Special Articles / T.K. Nair / Older People in Rural Tamilnadu
Old age is often considered the synonym for disease. It is more so in the villages where “old age” is commonly referred to as the cause of death among the elderly. Diseases occur at all stages of human life and are not peculiar to old age. But the incidence of morbidity may be higher and the severity of illnesses may be more marked among the elderly than among people in the younger age groups. The medical explanation for this is the low resistance to fight diseases and the declining changes that normally occur in the systems of the body which contribute to easy susceptibility to diseases. The diseases of the circulatory system are cited as examples of this decline which, according to them, is an inevitable consequence of the ageing process. The diversity of the health-functioning of the elderly is seen from the following instances.
Chinnappa is 85 and he lives alone. He has difficulty in seeing as well as in hearing. But he can do all the personal tasks without difficulty including going outside and climbing steps.
Eighty-year old Kulandai is a symbol of robust health. He has a good vision and hearing capacity. He has absolutely no incapacity to do any personal task.
Muthu karuppa Nadar is another example. He is 82. His eyesight is good with glasses. His hearing capacity is also good. Except his dependence on the barber for cutting toe nails, he is quite independent in doing various tasks.
But 66-year old Murugesa Reddy has more health problems. His eyesight is not good, though he can hear without any difficulty. He has no difficulty in dressing, going to lavatory and getting about the house. But he needs help for bathing, going up and down steps, and going outdoors.
Perumalakka is now 82. She is deaf and has difficulty to see. She is not suffering from any disease. But, for the past five years, she has been staying indoors most of the time, though not in bed always.
She says it is due to old age. She goes to the toilet with difficulty. She has also difficulty in dressing herself.
Muthamma is living with her mother. She is 60. Her eyesight and hearing capacity are good. But she cannot do any personal task by herself. Her 80-year old mother helps her. Her mother is doing all the light and heavy household tasks.
The health status of the elderly was measured by (a) mobility status, (b) sensory impairments, (c) an incapacity index based on the ability to manage certain personal tasks by themselves, (d) self-perception of health, (e) illness during a reference period of twelve months preceding the date of interview, and (f) physician utilisation.
Seven in hundred old persons in rural Tamil Nadu are housebound or bedridden. At the same time, three–fourths are ambulatory without any difficulty. A fifth of the aged are mobile with minor or major difficulty. The housebound constitute one in twenty and the bedridden one in fifty. Thus a quarter of the older people have difficulty in movement ranging from mild to complete restriction. Old women are more restricted than old men. For every old man, who is housebound or bedridden, there are two old women. And the elderly women who can move about without any difficulty are slightly fewer than the elderly men.
Nearly a third of the old people report good eyesight without glasses: 35 per cent men and 30 per cent women. The blind or almost blind aged are around six per cent (5 per cent men and 7 per cent women). Sixty per cent of the elderly men and women have difficulty in seeing; but only about five per cent use spectacles. A very small percentage (1.7) reports good eye sight with glasses. Eyesight dims as age advances. The elderly claiming good eyesight decrease from 42 per cent among those aged 60-64 years to 20 per cent among those aged eighty and over. And the percentage with total or near blindness increases from 3 in the 60–64 age group to 14 in the last two advanced age cohorts.
Unlike eyesight, more than three-quarters (77 per cent) of the elderly claim good hearing ability and the men and women differ only slightly: 78 and 76 per cent. While a fifth have hearing difficulty, only one in forty is almost or totally deaf. Age appears to have a direct bearing on the hearing capacity. Of great significance is the range of decline which is more drastic for elderly women (from 85 per cent in the 60 – 64 age group to 43 per cent aged 80 and above) than for elderly men (from 88 to 58 per cent).
Giddiness and Falls
Forty four per cent of the old people say that they had never felt like falling. An eighth report that they had experienced vertigo the day or the previous day of the interview and slightly less proportion (11 per cent) within the last seven days. Thus, the old reporting giddiness within the past week are nearly a fourth (23 per cent). Though the majority of the elderly have experienced feeling of giddiness sometime or the other, those who report falls are comparatively fewer: 30 per cent–24 per cent men and 35 per cent women. Those who fell within the past week are fewer still: 6 per cent (5 per cent men and 6 per cent women). With advance in age, more and more old persons report giddiness as well as falls recently. The proportions of old people who felt giddy and who fell last week almost double between the ages 60-64 and 75 and above. Old women more often have vertigo and falls than old men.
