HEALTH M
AL
NATION
ISSI N
O
Ministry of Health & Family Welfare
Government of India
Training Manual on Elderly Care for Medical Officer
at Ayushman Bharat – Health and Wellness Centres
Training Manual on Elderly Care for Medical Officer
at Ayushman Bharat – Health and Wellness Centres
Contents
Chapter 1: Introduction to Healthcare of Elderly 1
Chapter 2: Ageing in Health and Disease - Understanding Elderly 4
Chapter 3: Approach to Evaluation of Elderly 11
Chapter 4: Managing Common Elderly Problems 17
Chapter 5: Health Promotion and Counseling in Elderly Care 44
Chapter 6: National Programme for Health Care of the Elderly 57
Chapter 7: Service Delivery Framework & Continuum of Care 61
Annexures 66
Annexure 1: Community based assessment checklist (CBAC) 66
Annexure 2: Comprehensive Geriatric Assessment (CGA)-CPHC 70
Annexure 3: Basic rehabilitation equipment for Sub Health
Centre Health &Wellness Center under NPHCE 97
References 99
List of Contributors 101
Contents
iii
Introduction to Healthcare
of Elderly 1
With increased access and advancement in health care combined with several other factors,
people all over the world are now living longer than before. It is natural, therefore, that health
care workers are likely to encounter older patients frequently in their practice and service.
Population ageing is one of the most discussed global phenomena in the current century. With
a comparatively young population, India is still poised to become home to the second largest
number of older persons in the world. India has many people now aged 60 years or more. The
population over the age of 60 years has tripled in the 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 the 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.1,2
India recorded a significant improvement in life expectancy at birth, which was 49 years in
1970-75 to 69 years in 2013-17, registering an increase of 19.3 years in the last four decades.3
The share of the population of the elderly was 8% in 2015 i.e., 106 million (10 crores plus) across
the nation, making India the second-largest global population of elderly citizens. Further, it has
been projected that by 2050 the elderly population will increase to 19%.4
As the elderly population continues to grow, the elderly dependency ratio will rise dramatically
from 0.12 to 0.31. Gender disparity has also been reported with 50% of women aged 75 years
and older report difficulty with at least one Activity of Daily Life (ADL) compared to only 24% of
men, adding the focus towards female elderly care.5
Introduction to Healthcare of Elderly
The Longitudinal Ageing Study in India (LASI) Wave 1, 2017-18, launched under the aegis of
Ministry of Health and Family Welfare has enabled better understanding of India’s elderly health
problems. The self-reported prevalence of cardio-vascular disease was 34% among those in
age 60-74 which increases to 37% among those age75 and above. 32% of the elderly reported
hypertension, lung disease, 5.9% reported asthma, 2.6% reported neurological and psychiatric
problems, 55.3% reported vision related problems, 9.6% reported ear related problems. A
higher proportion of elderly age 60 and above experienced difficulty in stooping, kneeling, or
crouching (58%), followed by difficulty in climbing upstairs without resting (57%) and pulling/
pushing large objects (53%). 11% of the elderly age 60 and above reported having at least one
form of impairment (locomotor, mental, visual and hearing impairment). A quarter (24%) of the
1
elderly age 60 and above reported having at least one Activity of Daily Living (ADL) limitation;
Difficulty in using the toilet facility is the most common ADL limitation faced. Although 43.3% of
elderly people use some kind of supportive device. However, 37.5% uses spectacles/contact
lens due to presbyopia, 3.1% uses dentures, 8.3% uses walker/walker sticks and 0.7% uses
hearing aids. More than a third (36%) are widowed. The proportion of widowed is higher among
older adult women (30%) than older adult men (10%).
Old age is a sensitive phase; elderly people need care and comfort to lead a healthy life
without worries and anxiety. Lack of awareness regarding the changing behavioral patterns
in elderly people at home leads to abuse of them by their kin. Various issues affect the
lives of senior citizens and further complicate into major physiological and psychological
problems. It is just not a disease that affects old age; there are various other issues that
govern the downfall of the health of old people. Old people need supervision, the laxity to
understand the needs and worries of elders make them appear strangers to the younger
generation, who later regard them as a burden. Elders suffering from cognitive challenges
undergo serious personality changes; at this point, they need care and attention. When
they are left unattended, most of them are gripped with overwhelming feelings of dejection,
purposelessness; some of them even turn violent. Although many of us know that ageing
is a natural progression and it has its own shortcoming, most of us tend to ignore this and
resort to an unruly approach.
Elderly populations have varying and complex social and health-care needs. For example,
while dementia may be addressed with health inputs, the social and financial insecurities that
may co-exist require inputs from the social welfare and finance sectors. A multidisciplinary
Training Manual on Elderly Care for Medical Officer at Ayushman Bharat – Health and Wellness Centres
and multisectoral approach, comprising professionals and general staff from several
relevant sectors, should be considered as the key mode of care delivery for the elderly
populations.
The National Sample Surveys of 1986-87, 1995-1996, and 2004, a comprehensive status report
on older persons have shown that6:
The burden of morbidity in old age is enormous.
