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41]

Review Article

Disability among the elder population of India: A public

health concern
Amit Agrawal
Department of Neurosurgery, Narayana Medical College Hospital, Nellore, Andhra Pradesh, India

Abstract
The Government of India adopted the National Policy on Older Persons in 1999, which defines a senior citizen or
elderly as a person who is of age 60 years or above. In India the elderly population accounted for 8.2% of the total
population in 2011 and the number is expected to increase over the next decades. The link between aging and disability
is a biological fact, and disability in the elderly is an important health indicator pointing to jeopardized quality of life.
But at the same time, aging should not be treated as synonymous with disability as a large proportion of older people
live with good health status. There are many studies from India that have addressed disability in the elderly population;
however, they lack uniformity in defining disability and largely address mostly one aspect, that is, the medical model of
disability. It is well recognized that disability and elderly encompasses a much larger spectrum of the conditions with
unique requirements and needs to be studied as a much broader concept.
Key Words: Aging, disability, India, rural

INTRODUCTION DEFINING ELDERLY AND DISABILITY

The significant increase in an aging world population has
resulted in rising proportions of older persons in the total
population with profound consequences on a broad range
of economic, political, and social processes. Although aging
partly reflects the longer and generally healthier lives of
individuals, it is simultaneously associated with chronic
and degenerative diseases, which become more common at
older ages. Disability can jeopardize the quality of life in the
elderly and is an important health indicator that can have
heavy social impact with long-term institutionalization
and increased use of medical care.[1] In addition, as people
age there are increased chances of becoming disabled, and
once disabled, there are increased chances of deterioration
with decreased likelihood of recovering from disability.[2]
Disability and elderly encompasses a large spectrum of
conditions, with unique requirements. In the present
review, we discuss the current status of disability patterns
in the elderly population from India.
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In most of the developed world, the accepted definition
of elderly or older person is the chronological age of
65 years minimum; there is no United Nations standard
numerical criterion, but the UN agreed cutoff is 60+
years to refer to the older population.[3] The Government
of India adopted the National Policy on Older Persons in
January, 1999 and this policy defines senior citizen or
elderly as a person who is of age 60 years or above.[4]
In India the elderly population accounted for 8.2% of the
total population in 2011, and the number is expected to
increase dramatically over the next four decades (to 19%
in 2050).[5]
The International Classification of Functioning,
Disability and Health (ICF) defines disability as an
umbrella term for impairments, activity limitations,
and participation restrictions.[6] Disability has been
defined as a restriction or lack of ability to perform an
This is an open access article distributed under the terms of the
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DOI: 10.4103/0972-4958.175791 How to cite this article: Agrawal A. Disability among the elder
population of India: A public health concern. J Med Soc 2016;30:15-9.

Address for correspondence: Dr. Amit Agrawal, Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore -
524 003, Andhra Pradesh, India. E-mail: dramitagrawal@gmail.com

