Who will look after the elderly?

Some children who are unable to keep up with the healthcare expenses for their elderly parent resort to abandoning them. — HASSAN BAHRI/The Star

The world’s population is changing in ways that could barely be imagined a generation ago.

Not only are we living longer, the richer, developed nations are also recording fewer births.

Soon, there will be more old people than young ones.

Japan is home to the oldest citizenry in the world, with 27% of its population being 65 years old or more – that’s just over one in four people.

By 2030, this figure is predicted to increase to 32.2% – just under one in three people.

In South-East Asia, Singapore leads the list with 26.6% of its population expected to be over the age of 65 in 2035, followed by Thailand with 22.8%.

On the local front, by 2030, Malaysia is expected to become an aged nation with the 60-and-above age group surpassing 15% of the population.

As a nation, we are still unprepared for this demographic shift as we have yet to create a “silver-friendly” economy and society.

Ageing is often looked upon as an added burden on society, especially when it comes to finances, healthcare services and long-term care.

Fuelled by increasing life expectancy and falling fertility rates, the number of older people with unmet care and support is also increasing substantially.

“The sad part is that our community doesn’t realise what they are facing these days.

“The statistics are all there in terms of ageing – you’ve got to start looking after yourself because there are not enough people to look after you!” says consultant occupational therapist Professor Nathan Vytialingam.

When a parent falls ill, care can be very expensive, especially after the parent has been discharged from the hospital as there are no insurance policies for long-term care.

He says: “We do have a few companies covering the elderly, but none for long-term care.

“For example, if someone has a stroke and is admitted in a private hospital, insurance (if you have any) will cover this, but when the acute phase is over and the patient goes home, there is no more coverage.

“People are unaware that we have no support system.”

This is where problems arise as children are at their wit’s end on how to manage financially, emotionally, psychologically and physically.

Long-term care

Global data from the United Nations shows that in 28 years’ time, three out of four elderly will need some kind of support, care and assistance. — 123rf.com

The patient would need nursing care, rehabilitation and a trained carer, all of which are not covered in insurance policies.

Speaking on Insurance and Long Term Care Coverage for Old Age at the 2022 Malaysian Hybrid Conference on Healthy Ageing, Prof Nathan says: “There are no tax exemptions for these expenses.

“You can claim tax benefits for aged parents, but not for long-term care.

“In Hong Kong, you can send parents to daycare services and it is covered under insurance.

“Here, we haven’t even started looking at such services for the elderly.

“We have poor health coverage and are depending on Indonesian or Filipino maids who are not trained to care for old people.”

Long-term care patients need nutritional support, medical support, an allied care support system (e.g. physiotherapy or occupational therapy), aids and adaptation (e.g. if a patient has an implant or undergone a knee replacement), and daycare support, among others.

Japan has already allocated part of its national budget to look into developing caregiving robots to assist in elderly care.

Prof Nathan says: “After a stroke or hip/knee replacement, patients recover much faster at home than in the hospital.

“With the multiple infections they can get at the hospital, you want to discharge the patient as quickly as possible.

“The quality of life is affected and their lifespan is going to be reduced if there is no proper care at home.”

He adds: “Some think the answer is to put the patient in a nursing home.

“So, we think we need more nursing homes, but WHO (the World Health Organization) says ageing in your own home is best.

“We cannot simply plug-and-pull (ideas) from another country and apply it here.

“It doesn’t work that way; instead, we have to build a care-giving workforce.”

One simply cannot hire a carer and say, “Please look after my mum” and leave.

The carer must know how to communicate, pick up signs of depression and so on; our domestic maids are not trained to do this.

Global data from the United Nations shows that currently 21 per 100 elderly people need some kind of support, care and assistance.

By 2035, it will be 36 per 100, and by 2050, 75 out of 100 will need support.

“The numbers are frightening.

“Ageing comes with certain medical conditions and this is common. All bodily systems are involved, including your skin.

“Mental health is an area that everybody neglects, but due to Covid-19, now everyone is paying more attention to it.

“At the height of the pandemic, old people were all at home and had no way of communicating or socialising except via phone calls or virtually, leading to depression.

“As soon as doors opened, they all wanted to go out and meet friends and loved ones,” Prof Nathan points out.

Abandoned and alone

Long-term care services are needed to help the elderly live as independently and safely as possible when they can no longer perform everyday activities on their own. — Filepic

And then there are cases where the children can no longer cope with the rising health costs and other expenses, and abandon their elderly parents.

“We have seen abandonment taking place, especially among the B40 and M40 income groups, though many people may not realise this is happening.

