CHAPTER TWO

REVIEW OF LITERATURE

2.0.0 INTRODUCTION

Review of related literature is an important pre-requisite for

actual planning and execution of any work. Review of related
literature implies locating, reading and evaluating the reports of
research as well as reports of casual observations and opinions that
are related to an individual’s planned area of work. Review provides
a better understanding of the problems, which helps the
investigator in gaining new insight and to formulate new
approaches to the problem that has been selected.

A literature review gives an overview of the field of inquiry:

what has already been said on the topic by great investigators what
the prevailing theories and hypotheses are, what questions are
being asked, and what methodologies and methods will be
appropriate and useful. A critical literature review shows how
prevailing ideas fit into your own thesis, and how your thesis agrees
or differs from them (Harper Rowena, 2011).1 (Best, 2000)
“Familiarity with the literature in any problem area helps the
students to discover what is already known, what others have
attempted to find out, what methods of attempt have been
promising or disappointing and what problems remain to be
solved.”2 “A literature review is a critical summary of research on a
topic of interest, often prepared to put a research problem in

1 Harper Rowena, Paper Presentation on defining Gerontology, Accademic

skills center, Canbarra.
2 Best, J. W. and Khan, J.V. (2000) Research in Education, 9th edition, New
Delhi: Prentice Hall of India. Pvt. Ltd.
 53

context. A literature review helps to spot the foundation for a study

and can also inspire new research ideas” (Polit and Hungler, 1998).3

2.1.0 Gerontology and Geriatrics

The size of India’s adult population is greater than the total

population of many developed and developing countries. According
to World health Statistics 2011, 83 million persons in India are 60
years of age and older, representing over 7% of the National total
population. Geriatrics is the study of health and disease in later life
and emphasizes comprehensive care for older persons as well as the
well-being of their care-givers. Gerontology is the study of the
ageing process and involves the study of the physical, mental and
social changes that occur as people age (WHO, 2011).4

The study of the physical and psychological changes which

are incident to old age is called gerontology. The care of the aged is
called clinical gerontology or geriatrics. Social gerontology which
was born on the one hand out of the instincts of humanitarian and
social attitudes and on the other out of the problems set by the
increase number of old people (Park, 2011).5 Gerontology is the field
of study that focuses on understanding the biological,
psychological, social and political factors that influence older
people’s lives. Geriatrics deals with clinical study and treatment of
older people and the disease that affect them (Nancy, R. Hooyman
et al. 2005).6

3 Polit, D.F. and Hungler, B.P.(1998). Nursing Research Principles and

Methods. (5th ed.) Philadelphia: J.B. Lippincott Company.
4 WHO, World Health Statistics. (2011).
5 Park, K. (2011) Preventive and Social Medicine,M/sBanarsidas Bhanot
Publishers, Jabalpur: India.p.481.
6 Nancy, R. Hooyman and Asuman Kiyak. (2005) Social Gerontology A
Multidisciplinary Perspective, New York: p. 69-70
 54

Gerontology is study of the aging process and individuals as

they grow from midlife through later life including the study of
physical, mental and social changes; the investigation of the
changes in society resulting from our aging population; the
application of this knowledge to policies, programs, and practice
(Quadagno, 2008).7 Geriatrics is the study of health and disease in
later life; the comprehensive health care of older persons; and the
well-being of their informal caregivers (Butler, 2008).8 Gerontology is
the study of the social, psychological and biological aspects
of aging. It is distinguished from geriatrics, which is the branch of
medicine that studies the diseases of older adults. Gerontologists
includes researchers and practitioners in the fields of biology,
medicine, nursing, dentistry, social work, physical and occupational
therapy, psychology, psychiatry, sociology, economics, political
science, architecture, pharmacy, public health, housing and
anthropology (Nancy, Hooyman R. 2011).9

Geriatrics is a branch of medicine and it deals with

gerontology and ageism. According to National Associations of
Social Workers, (NASW) “the geriatric social work is a profession,
which provides specialized service and opportunities for the elderly
and their family to enhance problem solving and coping skills of the
elderly and their care-givers and to help develop a social policy”.
Geriatrics is a profession, which deals with the physical, mental,
social, and medical aspects of old age. It stands for the over all
development of the elderly (Elizabeth, B. Hurlock, 1992).10

7 Quadagno, (2008) Defining Gerontology and Geriatrics, Journal of American

Geriatric Society, 50, 359-368.
8 Butler, 2008. AGHE Executive Committee.
9 Nancy, R. Hooyman and Asuman Kiyak. (2005) Social Gerontology A
Multidisciplinary Perspective, New York: p. 69-70.
10 Hurlack, B. Elizabeth, (1992) Development Psychology-a Life Approach (1st
Ed.) New Delhi: MG Gran Hill Publishing.
 55

Geriatrics derived from two Greek words, “Geras” means old

age and “Iatro” relating to medical treatment. Thus, geriatrics is the
medical specialty that deals with the physiology of ageing and with
the diagnosis and treatment of diseases affecting the aged. It is the
branch of medicine dealing with the problems of ageing and the
diseases of the elderly (Stephanie Nancy, 2010).11

With rapid advancementation in scientific developments,

improved health practices and better standards of living, the life
expectancy in many countries including India has gone up
considerably. In developed countries, many people live up to the age
of seventy years and over. In England, twelve percent of the people
are over sixty-five years of age, whereas in India it is 3.8 Per cent.
Life expectancy is affected by various factors such as the historical
period in which one lives, his family background, nationality, sex,
life style, etc.

The rapid urbanization and societal modernization has

brought in its wake a breakdown in family values and the
framework of family support, economic insecurity, social isolation,
and elderly abuse leading to a host of psychological illnesses. In
addition, widows are prone to face social stigma and ostracism
(Jamuna, D. 1997).12 The socio-economic problems of the elderly
are aggravated by factors such as the lack of social security and
inadequate facilities for health care, rehabilitation, and recreation.
In addition, in most of the developing countries, pension and social
security is restricted to those who have worked in the public sector
or the organized sector of industry. (Karthikeyan, 1999).13 Many

11 Nancy R. Hooyman and Asuman Kiyak, (2005) Social Gerontology A

Multidisciplinary Perspective, New York: p. 69-70
12 Jamuna, D. Reddy, L.K. (1997) The Impact of Age and Length of Widowhood
on the Self-concept of Elderly Widows. Indian J Gerontology; 7:91–5
13 Kartikeyan, S. Pedhambkar, B.S. Jape, M.R. (1999) Social Security the
Global Scenario. Indian J Occupational Health; 42:91–8.
 56

surveys have shown that retired elderly people are confronted with
the problems of financial insecurity and loneliness. (Bhatia,
1983).14 In the recent times individualism, independence, and
achieved position in the family are becoming part of family culture
in India. The aged would now prefer to live independently as long as
possible and the children do not feel guilt of being away from the
parents. Nevertheless there is no total societal acceptance to
deserting parents by their children. Living arrangements for the
elderly are influenced by several factors such as gender, health
status, disability, socio economic status, societal tradition and
cultural heritage (Madhav Rao, 2002).15

The 60th National Sample Survey (January–June 2004)

collected data on the old age dependency ratio. It was found to be
higher in rural areas (125) than in urban areas (103). With regard
to the state of economic development, a higher number of males in
rural areas, 313 per 1000, were fully dependent as compared with
297 per 1000 males in urban areas. For the aged female, an
opposite trend was observed (706 per 1000 for females in rural
areas compared with 757 for females in urban areas).National
survey (2006).16Overall 75% of the economically dependent elderly
are supported by their children and grandchildren. Despite this, the
elderly still tend to suffer from psychological stress as was found in
a survey conducted for a middle class locality in New Delhi. (Bose,
1997).17 Over 81% of the elderly confessed to having increasing

14 Bhatia, H.S. (1983). Ageing and society: A Sociological Study of Retired

Public Servants. Udaipur: Aria’s Book Centre Publishers; ion of Meerut.
Indian J Community Med. 1999; 28:165–6.
15 Madhav Rao, (2002) Economic and Financial Aspects of Ageing in India. A
paper presented at international Institute on ageing , Malta.
16 Morbidity, Health Care and Condition of the Aged; National Sample Survey
60th Round (January to June 2004) Government of India, March 2006. pp.
54–65.
17 Bose, A. (1997) The condition of the elderly in India: A study in Methodology
and Highlights of a Pilot survey in Delhi. UNFPA Project Report.
 57

stress and psychological problems in modern society, while 77.6%

complained about mother-in-law/daughter-in-law conflicts being on
the increase.

The elderly are also prone to abuse in their families or in

institutional settings. This includes physical abuse (infliction of
pain or injury), psychological or emotional abuse (infliction of
mental anguish and illegal exploitation), and sexual abuse. A study
that examined the extent and correlation of elder mistreatment
among 400 community-dwelling older adults aged 65 years and
above in Chennai found the prevalence rate of mistreatment to be
14%. Chronic verbal abuse was the most common followed by
financial abuse, physical abuse, and neglect. A significantly higher
number of women faced abuse as compared with men; adult
children, daughters-in-law, spouses, and sons-in-law were the
prominent perpetrators. (Chokkanathan, 2005).18

2.2.0 Ageing Process and Accompanying Changes

In advanced countries, the care of the aged is provided mostly

in institutions, unlike in India where the elders are still-some what
respected and cared for by the family members and support is given
mostly in the homes. There are also few institutions, which provide
care for the aged. Yet the status of the elders and the quality of the
care provided are satisfactory. The increased proportion of the
elderly segment in the community necessitates the services of
community health workers who can be of use to the family as a
whole. A trained home nurse knows the needs and problems of the
aged and their families better and meets them more efficiently. The
care of the aged is a part of clinical gerontology and geriatrics.
Besides the superior competency to meet the needs and problems

18 Chokkanathan, S. and Lee, A.E. (2005). Elder-mistreatment in Urban India: A

Community based Study. J Elder Abuse Negl. 17:45–61.
 58

concerned with the psychology and physiology of ageing, the social

aspects of ageing offers a great challenge to the caring profession.
Aged people are more vulnerable to illnesses such as bronchitis,
arthritis, avitaminosis, gastro-intestinal disorders, rheumatism,
diabetes and skin disorders etc. Their vision and hearing can be
impaired to an extent that their social activates are greatly
restricted.

It is clear from the above review of earlier studies on health of

the elderly that the health and wellbeing of the elderly are affected
by many interwoven aspects of their social and physical
environment. Family support is found to be an important factor for
socio-psychological well- being of the elderly (Devi and Murugesan,
2006).19

2.2.1 Social Aspects of Ageing

Some of the sociological changes that come with increasing

life span include reduced income, negative impact on in the life
style, loss of other family members and friends, which results in
social isolation and loneliness. The ageing population place greater
demand on community health services. They impose additional
responsibilities on the younger generation and the other family
members. With a reduced income, retirement and with very few
companions their life style is considerably altered, especially when
they are affected with some illness (Keshav Swarnkar, 2010).20
Many of the aged are reluctant to go to institutions for the care of
the aged. Thus, family care-giving is encouraged and promoted. In
some countries besides financial help, social workers, nurses and

19 Devi, N. Prabhavathy and P. Tamilarasi Murugesan, 2006. ‘Institutional

Care for the Elderly’, Journal of the Indian Academy of Geriatrics, 2(1),
March 2006, pp. 15-20.
20 Keshav Swarnkar, (2010) Community Health Nursing (3rd Ed.), NR Brothers
Publications, Indoor: p. 684-15.
 59

professionals provide supervision of care in the family in order to

lessen the strain in the family members. Many hospitals are now
having geriatric units for the care of the aged both in the in-patient
and outpatient departments. Specialized training is given to
medical, nursing and other health professionals for this purpose.
Health promotional and ailment prevention measures such as
health examination for early diagnosis and treatment are provided.

A man's life is normally divided into five main stages namely

infancy, childhood, adolescence, adulthood and old age. In each of
these stages an individual has to find himself in different situations
and face different problems. The old age is not without problems. In
old age physical strength deteriorates, mental stability diminishes;
money power becomes bleak coupled with negligence from the
younger generation. There are 81 million older people in India -11
lakhs in Delhi itself. According to an estimate, nearly 40% of senior
citizens living with their families are reportedly facing abuse of one
kind or another, but only 1 in 6 cases actually becomes known.
Although the President has given her assent to the Maintenance
and Welfare of Parents and Senior Citizens Act, which punishes
children who abandon parents with a prison term of three months
or a fine, situation is grim for elderly people in India (Yuman
Hussain, 2010).21

Living in Old Age Homes has also become common among the
elderly in Kerala. As per the Kerala Aging Survey done in 2009,
Kerala topped the country with 204 old age homes, and one out of
every 5 old age institutions in India is located in Kerala. And more
such centers that provide residential facilities for senior citizens are
coming up in the state. and Ernakulam has the highest percent of

21 Yuman Hussain, (2010) Azad India Foundation The Problem of Old Age in
India.
 60

elderly living in old age homes (23) and Kasargod has the lowest
(0.8 percent). More women are living in old age homes, and reports
say that the aged have a negative perception about such
institutions and majority of them prefer to stay in their homes. But
with more youngsters making their living in faraway places, the
living conditions of the elderly are undergoing a drastic change
(Kerala Ageing Survey, 2009).22

Maintenance of Health and Independence: Health education

is imparted on a three-tier basis ─ primary, secondary and tertiary
education. Primary education is provided for the prevention of
disease or injury and the promotion of positive health. The elders
are encouraged to participate in activities that are beneficial to
health and to avoid those that are injurious. Secondary education is
concerned with early detection of signs of ill health and timely
intervention and care. Tertiary education is given following disease
or injury to encourage the individual return to independent
existence as far as possible. They are encouraged to reduce
excessive intake of alcohol and to give up smoking. The
opportunities for health promotion are many, and include good
housing, balanced diet or education to adapt to the home
environment to counteract disability if any (TNAI, 2008).23

It is observed in many of the elders especially the very old

that there they are unable to manage their own physical needs
(washing, dressing, toilet, eating). There is also the loss of ability to
fulfill their psychological needs (security, status, social interacting).
In an institution or community, an initial assessment of the elderly
person can identify his abilities and limitations, with to direct
personal needs (toilet, washing, cleaning feeding), and extended

22 Kerala Ageing Survey, 2009.

23 Trained nursing Association of India, (2008) A community health nursing
manual, L-17 Green Park, New Delhi, p.82-86.
 61

personal care (shopping, cooking, housework and socializing). The

care should be planned according to individual’s strength and
limitations with frequent reviews of the situations. It is important
wherever possible to involve the relatives in the planning and
providing of care. The teaching role of the social worker should be
directed towards the practical aspects of promoting knowledge
concerning health, and adaptation to disability, teaching basic
skills and an acquisition of positive attitudes. In their scheme an
assessment of ‘readiness to learn’ and the coping ability of the
family are essential. Besides the capability of the person concerned
and his relatives to learn should be ascertained. The individual’s
interest in the problem and the incapacitation of any intellectual
ability that may have been caused due to illness should also be
identified in advance.

