The inter-disciplinary and inter-sectoral collaboration of geriatrics and gerontology is important for Sri Lanka as it can help address the multi-faceted health-care related needs and social needs of an ageing population since it will facilitate the provision of specialised care for older adults, optimise the use of the limited health-care resources, and provide disability-free, high quality of life while ensuring income security in the twilight days of life.
These observations were made in an opinion piece on "Ageing, gerontology: Geriatrics and Sri Lanka" which was authored by Consultant Physician and Specialist in Internal Medicine attached to a private hospital, A. Balasuriya and published in the Asian Journal of Internal Medicine's Second Volume's Second Issue in August 2023.
Geriatrics and Gerontology
Geriatrics or geriatric medicine is a medical specialty focused on providing care for the unique health related needs of the elderly. Gerontology is the study of the social, cultural, psychological, cognitive, and biological aspects of ageing.
“Ageing is not about decline, it's about growth, expansion, and the development of the full human potential,” says American gerontologist Kenneth M. Dychtwald.
Ageing is a universal phenomenon. No living being is exempted from ageing. Studying ageing communities has been in existence since the beginning of the 19th Century. There are various theories that explain ageing in different perspectives but the major views expressed are two-fold. The first theory suggests the wear and tear phenomenon, in which the building up of waste products that takes place over the years and the failure to clear up and repair that eventually leads to the gradual breakdown of the system that in turn results in cellular ageing (stochastic theories). The second view is based on our genetic memory and argues that our internal molecular clock is set to a particular timetable for each species. Support for this theory comes from animal studies where scientists have been able to cause an increased life span in some animals by altering just one gene.
As of now, there is no “cure” against ageing, and probably there will never be. Instead of struggling with getting older, we should endeavour to make the later years more enjoyable and productive. As stated by the French composer Daniel Francois Esprit Auber, “growing old is the only way to lead a long life”. As a country trying hard to qualify to be included in the “developed” category, Sri Lanka needs to plan for policies that will sustain our demographic trend in a favourable economic and social environment. We have already achieved longevity and the path to happy, healthy longevity remains an achievable goal with more focus and commitment from the policy makers and the health care professionals.
According to the statistics, Sri Lanka has a very fast ageing population and the elderly population (over the age of 60 years) in Sri Lanka in 2003 had a figure of 5.4% while this year, it has increased to 17%. It is estimated to be 27% in 2050. This rapid rise of the older population has direct implications on our existing health system and the socio-economic constitution of the country. A population with a longer lifespan is a success story of any health system in the world. Yet, it invariably translates into high dependency ratios, high disability figures and social poverty in a developing economy. Unless a country has planned well ahead of time to face this and celebrate this high longevity, the figures and statistics of older people in a community may not be a feature that can be celebrated for long.
The Sri Lankan Association of Geriatric Medicine was formed in 2011 and geriatric medicine was incorporated to the postgraduate curriculum in 2013 by the Postgraduate Institute of Medicine.
Geriatrics focuses on the health of the ageing body, and gerontology is the science, or the study of the physical, mental and social aspects of ageing. Geriatrics is actually a subset of gerontology since gerontology takes a broader perspective.
Gerontology was first attributed to Ukrainian Nobel Physiology or Medicine Prize Laureate, Ilya Ilyich Mechnikov who first used it in 1903. Geriatrics was introduced in 1909, by Austrian-American physician Ignatz Leo Nascher to describe the medical care of elderly patients. At that time, the population of older adults was growing, and physicians began to recognise that older patients often had unique health care related needs that required specialised knowledge and training. Over time, the field of geriatrics developed as a distinct area of study, encompassing a wide range of topics related to ageing and the health of older adults.
Gerontology is essentially a multi-disciplinary science that integrates several study areas. This specialty combines a staff working together that includes doctors, nurses, behavioural and social scientists, social workers, biologists, economists, psychologists, those who study the humanities and the arts, policy experts, and many other scholars and researchers. Gerontology includes investigation into changes in the society that come from the ageing process, studying the mental, physical, and social changes of individuals as they age and the application of this knowledge to programmes and policies dealing with older communities.
The demographic profile of Sri Lanka is fast changing. Scrutiny into our economic stability, inflation rates, and per capita income projections shows that our poverty rates will not be declining for the next few decades. This will severely impact the socially deprived communities like older people, especially more vulnerable groups like elders without social protection schemes or a fixed pension based income. As such, though our population dynamics show staggeringly high figures of older people, the question is whether they will be disability free with the added years to life. Will they have good quality silver years or are we just adding years to their lives with more disability and poverty? The medical field in the country has recognised geriatrics as a medical specialty and a few universities have included it in the final year medical school curricula. However, apart from recognising the diseases and disabilities of older age, the country’s responsiveness to sufficiently handle the demographic change is questionable.
Goal setting and planning
Ageing does not start when one is at 60 years of age or 70 years of age. The current view is that it starts during the time of conception. As such, planning for old age on a personal basis as well as planning for its ageing population from a country based perspective, has to be done fairly early. The modern day life needs proper goal setting and planning in order to prevent the wastage of money from a population point of view as well as to improve the quality of life from a personal standpoint.
