There is no escaping the demographic shift as birth rates decline and populations age. How do we address ageing and elderly care?
“It’s no use going back to yesterday, because I was a different person then”
— Lewis Carroll,
Alice in Wonderland
September is World Alzheimer’s month and September 21 is observed each year as World Alzheimer’s Day, named after German psychiatrist Alois Alzheimer who identified and reported the first case of the illness now named after him: Alzheimer’s disease (sometimes also called Alzheimer’s Dementia to differentiate it from other kinds of dementia which may result from other brain illnesses).
A few years ago, an old friend from school called and asked to come see me to discuss his elderly mother. He described how both his elderly parents were struggling with memory as well as general health issues. His mother though, was in a more advanced state of memory decay than his father, who was older. Her short-term memory had almost completely disappeared resulting in problems like daily arguments when she accused her children of not feeding her since she kept forgetting that she had eaten. On a few occasions, she had stepped outside their house and gotten lost, needing the neighbours to bring her back home. The most recent crisis had been precipitated after his father was hospitalised for a chest infection and she had become frantic at home in his absence. He recovered and was now back home but it was hard for him to rest. She kept wanting him to get out of bed and check if “the children were okay”. She couldn’t sleep at night and kept him awake with her. She also wanted to feed him even though his appetite was poor after his recent illness and would start fighting with him when he declined food. My friend and his family were at their wits’ end. The most painful thing, he said, was seeing his mother (and father) in such a dependent state.
Dementia is a generic term encompassing various illnesses, whose core feature is gradual loss of short term (recent) memory. Alzheimer’s disease makes up the vast bulk of cases of dementia accounting for about 70 percent of cases. The rest comprise brain or bodily illnesses: sequelae of strokes, Parkinson’s disease and other neurological illnesses, prolonged substance abuse (alcohol is the drug of abuse usually responsible) etc. It is usually a disease of old age although a very small percentage of cases (transmitted genetically within close family members) can happen in young people, sometimes as young as 30s or 40s.
Pakistan has one of the youngest populations in the world, thanks to our high fertility rate with over 40 percent of our people below the age of 15 and only a little over 3.5 percent over 65 years of age. This is good news in the short term. All these young people, if properly educated and trained, can be a huge resource for our society in the decades to come. Unlike the vast majority of Western societies (Japan being an extreme example), our population is not ‘graying’ (getting older) and thus, can be expected to continue working and contributing to the economy.
However, Pakistan cannot escape the inevitable demographic shifts over the coming decades as our birth rate begins to decline and the population starts ageing. As women enter the workforce in increasing numbers, birth rates are already beginning to drop (as has happened all over the world). Current estimates put the number of patients diagnosed with dementia in Pakistan at around 1 million. This is likely a huge underestimate since, despite the efforts of organisations like Alzheimer’s Pakistan (an affiliate of Alzheimer’s International), awareness about this very common illness remains poor. Population estimates worldwide indicate that, given current trends, the number of patients with dementia in the world will double every 20 years with the bulk of this increase coming in low- and middle-income countries like Pakistan.
As a practising psychiatrist, this is evident to me: my immediate family has five elders (over 75) with some having early symptoms of dementia. My wife’s family has about the same number. In my clinic, about 1 in five patients or families is struggling with the illness of dementia. Our changing socio-demographic trends do not bode well for the future. Dementia patients need ongoing supervision and care as the illness is progressive and the decline is inexorable, although gradual.
As women leave the home to enter the workforce, we stand on the precipice of a crisis which no one really appreciates. No resources have been allocated at the government level to develop facilities and services to replace the free home-based care that women have been providing for centuries. There are now large numbers of elders living alone in our cities (and, no doubt villages) whose children live and work abroad and have no intention of returning.
As someone on the threshold of old age, I have a very personal stake in this fight. So, is there something that people over the age of 50 (like me) can do to delay or prevent the onset of dementia?
Since dementia is basically a reflection of the ageing of the brain, the lifestyle and health strategies that are recommended to delay other aspects of ageing apply to dementia as well:
Maintain a “healthy lifestyle”. Manage your diet, don’t smoke or drink (to excess), make sure you get adequate amounts of sleep at night (6-8 hours is the average required) and treat any preexisting illnesses (diabetes, high blood pressure etc). Practice good “sleep hygiene” (Google it) since sleep quality also deteriorates with age. If you are over 50, get a regular medical checkup at least once a year even if you are symptom free. Exercise regularly not just for brain health but also for preventing other illnesses.
There is some evidence that higher levels of education and continued intellectual pursuits in old age help delay progression of dementia. Actively exercise your brain (avoid “passive brain stimulation” like television and social media). Playing chess, reading and regular social interaction help keep the brain active.
While there are practical advantages to rearranging society for the care of the elderly, there is a better reason for not discarding them. They are an enduring source of wisdom and knowledge that can never be gained from “leadership” and “management” seminars since there is no substitute for real life experience. In addition to the compassionate aspect of caring for those who spent their lives caring for us, in actuality, they can teach us a lot about the world as it is today. Continued social and occupational engagement is known to prevent and delay the onset and progression of dementia. As for me, I find hope in a quote from the Roman philosopher Seneca: “Let us cherish and love old age; for it is full of pleasure, if one knows how to use it”.
The writer is a psychiatrist and faculty member at King Edward
Medical University. He taught and practised psychiatry in the United States for 16 years and came back to Pakistan to be closer to his parents and family. He is an advisor to Alzheimer’s Pakistan. He tweets @Ali_Madeeh