Geropsychology in India
P. V. Ramamurti and D. Jamuna *
The phenomenon of ageing (i.e., changes across the lifespan) has been of interest to the scientist as well as to the common man, from time immemorial. The apparent phenomena of growth and decline (beginning with conception and ending with death) is the result of the predominance of processes of anabolism (growth) in the earlier phase of life, and of catabolism (destruction or decline) in the later phase of life. Birren and Birren (1990) consider ageing as the change in the individual across the lifespan, especially during the post-maturation phase of development. To the psychologist, the diverse types of behavioural changes during the lifespan and their underpinnings constitute the subject of his investigation.
Gerontology (geronto = old [age]; logos = science), the scientific study of the ageing process, is multidisciplinary in character and consists of many facets. For example, biogerontology refers to the biological aspects of ageing; geriatrics refers to the clinical or medical aspects of ageing; geropsychology is the scientific study of behavioural changes in the later years. The biological, psychological, and social aspects of ageing are intertwined. A sound knowledge of ageing, of course, would need a comprehensive and integrated understanding of its different facets.
Geropsychology focuses on the manifest changes or transformations that occur in human and animal behaviour related to the length of life (Birren & Schroots, 2001). Behaviour gets changed according to the institutions in which we grow up and grow old. As Birren and Schroots (2001) have stated, recent developments in the psychology of ageing concern the emerging field of gerodynamics that studies the organization of behaviour over the course of life from the gerontological perspective. Gerodynamics is primarily based on general and dynamic systems theory, and conceptualizes the ageing of individuals as a non-linear series of formations into higher or lower order structures and processes of entropic origin, showing a progressive trend towards more disorder than order over the lifespan, and ultimately results in the death of the individual. The intra-individual variations, in terms of functional variations, explain behavioural transformations across the lifespan (Birren & Schroots, 2001).
Behavioural development is the result of the dynamic interaction of genetic and environmental factors as one passes through the lifespan. What is seen at any point in the lifespan is a function of the developments in the preceding years. In other words, ageing changes depend on the complex interplay of factors that have occurred all along the preceding years. Therefore, a lifespan perspective is helpful in understanding ageing-related changes. Though ageing refers to changes across the lifespan, yet the focus in geropsychology is on the later years.
The field of gerontology is vast and work in this field is a post-independence phenomenon in India. The total number of scientific and popular articles published since then are reported to be around 4,500—a majority of which are on the psychological, social, and welfare aspects (Fig. 3.1). No pretence is made to include all of them. What is attempted is to indicate the major trends in the field of geropsychology, especially those in the last three decades. This is the first time geropsychology has been included in an Indian Council of Social Science Research (ICSSR) survey. Therefore, a brief historical development of the subject and some significant studies relating to the period prior to the period of review have been included for the benefit of the reader.
Figure 3.1: Research Output in Different Areas of Ageing (1960–2000).
Sources: Bali, 1995; Jamuna, 1998; Karkal, 1999, 2000b; Ramamurti & Jamuna, 1984, 1993c, 1995; Ruprail, 2002.
The narration is organized into a set of broad sections, commencing with a brief historical development followed by some implications of demography, bio-behavioural aspects, review of studies on adjustment, retirement, ageing in the socio-familial context, cognition, health behaviour, personality, etc. Some special aspects, like human rights, productive and successful ageing, and a research perspective are also covered. Finally, an epilogue on future trends is presented.
HISTORICAL ORIGINS OF GEROPSYCHOLOGY
Interest in ageing goes back to biblical times with the legendary mention of longevity as ‘three score and ten years’. Yet the average lifespan around 1000 BC was pegged at 18 years in contrast to nearly 70 years in contemporary times. The beginnings of scientific and empirical interest in ageing are attributed to Quetelet who was perhaps the first gerontologist. Quetelet described the distribution of human traits. Sir Francis Galton is credited with the study of characteristics of men and women aged 5 to 80 years (Woodruff & Birren, 1975).
The first compendium on ageing (psychological aspects) was by Stanley Hall in the United States America (USA) in 1922 titled Senescence the Last Half of Life. The next landmark was E. V. Cowdry's Problems of Ageing, published in the USA in 1939. Soon after the end of the Second World War, there was a spurt of activity in the USA with the formation of the Social Research Council in 1943, and the formation of the Gerontological Society of America (USA) in 1945, that initiated a series of researches that put the US in the lead with the maximum contribution to the field of ageing.
