S. A. Khan  ( Department of Elderly Care, Lister Hospital, Corey's Mill Lane, Stevenage, Herts SG1 4AB )
P. Ghosh  ( Department of Elderly Care, Lister Hospital, Corey's Mill Lane, Stevenage, Herts SG1 4AB )

Over the past fifty years the elderly population has increased rapidly in the developed world and is still rising.1 In some European countries the elderly population has already exceeded the 20 percent mark. These people tend to have greater health and social needs as seen in the United Kingdom where almost two third of general and acute hospital beds are occupied by people of 65 years and over.

With the rapid developments in clinical medicine and improvement in social sectors, the elderly population is growing at an astronomical rate. The current rate of growth of 2.4 percent per year is considerably higher than the world's total population growth. By the year 2025, 12% of the world's population will be over 60 years and 70% of them will live in developing countries.

For the first time Asia is experiencing the phenomenon of mass ageing with some societies ageing more quickly than others. The increase in the elderly population could be up to four hundred percent in some Asian countries by the year 2025.2 It took over a 100 years for Belgium's population aged over 60 to increase from 9% to 18% but Singapore will achieve this doubling in just 20 years. These trends are predicted for many South East Asian countries and will result in the emergence of new disease patterns, increasing chronic disability and changing social norms. There is only basic information on some aspect of ageing population but no reliable and up to date demographic data exists for Pakistan.3 None the less there is evidence to suggest a substantial increase in the older population over the next two decades.4

The phenomenon of chronic disease goes hand in hand with ageing. Globally there are indicators that chronic disease will form a much higher share of overall disease and most of this burden will fall on the developing countries.5 In south East Asian countries this has implications for health planners, economists, the socio-political framework of society and the private health sector. In less developed countries where resource is scarce, partnership between the patients and the health service providers would be of paramount importance for an effective health system, as highlighted in the recent World Health Organisation report.6
In Pakistan, traditionally families have looked after their elderly relatives. Though it is envisaged that in the short term these family values would continue, however, with the worldwide trend of declining birth rate, nuclear families, emancipation of women and increased migration for jobs, communities would replace the role of extended families. With paucity of state funded services for older people, the private and voluntary sector would play a major role in delivering the service.
There is no universally agreed definition of old age. The spectrum of disease starts to change and disability rises after the age of 60 years. Older people are not a uniform group and have a broad range of needs. For service development they could be separated into three main groups.
Firstly the Young Elders, these are the people who have just retired i.e., between 55 years to 65 years. They are generally well and are active. The goal for elderly care services is to promote and extend healthy active years.
The Transitional Group is in transition between healthy active life and frailty. This transition occurs between 65 to 80 years. The goal for health planners is to identify emerging problems, prevent disease and reduce long-term dependency.
In the developed world frail older patients are generally over 80 years of age but the frailty and chronic disease could affect people at a younger age in the developing countries where average age is shorter. These patients merit special attention as they have a significantly higher level of pathology, chronic disease and disability which requires specialist services, skills and higher resources. The goal is to recognize the complex interactions of physical, mental and social issues and provide a service which meets the needs of these patients and their careers. In some countries this group of very old people is growing faster than the rest of the elderly population.
The medicine of old age is the branch of general medicine concerned with the clinical, rehabilitative, preventative and social aspects of illness in middle age and beyond. On one hand there is a different pattern of disease presentation in later stages of life along with slower response to treatment. On the other hand the combination of multiple pathology, chronic illness and old age makes predicting the course of illness much harder. High morbidity with chronic disease and increased multidisciplinary rehabilitation needs, supports the call for specialist skills. The ethos is to help restore an ill, disabled person to the level of maximum ability. Hence a comprehensive service for elderly patients would need specialist departments to meet all health care needs.

The evolution of medical services for older people has resulted in different models of service deliveries. All of these models share the common goal of ensuring that elderly patients have access to the skills and experience of a physician in Elderly Care Medicine and the specialist services of the multi-disciplinary team. The local needs of the community and the location of the department influences the development of service on a specific model. The traditional 'Needs Related' model of care is more suitable for a service that is based at a non-acute site, whereas the 'Age Related' model has been favoured for years by many district general hospitals in the United Kingdom.
The most effective and robust model of care has been the 'Integrated Model', which is currently practiced in most hospitals in the United Kingdom where undoubtedly, Old Age Medicine is most well developed. The service provided by an individual organization may need to consider a combination of models or variations but the type of service must meet all the needs of elderly patients.
A preventative strategy is an integral part of Elderly Care Medicine. To extend an active and healthy life style is the biggest challenge for all involved with the health needs of the elderly population. Lifestyle changes to decrease cardiovascular risks, the benefits of physical activity with multifactorial intervention to decrease falls and nutritional support to maintain independence are but a few key areas. Vaccination, prevention for osteoporosis, thromboprophylaxis for thromboembolic diseases are some of the other areas in need of attention.
Last but not least is the issue of the end of life care. This aspect of treatment has been provided in the developed world on the principles of diagnosis rather than need. There are lessons to be learnt from the pitfalls of such a system which leaves many terminally ill patients without specialist care. The model most suitable for palliative care would be the one that would prioritise resource on the basis of need rather than the diagnosis.7
Developing countries need a cohesive strategy for dealing with the problems of the changing demographic process, increasing burden of chronic disease and limited resources. Without timely provision for the growing elderly population, the whole health and social system is at risk of meltdown. The patient groups, policy makers and service providers should join forces with international bodies to tackle the growing challenges before the eruption of the demographic volcano.

1. Greengross S, Murphy E, Quam L, et al. Ageing: a subject that must be at the top of world agenda. BMJ 1997;315:1029-30.

2. United Nations. UN Population Prospectus 1995 update. New York: UNO 1995.

3. 1998 Census Report of Pakistan: Population Census Organization, Statistic Division, Islamabad. Government of Pakistan, 2001.

4. Hobbs F, Damon B. 65 + in the United States. In: Current Population Reports. Washington: US Bureau of the Census, 1996, pp. 23-190.

5. Swart L, Dick J. Managing chronic disease in less developed countries. BMJ 2002;325:914-15.

6. World Health Organisation. Innovative care for chronic conditions: building blocks for action. Geneva: WHO 2002.

7. Murray SA , Boyd K, Kendall M, et al. Dying of lung cancer or cardiac failure: prospective qualitative interview study of patients and their carers in the community. BMJ 2002;325:929-32.