Geriatric mental health: The challenges for India

Pragya Lodha; Avinash De Sousa

doi:10.4103/jgmh.jgmh_34_17

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Year : 2018 | Volume : 5 | Issue : 1 | Page : 16-29

Geriatric mental health: The challenges for India

Pragya Lodha¹, Avinash De Sousa²
¹ Research Assistant, Desousa Foundation, Mumbai, Maharashtra, India
² Founder Trustee and Consultant Psychiatrist, Desousa Foundation, Mumbai, Maharashtra, India

Date of Web Publication

27-Jun-2018

Correspondence Address:
Avinash De Sousa
Carmel, 18, St. Francis Road, Off S.V. Road, Santacruz West, Mumbai - 400 054, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jgmh.jgmh_34_17

Abstract

Geriatric mental health has yet to receive its due recognition in India. Geriatric mental health is plagued by many challenges that prevent the development and progress of its services. The present article is a narrative review that looks at the various challenges faced by geriatric mental health in India. The article describes different specific and general unique challenges faced by geriatric mental health and discusses in detail the nature of each challenge and what must be done to overcome it. The challenges range from demography of Indian aging to sexual issues in the elderly, geriatric depression, dementia care, and the aging lesbian, gay, bisexual, and transgender community. Various issues related to policy and research that challenge geriatric mental health are also discussed. The need to incorporate geriatric mental health into primary health care along with the need to train primary care workers and preventive work aimed at suicide prevention in the elderly is stressed. The article addresses these challenges with the aim of positing before the clinician the various challenges faced by geriatric mental health in India in the current era.

Keywords: Caregivers, challenges, dementia, elderly care, elders, geriatric depression, geriatric mental health, geriatrics, mental health, suicide

How to cite this article:
Lodha P, De Sousa A. Geriatric mental health: The challenges for India. J Geriatr Ment Health 2018;5:16-29

How to cite this URL:
Lodha P, De Sousa A. Geriatric mental health: The challenges for India. J Geriatr Ment Health [serial online] 2018 [cited 2023 Apr 1];5:16-29. Available from: https://www.jgmh.org/text.asp?2018/5/1/16/235372

Introduction

India's demography consists of a geriatric population which shall increase in the years ahead.^[1] The scope of geriatric mental health differs from other areas of mental health as geriatric populations have unique needs, thereby fostering many challenges.^[2] These challenges are seen at every level of care and treatment, from acceptance of a mental health problem to seeking help and remaining compliant in treatment.^[3] Lack of trained professionals, scarce geriatric mental health infrastructure, and dearth of financial resources for geriatric mental health are some of the challenges that our nation faces.^[4] Geriatric mental health problems can be accurately diagnosed and effectively treated if help is sought early, but it is erroneously assumed that they are part of “normal aging.”^[5] The unprecedented pace of demographic aging makes geriatric mental health a huge public health challenge for India.^[6] The current review discusses the general and specific challenges for geriatric mental health in India from a clinical perspective while proposing some solutions to help encounter these challenges.

Method of Conducting This Review

Articles that assessed geriatric mental health and its challenges in India were identified through searches of the PubMed, EMBASE, and Google Scholar databases for articles published in English between January 1995 and December 2017. The search combined the terms geriatric mental health, challenges, geriatric mental health India, and challenges for geriatric mental health. Additional articles were identified by a manual search of the reference lists of the identified articles and book chapters and recent review articles obtained. Abstracts and posters from conferences and meetings were not included in the literature search. The authors then reviewed the identified studies and were able to determine the general and specific challenges faced by geriatric mental health in India. These were then discussed in the current article. Both the authors have sound clinical work in the area of geriatric mental health and their personal experience has added worth to the challenges described in the article.

General Challenges for Geriatric Mental Health in India

Challenge 1: The demography of aging in India

India has a total population of 1.31 billion, the second largest globally, and comprises 17% of the world's total population.^[7] Currently, the growth rate of individuals aged 60 years and older is three times that of the population as a whole.^[8] Rapid advances in medicine, public health, nutrition, and sanitation have led to large cohorts advancing to old age.^[9] A difference of percentage share in the aging population between rural and urban areas has resulted in larger number of aging citizens residing in rural areas.^[10] The aging population is >100 million, and projections predict a figure of 324 million, i.e., 20% of the total population, by 2050.^[11]

In large epidemiological studies, women have shown a preponderance to mental health issues as compared to men and this may be also due to predisposed biological and social risk factors.^[12],[13] Women in old age are more prone to social insecurity, health problems, and greater emotional/financial insecurities.^[14],[15] Lower levels of education are shown to be associated with higher rates of dementia and consequently more among females.^[16] As mentioned above, most of the elderly live in rural areas and may be poorly educated.^[17] The mere increasing demography of aging in India and social factors itself pose a challenge for geriatric mental health.

Challenge 2: The heterogeneity of clinical presentations in geriatric mental health

A key clinical issue in geriatric mental health is the heterogeneity in clinical presentations that confounds diagnosis and treatment of these problems. Patients usually deny the presence of mental health problems and are reluctant to seek help.^[18] In most cases, a clear textbook-like clinical picture is absent, and the skill and intuition of the psychiatrist with thorough understanding of psychosocial factors helps to determine diagnosis.^[19] Physical symptoms may be the chief complaint in many cases and the underlying psychological problems are obscured under a garb of physical complaints.^[20] There are incomplete clinical pictures where diagnostic criteria are not satisfied, but the problems are severe enough to warrant treatment. This leads to issues in diagnosis, and the management is based on clinical experience of the psychiatrist.^[21] The physical and psychological symptoms in geriatric patients may change during each visit and the clinician must understand the same. Patients differ in the degree of mobility they possess as some may be bedridden and malnourished, some may be wheelchair bound, and others are ambulatory.^[22] Varying degrees of medical illnesses also complicate the clinical picture. The patient being on multiple medications and multiple doctors treating the patient need to work in synergy for best results.^[23] Thus, clinical heterogeneity in presentation, varying symptoms, presence of medical illnesses, multiple medications, and being treated by multiple doctors poses a clinical challenge in geriatric mental health.

