This proposal discusses long term care in senior citizen rehabilitation. It outlines the biological, psychological, and social factors affecting rehabilitation for the elderly. It then discusses the process of rehabilitation and common chronic disabilities seen in different age groups. Key aspects of geriatric rehabilitation are described such as preventing secondary disabilities. Models for providing long term care in both institutional and community settings are proposed. The document concludes with care studies from the author's experience and recommendations for integrated planning of comprehensive healthcare for the elderly in India.

1. PROPOSAL PRESENTATION ON CGHS.
LONG TERM CARE IN SENIOR CITIZEN REHABILITATION
Goutam Chowdhary
Ex-Post Grad. Trainee
National Institute of Social Defence
Ministry of Social Justice and Empowerment (Govt. of India)
Introduction :-
Old age is often viewed as a gradual loss of physical and mental abilities
With an increasing difficult to maintain mobility & independence.
Age related factors influencing rehabilitation.
Biological Psychologic
Homeostenosis Decreased
In all system learning
Capacity. Personal
and religious beliefs
Social
Ageism by society, physician & self.
Financial reason.
Distribution of Chronic disability condition by age group.
45-64 Yrs 65 -74 Yrs >75 Yrs
Arthritis 253 229 383
Hypertension 27 239 360
Hearing Loss 118 231 353
Cataract 16 107 234
Vision Loss 45 69 101
Heart Disease 118 231 353
Source : National Health Interviews Survey 1989, Vital & Health Statistics, 10,176.1990

2. Disease related factors affecting rehabilitation.
Biologic Psychologic
Comorbility Cognitive
deficits
Deconditioning Depression
Poly pharmacy
Homeostenosis
Social
Ageism
Lack of facility,
financial problems
Process of Rehabilitation :-
As seen in Figures 1 & 2, there are many barriers for older people
In the Rehabilitation process. Nevertheless, the steps of rehabilitation
are the same for people of all ages, even through the process may
differ slightly.
POLY PHARMACY :-
It is a common problem in older patient because they are likely to
have multiple medical problems and to be taking multiple medications.This predisposes them
to having adverse drug-drug interactions. These drug-drug interactions can make the
difference in the older patients health.
Factors Responsible :
The major disabilities in elderly person which need long term
Care those are closely interrelated. Those are 5 – I’s
*INCOMPETENCE (DEMENTIA)
*INCONTINENCE
*IMMOBILITY
*IMPAIRMENT
*IATROGENIC PROBLEM.

3. The concept of geriatric rehabilitation began when physicians were faced
with many elderly immobile patients. They realized that it was crucial for
these patients to maximize The functional activities of daily living (ADLs)
such as personal hygiene, eating, toileting and Dressing.
It was believed that exercises and activities to maintain various
functions can retard deterioration of Physical and psychological processes.
Table 1
Demographic Data
[ Total Elderly population Approx 70 million (7%)]
Age Group 60 – 69 80%
(Years ) 70 – 79 18%
Socioeconomic status (Urban / Rural)
Chronic Diseases 45/45
Economically Independent 34/29
Employed 40/27
Living Alone 8/6
Source : Ageing : S.L. Yadav & K.K. Singh
Here Table 1. shows that 2/3rd of disabled population are
Over 60 years of age. Elderly people usually do not expect their independent
To their life style but only improve and maintain their active daily livings.
GERIATRIC REHABILITATION
Geriatric rehabilitation may be defined as the restoration of the disabled older
person to maximum capacity – physical and emotional. Improvements in
medical and scientific technology and in public health have dramatically
increased life expectancy in our country.

4. Table 2
Degenerative Disease in the Elderly that lead to need for rehabilitation
Disease Possible Problems
1. Stroke Paralysis,dysphagia,dysarthia
2. Peripheral Vascular disease Amputation
3. Impaired homeostasis (Vestibular, Sensory) Falls and Fracture
4. Orthostatic hypotension Falls and Fracture
5. Arthritis Immobility, Contractures
6. Osteoporosis Fracture, Immobility
7. Nervous System Incontinence, Immobility
8. Dementia Inability to perform activities of daily living
Ageing :- S.L. Yadav & K.K. Singh.
There are three major focus areas:
1. The obviously handicapped patients ( those with hemiplegia, arthritis, amputation
And neuromuscular diseases).
2. The chronically ill patients without signs of a manifest disability ( those with
chronic
cardiac Disease, chronic pulmonary disease etc.)
3. The elderly persons who are not obviously ill but whose physical fitness is
impaired.
Preventive Rehabilitation:
Restoration of maximal functions is the ultimate goal, sufficient for demand
of daily living and for psychological adjustments. The elderly may be said to
have been rehabilitated if one becomes self sufficient at least in ambulation,
washing, eating , dressing and toilet activities.

