Thursday, July 7, 2016

Introduction

 When does a person become ‘old’ and when does ageing begin?
There is no universally accepted definition of when an adult crosses a threshold and becomes "old". In the western, developed countries old age is synonymous with the time of retirement and eligibility to receive pensions. This corresponds to the ages of either 60 or 65 years and is, of course, based on chronological time. But chronological time may not have much meaning in certain parts of the developing world where functional ability is the criterion for old age. In Africa, for instance, a person is often considered old at 50 or 55 years of age (Ref). 

Ageing is not the same as being old. Ageing is a process that starts from birth and continues throughout life. Some of the changes of ageing seen in cells and tissues are genetically determined while others are determined by environment, nutrition and lifestyle. Ageing is also not a uniform process for everyone as some show the effects of ageing more than others of the same chronological age. 

The elderly population in Malaysia and in different parts of the world
The population of people above the age of 60 years in Malaysia in the year 2020 is expected to be about 10 percent of the population (approximately 3.3 million people will be considered old in 2020 - Ref.) The percentage of people above the age of 60 years in the world in 2017 is about 13% of the global population and it is Europe that has the highest percentage of those above 60 years (about 25% of Europe's population is above the age of 60 years). The United Nations has projected statistics which say that most regions of the world except Africa will have one-quarter of its population above the age of 60 years in the year 2050 (Ref.) Most of the currently developed countries in the world have become rich before their population becomes old while countries that are still developing appear to be becoming old before they become rich. 

Life expectancy in Malaysia and in other countries. 
The life expectancy in Malaysia according to statistics in 2015 was 73 years for males and 77 years for females. Some of the statistics for other countries can be found from this link (Ref.). Some examples are: 
Singapore 80 years and 86 years respectively. 
USA 77 years and 82 years respectively. 
India 67 years and 70 years respectively.
Kenya 61 years and 66 years respectively

The life expectancy of a population gives information about longevity but does not contain any information about the quality of life. A long life is only appreciated if it is lived without functional restrictions caused by diseases and disabilities. The impact on the quality of life caused by diseases can be captured by a parameter called disability adjusted life years (DALY). When comparing people with the same lifespan, those with greater DALY can be considered to have more disease-span than health-span. Lifespan = Health span + Disease span.

Socioeconomic conditions play an important role in determining the health status of a population as they grow older. There are statistical calculations that try to determine how many years of healthy life (health-span) can be expected from the age of 65 years onward. This is called the Healthy Life Expectancy (HALY) and data from 2016 show that the HALY after age 65 differs between countries and according to income (Reference.). The HALY for a few countries are given here:
Singapore: 18 years and 15 years for males and females respectively
USA: 15 years and 13 years respectively.
Malaysia: 13 years and 12 years respectively
India: 11 years and 10 years respectively.

Globally, those who live in higher income countries have increased HALY compared to those who live in low income countries (Females have additional 7 years of healthy life after 65 years while males have 4 years of healthy life after after 65 years of age).

Illnesses or disabilities that the elderly are more prone to. Economic / financial concerns for an elderly person.
In many parts of the world, the non-communicable diseases like diabetes, hypertension, coronary artery disease and cancers are increasingly responsible for disability and illness in the elderly. Depression and dementia are also a concern in the elderly. There are real financial concerns for the elderly related to loss of employment income. Financial weakness leads to the elderly being dependent on others. 

Ageing and suffering. Can people be happy as they grow old? Concerns of the children as their parents grow older
The reality of growing older has been explored in the writings of many authors. In the book ‘Tuesdays with Morrie’ (Albom, 1998), an important theme is the acceptance of the physical and mental changes that aging brings in its wake. To experience old age without regret, we have to find a purpose for living while we are still young. Being aware of our own mortality on a daily basis can help us do that. Grief comes easily to many older people because of the losses they experience. In the book 'Lapping’ (Halligan, 2001) the author compares the movement of the mind to the rise and fall of waves on the seashore with some memories becoming prominent and others fading away over time. Loss, and the grief that comes with aging, is also discussed in the article ‘A poetic life’ (Leser, 2005). We are reminded here that loss can sometimes be a time to learn valuable lessons. In old age there are many lessons that can be learnt about the strength of the spirit and those who find this inner strength can triumph over all kinds of physical limitations. Finding new directions in our lives after retirement is important and is the theme in the story ‘Not to yield’ (McDonald, 2000) where we are reminded that growing older need not be an excuse to stop learning or following our passions. Memories represent unique aspects of our personalities. In ‘Saying Goodbye’ (McInnes, 2005), we learn about what happens when Alzheimer’s disease robs people of their memories and they become strangers to themselves and to their loved ones. Sometimes we wonder if knowing the diagnosis of an incurable and progressive illness like Alzheimer’s serves any purpose. In ‘The right to self-determination’ (Pieters-Hawke & Flynn, 2004) this question is explored and the authors feel that early awareness of incurable diseases can enable people to plan ahead and to ensure that what happens to them in the future is according to their wish.