2016 Journal of Medical Society | Published by Wolters Kluwer - Medknow 15

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Agrawal: Disability among the elderly
activity in the manner or within the range considered
normal for a human being.[7] Operational measures of
disability vary according to the purpose and application
of the data, the conception of disability, the aspects of
disability examined impairments, activity limitations,
participation restrictions, related health conditions,
environmental factors [][8] Often, types of
disability are defined using only one aspect of disability,
such as impairments sensory, physical, mental,
intellectual and at other times they conflate health
conditions with disability.[8]
This holds true for many of studies from India where
there is no uniformity in defining the elderly or clear
demarcation of disability from morbid conditions. It
has been emphasized that most of the studies discuss
the morbid and co-morbid conditions but do not
address the issues of resulting disability.[9] Additionally,
people with chronic health conditions, communication
difficulties, and other impairments may not be included
in these estimates, despite encountering difficulties in
everyday life.[8] Disability in the elderly can be grouped
into who can manage in their daily activities with the
help of mechanical devices, who have multiple health
problems and severe limitations in mental and/or physical
functioning that require very intensive levels of care
and in between above two groups, they are functionally
disabled in one or two (activities of daily living (ADLs),
or have mild cognitive impairments.[10]
MORBIDITY AMONG ELDERLY
Many chronic illnesses can influence the quality of life
in elderly populations, and there is evidence that there
is increased risk of multiple comorbidities in elderly
populations that may lead to disability.[11] It has been well
recognized in many studies from India that morbidity
influences the physical functioning and psychological
well-being of elderly populations;[12-15] the need to
develop geriatric health care services in developing
countries on the basis of existing morbidity profile must
be emphasized.[15] A number of morbidity patterns have
been identified in elderly populations, which include
hypertension, diabetes, arthritis, constipation, cataracts
and hearing loss.[16] In another study, the authors
recognized many morbid conditions [p]ain/swelling of
joints, limitation of movement, indigestion/heart bum,
backache, breathlessness, giddiness/fainting, frequency/
urgency, change in bowel habits and blurring of vision
[] in the elderly population from a mix of rural and
urban communities.[15]
Chandwani et al.[16] found that 73% respondents felt that
their age affected their day-to-day life and 58% reported
that their age partially affected their daily activities. In
these studies, morbid conditions were recognized and it
was found that age was affecting their daily activities.
16
However, these studies did not define disability and
were unable to show quantitatively the effect of age and
morbid conditions as the cause of disability in greater
detail.
In one study it was found that 51.5% of elderly people
over 60 years of age had fallen (ending up on the floor
or ground unintentionally), and 21.3% sustained fractures
and 79.6% other injuries.[13] It is important to note that
the fall is not a diagnosis but can be a manifestation
of multiple underlying disease like visual impairment
(cataract, corneal opacity), postural hypotension,
degenerative joint disease, giddiness, and depression,
the effects of certain medications on homeostasis, and/
or environmental hazards or obstacles that interfere with
safe mobility.[13]
High prevalence of morbidity has been observed in
the elderly population residing in rural areas of the
country.[13,15,17] A study that included about 90% of the
population from urban areas and 10% from rural concluded
that the morbidity among urban subjects (90.7%) was
higher than among rural (77.6%) ones.[15] However, most
of these studies on multimorbidity in India are disease-
specific and do not provide a comprehensive overview of
the wide range of disabilities that can occur due to many
of the diseases among elderly populations.[9,15,17,18]
DISABILITY IN INDIA
It has been well recognized that elderly persons
constitute one of the most vulnerable groups, who have
more chances of developing chronic disease, infections,
and subsequent disabilities.[7] As a result, the elderly
population is at greater risk of being less healthy than
the nonelderly population.[19] It has been suggested that
the aging population in India will lead to increases in
the prevalence of chronic conditions, including diabetes
and hypertension, and nearly one-half (45%) of Indias
disease burden is projected to be borne by older adults
in 2030.[20] Early results from a pilot phase of the
Longitudinal Aging Study in India showed that 13% of
older Indians sampled have some type of disability that
affects at least one activity of daily living.[20] The survey
Report on the Status of Elderly in Select States of India,
2011 collected information on locomotor disability,
and questions were asked about the about difficulty
regarding vision, hearing, walking, chewing, speaking, and
memory.[21] It was found that the prevalence of locomotor
disability was highest for vision (about 60%) and lowest
for the speech (about 7%).[21]
In a study that used Barthels ADL questionnaire, the
estimated prevalence of functional disability was 37.4%.[12]
The disability was relatively less among men (35.9%)
than among women (38.8%) and the prevalence increased
with age (from 23.7% for age 60-64 years to 63.8% for
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Agrawal: Disability among the elderly
age >75 years).[12] Joshi et al.[13] assessed disability by the
standardized Rapid Disability Rating Scale-2[22] and the
overall prevalence of disability was 6.3%. Another study
that used World Health Organization (WHO) criteria[7]
found that the most common type of disabilities were
mental, locomotor, hearing, speech, and visual.[23]
The prevalence of disability among the elderly group
(>60 years) was high (21.5%); 80% of the disabled had
a single disability and the 20% had multiple disabilities;
as age advanced, there was significant increase in the
prevalence.[23]
Audinarayana et al. collected data regarding physical
disability from a mix of rural and urban populations
among the elderly in Tamil Nadu and the disability
was measured in terms of physical limitations.[24] The
information was collected about permanent loss of any
of the following and resulting inability to do the normal
