IPA Bulletin

The First Step in IPA's Southeast Asia Initiative

Vijay Chandra

Psychogeriatrics has often been dubbed as a "luxury of western countries". Historically this is appropriate as aging of the population first took place in the so called "western" countries of North America, Western Europe, Japan and Australia. Moreover, in these countries psychiatric services had advanced to the stage where subspecialties in psychiatry began to develop, and an important subspecialty which developed was psychogeriatrics. These services were also linked to the economic development of these countries.

However, a substantial part of the world has not been covered by adequate psychogeriatric services. This includes South America, Eastern Europe, Arab world, former Soviet Union and much of Southeast Asia. Many of the countries in these regions are economically far advanced and many of them are "graying" rapidly. Thus the International Psychogeriatric Association (IPA) recognizes that a substantial part of the world is underserved with psychogeriatric services and has started a major initiative in the development of these services.

IPA recognizes that "local culture" plays a significant role in how psychogeriatric illness is managed by the physicians and society. Economic development although important is not critical in the provision of psychogeriatric services. Thus in targeting psychogeriatric services to those parts of the world where it is not yet developed, IPA has established a committee on Diverse Cultures. This recognizes the fact that the need for cultural sensitivity is more important than a country's stage of economic development.

The countries of Southeast Asia deserve special attention. The Southeast Asia region contains 5 of the 32 most populous countries in the world. In mid-1990, the population of these 5 countries accounted for 23.6% of the world's total population. Three of the ten countries in the world having populations of more than 100 million are in Southeast Asia-Bangladesh, India, and Indonesia. The percentage of children (under 15 years of age) in this region is predicted to decrease from 41% in 1980 to 25.3% in 2002. In contrast, the percentage of elderly people (age 60 and above) is expected to increase from 5.3% in 1980 to 6.6% in 2005 and to 10.8% by 2025. In India, the projected increase during the period 1980-2000 is 93% for the population age 60 and above and 101.8% for the population age 70 and above; the total population will increase only by 40% during the same period.

Thus the relative weight of society's main dependent groups - children and the elderly - is shifting to the elderly, as fertility declines and more people live longer. Because older dependents lay claim to more public resources than young dependents, the weight of the "old" component of the total dependency ratio has great economic significance.

Numerous demographic and social changes are occurring for the first time in the history of many parts of the world. There are proportionally more older people today because of increasing life expectancy. Reduced fertility has at the same time resulted in a decrease in the number of younger people available to take care of older people. Most developing countries depend on family members to care for the elderly. The traditional pattern of multiple families of the same generation living together and sharing the burden of caring for the elderly is rapidly disappearing. Land in rural areas has been divided again and again over generations, so that each family member now has a small patch of land that is not economically viable. Many people have been forced to give up farming and migrate to urban areas, leaving their elderly people uncared for. Increasing economic expectations have also led to abandonment of traditional family occupations such as farming, fishing, or mining and to migration of younger people from villages to urban areas, leaving behind the elderly.

In urban areas, the problems are different but also immense. Several family generations must live together in small city apartments; intergenerational conflict often results. Servants, the mainstay of caretaking, are rapidly disappearing, so family members are being forced to do all the caretaking work themselves. Women are entering the work force in large numbers and thus becoming unavailable to care for the frail or sick elderly. Pressures on the family are immense. New and innovative methods must be considered to manage this phenomenon.

One of the issues related to population aging is the mental health of the elderly, which historically has been ignored in Southeast Asia. In most parts of the world, awareness is increasing among lay people and professionals of the special issues related to the mental health of the elderly. Potentially, large numbers of elderly people are in need of mental health services. For example, 10% of the elderly in India - about 8 million people - have been reported to be in need of psychogeriatric services. It is a challenge in all countries with large populations, such as China and Indonesia, to provide adequate services to all who need them.

IPA has played a pioneering role in developing psychogeriatrics as a specialized service and in promoting its cause around the world. IPA recognizes that culture strongly influences mental well-being and psychiatric services in general. Thus, formation of a committee on diverse cultures has been under consideration by the IPA Board of Directors. The IPA Latin America and Southeast Asia initiatives recognize the distinctive cultures and social and demographic characteristics of these regions.

The New Delhi workshop was the first step in the Southeast Asia initiative. Coinciding with the meeting of the IPA Board of Directors, a 3-day workshop was held in New Delhi March 9-11, 1996. Approximately 100 Indian delegates and over 60 foreign delegates attended. The first day was devoted entirely to Alzheimer's disease, the second day to other psychiatric disorders, and the third day to caring for the elderly. The scientific content of the presentations was excellent and was very well received by the Indian delegates, for whom it was a learning experience. In the session on Alzheimer's disease, it was clearly brought out that Alzheimer's disease occurs in India and in other parts of the developing world, just as it does in the developed countries. One major problem is failure to recognize it as a disease, which often leads to inappropriate diagnosis and management, much to the detriment of the patient and family. In the session on other psychiatric disorders, it was brought out that depression in old age remains a significant untreated problem that leads to substantial avoidable suffering amongst the elderly. The day on caring for the elderly was devoted to innovative methods of caring for the elderly in the countries of Southeast Asia, recognizing the existing cultural strengths and financial limitations.

Other high points of the meeting included the opening keynote address by the regional director of the World Health Organization (WHO), Dr. Uton Muchtar Rafei. He emphasized the importance of psychogeriatrics in this part of the world and the role of WHO in promoting the mental health of the elderly. Dr. Karan Singh, former king of Kashmir and Union Minister of Health, was an invited speaker. He gave a stimulating discussion of aging.

A major outcome of this meeting is the general awareness it has created about psychogeriatrics. The meeting was well covered in the lay newspapers. Another significant outcome of this meeting is the birth of a psychogeriatric society in India, which will interact closely with IPA to promote the mental health of the elderly in India and other countries of the region.

For more information about the work of the Southeast Asia Initiative, contact:

Vijay Chandra, MD
Director
Centre for Ageing Research, India
F-1/3 Vasant Vihar
New Delhi 110 057
India
91 11.614.3888
91 11.614.8167
vijay@cari.ernet.in

Vijay Chandra, MD, an IPA director, is the Director of the Centre for Ageing Research in New Delhi. He has served as Chair of the Section of Neuroepidemiology of the American Academy of Neurology and as an Executive Committee Member of the Research group on Dementia of the World Federation of Neurology. Dr. Chandra has been engaged in a cross-cultural study of Alzheimer's disease to determine if the prevalence of Alzheimer's disease varies in different cultures.