(Park, 2011) Practical skills, (such as testing urine, changing

appliances, drawing up and giving injections, inhalations) are best
taught by demonstration with accompanying explanation.
Opportunity should be given to the person and or his relatives to
handle the equipments and clear doubts by questioning. Regular
supervision with encouraging praise, reinforcing success will help
the teaching.24There is an adage: attitudes are caught and not
taught. The social workers have the responsibility of promoting
positive attitudes to health, aging and the management of disability.
The right attitude of the nurse promotes desirable attitudes in
others. The family is a unit through which maximum satisfaction is
obtained through mutual sharing and a genuine show of concern.
But in old age a person’s family status often undergoes a negative
change. A father, who was the chief of the family till then, may
suddenly turn a dependent on his children. A mother may have to

24 Park, K. (2011) Preventive and Social Medicine, M/s Banarsidas Bhanot

Publishers, Jabalpur: India.p.481.
 62

subject herself to the rule of daughters-in- law. If one of the

partners is dead, the other is prone to feel lonely. The decision
making process in the family changes and the control is
transferred.

Under such circumstances, the best thing to do is that the

old person to eschew the desire for power and to avoid unnecessary
interferences. They may give advice, when needed. They should also
try to adjust their own needs and daily living activities to the
routine of family. By adjusting with the generation gap and modern
trends as far as possible, old age can be made pleasant. Though the
ashram system is not possible in modern times, an old person can
adopt the attitudes of a vanaprastha and make his own life more
congenial and rewarding (Keshav Swarnkar, 2010).25

2.2.2 Biological Aspects of Ageing

Biological ageing, or senescence, is defined as the normal

process of changes over time in the body and its components. It is a
gradual process common to all living organisms that eventually
affects an individual’s functioning vis-à-vis the environment but
does not necessarily result in disease or death. It is not, in itself, a
disease. However, aging and disease are often linked in most
people’s minds, since declines in organ capacity and internal
protective mechanisms do make us more vulnerable to sickness.
Because certain diseases such as Alzheimer’s, arthritis, and heart
conditions have a higher incidence with age, we may erroneously
equate age with disease. However, a more accurate concept of the
aging process is gradual accumulation of irreversible functional
losses to which the average person tries to accommodate in some
socially acceptable manner. People can continue to maintain an

25 Keshav Swarnkar (2010). Community Health Nursing (3rd Ed.), NR Brothers

Publications, Indoor: p. 684-15.
 63

active lifestyle as they experience age-related changes in their

biological and physiological systems. In order to achieve active
aging, people may alter their physical and social environments by
reducing the demands placed on their remaining functional
capacity (Nancy, 2005).26 This is consistent with the person-
environment model of ageing; as their physical competence
declines, older people may simplify their physical environment to
re-establish homeostasis or their comfort zone.

Popular culture, as reflected in books and magazines, is full

of stories about “anti-ageing hormones,” “fighting ageing,” and
“preventing death.” The problem with these optimistic projections is
that no single scientific theory has yet been able to explain what
causes ageing and death. Without a clear understanding of this
process, it is impossible to prevent, fight, or certainly to stop this
normal mechanism of all living organisms. The process of ageing is
complex and multidimensional, involving significant loss and
decline in some physiological functions and minimal change in
others. Scientists have long attempted to find the causes for this
process. A theme of some theories is that ageing is a process that is
programmed into the genetic structure of each species. Others
theories state that ageing represents an accumulation of stimuli
from the environment that produce stress on the organism. Any
theory of ageing must be based on the scientific method, using
systematic tests of hypotheses and empirical observations (Nancy,
R. Hooyman).27

Successful ageing means a positive approach to ageing.

“Successful ageing refer to modification of behavioral diet exercise

26 Nancy, R. Hooyman and Asuman Kiyak. (2005) Social Gerontology A

Multidisciplinary Perspective, New York: p. 69-70.
27 Nancy, R. Hooyman and Asuman Kiyak. (2005) Social Gerontology A
Multidisciplinary Perspective, New York.
 64

and attaining/retaining autonomy and social support. This concept

provides an access to achieve the best possible outcomes of ageing”
(Krishna Kumari, 2005).28

The successful ageing is thus an active process in which an

individual has to make choices to age in a healthy manner. For
successful ageing such factors as diets, exercise, life style, social
support and maintenance of personal autonomy need to be
accepted as part of the philosophy of health promotion in old age.
The ageing population needs to be encouraged to adopt healthy life
style and a congenial environment to live long and have quality in
life. The study of ageing process and its effect on older person is
known as gerontology. The study approaches can be cross-sectional
or longitudinal or both (Krishna Kumari, 2005). 29

The various changes that occur in the natural process of

ageing are classified as physical, mental and psychological,
sociological and spiritual. Physical changes are usually noted first.
These include degeneration of bone tissues and muscle tissues
which result in changed body structure and posture, weakening of
muscles, graying of hair, loss of teeth retraction of gums and
difficulties in mobility. There is a weakness in the circulatory and
cardiac efficiency, slowing of digestive process, alteration in the
functions of endocrine system, decrease in the size of kidneys a
marked reduction in reduced lung capacity etc. which let loose
numerous problems to the ageing individual.

2.2.3 Psychological Aspects of Ageing

The major psychological factors found related to old age are
disrespect, death of dear ones, stained in-house relations,

28 Krishna Kumari Gulani,K. (2005) Community Health Nursing Principles and

Practices, Kumar Publishing House, New Delhi
29 Krishna Kumari Gulani, K. (2005) Community Health Nursing Principles
and Practices, Kumar Publishing House, New Delhi
 65

disappointment, mental tension, loneliness and lack of freedom.

Senility, dementia, sexual problems and emotional disorders arise
due to hormonal changes. Reduction in income and change in
social status due to retirement and lack of employment also affect
the aged (Pappathi, 2007).30 Hussain analysed the psycho-social
problems of the rural aged in India. Psychological changes of
normal ageing include loss of self-esteem, acceptance of physical
changes, coping with personal loss, slower process of information
and possible depressions. Mental changes include gradual mental
dysfunction due to gradual decline in intelligence, memory, sensory
changes resulting in inaccurate communication, disruption of sleep,
etc. The psychosocial changes occurring in old age cannot be
separated from physical changes. Because of decreased activity of
sensory organs, a person is not able to work with full efficiency in
his environment. Due to this, psychosocial state is affected. The
person feels a sense of ‘uselessness’. Social and psychological
changes of old age are as follows: Because of the experiences and
happenings of life, a person’s personality is affected. However, in old
age no remarkable changes occur in the basic personality structure.

Changes may occur in the personality due to the death of the

life partner, loss of self-dependence, loss of source of income,
incapacity, etc. Memory power may decrease with increases in age.
Recalling of less frequently used information is difficult. In some old
people, the tendency to repeat facts and information increases and
a confused memory may manifest in disconnected utterances. If the
old person is not sick, usually his intelligence is not affected. Old
age does not make a person more intelligent, or less intelligent; yet
because of the increase in knowledge and experiences, the person’s
status of intelligence becomes more fertile.

30 Pappathi, K. (2007) Ageing: Scientific Perspective and Social Issues, A.P.H.

publishing corporation. NewDelhi. p.10
 66

2.2.4 Spiritual Aspects of Ageing

The spiritual changes are both internal and external. The

religious attitude and feelings tend to increase. While attendance in
religious services tends to decrease with increasing age for reasons
such as functional disabilities, lack of company, shortage of funds
and related means and facilities, etc. All these changes may cause
feelings of rejection, hopelessness, depression, powerlessness,
loneliness, anxiety and insecurity.

Some believe modern medicines and artificial limbs can help

senior citizen cope with ageing. But in the Indian context, ageing is
not just about adding years. And while Indians do not consider
death as the end of the chapter, it is spirituality that is the answer
for most of us. We have a right to live life with dignity and
spirituality does show a way said Gokhale (Anuradha Mascarenhas,
2012).31

A sense of psychological loss decreases vitality and increases

vulnerability to psychophysical problems. Most of the elder people
fears these changes, as they grow older, whereas they are not afraid
of death many are fully satisfied with their life, lived fully, and are
thus ready for the ultimate experience of life. Often they are willing
to die. This does not imply that they are depressed. Similarly, some
of the old people may be tired of life because of the impact of bitter
experiences in their life. They are fed up with life and express their
desire to die, for which they are ready (Krishna Kumari, 2005).32

Self-concept can be enhanced in older persons by

communicating respect and demonstrating caring behaviours,
reinforcing health-promoting behaviours, encouraging activities of
31 Anuradha Mascarenhas, (2012), Spirituality to assist healthy ageing, April,
7 WHO New Delhi.
32 Krishna Kumari Gulani, K. (2005) Community Health Nursing Principles
and Practices, Kumar Publishing House, New Delhi
 67

daily living that contribute to independence, and by avoiding a

focus on self-care deficits.

The level of self-care practice among the elderly is high.

Universal self-care requisite scores are high in the areas of
maintenance of sufficient intake of air, water and food, the
provision of care associated with eliminative process and
excrements, the prevention of hazards to human life, human
functioning and human well-being and the promotion of normalcy.
The score are moderate in the maintenance of a balance between,
going for walks and caring for children - 20% each.

Senility is greater in people who are introverts than in those

who lead a normal life. Loneliness can lead to depression. One
should be involved in indoor games, social activities and reading.
Developing an attitude of “thinking outside oneself” is what an
elderly person should aim at. According to researchers, people who
participate in cultural activities are more likely to live longer
because they follow a more leisurely, low risk life style.

(Vijaya Kumar 1991) conducted a study on the family and the

health of the aged. For this study, 200 aged respondents (60+years)
with gastro intestinal, heart and circulation and muscular skeletal
disorders. The samples were randomly selected, 491 community
dwelling older adults were selected. In the area of psychological
health, women tended to show greater anxiety than men did.
Gender differences in self-assessed health, body awareness of
health problems or symptoms were. Men reported greater body
awareness than women. Men were found to fatal illness such as
strokes and heart attacks. Women regarded higher rates of
depression than men, but men showed more personality and
 68

substance misuse disorders than women.33 The goal of health care

reform for the elderly must be to evolve a service delivery system
test ensuring a comprehensive, continuous care for the older adults
in diverse setting (Clare Callins, 1997).34

Preventive health care services should play a significant role

in the program. The two most important means of promoting health
and preventing chronic diseases in the elderly are health education
and regular health check up (The Hindu, 1998).35

(Pankajam, 2004) was also of the opinion that surface signs of

ageing are obvious in their appearance. The skin wrinkles, hair
loses color, muscle strength diminishes, the shoulders become
stooped and a reduction in height characterized the elderly persons.
As regard to physical health and mental activity, as Pankajam said
that persons over 60 might lose 50 percent of their power, which
forces them to lose interest in personal life and family
responsibility.36

2.3.0 National Policy on Older Persons (NPOP) 1999.

National Policy on Older Persons (NPOP) 1999.37 was announced

by the Government of India in the year 1999. It was a step in the
right direction in pursuance of the UN General Assembly Resolution
47/5 to observe 1999 as International Year of Older Persons and in
keeping with the assurances to older persons contained in the
Constitution. The well-being of senior citizens is mandated in the

33 Vijayakumar, S.(1991) Ageing in India: An Anthropological Outlook. Help

Age India-Research and Development journal.
34 Clare. (1997) Cognitive Rehabilitation and Cognitive Training for early stage
Alzheimer’s Disease and Vascular Dementia.
35 The Hindu Magazine, Adding Life to Years, October 18, 1998
36 Pankajam, G. (2004) Are We Aged Friendly. Social Welfare.
37 Satyendra Prakash, (25-27 July 2007) Seminar on the Social, Health and
Economic Consequences of Population Ageing in the Context of Changing
Families, Policies and programmes on population ageing: Indian
perspective.
 69

Constitution of India under Article 41. “The state shall, within the
limits of its economic capacity and development, make effective
provision for securing the right to public assistance in cases of old
age”. The Right to Equality is guaranteed by the Constitution as a
fundamental right. Social security is the concurrent responsibility
of the central and state Governments.

Subsequent international efforts made an impact on the

implementation of the National Policy on Older Persons. The Madrid
Plan of Action and the United Nations Principles for Senior Citizens
adopted by the UN General Assembly in 2002, the Proclamation on
Ageing and the global targets on ageing for the Year 2001 adopted
by the General Assembly in 1992, the Shanghai Plan of Action 2002
and the Macau Outcome document 2007 adopted by UNESCAP
form the basis for the global policy guidelines to encourage
Governments to design and implement their own policies from time
to time. The Government of India is a signatory to all these
documents demonstrating its commitment to address the concerns
of the elderly.

