Asian Journal of Psychiatry 13 (2015) 1–2
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Editorial
Aging population in Asia: Are we preparing ourselves enough?
More than 4 billion people live in Asia and this amount to 60% of the world’s population. Two countries, i.e., China and India, which have the highest population compared to any other country in the world, are in the Asian continent. It is projected that by 2040, of the 2.1 billion increases in population worldwide, 1 billion will occur in Asia. At present the major proportion of population of countries in Asia is young and elderly contribute only a very small proportion of the total population, but this is changing. Due to the major proportion being in the young working age, Asia is seeing increase in the per capita output, a phenomenon labelled as ‘demographic dividend’. Additionally, there is rapid urbanization in most of the Asian countries, which provides opportunity for better income and health care facilities. This change in demographic is also accompanied by social changes like increase in the proportion of working women, delayed marriages, decrease in the average size of household and less number of people available at home to take care of children and elderly (Chomik et al., 2013). If one examines the demographic trends, over the years due to decrease in the fertility rates and increase in the life-expectancy, there is increase in the proportion of elderly population in most of the Asian countries. As Asia is a huge continent with variable demographic trends, some countries like Japan are already facing the consequences of increase in the proportion of the elderly people. However, it is important to note that this is just a beginning for other countries, especially China and India, as with the persistence of current demographic trends, the proportion of elderly is going to increase very rapidly by 2050. For example in India, in 1951, those aged more than 60 years formed only 5.5% of the total population and this increased to 8.5% as per the 2011 census. However, it is projected that by 2050, 19% of the population of India will be of elderly (UNDESA, 2002). In terms of increase in elderly population compared to other age groups, between the years 2000 and 2050, India will see a population growth of 55%, however, the elderly (>60 years) population will increase by 326% and ‘older old’ (i.e., those with age 80 or more) are going to increase by 700%. However, when one looks at these changing percentages from the point of absolute numbers, the change will be of staggering dimensions. For example, in terms of absolute numbers, it is estimated that India will be home of 323 million elderly by 2050, a number which is greater than the total population of United States of America in the year 2012 (United Nation Population Division, 2014). For the Whole Asia it is projected that between the years 2000 and 2050, there will be 314% increase in elderly population. However, it is important to note that half of the extra 1 billion which is going to be added to Asia by 2050 will be aged more than http://dx.doi.org/10.1016/j.ajp.2015.02.003 1876-2018/ß 2015 Elsevier B.V. All rights reserved.
65 years. The increase in proportion of elderly population in Asia will lead to increase in the ratio of older (i.e., those aged more than 65 years) to the working age population (i.e., those aged 15–64) indicating an increase in the ‘dependency ratio’ or reduction in the ‘potential support ratio’. Another index, i.e., ‘parent support ratio’, which is defined as the ratio of people aged 85 years and above to the people aged 50–64 and reflects the burden of those aged 85 or above on their offspring, is also going to increase 5 times the current level in Asia by 2050. Other demographic trends important from the health care perspective is that women will constitute the major proportion of the elderly, who will be single, economically dependent and will be living in rural areas (UNDESA, 2002). Another important aspect from health care perspective is that over the years with the better control of infectious diseases and people living longer, there is increase in those with chronic noncommunicable diseases like diabetes mellitus, hypertension, etc. Infact, with the current trend, some consider India to be the capital of diabetes mellitus. Further the prevalence of obesity and hypertension is also proportionately high (Joshi and Parikh, 2007). The changing demographic profile and accompanying social changes will bring along a major crisis for health care, if the governments in these countries do not rise up to the call. These changes are going to increase the demand for health services, increase in need for long term care, increase in the needs for income and social security along with decline in social support. At present in many Asian countries, because of the traditional family culture, family members take care of their sick relatives. However, with the shrinkage in the family size, increase in the dependency ratio and parent support ratio, there would be more people requiring help rather than taking care of others. From mental health perspective, elderly not only will require care for chronic mental disorders which begin in younger age, but also develop mental health problems which are specific to this age group. Older people more often experience stressors like bereavement, drop in financial resources with retirement, increase in prevalence of chronic physical illnesses and overall disability. Mental health problems are compounded by frail physical health as these compromises with ability to live independently because of chronic pain and limited mobility. All these factors contribute to isolation, loneliness, dependency and psychological distress. Further it is important to remember that poor mental health and physical health can impact each other not only in terms of prevalence, but in terms of participation and cooperation for treatment and ultimately the overall outcome (WHO, 2013). It is estimated that more than 20% of elderly aged more than 60 years of age suffer from one or other mental and neurological
