Amin A. Muhammad Gadit ( Discipline of Psychiatry, Memorial University of Newfoundland, St. John's, NL, Canada. )
The current demographic profile1 of Pakistan shows the total population as 172,800,048 among which the elderly population over 65 years of age constitutes 4.2%. The overall population pyramid is broader in the middle with the highest figures (58%) being from 15-64 years. In view of poverty, economic disparity and inadequate health facilities, the elderly population suffers a number of set backs. There is a trend for nuclear families that has augmented the social care problems for this group of people. The government of Pakistan sought consultation on National Strategy on Health for Elderly2 in which a number of problems among elderly were identified like: loneliness, depression, fear of dying, lack of social relations, painful medical conditions, deprivation, lack of resources, and loss of a partner. In a local study3 five or more health problems were found in 72% elderly subjects with almost half of them taking three or more different medications daily, issues of immobility, urinary incontinence, dyspnoea, fatigue and visual impairment. Hypertension, diabetes and arthritis were the most commonly reported chronic ailments. Among the mental illnesses, depression has been identified as a significant problem. In a local study there was a noted 22.9% prevalence of depression among elderly.4 It has also been shown that chronic diseases in the elderly are consistent risk factors for depression.5 Important aspect that is not yet covered empirically is the issue of elder abuse. Local report indicates about lack of appropriate health care facilities and schemes as well as policies for the senior citizens.6 This is in a way a subtle form of neglect or abuse. Speaking from a global perspective, it is being predicted that by the year 2025, the global population of those aged 60 years and older will be around 1.2 billion.7 Few population-based studies suggest that between 4% and 6% of elderly people have experienced some form of abuse in the home. As per W.H.O. report7 elderly are at risk of abuse in institutions such as hospitals, nursing homes and other long term care facilities. Abusive acts in institutions include physically restraining the patients, depriving them of dignity and choice over daily affairs.7 The definition of elder abuse as adopted by the International Network for the Prevention of Elder Abuse states, "Elder abuse is a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person."8 It can take any form, physical, emotional or sexual abuse with long lasting consequences. Research conducted in New Zealand reveals that"0f 1288 cases in 2002-2004, 42 couples and 45 groups were found to have been abused. Of these, 70% were female. Psychological abuse (59%), followed by material/financial (42%) and physical abuse (12%) were most frequently identified types of abuse. Sexual abuse occurred in 2% of reported cases.9 Canada is among the world's highly developed countries with an excellent health and social system. Ironically, 'elder abuse' has been an important issue for this country. According to a report,10 99% of Canadians think most of the abuse experienced by older adults is hidden or goes undetected, 22% of Canadians think a senior they know personally might be experiencing some form of abuse, 90% feel that the abuse experienced by an older person often gets worse over time, and 67% feel older women are more likely to be abused than older men. Various sampling and survey methods and case definitions have been summarized by Thomas;11 the range of estimates from these studies is between 2% and 10%. Elders with dementia are at higher risk of physical abuse, alcohol misuse and mental illness among perpetrators and depression among elderly are significant risk factors for elderly abuse.12 Another study13 highlights a high prevalence of depression as well as dementia in mistreated older people. Reverting back to Pakistan, we see that despite tall claims, successive governments have not done anything significant for the welfare of elderly population. As mentioned earlier, the elderly population suffer from a number of chronic physical as well as mental illnesses. Old age is vulnerable for abuse in view of infirmity, ill health and mental health morbidity. Augmenting these problems, the country's health care system is still in doldrums with poverty and violence taking further toll. The once popular joint family system is breaking up rapidly and elderly population is facing loneliness and abandonment. There is no systematic or empirical study which would highlight the magnitude of abuse of elderly yet anecdotal evidence is replete with such examples. Edhi Foundation is one glaring example of a service where abandoned elderly people are housed. These elderly people are shunned away by their children under different pretexts like poverty, illness among elderly and general intolerance. Such vulnerable elderly population is abused in institutions, homes, streets and hospitals. In many instances, there is evidence of deprivation from basic human rights that would fit well with the concept of abuse. There is a great need for extensive work on the issue of Elderly Abuse in Pakistan at this time. A number of countries are working for the prevention of elder abuse. The Japan Elder Abuse Prevention centre is worth-mentioning besides the Canadian network and school curriculum to prevent elder abuse.7 At our local level, steps should be taken to prevent this abuse by means of raising awareness through both print and electronic media, policy for senior citizens, improvement in social services, provision of specially funded old age homes, free health care facilities and effective laws to start with. Health care professionals should be trained further in recognizing the signs and symptoms of abuse among elderly and assume active role in addressing this issue at all levels. Special attention should be given to clues that cannot be explained medically as these may a signal of elder abuse.14 Elderly people form an important group of the population and any aspect of neglect or abuse will have long term negative repercussions for the society in general and country in particular. Hence, there is a need for strict vigilance as well preventive and remedial measures at all levels.
1.Pakistan Demographic Profile 2008. (Online) (Cited 13 July 2009). Available at URL: http://indexmundi.com/pakistan/demographics_profile.html.
2.Provincial Workshop for Consultation on National Strategy on Health of Elderly 2007. (Online) (Cited 13 July 2009). Available at URL: www.elderlyhealth.com.pk/lahore_workshop.htm.
3.Zafar SN, Ganatra HA., Tehseen S, Qidwai W. Health and needs assessment of geriatric patients: results of a survey at a teaching hospital in Karachi, Pakistan. J Pak Med Assoc 2006; 56: 470-4.
4.Ganatra HA, Zafar SN, Qidwai W, Rozi S. Prevalence and predictors of depression among an elderly population of Pakistan; Aging & Mental Health; 2008; 12: 349-56.
5.Djernes JK. Prevalence and predictors of depression in populations of elderly: A review. Acta Psychiatrica Scandinavica 2006; 113: 372-87.
6.Elder Care and Abandonment of the Elderly (Pakistan) 2008. (Online) (Cited 13 July 2009). Available at URL: http://elder-abuse-spotlight.blogspot.com/2008/12/elder-care-and-abandonment-of-elderly.html.
7.W.H.O. Abuse of the Elderly 2002. (Online) (Cited 14 July 2009). Available at URL: www.who.int/violence_injury_prevention.
8.U.K. Action on Elder Abuse. What is elder abuse? Action on Elder Abuse Bulletin, 1995, pp11 (May-June).
9.Age Concern Elder Abuse and Neglect Prevention Services: An analysis of referrals for the period 1 July 2002 to 30 June 2004. Age Concern New Zealand, November 2005. (Online) (Cited 29 June 2009). Available at URL: http://en.wikipedia.org/wiki/Elder_abuse.
10.Government of Canada. Quick Facts on Elder Abuse in Canada. (Online) (Cited 14 July 2009). Available at URL: www.seniors.gc.ca.
11.Thomas C. First National Study of Elder Abuse and Neglect: contrast with results from other studies. J Elder Abuse Neglect 2002; 14: 1-14.
12.Lachs MS, Pillemer K. Elder Abuse; The Lancet, 2004; 364: 1263-72.
13.Dyer CB, Pavli VN, Murphy KP, Hyman DJ. The high prevalence of depression and dementia in Elder Abuse or Neglect. J Am Geriat Soc 2000; 48: 2.
14.Marshall CE, Benton D, Brazier JM. Elder abuse: using clinical tools to identify clues of mistreatment, Geriatrics, 2000; 55: 42-4.