To mark World Elders’ Day, the Sri Lanka Association of Geriatric Medicine ( SLAGM) made a strong plea for holistic care and treatment of elderly persons in keeping with the Integrated Care for Older People ( ICOPE) concept of the WHO. The Sunday Observer spoke to founder President of the Sri Lanka Geriatric Association and Consultant Physician, Geriatric Unit, Colombo South Teaching Hospital Dr Dilhar Samaraweera to get a better understanding of Geriatric Medicine, a relatively new approach to elderly care in Sri Lanka.
Excerpts
Q: What is Geriatric Medicine and what does holistic approach to elderly care mean?
 Dr Dilhar Samaraweera |
A. Geriatric Medicine is a specialty in medicine dealing with prevention and treatment of diseases in persons older than 60 years of age. The practice of Geriatric medicine shifts away from a ‘disease centered’ to a ‘person centered’ approach.
The management of the elderly person involves a holistic approach which is a multimodal approach consisting of comprehensive assessment of physical, psychological and social aspects. The management is done by a multidisciplinary team enabling achievement of the elderly patient’s goals and a better quality of life.
Q: Integrated Care of Older Persons (ICOPE)- how exactly does it help improve the life of elders?
A. Integrated Care of Older Persons (ICOPE) is a novel approach initiated by the World Health Organization focusing on optimising intrinsic capacity and functional ability of older persons in the community by strengthening primary care.
Health and social care workers in the community at the primary care level can identify older persons with loss of capacity and provide appropriate care to reverse or slow these losses by following the guidance of ICOPE. This approach is simple and low cost which suits our country. Conditions associated with loss of intrinsic capacity and functional decline are interrelated and need an integrated and person centered approach for assessment and management.
Q: What age group falls into the category of an elderly person?
A. The age cut off is 60 years. However, what is more important is the biological age (age determining the functional ability) rather than the chronological age which is the age calculated from the date of birth.
Q: What is the current estimated percentage of hospital admissions of elderly persons per day/ year?
A. About 70 percent of admissions are over 60 years of age in hospitals.
Q: There seems to be a severe dearth of Geriatric units to meet the current demand of elderly patients. How do you deal with this problem? Where are they looked after when space in the few Geriatric wards runs out?
A. Acute care is provided for all adults regardless of age in the general medical wards. I think it is acceptable as age discrimination should not occur during acute care, the problem occurs when providing post- acute care when prolonged stay cannot be offered for the elderly due to the pressure for beds in wards with a high turnover of patients with a need for clearance of patients.
It is in these situations that we need intermediate care wards or centres fortified with multi-disciplinary teams to re-enable these patients to go back to their homes or placement in elders’ homes when homeless.
Q: Health problems facing the elderly are different from those of others who are younger. What are these problems and what organs in their bodies are affected by such problems?
A. The young are often affected by a single disease whereas older persons have multiple diseases affecting multiple organs and domains, physical, social and psychological. Older persons have specific syndromes which result in impairment of their activities of daily living.
The specific geriatric syndromes are, decreased mobility, instability, falls, frailty, incontinence, dementia, depression and polypharmacy.
They also suffer from degenerative diseases like osteoarthritis, back and neck problems due to lumbar and cervical spondylitis. The diseases of the elderly are not unique to one organ but are due to reduction in capacity of multiple organs as a result of the ageing process.
Q: What do non communicable diseases ( NCDs) contribute to their declining health ?
A. There has been a paradigm shift from increased prevalence of non communicable diseases to communicable diseases. The development of infrastructure facilities and equity in health care resulted in a decrease in the communicable diseases. A few decades ago many people died of infections, such as malaria, dysentery and other infections.
The change in lifestyle and diet has contributed to increased incidence of non communicable diseases. More people live into old age due to advanced treatment of myocardial infarction, stroke and other diseases. Accumulation of non communicable diseases, such as Hypertension, heart disease, diabetes mellitus, chronic kidney disease, chronic lung diseases and cancers result in the rapid decline of health leading to physical and mental frailty in the elderly.
Q: What about poor nutritional status in the majority of elders?