2
Editorial / Asian Journal of Psychiatry 13 (2015) 1–2
disorder and 6.6% of all disability adjusted life years (DALYs) among elderly are due to the mental and neurological disorders. Among the various disorders, dementia and depression are the most common (Institute of Health Matrics and Evaluation, 2010). The prevalence of Alzheimer’s dementia and other type of dementia increases with age (Alzheimer’s Association, 2014). It is estimated that number of people suffering from dementia are going to double every 20 years and by 2030, there would 65.7 million people with dementia, which is going to increase to 115.4 million by 2050 with 71% of them living in low and middle income countries (Prince et al., 2013). Depression among elderly is often overlooked, under-diagnosed and undertreated because it is considered as a part and parcel of problems in old age (Wang et al., 2013). Substance abuse among the older subjects is often overlooked (WHO, 2013). When it comes to health care services, in most of the Asian countries, there are no specific services for elderly and they have to compete with younger persons to receive the health care, which is limited in many of the Asian countries. All these problems are compounded by the fact that there is no concept of healthy aging in many of the Asian countries. Further, in terms of trained manpower, the physicians and mental health professionals are not trained to specifically to handle geriatric patients. For example, in a country like India, there are only two institutes in the whole country which specifically provides sub-speciality degree (DM in Geriatric Mental Health) or diploma (Post Doctoral Fellowship in Geriatric Mental Health). Resultantly, physicians and mental health professionals who are interested in Geriatric Medicine and Geriatric Psychiatry do not get opportunity to train themselves. The situation is no different in other Asian countries (Wang et al., 2013). Research in the Area of geriatric psychiatry is meagre from Asian countries. Considering the sociocultural and genetic variation it can be safely said that findings from the Western countries cannot be generalised to whole extent to the Asian population (Wang et al., 2013). Further considering the huge population in some of the Asian countries, the western models of providing services may not be applicable to Asian Countries (Wang et al., 2013). Accordingly, there is an urgent need to reorganize the health care services for addressing the issues of elderly. This will involve improving the training of health care professionals for caring for elderly, devising strategies to prevent and manage chronic diseases associated with old age including mental, neurological and substance use disorders, developing elderly friendly services and settings (WHO, 2013). Additionally there is a need to design sustainable policies for long-term and palliative care (WHO, 2013). Keeping these things in mind, the theme issue of Asian Journal of Psychiatry on Geriatric Psychiatry is a step in the right direction. The population based study from Karachi which assessed the relationship of functional status and physical activity with depression among elderly is a brave effort to understand the role of physical activity in countering depression. This study shows that spending more time per week in physical activity reduces the chances of developing depression (Bhamani et al., 2015). There is a need for similar large sample, multicentric studies from other parts of the Asia to understand other important preventive aspects related to geriatric mental health. The Magnetic Resonance Imaging study on patients with late onset depression elucidates the role of hippocampal atrophy, especially posterior hippocampus in elderly depression (Sivakumar et al., 2015).
There are efforts throughout the globe to understand the pathophysiology of dementia and to identify the markers which can help in making a robust diagnosis. The paper by Huded et al. (2015) in this issue of the journal looks at the usefulness of Cerebrospinal fluid (CSF) biomarkers to enhance the National Institute on Aging-Alzheimer’s Association criteria for diagnosis of Alzheimer’s type dementia – a study from Southern India and the authors show that p-tau/t-tau and p-tau/Ab ratio are good indicators of severity of dementia and can be useful in differentiating mild Alzheimer’s Dementia from moderate to severe Alzheimer’s Dementia. If these findings are further replicated this can have lot of clinical implications in terms of making treatment decisions and overall management of patients with Alzheimer’s Dementia. It is expected that similar research efforts in future will strengthen the subspecialty of Geriatric Psychiatry in Asia. There is a need to form a consortium of researchers from Asia interested in the field of Geriatric Psychiatry to conduct large multicentric studies which will focus on issues specific to elderly population living in Asia. Similarly, there is an urgent need to improve training in the area of geriatric medicine and geriatric psychiatry so as to develop manpower. The professional bodies should liaise with the governments to bring about change in the existing policies to strengthen the subspecialty of geriatric psychiatry. References Alzheimer’s Association, 2014. 