Challenge 3: The challenge for dementia care in India

Dementia is the most common neuropsychiatric illness besides depression as the major contributor to disability in people above 60 years of age, accounting for one-quarter of all disability-adjusted life years.^[24] Eight large-scale epidemiological studies have indicated that prevalence for dementia for those aged >85 years in India ranges from 18% to 38% and, in those >90 years, it ranges from 28% to 44%.^[25] In 2010, there are 3.7 million Indians with dementia and the total societal costs is about 14,700 crores. While the numbers are expected to double by 2030, costs would increase by three times.^[26] Research indicates that up to 90% of the time, challenging/psychiatric behaviors (agitation, irritability, restlessness, sleep disturbance, and/or emotional distress) that occur in persons with dementia may be caused by either factors in the environment or by a caregiver approach.^[27] The management of behavioral and psychological symptoms in dementia is challenging as many of these patients show an intolerance and side effects to medication. They also may lack the ability to describe and understand their own symptoms.^[28] The growth in dementia patients entails the need for specialized dementia care units which are conspicuous by their absence. Dementia care homes and rehabilitation centers along with dementia day-care centers have not been developed in India, and this is the need that must be addressed to meet the challenge of dementia care in India.

Challenge 4: Social factors that play a role in geriatric mental health problems

Multiple social, psychological, and biological factors determine the level of mental health of a person at any point of time.^[29] Along with the typical life stressors common to all people, many older adults lose their ability to live independently because of limited mobility, chronic pain, frailty, or other mental or physical problems.^[30] In addition, older people are more likely to experience some events characteristic of the phase of the life they are in such as bereavement, a drop in socioeconomic status with retirement, or a disability.^[31] The special social challenges of the elderly population in India are as follows:

A majority (80%) of them are in the rural areas, thus making service delivery a challenge ^[32]
The government pension scheme currently reaches only 2.76 million out of 28 million elderly people, mainly urban ^[33]
Feminization of the elderly population (51% of the elderly population are women)^[34]
Increase in the number of the older-old (persons above 80 years)^[35]
A large percentage (30%) of the elderly is below the poverty line.^[35]

There are several social factors that subliminally or sometimes, directly, affect the mental health of the geriatric age groups as follows:

Retirement: In India, the retirement age is approximately 56–65 years for men and women and varies across the states. Retirement is one of the strongest social factors that bring an overhauling change in a working individual. From the next day of retirement, the individual has no work to engage in (physically or mentally), his or her daily schedule is lost, and the motivation to look forward to something is also gone. With retirement, also comes a sense of loss of authority. Dips in self-esteem and self-confidence are also witnessed as the retired individual seems to have become more dependent than he or she was before. Retirement brings in a sense of dependency which is not very pleasant to the senior citizen ^[36],[37]
Housing issues: The growing trend of nuclear families in India has inadvertently reduced the structure of families as support systems. Children no more wish to stay with their aging parents due to the burden of care. In another scenario when housing becomes a challenge for the geriatric age group is when children decide to move in to another space or locality. Psychosocially, adjustment to a new place after having lived in a locality for 60 years is a difficult adjustment to make for the elderly ^{[11],[38],[39]}
Financial issues: With retirement, financial dependence is one of the greatest challenges that the elderly face. A loss of steady source of income does bring in a sense of helplessness and dependency. An National Service Scheme (NSS) survey reveals that 12% of the oldest-old, i.e., persons above the age of 80 years are still involved in some economic activity in order to meet their daily needs. Remittances from children are reported as their main source of income, as reported by 49% across the cities in an NSS survey.^[40] Most geriatric population finds it difficult to get insurance coverage and therefore have to bear the cost of their health-care expenses. Several times, the elderly are denied adequate health care due to shortage of funds. Thus, financial dependence has a huge influence on the quality of life for the geriatric individuals.^[41],[42] Financial abuse is incurred by family members, friends, and caregivers of the elder person and financial abuse within institutional settings or by strangers may also impose a debilitating effect.^[43] Domestic settings are not only a frequent setting for this abuse, but also their tendency to involve complex family dynamics and deep-seated conflicts tends to make them particularly challenging ^[44]
Lack of transport: Many senior citizens from the urban and suburban areas, especially from rural areas, struggle to find reliable transportation. The result is missed appointments and poor illness management, even when care is readily available. Some households do not have a vehicle, or share one among multiple family members. Many low-income neighborhoods are hit particularly hard by shoddy transportation infrastructure and subways may not act as service areas on the fringes of a city, buses may be unreliable, and both are vulnerable to strikes or service suspensions. For those who are disabled, obese, or chronically ill, riding the bus or the subway can be a difficult undertaking ^[45],[46]
Parents in India and Children Abroad: The extended family consists of at least two generations living together and this arrangement has usually been to the advantage of the elderly as they enjoy special status and power. However, with growing urbanization and dependency on the availability of jobs, children are increasingly opting out of the extended family setup, leaving behind an “empty nest” and establishing their own nuclear families.^[47]

These social problems lead patients to seek solutions not only to their psychological problems, but also to these social problems which may be beyond the realm of geriatric mental health services and thus posing a huge challenge to geriatric mental health-care workers.

Challenge 5: Rehabilitation facilities for the elderly and interventions in old-age homes

The changing family value system, economic compulsions of children, neglect, and abuse have caused elders to fall through the net of family care. Homes for the aged are ideal for elderly people who are alone and face health problems, depression, and loneliness.^[48] India has four types of resources to address geriatric mental health issues, namely state-funded government psychiatric hospitals and nursing homes; private psychiatric hospitals and nursing homes; nongovernmental organizations (NGOs); and, the most important, informal sources – family as caregivers.^[49]

Countries like India can develop adequate training programs for the family members who are the most available and largest chunk of caregivers in the service of the elderly. Supporting, educating, and advising family caregivers is a cost-effective strategy for developing countries as it requires only one-tenth of the resources as invested in residential care.^[50]

The State and Central provide scarce facilities for day-care centers and respite care. There is an absence of any home-based rehabilitation measures or benefits accorded by the State to families to address caregiver burden. However, various types of early intervention for health and social services are in practice today (and can be accommodated in our country), as follows:

Community-based interventions: These are important as early interventions as they improve the subjective well-being and quality of life of the elderly. These services also strive to give a greater degree of functional ability and independence. A challenge that remains is to have cost-effective programs ^[51]
Outpatient clinics: These clinics are important for assessment and follow-up of mobile, geriatric patients. There are advantages when these clinics are staffed jointly by internists and psychiatrists. In some areas, memory clinics have been developed for the assessment of patients with early memory problems ^[52]
Domiciliary visits: Increasingly, assessments and treatments are offered in the patient's home; community psychiatric nurses act as a bridge between primary care and specialist service. Domiciliary visits also reduce the rate of hospital admissions ^[53]
Geriatric day care: Day care should provide a full range of diagnostic services and offer both short-term and continuing care for patients with functional or organic disorders, together with support for relatives. There are few day-care services by NGOs in India (i.e., HelpAge India) and also state governments. Definitive criteria for referral have not been essentially established. Some of the targeting criteria for community-based services include dependency in two or more activities of daily living, no family support, dementia, many long-term illnesses, and many hospital stays.^[54]

Other forms of rehabilitation:

Residential care and nursing care: Residential care involves accommodation, ranging from independent housing to sheltered housing schemes. In residential homes, the needs of the elderly can be met by care assistants with relatively little training. Nursing care involves trained nurses, and it is for individuals with more medical problems.^[55] The residents in both setups face more cognitive impairment, depression, and behavioral disturbances. They also face inadequate quality of medical care. Training the assistants and nurses can improve the functional ability of the residents ^[56]
Hospital care: This may be either acute or a long-term care – depending on the purpose of admission. Inpatient teams should be able to provide multidisciplinary assessment and treatment of patients with severe mental health problems. There is variation in different areas as to who should be a part of the multidisciplinary setup and whether patients with functional illnesses need to be cared for separately or together with organic disorders.^[57],[58] However, prompt discharge should be the aim in acute setup because of the vulnerability of the elderly to nosocomial infections. There is still a gap in the Indian hospitals for separate wards and care units for the geriatric population
Respite care: It involves care given to the elderly so that caregivers can take time off to relax or take care of other responsibilities. Respite can vary in time from part of a day to several weeks. It encompasses a wide variety of services including traditional home-based care, as well as adult day care, skilled nursing, home health, and short-term institutional care.^[59] Research indicates that respite care decreases family stress and improves family functioning, life satisfaction, attitudes toward family members with disabilities, and the physical and emotional health of the elderly. Respite care significantly decreases the need for costly out-of-home placements, such as hospitalization, and nursing home care ^[60]
Home-based setups: Informal care often provided by spouses, adult children, and other family members accounts for most of the care the elderly currently receive in developing countries. Even today, the younger generation in India sees it as their responsibility to care for their elderly and they are under social and cultural pressure to do so. Care provided at home is often considered the preference of the elderly and the cost is most often borne by the family. However, despite the increasing demand for home-based care due to population aging, factors such as urbanization, migration, break-up of the joint family system, change in the role of women from being full-time carers, and decreasing fertility rates mean that future cohorts of the elderly will have smaller networks of potential family caregivers.^[61]

These services have shown to be extremely necessary in India due to varied reasons as follows:

Primarily, the services deem to be necessary due to the breakdown of the traditional familial structure, which creates a niche in the support system for the elderly. With the given decrease in family sizes, and the patriarchal society of India, the woman of the family, who is more often than not the daughter-in-law in relation to the elderly of the house, is forced to take up the sole responsibility of care for the elderly.^[62] Not surprisingly, but larger households have remained associated with lower caregiver strain.^[63] Studies show that, even when the responsibility of caring for the elders is taken up willingly, such prolonged caregiving frequently leads to a negative impact on the caregivers' emotional and physical health ^[64]
Geriatric patients suffering from prolonged mental disorders that severely decrease their functioning capacity, especially with disorders that are accompanied with psychosis, require constant observation and care. Due to this increased responsibility, a greater caregiver strain has been reported with greater patients with greater psychotic symptoms ^[65]
Similarly, it has been reported that half of those providing care for someone with Alzheimer's disease develop significant psychological distress. Moreover, due to the lack of understanding among people of behavioral and psychiatric symptoms of dementia, the caregivers are blamed for their behavior and are often accused with providing inadequate care, adding to the jeopardy of the caregiver.^[66]

In such scenarios, community-based services that aid the caregivers in coping with the stress and help in providing care are necessary. Unfortunately, the reliability and universality of the family care system is often overestimated and there are minimal community-based mental health services that provide aid for the elderly suffering from chronic disorders and almost none that provide support to caregivers.^[67] There are a few community-based health care-providing NGOs in India. The lack of community-based mental health-care services is a challenge for geriatric as mental health it hinders adequate care for the elderly and also increases their chance of developing mental disorders.^[68] Thus, rehabilitation of the elderly and those residing in old-age homes is a challenge for geriatric mental health in India.

Challenge 6: Lack of awareness regarding geriatric mental health care at a primary care level

In India, elderly people living in nursing homes and old-age homes are usually in a state of mediocrity until it is an extremely well-paid setting (which is afforded by few). These homes do not have a psychiatrist for their residents. The primary health-care physicians who visit are not trained to identify and treat psychiatric issues such as dementia or depression in the elderly, seen in more than 40%–50% of the population.^[69]

Primary health-care practitioners often provide the diagnosis and pharmacological treatment of mental illnesses for older adults. Despite an increase in subspecialty geriatric training in internal medicine, family practice, and psychiatry, instruction in the recognition and treatment of geriatric mental illnesses remains uncommon in training.^[70] Since most of the elderly reside in rural areas, it is important that geriatric mental health-care services are a part of the primary health-care services. Specialized training of all primary health-care medical officers in geriatric medicine should happen. The focus of mental health care in India is still on tertiary care and acute management as opposed to developing primary care or rehabilitative services.^[71] Although new initiatives such as day-care centers, old-age residential homes, memory clinics, helplines, counseling, and recreational facilities are being developed, most of them are urban based and concentrated mainly in the southern part of India. NGOs such as HelpAge India, the Agewell Foundation, and the Dignity Foundation too are actively contributing, but still efforts are far from reaching to the masses.^[72] Furthermore, factors such as a lack of transport facilities and dependency on somebody to accompany an elderly person to the health-care facility impede them from accessing the available health services. Thus, peripheral health workers and community health volunteers should also be trained to identify and refer elderly patients for timely and proper treatment.^[73]

