Health and Wellbeing in Late Life

Front matter

Prasun Chatterjee

Health and Wellbeing in Late Life

Perspectives and Narratives from India

Foreword

It gives me immense pleasure to write this foreword to Dr. Prasun Chatterjee’s book Health and Wellbeing in Late Life: Perspectives and Narratives from India. This book will break a new ground in India as it is placed at a unique confluence of medical knowledge and expertise and experiences of layman. Geriatric Medicine is a relatively new discipline in India with only a few medical schools offering a postgraduate training programme in this discipline. Dr. Prasun Chatterjee is a postgraduate from the first department which started the programme in Madras Medical College, Chennai. This discipline has now caught the attention of policy-makers and planners in the health system. Geriatric Medicine post-graduation is now a mandate of the National Programme for the Health Care for the Elderly, a flagship programme of the Government of India.

Childhood and old age are two extreme stages of one’s lifespan where one behaves differently from adulthood in terms of health status, profile of illness, management strategies and response to the treatment. Sixty years ago, a similar debate was going on as to how paediatrics was different from the adult medicine. But now it is an established specialty of medicine, even though most of the illnesses are similar. This development of paediatrics as a separate department and discipline was also a response to a changed population structure. Geriatric Medicine is a response to the rapid change in population structure towards an ageing population.

The inevitable structural and functional changes in the body increase the vulnerability of the individual to multiple chronic diseases which are mostly noncommunicable in nature. Altered drug handling and high risk of adverse drug reaction, functional decline to the extent of dependence on another individual, greater vulnerability to life-ending infections, etc. make an older individual’s health needs different from that of an adult.

The complexity of health problems makes Geriatric Medicine the most difficult branch of medicine. Physical and socio-economic dependence of older persons raises the issue of long-term care, which is a medico-social issue like infant and childhood mortality. In the face of rapid changes in function and structure of families in India, long-term care of older family members has become an epidemic-like situation. Long-term care is beyond the realms of curative adult medicine.

Vii viii Foreword

Hence, a discipline like Geriatrics has more than a medical aspect to it. The sociological dimension of elderly care is what makes this discipline relevant to every person in the society. Traditionally, we lived in an integrated family structure, but contemporary times do not allow the existence of joint families. At such a juncture, the role and status of older adults are of crucial importance and relevance to us. India is at the brink of its majority population groups being the seniors and the youth. Together, these two groups would outnumber the intervening age-bracket population. This book paves the way for a dialogue and discussion on the multipronged solutions that the society will need to devise for meaningful sunset years to one and all.

Head of the Department of Geriatric Medicine A. B. Dey AIIMS, New Delhi, India

Prologue

Great people often live in plain garb, touching and altering the lives of many. The spirit that would make a difference in the lives of one and all was embodied in one of my school teachers, late Shri Pranab Kumar Singh. In my journey towards Geriatrics and my endeavour to bring a meaningful change in the lives of elderly people and consequently in every home, my teacher played a big role in moulding my personality in the early years, honing my talent, raising me when I faltered, encouraging me to work harder and boosting my self-confidence. The last time I met him and noticed his deteriorating health, I started advising him as a doctor, and he listened to me just like I did decades ago. Today as I pen this book, it is him that I remember and owe thanks to, but he is no more in this world to accept it.

In May 2015, while flying to Boston for a conference, a passenger sitting adjacent to me smilingly introduced himself as Mr. Mathew Joseph, “Hi, I am an advocate at Delhi High Court, going to New York to take part in the marriage ceremony of my cousin”. My spontaneous response was “Hi, I am Dr. Prasun, Geriatrician in AIMS, New Delhi’. In response to which, he asked, “What is that?”

I explained my practice to him, “We deal with age-related health problems of older adults in a holistic fashion”. He queried further, “So you treat everything starting from blood pressure, sugar, heart problems, forgetfulness, depression, etc. Am I right?”

I elaborated, “We do more than that; other than organ-specific management, we also try to improve their functional status and quality of life with minimal and essential drugs. We prepare older adults for active ageing”.