The policy and plans were put in place by Central and State
Governments for the welfare of older persons. The State
Governments issued their policies and programmes for the welfare
of older persons. While some States and Union Territories
implemented their policies with vigour, most States, particularly the
big ones were behind perhaps due to financial and operational
deficiencies.

Pensions, travel concessions, income tax relief, medical

benefit, extra interest on savings, security of older persons through
an integrated scheme of the Ministry of Social Justice and
Empowerment as well as financial support was provided for Homes,
Day Care Centres, Medical Vans, Help Lines etc are extended
 70

currently. The Ministry of Social Justice and Empowerment

coordinates programmes to be undertaken by other Ministries in
their relevant areas of support to older persons. The Ministry of
Social Justice and Empowerment piloted landmark legislation the

Maintenance and Welfare of Parents and Senior Citizens‟ Act 2007

which is being promulgated by the States and Union Territories in
stages.

The Government of India announced the National Policy on

Older Persons in 1999 to reaffirm its commitment to ensure the
well-being of the older persons in a holistic manner. Reiterating the
mandate enshrined in Article 41 of the Constitution of India, the
Policy placed the concern for older persons on top of the National
Agenda. The NPOP while promising to safeguard their interest in
terms of financial security, health, legal, social and psychological
security, also envisages a productive partnership with them in the
process of development by creating opportunities for their gainful
engagement and employment. The Policy also appreciates the
special needs of older persons and therefore lays emphasis on
empowerment of the community as well as individuals to
adequately meet the challenges of the process of ageing.

The NPOP broadly provides for the following to fulfill these

objectives: Financial security through coverage under Old Age
Pension Scheme for poor and destitute older persons, better returns
on earnings/ savings of Government/Quasi-Government employees’
savings in Provident Fund, etc., creating opportunities for
continued education/skill up-gradation ensuring thereby continued
employment/self-employment and income generation and provision
for Pension Scheme for self-employed, employees of the non-formal,
and non-Governmental sector.
 71

Health Security: The NPOP recognizes the special health

needs of the older persons to be met through strengthening and
reorienting the public health services at Primary Health Care level,
creation of health facilities through non-profit organization like
trust/charity, etc., and implementing health insurance.

Recognizing Shelter as the basic human need, the NPOP

provides for earmarking 10 percent of the houses/housing sites in
urban as well as rural areas for older persons belonging to the lower
income groups, special consideration to the older persons falling in
the category of Below Poverty Line (BPL) and destitute in housing
schemes like Indira Awas Yojana, loans at reasonable interest rates
and easy repayment installments with tax relief for purchase of
houses etc.

Education/information needs of older persons too have been

adequately reflected in the National Policy. Education/information
material relevant to the lives of older persons should be developed
and made available through mass media. Education, training and
information being the important human requirement, the NPOP
provides for proactive role in ensuring the same by disseminating
knowledge about preparation of Old Age. It is also emphasized for
schools to have programme on inter-generational bonding.

Welfare and Institutional Care: Institutional Care has been

provided for in the NPOP as the last resort. The care in a non-
institutional set up i.e. within family and the community needs to
be strengthened and encouraged. This apart, the State should also
create infrastructure in partnership with voluntary organizations to
provide for poor, destitute and neglected older persons whose care
cannot be ensured within the family. This is to be ensured through
Old Age Homes and other such institutional facilities that would be
needed. Voluntary efforts needs to be encouraged for creating
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facilities for day care, outreach services, multi-service citizen

centers, etc.

Protection of Life and Property of Older Persons: The State is

made bound to gear up the security network to save older persons
from criminal offences and the police is required to keep friendly
vigil. Early settlement of property/inheritance disputes is to be
done, safeguards to protect them from fraudulent dealings in
transfer of property through sale/’Will’ are to be put in place and
free legal aid and toll free helpline services are to be placed across
the country. Maintenance of elderly within family resorting to the
provisions of law viz. Criminal Procedure Code, (Cr.P.C.) 1973,
Hindu Adoption and Maintenance Act. (HAMA) 1956 etc., whenever
needed is required to be ensured.

Training of Human Resource to care for Older Persons: The

Policy lays emphasis on the need for trained personnel/care givers.
This envisages the training of human resource in the areas like
specialization in Geriatrics in medical courses, special courses on
Geriatric Care in nursing training, training of social workers
especially for geriatric care and professional caregivers.

Media: The Policy enjoins the media to take up a special

responsibility for the care of older persons. Media is to play a role in
identifying emerging issues and areas of action, dispelling stereo-
types and negative images about the old age, maintaining restraint
from creating fear psychosis by responsible reporting, promoting
intergenerational bonds and informing individuals/families/groups
with appropriate information on ageing process.

2.3.1 Available Support Services

National Social Assistance Programme (NSAP) The National

Social Assistance Programme came into effect on 15th August,
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1995. NSAP is a social assistance programme for the poor

households and represents a significant step towards the fulfillment
of the Directive Principles enshrined in Article 41 and 42 of the
Constitution of India, recognizing the concurrent responsibility of
the Central and State Governments in the matter.

2.3.2 The National Old Age Pension Scheme (NOAPS)

The Scheme covers older persons/destitutes having little or

no regular means of subsistence from his/her own source of income
or through financial support from family members or other sources.
The age of applicant must be 65 years or above. At present 50% of
the older persons under Below Poverty Line (BPL) destitutes are
covered under NOAPS. The Central Government contributes
Rs.200/- per month per beneficiary. The State (Provincial)
Governments are advised to add matching amount or more as their
contribution in the federal set-up. During the Tenth Five Year Plan
(2002 – 07), 110,793,860 elderly people were covered and US $
1002.20 million (approximately) was incurred on this count.

2.3.3 Annapurna Scheme

Annapurna Scheme covers all the other elderly below poverty

line, who are not covered under the NOAPS. A provision of 10 k.gs.
of rice or wheat is provided to the needy elderly. Under this scheme
US $ 56 million was expensed and 43, 03,491 elderly were covered
in the Tenth plan (2002-07)

2.3.4 Concessions/Tax Rebate/Other Incentives

Presently persons of 60 years and above are entitled to 30%

concessions in train fare in all the classes. There are airlines
providing 45% to 50% concession in air journey to senior citizens.

Older persons who are above 65 years of age also enjoy

income tax rebate up to 15,000 of actual tax with provision for
 74

deduction of Rs.20,000 spent on account of medical insurance

premium and Rs.40,000 spent on account of medical treatment,
from taxable income. Senior citizens are exempted from Income Tax
up to 1.95 lakh as per the union Annual Budget, 2007.Banks are
providing 0.5% - 1% additional interest to older persons of 65 years
and above, on fixed deposits. The public facilities for the elderly,
initiated by the Government, include reservation of seats for the
elderly in the public transport, railways and airways.

2.3.5 Insurance Coverage

Some of the public sector insurance companies provide life

insurance coverage up to 75 years of age and many private
insurance companies have 55 years as the last entry age. The
Insurance Policy Schemes announced for older persons include
Jeevan Dhara (18-65 years), Jeevan Akshay (30-75 years), Jeevan
Suraksha (25-60 years), Senior Citizen Unit Plan (18-54 years). In
addition, Health Insurance Schemes covering Mediclaim Policy and
other individual and Group Mediclaim Policies are also offered by
Nationalized as well as private insurance companies. The
Government is taking steps to enforce a uniform policy on all
Insurance Companies as regards entry age of Senior Citizens.

The Government has launched a Reverse Mortgage System for

senior citizens to extract value out of their property and lead a
hassle free life by securing a regular income as loan against their
existing property.

2.3.6 Integrated Programmers for Older Persons

Ministry of Social Justice & Empowerment, Government of

India, is implementing an Integrated Programme for Older Persons
with an aim to empower and improve the quality of life of older
persons. The basic thrust of the programme is on older persons of
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60 years and above, particularly the infirm, destitute and widows.

Under the scheme, financial assistance is provided to Non-
Governmental Organizations, Autonomous Bodies, Educational
Institutions, Cooperative Societies, etc., up to 90 per cent of the
project cost for the setting up and maintenance of Day Care
Centers, Mobile medi-care Units, Old Age Homes and Non-
Institutional Service Centers. During the Tenth Five Year plan,
Ministry provided financial assistance to voluntary organizations to
the tune of US $ 18.6 million.

2.3.7 Construction of Old Age Homes

The scheme for Assistance to construction of Old Age Homes

provides one time grant to Local Bodies, NGOs etc. for construction
of Old Age Homes or Multi-Service Centers for older persons. The
Ministry also incurred an expenditure of US $ 70,000 for
construction of Old Age Homes during the Tenth Five-year Plan.
Growing old is also marked by failing health and advancing age may
bring with it innumerable health complications. Restricted physical
mobility, coupled with crippled health, makes it difficult for older
persons to have access to the health facilities if they do not enjoy
the support of the family or have a care institution within their easy
access. Realizing the real situation wherein the older persons live,
Para 36 of the National Policy envisages covering of health
insurance and financial security towards essential medical care and
affordable treatment process. Some of the initiatives by the
Government provide for a separate counters/O.P.D. in hospitals
and free medical services in Central Government Health Scheme,
Government Hospitals to facilitate easy accessibility to the elderly
including Geriatric Units in the Hospitals.
 76

2.3.8 Care of Alzheimer’s Disease and other Forms of Dementia

Dementia due to Alzheimer’s disease and other causes is one
of the most serious degenerative diseases that affect the older
persons. The loss of memory with advancing age is a common
phenomenon. However, dementia, which is a progressive disease of
the brain, affects the memory, intellect and personality. Of all the
categories of the dementia, Alzheimer’s disease is the commonest
and the severest.

Many of the Government and public hospitals have started

Memory Clinics, Mental Health Programmes to facilitate proper
diagnosis of Dementia to achieve the slowing down in the process
and for preparing the care-givers and the family to manage
Alzheimer’s and Dementia Care. The National Institute of Social
Defense under the Ministry of Social Justice & Empowerment has
initiated training of care-givers and functionaries as a special
initiative apart of the centenary observances of Alzheimer’s.
Covering all the districts to ensure that facility to accommodate 150
needy elderly in each of them.

Helpline Services for Older Persons: The State Governments.

and Office of the Commissioner of Police in collaboration with NGOs
have initiated special protective measures for safeguarding the
elderly and one such innovative approach is “Helpline Services” in
some big cities.

Training & Human Resource Development for Home Care In

the changing family context, role of professionally trained home
carers have become very crucial. Therefore, preparing a frontline
cadre of care-givers to ensure quality care at home as well as in the
institutions is one of the important strategies. In the wake of
disintegration of Joint Family System, it is ensured that
professionally trained carers are available to meet the demand. In
 77

order to meet this objective, Ministry of Social Justice and

Empowerment launched the Project ‘NICE’ (National Initiative on
Care for Elderly) through National Institute of Social Defense (NISD)
an autonomous body of the Ministry of Social Justice and
Empowerment in 2000. The NISD organizes one year P.G. Diploma
Course and Six Month Certificate Courses under Project NICE to
meet the demand for care-givers. In addition, Short Terms Courses
varying from 5 days to One Month are also organized for skill up
gradation of Service Providers working in Old Age Homes, etc. In the
X Five year plan, NISD has so far organized 85 training programmes
and 2535 care-givers and service providers have been trained.

A general plan of action for the elderly persons has to take

into account (a) the rapid demographic changes taking place in the
country in favor of the increasing number (1901:1.2 crore/1951:3.2
crore/ 2001: 6.6 crore/2025: 14.6 crore) and proportion of persons
above the age of 60, (b) declining labor-participation rates of elderly
in economy, (c) increasing financial strains on account of early
retirement trends, slow economic growth, spiraling medical costs
and inflation, (d) a slow, but, marked withdrawal of family support
due to weakening of joint family ties and migration of children to
cities and developed regions, and (e) the special biological, social
and emotional needs associated with the old age.

Policy formulation concerning the aged persons should also

draw on developments in the international field, beginning with the
World Assembly on Ageing (1982), the Vienna International Plan of
Action (1982) and its two subsequent reviews in 1985 and 1989, the
United Nations Principles for Older Persons (1991) and finally the
Global Targets on Ageing for the Decade 1991-2001 adopted by the
U.N. General Assembly (1992). As an instrument of Government
policy, the plan of action for the aged persons has to take into
 78

consideration the broad constraints of resources of developing

country and the limited income-base of the taxpayers/persons
paying insurance premium. It is also required to take cognizance of
the fact that, unlike the developed countries, aged population in
India has a high proportion of destitute elderly living primarily in
rural areas and working in the unorganized sector of economy
without any reasonable prospect of pension of job security. It can,
however, draw its strength from the strong family ties and the
overall respect the aged persons still command in Indian society as
a reservoir of socially useful talent and experience. It can also build
up a framework based on the promise shown by the voluntary
organizations in providing health, shelter and daycare services to
the aged persons. It can improve upon the initiatives taken by the
State Governments and Union Territories in introducing old age
pension scheme for the destitute elderly.

2.3.9 The Objectives of the Old Age Policy may be

Summarized as follows:
1) Providing increasing employment options and evolving
mechanisms for assisting elder persons seeking work
after retirement.

2) Providing (a) family support, (b) mutual benefit societies,

(c) income security through personal savings policies, (d)
social insurance, (e) occupational pensions, (f) provident
funds, and (g) public and private social assistance.

3) Social and economic support to the old age persons living

without families (on account of childlessness, death of
spouses, migration of children, destitution, etc.).

4) Re-evaluating healthcare priorities and providing

access to health services, 5) Reorienting housing and
area planning to suit the special needs of the elderly.
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A review of current approaches and programmes reveals the

status of the existing legal, economic, policy framework, and the
areas requiring special attention.