Challenge 7: Incorporating religion and spirituality into geriatric mental health care

Religion and spirituality remain important social and psychological factors in the lives of older adults and there is continued interest in examining the effects of religion and spirituality on health status.^[74] Elders with greater religiosity were more likely to report good health status in various studies, and a positive association between organized religiosity (i.e., religious service attendance) and health status has been found.^[75] Religious service attendance and functional status have a significant association, which accounts for the varied reported effects of religiosity on health status. In a review of religiosity and subjective health in elderly community-dwelling adults, it has been concluded that the effect of religious activity on perceived health disappeared when functional status was controlled.^[76]

Many patients in geriatric mental health care may want to discuss different aspects of religion and spirituality with the treating psychiatrist and may also want to discuss the same with the psychotherapist. Questions such as death, life after death, and heaven or hell along with religious dialogs interest the elderly.^[77] Psychiatrists treating the elderly need to be abreast with religion and spirituality as well as religious philosophies so that they may discuss the same with their patients. There is a need for psychiatrists being open to discuss the same as well as to respect the religious beliefs of clients that they treat.^[78] While this may sometimes seem challenging and outside the realm of mental illness, it is vital to use religion and spirituality in geriatric mental health care during rapport building and to enhance the faith of patients in treatment.

Challenge 8: Setting up geriatric mental health clinics in India

The country has a limited number of mental health professionals of around 5000 psychiatrists catering to the 21 million geriatric populations in need of mental health services.^[79] At present, most of the geriatric outpatient department services are available at tertiary care hospitals in big cities. Public sector hospitals suffer from problems of inaccessibility, inequitable distribution, and lack of staff, drugs, and equipment, while the private sector is largely unregulated with serious complaints regarding poor quality of care and unethical behavior.^[54]

Quoting the Dementia India report, there are only 100 memory clinics in the country. This figure is appalling as India has a population of over 100 million elders. There should be at least one memory clinic attached with a dementia day-care facility in each district of the state.^[26] Memory clinics are equipped to diagnose elders with dementia and also educate and provide families with the supportive guidance required to manage those with dementia. In the absence of memory clinics, dementia is diagnosed but not explained properly, resulting in untold distress to the caregiver. In addition, the functions typically performed by a memory clinic may be part of a larger special clinic that helps elders or focuses on mental health and well-being. Often, such clinics are run in hospitals by departments such as neurology, psychiatry, and geriatrics.^[80]

In the Indian context, there is a dire need for the following:

Free or subsidized memory clinics for the underprivileged would be particularly helpful, as would free or subsidized medicine
The naming, positioning, and publicity of the clinic should take into account the current pathetic awareness around dementia in India and the stigma around a problem (the condition is often translated to local languages using stigmatizing terms)
People may assume that a memory clinic is only for memory problems; they may not visit it for cognitive problems if there is no predominant memory problem
Keeping families engaged enough to come for repeated visits is a major challenge in India. Special care needs to be taken while conveying the diagnosis initially as many families may not come for the next visit
The clinic may need to design and implement several processes it needs. It may have to prepare or procure material required for its functioning, keeping in mind the societal environment and the target audience
Modified instruments and procedures for checking cognitive status (such as tests in local languages and tests for illiterate persons)
Treatment pathway, communication conventions, and counseling approach that take into account the need for overcoming stigma and myths and for reinforcing the diagnosis, possibly through repeated sessions
Awareness material and caregiver training modules suitable for the literacy and language proficiency of the target audience. Some materials should be usable to convince friends and neighbors about the diagnosis
More outreach efforts may be needed. As families may not think of coming to the clinic, you may need to actively reach out to families that may need help
Active publicity and myth-busting in the localities may be needed to make people aware that the clinic can be useful to them
Use of the existing patient base and inpatient wards of hospitals to identify persons who may benefit from memory clinics.

Challenge 9: Research in geriatric psychiatry

Before delivering any form of relief mechanism to the general elderly population, it needs to be tested.^[81],[82] There are many barriers for research to be conducted in India, which range from monetary to ethical and permission delivery dilemmas. Primarily, the lack of research can be attributed to the lack of funding from the government to support ongoing research. The Government of India is currently spending <0.1% of its gross domestic product on geriatric health research and care.^[83] With such little sponsorship, there is a huge lack of national data of the prevalent mental disorders, their epidemiology, and impact across different religious, socioeconomic, regional, cultural, and ethnic diversity.^[84]

Second, it is hard to conduct research on the elderly, especially in relation to their inclusion in clinical drug trials with pharmaceutical interventions, due to their age-related physiological changes. The relationship between age and the dynamics of drugs is not well established, but it is generally believed that geriatrics are more prone to adverse effects of a drug than younger participants due to the prevalence of comorbidities and concomitant drugs among them.^[85]

It is believed that psychiatric disorders incapacitate the ability to understand procedures of a study and give informed consent. It has been reported that nearly one-third of those with cognitive impairment were found to lack decision-making capacity.^[86] While in these cases, proxy consent can be taken from one's caregiver, it was found that proxies often underestimated the risks associated with participation in a study due to their belief that all institutionally conducted studies were safe. The inability to give informed consent breaches one of the basic ethical guidelines set up for all researches and thus this prevents researchers from taking up geriatric studies. Until Central Drugs Standard Control Organization (India) changes its age limits on patient recruitment, geriatrics with mental disorders will continue to suffer due to the shortage of effective relief mechanisms. Thus, the lack of research continues to be a challenge for geriatrics in India.