James Birren and Jack Botwinick (Birren, 1961a, 1961b) initiated a broad range of topics of psychological research on ageing in the US in 1947. The American Psychological Association's (APAs) initiative in organizing a research conference on ageing, which the National Institute of Mental Health funded, gave an impetus to the spread of geropsychology. Publication of A Handbook on Psychology of Ageing, summarizing the research progress on ageing and behaviour was another landmark in the development of geropsychology (Birren, 1959, 1964). It is worth noting that in 1947, the APA founded Adult Development and Ageing as its division 20. Today, it has a larger membership than its parent division, developmental psychology, which primarily focuses on the young. Also, the National Institute on Ageing (NIA) was started as a division of the National Institute of Health (NIH), which is the Federal Government's focal agency for organizing biological, behavioural, and social research on ageing. The large number of specialized journals and publications suggest an exponential growth of geropsychology in the US (Birren & Schaie, 1996). A research compendium on the History of Geropsychology became a source of information on its historical origins in different nations of the world and of the persons who pioneered the beginnings of geropsychology in those countries (Birren & Schroots, 2000).
In the post-War period, funding by the NIA gave a spurt to the primary thrust of research to delay the onset of ageing and improve treatments for diseases of ageing, particularly Alzheimer's disease, heart disease, and cancer. One of NIA's significant projects is its Memory Impairment Study, launched in 1999 to study individuals with mild cognitive impairments who are likely candidates for Alzheimer's or other related dementias. The NIA also oversees the Baltimore Longitudinal Study of ageing, the longest prospective ongoing scientific examination of human ageing, which since 1958 has measured continually changes in biological and behavioural processes in more than 2,000 people.
Our own ancient writings in India speak of interest in longevity. People were blessed with the words Dheergha Ayushman Bhava (be of long life). The elderly were held in high regard and many duties and responsibilities of older persons were spelt out. It is stated that the lifespan in the Kruta Yuga was 400, in Treta Yuga 300, in Dwapara Yuga 200, and in Kaliyuga 200 (Ayyar, 1957). The average lifespan in India was 27 years in 1951 and grew to 63 in 2001 (Registrar General of India, 1996).
Any understanding of older people in India is incomplete without knowing the four Asramas as propounded by Manu (Manu, 1932). The lifespan of an individual was divided into four periods or Asramas, with duties and responsibilities for each period broadly indicated. These were—(i) Balya/Brahmacharya asrama (the celibate educational phase, 0 to 25 years), (ii) Grihastha asrama (the family phase, 25 to 50 years), (iii) Vanaprastha asrama (the disengagement phase, 50 to 75 years), and (iv) Sanyasa asrama (the renunciation phase, after 75 years). The Vanaprastha asrama marks the beginning of old age while the last, Sanyasa, refers to the end stage of life. During Vanaprastha asrama one gradually disengages from the worldly pursuits of life, severing one's emotional and possessive bonds to prepare for the final renunciation of everything, to lead the life of an ascetic, ready to give up his physical body. Each stage prepares for the next stage. There is a social construction of the stages of ageing (Prabhu, 1954). Kakar (1981) refers to an ‘inner world’ relating to these asramas.
It is interesting to note that in USA Cumming (1964), Cumming and Henry (1961), had proposed a theory of disengagement, somewhat similar to Vanaprastha, in the older years when the individual and society appear to mutually withdraw from one another. In contrast, the activity theory of ageing propagates promotion of ‘Active ageing’, almost fighting the onset of ageing changes (Atchley, 1989). Havighurst (1953) came up with sets of developmental tasks for the various stages of life. He believed that these tasks need to be mastered at the given stage before proceeding to the next. The developmental tasks of old age (later maturity) were—adjusting to retirement and reduced income; adjusting to death of spouse; establishing an explicit affiliation with one's age group; establishing satisfactory living arrangements; adapting to changed social roles in a flexible way, etc. (Hurlock, 1981).
