Saleem could not afford the luxury of enjoying his retirement. He had responsibilities; his children were still studying. Belonging to the lower middle class, Saleem took up a couple of jobs successively but it was not as easy to cope as it used to be. A few years into retirement, he started having difficulty concentrating on his work.
Then, his family noticed, he started misplacing his things, leaving them somewhere and searching for them in another place. Then one day, he lost his way home from work. “Thankfully, an acquaintance saw him and brought him home,” says his son, who now works at a factory. “We were upset and took him to a doctor who prescribed Abba some medicine and advised us not to let him go out alone. It’s two years now that he has been under treatment, but his condition seems to have deteriorated. He is becoming quieter and the way he is declining we are afraid one day he will not even recognise us.”
The Rehmans, an ageing couple who live in the upper-class residential area of North Nazimabad in Karachi, are luckier than Saleem in that they do not need to work and can afford to stay comfortably at home post-retirement. But they have time on their hands which can sometimes weigh heavy on their minds, like the quiet that stretches through the most part of their days.
“I don’t know how to pass my time through the day,” laments 80-year-old Habibur Rehman. He suffers from severe arthritis and has almost lost sight in one eye because of retinal issues that cannot be corrected. “I can walk within the home with the help of a stick but I can only read or watch TV for about 10-15 minutes at a time.” Rehman worked as an engineer and spent an active life even after he gave up his job at the age of 70. He kept himself busy driving down to the local library and spending a few hours there reading. When he was at home he watched the news on TV. He didn’t know how to use a computer, so he learnt the basics from his children and he would enjoy browsing the internet. “I had so much to do that I would never get bored. But now since I cannot read or browse online for long because of my eye problem, I don’t know how to kill time,” he says.
From mobility to health to loneliness, a number of issues plague the lives of the senior citizens of the country. But society seems to want to look the other way rather than dealing with and addressing them
Most of the day Rehman and his wife are alone with only the domestic staff at home. Their children and grandchildren come home in late afternoon or evening from school or work, so there is no one there to talk to during much of the day. Rehman’s wife, despite her age and health problems, keeps herself busy in household chores and supervising the house staff. “He sometimes gets very depressed,” she says of her husband. “He also seems confused, as he often mixes up what he is told. Either he doesn’t understand or he forgets.”
Sadia had always been a busy homemaker. Looking after her home and children were her priorities in life. With time, she developed arthritis along with other minor health problems, but she was determined to continue to give her all to her home and family. Now, in her late 70s, most of her children are abroad. After the death of her husband, she lives in an apartment with a daughter who is busy with her own job.
Read: Elderly care in Pakistan
Sadia’s arthritis has restricted her mobility. “I cannot take a single step without the aid of a walker, and then too am afraid of losing balance. So I’m now confined to my home. I would love to go out, meet people and socialise but that is almost impossible,” she says. “If the loneliness and confinement doesn’t kill me first, I am sure I will lose my mind.”
Slipping into silence or invisibility can be the fate of many senior citizens who are not fortunate enough to live with a caring family or be supported by attentive caregivers. At present, about five percent of the population of Pakistan is above the age of 65. UN projections indicate that, by 2045, the 65-and-above population in the country will reach seven percent.
With improvement in medical science and health facilities, average life expectancy has increased worldwide. According to the World Population Bureau, the world population continues to age, with variations by country. “By midcentury, projections indicate that 16 percent of the world population will be ages 65 and older, up from nine percent now. The percentage of people in this age bracket in the world’s more-developed countries is projected to reach 27 percent, up from 18 percent now, while the percentage of adults aged 65 and older in less-developed countries is projected to double to 14 percent.”
Pakistan’s youth bulge — the large number of citizens below the age of 30 — is often the subject of political and social commentary. This is understandable since this demographic is not only a source of opportunity for the country but also a potential ticking social time-bomb. But what about the elderly? Are we paying adequate attention to this segment of the population who, by and large, contributed to their families and society in their heyday of physical and mental liveliness, but who are often left feeling marginalised by society in their advancing years?