Challenge 10: Lack of Indian diagnostic tools

The diagnosis of mental disorders in geriatric psychiatry can be particularly difficult. This is primarily because the preexisting diagnostic criteria are not designed specifically to assess the mental health status of older people and thus leads to either a misdiagnosis of one's condition or leads to no diagnosis at all, leaving the disorder untreated. Indian criteria keeping in mind the cultural aspects of psychiatric diagnosis are a must.^[87],[88]

The inadequacy of these tests can be attributed to its incapability to recognize the differing psychopathology between younger adults and older adults that lead to a mental disorder. A large autopsy study reported that older adults with less severe Lewy body pathology met the pathological criteria for dementia with Lewy bodies (DLB). They noted a shift in the localization of Lewy bodies that were diffused in the neocortex of the younger adults who met the criteria for DLB, to the restriction of the Lewy bodies in the brainstem in the oldest-old with cognitive impairment associated with DLB. None of these oldest-old patients with Lewy body pathology localized to the brainstem met the pathological criteria for Alzheimer's dementia either. These findings indicate that dementia in the oldest adults is a result of a DLB phenotype, which is different from that in the younger adults.^[89] In sum, the lack of diagnosing criteria and clinical interventions adds to the adversity of geriatric mental health in India.

Challenge 11: Revision of geriatric mental health policies

The Indian government launched the National Programme for the Health Care of the Elderly (NPHCE) in 2011, as an implementation of India's international commitments to the UN Conventions on the Rights of Persons with Disabilities and the National Policy on Older Person as well as its national commitments to the Maintenance and Welfare of Parents And Senior Citizens Act, 2007.^[90],[91] The main aim of NPHCE is “to provide an easy access to promotional, preventive, curative and rehabilitative services through community based primary health-care approach.”^[92] Through the programme, the government aims to collaborate the health-care services with the rural health development-oriented schemes and social welfare schemes to improve the quality of life of the elderly in the country. While this programme is criticized not only for completely neglecting the role of home-based care of the elderly within the family, which still remains to be their primary source of care within the nation, but also for giving no specific importance to the mental health of the elderly, it is considered extremely important as it recognizes the different, specialized needs of the geriatrics.^[93] Nevertheless, governmental support programs that address geriatric mental health are still almost nonexistent and therefore such lack of support presents itself as a challenge for geriatrics in India.

Challenge 12: Myths related to aging in India

There are a number of myths about aging. Of note, they are shared by practitioners, patients, and policymakers alike. These are as follows:^[94]

Age is an illness
Genetics determines illness and disability
Disability is inevitable and increasing among seniors
Loss of social ties leaves the older adult alone and isolated
Most elderly are depressed, demented, or dependent
In a chronic illness, social factors are less important in late life
Old age leads to physiologic and social homogeneity (i.e., seniors generally have the same needs and potentials)
Advances in biotechnology and pharmacology are the most important elements in reducing late-life dependency
Projections based on the present data are sufficient for social policy planning over the next decades
Aging and mortality are synonymous
The older the patient, the greater the cost.

There are a lot of myths that surround old age. Senility, myths, and taboo around sexual health among the elderly, lack of productivity, cognitive memory, changed human needs in the old age, and irritability are some of the myths that research does not support (and rather supports the contrary).

The term ageism refers to a deep and profound prejudice against the elderly.^[95] In simple terms, ageism occurs when people stereotype others based on old age. Ageism occurs throughout the society in varying degrees, in television, advertising, movies, stores, hospitals, and jobs. The four types of ageism are as follows:–^[96]

Personal ageism is an individual's attitudes, ideas, practices, and beliefs that are biased against older persons
Institutional ageism involves rules, missions, and practices that discriminate against older individuals or groups based on age
Intentional ageism is attitudes, rules, or practices that are implemented knowing they are biased against older people
Unintentional ageism is ideas, attitudes, rules, or practices carried out without the perpetrator knowing these are biased against older persons.

Stigma and ageism are two phenomena that greatly affect the accurate assessment of mentally ill elderly and ultimately, their health care. Health-care providers, doctors, nurses, and others, including mental health-care providers, would benefit from awareness of stigma and ageism and their impact on psychiatric care for the elderly, many of whom also have physical problems. Understanding these influences may assist providers to make more accurate diagnoses and a more appropriate plan of care.^[97]

Specific Challenges for Geriatric Mental Health in India

Challenge 13: The clinical challenges posed by geriatric depression

Geriatric patients comprise a particularly vulnerable group as they often have multiple co-existing medical and other psychological problems with depression.^[98] Depression is undertreated in this group, owing to its lack of priority as a public health problem in developing countries.^[99] Many studies have looked at psychosocial factors associated with geriatric depression. Variables such as female sex, widowed status, nuclear families, and stressful life events were found to be associated with geriatric depression.^[100]

Older adults are likely to suffer from sub-syndromal depression, i.e., depression that does not (always) meet the full criteria for major depression but can lead to major depression if left undiagnosed or untreated.^[101] Geriatric depression reduces the quality of life and increases the risk of suicide in the elderly. According to a WHO report, patients over the age of 55 who suffer from depression have a four times higher death rate than those without depression.^[102] Research indicates comparatively higher prevalence of geriatric depression in India, with a median prevalence rate of 21.9%.^[103] Studies have identified demographic factors associated with depression such as being unmarried, divorced, or widowed; residing in rural areas; illiteracy; increasing age; lower socioeconomic status; and unemployment.^[104] There is no single cause of geriatric depression, and multiple factors at biological, social, and psychological levels interact to cause depression in old age. Symptoms of geriatric depression affect behavioral, physical, and cognitive domains of an individual, while many elderly do not seek help as a stereotype myth prevails that geriatric depression is normal in old age.^[105]

Depression may also be the first presentation of dementia in people above the age of 60–65 years.^[106] Geriatric depression can either be recurrence of a previous depressive episode experienced earlier at younger ages or it be a first-episode depression in late life.^[107] Depression in older adults is most frequently associated with physiological changes or abnormalities of the brain, and the phenomenon of vascular depression has been described well in literature.^[108] These changes may also be the result of early changes caused by Alzheimer's disease or vascular dementia in its initial stages.^[109] Antidepressant drugs are the mainstay of treatment combined with psychological interventions. Elderly persons are more prone to side effects of antidepressant drugs even at lower doses. A careful monitoring and motivation is often needed while treating these patients with antidepressants.^[110] Geriatric depression with its multiple facets and as a disorder thus is a challenge to mental health practitioners treating the elderly.