2.3.10 Legislative Framework

Article 41 of the Constitution recognizes the needs of the

elderly and enjoins upon the state the responsibility of making
effective provision for public assistance in case of unemployment,
old age, sickness and disablement and in other cases of undeserved
want. While the welfare of the aged is a state subject, the nodal
responsibility of the Centre is assigned to the Ministry of Welfare.
Under the section 20(1) of the Hindu Adoption and Maintenance
Act, 1956, an aged and infirm parent, if unable to maintain him or
herself, is entitled to maintenance. Muslim law also imposes an
obligation to support needy parents, subject to certain conditions.
Independent of the personal Law, the Code of Criminal Procedure
1973 (section 125(1) (d)) makes it incumbent upon a person, having
sufficient means to maintain his father or mother, who is unable to
maintain himself or herself and on getting proof of neglect or
refusal, a first class magistrate may order such a person to make a
monthly allowance, not exceeding Rs. 500.

2.3.11 Social Security Acts

(a) The Workmen’s Compensation Act, 1923.

(b) The Employee’s State Insurance Act, 1948.

(c) The Employees’ Provident Funds and Miscellaneous.

Provisions Act, 1952.

(d) The Maternity Benefit Act, 1961.

(e) The payment of gratuity Act, 1972.

(f) The Pensions Act, 1871.

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2.3.12 Tax Concessions to Elderly Persons Under

(a) Income Tax (Amendment Acts), and
(b) Finance Acts passed each year in favor of
(i) Pensioners (reduction allowed on pension) and
(ii) Taxpayers (below the age of 70 years on health
insurance).

2.3.13 Old Age Pension Scheme for the Destitute Elderly

All the State Governments and Union Territories are

currently implementing old age pension schemes to the destitute/
poor elderly. There are schemes, drawn up for the purpose by each
State/Union Territory according to their financial resources though
they are under statutory obligation to do so. These benefits cannot
be claimed as a matter of right. The first old age pension scheme
was started in U.P, in 1957. Rate of pension, eligibility criteria,
domicile conditions and coverage vary from State to State. The
quantum of pension ranges from Rs. 50 to Rs. 100 per month. In
Tamil Nadu, old age pensioners are eligible for free meals at the
nutrition meal programme centers. In 1987-8, Rs. 227 crore were
spent by the States/Union Territories to give pension to 49 lakh
beneficiaries. Another scheme in the State Sector which is catering
to the needs of a large number of destitute aged is that of homes for
the aged. Some States provide grant to voluntary organizations for
maintenance of the aged in these homes. In some places the old age
pension due to the inmates is paid to the voluntary organizations
for the upkeep of the aged. Besides, there are homes run by
Voluntary organizations without Government assistance. Since
1983-84, the Ministry of Welfare is providing general grant-in-aid
for assistance to voluntary organizations in the field of social
welfare for (i) rendering welfare services to the aged and (ii) for
constructing homes for the aged. A scheme called the Welfare of the
 81

Aged has been launched under the Eighth Five Year Plan (1992-97),
marking the entry of the aged in Indian planning.

2.3.14 Welfare of the Aged (Under the Eighth Five Year Plan)

The scheme aims at encouraging voluntary organizations/

organizations of the elderly to provide old age homes, day care
centers, Medicare and non-institutional services for the aged by
assisting through grant-in-aid. Under the Old Age Home
Programme, assistance is available for both maintenance and
construction of such homes. Old age homes are expected to be
residential units of the aged persons of 60 years and above. Old age
homes are expected to take care of the physical and psychological
well-being of their inmates with the help of trained social workers/
counselors and medical staff. Assistance for the building
construction/ extension of old age homes is also available under the
programme in the form of grant for construction.

In addition to the old age homes, the scheme aims at

providing assistance to voluntary organizations for setting up day
care centers for the aged. A day care centre should at least have
150 aged persons in its list so that even after dropouts and
absenteeism, its daily attendance does not fall below 50. Day care
centers should aim at gainful utilization of the spare time of the
elderly, living in the neighborhood and should appoint a part-time
qualified physician each for medical check-up and a full-time
trained social worker. A day care centre is required to establish
links with the medical, welfare and local institutions and services
available in the area. Under the Mobile Medicare Service
Programme of the scheme, grants are available to voluntary
organizations possessing experience and expertise in Medicare
services to the aged. Likewise, programmes can also be taken as
under the scheme for setting up or maintaining a foster care unit
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of 25 aged persons. National Housing Policy has given due

recognition to the special needs of the aged and the handicapped
and has recommended construction of dwelling units with designs
formulated to meet the specialized requirements of these
categories. A large number of housing finance schemes has been
formulated to subsidies the cost of housing for the priority groups.
Government employees are encouraged to avail of house building
loans at concessional rates during their service career.

2.3.15 Health Care System

Providing a minimum package of primary health and

medical services through the expansion of health care
infrastructure has been our country’s first priority. Being an
integral part of the overall population, the aged in rural, tribal and
urban slum areas have been benefited by the expansion of health
care infrastructure. In addition to these activities, voluntary
organizations are being assisted to run special programmes for the
health of the aged. Health insurance schemes such as Bhavishya
Arogya and Med claim (by the General Insurance Corporation of
India) also exist. The Central Government Health Scheme facilities
are now available to the retired Central Government pensioners.

2.3.16 Travel Concessions and Facilities

The Indian Railways provide 20 per cent concession in

second-class railway fare to every person, aged 65 years and above
for travel beyond 500 km. Free wheel-chairs are provided at all
important and ‘junction’ stations to the aged and priority is given
in the allotment of lower berths to passengers above 60 years of
age. At large computerized reservation offices, a separate
reservation counter is earmarked for the aged and handicapped
persons. Some State Transport Corporations have provided for
seat reservation in their buses for the aged persons. In most state
 83

transport buses, entry for the aged is allowed from the exit door.
Karnataka State Road Transport Corporation gives 50 per cent
travel concession to the citizens aged over 60 years in city/ sub-
urban services during restricted hours. The Inter Ministerial
Committee, set-up to formulate policy for the aged welfare was set-
up by the Government under the Chairmanship of a Secretary
(Welfare) with the representatives from the Ministry of Labour,
Department of Pensions, Ministry of Urban Development, Ministry
of Rural Development, Ministry of Human Resource Development,
Health Directorate, Department of Economic Affairs, Railway
Board and Planning Commission.

The terms of reference of this committee were: To examine

the recommendations of the Round Table discussions for the care
of the elderly, sponsored by the Indian Council of Medical
Research and other medical and family planning bodies and
suggest ways and means of implementing them. To consider the
draft national policy on care of the elderly suggested by the Round
Table discussions and suggest a policy frame for adoption. To
suggest programmes for the care and protection of the elderly in
keeping with the changing socio-economic conditions as for
utilization of their services and experiences with a view to
supplement the income as also channelize their energies in
community support activities. (Park, 2010).

2.4.0 National Policy on Senior Citizens 2011

National Policy on Senior Citizens 201138: the large increase in

human life expectancy over the years has resulted not only in a
very substantial increase in the number of older persons but in a
major shift in the age groups of 80 and above. The demographic
profile depicts that in the years 2000-2050, the overall population

38 National Health Policy for Senior Citizens, 2011.

 84

in India will grow by 55% whereas population of people in their 60

years and above will increase by 326% and those in the age group
of 80+ by 700% - the fastest growing group (see table and graph).

Years Total Population (millions) 60+ (millions) 80+ (millions)

2000 1008 76 6

2050 1572 324 48

Problems in any of these areas have an impact on the quality

of life in old age and healthcare when it is needed. Increase in life
span also results in chronic functional disabilities creating a need
for assistance required by the Oldest Old to manage simple chores.
This policy looks at the increasing longevity of people and lack of
care giving.

Elderly Women Need Special Attention

Women and men age differently. Both have their concerns.

The problems of elderly women are exacerbated by a lifetime of
gender based discrimination, often stemming from deep-rooted
 85

cultural and social bias. It is compounded by other forms of

discrimination based on class, caste, disability, illiteracy,
unemployment and marital status. Patriarchal hierarchy and access
to property rights are also discriminatory. Burdened with household
chores for a longer span of time compared to older men, older
women don’t have time for leisure or recreational activity. Women
experience proportionately higher rates of chronic illness and
disability in later life than men. Women suffer greater non-
communicable diseases and experience lower social and mental
health status, especially if they are single and/or widowed. Over
50% of women over age 80 are widows.

Elderly women and their problems need special attention as

their numbers are likely to increase in the future and, given the
multiple disadvantages they face in life, they are likely to be grossly
unprepared to tackle these issues.

Rural Poor Need Special Attention

Many households in rural areas at the bottom of the income

distribution in India are too poor to save for their old age. Available
resources are used to meet daily consumption needs. Even at
slightly higher income levels there is likely to be little demand for
savings and pension instruments that require a commitment of
several decades. Instead, the savings of households in the lower
deciles of the income distribution are likely to be earmarked for self-
insurance against emergencies; or perhaps, in short term
investments that increase their own productivity or the productivity
of their children. Liquidity is highly valued. The absolute poor in
India cannot be expected to participate in long term savings
schemes for old age and they do not. The poverty in rural areas for
older persons is increasing and needs attention. Hence rural poor
would need social security in large measure.
 86

Increasing Advancement in Technology

There have been several advancements in medical technology,

medicine and in technology for assistive living (and technology) for
elderly that have prolonged life for senior citizens and this needs to
be factored in the policy that not only for the eighty plus but rural
poor, women and disadvantaged seniors will have longer years and
will need many of the policy interventions.

Policy Objectives

The foundation of the new policy, known as the “National

Policy for Senior Citizens 2011” is based on several factors. These
include the demographic explosion among the elderly, the changing
economy and social milieu, advancement in medical research,
science and technology and high levels of destitution among the
elderly rural poor (51 million elderly live below the poverty line). A
higher proportion of elderly women than men experience loneliness
and are dependent on children. Social deprivations and exclusion,
privatization of health services and changing pattern of morbidity
affect the elderly. All those of 60 years and above are senior
citizens. This policy addresses issues concerning senior citizens

living in urban and rural areas, special needs of the „oldest old‟ and
older women.

In principle the policy values an age integrated society. It will

endeavour to strengthen integration between generations, facilitate
interaction between the old and the young as well as strengthen
bonds between different age groups. It believes in the development
of a formal and informal social support system, so that the capacity
of the family to take care of senior citizens is strengthened and they
continue to live in the family. The policy seeks to reach out in
particular to the bulk of senior citizens living in rural areas who are
 87

dependent on family bonds and intergenerational understanding

and support.

2.4.1 The Focus of the New Policy:

1. Mainstream senior citizens, especially older women, and

bring their concerns into the national development debate
with priority to implement mechanisms already set by
Governments and supported by civil society and senior
citizens associations. Support promotion and establishment
of senior citizens associations, especially amongst women.
2. Promote the concept of „Ageing in Place or ageing in own
home, housing, income security and homecare services, old
age pension and access to healthcare insurance schemes and
other programmes and services to facilitate and sustain
dignity in old age. The thrust of the policy would be
preventive rather than cure.
3. The policy will consider institutional care as the last resort. It
recognises that care of senior citizens has to remain vested in
the family which would partner the community, Government
and the private sector.
4. Being a signatory to the Madrid Plan of Action and Barrier
Free Framework it will work towards an inclusive, barrier-free
and age-friendly society.
5. Recognise that senior citizens are a valuable resource for the
country and create an environment that provides them with
equal opportunities, protects their rights and enables their
full participation in society. Towards achievement of this
directive, the policy visualises that the states will extend their
support for senior citizens living below the poverty line in
urban and rural areas and ensure their social security,
healthcare, shelter and welfare. It will protect them from
abuse and exploitation so that the quality of their lives
improves.
6. Long term savings instruments and credit activities will be
promoted to reach both rural and urban areas. It will be
necessary for the contributors to feel assured that the
 88

payments at the end of the stipulated period are attractive

enough to take care of the likely erosion in purchasing power.
7. Employment in income generating activities after
superannuation will be encouraged.
8. Support and assist organisations that provide counselling,
career guidance and training services.
9. States will be advised to implement the Maintenance and
Welfare of Parents and Senior Citizens Act, 2007 and set up
Tribunals so that elderly parents unable to maintain
themselves are not abandoned and neglected.
10. States will set up homes with assisted living facilities for
abandoned senior citizens in every district of the country and
there will be adequate budgetary support.

Areas of Intervention

The concerned ministries at central and state level as

mentioned in the Implementation Section would implement the
policy and take necessary steps for senior citizens as under:

I. Income Security in Old Age

A major intervention required in old age relates to financial

insecurity as more than two third of the elderly live below the
poverty line. It would increase with age uniformly across the
country.

1. Indira Gandhi National Old Age Pension Scheme

Old age pension scheme would cover all senior citizens

living below the poverty line.

Rate of monthly pension would be raised to Rs.1000 per
month per person and revised at intervals to prevent its
deflation due to higher cost of purchasing.

The oldest old would be covered under Indira Gandhi
National Old Age Pension Scheme (IGNOAPS). They
would be provided additional pension in case of
 89

disability, loss of adult children and concomitant

responsibility for grand children and women. This would
be reviewed every five years.

2. Public Distribution System

The public distribution system would reach out to cover
all senior citizens living below the poverty line.
3. Income Tax

Taxation policies would reflect sensitivity to the financial
problems of senior citizens which accelerate due to very
high costs of medical and nursing care, transportation
and support services needed at homes.
4. Microfinance

Loans at reasonable rates of Interest would be offered to
senior citizens to start small businesses. Microfinance for
senior citizens would be supported through suitable
guidelines issued by the Reserve Bank of India.
II. Healthcare

With advancing age, senior citizens have to cope with health

and associated problems some of which may be chronic, of a
multiple nature, require constant attention and carry the risk of
disability and consequent loss of autonomy. Some health problems,
especially when accompanied by impaired functional capacity
require long term management of illness and nursing care.

Healthcare needs of senior citizens will be given high

priority. The goal would be good, affordable health
service, heavily subsidized for the poor and a graded
system of user charges for others. It would have a
judicious mix of public health services, health insurance,
health services provided by not-for-profit organizations
including trusts and charities, and private medical care.
While the first of these will need to be promoted by the
State, the third category given some assistance,
concessions and relief and the fourth encouraged and
 90

subjected to some degree of regulation, preferably by an

association of providers of private care.