Difficulty with Common Tasks
Bathing, going to the toilet, dressing, cutting toe nails, getting about the house, going up and down steps or stairs, and going outdoors are important personal tasks that a person will have to perform himself or herself every day or often. Of these, the first four are tasks associated with personal care and the other three with free movement. Ability to do these tasks without any difficulty enables an individual to function independently and incapacity to do all these tasks makes the person completely dependent on others. In between this independence–dependence continuum are the aged who strive to maintain independence even with difficulty to perform the different tasks and who depend on others for one or more tasks because of inability. Some may manage to go to the toilet even with difficulty but would depend on others for bathing. Some may not have any difficulty at all in dressing but would need other’s assistance in going to the toilet. The cumulative capacity to perform each of the seven tasks of daily life is, therefore, taken as the indicator of the level of incapacity of the elderly. The aged have a variety of difficulties restricting both personal care and social activities. Negotiating steps is a difficult task for the maximum number of elderly with nearly nine in twenty reporting this task difficult. Following close on its heels are nearly a fourth of the aged who find going outdoors difficult. A substantial percentage has difficulty even in moving about the house: one in nine. More than a half of these old people are housebound.
Among the intimate personal tasks, one in five has difficulty in bathing, one in nine in going to the toilet, and one in thirteen in dressing. As bathing and going to the toilet also require going outdoors in many cases, the proportions reporting these inconveniences might have also been increased by the difficulty in going outdoors. More than a third report hardship in cutting toe nails. Many who have no difficulty in cutting toe nails or who manage to cut even with difficulty peel the nails off or rub them with stone.
Slightly more elderly women than men have difficulty with the different physical tasks except that of cutting toe nails in which fewer women figure, and that of moving about the house in which old men and women are in equal proportions.
The elderly with difficulty in doing the common physical tasks consist of two groups: those who manage the tasks even with difficulty and those who have inability to perform the tasks by themselves. The latter seek the help of others either in the household or outside the household. Barring cutting toe nails, more old people manage their personal activities even with difficulty than depending on others. The vast majority move outdoors, climb steps and get about the house on their own rather than waiting for others’ help. So also is the independence seen in the performance of intimate personal tasks, particularly dressing and going to the toilet. Quite significantly, one in eleven has to depend on others for bathing and one in four finds it impossible to cut toe nails. While one in twenty needs someone to accompany to go outdoors, one in eleven cannot climb steps without support.
In performing personal tasks with difficulty, independence is demonstrated equally by elderly men and women in all tasks, with the exception of cutting toe nails. More men cut toe nails on their own even with difficulty. But among the elderly with inability to perform personal tasks without external assistance, women exceed men (ranging from 1 to 5 per cent) particularly in bathing and going up and down steps. The cultural pattern prevailing in the villages is such that where the wife is living, the water is collected and the husband bathed by her so long as she is healthy. This is observed faithfully and is seldom considered as dependence. This may be the reason for fewer men expressing inability to bathe themselves. Inability to cut toe nails is expressed by slightly fewer women than men.
It is natural to anticipate association between increase in age and difficulty with the common physical activities. The more aged a person is the greater is the exertion or difficulty to perform the personal tasks. Among those in the eighties, nearly five times more than those in the youngest age cohort of 60-64 years report difficulty in bathing, about seven times more have difficulty in going to the toilet, seven times more express difficulty in dressing, approximately six times more have restriction in getting about the house, nearly two and a half times more have difficulty in manoeuvring themselves in climbing steps, about four times more are in difficulty in going outdoors, and around three times more find difficulty in cutting toe nails. Age thus seems to have a telling effect on the mobility and capacity for personal care of the old people.
The physical stresses and strains associated with ageing are more striking when we look at the percentage of elderly with capacity to do various common tasks. Nearly three quarters have to surmount difficulty in walking up and down steps and three–fifths are put to hardship in cutting toe nails. A half find it difficult to go outdoors and an almost equal proportion to bathe themselves. A fourth have difficulty in dressing and more than that proportion has to exert themselves in going to the toilet. More than three in ten feel strenuous even to get about the house.
Analysis of the old men and women in the different age groups reporting difficulty yields interesting findings. Higher proportions of the old women than men in the eighties have difficulty in bathing themselves and climbing steps, whereas a greater proportion of men as against women in the eighties has difficulty in cutting toe nails.