Challenge 14: Medical illnesses in the elderly affected by psychological problems

It is commonly known that geriatric patients have multiple illnesses, which include both noncognitive physical (sensory, musculoskeletal) and psychiatric illnesses. Often, some physical illnesses of the elderly present with psychological symptoms or vice versa.^[111] The prevalence of comorbid condition of illnesses is a powerful demonstration of the link between physical and mental illnesses and the interplay of multiple factors between them.^[112] In late life, the presence of comorbidity, chronic conditions, and frailty requires an approach less preoccupied with curative interventions and more focused on rehabilitative function. This functional approach requires a range of interventions that include supportive and restorative measures along with diagnosis and treatment. The goal here is to eliminate excess (avoidable) disability, especially when treating dementia and depression.^[38]

The concept of medical examination before treating psychiatric illness must be addressed, and its exact definition often is a matter of dispute. Consultants from the psychiatry service often question whether the patient's symptomatology represents a psychiatric disorder or whether behavioral and cognitive changes reflect manifestations of an acute, or chronic medical condition.^[113] Multiple medical conditions commonly encountered can present in an atypical fashion and mimic psychiatric disorders. A missed organic cause of psychopathology can lead to significant morbidity and mortality for individuals inappropriately admitted to a psychiatric unit.^[114] It is important for psychiatrists to build on their medical knowledge from medical school and internship and continue to be kept abreast of confounding symptomatology. Nevertheless, it is crucial for medical professionals to have fundamental understanding of psychiatric conditions.^[115] A team approach works best where multiple doctors come together to work as team. Liason between the psychiatrist and medical professionals is quintessential in order to ward off the overlapping diagnostic confusions and better geriatric care.^[116] Multiple medications when used in the same patient increase the propensity for side effects and drug–drug interactions which can only be addressed by a good liaison.^[117] Successful management of co-existing medical and psychological problems is possible through good teamwork between different medical teams and can at times be difficult to achieve.

Challenge 15: Geriatric substance abuse and its management

Substance abuse in patients aged 65 years and above is often underestimated and underdiagnosed, which can prevent them from getting the help they need.^[118] The Family Health Survey of India (1998–1999) reported that regular consumption of alcohol was 18.6% prevalent in elderly men and 3.1% prevalent in elderly women. The prevalence of alcohol consumption among the elderly between the ages of 60 and 64 years was found to be 25.4%, which declined to 10.5% in the older cohort consisting of the elderly above the age of 75.^[119] The data are suggestive of the fact that alcohol use may reduce with age, but it is difficult to completely rehabilitate geriatric alcohol and nicotine dependence. Clinically, not many elderly opt to get rid of or reduce their dependence on alcohol or nicotine.^[120] Late-onset abusers are those who start consumption of alcohol after the age of 65 years. It is believed to occur in response to negative life events such as retirement and the death of a loved one.^[121] It is often observed that the senior citizens, after their children have moved overseas or their spouse has passed away, start alcohol consumption, even if they have not been an active alcohol consumer in the past. In such times, alcohol becomes an escapist from negative life situations and stressors. These events are extremely common in old age and are further linked to psychological and psychopathological comorbidities, particularly mood and anxiety disorders.^[122] Some other reasons that the elderly take to drinking include retirement, financial strains, relocation, troubled sleep, familial conflicts, and physical or mental health degradation. Conclusively, the data are indicative of the fact that geriatric communities are extremely vulnerable to substance abuse, like other sociopsychological problems.^[123]

Tobacco consumption also falls under the umbrella of substance abuse. Similar to alcohol abuse, it was found that the number of heavy smokers decreased with age, the proportion declined from 22.7% between the ages of 60 and 64 years to 8.2% of heavy smokers between the ages of 65 and 75 years.^[124] Besides substances, older adults are more likely to take prescribed and over-the-counter medications than younger adults, increasing the risk for harmful drug interactions, misuse, and abuse.^[125] These trends were significantly observed among elderly men and women. Clinical research has elucidated the consequences of unrecognized substance abuse or dependence on an aging population. Complications that occur with increasing frequency with age, such as medical comorbidity, cognitive impairment, and frailty, contribute to the potential adverse interactions between substance misuse and an aging brain.^[126] Individuals over the age of 65 years have a decreased ability to metabolize drugs or alcohol along with an increased brain sensitivity to them. Drug or alcohol abuse among the elderly is particularly dangerous because senior citizens are more susceptible to the deteriorating effects of these substances. Geriatric substance abuse may need specialized care which may not be possible in routine rehabilitation centers. These patients cannot be admitted and treated with adult substance abuse patients as their needs and causative factors differ markedly from that of adult patients with substance abuse.^[127] Rehabilitation and management of geriatric patients with substance abuse poses a challenge for geriatric mental health. The reasons for the same are poor compliance and high relapse rates along with poor motivation to quit substances.

Challenge 16: The management of delirium in the elderly

Delirium is a common medical and psychiatric complication seen in geriatric patients. Most of these patients need Intensive Care Unit admissions, and the causes of elderly delirium vary from medical to a purely psychiatric etiology to a combination of both medical and psychological factors.^[128] Delirium may complicate the clinical picture of dementia and make it difficult to assess clinically due to fluctuating orientation and attention of the patient. Delirium can lead to death of the patient if not detected and treated early. It is paramount that there is good consultation liaison framework between the medical and psychiatric treating teams for optimal recovery of the patient.^[129]

Treatment in the right setting is prudent for recovery. Sometimes, delirium may be mistaken for excessive drowsiness and left untreated. Violent and aggressive behavior in delirium also affects recovery and care. Treatment, assessment, and clinical management of delirium in the elderly is yet another challenge in geriatric mental health. Delirium also puts an immense pressure and challenge to the caregivers dealing with the patient on a regular basis.^[130] There is a need for clinicians and psychiatrists to be trained in the management of delirium and to recognize it early so that mortality and morbidity are prevented.