Dr Imran Afzal, family physician at the Jinnah Medical and Dental Hospital on Shaheed-e-Millat Road, Karachi, comes across many elderly patients in his day-to-day practice who suffer like Sadia and Saleem. “Most people after the age of 70 suffer from cognitive decline resulting in some level of memory loss or what in medical terms is known as dementia,” he says. “The most common problem in this age is depression, followed by dementia, Alzheimer’s and Parkinson’s disease.” The person may increasingly become forgetful or appear confused or agitated, he explains, or keep repeating what they are saying. With the passage of time, the condition deteriorates and medical treatment has to be sought. There is no cure for these conditions says Dr Afzal, but “anti-depressant or anxiolytic medicines help.”
“Memory loss that is often undiagnosed and depression, linked to socioeconomic issues specific to this age group, is also of concern in the elderly,” says Dr Saniya Sabzwari, associate professor at the Department of Family Medicine at Aga Khan University, Karachi. With advancing age, not only a person’s health deteriorates but his/her mobility is often restricted — either due to weakness or disease. This combination of illness and restricted mobility, along with boredom and a feeling of helplessness and dependency on others, often lead to psychological issues such as depression and anxiety.
“A major cause of this is loneliness as children are either abroad or do not give their parents enough time,” says Dr Afzal. “They need company.”
While some senior citizens complain of boredom and not having anything to do, others, despite limited faculties, are not able to let go of their daily routine. They want to continue with the way they used to do everything. When age slows them down and they fail to keep up the pace, many elderly people end up feeling depressed. While keeping themselves busy is generally a good thing, experts stress that senior citizens need to also understand and accept their limitations. Rather than overstress themselves and then feel drained of energy or experience pain and depression at being unable to do things as they used to, they should be encouraged to accept their limitations and not be ashamed to ask for help when needed. But for many, this is a matter of self-worth and needs to be handled gently and tactfully.
HEALTHCARE AND FINANCIAL SUPPORT
Though people are living longer, the elderly across the world cannot escape a number of illnesses such as hypertension, cardiovascular diseases, diabetes, musculoskeletal diseases, kidney diseases and bronchitis. These tend to increase and aggravate with age, and often one disease leads to another; for instance, long-term hypertension or diabetes often causes kidney problems, and restricted mobility may also result in obesity and related illnesses.
“Here in Pakistan, we often see long-standing diabetes and hypertension with complications related to disease longevity among the elderly,” says Dr Sabzwari of Aga Khan University. “Besides that, a number of cases have musculoskeletal problems such as arthritis and osteoporosis, both of which increase the risk of falls and decline in mobility and functioning.”
When the body is racked with such limitations and ailments, it needs constant care. In Pakistan, some families can afford to hire at-home attendants as 24/7 caregivers for elderly parents or grandparents. But even so, most attendants are ordinary maids who are untrained and do not know how to help patients sit or feed or bathe. Some agencies/welfare organisations do provide trained or semi-trained nurses/attendants but they come with a hefty price tag. There are still issues of trust that arise even when a trained nurse is hired.
Pakistan’s youth bulge — the large number of citizens below the age of 30 — is often the subject of political and social commentary. This is understandable since this demographic is not only a source of opportunity for the country but also a potential ticking social time-bomb. But what about the elderly?
There is a need to disseminate education about dementia at family, community and all levels say geriatricians. “Until you know how to manage dementia other than with drugs, the patient’s family and others can’t do much,” says a doctor of family medicine who sees many such patients. “The reason is that the medicines for dementia are not too promising, despite tall claims by manufacturers. You wouldn’t see anyone’s memory coming back. I think it is better that we understand that they can fall, they can get abusive or strike the other person or tear off their clothes — if this happens, the doctor should be told and he or she should be know how to adjust the medicine.”
