|Year : 2016 | Volume
| Issue : 1 | Page : 15-19
Disability among the elder population of India: A public health concern
Department of Neurosurgery, Narayana Medical College Hospital, Nellore, Andhra Pradesh, India
|Date of Web Publication||5-Feb-2016|
Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore - 524 003, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
The Government of India adopted the National Policy on Older Persons in 1999, which defines a "'senior citizen' or 'elderly' as a person who is of age 60 years or above." In India the elderly population accounted for 8.2% of the total population in 2011 and the number is expected to increase over the next decades. The link between aging and disability is a biological fact, and disability in the elderly is an important health indicator pointing to jeopardized quality of life. But at the same time, aging should not be treated as synonymous with disability as a large proportion of older people live with good health status. There are many studies from India that have addressed disability in the elderly population; however, they lack uniformity in defining disability and largely address mostly one aspect, that is, the medical model of disability. It is well recognized that "disability and elderly" encompasses a much larger spectrum of the conditions with unique requirements and needs to be studied as a much broader concept.
Keywords: Aging, disability, India, rural
|How to cite this article:|
Agrawal A. Disability among the elder population of India: A public health concern. J Med Soc 2016;30:15-9
| Introduction|| |
The significant increase in an aging world population has resulted in rising proportions of older persons in the total population with profound consequences on a broad range of economic, political, and social processes. Although aging partly reflects the longer and generally healthier lives of individuals, it is simultaneously associated with chronic and degenerative diseases, which become more common at older ages. Disability can jeopardize the quality of life in the elderly and is an important health indicator that can have heavy social impact with long-term institutionalization and increased use of medical care.  In addition, as people age there are increased chances of becoming disabled, and once disabled, there are increased chances of deterioration with decreased likelihood of recovering from disability.  "Disability and elderly" encompasses a large spectrum of conditions, with unique requirements. In the present review, we discuss the current status of disability patterns in the elderly population from India.
| Defining “Elderly” and “Disability”|| |
In most of the developed world, the accepted definition of "elderly" or "older person" is the chronological age of 65 years minimum; there "is no United Nations standard numerical criterion, but the UN agreed cutoff is 60+ years to refer to the older population."  The Government of India adopted the National Policy on Older Persons in January, 1999 and this policy defines "'senior citizen' or 'elderly' as a person who is of age 60 years or above."  In India the elderly population accounted for 8.2% of the total population in 2011, and the number is expected to increase dramatically over the next four decades (to 19% in 2050). 
The International Classification of Functioning, Disability and Health (ICF) defines disability as an umbrella term for impairments, activity limitations, and participation restrictions.  Disability has been defined as a restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being.  "Operational measures of disability vary according to the purpose and application of the data, the conception of disability, the aspects of disability examined - impairments, activity limitations, participation restrictions, related health conditions, environmental factors […]"  "Often, 'types of disability' are defined using only one aspect of disability, such as impairments - sensory, physical, mental, intellectual - and at other times they conflate health conditions with disability." 
This holds true for many of studies from India where there is no uniformity in defining the elderly or clear demarcation of disability from morbid conditions. It has been emphasized that "most of the studies discuss the morbid and co-morbid conditions but do not address the issues of resulting disability."  Additionally, people with chronic health conditions, communication difficulties, and other impairments may not be included in these estimates, despite encountering difficulties in everyday life.  Disability in the elderly can be grouped "into who can manage in their daily activities with the help of mechanical devices, who have multiple health problems and severe limitations in mental and/or physical functioning that require very intensive levels of care and in between above two groups, they are functionally disabled in one or two (activities of daily living (ADLs), or have mild cognitive impairments." 
| Morbidity Among Elderly|| |
Many chronic illnesses can influence the quality of life in elderly populations, and there is evidence that there is increased risk of multiple comorbidities in elderly populations that may lead to disability.  It has been well recognized in many studies from India that morbidity influences the physical functioning and psychological well-being of elderly populations; ,,, the need "to develop geriatric health care services in developing countries on the basis of existing morbidity profile" must be emphasized.  A number of morbidity patterns have been identified in elderly populations, which include "hypertension, diabetes, arthritis, constipation, cataracts and hearing loss."  In another study, the authors recognized many morbid conditions "[p]ain/swelling of joints, limitation of movement, indigestion/heart bum, backache, breathlessness, giddiness/fainting, frequency/urgency, change in bowel habits and blurring of vision […]" in the elderly population from a mix of rural and urban communities. 