We have discussed the varying levels of difficulty of the elderly in performing the seven personal tasks of day-to- day living. The ability to perform all the seven tasks is measured using the incapacity index. The index was developed on the lines of the incapacity index used for the study for the old people in three industrial societies (Shanas, et al, 1968) with necessary adaptations. For the computation of the index, the capacity of the individual to perform each task is quantified as follows: 0 for ability to do the task without any difficulty, 1 for performance of the task with difficulty and 2 for total incapacity to perform the task. The total score on the incapacity index ranges from 0 to 14, with 0 meaning complete independence or freedom from any difficulty to perform all the common physical tasks and 14 implying incapacity to perform even a single task or total dependence.
More than two in five of the rural old have no incapacity to perform any personal task. Those who have no incapacity or have only minimal incapacity (with an incapacity score of 1 or 2) are nearly three quarters. The severely incapacitated with score of 8 or more are one in fourteen. One in five is moderately (with an incapacity score of 3 or 4) or markedly incapacitated (with incapacity scores between 5 and 7).
There does not appear significant difference between men and women in their incapacity levels, though slightly more men are in the no incapacity group and slightly fewer are in the highly incapacitated group.
Age and incapacity register significant association. The younger a person is the more likely is he or she to have no or marginal incapacity. While three in five people in the age group 60- 64 years have no incapacity, only one in fifty in that age group is highly incapacitated. The proportion of the highly incapacitated older people increases drastically from age–group to age–group: 2 to 23 per cent. Similarly, the proportion of old persons with no or minimal incapacity decreases with age registering significant reduction as age advances (86 to 42 per cent) from 60–64 to 80 years and above. The change in incapacity status with age is more striking among women. While one in ten older women in the eighties is free of any incapacity, three in ten in that group are handicapped with high incapacity. In contrast, among men aged 80 and above, those who have no capacity as well as those who have high incapacity are equal in proportion. The fall in proportion of older women without any incapacity is concomitant with increase in age. So also is the rise in percentage with high incapacity. This is not so in the case of elderly men. Though the highly incapacitated old men show consistently increasing trend like women, the older men with no incapacity show distinct variation. Their decline in proportion is not steady from the youngest to the most advanced age group; those in the eighties exceed significantly those between 75 and 79 years. A closer analysis shows that for men, marked decline in capacity or increase in serious incapacity (with incapacity scores of 5 or more) starts from 75 years onwards.
What characteristics distinguish between those who are incapacitated and those who are well? We have already seen the direct association between age and high incapacity. Further analysis shows that aged who are 75 and over increase steadily in proportion with increase in the level of incapacity. But not the proportions of women and the widowed, though the association between widowhood and high incapacity is marked. Women are in almost equal proportion from the no incapacity category to the marked incapacity group. But, as the level of incapacity reaches the maximum, there is a sudden increase in the proportion of women. Similar is the pattern of decline of the proportion of the married; but among them, the swift reduction in proportion takes place after the moderate incapacity stage.
Income and incapacity are inversely related. The proportion of the elderly with no income of their own trebles between those in the no incapacity category and those who are extremely incapacitated. The more incapacitated a person is the greater is the likelihood that he or she is among the very poor.
In sum, nearly a half of the severely incapacitated are 75 years and above, about three- fourths have no income, nearly three-quarters are widows and widowers, and three–fifths are women. The highly incapacitated are, therefore, more likely to be the widowed, who in turn are also the poorest. A widow, who has crossed seventy five, is most likely to be highly incapacitated: she is also without any means of her own.
The correlation between poor vision and incapacity is strikingly pronounced. Restricted mobility is a corollary of incapacity. While three–fourths of the ambulatory have no incapacity or only marginal incapacity, nearly the same proportion of the house bound is severely incapacitated. Significantly, only three in four housebound are extremely incapacitated. The proportion of the ambulatory falls strikingly with increase in the level of incapacity while that of the house bound rises drastically. Higher level of incapacity is an indicator of the greater likelihood of falling sick. This is clearly borne out by the data, though there is a slight drop in the trend of proportions of the elderly, who fell ill during the past twelve months, in the highly incapacitated category.
Self –Assessment of Health
Health has two dimensions–physiological and psychological. While the former refers to the state of physical health as determined by a physician, the latter signifies what the individual feels about his or her health condition. Thus a person who is healthy based on objective assessment by a physician may consider himself to be in poor health, whereas another person who suffers from a serious ailment may feel that he is “fit as a fiddle”. And in between falls those whose self–assessment of health may well coincide with the real physical condition. Thus the aged will fall into the categories of health realists, health optimists and health pessimists. (These terms are adapted from the studies of self–assessment of health made by Maddox and others at Duke University. These are quoted in Ethel Shanas, et al, op.cit)
Madathi Ammal is in poor health, though she is only 62. Her incapacity score is 10. She has difficulty in seeing. She needs help in bathing and going to the toilet. During the past twelve months she was in bed for twelve days.