Children may struggle with feelings of guilt for not doing enough for their parents and with anger for being in circumstances where they are forced to choose between being caregivers for their parents and living their own lives in the way they want. They can face burnout from being caregivers as they struggle with conflicting emotions and societal expectations. 

Institutional care (nursing homes or managed residential facilities) versus domiciliary care for the elderly. The concept of “respite care” in the context of caring for the elderly.
Institutional care, in this context, is different from admitting a patient in a hospital because of a medical problem. It refers to the provision of long term care and is a choice made for ensuring a safe and comfortable environment for the person towards the end of life. It is a choice that caregivers make hoping to achieve a 'good death' for the elderly person. Long term care, whether in institutions or at home, can be of two types - assistance in activities of daily living and assistance in other aspects of daily living. Assistance in bathing, using the toilet, getting up from bed are examples of the former while assistance in shopping, cooking and using transportation are examples of the latter.

While most people wish to experience 'a good death' at home, statistics from the UK indicate that the majority of deaths in the elderly happen in hospitals. When people say that they wish to have a good death, it implies that they wish to feel in control of what is happening to them; they wish to be free of pain and unpleasant symptoms; they wish to die in a place of their choosing with privacy and dignity, and they have the time to resolve personal conflicts, unfinished business and the knowledge that their wishes will be respected.

Statistics from USA in 2016 suggest that about 5% of the population above the age of 65 years live in nursing homes or assisted living facilities (Ref.). The common reasons for admitting the elderly in managed care facilities will be inability to provide care at home and the need for constant medical attention. People from Asia, because of their family oriented culture, tend to hesitate before admitting their aged parents in institutions for long term care. Mobile domiciliary care might be a solution. A service called 'Love on Wheels' was started in Malaysia for providing nursing care to the elderly in their homes (Reference).

Respite care refers to the use of services designed to give family caregivers a break from their jobs of looking after their elderly dependents at home. Such periods of respite care can rejuvenate the caregivers and prevent burnout (Ref.).

 





Tuesday, June 28, 2016

The ability to choose

Based on: Pieters-Hawke, S., & Flynn, H. (2004). The right to self-determination. In Hazel’s journey : a personal experience of Alzheimer’s (pp. 71-84). Sydney : Pan Macmillan.


As people grow older, one of the things that they may fear is the inability to make their own choices about how they want their lives to be.

In this story, Hazel is a woman who has just been given a diagnosis of Alzheimer’s disease. While she is not in any way dramatically different in the day after knowing the diagnosis (versus the day before the diagnosis), Hazel is nevertheless more apprehensive, after the diagnosis, about a future where her sense of self will be eroded away.

Sometimes one wonders whether there is any purpose in knowing the diagnosis of a disease for which there is no treatment. Because whether one remains blissfully unaware or fearfully apprehensive, the disease will unfold the same way, isn’t it? Hazel’s story tells us that an early diagnosis of Alzheimer’s disease gives people an opportunity to provide instructions for those situations in the future when they would no longer be able to make decisions. It helps family and friends know what they must do without feeling guilty or anxious. One of the important decisions that Hazel communicated to her family was that she did not wish for her life to be prolonged simply for its own sake. She had no wish for medical interventions to keep her alive when she reached a state where she was of no use to herself or to anyone else. The ability to articulate such desires and to ensure that everyone will understand and follow them is the main benefit of knowing early the diagnosis of a disease like Alzheimer’s.


Much of what we fear may never happen. Whatever the situation we are in, we have the ability to create in our own minds the kind of future we want.  We have the power to construct, if we so choose, our own narratives of what our lives will be in the future as we age. These mental constructs can be safety nets that allow us to move bravely towards an uncertain and potentially fearful future. We must learn to exercise this cognitive choice while we can.

Monday, June 27, 2016

Losing memories

Based on: McInnes, W. (2005). Extract from Saying goodbye. In A man’s got to have a hobby:long summers with my dad (pp. 231-246). Sydney : Hodder Australia.

Memories accumulate as we grow older. These memories define us and connect us to our past. Alzheimer’s disease robs us of these memories and we become strangers to our former selves and to the people whom we knew in the past. 

When Colin developed Alzheimer’s disease, his wife wanted to care for him in their house and not keep him in a nursing home. As the disease progressively robbed Colin of his memories and his links with those who loved him, their house seemed to shrink because most of their daily activities revolved around his needs. Colin became increasingly suspicious as his memories were slowly extinguished. This made it increasingly distressing for his family. 

As people grow older with chronic progressive diseases, there will come a time when there is nothing more to be done, nothing that will make things better. It is then a time of waiting, of waiting for death. This is the time when loved ones struggle with their own emotions and try to find meaning in loss. 


Wednesday, June 22, 2016

Retirement

Based on: McDonald, D. (2000). Not to yield. In T. Koch, M. Annells & M. Brown (Eds.), Still doing : twelve men talk about ageing (pp. 115-131). Kent Town, S. Aust. : Wakefield Press.