Early interest in the subject of ageing in India was seen in the form of indirect reference to old age (Ruprail, 2002), followed by stray popular articles on old age in the late fifties (e.g., editorial in The Hindu, 3 December 1953; Amesur, 1959) while scientific studies appeared a little later (Ramamurti, 1956). Research articles, doctoral dissertations, and research projects followed in the 1960s and 1970s, for example, Desai (1967), Desai and Naik (1971) on retirement and pensions; Marulasiddaiah (1969, 1970) on the village elderly; Paintal (1971) on adjustment and life satisfaction; Ramamurti and Parameswaran (1963, 1964) on learning and perception; Ramamurti (1968a, 1968b, 1969, 1978a, 1978b) on adjustment of the urban aged.
Also, work in Indian gerontology in the 1970s and 1980s came from the sociologists and social workers as well. Established in their own fields of anthropology, demography, sociology, and social work, they contributed to the field of gerontology, writing about the elderly in the family, and on social relationships, social structure, stratification and several other social aspects (Ramamurti & Jamuna, 1984, 1993a, 1993b, 1995; Ruprail, 2002). A multidisciplinary journal, The Indian Journal of Gerontology, was published from Jaipur and another journal named Ageing and Society: The Journal of Gerontology, was published from the Calcutta Metropolitan Institute of Gerontology.
The declaration of the first UN World Assembly on Ageing held at Vienna in 1982 spurred worldwide activity. Intense interest in the study of ageing, which accelerated developments in India, started with the formation of the Association of Gerontology India (AGI) in 1982 and the Geriatric Society of India (GSI). The teaching of psychology of ageing at the Master's level was started in 1973 in the Department of Psychology, Sri Venkateswara University; a Centre for Research on Ageing as part of the Department came into being in 1983–1984, and the University Grants Commission (UGC) extended its Special Assistance Programme (SAP-DSA) to the department. The departments of human development, psychology, sociology, and anthropology in several universities in India have included the teaching of ageing as a subject.
The Government of India promulgated a National Policy on Older Persons (NPOP, 1999), and constituted a National Council for Older Persons (NCOP) to implement the action plan of the policy with the Ministry of Social Justice and Empowerment as the nodal agency. The related ministries, the Indian Council of Medical Research (ICMR), the Institute of Social Defence, the ICSSR, the Indira Gandhi National Open University (IGNOU), the Department of Science and Technology (DST), the Council of Scientific and Industrial Research (CSIR), and several other agencies have encouraged research, teaching, and training in ageing. The UGC and NCERT have developed curricula for adoption by institutions. Several reviews and bibliographies on ageing are available in print (Karkal, 1999; Ramamurti & Jamuna, 1984, 1993b, 1993c, 1995; Ruprail, 2002).
The manner in which the elderly are treated, largely depends on prevailing social and cultural practices. There are not many national level studies on the characteristics of older people in India. The bulk of the work on the Indian elderly comes from the fields of psychology, social work, and sociology. The reports of these studies are spread over a variety of academic journals and it is no easy task compiling them. Yet, a modest attempt is made here to delineate the main trends emerging from these researches. The reader's attention is drawn to earlier reviews on the subject of ageing by the authors (Ramamurti & Jamuna, 1984, 1993b, 1993c, 1995).
DEMOGRAPHIC SCENARIO—IMPLICATIONS FOR GEROPSYCHOLOGY
Demography refers to the statistical study of human populations. The United Nations regards all persons above the age of 60 as older people (the aged). At present, for the sake of convenience, people aged above 60 are sub-divided into the young-old (60 to 75), the old-old (75 to 90), the oldest old (90 and above), and centenarians (those above 100 years of age).
The census statistics of the older people in India have been analysed and their implications discussed by reputed demographers, namely Asish Bose, Biswas, Guharoy, Goyal, Irudaya Rajan, Xenox, and Sharma. One of the many reasons that focused national and international attention on the elderly was the implication of the set of demographic indicators pertaining to the elderly in the analysis of population (population ageing), and the consequences of demographic transition in India (see Table 3.1).
Table 3.1 The Elderly Population (in Millions)—World, Asia and India (1999)
Source: UN Population Ageing Reports, 1999.
Some of the implications of demographic changes for the future are—(i) a generation (20 years) has been added to the average span of life over the past century; (ii) some nations have families with many more elders and fewer children than families 50 years ago had; (iii) increased state responsibility towards the elderly; (iv) increasing irrelevance of families and obligations across the generations; (v) growth rate of the older population in developing countries is expected to rise to over 3.5 per cent annually from the year 2015; (vi) there will be an ‘ageing’ of the aged, and (vii) there may be longer years of shared lives across generations (Bengtson & Lowenstein, 2003).