Chandwani et al.  found that 73% respondents felt that their age affected their day-to-day life and 58% reported that their age partially affected their daily activities. In these studies, morbid conditions were recognized and it was found that age was affecting their daily activities. However, these studies did not define disability and were unable to show quantitatively the effect of age and morbid conditions as the cause of disability in greater detail.
In one study it was found that 51.5% of elderly people over 60 years of age had fallen (ending up on the floor or ground unintentionally), and 21.3% sustained fractures and 79.6% other injuries.  It is important to note that the fall is not a diagnosis but can be a manifestation of "multiple underlying disease like visual impairment (cataract, corneal opacity), postural hypotension, degenerative joint disease, giddiness, and depression, the effects of certain medications on homeostasis, and/or environmental hazards or obstacles that interfere with safe mobility." 
High prevalence of morbidity has been observed in the elderly population residing in rural areas of the country. ,, A study that included about 90% of the population from urban areas and 10% from rural concluded that the morbidity among urban subjects (90.7%) was higher than among rural (77.6%) ones.  However, most of these studies on multimorbidity in India are disease-specific and do not provide a comprehensive overview of the wide range of disabilities that can occur due to many of the diseases among elderly populations. ,,,
| Disability in India|| |
It has been well recognized that elderly persons constitute one of the most vulnerable groups, who have more chances of developing chronic disease, infections, and subsequent disabilities.  As a result, the elderly population is at greater risk of being less healthy than the nonelderly population.  It has been suggested that the aging population in India will lead to increases in the prevalence of chronic conditions, including diabetes and hypertension, and nearly one-half (45%) of India's disease burden is projected to be borne by older adults in 2030.  Early results from a pilot phase of the Longitudinal Aging Study in India showed that 13% of "older Indians sampled have some type of disability that affects at least one activity of daily living."  The survey "Report on the Status of Elderly in Select States of India, 2011" collected information on locomotor disability, and questions were asked about the about difficulty regarding vision, hearing, walking, chewing, speaking, and memory.  It was found that the prevalence of locomotor disability was highest for vision (about 60%) and lowest for the speech (about 7%). 
In a study that used Barthel's ADL questionnaire, the estimated prevalence of functional disability was 37.4%.  The disability was relatively less among men (35.9%) than among women (38.8%) and the prevalence increased with age (from 23.7% for age 60-64 years to 63.8% for age >75 years).  Joshi et al.  assessed disability by the standardized Rapid Disability Rating Scale-2  and the overall prevalence of disability was 6.3%. Another study that used World Health Organization (WHO) criteria  found that the most common type of disabilities were mental, locomotor, hearing, speech, and visual.  The prevalence of disability among the elderly group (>60 years) was high (21.5%); 80% of the disabled had a single disability and the 20% had multiple disabilities; as age advanced, there was significant increase in the prevalence. 
Audinarayana et al. collected data regarding physical disability from a mix of rural and urban populations among the elderly in Tamil Nadu and the disability was measured in terms of physical limitations.  The information was collected about permanent loss of any of the following and resulting inability to do the normal day-to-day functions from the elderly, for "visual (loss of sight), hearing (loss of hearing), walking (loss feet or legs), dental (falling of teeth) and complete loss of arms or fingers (including fractures) and many other problems like apoplexy, speech difficulties, paralytic condition and trembling."  It was found that 47% of the elderly persons were suffering from one or the other physical disability condition; the extent of physical disability was lower among the elderly belonging to higher socioeconomic background (educated, engaged in own cultivation, higher-salaried occupation, and belonging to higher family monthly income bracket).  However, in this study the details of underlying morbid conditions or any other factors responsible for physical disability have not been addressed.
