THE INDIAN GERIATRIC TALE

Geriatric medicine in India is the least known form of medicine. Becoz no one practices it, because no one gets trained in it. Presently the focus of the health administration is still on decreasing the IMR (infant mortality rate) to less than 30 per 1000 live births which right now, in India, is 54.63 per 1000 live births. It is one of the factors in determining the PQLI - Physical quality of life index in the country. PQLI is determined by the follwing

- IMR

- Life expectancy at age 1

- Literacy rate

If you notice, Life expectancy is also a determinant and presently the Life expectancy in India is 64.71 years (male: 63.9 years female: 65.57 years). That is pretty ok, so it will be a while before Geriatric medicine training is introduced into the mainstream health education. However, I am basically writing this post to string together my experiences with the elderly population.

There is no doubt most of the ailing people who are admit chronically in hospitals are about middle aged. Here I am talking about routine cases like CVE, IHD, Uncontrolled Diabetes and Hypertension and of course Cancer patients. And often instances come where there is nothing much you can do for them. I’ve come across such patients being described as ‘Gomers’ in a few Robin Cook novels. They take up hospital beds and resources that could be more effectively used otherwise. There is a solution possible for this in the form of Nursing homes and Recovery homes and such.

But there are very few such nursing homes and recovery homes in India that will take care of such patients for optimized economic disbursals. And the burden falls on mainstream hospitals. There are often scenarios played out, especially in Government run hospitals, where the doctor takes the family aside and tells them that there is nothing much they can do for their patient, so they can take him home if they wish to. There is no ‘all we can do for him is to keep him comfortable’ (as in pain relief). It’s different when a patient chooses to die in the familiarity of his home and it is different when due to lack of facilities in the hospital or due to the financial situation of the family the patient is taken home to die. Medical insurance is still in its primitive form here and government subsidies for the elderly are limited to separate Qs at railway stations and such.

This is a sore point with me becoz I lost my grandfather in exactly the same way. He was diagnosed with Carcinoma prostate and on diagnosis, his PSA levels were approximating 40 ng/ml with bone and lung mets and it was too late for any modality of treatment to be effective. He was taken to one of the better Cancer hospitals in India but after running tests and treating him for a week, the doctors promptly told my relatives to take him home, as there was nothing much they could do for him. I was 17 and a first year medical student then in the midst of exams, so I could not go visit him. But I was appalled when I learned that instead of keeping him in the hospital in pain relief, my uncle chose to bring him home. My grand father died at home, one and half months after his diagnosis amidst his family in, god - only - knows how much pain. Now after a few years of experience I realize that this should not have happened. My grandfather, 78 when he died, had been complaining of prostatism and acute body pain for 3-4 years. But as is the plight of most elderly who have to depend on their offsprings for getting them medical attention, my grandpa waited and my uncle kept dismissing it, till it was too late.

I am not sure whom to blame, the government which doesn’t make better facilities available for the elderly or my family who didn’t help him in time. 

Please note, that most of all this applies to people who are not so affording, though there are the occasional odd rich examples .It’s the norm in India for the kids to look after their parents in their old age. But there are way too many people who think of it as a burden to take care of people who have practically spent their whole life looking out for you. Its only recently that people have started saving for themselves in their retirement and old age, rather than give it all away to their kids and expecting them to fend for them in their bleak years. Also more and more old age homes are coming up in cities and many of the about-to-age populace, including my mom, have decided to live there (and die) in dignity! About my mom, its remains to be seen, as it’s a constant debate between us with me saying I won’t let her!

Examining the other side of the coin, I should mention what is being done for the elderly other than separate senior citizen Qs and concessions. The hospital, where I studied, was a tertiary Government hospital meaning that most of the difficult cases were referred there from the peripheral districts outside the city. The department of Internal medicine conducted weekly clinics for Diabetes, hypertension and Ischemic heart disease, which basically consisted of a bunch of doctors refilling prescriptions of patients and ordering tests as required. The medicines were free as were the tests. And yes, there was a geriatric clinic too, which was in conjunction with other relevant departments like surgery and orthopedics, but that was mostly prescription refilling too.

However my personal brush with elderly patients happened in two particular places. The first was in the Ophthalmology department as in intern. The most common cause of blindness in India is Cataract. In my hospital an average of 40-50 cataract extractions were done a day, and it was the interns’ responsibility to get all the relevant tests out of the way before admitting the patient. That meant giving the patient a list of tests that needed to be done and making sure they went to the right departments to get blood tests and urine tests etc done. Trust me when I say that it is one of the most challenging things to explain to an elderly, illiterate, unaccompanied lady who walks leaning on a staff and is invariably hard of hearing too, the various directions to the get her tests done. Dozens of times I have wound up taking them around for their tests and ultimately depositing them in the Ophthalmology ward, which, unfortunately, was on the fourth floor with no elevators. I suppose it was one of those times that I promised myself that my mother will never suffer a lonely older age.

The other place where I came across multitudes of geriatric patients was during my rural posting, which is a three-month long stint in one of the government run Primary Health Centers or PHCs in rural areas. Apart from the Obstetric patients who came in hordes to avail the Antenatal facilities, (India does have one of the highest populations and population growth rates in the world!), the major bulk of patients were geriatric females and occasionally males. The hypertensives and diabetics aside, they invariably came with complaints of generalized weakness, body ache and joint pains. Osteoarthritis at such a grass root clinic could hardly be treated with HRT (hormone replacement therapy). We had to resort to the NSAIDs (aspirin, Paracetamol etc) along with antacids for treating their symptoms and giving them a week’s worth of calcium supplements and Multivitamin tablets which were free of course. As per protocol, we could only prescribe a week’s worth of medication, but rest assured they returned every week.

As a Primary care physician, I could not bring myself to prescribe virtually unlimited supply of NSAIDs to any patient, over and over again, for fear of giving them Gastritis or Ulcers. Initially I tried to teach them exercises to keep the joints supple but they were more interested in the painkillers.

Then there were those who demanded injections. Not for the pain but for the weakness. It’s a habit in PHCs to give intramuscular injections of Vitamin B12 to anemic patients. The illiterate patients call them ‘Strength booster shots’ or ‘Red strength shots’ as the solution is light red in color. It’s a common for patients suffering form easy fatigability to visit such clinics and demand for ‘Strength shots’. And so used are they to them that when in shortage of Vitamin B12 injections a placebo like distilled water helps as well.

I think I have been rambling too long in this post. I will conclude by saying that much needs to be desired in the practice of Geriatric medicine in India and hope that things change soon for the better.

Source: IndianMedic

by

Akshaya Srikanth

Pharm.D Intern

Hyderabad, India