A. As we age, nutritional status declines due to multiple factors. The taste, smell and vision decrease, muscles become weak resulting in poor mastication and swallowing of food, loss of teeth results in poor bite, the amount we eat decreases with reduced appetite, the reduced mobility results in reduced exposure to sunlight and difficulty in shopping for food, the decline in mood and cognitive capacity and poor financial status all contribute to poor nutritional status in old age.
The restrictions posed by non-communicable diseases, such as hypertension, diabetes mellitus directing towards low salt and low sugar and the spiritual impact leading to a diet low in animal protein further compromises the diet of the older persons.
We need to have less restriction on the amount of salt in the diet of older persons who have problems with low salt resulting in falls and confusion; we need to increase the protein content of the diet in older persons which in fact should be more compared to younger people.
Animal protein is easier to take due to more protein per weight and easily absorbed. Eating eggs with the yolk is healthy and should be encouraged. Vegans should drink milk to maintain adequate protein and vitamin B12 intake.
Food with calcium, such as milk and dairy products, and small fish and exposure to sunlight to enable adequate calcium vitamin D levels is important for muscle and bone health. Where intake is inadequate, food supplements should be given with minimal disturbance to the main meals, placed a few hours away from main meal times.
Food should be made energy dense and thick, sugar and other additives could be added to enhance the flavour. Physical exercise should be coupled with good nutrition to achieve maximum benefits.
Q: Sri Lanka is now in the midst of a Corono19 pandemic. How vulnerable are elders to this new virus?
A. Covid-19 infection can lead to severe lung infection due to low immunity and result in confusion due to preexisting cognitive impairment, can result in falls, fracture of hip leading to complications of immobility and death.
Therefore, the elderly will die due to various factors precipitated by Covid-19 rather than from the respiratory illness.
Q: According to the new concept of ICOPE, elders have ‘intrinsic’ capacities. Can you explain what they are, how they are assessed and how they give elders a better quality of life?
A. A simple way is to assess the intrinsic capacity of an older person with a tool introduced by the WHO. Intrinsic capacity is defined as a combination of physical and mental capacities.
The functional ability of an older person is the combination and interaction of the intrinsic capacity with the environment a person inhabits. The following six key domains are assessed
• Mobility
• Vitality/Nutrition
• Vision
• Hearing
• Psychological – Depression
• Cognitive capacity- Dementia
The assessment of the six key domains of an individual with this tool at primary care level will lead to a more comprehensive assessment at tertiary care level.
The management of these older persons will result in improvement in the intrinsic capacity resulting in a functional ability at community level with appropriate modifications of the environment they inhabit.
Q: I understand that various interventions including an elderly friendly environment have already been made by the Health Ministry in conjunction with your Association to provide elders a better quality of life. What more needs to be done?
A. The new buildings need to fulfil certain criteria for approval. The buildings need to be disable-friendly and enable older persons to use the facilities.
The hospitals should have elderly friendly infrastructure. There is a need to build a society for all, not only for the young.
The authorities must give priority to create an elderly friendly environment. All these would prevent injuries to elderly and reduce dependency, leading to gains in the economy of the country in the long run.
Q: Do you agree that family doctors, mid wives, public health inspectors play a vital role in identifying the health needs of elders as they are the first point of contact for most elders?
A. Yes. To enable efficient geriatric care in the community, we need to strengthen primary care. The first contact health personnel need to have knowledge and skills in handling specific problems of the elderly. Most elders live in the community and not in hospitals, and frail elders in the community have difficulty in access to health care.
Strengthening of services by the first contact persons will help deliver health care to the doorsteps of the frail elderly.
Q:The theme of this year’s motto is, ‘Think wise and age well.’ What are your plans for the future in this respect?
A. The Postgraduate Institute of Medicine is conducting training programs in Geriatric Medicine. Board certified Geriatricians will be available soon to take this specialty ahead. Training of other multiple disciplines is under way.
We should build more hospitals dedicated for elderly care. We need to strengthen primary care to deliver community care including home visits.
Informal care givers need to be complemented and encouraged to look after the elderly in their own homes preventing isolation of elders in places devoid of loved ones.
Q: Your message to elders?
A. All elders should maintain a healthy lifestyle, engage in exercise and have a healthy diet. It is important to have adequate amount of protein in the diet to reduce muscle wasting in old age leading to falls and fractures.
Maintaining good physical and mental activity with participation in social activities is very important to achieve active healthy ageing and prevent dementia.