“Even in the 1980s when I was doing ward rounds in Hospital Kuala Lumpur, I recall patients abandoned by their families, who would give false phone numbers so we couldn’t trace them.

“It’s the greatest human misery – after working hard your whole life to raise your children, you are abandoned by them and society in your golden years,” says Prof Nathan.

Perdana University did a recent study on the “Perception of Malaysian Working Adults on Tax Exemption on Purchasing Insurance for Parents with Pre-Existing Illness” with 345 participants.

The subjects were mostly graduates who were earning between RM3,000 to RM3,999 a month.

Results showed that the younger generation need a lot of incentives to look after older persons.

“More than 50% of the respondents conceded that they were caregivers for their parents with pre-existing illness and spent around RM500 a month for medical expenses.

“They relied on government healthcare facilities because they couldn’t afford to buy insurance policies.

“They had an indifferent attitude towards purchasing insurance coverage,” shares Prof Nathan, who is also dean of Perdana University’s School of Occupational Therapy.

The younger ones cannot always be blamed.

“It’s easy to say the younger generation are not supporting the older generation, but they don’t have enough for themselves and are sandwiched in between.

“Policymakers should provide incentives.

“When we purchase insurance policies, we do not read in between the lines, and only much later do we realise certain things are not provided at all,” he says.

The national average for long-term care expenses in Malaysia is high, varying from RM20 per hour to RM300 for eight hours for a nurse.

This is going to blow a hole in the pockets of the family.

“If a tax exemption is given for purchasing health coverage for parents, it will definitely lessen the burden of medical expenses that consumers need to bear,” he points out.

Suicidal behaviour

Globally, older persons have a higher suicide rate than younger people, and they are more likely to succeed in their attempts.

Why?

“They are more determined and less impulsive when attempting suicide.

“Since they are generally frailer, they tend to die before being discovered and rescued,” says consultant geriatric psychiatrist Dr Teh Ewe Eow in his paper Suicide Prevention in Older Persons.

Depression is common among this subset of the population, but they seldom seek help.

The elderly are less likely to complain of feeling sad when they are depressed.

Instead, they complain of anxiety, forgetfulness, sleep disorders and so on.

They are also more worried about illness, and some may have psychosis, poor eating and drinking, or poor motivation to do things.

Older persons also face religious struggles, e.g. they take illness as a sign of being punished by God, and this may paradoxically increase the risk of suicide.

Says Dr Teh: “Patients tend to complain of somatic (body) symptoms and they consult a general practitioner (GP) first before attempting suicide.

“The GP must know how to pick up signals and refer them to a psychiatrist.

“Generally, the more ill the population, the higher the prevalence of depression.

“Although there is no single intervention that can stop suicide, it can be prevented by enhancing medical care, establishing social support networks and adapting coping behaviour, but these need to be started from a younger age.”

Harder to die

Malaysia has yet to think of setting up daycare facilities for the elderly such as this one in Tokyo, Japan. — AFP

Yes, we are living longer, but we are not in perfect health.

Increasing medical knowledge and advances in technology is leading to a push by the patient and/or their family and a pull by the medical profession.

According to consultant geriatrician Datuk Seri Dr Thamboo Pragasam Devaraj, this may lead to overmedicalisation.

“Dying is becoming harder for patients, family and healthcare workers,” he says in his paper End of Life.

“We cannot deny that death is imminent, but we cannot postpone death either.

“When the final milestone comes, some of the beliefs are more the manner of dying rather than dying itself.

“Will there be a lot of suffering? Will it be protracted? Will I be alone and what happens after death?”

As far as the individual is concerned, awareness that life will end is something real, but sometimes, death is not of immediate concern unless a family member or friend is ill.

It then serves as a reminder that death is certain and personal.

At the same time, it gives an option for one to find the meaning and purpose of life.

Dr Thamboo says: “For every progressive illness, there is hope.

“It’s amazing to see that no matter how advanced the illness is, there is hope for a cure or control, or hope that the end will be peaceful and quick.

“But the reality is that those with progressive illness can be stable for months or years, or unstable, or deteriorate rapidly.

“There is always this push and pull with clinical intervention, which may be inappropriate and costly.”

Some patients may also ask why it is taking so long to die.

“It is very difficult to say when the final days will be, but there is a gradual withdrawal.

“Their desire is not to suffer and they want to go, especially if they have finished their agenda.

“They don’t want to be a burden, and will look for reconciliation and forgiveness.

“The family future is safeguarded, and very often, they want to die at home.

“And they want to be remembered,” he says.