When Don McDonald retired, he felt that he had stepped out of a very rewarding phase of his life. He felt that he had closed the door to a life filled with people, noise and action. He felt adrift but he consoled himself that he would now be able to march to the rhythm of his own drumbeat. He had to remind himself that retirement would give him the opportunity to explore new horizons. One of these opportunities was in the form of being able to spend time reading aloud to his wife who lost her vision after a stroke.

Retirement also enabled him to find meaning and fulfilment in domestic chores like cooking and keeping the house and garden tidy. Retirement spurred him to involve himself in the University of the Third Age (U3A) which is a network of older people who are interested in learning for its own sake. Don found enthusiasm and purpose by trying to light the “fires of curiosity” in the English language through teaching a class called Words Alive in U3A. Involvement in the activities of U3A also gave Don the opportunity to meet and know people with different kinds of attitudes and interests.

Retirement is the pause button of life, a time for reflection on the meaning and significance of life. Growing older should not be an excuse to stop learning. Rather it should be the opportunity to focus on the kind of learning that we are really passionate about and interested in. Teachers are also learners for it is a poor teacher who does not learn from students. Tennyson’s words can indeed be a guide for older folks:

Though much is taken, much abides;
And though we are not now the strength which in the old days
Moved heaven and earth; That which we are, we are;
One equal temper of heroic hearts made weak by time and fate, but strong in will;
To strive, to seek, to find, and not to yield.





Old age can unmask inner strength

Based on: A poetic life written by David Leser in the Australian Women's Weekly (January 2005)

Old age is often associated with loss and loss is often associated with regret. But, as Barbara’s life in this article shows, the loss of even a vital function like eyesight can be the key to an aspect of life that is fulfilling and rewarding. Barbara was able to reach out and touch people because of her blindness. She developed the ability to intuitively understand the emotions and needs of others by developing a hidden resource inside her, something she would never have been able to do if she had not lost her eyesight. Her life can be an inspiration to all those who are growing old with the regret of losing the strength and beauty of youth.

Old age can be a fulfilling place if, like Barbara, we learn to develop unique strengths within us that were unacknowledged earlier. Old age can be the time when the strengths of the spirit become more evident and stronger. Without the inevitable (physical) losses of old age, such inner strengths may never be discovered. When such inner strengths are discovered and strengthened, we develop the ability to look forward to the future with hope instead of looking at the past with regret. 

Tuesday, June 21, 2016

The grief that comes with aging

Based on: Halligan, M. (2001). Lapping. In The fog garden : a novel (pp.1-8). Crows Nest, NSW. : Allen and Unwin.

Growing older increases the risk of experiencing loss. 

The movement of the mind is like the lapping of waves. Some memories are intensified while others are erased; like the waves which ebb and flow, creating and removing, patterns on the sand. When one is grieving, one may observe commonplace activities in great detail. Halligan, after the death of his wife, was exquisitely sensitive to the sounds of the birds around his house and to the activities of children playing on the beach. His memory sharpened the images of his wife greeting him with a kiss every time he returned home and there is a painful intensity in the way he remembered always being comforted by the sight of his wife’s car even though it was of a colour that he detested. 

Grief can also be externalised. Halligan takes the large cathedral he used to frequent with his wife to be symbolic of the enormity of his grief. The analogy is apt.  Grief can be as complex as a cathedral with all its intricate sculptures and carvings and grief, like the cathedral, has a way of hushing and silencing interactions between people.  


Sunday, June 19, 2016

Growing old

Based on: Tuesdays with Morrie -  a novel by Mitch Albom

Growing old need not be an uncomfortable feeling. Ageing is like an irresistible force that will take place whether we want it or not. Morrie says that resisting ageing is what creates uncomfortable feelings and unhappiness. He feels that those who resist ageing are mainly those who have unsatisfying or unfulfilling lives. Those who have found a meaning for their lives will generally be grateful for the experiences of the past and will not be unhappy to move onward to whatever the future holds for them. 

Envy for the young and the healthy is something that older folks will always experience from time to time but it is possible to feel it and let it go by replacing that feeling with the awareness that ageing is also a form of growth and maturation. Morrie finds comfort in imagining ageing as a process that takes one onward from infancy to childhood to adulthood and old age. The young and the old, at any point in time, are simply at different points in this spectrum of time.  Those who are old have already traversed a greater part of this spectrum and should feel a sense of accomplishment for having done so.

Our priorities often change in ways that we cannot imagine when we are faced with the reality of dying within a finite period of time. Morrie tells us that he feels the soft and gentle emotion of love connecting him very strongly to others, even strangers. He implies that love is a force that connects us all to one another, like beads on a string. His awareness of being connected to others is probably what has given him the ability to accept being dependent on others in his eight decade of life.


Morrie feels that we tend to ignore the reality of death when we are young and healthy and that this makes us unappreciative of the gifts which we receive in this world from Nature and from others. He feels that being aware of one’s mortality on a daily basis is the right thing to do for it gives us valuable insights into how we need to use our time on earth.