Challenge 17: Sexual issues in the elderly

Sexuality is widely considered a taboo in India, let alone sexuality in older adults. Many myths surround sexuality in old age, the most common being that older people are asexual and do not practice or desire sex.^[131] On the contrary, the majority of people aged 60 and older continue to engage in and, most importantly, enjoy sexual activity. It is also erroneously believed that older people (especially older women) are unattractive that older sex is disgusting, risky, or wrong; aging entails sexual dysfunction and sex, as a rule, should be discouraged in old-age homes and other facilities.^[132] Such beliefs are internalized leading people to believe that old age and an active sex life are mutually exclusive. The media, with its huge influence on popular culture, often neglects to depict older sexuality or portrays it in negative light, especially in the case of older women, who have often been shown to exist contentedly in a chaste sexual vacuum.^[133] Older men may be portrayed as sexually attractive, but usually from the perspective of younger and not older women. Media portrayals of older people also tend not to depict their normalcy, virility, and intimacy, and older adults are often the subjects of humor directed at physical, cognitive, and sexual impotence.^[134],[135]

It is hard to disentangle sexual changes of normal aging from those related to illness and psychosocial problems. Further, there is a dearth of population-based studies aimed at assessing normal older sexuality; the bulk of currently available research tends to equate having sex with heterosexual vaginal intercourse, leaving out a host of other orientations and activities related to sexual expression, thus providing incomplete and misleading information.^[136] Available data suggest that both older men and women consider sexuality an important part of their lives, continue to possess sexual desires, and wish to engage in intimate relationships and sexual activity (kissing, cuddling, foreplay, vaginal intercourse, oral sex, and masturbation) at similar frequencies as younger adults (18–59 years old), despite the presence of sexual problems. Sexual activity may undergo adaptations or be less vigorous with age. Nevertheless, it has been shown to be as enjoyable and satisfying as in younger adults.^[137],[138]

Concomitant medical disorders are an extremely prevalent confounding factor when considering sexuality across all age groups. Lack of careful segregation of aging from morbidity is a major contributor to the widespread false perception that older people are asexual. Some common medical issues encountered in old age that affect sexuality are hypertension and cardiovascular illnesses, diabetes, stroke, arthritis, depression, Parkinson's disease, multiple sclerosis, dementia, visual or hearing impairment, lower urinary tract symptoms, and incontinence. Apart from these, abdominal and genitourinary surgery, reconstructive surgery, or malignancies and medical devices such as catheters may all affect self-image and impede sexual expression.^[139]

Many studies quantify geriatric sexual dysfunction, but few provide details. In women, the most common perimenopausal complaints are dyspareunia and reduced sexual desire, often associated with decreased lubrication, prior hysterectomy, loss of a partner, depression, lack of physical activity, smoking, or financial problems.^[140] An Indian study on geriatric sexuality found that 20% of women reported reduced sexual activity due to the loss of a partner as opposed to 3.3% of the men. More women tended to report self-image as a reason for decline in sexual activity. The same study found that erectile dysfunction was reported significantly more frequently in those men with comorbid illnesses than in those without (26% vs. 9%).^[141]

Social stigma that enshrouds sex in general coupled with ageism and the lack of time and space allocated to sexuality, and especially geriatric sexuality, in medical schools and residency programs sets the scene for consistently bashful patients, unsure clinicians, and an overall neglect of geriatric sexual health. Other compounding issues include the many myths surrounding older sexuality, the discouragement of older sex by power-wielding entities such as residential homes or caregivers, stereotyped media portrayals of older sex, a total absence of acknowledgment of older lesbian, gay, bisexual, transgender (LGBT) and queer adults as sexual beings, and the archaic view of sex solely as heterosexual intercourse or a means of reproduction.^[142],[143] Essentially, geriatric sexuality in psychiatric practice remains a mostly unchartered sea and currently, those who venture out are map-less pioneers. Clinicians across specialties must incorporate inquiry into geriatric sexual health as a part of the routine patient interview. In general, there is a dearth of research on the sexual issues in the elderly and even more so in India, although there has been a recent trend of research being boosted in this area. Sexuality is a life-long phenomenon and its expression is a basic human right across all ages. Health care is currently nascent in its understanding and acceptance of geriatric sexuality and its related problems. Medical training, treatment guidelines, awareness among medical and mental health professionals, and geriatric care staff's need to be disseminated their openness in outlook toward geriatric sexuality need cultivation. Physicians of all specialties must routinely inquire in histories about the sexual concerns of older patients while being nonjudgmental and understanding.^[144],[145]

Challenge 18: End-of-life care and cancer in the elderly

There are various situations that are characteristically encountered by the elderly. End-of-life issues and elderly with cancer are characteristic in old age. There is a lack of awareness of end-of-life care (EOLC) for people with chronic, serious, progressive, or advanced life-limiting illnesses, including dementia in India.^[146] EOLC involves good communication, clinical decision-making, liaison with medical teams and families, comprehensive assessment, and specialized interventions for physical, psychological, spiritual, and social needs of patients and their caregivers.^[147]

Most patients with advanced, progressive, life-limiting illnesses in terminal stages get transferred to hospitals and Intensive Care Units for acute, medically life-prolonging or supporting interventions. They later die in the hospital in an environment away from their loved ones. Due to lack of clear guidelines for physicians on EOLC, patients are subjected to futile treatments, often expensive, pushing the families into grave economic crises. Relatives, therefore, are often forced to take the patients home on leave against medical advice.^[148] Misconceptions exist among health-care providers about EOLC, with misrepresentations of EOLC as euthanasia, resulting in controversies. It is, therefore, necessary to have a clear understanding of various aspects of EOLC in India and future directions that need to be taken. The primary caregivers, along with the treating team, have to be involved in the decision-making process which might be complex.^[149]

Cancer is a major public health problem worldwide, and the burden caused by cancer continues to increase. Depression, anxiety, fatigue, pain, and delirium are problems that can affect any cancer patient, but can present unique challenges in the elderly population. In addition, the elderly may be contending with cognitive deficits or dementia that can coexist with any of the above problems. Each of these issues alone can adversely impact the care and outcome of these patients. More often than not, however, the elderly are challenged with not just one but a combination of these problems. Geriatric psycho-oncology is still in a nascent state and needs to be developed in India.^[150],[151]