The basic structure of public healthcare would be

through primary healthcare. It would be strengthened
and oriented to meet the health needs of senior citizens.
Preventive, curative, restorative and rehabilitative
services will be expanded and strengthened and geriatric
care facilities provided at secondary and tertiary levels.
This will imply much larger public sector outlays, proper
distribution of services in rural and urban areas, and
much better health administration and delivery systems.
Geriatric services for all age groups above 60─
preventive, curative, rehabilitative healthcare will be
provided. The policy will strive to create a tiered national
level geriatric healthcare with focus on outpatient day
care, palliative care, rehabilitation care and respite care.

Twice in a year the PHC nurse or the ASHA will conduct

a special screening of the 80+ population of villages and
urban areas and public/private partnerships will be
worked out for geriatric and palliative healthcare in rural
areas recognizing the increase of non-communicable
diseases (NCD) in the country.

Efforts would be made to strengthen the family system so

that it continues to play the role of primary caregiver in
old age. This would be done by sensitizing younger
generations and by providing tax incentives for those
taking care of the older members.

Development of health insurance will be given priority to

cater to the needs of different income segments of the
population with provision for varying contributions and
benefits. Packages catering to the lower income groups
will be entitled to state subsidy. Concessions and relief
will be given to health insurance to enlarge the coverage
base and make it affordable. Universal application of
health insurance – RSBY (Rashtriya Swasthya Bima
Yojana) will be promoted in all districts and senior
 91

citizens will be compulsorily included in the coverage.

Specific policies will be worked out for healthcare
insurance of senior citizens.

From an early age citizens will be encouraged to

contribute to a Government created healthcare fund that
will help in meeting the increased expenses on
healthcare after retirement. It will also pay for the health
insurance premium in higher socio economic segments.

Special programmes will be developed to increase

awareness on mental health and for early detection and
care of those with dementia and Alzheimer’s disease.

Restoration of vision and eyesight of senior citizens will

be an integral part of the National Programme for Control
of Blindness (NPCB).

Use of science and technology such as web based

services and devices for the well being and safety of
senior citizens will be encouraged and expanded to
under-serviced areas.

National and regional institutes of ageing will be set up

to promote geriatric healthcare. Adequate budgetary
support will be provided to these institutes and a cadre
of geriatric healthcare specialists created including
professionally trained caregivers to provide care to the
elderly at affordable prices.

The current National Programme for Health Care of the

Elderly (NPHCE) being implemented in would be
expanded immediately and, in partnership with civil
society organizations, scaled up to all districts of the
country.

Public private partnership models will be developed

wherever possible to implement healthcare of the elderly.
 92

Services of mobile health clinics would be made available

through PHCs or a subsidy would be granted to NGOs
who offer such services.

Health Insurance cover would be provided to all senior

citizens through public funded schemes, especially those
over 80 years who do not pay income tax.

Hospices and palliative care of the terminally ill would be

provided in all district hospitals and the Indian protocol
on palliative care will be disseminated to all doctors and
medical professionals.

Recognize gender based attitudes towards health and

develop programmes for regular health checkups
especially for older women who tend to neglect their
problems.
III. Safety and Security

Provision would be made for stringent punishment for

abuse of the elderly.

Abuse of the elderly and crimes against senior citizens

especially widows and those living alone and disabled
would be tackled by community awareness and policing.

Police would be directed to keep a friendly vigil and

monitor programmes which will include a comprehensive
plan for security of senior citizens whether living alone or
as couples. They would also promote mechanisms for
interaction of the elderly with neighbourhood
associations and enrolment in special programmes in
urban and rural areas.

Protective services would be established and linked to

help lines, legal aid and other measures.
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IV. Housing National Policy on Senior Citizens 2011

Shelter is a basic human need. The stock of housing for

different income segments will be increased. Ten percent of housing
schemes for urban and rural lower income segments will be
earmarked for senior citizens. This will include the Indira Awas
Yojana and other schemes of the Government.

Age friendly, barrier-free access will be created in buses

and bus stations, railways and railway stations, airports
and bus transportation within the airports, banks,
hospitals, parks, places of worship, cinema halls,
shopping malls and other public places that senior
citizens and the disabled frequent.

Develop housing complexes for single older men and

women, and for those with need for specialized care in
cities, towns and rural areas.

Promote age friendly facilities and standards of universal

design by Bureau of Indian Standards.

Since a multi-purpose centre is a necessity for social

interaction of senior citizens, housing colonies would
reserve sites for establishing such centres. Segregation of
senior citizens in housing colonies would be discouraged
and their integration into the community supported.

Senior citizens will be given loans for purchase of houses

as well as for major repairs, with easy repayment
schedules.

V. Productive Ageing

The policy will promote measures to create avenues for

continuity in employment and/or post retirement
opportunities.
 94

Directorate of Employment would be created to enable

seniors find re- employment.

The age of retirement would be reviewed by the Ministry

due to increasing longevity.

VI. Welfare

A welfare fund for senior citizens will be set up by the

Government and revenue generated through a social
security cess. The revenue generated from this would be
allocated to the states in proportion to their share of
senior citizens. States may also create similar funds.

Non-institutional services by voluntary organizations will

be promoted and assisted to strengthen the capacity of
senior citizens and their families to deal with problems of
the ageing.

All senior citizens, especially widows, single women and

the oldest old would be eligible for all schemes of
Government. They would be provided universal identity
under the Adhaar scheme on priority.

Larger budgetary allocations would be earmarked to pay

attention to the special needs of rural and urban senior
citizens living below the poverty line.

VII. Multigenerational bonding

The policy would focus on promoting bonding of

generations and multigenerational support by
incorporating relevant educational material in school
curriculum and promoting value education. School

Value Education modules and text books promoting

family values of caring for parents would be promoted by
NCERT and State Educational Bodies.
 95

VIII. Media

Media has an important role to play in highlighting the

changing situation of senior citizens and in identifying
emerging issues and areas of action.

Involve mass media as well as informal and traditional

communication channels on ageing issues

Natural disasters/ emergencies

Provide equal access to food, shelter, medical care and

other services to senior citizens during and after natural
disasters and emergencies.

Enhance financial grants and other relief measures to

assist senior citizens to re-establish and reconstruct
their communities and rebuild their social fabric
following emergencies.
Implementation Mechanism

There will be efforts to provide an identity for senior citizens

across the country and the ADHAAR Unique identity number will be
offered to them so that implementation of assistance schemes of
Government of India and concessions can be offered to them. As
part of the policy implementation the Government will strive for:

I. Establishment of Department of Senior Citizens under the

Ministry of Social Justice and Empowerment

The Ministry of Social Justice and Empowerment will

establish a “Department of Senior Citizens” which will be the nodal
agency for implementing programmes and services for senior
citizens and the NPSC 2011. An inter-ministerial committee will
pursue matters relating to implementation of the national policy
and monitor its progress. Coordination will be by the nodal
 96

ministry. Each ministry will prepare action plans to implement

aspects that concern them and submit regular reviews.

II. Establishment of Directorates of Senior Citizens in states and

union territories

States and union territories will set up separate Directorates

of Senior Citizens for implementing programmes and services for
senior citizens and the NPSC 2011.

III. National/State Commission for Senior Citizens

A National Commission for Senior Citizens at the centre and

similar commissions at the state level will be constituted. The
Commissions would be set up under a National Policy on Senior
Citizens 2011.

Act of the Parliament with powers of Civil Courts to deal with

cases pertaining to violations of rights of senior citizens.

IV. Establishment of National Council for Senior Citizens

A National Council for Senior Citizens, headed by the Minister

for Social Justice and Empowerment will be constituted by the
Ministry. With tenure of five years, the Council will monitor the
implementation of the policy and advise the Government on
concerns of senior citizens. A similar body would be established in
every state with the concerned minister heading the State Council
for Senior Citizens. The Council would include representatives of
relevant central ministries, the Planning Commission and ten states
by rotation. Representatives of senior citizens associations from
every state and Union Territory. Representatives of NGOs,
academia, media and experts on ageing. The council would meet
once in six months.
 97

V. Responsibility for Implementation

The Ministries of Home Affairs, Health and Family Welfare,

Rural Development, Urban Development, Youth Affairs and Sports,
Railways, Science & Technology, Statistics and Programme
Implementation, Labour, Panchayati Raj and Departments of
Elementary Education and Literacy, Secondary & Higher Education,
Road Transport and Highways, Public Enterprises, Revenue,
Women and Child Development, Information Technology and
Personnel and Training will setup necessary mechanism for
implementation of the policy. A five-year perspective Plan and
annual plans setting targets and financial allocations will be
prepared by each Ministry/ Department. The annual report of these
Ministries Departments will indicate progress achieved during the
year. This will enable monitoring by the designated authority.

VI. Role of Block Development Offices, Panchayat Raj Institutions

and Tribal Councils/Gram Sabhas, Block Development offices
would appoint nodal officers to serve as a one point contact for
senior citizens to ease access to pensions and handle
documentation and physical presence requirements, especially by
the elderly women. Panchayat Raj Institutions would be directed to
implement the NPSC 2011 and address local issues and needs of
the ageing population. In rural/ tribal areas, the tribal council or
gram sabha or the relevant Panchayat Raj institution would be
responsible for implementation of the policy. The provisions of the
13th Finance Commission for special funding to them would be
made applicable.

2.5.0 Gandhian Concept of Family Systems

A mother who does not listen to her daughter’s complaints is

no mother, similarly a daughter who feels shy in opening her heart
to her mother, thinking that she is too busy to listen to her, is no
 98

true daughter. It is the vital role of all parents that they should
train their children for character formation and to serve the
country. They should be self-reliant. The aim and motto of the
children should be the welfare of all the people. The beauty of the
things lies in the fact that by serving the world, one does not cease
to serve one’s family is included in the service of the world.39

According to Gandhi, “I believe that whatever I have achieved

is due to my devotion to my parents who have been given the place
of a teacher and of God, who have been thought of as perfect
beings, so that to their offspring they are perfect.40

All parents should give, according to Gandhi, the prime

importance to develop the character formation of their children.
They should not give costly ornaments, clothes, and palatal food
and give money only for their needs. The family is the center of
human preparation for the social life, that is to say, all preparation
for responsibility, sympathy, self-control and mutual tolerance.

2.6.0 Scriptural Teachings Related to Old Age

Show respect for old people and honour them reverently obey
me, I am the Lord.41 Old men have wisdom and old men have
insight. green and strong.42

Long life is the reward of righteous: gray hair is a glorious

crown.43 Respect your father and your mother so that you may live
a long time on the land that I am giving you. 44 He was then almost

39 The collected works of Mahatma Gandhi, (1973), New Delhi: The

Publications divisions, The Government of India, 11:362.
40 op.cit.pp.373-374
41 Leviticus 19/32
42 Psalm 92/14
43 Proverb 16/31
44 Exodus 20/12
 99

one hundred years old: but his faith did not weaken.45 Is there any
one who is ill? He should send to the church elders, who will pray
for him and rub olive oil on him in the name of the Lord. Gray hair
is a crown of splendor; it is attained by a righteous life.46 if a man
curses his father or mother, his lamp will be snuffed out in pitch
darkness.47 The glory of young men is their strength, gray hair the
splendor of the old.48 Listen to your father, who gave you life, and
do not despise your mother when she is old.49

2.7.0 Chavara Kuriakose Elias Message to Families

Kuriakose Elias (founder of CMI, CMC and CTC) wrote his
famous book, oru nalla appante chavarul, to the families of
Kainakari village. According to him a good family resembles the
heavenly abode. All the members in the family, who are either
related by birth or bonded in nuptial relations, shall regard the
elders in high esteem and live together in unity and solidarity.
Every person shall maintain the highest dignity and self-realization
in all his words and deeds. It is the sacred duty of the children to
respect their parents diligently. They shall be taken care of as a
treasure in their old age and sickness. Such children are eligible for
the grace of God.50

All the members in a family shall have a deep-rooted love for

one another. This underlying love can bring in peace and friendship
in the family which, in turn, enables them to face the trials and
tribulations with utmost calm and, thereby overcome all the
tragedies in life. Your children are divine instruments; they shall be

45 Jacob 5/4
46
Proverb 16/31
47
Proverb 20/20
48
Proverb 20/29
49
Proverb 23/22
50 Kuriakose Elias, “Oru Nalla Appante Chavarul”, Mannanam Publications, 1999.
 100

brought up in the best way possible, and you shall extend to them
all kinds of protection.51

2.8.0 Subjective Well-Being of the Care-Givers of the

Victims of Dementia
In a study by (Nygaard, 1988) 46 patients with senile
dementia and their primary care-givers were studied. Eighty five
percent of the care-givers felt despair and anger and 75%
complained of chronic fatigue. There was significant correlation
between care-givers’ strain on one hand and the duration of
symptoms, degree of dementia and deviation of behaviour on the
other hand.52 (Morris, et al.1988) found that care-givers who
experienced lower levels of marital intimacy, both currently and
before the onset of dementia, were found to have higher levels of
perceived strain and depression.53 (Brown, et al.1995) found that
caregivers predominantly used problem-focused strategies. Further
analysis demonstrated that employing more positive coping
strategies did not necessarily result in a reduced sense of burden.54

Care-giver’s commitment or lack of commitment constituted a

superior level that determined whether the patient was seen as a
subject or as an object. Subcategories that were found were
knowledge of the patient’s disease and personal history, intuition,
identification, empathy, generalization and reutilization. (Athlin,55 et
al.1990). (Hooker, et al.1992) reported that neuroticism and

51 Kuriakose Elias, “Oru Nalla Appante Chavarul”, Mannanam Publications, 1999.

52 Nygaard, H.A. (1988) Scandinavian Journal of Primary Health care, 6: 33-37.
53 Morris, L.W, et al. (1988) The Relationship between Marital intimacy,
Perceived Strain and Depression in Spouse Care-givers of dementia
sufferers, British Journal of Medical Psychology, 61:231 - 236.
54 Brown, P.J. et al. (1995) Copying Strategies of Care-givers of Family
members with dementia, Journal of Mental Health Nurses.
55 Athlin, E. et al. (1990) Members Caring for an Elderly Person with
Dementia, Journal of clinical Epidemiology, 45:61-70.
 101

optimism were significantly related to mental and physical health.56

(Carcoran, 1992) reports that husbands and wives have different
approaches to care-giving; each approach has consequences. Male
care-givers adopt a task-oriented approach to their duties and carry
out their activities in a linear fashion; female care-givers use a
parent-child approach and nest activities inside one another in a
constant stream of work.57 Family members of demented elderly
people have narrated their feelings toward their care recipient as
mothering, grieving, feeling guilty, distancing and objectifying.
When the family members expressed mothering thoughts, there
were no expressions of guilt; objectifying or distancing and prior
relationship was narrated as good.