He responded with a bright smile, “Oh! Then I must keep your number for my father who is a 74-year-old retired Customs officer”. After some general discussion, he informed me, “You know doctor, although he is hale and hearty physically, I have noticed that he is gradually becoming slow in all domains. According to my 14-year-old son, his grandpa is no longer enjoying life the way he used to”.

He continued after a pause, “Doctors have informed us that there is nothing serious or wrong with him, but I could feel all is not well; I am worried as he is the pillar of the family. A few days ago when we were both walking in the colony park and I prodded him to tell me if anything was bothering him, he didn’t open up”.

x Prologue

In the 16-hour-long journey, we shared our thoughts about ageing and age-related issues. He had many more unanswered questions in his mind, such as:

(a) “Is this the way ageing happens?”

(b) “Is this the way people become lonely and dependent?”

(c) “What is the solution for him?”

(d) “How do we revive him back to active and purposeful ageing?” (e) “How do we revive the positive vibe in the family?”

The answer to most of his questions was “unpreparedness”’, starting from his father, family and most importantly the society not being prepared to help the graying population to lead a purposeful and active ageing.

In July 2016, I was coming back to Delhi from Dehradun in train, Nanda Devi Express. I came across Mr. Rabinder Mukherjee (70 years old), a retired IFS officer, living in CR Park Delhi. He was returning from an alumni meet at Forest Research Institute, Dehradun. He was the vice president of the senior citizen association of his colony. His association had initiated a novel drive of enquiring about the health of all people aged 80+ of their colony carried out by the comparatively less elderly (60-79 years old) and adult population on a weekly basis. He also mentioned that they have shared their contact numbers with the vulnerable elderly of their colony, which they can use in case of an emergency.

But when I asked him about his personal goal for the next 5—10 years (that is, when he would be around 80 years old), his response, “I want to be active and joyfully engaged with life till Iam 75 years old, but I am clueless about my 10-year goal”.

I asked further, “Why don’t you have any dream?”

He replied, explaining logically, “You dream of something when there are multiple pragmatic options to be fulfilled. I dreamt about Civil Services when I was in college. I could visualize my dream from various options available at that time”. He continued after a pause, “But at the age of 70, I don’t see any viable avenue to pursue”.

This is a very commonly held attitude among older adults of this country, where people do not dare dream big at the age of 70, which is again due to unpreparedness.

ĮI also asked him, “What is your most common apprehension?”

He replied immediately, “I look at my peer group, many of them are suffering from forgetfulness and problems of dependency, and many of them are dying of cancer”. He continued, “We are aware of most of the diseases and their prevention but do not know much about cancer and dementia”.

When I enquired about his health profile, I found that he was on multiple medications for high blood pressure, diabetes and sleep problems.

But to my surprise, he was not aware of:

(a) Vaccinations at old age (that promotes healthy wellbeing), role of diet and physical therapy in active ageing and environmental modification appropriate to old age

(b) The end-of-life options like “do not resuscitate” or “advance directive”

Prologue xi

Even being part of one of the most well-informed communities with access to the best possible healthcare facilities, a civil servant like Mr. Mukherjee was not adequately aware of age-related changes and diseases and important late-life issues. Though a host of super-specialists have sensitized him about organ-specific problems, they failed to make him aware about age-related functional issues or about active ageing, which mandates lifestyle practices and preventive methodology. In his own words, “Nobody ever discussed ageing issues so vividly and scientifically the way you did! I will definitely prepare myself’.

I still remember 2 May 2007 when I opted for Geriatric Medicine at Madras Medical College, during all India medical second counselling sessions. I did my residency in Psychiatry for 1 year at Bankura Medical College (2004—2005) and then 2 years training in Thoracic Medicine (2005-2007).

The most common responses from various medical colleagues and teachers were:

“Why did you opt for that? Was it by choice or chance? Didn’t you have any better option?"

“You should have chosen Thoracic Medicine or Radiation Oncology”.

The only positive response I received was from my teacher, Professor Apurva Mukherjee, a then faculty in Medicine at R. G. Kar Medical College and Hospital. He encouraged me over the phone, “Go for it! It is the future”. When I did an extensive literature search in Google on Geriatrics around 2006-2007, I could only find the basic meaning of the term, nothing much, which was “A specialty that focuses on health care of elderly people. It aims to promote health by preventing and treating diseases and disabilities in older adults”. But it was enough to convince me as I was able to relate it to my own family.