day-to-day functions from the elderly, for visual (loss
of sight), hearing (loss of hearing), walking (loss feet or
legs), dental (falling of teeth) and complete loss of arms
or fingers (including fractures) and many other problems
like apoplexy, speech difficulties, paralytic condition
and trembling.[24] It was found that 47% of the elderly
persons were suffering from one or the other physical
disability condition; the extent of physical disability
was lower among the elderly belonging to higher
socioeconomic background (educated, engaged in own
cultivation, higher-salaried occupation, and belonging to
higher family monthly income bracket).[24] However, in
this study the details of underlying morbid conditions or
any other factors responsible for physical disability have
not been addressed.
Chakrabarty et al.[25] used an ADL scale and reported
16.16% prevalence of disability in the study population,
and 92.5% had one or more associated chronic conditions.
They found that the different chronic conditions like
osteoporosis, anemia, chronic obstructive pulmonary
disease, scabies, prostate hypertrophy, ischemic heart
disease, osteoarthritis, acid peptic disorder, age and sex
were significantly associated with functional disability
of the geriatric population.[25] In that study the authors
were able to explain risk factors in only 58.2% of the
cases, and identified that, the study being a descriptive
study, the factors found as associated with disability could
be suggestive, not a causal one and there may be other
factors for disability, which could not be identified.[25]
Venkatorao et al.[26] studied the impact of functional
limitation on handicaps, technical aids, environmental
adaptation, human assistance, limited community access,
confined to home and confined to bed parameters to
assess disability. The authors reported prevalence of
functional limitation among the geriatric population and
found speech disability (4%), hearing disability (10%),
visual disability (56%), and agility (locomotion, walking,
Journal of Medical Society / Jan-Apr 2016 / Vol 30 | Issue 1
climbing stairs, body movement and dexterity; 33%),
respectively.[26] However, this study did not provide the
underlying causes of disability in the population studied.
SOCIODEMOGRAPHIC VARIABLES
AND DISABILITY
It is commonly accepted that there is a relationship
between poverty and disability, and it is widely
hypothesized that it is a vicious cycle, i.e. disability
increases the risk of poverty and conditions of poverty
increase the risk of disability.[27] In one study, the
authors analyzed the data from a survey conducted
by the 58th round of the National Sample Survey
Organization (NSSO) and found that higher level of
poverty and income inequality among disabled elderly as
compared to non-disabled elderly and those differences
in the income levels vary significantly across different age
groups, gender, social groups and educational status.[27]
In another study, it was observed that elderly people who
live in the rural area, who are unmarried or divorced, and
those who belong to Scheduled and Backward castes had
higher levels of morbidity.[13] In this study it was also
found that lower education is consistently associated with
higher levels of morbidity and subsequent disability.[13]
Another study from the rural community of Karnataka
also revealed that illiteracy, primary schooling, and
unemployment have independent significant association
with disability.[23]
PSYCHOLOGICAL WELL-BEING
AND DISABILITY
In one study where the investigator assessed the
psychological well-being and disability status among
elderly people, it was found that minimal disability was
seen in 22%, moderate disability in 48.5%, and severe
disability in 17%, respectively.[13] It was also noted that
as the number of morbidities increases, the psychological
well-being deteriorates and disability increases.[13]
CHALLENGES
Inability to largely understand and accept the concept of
disability is a major challenge in India.[28] Aging should
not be treated as synonymous with disability, as a large
proportion of older people live with good health status
and without significant mental or physical decline.[27]
The link between aging and disability is a biological fact
as the risk of disability increases with increase in age.[27]
With rapid increase in elderly population accompanied
by a decline in physiological functions in this age
group, the foremost apparent challenge is to prevent
physiological aging translating into pathological aging, as
when diseases supervene.[16] Disability could be prevented
17
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Agrawal: Disability among the elderly
either by preventing the disease or by preventing the
impairment. As chronic conditions are the major causes
of disability, the assessment of chronic diseases and their
association with disability will help in implementation of
different preventive programs and thus reduce the health
burden of the nation.[25] Gerontology, which deals with a
set of conditions specifically associated with old age, is
still nascent in India: The facilities are largely inadequate
(confined mainly to urban areas), and the average
Indian doctor is not exposed to the education required
to manage such conditions.[29] In addition, the presently
available facilities largely address health-related issues;
however, disability and elderly encompasses a much
larger spectrum of conditions and needs to be recognized
and studied as a much broader concept.
It is also important to understand that with proper policy
interventions, the onset of disability can be delayed.[27]
DISABILITY SUPPORTIVE SERVICES IN INDIA
In India, the Central government with the help of State
governments runs many programs to support persons
with disability.[30-32] The majority of elders are outside the
social safety net, and they face economic, health, and
emotional insecurity and inequity that pose a challenge
to an already overburdened societal system.[33]
CONCLUSION
Disability is a major public health challenge that requires
knowledge and understanding of the risk factors involved
in order to allow efficient preventive strategies. Since
2011 there is a National Policy for Senior Citizens
that discusses issues related to disability in the elderly
populations in India. Although many studies have
addressed the issues related to disability in elderly
populations, they lack uniformity in many domains (most
importantly, different criteria to define disabilities), and
these studies are largely confined to the medical model
of disability.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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