Challenge 19: Elder abuse and the role of the psychiatrist

Older adults are also vulnerable to elder abuse – including physical, sexual, psychological, emotional, financial, and material abuse; abandonment; neglect; and serious losses of dignity and respect. Current evidence suggests that 1 in 10 older people experience elder abuse.^[152] Elder abuse can lead not only to physical injuries, but also to serious, sometimes long-lasting psychological consequences, including depression and anxiety. The intersection of elder abuse and mental health is important and complex.^[153] We know from research that elder abuse victims have a high prevalence of depression. Depression can easily lead to social isolation, a significant risk factor for abuse. This, in turn, increases the risk of suicide and the emotional devastation of abuse encompasses far more than depression. Anxiety is common for victims due to the trauma previously experienced, continual fear for their current and future safety, and the worry they feel for their abusive family members whom they often care deeply about.^[154] Victims feel shame and guilt, which also contributes to social isolation. Victims may suffer from a range of physical complaints, including chronic pain, gastrointestinal complaints, neurological complaints, arthritis, and gynecological problems, such as vaginal bleeding and pelvic pain.^[155] Early death is very often the result of the slow and corrosive nature of abuse. Abused elders are 300% more likely to die a premature death than their nonabused counterparts. Elder abuse victims who are depressed or have other debilitating mental health problems cannot readily protect themselves.^[156] Victims of abuse often do not or cannot adhere to medical regimens and basic health maintenance because of their depression or anxiety. Some may manifest multiple physical/somatic complaints without a plausible diagnosis.^[157] The psychiatrist treating a victim of elder abuse has to work outside the realm of his/her psychiatric work if/she needs to provide support and solace to the victim. It is also the duty of the mental health professional to lodge a complaint and ensure that no more abuse occurs while protecting the rights of the patient.

Challenge 20: Suicide in the elderly

Suicide is known to show a peak in two age groups, i.e., the adolescent age group and the elderly. Developed countries also depict a peak of suicide rate in the elderly compared to other ages.^[158] On the contrary, in India, the peak in the rate of suicide is seen in the 15–29 years' age group. However, the comparatively lower rate of elderly suicide in India of 7/100,000 should still be considered a significant statistic.^[159] Moreover, the ratio of completed suicide to attempted suicide for elderly in India is 1:7, which is double than that of the lower age group which is 1:15.^[160] Among the elderly, isolation and loneliness, loss of economic independence, and reduced social activity contribute to negative thought patterns.^[161]

Postmortem autopsy studies have revealed that between 71% and 95% of the elderly who completed suicide had been diagnosed with at least one mental disorder. The presence of serious, chronic medical illnesses is also considered to be a risk factor for elderly suicide.^[162] However, no direct link between the status of physical health and suicidal ideation or attempt has been established yet. Many researchers speculate that physical illnesses trigger certain mental illnesses, particularly depression that leaves them vulnerable to suicidal behavior. Researchers have found that one in four persons in his/her sample of terminally ill elderly patients expressed a desire of ending their lives. Out of this sample, 25% of them were diagnosed with depression.^[163] Suicide is a neglected phenomenon in the elderly as suicidal ideation is rarely expressed by them and there is a dearth of suicide prevention programs for the elderly as compared to youth and adolescents. Suicide prevention in the elderly and bringing down suicide rates in geriatric populations are a major challenge for geriatric mental health.

Challenge 21: Meeting the needs of lesbian, gay, bisexual, transgender, and queer elderly

Prior research has indicated that the LGBT populations have a higher incidence of mental health distress than the general heterosexual population due to the brutal discriminatory treatment they are subjected to.^[164] The LGBT population are subjected to discrimination, stigmatization, and harassment that often lead to them being marginalized from many social structures including one's family. Primarily, higher poverty rates among members of the community present itself as a risk factor for mental health disorders. A study reported that 9.1% of elderly lesbian couples and 4.9% of elderly gay couples were poor, as compared to 4.6% of their heterosexual couple counterparts.^[165]

Second, the lack of social support and marginalization also leaves them vulnerable to psychiatric illnesses. The social ostracism is believed to increase psychological distress. Further, LGBT elderly are twice as more likely to live alone and almost four times less likely to have children than their heterosexual counterparts.^[166] Thus, the lack of informal caregiving structure not only leads to social isolation, but also increases the costs of health care as the LGBT older adults would have to rely on the formal health-care structures. Finally, poorer physical health of the LGBT elderly also leaves them more vulnerable to mental illnesses.^[167]

Their sexual orientation, moreover, has frequently been reported as a barrier to adequate care. The social prejudices that exist in Indian society also prevent the LGBT elderly from receiving adequate care. However, greater dearth of research is required to understand the dynamics of elderly in the LGBT community. It is an unexplored and underresearched area in geriatric mental health in India.

Conclusions

The world's population is aging rapidly. Between 2015 and 2050, the proportion of the world's older adults is estimated to almost double from about 12% to 22%. In absolute terms, this is an expected increase from 900 million to 2 billion people over the age of 60. Older people face special physical and mental health challenges which need to be recognized.

Mental health problems are under-identified by health-care professionals and older people themselves, and the stigma surrounding mental illness makes people reluctant to seek help. Lack of awareness, inadequate training opportunities, inequitable distribution of health resources, and virtual absence of chronic care disease models are the challenges that confound the future of geriatric psychiatry in India. Government policies providing social benefits to the elderly population are in place, but coverage is inadequate. For addressing geriatric mental health issues, the need of the hour is to increase awareness, capacity building, strengthening training and research activities, developing community-based rehabilitation programs, and developing a holistic primary health-care system.

There is a need to raise awareness in public and other professionals about the unmet needs of geriatric mental health, develop adequate human resources, and strengthen intersectorial collaboration. There is an urgent need to implement national policies, programs, and legislation targeting geriatric mental health and promoting advocacy and empowerment. Small steps in all directions shall go a long way in improving geriatric mental health in India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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