My grandmother was suffering from multiple issues, like severe osteoarthritis knee, non-ulcer dyspepsia and recurrent falls, but neither the doctor nor we could understood her loneliness and bereavement after the demise of my grandfather from lung cancer, even when she had strong community support in our village.

Despite being a medical graduate, I did not have much information on her disability related to an osteoarthritis knee and psychological trauma, as our medical curriculum does not shed any light on old-age-specific issues. But we all noticed how rapidly her health deteriorated and made her highly dependent from being one of the most active ladies of the village and how it impacted our family and intergenerational relationships.

I noticed that every family had a history like my family or Mr. Mathew Joseph’s family. We, therefore, need qualified and specialist manpower that will not only focus on organ-specific diseases but will think beyond it to prevent disability in the later part of life.

Older adults like Mr. Mukherjee, who are influential and can afford, still believe organ-specific symptoms should be treated by respective specialists. They visit respective specialist for each symptom (chest pain, knee pain, stroke, diabetes, high blood pressure, constipation) and get evaluated in full scale, which may or may not be always based on guidelines. They get multiple opinions for multiple systems and then land up with multiple medicines (polypharmacy), whereas the economically xii Prologue weaker or less-informed elders accept every symptom as a part of the ageing process.

The youth of this country is also not anticipating the future challenges for ageing population. Thus, whenever I ask young people the question “Do you see yourself getting old?”, the recurring instant reply is no, revealing their unaware attitude.

Why do we perceive old age as an agony? Probably, this is because we relate growing old to loneliness, nonproductivity and dependency.

Over the course of the last decade, I have interacted with approximately one lakh elderly people (both nationally and internationally). Whenever I ask them, “Are you prepared for ageing?”, the response, in almost all the cases, draws a blank, irrespective of their social, economic or educational status.

Now if I discuss with our grandparents, parents or the elderly next door, don’t you think that they can still be a great mentor with their nonjudgemental attitude, perseverance and unconditional love? The journey of life that we have just started is the same one that they are about to complete. They could sometimes be cranky, demanding and rigid, but they have lived and learned the most important lessons and realizations of life. They are far above the daily rat race for success, name, fame and wealth. They have lived through the answers to our random events of life and its vagaries. Most of them are lonely and do not ask much but a little compassionate care and support to lead a dignified life. The need of the hour is to create a variety of suitable activities in which the elderly can participate at family and community levels that make them gainfully engaged and proud as a contributor. Intergenerational approach could be one of the many solutions to the growing need of elderly care that can benefit all the three generations, which for now are mostly living psychologically detached from each other.

The ageing population surely has multi-faceted problems concerning their health, family and society. These problems are usually interrelated to their medical illiteracy, perception towards random events of life, incomplete wishes and the attitude of the next two generations of society towards them.

Unfortunately, we are not yet geared to cater to the needs of the elderly. India is home to more than 120 million older adults, but trained elderly care physicians do not exist even in the triple digit. The concept of active and healthy ageing is still new to India. The idea of active and healthy ageing, which incorporates preventive, primitive, corrective and rehabilitative parts of wellbeing, should be promoted among the elderly.

The sandwiched generation, many a times, has to take some tough decisions in life, such as shifting and living far away from their native place to advance their careers. The elderly parents prefer not to move out from their homes where they have spent their lifetime. The elderly, at this age, want a dignified life with their sociocultural identity intact—be it with their peer group—retaining own autonomy and independence. So, in the case of medical or psychosocial emergency, it becomes practically impossible for moved-out generation to help their parents or relatives. There is lack of sync between these two generations, and it has become a major problem without much viable solution.