As far as India is concerned, there are 75 million elderly out of a total population of about 1,050 million (7.5 per cent). The average life expectation at birth has risen to 62 years (men 61.5 years and women 62.5 years). For those aged 60 years, the average life expectation was 16.75 years for men and 19.2 for women. Gender-wise, there were more elderly women than elderly men. Women generally outlive men, (and become widowed) probably because women marry men much older than themselves. This apart, longevity seems to favour the feminine gender (Rajan, 1999; Rajan et al., 1999, 2003; United Nations, 1998).
About two-third of the total Indian population hails from rural areas and nearly a third of the population is below the poverty line. Poverty and poor hygiene, which characterize this section, add considerably to the woes of the elderly and their supporting/caring families. The appalling situation of the elderly in the country has a negative impact on their self-perceptions. This state of affairs drew the immediate attention of academia to conduct research on the elderly and to find adequate solutions in an integrated fashion to the social, behavioural, financial and health problems that they face.
Talking of the biological bases of behaviour, we are confronted with the interesting question of primacy of biology or behaviour—the chicken or the egg, which comes first? Psycho-physical interactionism is a generally prevalent view among psychologists. Stress effects, psychogenic hypertension, peptic ulcer, etc., exemplify psychogenic effects on the body. The observation of brain activation during volitional mental activities, studied using functional Magnetic Resonance Imaging (fMRI), and widely reported in current science, is evoking considerable interest. Currently, neuropsychology is a rapidly developing field that correlates neurological processes and psychological (behavioural) processes. Nevertheless, the vast field of molecular biogerontology is basic to the understanding of the ageing process.
A discussion of the work in biogerontology, strictly speaking, may be out of place in a review of Indian geropsychology. Yet, a brief mention of the Indian thrust in this regard may not be altogether irrelevant. The reader's attention is drawn to several articles in this context (e.g., Kanungo, 1994, 2004a; Subbarao, 1997; Thakur, 2004).
Biology of ageing refers to the anatomical, physiological, biochemical and molecular (biological) level changes that occur in an organism especially in the post-reproductive phase of life. These changes result in a progressive decline in homeostatic and adaptational functions in the various organ systems that ultimately end in the death of the organism. Interestingly, there is an apparent relationship between the length of the period to attain reproductive maturity, the number of progeny delivered at birth, and the maximum lifespan. Another significant observation seems to be that few organisms live long enough to die of sheer age, as most of them die due to predatorial attacks (e.g., infection by invading organisms or attacks by other organisms), accidents, etc. Research evidence points to no specific gene or specific genetic programme selected by natural selection in evolution to cause ageing, though the processes up to reproductive maturity seem to depend on an established programme of sequential activation.
PSYCHOSOCIAL ASPECTS OF AGEING
Public Perceptions of Ageing (Attitudes)
A crucial issue of how the older persons in a country are treated is how the public regards them. Therefore, public perceptions (attitudes towards the elderly), as well as their determinants need to be assessed. This knowledge may help in planning appropriate interventions to improve these perceptions.
Attitudes were respectful and reverential towards the elderly especially in village settings (Marulasiddiah, 1966). Most cultures have negative stereotypes of old people's conservatism, personality, and interfering behaviour (Sharma, 1971). But Parikh (1983) found that both younger and older age groups held generally favourable attitudes towards the aged. Favourable attitudes towards ageing rose with increasing age of the person (Reddy, 1990b; Ramamurti & Reddy, 1986). There was a significant correlation between attitudes towards the aged and problems of adjustment among aged (Reddy & Ramamurti, 1988).
Attitudes change with age. There was a positive correlation between attitudes towards the aged and attitudes towards ageing (Reddy, 1984b, 1990b). Persons with low death anxiety had a more positive attitude towards old age than those with high death anxiety did (Roy & Thakur, 1988). Higher socio-economic class retirees had more liberal views on life (Randhawa & Bhatnagar, 1985). Age, sex, work status, and religion were factors affecting the attitudes (Prakash, 1992).
Older subjects showed more traditional attitudes than younger men who had more stereotyped attitudes (Prakash, 1996b). Arvind and Ilango (2000) found no gender variation in attitudes towards elderly of P. G. students.