Read: Supporting seniors
Another area of concern, which is often overlooked is the diet and nutritional needs of the elderly. They often do not eat a balanced diet, either out of ignorance — some think they don’t need as much nutrition as younger and more active people — or due to dental or digestive issues. “Elderly people are at greater risk for malnutrition and vitamin deficiencies and suffer from protein or calorie malnutrition causing weight loss, fatigue and increased risk of infections, etc,” says Dr Sabzwari.
Elderly people often suffer from both physical and psychological issues or they have physical problems that lead to psychological problems. Sometimes one medicine prescribed for some ailment does not interact well with medicine for another ailment, and they run the chance of experiencing a reaction or aggravating the problem. They not only end up taking several medicines but also going to various doctors for different ailments, which only adds to the hassle of seeking treatment.
One way to avoid frequent visits to a number of doctors is to consult a geriatrician, doctors who specialise in elderly care. Professor of medicine and senior consultant at the Indus Hospital, Dr Mohammed Junaid Patel explains that such physicians “focus on all aspects of healthcare in this age group, including their social support — which means spouse, children, relatives — living conditions, and home and community life, in collaboration with nurses, social workers, nutritionists, physical and occupational therapists, pharmacists and geriatric psychotherapists.” Dr Sabzwari says, “Ideally it should be one doctor dealing with most of [an elderly person’s] health needs. This facilitates health access, decreases cost and allows continuity of care.”
She further explains that, “Older individuals should be seen by geriatricians who are trained to manage this vulnerable population. However, worldwide there is a shortage of these specialists so they are managed by regular doctors, some of whom are not familiar with the special needs of this age.” In the West, the culture and certification for geriatric medicine developed only in the last 20 years. “In Pakistan, no geriatrics services or geriatric training programmes are offered,” says Dr Patel, “and there is no course with our certification bodies like CPSP [College of Physicians and Surgeons] which offer fellowship in geriatrics.”
There is also an abysmal lack of social security that could cover health expenses for the elderly in Pakistan. As senior citizens can no longer earn a living, they often ignore or delay seeking treatment if they are not well-off. Those dependent on their pension/savings, or on their children, do not take minor problems seriously, not realising that, at their age, minor problems can lead to complications, especially if they have some long-standing health issue.
“There are no subsidies on service fees or medicine for this age group in which a large majority are financially vulnerable and, for most of them, healthcare is a luxury that often gets sidelined,” says Dr Sabzwari. “They are only given attention when health problems become serious or life threatening.”
THE CURSE OF LONELINESS
Illnesses are not the only cause of discomfort for the elderly population. Loneliness, boredom and, in many cases, the feeling of financial dependence disturbs those who were used to being the breadwinners and homemakers. Often this worry can lead to health problems. Moreover, losing financial independence can divest one of their social standing as well.
Shahid, 70, had been gainfully employed in a government office, but after retirement he feels at a loss as his children are abroad or married and living separately. His busy work schedule did not allow him to make many friends or acquire a hobby. “I feel lonely as there is no one to give me company. I even tried to take up a job after retirement, but who hires a person of my age?” he says. “My former colleagues do not have time or the inclination to see me as now I have no position or influence. I have lost the social status that attracted people to me.”
Unfortunately, Shahid is not alone in his predicament. Senior citizens in Pakistan have few avenues to keep themselves busy once they leave the workforce. In government service as well as in many private organisations, the retirement age has been set at 60, although it can be argued that, at this age, most people are capable of and want to continue working. Recently, the age limit has been increased to 63 for government employees in Khyber Pakhtunkhwa; but, in the rest of the country, the matter is still awaiting decision. But even when they are inclined to find an occupation after retirement, there are not many employment options out there in a country where even the youth suffers from surging unemployment. When the mind is not applied to something productive and the body is slowing down as well, the result is a loss of self-worth, and loss of social status. Often the changes in lifestyle that this brings, in turn, result in depression and other psychological problems.