Prologue xiii

We have tried the didactic approach, where readers from all the generations will gather some knowledge about “how ageing can be joyful” and “how an aged person can contribute to society”. We have tried to highlight the day-to-day problems of the families that have at least one elderly living with them. We have made efforts to highlight the inhabitable but not commonly discussed issues faced by the ageing population. Real-life experiences and live case studies have been used as the medium to bring forth the issues of fall, frailty, dementia, etc., which are some of the notable maladies of most of this precious community.While working on the idea of the book, my aim was to harmonize the difference between multiple generations by joyfully engaging all of them. With the help of real-life incidents, I have made an attempt to spread a positive vibe to intergenerational solidarity to be healthy and active in spite of natural process of ageing body and mind. We have tried to illustrate some historical real-life stories as examples of successful ageing that may apparently appear impossible to adapt but can be practiced by all. For the present book, all the patients’ case studies have been anonymized, and due care has been observed in order to secure their identity.

Department of Geriatric Medicine, AIIMS Prasun Chatterjee New Delhi, Delhi, India

Acknowledgements

First of all, I thank the Almighty God for granting me a good mental and physical health to undertake this task and enabling me in its completion.

I owe my profound gratitude to my mentor Prof. Dr. A. B. Dey and my colleagues, students and friends for their encouragement, support and timely suggestions during the preparation of this book.

I remain grateful to Ms. Shyama Gupta, Ms. Manjari Chaturvedi, Dr. Deepa Anil Kumar and Aditi Dey for editing this book. I also appreciate their valuable advice, constructive criticism and assistance in preparation of the manuscript. My sincere thanks to Mr. Soumitra Dasgupta for illustrating my ideas into beautiful and meaningful pictures.

I respect and thank Shinjini Chatterjee, the editor, and Priya Vyas for the valuable professional guidance during a period of more than 3 years. Their professional contributions have been immense for the development of this book.

Iam extremely fortunate to have wise older adults as my patients and their caregiver family members who shared not only the medical history but their personal stories with me. Through their experiences, the book becomes richer and wider in expanse for its subject matter and relevance for society.

Finally, I have no word to explain the support of my family members, who always stood by my passion empathetically.

XV

Contents

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Chapter 1 A) Understanding Frailty: The Science gest and Beyond

I want to go to the park for a walk, but my leg muscles are not strong enough to take even a few steady steps. I am weak, shaky and slow. I am not depressed but I am not happy either. The doctor assures me that my heart, lungs, nerves and stomach are fine. I know I should eat a proper diet and do exercise, but I do not feel motivated to do anything except to just escape this life. The only thing that is remaining in me is my beautiful mind that urges me each day to love all and pray for all. I often wonder whether these are the features of a fast decaying mind and body? Or are these the perceptions and emotions of a frail person surrounded by decay and death.

Mr. M Kuppuswamy, an 87-year-old retired banker, wrote to me in his letter about his failing body and mind from Chennai. These thoughts resonate in the minds of several octogenarians (80-89 years) suffering from frailty. In his late 20s, Gautama Buddha, before leaving behind his materialistic royal life, had understood that old age was all about frailty [1]. Shakespeare in his masterpiece Hamlet talked about frailty; he considered it to be breakable, weak and delicate [2].

Several centuries after Shakespeare, in 2001, Dr. Linda Fried from the John Hopkins Institute tried to enlist “frailty” in the medical literature to explain the sudden decline in physical fitness of the elderly. This was an era when the word “frailty” did not even have a place in medical dictionaries. Although clinicians gave a subjective definition of frailty, Dr. Fried tried to explain the concept scientifically by introducing a phenotype, which included weakness, slowing, decreased energy, lower activity and unintended weight loss [3].

The frailty phenotype gained popularity among specialists in clinical practice as a method to identify vulnerable individuals undergoing medical or surgical interventions. Rockwood el. from Dalhousie University, Canada, viewed frailty in terms of health deficits that are observed in an individual, leading to the continuous measure of frailty [4].

With increase in ageing population, frailty has become the foremost cause of disability and death among the elderly (Lang et al.) [5]. Prevalence of frailty exponentially increases with ageing in the 80+ American population (30%—45%), as per numerous studies. However, in India, the prevalence for hospital-seeking older adults is between 15% and 40% as per various studies [6, 7]. Starting from older adults, elderly care physician to policy planners has accepted frailty as an epidemic and probably a source of unavoidable agony for older adults [6, 8].