Personal and Social Adjustment
Many of the early empirical studies on the psychological aspects of ageing were exploratory, and dealt with the expressed problems of the elderly using open-ended questions or checklists. Some had used custom-built problem inventories fashioned after the Mooney's Problem Checklist for adults but dealing specifically with problems experienced in old age (e.g., Ramamurti, 1969, 1970a). They covered several areas such as the financial, family, personal, health, religious, and recreational aspects of life.
A large number of such studies covering different regions of India (mostly urban) were published (see reviews: Bali, 1995; Biswas, 1987; Ramamurti & Jamuna, 1984, 1993a, 1993c, 1995; Saraswathi & Dutta, 1998). In general, the studies showed that there were significant differences based on gender (male vs. female), locality (rural vs. urban), educational level, etc., in the different sub-areas of problems experienced by the older people (Deepti, 1984; Dharanendriya et al., 1983; Mangla, 1994).
Adjustment refers to how an individual negotiates or meets the problems in different areas of his or her day-to-day life at a given juncture. Adjustment is often measured using a self-report adjustment questionnaire or inventory (depending on whether it is in the form of a questionnaire or a statement). Some inventories give a score for maladjustment (e.g., Hussain & Kaur, 1993; Ramamurti, 1968a) while others may give a positive score of adjustment. Generally, they cover adjustment to problems in the areas of health, social, family, finance, personal behaviour, leisure, recreation, spirituality, etc. There have been myriad studies on adjustment of older people in India over the years starting from the 1960s. According to their findings, persons from the higher socio-economic status (SES), those in joint families, those with spouse alive, and community dwellers (non-institutional) showed better overall adjustment (e.g., Achamamba, 1987; Alam & Hussain, 1997; Anand, 1995; Anantharaman, 1979b, 1980c, 1981a, 1981b; Asha & Subramanian, 1990; Banerji, 1983; Behere et al., 1991; Bhatia, 1983; Biswas, 1987; Chadha, 1990; Chakravarty, 1993, 1995; Chandrika & Anantaraman, 1982; Dutt, 1987; Easwaramoorthy, 1991; Jamuna, 1984, 1987a, 1988, 1989a, 1989b, 1994b, 1995a; Jamuna & Ramamurti, 1984, 1988a, 1989c; Jayasree, 1987; Kelkar, 1974; Koteswariah & Ujjwalarani, 1994; Lakshminarayan, 1997; Mohanty, 1982; Nandini & Parvathi, 1996; Narang, 1968; Paintal, 1971; Ramamurti, 1968b, 1970c, 1972, 1976a, 1982b, 1987, 1989g; Ramamurti & Jamuna, 1994b; Saraff & Mohanta, 2002; Singh, 1997; Ushasree & Sunanda, 1987). For other studies prior to 1984, please see the review article (Ramamurti & Jamuna, 1984).
Adjustment to Retirement
Most people engage themselves in a vocation or employment. As they grow older and reach a certain age (58 or 60) they are mandatorily retired by their employers (Ramamurti, 1989f). The self-employed retire voluntarily or cease working. Either way their earnings reduce. They may also experience loss of status or power which their occupation had provided. For many, adjusting to retirement, reduced income and changed roles is a difficult challenge (Easwaramoorthy, 1993; Ramamurti, 1969, 1982b; Sati, 1972). This period could be fraught with anxiety, stress, frustration, and even depression which may affect their mental and physical health (Jamuna, 1985, 1987c; Mishra, 1993; Ramamurti, 1968b, 1996c) particularly during the years preceding and succeeding retirement or on loss of job (Anantharaman, 1979b, 1990; Kunwar & Chadha, 1997; Malhotra & Chadha, 1996; Ramamurti 1965, 1969).
The loss of status, power, and reduced or loss of regular income that go with a job or occupation, have a telling effect on the ageing individual. The sudden and drastic change from the pinnacle of a career in an engaging occupation may have a shock effect on many (retirement shock). This is particularly so in the absence of a plan to meet the anticipated effects of retirement (Ramamurti, 1969). Studies have shown stress periods immediately precede and succeed retirement but the situation improves, as they grow accustomed to it in a few years (by the mid 1960s) (Cecile, 1970; Dhillon & D'Souza, 1992; Ramamurti, 1968b).
