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The role of geriatric psychiatry in an ageing Kerala
Geriatric psychiatry – more simply known as old age psychiatry or psychiatry of the elderly –is, as of now, novel enough to merit an introduction. At it’s very heart, it is a simple enough affair. It is concerned with the mental health of older adults – those aged 60 years and above in Indian demographic terms.

To embrace its full complexity and diversity, however, requires an appreciation of the emphasis it places upon the biological and psychological parts of normal aging. Geriatric psychiatry also looks at the psychiatric effect of both acute and chronic physical illness in older adults. Finally, it addresses the biological and psychosocial care of psychiatric illnesses in older age.

India, in general, and the state of Kerala, in particular, is poised to need this particular mental health speciality more so than ever before in the years to come. Our nation is transitioning quite rapidly from a youth predominant population to a more mature demographic. Further, while developed nations in the global North navigated this transition over about 150 years, India, in common with other developing countries in the global South, has had less than 50 years to do so.

The Technical Group on Population Projections for India and States 2011-2036 estimated the presence of around 138 million older adults in India in 2021. That is, about 67 million men and 71 million women. Overall, the population of India grew by about 18% during 2001-2011 and 12.4% during 2011-2021. Meanwhile, the population of older adults, in India, grew by about 36% during these last two decades (2001-2011 and 2011-2021).

The growth in the number of older adults is particularly striking in our sunny, southern, coastal state. In 2021, 10.1% of the population of India and 16.5% of the population of Kerala was aged 60 years and above. In 2031, it is estimated that 13.1% of the population of India and 20.9% of the population of Kerala will be aged 60 years and above. That is, in about 10 years, one in five out of the people of Kerala will be a senior citizen.

There are several factors contributory to this state-specific phenomenon – high literacy rates, good performance on most health indices, high migration rates, declining fertility rates and longer life expectancies. The current life expectancy at birth is 72.5 years for men and 77.9 years for women – the highest in the country.

While reports of population ageing tend to be alarmist in tone, that our population is growing older is not necessarily an untoward consequence. Ageing is now recognized as a decline of adaptation with increasing age. This is in contrast to older concepts of ageing that once considered it merely a decrease in fertility rates and an increase in mortality rates.

It is not sufficient that people live longer, however. Successful or healthy ageing is conceptualized by the World Health Organization (WHO) as the process of developing and maintaining functional abilities that enables wellbeing in older age. Put simply, it means the ability to be whom we want to and do what you want to, as we grow older. It isn’t merely the responsibility of the older person to age successfully, however. Healthy ageing depends upon the individual, the environment and upon the interaction between them.

Aptly enough, the WHO had declared 2021-2030 to be the UN Decade of Healthy Ageing, dedicated to improving the lives of older persons, their families and the communities in which they live. The COVID-19 pandemic acted as a party pooper, to a large extent – hijacking the decade and diverting funding and healthcare resources away from older adults to infection control. However, the pandemic has also helped to identify gaps in public health that affected vulnerable older adults disproportionately.

Practices such as reverse quarantine, social distancing and digital health delivery served Kerala well during the first two waves of the pandemic, but also contributed to loneliness and isolation in older adults in the community. A recent community study in the state demonstrated depression was a major problem faced by people under home quarantine (75.2%) followed by stigma (69.5%) and anxiety (69.4%).

This increase in mental health need is to be taken in context of the already high burden of mental illnesses in Kerala. From 2002 to 2018, the number of people living with mental illnesses in the state increased from 272 persons per 100,000 to 400 persons per 100,000. This was, during this period, pre-COVID, approximately three times higher than the national average.

It has long been a matter of debate, whether the higher than (national) average of mental illnesses in Kerala is due to a higher burden of mental illness or due to better case detection rates. A similar debate played out this year and the last with regard to our COVID case load and detection rate.

The Global Burden of Disease Study has indicated that high levels of education are associated with lower rates of suicide in developed countries and higher rates of suicide in developing countries. This is particularly so when high levels of education are combined with high unemployment and/or underemployment. Concurrently, migration studies have indicated an increase in vulnerability to mental illnesses associated with cultural dislocation. Thus, some of the most striking demographic features of Kerala – near universal literacy and high migration rates – are associated with both longer life spans and better physical health, while increasing the vulnerability to mental illnesses. The COVID-19 pandemic has served to accentuate this paradox.

What does this imply for public health in Kerala? Among other things, that our rising number of older adults and higher than average burden of mental illnesses, along with age related changes in mental and physical capacity imply the need for greater investment and development of services dedicated to geriatric psychiatry. This would encompass the emotional, psychological, and social well-being of older adults in a

holistic manner. It would also impact upon how older persons handles stress, interpersonal relationships, and decision-making in the community. Mental healthcare facilities built upon the principles of geriatric psychiatry and healthy ageing would be able to tailor care to the unique strengths and vulnerabilities of older age. Older adults are a valuable constituent of the community and their mental health is very much worth the investment.

Dr. Migita M. D'cruz
Associate Consultant, Psychiatry and Behavioural Medicine
KIMSHEALTH, Trivandrum

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