But 75 year old Veerammal is quite different. She says that she is in good health. She is almost blind, and yet she moves around the house and even outside, with the help of others. Her incapacity score is twelve. Except for dressing, she needs the help of others for all personal tasks.
Sixty five–year old Narayanan is a health realist He reports that he is in fair health. He feels that his health condition is similar to that of the elderly of his age. His eyesight is good. His hearing capacity is sound. Within the last twelve months, he was in bed for twenty days.
Although 80 years of age, Ramaswamy is working in an estate. He works eight hours a day on all the seven days of the week. He experiences some difficulty in seeing. But his hearing capacity is good. He does all the personal tasks by himself. He not only rates his health as good but also feels that he is in better health than others of his age. He says proudly that he had never seen a doctor.
Raghavan is another optimistic octogenarian. He is 80. Despite his difficulty in seeing and hearing, a fall on account of dizziness during the previous week of the interview and some restrictions in doing personal tasks, he claims that he is in good health and when compared with those of others of his age, he feels that his health is better.
But seventy–year old Pichai is in sharp contrast to Ramaswamy and Raghavan. He is employed. But he says that his health is in poor state and when compared to others of his age, he feels that his health is worse. He works only because he has no one to support him financially. His eyesight and hearing are in good condition. His incapacity score is nil.
As large number of old people have no incapacity, large number of them were expected to rate their health as good. But the data belie the expectation. The vast majority of the elderly (more than four in five) do not rate themselves as in good health. Health pessimism thus appears to be a predominant characteristic of the old people in rural Tamil Nadu. The difference between men and women in their self- perception of health is not significant among those who rate their health as good. But, more older women than men view their health as poor.
Only a fourth of the old people with no incapacity rate their health as poor while nearly a half rate as fair. Though not substantial, more elderly in the no incapacity group consider themselves in poor health than in good health. However, the old people in the severely incapacitated group are health realists. Self–rating of health is convincingly influenced by the level of incapacity. The higher the level of incapacity the greater is the likelihood of the elderly assessing his or her health as poor or the least likely to assess it as good. The proportion of good health raters falls from more than a fourth in the non-incapacitated group to negligible in the highly incapacitated category. The proportion of poor raters almost trebles between no incapacity and severe incapacity. Similar is the decline of the proportion of fair raters. Having established significant association between incapacity status and self–evaluation of health, and earlier between mobility status and incapacity level, the relationship between state of mobility and self– perception of health is a direct derivative. The greater the restriction on one’s mobility, the greater is the tendency to rate the health as poor. If an old person is able to move about freely he or she is most likely to say that his or her health is good or fair. The old men and women who report that they are in good health condition decline with more and more difficulty of movement.
Poor self-rating of health is influenced by the marital status of the elderly. This is highly perceptible among elderly women. Marital status does not seem to influence the pattern of self-evaluation of health by elderly men. More widowed, divorced and separated than married women evaluated their health as poor. But among men, the proportions of the married and unmarried do not differ significantly in their assessment of health. Widowhood and separation from husband seem to influence the psychological functioning of health of older women.
The activity status of a person has a direct bearing on the self-evaluation of health. The contrast between the employed and the retired in the pattern of self reporting of health is revealing. The more active the aged, the less is the likelihood of his rating his or her health as poor. The proportion of the retired reporting their health as poor is more than double that of the employed. Those who are employed should normally be in better physical health while many of those who are retired might have done so due to health reasons. Further, the very fact that a person is employed gives a positive self-perception than one who is retired. Work often is an antidote to ill-health, particularly in the perceptional realm.