(Norberg, et al.1993) Face to face interviews with 50 older

women caring at home for a husband with dementia revealed that
gratification was associated with greater well being and frustration
with more distress. Wives who perceived continuity in marital
closeness since the illness had greater gratification than those who
perceived change. Frustrations in disrupting life plans are
apparently greatest at the onset of symptoms and as routines are
developed, diminish despite the need to provide more care.58
(Gilhooly et al.1988), in his study, expressed emotion care-givers of
the demented elderly revealed significant correlations between
expressed emotion and care-givers psychological well-being,
contact with friends and the quality of the relationship between the
care-givers and demented relative.59 (Leiberman, et al. 1995) found

56 Hooker, K. et al. (1992) Mental and Physical Health of Spouse Care-givers:

the role of Personality, Psychology of Ageing, 7: 367-375.
57 Norberg, A. et al.(1993) Relationships between Demented Elderly People
and their Families: a follow-up study of Care-givers who had
previously reported Abuse when Caring for their Spouses and Parents,
Journal of Advanced Nursing, 18: 1747-1757.
55 Gilhooly, M.L. (1988) Expressed Emotion in Care-givers of the ementing
elderly, British Journal of Medical Psychology, 62: 265- 272.
 102

that severity was significantly associated with health and well-being

for spouses, offspring and in-laws, regardless of the amount of care-
giving, demonstrating the potential cascading effect of the illness
through the family.60

(Majerovitz, S.D. 1995) found that greater memory and

behaviour and depression. For care-givers who were lower in
adaptability, longer hours of care were related to greater depression.
For care-giver higher in adaptability, hours of care were unrelated
to depression.61

(Asada, 1991) pointed out that social activity, individual free

time and familial interaction, as well as many emotional and
physical aspects were more severely affected in the subject carers.
Many of carers reported recurrent falls by the patients.62
(Parmelee, 1983) studied two care groups who did not differ in self-
rated depression or in feelings of dependency upon care providers.63

2.8.1 Cognitive and Behavioral Interventions

(Kahan, et al.1985) examined the effect of 8-session group

intervention based on cognitive and behavioral approach to provide
information about dementia care and improve problem solving
skills. Experimental group consisted of 22 and control group 18
care-givers of demented elderly. Using outcome measure as burden
and depression, they found that there was a decrease in family

56 Leibermen, M.A. et al.(1995) The impact of chronic illness on the

health and well-being of family members, Gerontologist, 35: 94-102.
61 Rovitz, S.D. (1995) Role of family adaptability in the psychological adjustment.
Psychological adjustment of spouse caregivers to patients with dementia,
Psychology of ageing, 10: 447 - 547.
62 Asada, T. (1991) Analysis of breakdown in family care for patients with
Dementia, Seishia Shikeigaku Zassi, 93: 403-43.
63 Parmelee, P.A. (1983).Spouse versus other family caregivers: Psychological
impact on impaired aged. American Journal of Community Psychology, 11:
337-349.
 103

burden and depression in experimental group while the control

group revealed increased burden and depression.64

(Haley, et al. 1987) conducted 10 session of support group

including skills training and problem solving methods and found no
difference between experimental and control group on outcome
measures (Beck Depression Inventory, Negative Family Impact,
Health and Daily living form), but the care-givers reported support
groups as helpful.65

(George, et al. 1988) did a cross-sectional comparison of

support group attendees and non-attendees. Sample consisted of
510 care-givers providing home or institutional care. Results
revealed that support group participants had higher knowledge of
disease and community services, higher use of counseling and part
time paid help and lower loneliness scores.66

(Farran, et al.1994) divided 139 care-givers in 3 groups: 62 in

educational support; 19-Alzheimers Association support group and
58 did not receive any treatment. Outcome measured coping styles,
burden, care-givers concerns and symptom profile in caregiver.
Results revealed that the distress increased in educational support
group after intervention; high participant satisfaction with groups;
support group members reported higher distress and life impact

64 Kahan, J. Kemp, B. et al. (1985) Decreasing the burden in families caring

for a relative with a dementing illness: A controlled study. Journal of
American Geriatric Society, 33, 664-670.
65 Haley, W. E. Levine, E. G. Brown, S. L. Berry, J. W. and Hughes, G. H.
(1987). Psychological, social and health consequences of caring for a
relatives with senile dementia, Journal of American Geriatrics society,
35: 405-411, Population-based study, Scandinavian Journal of Social
Medicine, 21 : 247 – 255.
66 George, L. K. and Gwyther, L.P. (1998) Care-giver well-being: a
multidimensional examination of family care-givers of demented adults,
Gerontologist, 26: 253-259.
 104

and lower anxiety. Control group had lowest distress and lower
care-giving satisfaction.67

(Herbert, et al. 1995) in randomized controlled trial conducted

structured program of 8 weekly sessions of 3 hour each, which
focused on providing information on dementia, role playing and
relaxation training. Total of 45 patient-care-giver pairs participated
in the study with 24 in the experimental group and 21 in control.
Control group referred to informal meetings of Alzheimer’s society
for care-givers of dementia. Results through 24 months survival
analysis showed no significant difference in institutionalization.68

(Bass, et al.1998) in a randomized control trial over 12

months provided computer link based support to 102 primary care-
givers of Alzheimer’s disease patients. The program included 24
hours access to communication network, encyclopedia of AD, and
monthly phone call on service use. The control group received 90-
minute placebo training session on identifying local services and
resources. The participants were assessed at baseline (T1) and 1
year (T2) to see effect on emotional, physical and relationship
strain. Results showed that participation in the intervention did not
alter the relationship between T1 and T2 care-giver strain.
Computer link access led to significantly greater reduction in
emotional strain for care-givers with more informal support.69

67 Farran, C. and Keane Hagerty, E. (1994) Multimodal intervention strategies

for care-givers of persons with dementia. Bright, E, Neidereki, B. and
Liebowitz, B. Future directions in Alzheimer’s disease and family stress,
Springer: Newyork.
68 Herbert, R. Girouard, et al. (1995)The impact of a support programme for
care-givers on the institutionalisation of demented patients. Achieves of
Gerontology and Geriatrics, 26,129-134
69 Bass, D. M, McClendon, M. J. Brennan, P.F. and Mc Carthy, C. (1998). The
buffering effect of a computer support network on care-giver strain, Journal
of ageing and health..
 105

(Hosaka, et al. 1999) conducted group intervention on 20

family care-givers, having series of 5 weekly sessions using
educational approach, psychological support, and ventilation. Pre-
post measures were Profile of Mood States (POMS) and General
Health Questionnaire (GHQ-30). Results indicated significant
improvement in depression, anxiety, fatigue, confusion in POMS
and physical symptoms-anxiety, sociality-depression on GHQ-30.70

(Hepburn, et al. 2001) tested role-training intervention as a

way to help family caregivers appreciate and assume a more clinical
belief about care-giving. The group training programs were
conducted for 2 hours for the period of 7 weeks. Standard measures
were used for depression, burden and reaction to the care receiver
behaviour. Total of 94 care-givers participated in the study and they
reported that group participation was helpful. There was significant
change in their reaction to the behaviour of the patient, decrease in
depression and burden.71

These studies provide evidence to support the potential of

family group intervention in improving the psychological well-being
and the knowledge about dementia care among their care-givers.
However, the efficacy of these researches has been limited. Despite
this, care-givers value their participation in these groups and
indicate high levels of satisfaction with them. These approaches
have been wide ranging, and have focused on teaching specific
behavioural skills to the care-giver along with problem solving,
relaxation training, self improvement and combination of these
techniques.

70 Hosaka, T. and Sugiyama, L. (1999) A structured intervention for family

care-givers of dementia patients, A pilot study, Tokai Journal of Clinical
Experimental Medicine, 24(1): 35-39.
71 Hepburn, K. W, Tornatore, J., and Ostwald, W. (2001). Dementia family
care-giver training: affecting beliefs about care-giving and care-giver
outcomes, Journal of American Geriatric Society, Apr 49(4): 450-457.
 106

(Lovett, et al. 1988) in their psycho educational program

included problem solving skills and techniques for improving self-
efficacy. 107 care-givers participated in the study and were
randomly divided in experimental and control group. 10 sessions
were conducted, once a week and the results showed that there was
decrease in depression and increase in morale overtime. However,
perceived stress remained unchanged. Control group did not reveal
any changes.72

(Brodaty, et al.1989) examined the effectiveness of training

programme to reduce stress in care-givers of patients with
dementia. Eligible patients were less than 80 years old, had mild to
moderate dementia, and lived at home with their care-giver. Of the
96 patient-care-giver pairs in the study, 33 were in the dementia
care-givers programme group who received training in coping with
the difficulties in looking after the patients with dementia and
memory training. 31 were in the memory-training group who also
received 10 days of respite and 32 were in the waitlist group who
waited for 6 months before undertaking the care-givers programme.
At 12 months follow-up the care-givers programme had resulted in
significantly lower psychological stress among the care-givers than
memory retraining group. In the waitlist group the distress scores
remained stable even after the care-givers and patients had
undertaken care-givers programme.73

(Chiverton et al. 1989) conducted three 2-hour group

discussions taking equal number of subjects (20) in experimental
and control group. After four weeks, post assessment was done and

72 Lovett, S. and Gallagher, D. (1988)Psycho-educational interventions for

family care-givers: Preliminary efficacy data, Behaviour Research and
Therapy, 19:231-330
73 Brodaty, H. and Gresham, M. (1989) Effect of a training programme to
reduce in stress in carers of people with Dementia, British Medical
Journals. 299:1375-1379
 107

it revealed that the care-givers in experimental group found the

program beneficial to feelings of competence related to disease and
to function with greater independence.67 (Mittelman, et al. 1994)
examined the effect of family education and counseling session
followed by weekly support group in reducing burden of care-givers
of dementia patients. Care-givers in the treatment group showed
increased satisfaction with the social network and no effect on
burden, mental or physical health was seen in early stages but was
evident at the end of 12 months. Control group placed patients 2
times more in nursing homes.74

(Teri, et al.1997) in their randomized controlled trial designed

60 minute weekly sessions for 9 weeks. 72 care-giver-patient pairs
participated in a program they were divided into 3 groups: first
group provided pleasant events schedule used by the care-giver to
generate and plan pleasant activities for the patient (BT-PE).The
second group was taught problem solving strategies (BT-PS). The
third group was given typical advice and support through
community services (TCC).The stress was on care-giver depression
(P<0.01). BT-PE & BT-PS care-givers depression improved more
significantly than the other group on Hamilton Depression Rating
Scale (HDRS). This improvement maintained at six months.75

(McCurry, et al. 1998) in a randomized controlled trial

provided active treatment in two phases to the care-givers of patients
with dementia-six weeks (Phase 1) and four weeks (Phase 2). Phase 1
comprised of 7 patient-care-giver pairs who were provided 6 weekly
small group sessions focusing on sleep hygiene, stimulus control,

74 Mittelman, M. S. Ferris, S. Shulman, E. et al. (1994) Efficacy of multi

component individualized treatment to improve the well-being of Alzheimer’s
disease care-givers, New York
75 Teri, L, Logsdon,R.G. Uomato, J. et al.(1997)Behavioural treatment of
depression in dementia patients: A controlled clinical trial, Journal of
Gerontology. 52(4): 159-166.
 108

relaxation, community resource information and behavioural

techniques. Phase 2 included 14 patient-care-giver pairs who
received the same as in phase 1 but condensed into four weeks
individual sessions. Wait list control consisted of 10 patient-care-
giver pairs. Outcomes measures were care-giver sleep, caregiver
mood, reactions to behavioural problems of the patients and sleep
diary. Results indicated that overall sleep quality was significantly
better for care-givers in the active conditions at post treatment and
follow-up than for control care-givers. There were no significant
differences in care-giver mood, burden or patient behaviours at post
treatment and follow up but there was tendency for depression
scores to decline at post treatment in both conditions. 60% of the
care-givers were judged to have demonstrated clinically significant
improvements.76

(Zannetti, et al.1998) in a non-randomized controlled trial,

conducted six weekly 1-hour behavioural management technique
and group discussion. Control group did not receive any specific
intervention, outcome measures were care-givers depression,
perceived stress, knowledge of disease and functioning of the
patient. They found that care-givers in the experimental group
showed an increase in disease knowledge from baseline to post,
while control showed none. After 3 months experimental caregivers
showed a significant decline in perceived stress relating to patient’s
disturbances, even though the behavioural disturbances of the
patient did not change significantly. There was no reduction in
emotional symptoms such as depression or anxiety.77

76 McCurry, S. M. Logsdon, R. B. et al. (1998) Successful behavioural

treatment reported for sleep problems in elderly care-givers of dementia
patients, Journal of Gerontology. 53:122-129.
77 Zannetti, O. Metitieri, T. Bianchetti,A. et al. (1998) Effectiveness of an
educational programme for demented person’s relatives, Archives of
Gerontology and Geriatrics. 6: 531-538.
 109

