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The elderly refers to men and women aged 60 years and above (according to the Ministry of Health and United Nation’s recommendations). Life expectancy in our country is near equivalent to that of a developed nation because of improved health care and standard of living, which has brought about a decline in mortality. These together with the decline in birth rate contribute to an aging population in Malaysia. Smaller sized families, together with breakdown in extended families, urban migration for jobs, longer life-span and changing lifestyles give rise to special health problems and needs in the elderly. These are as follows:

1.  Due to physiological changes with age
2.  Due to diseases (including complications/ management) associated with ageing population
3.  Psychological and social problems as a result of 1 & 2
 
1  Physiological changes

Generally there is slowing down with age with a decreased ability to respond to stress and environmental changes and a decrease in stamina. Changes in the gastrointestinal tract results in constipation and faecal incontinence. Poor dentition gives rise to nutritional problems and anaemia. Muscular-skeletal changes result in kyphosis and bone loss. Increased wear and tear to cartilage and joints leads to painful and stiff joints reducing mobility. Neurological changes can result in urinary incontinence and poor memory. Also with age there is a decrease in hearing and vision. There is an increase in susceptibility to infection due to changes in immunity.

2.  Diseases (including complications/management) associated with aging population

Chronic diseases are more common in the elderly e.g. diabetes mellitus, hypertension, cardiovascular & cerebrovascular diseases, cancer, osteoarthritis, temporal arteritis, polymyalgia rheumatica, Parkinsonism, Paget’s disease and Alzheimer’s Disease.

 The elderly also has atypical responses to common diseases e.g. infection with no fever, decreased pain perception and pain reaction threshold, sensation of breathlessness masked by changes in mental status.

Response to drug treatment differs from the younger population because of changes in hepatic and renal function with age. Therefore doses need to be adjusted. Drug interactions are more common. In view of multiple problems and diseases, polypharmacy is frequent and drug interactions and side effects are common.

3.  Psychological / Social problems

Depression, loneliness, social isolation can result from a number of factors. These include decrease ability to cope, living alone, presence of chronic diseases and financial problems from decrease or no income. The elderly can experience special problems coping with activities of daily living especially if staying alone. They may have difficulties in bathing and going to the toilet when suffering from diseases such as chronic arthritis and stroke. Buying of groceries, cooking, housework, taking of medication can be a problem if eyesight and co-ordination are poor. Financial problems can also result in inadequate medical and dental care and poor nutrition. The elderly especially those with terminal illnesses will also have to cope with fear of death, dying and suffering. Caregiver abuse and neglect also need to be considered.

The role of the Family Physician in catering to the needs of the elderly population can be discussed under the following headings:

1.  Role as family doctor
2.  Role in community / personal / own family

Role as family doctor

As family physicians we need to develop rapport and spend more time with elderly patients because of their numerous health problems. Involvement of the family in management and care of elderly patients from the beginning is essential. Management of the elderly includes preventive aspects, promotion of healthy lifestyle, curative, rehabilitative, psychological / social aspects which are listed below.

Preventive / Promotive aspects

Periodic health examination need to be carried out on the following:

a.  To look for hearing impairment together with evaluation and counselling on hearing aids.
b.  Vision and refractive defects checked and to refer to the ophthalmologist when necessary.
c.  Detailed examination for functional incapacity with age to detect impairment in sensory, psychological function and locomotion
d.  Activities of daily living - assess functional status at home / work.
e.  Counselling and assessment for household and recreational injuries and its prevention. Look for adequate lighting at home, repair/remove structure predisposes to tripping, handrails and traction strips to stairways and bathtubs. Prevention of falls is a top priority in the elderly.
f.  Counsel on medical conditions and drugs affecting mobility
g.  Recommend exercise program like tai-chi to improve & maintain mobility & flexibility
h.  Nutritional history and recommend balanced diet. Regular height and weight measurement is recommended especially in elderly living alone.
i.  Recommend influenza vaccination.
j.  Assessment for complications in high risk groups e.g. diabetic retinopathy

Curative aspects

Management of diseases includes non-pharmacological treatment first. A family doctor need to be cautious in prescribing drugs (dosages used / drug interaction) and polypharmacy should be avoided as much as possible. Drug treatment should constantly be reviewed and drugs that cause sedation should be used with extreme caution. Drug dosages also needs to be made as simple as possible so that the elderly can remember. The prevention and early detection of complications is important especially in chronic diseases like diabetes mellitus and should be screened regularly. Unusual disease presentations in elderly need to be recognised. When needed the family doctor refers the elderly patient to various specialists or admits the patient.

Rehabilitative aspects

The family doctor co-ordinates a team effort involving physiotherapists, occupational therapists, social worker and specialists in management of elderly patients with strokes, chronic debilitating arthritis and others. Facilities should be provided in the clinic to help elderly patients e.g. walkers/wheelchairs. The family physician’s role also involves referring to specialists if required e.g. orthopaedic surgeon, rheumatologist etc.

Psychological / social aspects

As family doctors we need to be alert to depression, suicidal tendency, feelings of loneliness and problems of coping in the elderly. This is especially important in our society where patients may not be so forthcoming with their what is perceived as non-medical problems. We should encourage our elderly to socialise by joining a senior citizen or social club. Demented patients pose a lot of problems to the caregiver. The family doctor has to be alert to caregiver stress, abuse or neglect. The best place to take care of the elderly is at home. However if this is not possible, alternative nursing home, day care centres should be recommended. Home visits by the family physician are important to assess home environment and provide treatment for those who are bedridden. On the other hand, a demanding elderly patient can give rise to a lot of stress to the caregiver. Proper advice need to be given to the caregivers and to equip them with skills to cope with the patient. The caregiver should be given time to be away from constant stress and burden of looking after the elderly to prevent burnt-out.

2. Role in Community / Personal & own family

Personal / own family

As family physicians we need to be well equipped to look after the special health care needs of elderly patients e.g. through attending continuous medical education and courses in geriatrics. We need to demonstrate a caring attitude with patience towards elderly patients who may be long winded, hard of hearing, difficult to handle. It is important to set an example in care of elderly in our own family. Those family physicians interested can also contribute through research into the elderly and their problems.

Community

Family physicians participate through a co-ordinator role as head of team in the community, using its resources for the management of his / her elderly patients. Family physicians can also contribute through active participation in community projects and organisations helping the elderly e.g. non government organisations, palliative society., senior citizen’s clubs etc. We can also give health talks on the elderly, provide free screening programs and offer financial aid. We can also help to lobby for more facilities to aid elderly. These include facilities in public transport vehicles, day centres, social clubs, mobile libraries, home nursing, volunteer schemes, suitable housing designs for elderly, education programmes to learn new skills and self management, pre-retirement seminars/ courses, sheltered workshops / cottage industries for the elderly.

Family physicians are in an important position to help the elderly with their special health problems and needs. Our contributions as stated above can help reduce disability, improve and maintain the quality of life of our elderly in the community.