Chakrabarty et al.  used an ADL scale and reported 16.16% prevalence of disability in the study population, and 92.5% had one or more associated chronic conditions. They found that "the different chronic conditions like osteoporosis, anemia, chronic obstructive pulmonary disease, scabies, prostate hypertrophy, ischemic heart disease, osteoarthritis, acid peptic disorder, age and sex were significantly associated with functional disability of the geriatric population."  In that study the authors were able to explain risk factors in only 58.2% of the cases, and identified that, the study being "a descriptive study, the factors found as associated with disability could be suggestive, not a causal one" and "there may be other factors for disability, which could not be identified." 
Venkatorao et al.  studied the "impact of functional limitation on handicaps, technical aids, environmental adaptation, human assistance, limited community access, confined to home and confined to bed" parameters to assess disability. The authors reported prevalence of functional limitation among the geriatric population and found speech disability (4%), hearing disability (10%), visual disability (56%), and agility (locomotion, walking, climbing stairs, body movement and dexterity; 33%), respectively.  However, this study did not provide the underlying causes of disability in the population studied.
| Sociodemographic Variables and Disability|| |
It is commonly accepted that there is a relationship between poverty and disability, and it is widely hypothesized that it is a vicious cycle, "i.e. disability increases the risk of poverty and conditions of poverty increase the risk of disability."  In one study, the authors analyzed the data from a survey conducted by the 58 th round of the National Sample Survey Organization (NSSO) and found that "higher level of poverty and income inequality among disabled elderly as compared to non-disabled elderly and those differences in the income levels vary significantly across different age groups, gender, social groups and educational status."  In another study, it was observed that elderly people who live in the rural area, who are unmarried or divorced, and those who belong to Scheduled and Backward castes had higher levels of morbidity.  In this study it was also found that lower education is consistently associated with higher levels of morbidity and subsequent disability.  Another study from the rural community of Karnataka also revealed that illiteracy, primary schooling, and unemployment have independent significant association with disability. 
| Psychological Well-Being and Disability|| |
In one study where the investigator assessed the psychological well-being and disability status among elderly people, it was found that minimal disability was seen in 22%, moderate disability in 48.5%, and severe disability in 17%, respectively.  It was also noted that as the number of morbidities increases, the psychological well-being deteriorates and disability increases. 
| Challenges|| |
Inability to largely understand and accept the concept of disability is a major challenge in India.  Aging should not be treated as synonymous with disability, as a large proportion of older people live with good health status and without significant mental or physical decline.  The link between aging and disability is a biological fact as the risk of disability increases with increase in age.  With rapid increase in elderly population accompanied by a decline in physiological functions in this age group, the foremost apparent challenge is to prevent physiological aging translating into pathological aging, as when diseases supervene.  Disability could be prevented either by preventing the disease or by preventing the impairment. As chronic conditions are the major causes of disability, the assessment of chronic diseases and their association with disability will help in implementation of different preventive programs and thus reduce the health burden of the nation.  Gerontology, which deals with a set of conditions specifically associated with old age, is still nascent in India: The facilities are largely inadequate (confined mainly to urban areas), and the average Indian doctor is not exposed to the education required to manage such conditions.  In addition, the presently available facilities largely address health-related issues; however, "disability and elderly" encompasses a much larger spectrum of conditions and needs to be recognized and studied as a much broader concept.
It is also important to understand that with proper policy interventions, the onset of disability can be delayed. 
| Disability Supportive Services in India|| |
In India, the Central government with the help of State governments runs many programs to support persons with disability. ,, The majority of elders are outside the social safety net, and they face economic, health, and emotional insecurity and inequity that pose a challenge to an already overburdened societal system. 
| Conclusion|| |
Disability is a major public health challenge that requires knowledge and understanding of the risk factors involved in order to allow efficient preventive strategies. Since 2011 there is a National Policy for Senior Citizens that discusses issues related to disability in the elderly populations in India. Although many studies have addressed the issues related to disability in elderly populations, they lack uniformity in many domains (most importantly, different criteria to define disabilities), and these studies are largely confined to the medical model of disability.
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Conflicts of interest
There are no conflicts of interest.
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