigeria and outcome
of management.
2018.
Tobi KU,
Ndokwu EO,
Edomwonyi NP
Cerebrovascular accidents (stroke)
contributes 12.6% of ICU admissions of
the elderly.
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50. Overview of elderly care in Nigeria
Research title, location and date Author(s) Finding(s)
Enacted and implied stigma for dementia in a
community in south-west Nigeria.
Ibadan.
2016.
Adebiyi AO et al Presence of enacted and implied
stigma against dementia in the elderly.
36% of respondents felt dementia is
associated with shame and
embarrassment. 28% felt that people
do not take those with dementia
seriously
A four-year review of geriatric mental health
services in a Lagos based hospital, Nigeria.
Lagos.
2016
Adebayo RA et al 62.4% of the elderly commute for at
least 1 hour to get treatment
Physician’s knowledge of appropriate prescribing
for the elderly – A survey among family and
internal medicine physicians in Nigeria.
Ekiti, Ibadan, Ilorin, Orlu.
2019
Fadare JO et al 30.5% and 39% of physicians had low
and average knowledge scores
respectively on appropriate
medications for the elderly
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51. Overview of elderly care in Nigeria
Research title, location and date Author(s) Finding(s)
Knowledge about risk factors for falls and
practice about fall prevention in older
adults among physiotherapists in Nigeria.
6 geopolitical zones.
2019
Kalu ME,
Viachantoni A,
Norman KE
50% of physiotherapists reported a low
level of practice of referral to other health
care professionals.
Caring for the seniors with chronic illness:
The lived experience of caregivers of older
adults.
Osun state.
2019.
Faronbi JO et al Caregivers of the elderly admit that caring
for the elderly affects other aspects of
their lives e.g disruption of family, poor
health, social isolation
51

52. Facilities for Elderly care in Nigeria
• Hospital: The Chief Tony Anenih Geriatric Centre at the University
College Hospital in Ibadan and the geriatric units at the University of
Benin Teaching Hospital and the University of Port Harcourt Teaching
Hospital
• Residential/Nursing: At least 14 in Ibadan. 1. Quendom Genesis -
Oluyole Extension, 2. Rossetti Care – Moniya, 3. Primary Health Care
and Health, Management(PRIHEMAC) - Olubadan Estate, 4. VOG
Consult – Onireke, 5. New Concept Healthcare and Life-Support –
Eleta (Source: CTAGC)
• Informal care: MAJORITY
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53. Challenges in Nigeria
• Inadequate facilities
• Inadequate funding
• Pension Scheme Inadequacies
• Retirement age
• Paucity of geriatric units
• Specialty-isolated care
• Poor knowledge especially on proper medications and referral
• Stigma and elderly abuse/bullying
• Caregiver burden
53

54. Conclusion
• The elderly are humans with rights; they undergo changes due to
increasing age that may result in reduced physical and mental capacities
and in the long run disabilities and death if not well taken care of.
• They constitute a significant proportion of the population and can be
resourceful to the society and lessen dependency burden if properly cared
for.
• Hence, caring for the elderly is actually an investment and not an
economical or health system burden.
• Promotion of healthy habits, prevention of diseases, early detection and
management of diseases, rehabilitation and creation of age-friendly
environment and polices are all key in optimum adult care.
54

55. References
• Proposed working definition of an older person in Africa for the MDS Project
https://www.who.int/healthinfo/survey/ageingdefnolder/en/
• Orimo H. et al. Reviewing the definition of “elderly”. Geriatrics and Gerontology International,
2006. dox: 6. 10.1111/j.1447-0594.2006.00341.x.
• Kalache A. Editorials - Active ageing makes the difference. Bulletin of the World Health
Organization, 1999, 77 (4).
• World Health Organization. Active Ageing - A Policy Framework. A contribution of the World
Health Organization to the Second United Nations World Assembly on Ageing, Madrid, Spain,
April 2002.
• World Health Organization. Ageing and health fact sheet. Published on 5 February 2018.
https://www.who.int/en/news-room/fact-sheets/detail/ageing-and-health
• World Health Organization. Integrated care for older people: guidelines on community-level
interventions to manage declines in intrinsic capacity. 2017. Licence: CC BY-NC-SA 3.0 IGO.
• Nilesh Shah, Parul Tank. Rehabilitation and Residential Care Needs of the Elderly (Clinical Practice
Guidelines)
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56. Thank you
56