For some years, Fazila has been taking care of her parents who are both in their 80s. She is a professional, in her early 50s and single. “Because of my job I cannot give [my parents] much time. Plus how much can I talk to them and share their interests?”
“What they need is companionship,” she says. “There should be community centres or clubs for the elderly where they can go and spend some time in the company of like-minded people of their own age. There they can chat or play cards or board games and enjoy themselves for a while. They can even discuss their problems amongst themselves, which the younger generation may not be interested in or relate to.”
“A major problem these days is loneliness,” agrees Dr Patel. “A lot of the times the spouses are not able to keep up with each other due to ailments or even social reasons. There are times when a spouse is deceased but even talk of a second marriage is taboo.”
Public parks are accessible venues for senior citizens where they can spend leisure time and socialise. If they are lucky enough to meet someone their age in a park in their locality with whom they can talk to, they form an affinity and try to meet often. But roads are unsafe to walk on and whatever public libraries are there, are often not senior citizen-friendly, with reading rooms situated upstairs.
In the absence of formal or organised facilities, in lower-middle-class localities, one often sees elderly people from the neighbourhood sitting outside some house, chatting or playing board games. They form a group of their own and since they get to meet people of their own age, they feel less isolated.
OLD PEOPLE’S HOMES
Despite the stigma attached to the western idea of old people’s homes, it is not that there are no old homes in Pakistan. The idea is catching up, though such a facility is mostly used by those belonging to the middle class and sometimes the lower class; the well-to-do families can often afford to hire trained help and prefer to take care of their elderly relatives at home.
A couple of old people’s homes, located in North Nazimabad, do not present a picture of solace, however. Set up in small residences, with not much open space, both these centres are crammed living quarters, with six to eight beds in one room. There is no airconditioning, even though the temperature is in the high 30s outside. At one in the afternoon at one centre, most inhabitants are in their beds, waiting for lunch which is still being prepared in the kitchen. They all have only tales of woe and heartbreak as their relatives sent them here and have refused to take care of them. At an all-male facility a woman takes care of the inmates, helped by two boys. If anyone needs medical attention, the family is contacted to arrange a doctor. If the relatives are somewhere far, they ask the attendant to take the patient to the hospital before they arrive.
At another facility in North Nazimabad, men sit in the driveway as it is cleaning time indoors. The women are still cooped up inside their rooms and are not allowed outside for some reason. The men will be served tea in the evening outside the gate so that the ladies can come out for fresh air. The men say they enjoy sipping on tea outside the centre’s gate, as some residents of the neighbourhood often just come by to chat with them. The women have to be content indoors.
Given the state of affairs of this old people’s home, one wonders whether the families ever visit them or are satisfied to be merely paying for the lodging and boarding of their ageing parents.
Although society frowns on leaving the elderly in the care of strangers, seeing it as selfish and cruel, modern urban life has its own compunctions. Fahad, a banker in his late 40s, tries to provide his parents with the best care he can but it is challenging. “Why can’t we have places where I can leave my parents in the morning, if there is no one at home to take care of them, and take them back home once I return from work?” he says. “This way they wouldn’t be alone or dependent on untrained staff and will have company of people of their age group.”
A caring attitude is important. Dr Patel says, “What you have to do is to live with them not — keep them with you. Don’t say they live with you, say you live with them. They feel good having their independence and ownership. You have to give them their due respect. Whatever they do, we should tolerate as we do our kids.”
In our society, the twilight years are generally considered to be spent in prayer. One often hears the adage “Yeh to Allah Allah karney ke din hain”, implying the elderly are only counting down their days. Such comments about thinking and feeling individuals who can still contribute much to society should be taken with a pinch of salt. Meanwhile, society itself needs to give serious thought to taking care of the needs of an elderly population who have given the best years of their lives contributing to it.
The writer is a member of staff
Published in Dawn, EOS, July 7th, 2019