5.  Primary Prevention:
Some of the steps enumerated below :
- use of hand rails while negotianting stairs.
- Standing up with support of chair arm of mattress.
- Tidy house keeping to create safe living conditions.
- Prevention of the metabolic disturbances which cause osteoporosis.
- Conditioning exercises to improve cardio – vascular conditions.
- Postural guidance to make positive changes in their posture.
- Adequate pain management.
- Care of skin to avoid the risk of dermal wounds.
- Patients education depending upon physical condition level of motivation
- and support systems.
 Secondary prevention:
The prevention of a secondary disability is a major responsibility of the
Rehabilitation team before the era of surgical reduction of hip fracture, the
mortality of hip fracture patients was high because prolonged
immobilization resulted in the development of venous thrombosis,
hypostatic pneumonia and decubitus ulcer.When immobilization
or prolonged bed rest is imposed, the process of demineralization
gets accelerated.
Contracture is another frequently observed secondary disability.
Another preventable but sometimes fatal secondary disability is decubitus ulcer.
The long term care in Geriatric Rehabilitation means not only support elderly by
physically also by Socially, mentally environmentally and spiritually.
This care can be defined as health, Social and Personal services provided to
the chronically ill and disabled of any age over an extended period
of time in variety of settings.
Goals of Long Term Care.
(a). Restoring & maintaining Function
(b). Maximising quality of life
©. Preserving Autonomy.
(d). Maintaining safety & providing comfort ;
(e). Dignity in dying.
Goal achieve- even with the most devoted, caring & intelligent
Animator and funding.

6. Lack of care facilities:-
The two equally important dimensions of care of a patient having dementia are the
Quality of the patient and the burden of his/her family. Multi – model inputs are essential to
optimise the quality of life the patient and to alleviate the family’s burden of caring for the
patient.
The 6 – tier care model for the demented elderly:-
Long
Term
Care
Respite Care
Counselling
Day Care.
Counselling
Community Care
By Trained Personal
Counselling
Information and Guidance in Care.
Counselling
Information only : Formation of Care
Giver’s Groups.
For the comprehensive care of the demented elderly and their families, we propose
A 6 – tier care model taking into consideration the different degrees of care
Requirements.
1. Information only
During the initial stages of dementia, the care needs of the patient will be often
Minimal. With some supervisions by the care – giver the patient will be
competent
To care for himself/herself. What the family requires at this initial stage is mainly
Information about the nature and course of the illness and the potential disability
and
psychiatric and behavioural problems the patient may develop in future. These
information
may be conveyed to the care – givers during group meetings.

7. 2. Information and guidance in care
With the progression of the disease, various disabilities in self care may begin to
Manifest in the patient. Along with this, several psychiatric and behavioural
problems
May also make their appearance in the patient. At this stage the care giver may be
provided
With information and guidance in the specific care giving techniques. Also the
primary care
Givers often require counselling to alleviate their burden of care-giving. Periodic
meetings of
care – giving. Periodic meetings of care-givers group are essentioal.
3. Community Care
The disability of many patients may become very severe. So the care – givers
often
Find the care – giving process difficult which creates significant physical and
Psychological strain in them. In such families, trained personnel need to share the
Burden of care – giving with the family. This should be supported by regular
Counselling of the primary care – giver.
Institutional Care
Institutional care may be at different levels namely day care, respite care and
long termCare. In a rural agrarian community, the cultural milieu and the family
structure are competent to adequately care for the patient to a great extent.
But in the urban setting, due to the nuclearisation of families and the different
cultural milieu. The family of patients find the care – giving process extremely
burdensome.So in the urban context, institutional care should form n integral part
of the total care- giving process. This will ensure the quality of life the patients
and will alleviate the burden of the families. Facilities which provide such
comprehensives care are virtually absent in our community. Necessary measures
need to be taken to tackle this issue at the earliest.
4. Care-giver’s issues.
As many chronic care patients, the patients having dementia cannot be considered
in isolation
From his/her family. Both the patient and the family are victims of this
devastating ailment in
Their separate ways.

8.  TRAINING OF ELDERLY ABOUT EXERCISE
Exercise can be used to prevent or reverse the effects of disuse of muscle or
Body part caused by injuring or inactivity.
The Preventive measure of Geriatric patients by remembering the
“USE IT OR LOSE IT” principle.
1. Touch top of head by both hand;
2. Touch waist in back by hand;
3. Grip strength;
4. Place palm on hip;
5. Sitting on chair and lean forward to touch great toe by finger.
6. Stand unassisted;
7. Step over a 6” block (wooden) to improve muscle power of
Lower extremities.
Types of Long Term Care
1. Institutional Long Term Care: -
(a). Chronic Care Hospital
(b). Sub- acute Care Unit
©. Inpatient Rehab. Unit
(d). Skilled Nursing facilities
(e). Geriatric Care – giver facilities (Geriatric Animator Facilities)
Under Non- Skilled Nursing Facilities.
Long Term Care in Community Setting: -
(a). Home Health Care
(b). Skilled Home Care.
©. Day Geriatric Hospital
(d). PACE (Program for All – inclusive Care of the Elderly)
Continuing Care Retirement Centre – in one campus.
(a). Congregate Living
(b). Assisted Living Facilities (ALF)
©. Adult Foster Care
(d). Hospice Services
(e). Respite Care Services.
STAFFING FOR LONG TERM CARE.
Geriatric Physician – Nursing – Pharmacist – Therapist – Dieticians – Geriatric Cover
–
Social Worker – Psychologist – psychiatric – Dentist – Ophthalmologist.