(Ostwald, et al.1999) tested the effect of interdisciplinary

psycho educational family group intervention in decreasing care-
givers’ perceptions of the frequency and severity of behavioural
problems in demented elderly and their reactions to their problems
and decreasing care-giver burden and depression. They conducted
7 weekly, 2-hour multimedia training sessions including education,
family support and skills training. Repeated measures ANOVA was
used to test the significance differences between the experimental
and control group. Intervention group showed decreased burden
and depression over time and diminished negative reactions to
disruptive behaviour of the patients.78

(Haupt, et al. 2000) examined the effect of psycho educative

group intervention on the behavioural and psychological symptoms
of the dementia patients in a 3-month, expert-based and
conceptualized group intervention with care-giving relatives of
dementia patients. The 3-month group intervention yielded a
significant improvement in agitation and anxiety of the dementia
patients.79

(Marriott, et al. 2000) studied the effectiveness of cognitive

behavioural family intervention in reducing the burden of care in
care-givers of patients with Alzheimer’s disease. The intervention
included care-giver education, stress management and coping skills
training spread over 14 sessions with 2 weekly intervals between
each session. Experimental group received family intervention and
was compared with two control groups. There were significant

78 Ostwald, S. K and Hepburn, K. (1999) Reducing caregiver’s burden: A

randomized psycho-educational intervention for caregivers of persons with
dementia, Journal of Gerontology. 39: 299-309.
79 Haupt, M. Karger, A. and Janner, A. et al.(2000) Improvement in agitation
and anxiety in dementia patients after psycho-educational group
intervention with their care-givers, International journal of Geriatric
psychiatry,15: 1125-1129.
 110

reductions in distress and depression in intervention group at post

treatment and follow up. Positive outcomes of studies using
cognitive and behavioural approaches have been reported in most of
the studies which include increased social support, decreased
depression, decreased burden and increased knowledge about
dementia care. Research indicates that combination of behavioural
and cognitive components in the therapeutic program is effective in
reducing the behavioural problems of patients and decreasing the
burden of care-givers.80

Studies have also examined the effectiveness of combinations

of different types of interventions for care-givers of patients with
dementia. It includes cognitive and behavioural approaches, psycho
education, support, and community and respite care services. The
above therapeutic approaches have been tried out in different
combinations.

(Mohide, et al.1990) investigated the effect of randomized

controlled trial of family care-giver support in the home
management of dementia patients. Total sample was 60 care-givers
(30 in experimental and 30 in control group). Patients were having
moderate to severe dementia. The experimental group received
education about dementia, assistance in problem solving, care-giver
focused health care, 4 hour block of weekly and on demand in-
home respite and 2 monthly support group. Control group received
conventional nursing care for the patient. Outcome measures were
depression, anxiety, quality of life ‘and life satisfaction of the care-
givers. Assessment was done at baseline, 3 months, 6 months and
follow-up at 12-18 months to assess service needs. Results revealed

80 Marriot, A, Donaldson, C. Burns, A. (2000) Effectiveness of cognitive

behavioural family intervention in reducing the burden of care in care’s of
patients with Alzheimer’s disease, British journal of psychiatry,176: 557-562.
 111

clinically significant improvement in quality of life of care-givers in

the experimental group by 20%.81

(Hinchliffe, et al. 1995) examined the effect of multimodal

intervention on care-giver psychological distress and behavioural
problems of the patient with dementia. 40 patient-care-giver pairs
participated in a program (experimental=22, control=18).
Individualized plan was generated by multidisciplinary team derived
to reduce most distressing problem behaviours in patient
(medication, psychological techniques and social measures). Group
1 - received immediate intervention and Group 2-received delayed
intervention. Assessment was done at baseline 16±2 weeks (phase
1), 38 weeks (phase 2). Blind raters were used. Results showed
statistically and clinically significant reduction in care-giver General
Health Questionnaire (GHQ) score for the immediate intervention
group. Behaviour problem of the patients improved in Group 1
compared to Group 2 at phase 1, which was maintained at
phase 2.82

(Mittelman, et al.1996) provided family intervention to delay

nursing home placement of patients with Alzheimer’s disease. In the
randomized controlled trial of four months of individual and family
counseling, support ongoing, total of 206 patient-care-giver pairs
participated. Control group did not receive any active intervention
or counseling. It was found that the patients in the treatment group
remained at home significantly longer than those in control groups,

81 Mohide, E. A. Torrance, G. W. Streiner, D. (1988). A randomized trial of

family caregiver support in the home management of dementia, Journal of
the American Geriatrics society, 38: 446-454
82 Hinchiffe, A, C. Hyman, I. L. Blizard, (1995) Behavioural complication of
dementia-can they be treated? International journal of Geriatric psychiatry,
10: 839-847.
 112

using the same Module.83 (Mittleman, et al. 1993) found that within
one year of intake, the treatment group had less than half as many
nursing home placements as the control group.84

Studies reveal the greater effectiveness of a combination of

different types of interventions for care-givers. Care-giver
interventions have the capacity to improve care-giver’s psychological
well-being and delay admission in nursing homes and can reduce
behavioural problems of patients with dementia. Interventions with
dementia patients and their care-givers in India are now at its
initial phase. The investigator did not come across any published
study on intervention with this population in India. The studies
have focused more on the behavioural problems of the patients with
dementia and the psychiatric morbidity in Care-givers, which
suggest that care-givers experience significant distress, care-giving
burden and their quality of life is poor (Sunanda, 2000).85 In a
study on behavioural problems of dementia patients and care-givers
stress, (Srinivas, 2002) found significant correlation between the
severity of the disease and care-givers stress. Two third of the care-
givers had GHQ scores indicating psychological problems, which
they were unable to cope with.86

2.8.2 Need of Social Support to the Dementia Patients and

Care-Givers.
Investigating the experiences of care-givers in looking after
chronically ill and impaired elderly persons, one topic of increasing

83 Mittleman, M. S. Ferris, S. Shulman, E. (1994) Efficacy of multi component

individualized treatment to improve the well-being of Alzheimer’s disease
care-givers, New York .
84 Mittleman, M, S, Ferris, S, Shulman, E, (1994). Efficacy of multi component
individualized treatment to improve the well-being of Alzheimer’s disease
care-givers, New York
85 Sunanda, R. (2000) Behavioural problems of dementia patients and
perceived burden and quality of life in their care-givers. Department of
clinical Psychology, NIMHANS, Bangalore.
86 Srinivasa,M.(1995) Community care for the Elderly Dementia news- 5:95
 113

interest has been the effect of social support on care-giver’s well

being. While there is a consensus that social support is important,
little attention has been paid to the factors that affect the provision
of support. The available literature on social support and social
networks provides inconsistent findings regarding the relative
importance of various sources of support.

(Suitor, et al.1993) Community surveys have established that

the great majority of dementing elderly people are cared for at
home. This is to say that the burden of caring for such patients falls
specifically on those relatives and friends who are generous enough
to support them. There is reason to believe that these supporters of
the demented elderly are themselves under considerable strain and
have to be treated as hidden patients.87 (Fengler, et al. 1979).
(Bergmann, et al.1979) found that family support was more
important than other indicators in achieving home care of the
demented patient.88 (Zarit, 1980) found that the lowest burden
ratings were reported from families receiving most frequent visits
from others.89

(Cohen, 1983) identified one of the greatest burdens of the

care-givers to be lack of free time; other investigators have identified
the sense of guilt felt by the closer relations in handing over the
burden of care to someone else.90

87 Suitor, J. and Pillemer, K. (1991) Support and interpersonal stress in the

social network of married daughters caring for parents with
dementia, Journal of Gerontology, 48: 51-58.
88 Fengler, A. and Goodrich, N.(1979).Wives of elderly disabled men - The
hidden patients,Gerontologist,19: 175-183.
89 Zarit, S, H. (1986) Subjective burden of husband and wives as care-
givers
90 Cohen, D. and Eisdorfer, C. (1998) Depression in family members caring for
a relative with Alzheimer’s disease, Journals of American Geriatrics society,
36: 885-889
 114

(Pratt, C.1985) found that burden in Alzheimer’s care-givers

was reduced by coping strategies of problem solving, through
support from the family and the church.91 (Scott, et al. 1986) found
socio-emotional support from the family members was positively
associated with more effective coping styles in care-givers. The
instrumental and social emotional support provided by the families
to the primary care-givers of Alzheimer’s patients were examined.
Ratings of instrumental assistance, social emotional support,
adequacy of support and coping effectiveness were made on 23
primary care-givers. Also a second family member, who was closest
to the kin of the care-giver was interviewed with a view to elicit
another perspective of the support, the family provided.92

The majority of the care-givers felt a high degree of support

from their families and reported low levels of emotional stress and
strain in consequence. The most common family problems reported
were lack of visits, disagreement over the level of patient’s mental
and physical condition and lack of consensus over the type of care
required. Overall, the data indicated that family support is an
effective resource that improves a person’s capacity to meet
stressful events.

(Engles, 1587) found that care-givers who are suffering from

high stress levels tend to receive more support from services.
Informal supports from family and friends have been shown to
reduce levels of stress and depression.93

91 Pratt, C, Schmall, V. Wright, S and Cleland, M. (1985) Burden and coping

strategies of care-givers of Alzheimer’s disease patients, 34: 27 – 33.
92 Scott, J, P, Roberto, K, A, Hutton, J, T. (1986) Families of Alzheimer’s
victims: Family support to care-givers”. Journal of American Geriatric
society, 34: 348 – 354.
93 Engels, J.M. Beattie, J.A.G. Blackwood, G.W., Restall , D.B. and Asheroft ,
G.W. (1987). “The mental health of elderly couples. The effects of cognitively
impaired spouses”. British Journal of Psychiatry, 15: 299 – 303.
 115

(Morris, et al. 1987) found that care-givers expressed less

satisfaction with their social networks than did controls but the
groups did not differ in objective size of social network or number of
network contacts. However, they do express more dissatisfaction with
the adequacy of their support network.94 The importance of social
supports in the care-giving role has been documented by (Aronson, et
al.1984) and Cantor (1983)95. This relationship has been further
clarified by Fiore, et al. (1983) who separated perceived network
support from upset in Alzheimer’s care-givers with the latter found to
be a stronger predictor of depression.90 In a study by (Quayhagen, et
al.1988) 58 care-givers of dementia were interviewed. They found that
the most commonly identified source of emotional support across
groups was a blood relative (87%), followed by support group (43%).
Information support was primarily from books and magazines (51%)
and secondarily from health professionals (31%).96

In a study made by (Pruncho and Resch,1989) based on

traditional gender role theory, women were found more capable than
men in exhibiting skill and confidence in helping the spouses in
trouble. Social support was more effective than drugs and
antidepressants in retrieving a demented person from the clusters of
dementia. This was true in the case of care-givers too. More than half
the number of care-givers felt they needed greater support in caring
for the patients than they were currently receiving room family and

94 Morris, L.W., et al. (1988) “The relationship between marital intimacy,

perceived strain and depression in spouse care-givers of dementia
sufferers”. British Journal of Medical Psychology, 61: 231 - 236.
95 Haley, W. E. Levine, E. G. Brown, S.L. Berry, J.W. and Hughes, G.H. (1987)
“Psychological, social and health consequences of caring for a relatives with senile
dementia”. Journal of American Geriatrics society, 35: 405-411, “Population-
based study”. Scandinavian Journal of Social Medicine, 21: 247 – 255.
96 Quayhagen, M.P. and Quayhagen, M. (1988). “Alzheimer’s stress: coping
with the care-giving role”. The Gerontologist, 28: 391 - 396.
 116

friends.97 These findings have been reported by (Clipp and George,

1990) in their study of care-givers in order to determine the correlate
on between psychotropic drug use and family support.98

(Suitor, 1993) in their study in which they interviewed 95

care-givers found the relative importance of friends and siblings as
sources of support and means of reducing stress. Siblings provided
about the same amount of support as did friends. While siblings
were a greater source of instrumental support than friends, they
played a far less important role than friends in providing emotional
support. In fact, friends were clearly the greatest source of
emotional support for these care-givers.99Persons who care for
family member with dementia experience high levels of
psychological distress and clinical depression. (Brodatay, 1996).100

(Clipp and George, 1993) found that facilities for social life
and recreational participation revealed a similar negative scenario
for dementia care-givers in comparison with cancer spouses.
Overall satisfaction with social activities was significantly lower for
the dementia care-givers, who also reported feeling more alone and
in need of more help from friends and family than did cancer care-
givers. This apparent need for outside contact also was reflected in
support group membership. Over half of dementia care-givers mere
support group members compared with 4% of the cancer group.
Finally, two indicators of financial resources revealed that in
comparison with cancer care-givers, dementia care-givers reported

97 Pruncho, R. A. and Resch, N.L. (1989) “Husbands and Wives as care-givers

antecedents of depression and burden”. The Gerontologist, 29: 159 - 165
98 Clipp, E.C. and George, L.K(1993). “Dementia and Cancer: A comparison of
spouse care-givers”. The Gerontologist, 33: 534 -540
99 Suitor, J. and Pillemer, K. (1991) Support and interpersonal stress in the
social network of married daughters caring for parents with dementia,
Journal of Gerontology, 48: 51-58
100 Brodaty. H. (1996). Care-giver behavioural disturbances effect and interventions.
International psycho geriatric 8 (3) 455-458.
 117

significantly lower incomes and perceived themselves as less

economically secure.101

(Hannapel, et al.1993) studied 93 family care-givers. Contrary

to most other findings the care-givers who received more support
were found more depressed.102 In a survey of those involved in the
care of the frail elderly, (Temstedt, 1983) found that 60% of
secondary care-givers were women and that the proportion of men
who were secondary care-givers were greater than those who were
primary care-givers. Often several secondary care-givers provide
assistance by performing a wide range of activities including
washing and shopping. All these studies indicate that social
support availability decreases the burden felt by the family care-
givers. Care-giving should not be solely and individual duty, but a
group work. Even these studies have primarily focused on the
individual care-givers support system and its effect on stress,
burden and other impact on health.103

2.8.3 Family Burden on the Care-givers of Dementia

(Orford, et al.1987) made a study on the expressed emotion

and perceived family interaction in the key relatives of elderly
patients with dementia and reported the protective behaviors,
hostile- dominance with little loving care.104

(Drinika, et al.1987) reports that the level of patient’s

depression is significantly correlated with the extent of care-givers

101 Clipp, E. C. and George, L.K. (1993). “Dementia and Cancer: A comparison
of spouse care-givers” . The Gerontologist, 33: 534-540
102 Hannapel, M. Calsyn, R.J. Gary, A. (1993). “Does social support alleviate
depression of care-givers of dementia patients . The Gerontologist, 20: 35 - 51.
103 Temstedt, S. L. Mckinlay, J.B.,Sullivan ,L.M.(1989).Informal care for frail
elders. The role of Secondary care-givers”. Gerontologist, 29: 677 – 683.
104 Orford, J. (1987) “Expressed emotion and perceived family interaction in
the key relatives of elderly patients with dementia”. Psychology of
Medicine , 17 : 963 – 970.
 118

depression and burden. The study reveals that care-givers of

chronically ill, elderly men cope better with physical and cognitive
incapacity than with affective symptoms, because the care-givers
support is the most important factor in safeguarding the well being
of disabled elder in the community.105

(King, 1995) explored the barriers in using home health aide

services as perceived by family care-givers of relatives with
dementia. The major findings included the high cost of the
resources, often recurring and prolonged made them beyond the
reach of the common man. Care-givers in many cases indicated that
the price paid for services outweighed benefits.106

Another serious problem experienced by most of the care-

givers is that owing to the weakening of the patient’s memory, all
sorts of accusations are heaped on the care-givers, which cause a
drift in the relationship between patient and the care-giver.

