There are more older people on the globe now than ever before in the history of humanity. In 2022, the number above 60 was 1.1 billion, comprising 13.9 % of the population. By 2050, the number of older people is expected to increase to 2.1 billion, constituting 22%. India is not far behind. It had 149 million older adults (10.5%) in 2022, this figure will grow to 347 million (20.8%) by 2050 according to projections. The bottom line is that many of us are living longer than our ancestors.
Despite this imminent crisis, we know little about healthy ageing and elders’ mental health. Even worse, we have many misconceptions and fears about ageing, especially mental health problems in older people, such as depression, anxiety, and dementia.
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Getting old is a normal physiological process. For convenience, we can consider ageing in the physical, social, and psychological domains. It is important to remember that the issues in each domain interact with one another, within and outside the domains.
The physical aspects of ageing are apparent, for example, greying hair and decreasing muscle mass. However, there is considerable heterogeneity, with no two 70- or 80-year-olds being similar. We know of active, marathon-fit elders, while others, perhaps younger by a few years, are immobile. Also, different organs age differently, some faster than others, depending on genes, lifestyle, environment, and diseases.
Increased dependency, social isolation, poverty, ageism, pessimism, and nihilism are significant social challenges our elders face. They are vulnerable to emotional, physical, sexual, and financial abuse by others. Often, the perpetrators are known to them, commonly a family member. Many towns and cities in India are not “elder-friendly“. Many public buildings are inaccessible without ramps or handrails, pavements are non-existent, uneven, or used for parking, and public transport is limited. These make access to health care services difficult .
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Coming to the psychological aspects, as we age, we are expected to be wiser, with a broader understanding of “life“ and its challenges from our experience, either personal or vicarious. Erik Erikson proposed ‘Ego integrity versus Despair’ as his final psychosocial development stage in a human. According to him, older persons should view their accomplishments positively. They would be filled with despair if they did not consider themselves successful. Indian culture emphasises “acceptance“ of the past, the present and the future as a means of achieving “peace of mind“ in old age. “Accepting“ the limitations that old age imposes on us and “renouncing“ our responsibilities without a sense of suffering or loss are essential to age well psychologically. However, this is not easy, and many elders struggle to accept the changes accompanying ageing. As Abraham Lincoln said, “...It is not the years in your life that count. It’s the life in your years”.
Many elderly men especially feel lost and become unproductive after retirement. It is critical to develop from a young age, other interests in life, be it music, sports, social work, domestic responsibilities etc. This helps mitigate the feeling of lack of purpose after retirement which very often leads to depression.
Roughly 15% of elders (22 million in India) have serious mental illness. To provide context to this number, if we were to bring all the elders with mental illness from all over India together, we would need two cities the size of Chennai to accommodate them. Common mental health problems elders face are depression, anxiety, dementia, and substance use disorders.
Often, elders with mental illness do not seek treatment and the “treatment gap“ is a staggering 90% in India. A lack of awareness among the public and healthcare professionals is the main reason for this vast gap. Many symptoms of mental illness in the elders are dismissed as “normal“ for ageing.
Also, we have seen that many healthcare professionals are pessimistic about treatment of mental health problems in elders. Families are often asked to lock their relatives with dementia in a room, as nothing much can be done for them. This is far from the truth, as many confuse treatment with cure. While we do not have a cure for a neurodegenerative condition such as dementia, there are treatments that can reduce their suffering, improve their quality of life, and reduce the burden on families.
In addition, elders with mental illness face the double whammy of stigma associated with ageing and mental illness. Stigma makes it difficult for families to admit that an older relative has a mental illness and also creates reluctance to take them for treatment. Poverty and lack of access to services are other important factors. Most elders in India are impoverished and lack access to health care. Many interventions, such as psychosocial treatments, day centres, and particular medicines, are available only to a limited extent in cities.
To address some of these challenges, especially in rural communities, the SCARF (Schizophrenia Research Foundation) has partnered with Azim Premji Foundation to raise awareness about elder mental health in four rural Taluks of Chengalpet district in Tamil Nadu, reaching more than 350 villages. They have recruited 60 volunteers from these villages. These volunteers are sensitised about mental health problems elders face, and they encourage elders to seek help from the SCARF community outreach team and other service providers, including the District Mental Health Programme. The aim is to create a network in the rural community to improve elders’ mental health.
The Indian tradition of a joint family system has many advantages that supports elders. The multi-generational interactions and bonds fostered in joint families are crucial to the well-being of elders while providing essential care for children and young adults. Unfortunately, joint families are rare now, even in villages, due to migration, both within and outside the country, and smaller family sizes.
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Festivals and rituals also encourage socialisation for elders. Drawing “kolams“ or “rangolis“ requires complex cognitive skills that help to keep the brain active. We risk losing the potential protective effects of these traditions and rituals.
In future, given that most readers of this article will age, we need to ensure that mental health services are available for elders in our community. The co-ordinated actions of the individual, families, civic society, private organisations, non-governmental organisations, and government can achieve healthy ageing.
At the individual level, we need to plan for our old age with financial savings and lifestyle changes to maintain good physical health and a satisfying social life.
Healthy ageing, as a concept, should be introduced in the school curriculum. At a community level, services for elders with mental illness should be available and accessible.
City and town planners should consider elder-friendly designs to improve mobility and reduce dependency. Many retirement homes and elder care facilities are available in cities now, providing excellent care and a fantastic opportunity for elders to beat social isolation. These may fill the void left by the loss of the joint family system. However, most of them cannot care for those with dementia or other mental illness, which needs to be addressed urgently.
The government must frame policies for elders with mental illness, allocate resources, and implement services. We must remember that caring for our elders is everyone’s responsibility.
(Dr. Sridhar Vaitheeswaran is psychiatrist and head, Dementia Care Services at SCARF (DEMCARES). Dr. R. Thara, is co-founder and vice chair, SCARF)
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