© The Author(s) 2019 1 P. Chatterjee, Health and Wellbeing in Late Life, https://doi.org/10.1007/978-98 1-13-8938-2_1

When I ask any octogenarian (80-89 years) or nonagenarian (90-99 years) about their biggest apprehension, if any at all, their concern is whether they will leave this planet with autonomy and independence. To alleviate these problems, they are ready to try every possible thing at hand, i.e. allopathic medication, homeopathy, ayurveda and/or spiritual healing. They want to bypass the problematic expression of ageing, i.e. frailty.

The natural path of extreme ageing and the last phase of life may not be similar. For some people, it may be from robust late adulthood, i.e. when the individual is at their peak, to subclinical frailty, i.e. they become lower in functional and physical domains. This is followed by early to late stages and then severe frailty, which results in a rapid downhill course that makes an individual completely dependent on others to perform their daily activities (Fig. 1.1).

Ata subclinical stage, the person is clinically resilient but takes longer time to recover from any external or internal insult (e.g. after a fracture or any infection in vital organs). This stage is still reversible if noticed by an individual or the caregiver and intervened by medical team in the form of lifestyle modification, exercise and nutritional support. But, medical team should put maximum efforts to provide appropriate solutions instead of ignoring it as age-related phenomenon. If not intervened, the course could progress from early to late frailty, indicated by a steady decline in functional reserves and development of acute reversible disability and chronic irreversible disability.

However, a more desirable course could be from a robust and active life till their late 80s or 90s to sudden demise because of vital organ failure. The great Indian scientist and ex-president, Dr. A.P.J. Abdul Kalam, set a beautiful example of this. He led an active life all throughout and died a sudden, painless death, a course of life that many would desire.

Continuum of Frailty

Clinically Resilient, Slow

Robust Recovery

Clinically Frail, Disability

Pre Frail/ Sub-Clinical Clinically Frail, Disability++ Early Frail : Clinically Frail, Dependent

Later Frail

Severe Frailty

Death

Fig. 1.1 A schematic demonstrating the continuum of frailty

1.1 Active Ageing and Life Course 3 1.1 Active Ageing and Life Course

Ageing is probably an individualistic and unique experience, a demonstration of multiple biological events that occur throughout life. How and why do we age? What is the secret of active ageing? Both these questions cannot be answered easily. My conversations with Mr. A. B. Tripathy, an 85-year-old retired engineer from Uttar Pradesh, would probably help improve our understanding of ageing and frailty.

I initiated the discussion with Mr. Tripathy, “Sir, what is your notion of old age?” He promptly replied, “Nothing specific, doc! To me, it is just a phase of life where I cannot concentrate for long. I cannot join various clubs and associates. And I am bound to keep away from the conflict of two or more generations, which is something most senior citizens are suffering from”.

After a pause, he added, “Anyway, I have accepted it on a positive note and in good spirits. At the age of 88, I am happy with my family”. I was really surprised by his positivity and understanding of his health and wellbeing. He continued, “I am still alive and in good spirits. I have conquered many morbidities and thankfully, God has not cursed me with cancer, major stroke, forgetfulness, or any other disabling/painful disease”. Probably, he was unaware of the fact that frailty is an equally or even more disabling truth of life.

Mr. Tripathy rightly said that an individual who had survived till the age of 80 (or above) had already escaped non-communicable diseases like diabetes, hypertension and coronary artery disease. Because of his lifestyle, optimism and adoption of active ageing, he had compressed the morbidity till his present age. “Compression of morbidity” is a concept encouraged by James Fries whose hypothesis was confirmed in 1998. He explained that if a person can postpone the development of chronic disease and simultaneously expand life expectancy, then they would enjoy more fruitful years without any morbidity. So, lifestyle with a healthy diet and regular exercise is probably the best way to compress the morbidity [9]. To better understand the concept of “compression of morbidity”, let us consider that a person develops diseases like hypertension, diabetes and arthritis at the age of 60 and his life expectancy is 80 years. For such a case, his living will be compromised in the last 20 years. But, with the help of a healthy lifestyle, another person can lead a healthy life and delay the onset of morbidity till 80 years and dies at the age of 90; thus, his compromised life is only 10 years (Fig. 1.2).