To overcome this problem, employees are put through pre-retirement training modules to equip them to deal with the changes following retirement (Chakravarty, 1997; Ramamurti, 1995, 1997c). Today, many organizations conduct pre-retirement counselling programmes for their senior employees who are nearing retirement. Such programmes are best executed when there is sufficient time for the employees to plan their retirement. These programmes usually consist of training to better equip employees meet the health (physical and mental), income, behavioural, social, legal and religious needs consequent on retirement or ageing (Ramamurti, 1995; Ramamurti, et al., 1991).
It is important to note that about two-third of the India's population hails from rural areas. About three-fourth of the people in the working age group in India (15 to 59) do not enjoy regular incomes, and only about 20 per cent of this group are employed in the organized sector and are likely to enjoy a pension or other retirement benefits. Consequently, about three-fourth of the population above 60 years of age have little or no income security during their old age (Kumar, 1999, 2003). The government has become aware of this problem only recently and has just evolved long-term saving programmes (old age social and income security—OASIS) for all (particularly for those in the unorganized sector). It encourages individuals to accumulate a pension fund (Bordia & Bharadwaj, 2001) through periodic or regular savings such that they receive a regular income in their older years. This scheme is envisaged in the action plan of the National Policy for Older Persons (NPOP, 1999). Many nationalized banks and the Life Insurance Corporation have announced pension plans for the public (Kumar, 1997, 2003; Ramamurti, 2004).
Retirement not only means adjusting to reduced finances, loss of status, and power, but also to changed family interrelationships and the overall changes of ageing that coincide with this event. Retirement puts an end to the lifelong habit of hurriedly preparing to go to one's workplace and attending to daylong occupational obligations. Retirement also ends the social contacts that were available at the work spot. Most people who do not find re-employment are ‘forced to’ remain at home with the new leisure hanging heavy and inability to find suitable replacement for the loss of work engagement (Ramamurti, 1976a, 1982a, 1995; Ramamurti & Jamuna, 1993a, 1995; Sinha & Singh, 1997).
Since work confers a special status to a person's identity, the loss of job or work during old age takes away this identity with significant deleterious changes in the person's self-concept (with feelings of negative self-reference). Even within the family, change in the position of chief breadwinner at home relegates his interpersonal status to one that is far inferior to the one he enjoyed when he was employed (Ramamurti, 1968a, 1976a). Several retirees (though some initially felt relieved of work obligations) expressed unhappiness and negative feelings over the ‘inevitable’ retirement (Ramamurti, 1968b, 1976a).
Adjusting to the several physical ageing changes that overlap retirement were also found to be problematic (Jamuna, 1994a; Ramamurti, 1968a, 1991a). They felt frustrated at not being able to physically do many things that they could do earlier (Ushasree, 1991, 1994). A crucial factor in adjustment is accepting the reality of ageing changes (Jamuna, 1989a; Ramamurti, 1989e; Ramamurti & Jamuna, 1992b). Those who coped by accepting the realities of ageing felt happier and showed less symptoms of anxiety or distress and maladjustment. Acceptance was measured by an inventory of self-acceptance of ageing changes (Jamuna & Ramamurti, 1989b; Ramamurti, 1990a). Therefore, counselling the elderly to accept them as normal and common place yielded good results.
An important factor that is related to adjustment is role activity in old age. All individuals as they pass through their lifespan play age- and context-based roles. For example, in young adulthood, individuals play the child-rearing role, the role of a worker, of a young spouse, etc. (Ramamurti, 1972, 1976b). By late middle age the parenting role ends. As persons enter old age, many of these roles are lost (e.g., as an employee, as a breadwinner) and some get constricted, while some new roles (e.g., grandparent) are assumed (Havighurst, 1957). Studies in India showed that the degree of role activity and role satisfaction also dwindle on entry into old age (Jamuna, 1988; Ramamurti, 1972, 1987). The degree of adjustment to the changes in roles reflected the sense of well-being, life satisfaction, and quality of life (QOL) (Anantharaman, 1979a, 1979b, 1980b, 1981a; Ramamurti, 1992a, Upadhyaya, 1998).