2014 Alzheimer’s disease facts and figures. Alzheimers Dement. 10 (2) . Bhamani, M.A., Khan, M.M., Karim, M.S., Mir, M.U., 2015. Depression and its association with functional status and physical activity in the elderly in Karachi, Pakistan. Asian J. Psychiatry 15 . Chomik, C.R., Piggott, J., 2013. Asia in the Ageing Century: Part I – Population Trends. CEPAR Research Brief 2013/01, CEPAR. Australian School of Business, Kensington Campus, The University of New South Wales, Sydney, NSW 2052. Huded, C.B., Bharath, S., Chandra, S.R., Sivakumar, P.T., Varghese, M., Subramanian, S., 2015. Supportive CSF biomarker evidence to enhance the National Institute on Aging-Alzheimer’s Association criteria for diagnosis of Alzheimer’s type dementia – a study from Southern India. Asian J. Psychiatry 13, 44–47. Institute for Health Metrics and Evaluation, 2010. Global Burden of Disease Study. Joshi, S.R., Parikh, R.M., 2007. India – diabetes capital of the world: now heading towards hypertension. J. Assoc. Physicians India 55, 323–324. Prince, M., Bryce, R., Albanese, E., Wimo, A., Ribeiro, W., Ferri, C.P., 2013. The global prevalence of dementia: a systematic review and metaanalysis. Alzheimers Dement. 9,, 63.e2–75.e2. Sivakumar, P.T., Kalmady, S.V., Venkatasubramanian, G., Bharath, S., Reddy, N.N., Rao, N.P., Kavoor, T.M.E., Jain, S., Varghese, M., 2015. Volumetric analysis of hippocampal sub-regions in late onset depression: a 3 T magnetic resonance imaging study. Asian J. Psychiatry 13, 38–43. UNDESA, 2002. World Population Ageing: 1950–2050. Department of Economic and Social Affairs, Population Division, United Nations, New York. United Nations Population Division (UN), 2014. World Population Prospects: The 2010 Revision. United Nations, 2011, New York. , http://esa.un.org/unpd/wpp/ index.htm (accessed on April 2014). Wang, H., Fernandes, L., Oster, S., Takeda, M., Brodaty, H., Mintzer, J.E., 2013. The state of psychogeriatrics in different regions of the world: challenges and opportunities. Int. Psychogeriatr. 25, 1563–1569. World Health Organization, 2013. Mental Health and Older Adults, Fact Sheet No381.
Sandeep Grover Associate Professor, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India E-mail address: [email protected] (S. Grover).
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Editorial
Aging population in Asia: Are we preparing ourselves enough?
More than 4 billion people live in Asia and this amount to 60% of the world’s population. Two countries, i.e., China and India, which have the highest population compared to any other country in the world, are in the Asian continent. It is projected that by 2040, of the 2.1 billion increases in population worldwide, 1 billion will occur in Asia. At present the major proportion of population of countries in Asia is young and elderly contribute only a very small proportion of the total population, but this is changing. Due to the major proportion being in the young working age, Asia is seeing increase in the per capita output, a phenomenon labelled as ‘demographic dividend’. Additionally, there is rapid urbanization in most of the Asian countries, which provides opportunity for better income and health care facilities. This change in demographic is also accompanied by social changes like increase in the proportion of working women, delayed marriages, decrease in the average size of household and less number of people available at home to take care of children and elderly (Chomik et al., 2013). If one examines the demographic trends, over the years due to decrease in the fertility rates and increase in the life-expectancy, there is increase in the proportion of elderly population in most of the Asian countries. As Asia is a huge continent with variable demographic trends, some countries like Japan are already facing the consequences of increase in the proportion of the elderly people. However, it is important to note that this is just a beginning for other countries, especially China and India, as with the persistence of current demographic trends, the proportion of elderly is going to increase very rapidly by 2050. For example in India, in 1951, those aged more than 60 years formed only 5.5% of the total population and this increased to 8.5% as per the 2011 census. However, it is projected that by 2050, 19% of the population of India will be of elderly (UNDESA, 2002). In terms of increase in elderly population compared to other age groups, between the years 2000 and 2050, India will see a population growth of 55%, however, the elderly (>60 years) population will increase by 326% and ‘older old’ (i.e., those with age 80 or more) are going to increase by 700%. However, when one looks at these changing percentages from the point of absolute numbers, the change will be of staggering dimensions. For example, in terms of absolute numbers, it is estimated that India will be home of 323 million elderly by 2050, a number which is greater than the total population of United States of America in the year 2012 (United Nation Population Division, 2014). For the Whole Asia it is projected that between the years 2000 and 2050, there will be 314% increase in elderly population. However, it is important to note that half of the extra 1 billion which is going to be added to Asia by 2050 will be aged more than http://dx.doi.org/10.1016/j.ajp.2015.02.003 1876-2018/ß 2015 Elsevier B.V. All rights reserved.