Mr. Tripathy never indulged in unhealthy practices like consumption of tobacco, alcohol or rich diets or so-called fast food. Instead, he was passionate about physical activities since childhood and continued to pursue them throughout his life. This helped him in compressing his morbidity till the age of 80, which was also very much in tune with the World Health Organization’s (WHO) concept of active ageing as an outcome of a lifelong process. Thus, at the population level, the WHO posited six primary determinants of active ageing: behavioural styles; personal, biological and psychological conditions; health and social services; physical environment; and social and economic factors [10]. In addition to having lifelong healthy practices,

Compression of morbidity <—>|

Morbidity Morbidity Better Lifestyle and IC* onset (A) onset (B)

Years 60 80 90 Years Years Years

Life expectancy (A) pectancy >

Life expectancy (B)

*IC : Intrinsic capacity = Cognitive +Functional capacity

Fig. 1.2 Schematic explaining the concept of compression of morbidity

Mr. Tripathy was lucky to have been born to a mother whose nutrition was taken care of before and during her pregnancy to give birth to a healthy baby. There is a partially proven theory of anti-natal influences on the emergence of risk factors for chronic diseases during adulthood [11]. To me Mr. Tripathy was the epitome of active ageing. He had the fantastic ability to adapt to any situation. He told me:

I feel that I have the ‘let-go attitude’ that keeps me going. I try to learn new things from the next generation. My granddaughter is in Canada and my daughter has taught me to talk over Skype, which I use regularly. I enjoy the wonders of science and I take full advantage of digital ageing. I give regular updates to my family doctor through my smart phone. I am financially secure and happy as we (me and my daughter) are in the elite club of the elderly and enjoy each other’s company.

1.1 Active Ageing and Life Course 5

Studies have suggested that a sexagenarian (60—69 years) can be the best caregiver for an octo- or nonagenarian. This was the case with Mr. Tripathy and his daughter; they were able to positively engage with each other and understand each other’s psycho-familial-societal problems more empathetically. The National Center on Caregiving has confirmed this in the results of their report: Selected Long-Term Care Statistics [12]. Digitization has opened various possibilities to positively engaging the elderly with enhanced access to up-to-date information and widening of social connections. It has often become the best vehicle to connect different generations together. Moreover, studies have suggested that learning new skills, like working with computers, keeps an elderly person cognitively healthy and reduces the risk of developing dementia and frailty [13].

I met Mr. Tripathy in November 2013 when he visited me at my OPD with a complaint that he has become relatively slower in the past 2 or 3 months.

This is a common issue in the day-to-day practice of an elderly care physician. The usual approach would be to counsel the patients and convince them that these are just age-related changes and nothing much is required.

During our discussion, I came to know that he had a decreased appetite but no apparent weight loss. I asked him a few more questions related to cancer of the gastrointestinal tract and tuberculosis (TB). He mentioned that his previous doctor had performed all the relevant tests and examinations like endoscopy and CT scan of the chest and stomach. Reports revealed that he had no major disease like TB or cancer; however, he was worried about losing weight.

Among the elderly in India, acute weight loss with loss of appetite should be investigated thoroughly for TB and cancer. Cancer of the lungs, oral cavity and stomach are the most prevalent forms, often underdiagnosed and undertreated.

Among Indian elderly women, breast cancer and lung cancer are very common [14], similar to the prevalence of cancer in developed nations. However, cervical cancer is largely prevalent but underdiagnosed in developing nations like India. Developed nations are not that concerned about diseases like TB compared to developing nations like India, which bears the major brunt of this disease and accounts for nearly two-thirds of the world’s tuberculosis prevalence [15].

In subsequent conversations with Mr. Tripathy, I realized that he was an 85-year-old retired engineer from the Uttar Pradesh government in north India. After his retirement in 1988, he kept himself busy by providing consultancy services to various private firms. On his health front, he regularly went for morning walks, prayers and laughter clubs and to the bank. In fact, he had been doing most of his tasks by himself. He said, “I know that the secret of successful ageing is to be physically and cognitively active [16]. So, I have a plan for every decade unlike most elderly patients in India”.