Loneliness and psychological state of health are related. More of the old people who report their health as good seldom report loneliness often, while more of those who view their health as poor are also those who are often lonely than those who rate as fair or good. The more sick a person feels the more likely is he or she to feel lonely often. The percentage of old people who are often lonely registers nearly a four-fold increase (12 to 43 per cent) between good and poor rating of health. The often lonely elderly among the poor health raters are three and a half times more than those among the good health raters. The association between loneliness and self-rating of health is more pronounced among elderly women than men. The proportion of older women who are often lonely among those who rate their health as poor is nearly five times more than that of those among the good raters. The difference between old men and women is high. While 11 per cent of the good raters among women are often lonely, 50 per cent of the poor raters report loneliness often. At the same time, among men, 13 per cent of the good raters report that they are often lonely as against 34 per cent of the poor raters. For elderly women, we have already seen the association between widowhood and self -rating of health. This explains the high degree of association between loneliness and health rating among them. Loneliness is not explained solely by the health condition or self-perception of it by the elderly. A fifth of the poor health raters are never lonely. Though they are only a half of those who assess their health as good, they are quite substantial in proportion. Further, they are nearer to the proportion of never lonely elderly among the fair raters.
Only less than a fifth think that their health is better than that of old people of their age. And nearly a half think that their health is worse than their counterparts. On the whole, slightly more than a half view that their health is better than or about the same as people of their age. Men outnumber women in comparing their health better than that of the elderly of their age.
The elderly who rate their own health as good are most likely to rate their health better in comparison with other older people. More than three in five who rate their health as good think that they are in a better health condition than others. Only three per cent of the elderly who assess their health as good rate it as worse than their counterparts. Old women in contrast to old men underestimate their health status in comparison with others of their age. Seventy per cent of the old men who rate their health as good also think that they are in a better state of health than other old people as against 50 per cent women. Most of the older people who view that their health is poor also think that they are in a worse condition than their contemporaries. This tendency is more or less similar among elderly men and women, though women are in slightly greater proportion than men. Quite expectedly, the majority of the elderly who assess their health as fair think that they are in a similar state of health as other old people of their age are.
We have already seen that more than four in five of the elderly do not rate their health as good. But the majority of those who rate their health as good do think that their health is better than that of the old people of their age. Thus one should expect this optimism to grow with age. More elderly who survive into higher and higher age levels should feel that their health is better than that of elderly of their age. But our data do not indicate this both among elderly men and women. The only significant feature is that more old men and women in the youngest age group of 60-64 than the elderly men and women in the other age groups think that their health is better than that of others of their age. One possible reason for the reversal of the expected response pattern is that those in advanced ages may be comparing their health with people younger to them or persons who are more agile or healthier than them. More elderly women tend to do so than men. An equally justifiable anticipation is that those who rate health as worse than their counterparts must increase with age. This to a great extent is borne out by the study though the elderly in the eighties defy the rising trend of percentage. Among them, more than a half of the men (55 per cent) consider that their health is better than or about the same as that of old people of their age. But not the women.
More than a half of the elderly were ill in bed during the past twelve months. The difference in proportions between men and women reporting illness is not significant. Four in hundred old men and women (excluding bedridden) were never in bed in their life time. There is no association between illness and age for older women. But among men, there is association, though the trend is upset by the aged in the eighties.
Nearly a fifth of the sick elderly were confined to bed over a month, and more than a fourth between a fortnight and a month. Those who were in bed for a fortnight or less are a half of the aged reporting illness during the past twelve months. Among the short-term sick, men and women are in equal proportions. But more elderly women than men were ill in bed for a longer period. That is more than a month.
Of the 884 elderly who were sick in bed during the past twelve months, 12 per cent did not receive any treatment; more of them were women (14 per cent as against 9 per cent men). Nearly a fifty (19 per cent) were satisfied with some home remedies. However the majority (seven in ten) received medical treatment.
Contrary to the popular notion, 87 per cent of those who received medical treatment got so from allopathic physicians. Homeopaths came next with 8 per cent. Ayurveda or siddha treatment was resorted to by only 4 per cent. The remaining had approached others including the National Malaria Eradication Programme staff. The establishment of primary health centres in villages, the nearness to towns and the availability of private practitioners (though not often fully qualified professionally) may be the reasons for the predominant use of allopathic medicine.
About a seventh of the old people who were ill in bed during the past twelve months had to be hospitalized. More men than women were hospitalized. A fifth of those who were hospitalized were long-term patients of more than four weeks and nearly a fourth were in the hospital for a long period of two to four weeks. The duration of hospitalization does not differ significantly between older men and women. Among the non-bedridden aged population, the hospitalized constitute one in thirteen.
Normally one may expect association between advanced age and hospitalization. But this study does not support the anticipation that with increase in age mere old people are likely to be hospitalized. On the other hand, among men the lowest proportion of the aged who were hospitalized belongs to those in the eighties.
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