65 years. The increase in proportion of elderly population in Asia will lead to increase in the ratio of older (i.e., those aged more than 65 years) to the working age population (i.e., those aged 15–64) indicating an increase in the ‘dependency ratio’ or reduction in the ‘potential support ratio’. Another index, i.e., ‘parent support ratio’, which is defined as the ratio of people aged 85 years and above to the people aged 50–64 and reflects the burden of those aged 85 or above on their offspring, is also going to increase 5 times the current level in Asia by 2050. Other demographic trends important from the health care perspective is that women will constitute the major proportion of the elderly, who will be single, economically dependent and will be living in rural areas (UNDESA, 2002). Another important aspect from health care perspective is that over the years with the better control of infectious diseases and people living longer, there is increase in those with chronic noncommunicable diseases like diabetes mellitus, hypertension, etc. Infact, with the current trend, some consider India to be the capital of diabetes mellitus. Further the prevalence of obesity and hypertension is also proportionately high (Joshi and Parikh, 2007). The changing demographic profile and accompanying social changes will bring along a major crisis for health care, if the governments in these countries do not rise up to the call. These changes are going to increase the demand for health services, increase in need for long term care, increase in the needs for income and social security along with decline in social support. At present in many Asian countries, because of the traditional family culture, family members take care of their sick relatives. However, with the shrinkage in the family size, increase in the dependency ratio and parent support ratio, there would be more people requiring help rather than taking care of others. From mental health perspective, elderly not only will require care for chronic mental disorders which begin in younger age, but also develop mental health problems which are specific to this age group. Older people more often experience stressors like bereavement, drop in financial resources with retirement, increase in prevalence of chronic physical illnesses and overall disability. Mental health problems are compounded by frail physical health as these compromises with ability to live independently because of chronic pain and limited mobility. All these factors contribute to isolation, loneliness, dependency and psychological distress. Further it is important to remember that poor mental health and physical health can impact each other not only in terms of prevalence, but in terms of participation and cooperation for treatment and ultimately the overall outcome (WHO, 2013). It is estimated that more than 20% of elderly aged more than 60 years of age suffer from one or other mental and neurological
2
Editorial / Asian Journal of Psychiatry 13 (2015) 1–2
disorder and 6.6% of all disability adjusted life years (DALYs) among elderly are due to the mental and neurological disorders. Among the various disorders, dementia and depression are the most common (Institute of Health Matrics and Evaluation, 2010). The prevalence of Alzheimer’s dementia and other type of dementia increases with age (Alzheimer’s Association, 2014). It is estimated that number of people suffering from dementia are going to double every 20 years and by 2030, there would 65.7 million people with dementia, which is going to increase to 115.4 million by 2050 with 71% of them living in low and middle income countries (Prince et al., 2013). Depression among elderly is often overlooked, under-diagnosed and undertreated because it is considered as a part and parcel of problems in old age (Wang et al., 2013). Substance abuse among the older subjects is often overlooked (WHO, 2013). When it comes to health care services, in most of the Asian countries, there are no specific services for elderly and they have to compete with younger persons to receive the health care, which is limited in many of the Asian countries. All these problems are compounded by the fact that there is no concept of healthy aging in many of the Asian countries. Further, in terms of trained manpower, the physicians and mental health professionals are not trained to specifically to handle geriatric patients. For example, in a country like India, there are only two institutes in the whole country which specifically provides sub-speciality degree (DM in Geriatric Mental Health) or diploma (Post Doctoral Fellowship in Geriatric Mental Health). Resultantly, physicians and mental health professionals who are interested in Geriatric Medicine and Geriatric Psychiatry do not get opportunity to train themselves. The situation is no different in other Asian countries (Wang et al., 2013). Research in the Area of geriatric psychiatry is meagre from Asian countries. Considering the sociocultural and genetic variation it can be safely said that findings from the Western countries cannot be generalised to whole extent to the Asian population (Wang et al., 2013). Further considering the huge population in some of the Asian countries, the western models of providing services may not be applicable to Asian Countries (Wang et al., 2013). Accordingly, there is an urgent need to reorganize the health care services for addressing the issues of elderly. This will involve improving the training of health care professionals for caring for elderly, devising strategies to prevent and manage chronic diseases associated with old age including mental, neurological and substance use disorders, developing elderly friendly services and settings (WHO, 2013). Additionally there is a need to design sustainable policies for long-term and palliative care (WHO, 2013). Keeping these things in mind, the theme issue of Asian Journal of Psychiatry on Geriatric Psychiatry is a step in the right direction. The population based study from Karachi which assessed the relationship of functional status and physical activity with depression among elderly is a brave effort to understand the role of physical activity in countering depression. This study shows that spending more time per week in physical activity reduces the chances of developing depression (Bhamani et al., 2015). There is a need for similar large sample, multicentric studies from other parts of the Asia to understand other important preventive aspects related to geriatric mental health. The Magnetic Resonance Imaging study on patients with late onset depression elucidates the role of hippocampal atrophy, especially posterior hippocampus in elderly depression (Sivakumar et al., 2015).