Planning for an ageing population is important for any country so as to ensure that the needs of older adults are met, so that they can age with dignity.
We need to develop policies that support healthy ageing. These can help older adults stay active, engaged, and independent. This can include initiatives to promote healthy lifestyles, provide access to health care, and ensure that older adults have access to community resources and services. It is true that we have a Directorate in the Ministry of Health to cover the needs of older people, but, the concept of healthy ageing needs to be much more robust with country-wide dissemination, and in this regard, the media plays a major role.
From a country based perspective, if we look at the lifestyle of an average middle aged Sri Lankan man or woman, how many are overweight? How many suffer from diabetes, hypertension and other non-communicable diseases? The disease burden, hospital and medication costs, and the loss of the workforce power of caregivers, all add to the already frail economy of the country in a dramatic manner. The focus on healthy ageing from a gerontological perspective is vital for the next few decades as we move forward with the exponentially expanding ageing population.
From an individual perspective, how many people think that exercise is important for life and really engage in physical activity? How many people are prepared to plan for their old age at 30 years or 40 years of age? How many have a rough plan of how they are going to spend their life when they are 70 years and above? How many have income security at old age?
Old age does not happen overnight and hence, early preparation and planning for a stress, poverty and disability free old age is vital to a low income country like Sri Lanka.
The answers to these questions need input from both health care providers and sociologists. In short, these issues need the full focus if they are to make old age self sufficient from health and economy based perspectives.
Furthermore, due to the current economic crisis, we do witness a large number of young people migrating looking for greener pastures. Though they do bring along foreign revenue to the country, the elderly parents are often neglected and are helpless and vulnerable due to economic insecurity, poverty and the lack of caregivers. We are moving away from large families to nuclear families and family based social support is becoming a rarity.
As we boast of longevity in Sri Lanka, we also need to invest in infrastructure that supports older adults which includes accessible transportation, age friendly housing, and community facilities that support social and recreational activities. We also need more regularised caregiver training programmes apart from the few ad-hoc ones that we currently have. Thereby, we can get employment opportunities to the young while benefiting the older community. These investments can help older adults remain independent and connected to their communities.
Despite our economic constraints and poverty, we need to at least plan for the provision of financial security in old age. Many older adults rely on fixed incomes, such as social security or pensions, to meet their basic needs. Providing financial security through policies such as social security and retirement savings programmes can help ensure that older adults have the resources that they need in order to live with dignity.
Ageism
The other important issue is addressing ageism. Ageism, as described by the World Health Organisation, refers to stereotypes (how we think), prejudices (how we feel) and discrimination (how we act) towards others or oneself based on age, and such can be a barrier to healthy ageing. Addressing ageism through education, awareness campaigns, and policies that promote age friendly environments can help ensure that older adults are treated with respect and dignity. Certain measures are already taken to give priority to old people at Government hospitals and certain institutions. However, the concept is not fully functional and it is saddening to note that if we visit a Government hospital, we can still witness many old and in fact very old people who come to obtain health services without a caregiver, staying in long queues for long hours, and not being considered for any priority care.
Sri Lanka has now taken steps to include geriatrics in the medical school curriculum and introduced postgraduate training in geriatrics as a specialised field which is a very timely and wise approach. In a couple of years, we would be having our first qualified geriatricians in the country.
There are a few gerontology courses that are being conducted in Sri Lanka. The National Institute of Social Development offers a Diploma in Gerontology, a one year programme that provides training in geriatric care for healthcare professionals and caregivers. The Institute of Gerontology of the University of Colombo, offers a range of short courses and workshops in geriatric care for healthcare professionals, including doctors, nurses, and caregivers. However, while there are around eight medical faculties, only the University of Sri Jayewardenepura conducts a postgraduate master’s programme in gerontology. It would be appropriate for other universities to commence graduate and postgraduate programmes in gerontology and to link such with geriatric postgraduate education so that these professionals can work efficiently and bring about a visible and tangible, productive change to our ageing population.
With regard to research collaborations, geriatrics and gerontology researchers can collaborate on studies that investigate the health and well-being of ageing communities. This can lead to a better understanding of the needs of ageing communities and inform the development of interventions and policies.
Concerning community partnerships, geriatrics and gerontology professionals can partner with community organisations and groups to provide outreach, education, and support to ageing communities. This can include programmes and services that address social isolation, housing, transportation, and other issues that impact the well-being of ageing communities.
On the aspect of advocacy and policy development, geriatrics and gerontology professionals can work in close liaison to advocate for policies and programmes that support the needs of ageing communities. This can include initiatives to improve health care access, affordability, and the quality of care, as well as policies that address social determinants of health.
Collaborations between geriatrics and gerontology can lead to better outcomes for ageing communities by providing comprehensive and personalised care, advancing research and knowledge, and promoting advocacy and policy development for the improved quality of life for the silver aged population in Sri Lanka.