9. PLANNING AND RECOMMENDATIONS
Planning health care for the elderly should involve long term care with an
involvement
Of the family, institutions and the doctor playing a major role in not only providing
Health services, but integrating then with other professional and multidisciplinary
Services.
Integrated planning for comprehensive health care in CGHS for the elderly should
aim at :
- Health planning with a moral orientation;
- Public involvement should be encouraged at every level of planning and
Management by NISD trainees (OLD AGE CARE DIVISION.)
- There should be efficient cost effectively use of resources;
- Health manpower research is necessary t o provide a sound basis
Of a decision-making.
- Health services should not be done in isolation, but in cooperation and
coordination
With other services connected with health.
- Health care should include domiciliary care, mobile geriatric clinic
Intensive health education, programming information and advise on nutritional
Needs and promotion of self care for physical activity and recreation
(Kumaraswami, 1991)
Planning for related services to assist health care and making them accessible should
Involve recommendation as given below;-
1. Primary health Care schemes should be strengthen by Central Govt.
Polypathy scheme and a multidisciplinary team.
2. Every old age centre, Day care centres attached with primary schools for
Psychologically upliftment.
3. Every day care centre in every village with drug stores (Polypathy) and
diagnostic centre.
4. Old age home, day care centre are also run as private concern for the welfare
of the inmates To create fund through direct share market basis, as iquity and
debenture made and make Geriatric Care Employment Services.
I, at last suggest that in every rural care centre must have multidisciplinary
team
of police, Geriatrician Care – giver, psychologist, Social worker and engineer.
I think that team will appropriate to develop the Geriatric Care facilities in the

10. Particular area of every block of District. Then Govt. will get relief from the
Heavy task for welfare o elderly. So for our today to be beautiful that our
Elderly sacrificed their yesterdays, now it is our duty to build their tomorrows.
CARE STUDIES
In my short practice as a physiotherapist in the team of Calcutta Metropolitan
Institute of Gerontology along with Dr. Kaushik Mazumder (Geriatrician),
Social Worker and Psychologist from 1998 till join this geriatric care Post
Graduate Diploma Course by NISD, Delhi.
Here I met several patients who need long term Care in (CMIG, CALCUTTA).
CARE - 1.
A male patient aged about – 77 Yrs. suffering from stroke lived in City
Who needs Physiotherapy, Speech – Therapy along with medical care.
After knowing all facts from his wife our team from CMIG went there and
Managed the patient and him family also. Then after 8th month from the
Day of attack, I found the good response from the elderly patient due to
Long term care in Geriatric Rehabilitation.
CARE – 2.
A female patient aged about 82 yrs, suffering from back pain and
Osteoarthritis of knee, she was fatty in figure. One day she fell down in her
Bedroom. Our CMIG multidisplinary team attended that case and that
Patient got recovered after one-year. Here also we found the long term
Care in Geriatric Rehabilitation.
I have seen more than 317 cases in my short practice life.
CARE – 3.
This case from rural area of North 24 PGs District place Rajarhat
In West Bengal. A male patient aged about 71 yrs with stroke (Cerebral)
Was also found to be in urgent needs of medical care specially physiotherapy
But they were living under poverty. After knowing all our team went
There and found the patient laid down on the high bed and make him feel
easy.
Then we met with family carers and gave them moral support and arranged
Medicines. After 6 months patient make good response after regularly
Attending him every week.
CARE – 4
A female patient aged about 68 yrs lived at Kalikapur Village, in 24
Pos (South) Near CMIG campus suffering from Kyphosis. i.e. front bend
Of Spine. I talked to that patient to care on her posture and advise her to

11. Took help of a stick to travel here and there for mobility. I also advised
Her to do some easy exercises, which help her more. Now she is improved
In health and a bit straight spine. She attend to CMIG Care Centre herself
For exercise to keep fit.
So, all above inspired me to take long-term care in Geriatric Rehabilitation.
I will do this care service as my level best for development of elderly care.
CMIG started 4 tiers Geriatric Care Services for elderly in Calcutta under
Supervision Dr. K.Mazumder, Geriatrician followed by :-
(1). Elderly Clinic Care
(2). Elderly Care outreached
(3). Day Hospital
(4). Short stay Respite care
References :-
i) Life in twilight years – Dr. Indrani Chakraborty
President, Calcutta Metropolitan Institute of Gerontoloy.
ii) Ageing Dr. Vinod Kumar, AIIMS Delhi.
iii) Bradomm’s physical Medecine.
iv) Primary on Geriatric Care, Rosenblatt & Natarajan.
v) Geriatric Care – Dr. K. Mazumder, CMIG. Calcutta.
vi) Dr. A.K. Mukherjee. NRS Hospital – Calcutta.