Cognition encompasses knowledge acquisition, perception, reaction time (RT), general ability, and learning, memory, and other higher mental processes. Significant longitudinal prospective studies were carried out in the West, for example, the Duke (Palmore, 1985), Seattle (Schaie, 1983), Baltimore (Libow, 1974), Georgia (Poon, 1992), Bonn Longitudinal Studies (Thomae, 1976). They generated substantial information. Salthouse (1991) reviewed the work on adult cognition. Accelerated changes in cognition are seen only after the eighth decade of age.
Studies carried out in India are only a few. Some of the early studies dealt with perception and learning. They showed that perceptual shifts in the elderly were few and were related to cognitive flexibility (Ramamurti & Ananthakrishnan 1964; Ramamurti & Parameswaran, 1964). Studies on cognitive flexibility showed a decrease with age (Ramamurti, 1968a). The elderly reacted slowly, that is, slow in simple and complex RT to stimuli (Pathak et al., 1983; Ramamurti & Jamuna, 1984). Acquisition was slow in motor learning on a mirror drawing task. However, the amount of bilateral transfer of learning from training accorded to one hand, to the other untrained hand was not substantially different when the old and the young were compared (Ramamurti & Parameswaran, 1963). But, significant differences were reported in eye-hand coordination among young-old, old-old, and the oldest-old (Jamuna & Ramamurti, 2000b).
Memory is a significant area of cognitive research with many clinical and policy implications. Memory decline may be age-associated [Age Associated Memory Impairment (AAMI)] (Ramamurti, 1999; Lalitha, 2001a). Many psychiatric disorders exhibit memory loss. A memory scale for assessing memory in the elderly was developed by Pershad and Wig (1976, 1977), which had low correlations with general ability test scores. Pershad (1979a, 1979b) also found that both retention and retentive recall were affected in the elderly. Isaacs and Akhtar (1972) developed a ‘set test’ to measure mental functions of the normal elderly, which is stated to be culture fair. It was found to be good for use in clinical settings (Anuradha et al., 1991), and for the normal elderly (Dubey & Verma, 1991) in assessing memory status in the aged.
The correlates of memory beliefs in the old and young were assessed by Dwivedi (1988) and Dwivedi and Misra (1991), and were found to be related positively to measures of intelligence, locus of control, and related negatively to anxiety in the elderly. Kohli et al. (1992) used a battery of tests on the depressive elderly, and found higher levels of depression, lower mental efficiency, and general information level compared to the normal elderly. In a study of ‘Geriatric Psycho-linguistic’, Sharma et al. (1992) observed mild language loss with ageing and found age-related decline (depending on type of material) in semantic and syntactic processing. Agrawal and Kumar (1992) observed that speed of information processing was a good predictor of everyday memory.
A scale of cognitive dysfunctioning applicable in clinical settings, developed by Dube (1996), evaluates higher mental functioning. Gupta and Srivastava (2000) found that memory processing is related to deficits in information processing and slow processing of working memory and attentional capacity (Lalitha, 2000d, 2001b). Jamuna and Ramamurti (2000b) used an adaptation of Mini Mental State Examination (MMSE) of Folestein et al. (1975) on Indian elderly to assess their cognitive status and found it to depreciate only in the old-old group (Jamuna & Ramamurti, 2000b).
In a detailed study of psychosocial correlates of memory in the elderly, Lalitha (2000a, 2000c) assessed several facets of memory viz., working memory, semantic memory, episodic memory, remote memory, auto-biographical memory, and long term memory in the elderly, and their relationship to demographic, psychological and personal variables. Age, gender, education, locality, and economic status were related to memory status among the aged. Of them, the level of formal education was found to be an important correlate of various facets of memory in the elderly. Further, familiarity of tasks, organization of the material, and speed of presentation also influenced memory (Lalitha, 2001a, 2001b). Role of personality factors including self-esteem, I-E locus of control, mental health, perception of social supports and physical health (self-rated) were found to be the significant correlates of memory performance (Lalitha, 2000a, 2002b; Lalitha & Jamuna, 2004b, 2004c; Ramamurti & Jamuna, 1993a). Perceptions of social supports and life stress were more related than the other variables. Using an interventional design Lalitha (2000a, 2000c) demonstrated that memory training was useful in improving performance particularly in digit span and verbal memory among the young-old.