Non-communicable diseases (lifestyle-related and degenerative) are extremely common
in older people irrespective of socio-economic status.
Disabilities are very frequent which affect the functionality in old age compromising the
ability to pursue the activities of daily living.6
However, very little effort has been made to develop a model of health and social care in
tune with the changing need and time. The developed world has evolved many models
for elderly care e.g., nursing home care, health insurance, etc. As no such model for older
people exists in India, as well as most other societies with a similar socioeconomic situation,
it may be an opportunity for innovation in health system development, though it is a major
challenge. The requirements for the health care of the elderly are also different for our
country. India still has family as the primary caregiver to the elderly and the scope for
training this lot to provide support to the program. Presently elderly are provided health
care by the general health care delivery system in the country. At the primary care level,
the infrastructure is grossly deficient. As per The National Policy for Older Persons (NPOP),
the Ministry of Health & Family Welfare was entrusted with the following agenda to attend
to the health care needs of the elderly7:
Establishing a geriatric ward for elderly patients at all district-level hospitals
Expansion of treatment facilities for the chronic, terminal, and degenerative diseases
2
Providing improved medical facilities to those not able to attend medical centers –
strengthening of CHCs / PHCs / Mobile Clinics
Inclusion of geriatric care in the syllabus of medical courses including courses for
nurses
Reservation of beds for the elderly in public hospitals
Training of Geriatric Caregivers
Setting up research institutes for chronic elderly diseases such as Dementia and
Alzheimer7
The elderly suffers from multiple chronic diseases. They need long term and constant care.
Their health problems also need specialist care from various disciplines e.g., ophthalmology,
orthopedics, psychiatry, cardiovascular, dental, urology to name a few. Thus, a model of care
providing comprehensive health services to the elderly at all levels of health care delivery
is imperative to meet the growing health needs of the elderly. Moreover, the immobile and
disabled elderly need care close to their homes.
Ayushman Bharat Health and Wellness Centres are envisioned to be providing healthcare
service closer to the community with comprehensive approach. The expanded service
packages are a part of this approach. Elderly care is an important package among these
expanded services. A Primary Health Centre (PHC) that is linked to a cluster of SHC-HWCs
would serve as the first point of referral for many disease conditions for the SHC-HWCs
in its jurisdiction. In addition, the PHCs are also being strengthened as HWCs to deliver
the expanded range of primary care services. The Medical Officer at the PHC would be
responsible for ensuring that elderly care services are delivered through all SHC-HWCs in
her/his area and through the PHC itself. This module would serve as a guide for Medical
Officer in ensuring elderly care services.
Key messages
With a comparatively young population, India is still poised to become home to the second
largest number of older persons in the world.
According to LASI Wave 1 survey of the older adult population undertaken under the aegis of
Ministry of Health and Family Welfare, elderly aged 60 years and above share a disproportionately
higher burden of chronic diseases than middle-aged adults.
Elderly needs a comprehensive care addressing their physical, psychological, social, economic
and spiritual health issues requiring the entire spectrum of primary, secondary and tertiary
healthcare interventions.
Elderly care is an integral part of the expanded package of services provided by the Ayushman
Bharath – Health and Wellness Centers (HWC). A Primary Health Centre (PHC) - HWC that is
linked to a cluster of SHC-HWCs would serve as the first point of referral for many disease
conditions for the SHC-HWCs in its jurisdiction.
Introduction to Healthcare of Elderly
3
2 Ageing in Health and Disease -
Understanding Elderly
What is ageing?
Ageing is an incremental and universal phenomenon comprising of gradual loss of cells leading
to deterioration of organ functions in a human body. Ageing is an irreversible, unstoppable,
Training Manual on Elderly Care for Medical Officer at Ayushman Bharat – Health and Wellness Centres
time-dependent process that is neither detrimental nor good but should be assessed in the
individual context, which would permit an individualized intervention to adjust the process to
optimize functioning in the ageing body.
More than 300 theories exist trying to explain the concept of ageing. All these aspects
were recently summarized as the “nine hallmarks of ageing,” including the intercellular
communication, genomic instability, telomere attrition, epigenetic alterations, loss of
proteostasis, deregulated nutrient sensing, mitochondrial dysfunction, cellular senescence,
and stem cell exhaustion.
Gerontology is multidisciplinary and is concerned with physical, mental, and social aspects and
implications of ageing.
Geriatrics is a medical specialty focused on care and treatment of older persons. Although
gerontology and geriatrics have differing emphases, they both have the goal of understanding
ageing so that people can maximize their functioning and achieve a high quality of life.
Geroscience is an interdisciplinary field that aims to understand the relationship between
ageing and age-related diseases.
With the increase of the life expectancy, the incidence of chronic age-related diseases (ARDs)
has also increased.
What is intrinsic capacity?
WHO defines intrinsic capacity as the combination of the individual’s physical and psychological
capacities?
Functional ability is the combination and interaction of intrinsic capacity with the environment
a person inhabits.
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