(Shyu, et al.1996) reported that incontinence was identified

by 36% of 184 care-givers as a problem in their care of older
community dwelling patients with dementia. Such dementia
patients had greater impairment of cognitive function and more
frequent behavioural problems than those who live a sober,
disciplined life. Burden scores were higher among care-givers of
incontinent patients;107 (Robinson, 1990) studied predictors of
burden among wife care-givers. He reported that past marital
adjustment was a significant predictor of subjective burden. Socio-

105 Drinika, T.J. (1987) “Correlates of depression and burden for information
care-givers of patients in a geriatrics referral clinics”. Journal of American
Geriatrics Society, 35: 522 -525.
106 King, S.K. (1995) “Barriers to using home health aide services as perceived
by family care-givers of relatives with dementia”. Journal of home Health
Nurse, 13: 60- 68.
107 Shyu, and. Ouslander, J. G. et al. (1990). “Incontinence among elderly
community dwelling dementia patients. Characteristics, management and
impact on care-givers”. Journal of American Geriatric Society, 38: 440 - 445.
 119

economic status and attitude toward asking for help were the
significant predictors of objective burden.108

(Macmillan, 1960) pointed out that the emotional relationship

between an elderly patient and the relative, responsible for him
determines whether family care will be a blessing or a curse. As to
the problems faced by those following some careers, an appreciable
number had been forced to give up their jobs to devote them to
patient care. In general, female care-givers with husbands younger
than 65 years reported economic distress.109

The adverse impacts of dementia on the patient’s family’s

economy, relationship among family members and social life are
well recognized. The majority of people have only a vague
understanding of dementia. Medical insurance may helps the family
in caring for the demented patients, financially but it cannot meet
the emotional and social needs of the patient and the care-giver
(Liu, et al.1991). The association between care-giving and the health
variables was found to be stronger when the patient is the spouse
than when it was the child. Greater behavioural disturbance in the
demented patient was associated with higher levels of morbidity in
the care-givers.110

(Baumgarten, et al.1992) Twenty-six family members in the

case-group reported abusive behaviour in the care of the elderly at
home. These family members were compared with 154 family
members in the control group, applying other coping strategies than
abusive. In the abusive group most of the elderly were in a mild

108 Robinson, K.M. (1990) “Predictors of burden among wife care--givers”.

School Inquiry Nursing practice, 4: 189 – 203.
109 Macmillan, (1960) Analysis of breakdown in Family care for patients with
dementia”. Cantor, M.H. (1983) “Strain among caregivers: A study of
experience in the US. The Gerontology, 23: 597 - 604.
110 Liu, H.C. et al. (1991) “Impact of demented patient on their family members
and care-givers in Taiwan”. Neuro epidemiology, 10: 143-149.
 120

stage of dementia, and the family members expressed greater strain

in the caring situation. The family members were older, judged their
health as deteriorated, and were mostly living together with the
dependent elderly.111

(Graftstrom, et al.1993) A higher level of behavioural

disturbance in the patients with dementia were indicators of the
worsening of the care-givers depression and physical symptoms
during the study period. The magnitude and direction of changes in
the care-givers health varied considerably.112 (Baumgarten, et al.
1994 and Hinrichsen, et al. 1994) reports that dementia
management strategies accounted for a significant variance in the
family members’ burden, which most often induced them to
institutionalize the patient.113

(Suwa-Kobayashi, et al. 1995) reported that the difficulties

faced by care-givers could be divided into five categories:
incomprehensible situations, strange behaviour, deterioration of
dementia, trouble or inconvenience caused by demented behaviour,
remarks and support network.114

Looking back, there is a need to study the specific deficits in

the profile of subjective well-being of the care-givers of the
demented. Most studies have taken into account only the impact of
burden on care-givers. It would be interesting to study the specific

111 Baumgarten, M. Battista. R.N. Infant – Rivard C, Hanley J. A, Becker R

Gauthier S. (1992) The physiological and Physical health of family members
caring for and elderly person with dementia. Journal of clinical Epidemiology:
45(1):61-70
112 Graftstrom, M. et al. (1993). “Abuse is in the eye of the behold. Report by
family members about abuse of demented person in home care - A
total Seishin Shinkeigaku Zasshi, 93: 403-433.
113 Hinrichsen, G. A. et al. (1994) “Dementia management strategies and
adjustment of family members of older patients”.Gerontologist, 34: 95-102.
114 Suwa-Kobayashi, S. et al. (1995) “Nursing in Japan caregivers of elderly
family members with dementia”. Journal of Gerontological nursing, 21: 23-
30.
 121

care-givers’ deficits and the quality of life and the relationship

between the subjective well-being of and the burden on care-givers.
It is for this reason that the researcher felt it necessary to explore
the area of subjective well-being and the factors co-related to it.

2.8.4 Psycho-Social Problems of Family Care-Givers

(Coombs, 2007) conducted a study on- “Spousal care-giving

for stroke survivors’. Van Mane’s approach was used for examining
the spousal care-givers. Data were collected through audiotapes
from semi structured interviews. Six inter-related themes emerged
from data analysis: experiencing-a profound sense of loss. Feeling
the demands of care-giving, adjusting to a relationship with a
spouse, the reluctance to take up new responsibilities, feeling
belittled in having to depend on the support of others and the
struggle for maintaining hope and optimism. Eight spouses who
met the inclusion criteria participated in the study.115

(Larson, et al. 2007) conducted a study on ‘The impact of

gender on the psychological well-being and general life situation
among spouses of stroke patients during the first year after the
patient’s stroke event’. This study was conducted with three
assessments regarding the psychological well-being and the general
life situation. 20 female and 20 male spouses of stroke patients,
admitted to a stroke unit, participated in the project study. The
findings: there are gender differences among spousal care-givers of
stroke patients and females are more adversely affected in the
unwelcoming development.116

(Blake, et al. 2006), conducted a research on care-giver strain

in spouses of stroke patients”. The study was conducted on 400
115 Coombs, U.E. (2007) “Spousal care-giving for stroke survivors.” Journal of
Neuro science Nursing, 39:12-19
116 Larson, J. and Billing, E. (2006) Psychological well-being and general life
situation among spouses of stroke patients. Journal of Nursing
 122

care-givers of whom 276 had an identifiable co-residence spouse

114. The result was that the carers at risk of later strain could be
identified for further follow up. Services to provide emotional
support to carers could affect considerable in the reduction of
caring strain.117

(Thommessen, et al. 2002) conducted a study on

‘Psychosocial burden on spouses of the elderly with Stroke.
Dementia X-Parkinson’s disease’. They studied 36 couples who were
victims of stroke. They concluded that spouses caring for patients
with stroke experience a similar type and level of psychosocial
burden, independent of the disease.118

(Forsberg, 2002) conducted a study on care giving strain and

care giving burden of primary care-givers of stroke survivors with
and without aphasia. They examined the relationship between
stroke and care-giver burden and strain. The results spotted that
there is a lack of research in this area and pointed to need for
determined initiatives, including the development of an instrument
with psychometric properties, capable of assessing the burden, and
strain on the care-givers of stroke patients.119

(Smith, 2005) conducted a Randomized trial to evaluate the

education programme for patients and carers after stroke. The
study was conducted on 170 patients admitted to a stroke
rehabilitation unit and the care-givers of the patients. They found
that the education programme did not result in improved knowledge
about stroke and stroke service but there was a significant

117 Blake, H. and Lincoln, N.B. (2003) Care-giver stress on spouses of stroke of
patients. Clinical rehabilitation.; 17:312-317
118 Thommessen, B. (2002) International journal of Geriatric Psychiatry. 17:78-
84
119 Forsberg (2002) Life satisfaction of spouses of patients. International
Geriatric Psychiatry.1, 78-84.
 123

reduction in patient anxiety and carer anxiety at six months post

stroke onset.120

(Bethoux, et al.2004) Conducted a study on the ‘Quality of life

of the spouses of stroke patients’. They assessed stroke patients
and their spouses using Barthel index. A 10cm visual analogue
scale was used to evaluate the spouse’s quality of living. This study
confirms the constant impact of stroke on the quality of living of
spouses resulting from the patient’s physical disability.121

(Lincoln, et al. 2004) conducted a study on the ‘Evaluation of

a stroke and family support, organizing a randomized controlled
trial’. They noted that care-givers in the intervention group were
significantly more knowledgeable about whom to contact for
information on stroke, reducing the risk of stroke and the need for
community services and emotional support. Care-givers were more
satisfied with stroke information.122

(Jo S, et al. 2003) conducted a study titled ‘Care-giving at the

end of life: perspectives from spousal care-givers and care
recipients’. Spousal care-givers identified many negative reactions
to care-giving such as fatigue or weariness, depression, anger,
sadness, financial difficulties and lack of time. Additional positive
results of care-giving, reported by spouses included strengthened
relationship with their spouses and enhancement of emotional
strength and physical abilities in managing care.123

120 Smith, et al. (1986). The Older Patient Introduction to Geriatric Nursing,
(14th ed).U.S.A., Hodder Stoughton Company
121 Bethoux, F. and Calmels,P.(2004). Quality of life of the spouses of stroke
patients: A premilinary study. Journal of Rehabilitation Med.1, 4-11.
122 Lincoln, NB. and Blake, H. (2003) Care-giver stress on spouses of stroke of
patients. Clinical rehabilitation. 17:312-317
123 Jo, S. and Williston, (2007) “Care-giving at the end of life: perspectives from
spousal care-givers. Palliative support care. 1, 11-17.
 124

(Mant, 2003) conducted a study on ‘Family support for

stroke: a randomized control trial in the department of primary care
and general practice, University of Birmingham’ which revealed
family support significantly increased social activities and improved
the quality of life of careers, without any adverse effects on
patients.124

(Van den Heuvel, et al.2002) Conducted a research on the

“Short term effects of a group support program and individual
support for care-givers of stroke patients’. The research was
conducted on 2/4 primary care-givers in order to examine the
impact of care-giving stressors. Their conclusion was that higher
levels of both objective and subjective stressors were associated
with all three dimensions of care-giver health, power self reported
health more, negative health behaviors are greater.125

(Bugge, C.1999) ‘Conducted a study on Stroke patient’s

informal care-givers, patient, care-giver and the service factor that
affect care-giver strain’. Some of care-givers were experiencing
considerable strain. The amount of time a care-giver spent on
helping a stroke patient, the amount of time the care-giver spent
with the patient and the care-givers health were associated with the
level of strain experience.126

(Larson, et al.2004), conducted a study on ‘the impact of a

nurse led support and education programme for the spouses of
stroke patients’ it was a randomized controlled trial. 100 spouses
were randomly assigned to intervention. The result was that no

124 Mant, J. and Carter, J. (2003) Family support for stroke:4, 381-9
125 Van den Heuvel, E.T. and Stewart, R.E.(2002)”Long-term effects of a group
support programme for informal care-givers: Patient education counselling,
.4,291.
126 Bugge, C. and Hagen, S. (1999) Stroke patients informal care-givers, stroke.
8, 1517- 23.
 125

significant differences found between intervention and control

groups over time.127

Conclusion

The investigator thoroughly went through some of the

previous studies related to the topic under investigation with a view
to get an insight into the theoretical background of the subject of
study and to gather ideas. The knowledge secured from such
reading helped the investigator to define the exact problem and
select suitable methodology and make correct interpretations of the
findings. Looking back, the need to study the specific deficits in the
profile of subjective well-being of the care-givers of the demented
has been detected. Most studies have taken into account only the
impact of burden on care-givers. It would be interesting to study the
ageing process, specific care-givers’ deficits and the quality of life
and the relationship between the subjective well-being of and the
burden on family care-givers. It is for this reason that the
researcher felt it necessary to explore the area of their subjective
well-being and the factors co-related to it.

127 Larson, J. and Billing, E. (2006) Psychological well-being and general life
situation among spouses of stroke patients. Journal of Nursing.