There are efforts throughout the globe to understand the pathophysiology of dementia and to identify the markers which can help in making a robust diagnosis. The paper by Huded et al. (2015) in this issue of the journal looks at the usefulness of Cerebrospinal fluid (CSF) biomarkers to enhance the National Institute on Aging-Alzheimer’s Association criteria for diagnosis of Alzheimer’s type dementia – a study from Southern India and the authors show that p-tau/t-tau and p-tau/Ab ratio are good indicators of severity of dementia and can be useful in differentiating mild Alzheimer’s Dementia from moderate to severe Alzheimer’s Dementia. If these findings are further replicated this can have lot of clinical implications in terms of making treatment decisions and overall management of patients with Alzheimer’s Dementia. It is expected that similar research efforts in future will strengthen the subspecialty of Geriatric Psychiatry in Asia. There is a need to form a consortium of researchers from Asia interested in the field of Geriatric Psychiatry to conduct large multicentric studies which will focus on issues specific to elderly population living in Asia. Similarly, there is an urgent need to improve training in the area of geriatric medicine and geriatric psychiatry so as to develop manpower. The professional bodies should liaise with the governments to bring about change in the existing policies to strengthen the subspecialty of geriatric psychiatry. References Alzheimer’s Association, 2014. 2014 Alzheimer’s disease facts and figures. Alzheimers Dement. 10 (2) . Bhamani, M.A., Khan, M.M., Karim, M.S., Mir, M.U., 2015. Depression and its association with functional status and physical activity in the elderly in Karachi, Pakistan. Asian J. Psychiatry 15 . Chomik, C.R., Piggott, J., 2013. Asia in the Ageing Century: Part I – Population Trends. CEPAR Research Brief 2013/01, CEPAR. Australian School of Business, Kensington Campus, The University of New South Wales, Sydney, NSW 2052. Huded, C.B., Bharath, S., Chandra, S.R., Sivakumar, P.T., Varghese, M., Subramanian, S., 2015. Supportive CSF biomarker evidence to enhance the National Institute on Aging-Alzheimer’s Association criteria for diagnosis of Alzheimer’s type dementia – a study from Southern India. Asian J. Psychiatry 13, 44–47. Institute for Health Metrics and Evaluation, 2010. Global Burden of Disease Study. Joshi, S.R., Parikh, R.M., 2007. India – diabetes capital of the world: now heading towards hypertension. J. Assoc. Physicians India 55, 323–324. Prince, M., Bryce, R., Albanese, E., Wimo, A., Ribeiro, W., Ferri, C.P., 2013. The global prevalence of dementia: a systematic review and metaanalysis. Alzheimers Dement. 9,, 63.e2–75.e2. Sivakumar, P.T., Kalmady, S.V., Venkatasubramanian, G., Bharath, S., Reddy, N.N., Rao, N.P., Kavoor, T.M.E., Jain, S., Varghese, M., 2015. Volumetric analysis of hippocampal sub-regions in late onset depression: a 3 T magnetic resonance imaging study. Asian J. Psychiatry 13, 38–43. UNDESA, 2002. World Population Ageing: 1950–2050. Department of Economic and Social Affairs, Population Division, United Nations, New York. United Nations Population Division (UN), 2014. World Population Prospects: The 2010 Revision. United Nations, 2011, New York. , http://esa.un.org/unpd/wpp/ index.htm (accessed on April 2014). Wang, H., Fernandes, L., Oster, S., Takeda, M., Brodaty, H., Mintzer, J.E., 2013. The state of psychogeriatrics in different regions of the world: challenges and opportunities. Int. Psychogeriatr. 25, 1563–1569. World Health Organization, 2013. Mental Health and Older Adults, Fact Sheet No381.
Sandeep Grover Associate Professor, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India E-mail address: [email protected] (S. Grover).