The level of memory and cognitive functioning are critical for the daily functioning of the elderly. They also affect the quality of response to investigator-conducted interviews and consequently research outcomes in studies on the elderly (Ramamurti, 2004). Memory interventions in the community are needed, and may be beneficial to the elderly (Lalitha & Jamuna, 2004b, 2004c; Verma & Pershad, 1996) if systematically carried out. Memory training in the elderly is a ‘state of the art’ subject (Brush & Camp, 1998).
Personality in Later Years
Researches on optimal ageing had focused on the lifelong importance of health-related behaviour such as, eating and drinking in moderation, not smoking, exercise, being actively engaged in life, and having a strong social network. Other known predictors of late life adaptation include education level, socio-economic status, and social-structural variables serving as ‘risk factors’ such as, gender and race. Surprisingly, little is known about the person in whom these risk factors are located. In fact, personality is the driving force behind all antecedents of successful ageing, except the structural ones. What type of person one is, how reliably he can be and his attitude towards people—all are crucial for understanding social supports, coping strategies, stress, and other health-related behaviour.
In simple terms, personality is understood as an abstraction, a concept involving the sum total of an individual's habit systems, attitudes, dispositions, and generalized ways of behaving. Several studies in the West have shown that by and large, personality characteristics do not show any significant change in old age (Birren & Schaie, 1996).
There has been a long-standing split between the social cognitive processing approach and the structural and trait approaches to personality that has made an unified science of personality elusive (Fleeson, 2001; Mischel, 1999). This is despite the presence of developmentalists (e.g., Labouvie-Vief & Diehl, 1999) who have included both approaches in their work. The trait framework that dominated in geropsychology, may have been so well received because it clarified and simplified the field of personality in adulthood. Personality was seen as stable. This stability is often viewed positively, as personality is proclaimed to be the one domain in later life that will not decline, as opposed to the physical and cognitive domains. But this conception of personality as stable has made it difficult to conceive of a developmental, dynamic approach to personality in adulthood. The embeddedness of the individual in nested multilevel contexts, for example, day-to-day life situations, life-course temporal frame and socio-historical time, and the dynamic transactions between individuals and context, necessarily affect personality (e.g., Mroczek & Spiro, 2003). It is perhaps meaningful to conceive of personality as consisting of a core and a periphery. The core remains stable while changes occur in the periphery and if strong, may in course of time and gradually infiltrate into the core. However, some shocking experiences or life events may affect the personality (Ramamurti & Jamuna, 1984, 1993c, 1995; Srivastava & Gupta, 1994).
Indian studies on aspects of personality in the later years of life are few. Some have related it to adjustment (Anantharaman, 1982; Hussain & Narain, 1996; Verma, 1980). Studies related to locus of control showed wide individual variations in personality scores, though no age differences surfaced. Internal locus of control was found to be related to adjustment, life satisfaction, and contentment of life (Jamuna & Ramamurti, 1988a; Ramamurti & Jamuna, 1993a, 1993c). Experience of life stress was found to be related to personality adjustment in old age (Srivastava & Gupta, 1994).
Shanmugam (1970) using Eysenck's Personality Questionnaire (EPQ) found that there were significant differences in the personality traits of adolescents, adults, and the old, especially with changes taking place in the traits of extroversion and neuroticism. Thakur and Thakur (1986) adapted EPQ on a population of 17 years to 75 years old and its psychometric properties were computed. In this regard, though family living showed greater emotional security, more negative self-concept was seen in post-retired group compared to pre-retirement group (Rashid, 1987).
An aspect of personality, the self-concept, has been reported to show change with advancing age. Retirement, reduced income, frailty, illness, and disability, significantly affect what we think of ourselves (self-concept). Negative ideas of reference, loss of self-esteem, poor attitude to the future, anxiety over death and disability, and general anxiety appear to be affecting the ‘actual self’ perception (Jamuna, 1985, 1987b; Jamuna & Reddy, 1993; Reddy, 1984a, 1990a). A disparity between ideal-self and actual-self was strongly related to adjustment and life satisfaction in the older men (Jamuna, 1985; Jamuna & Ramamurti, 1989b; Ramamurti & Jamuna, 1994b) and women (Jamuna, 1989b).
Self-acceptance of ageing changes was found to be a significant psychological marker that influences adjustment, mental health, and life satisfaction in the older years (Jamuna, 1989a; Ramamurti, 1990a). Paintal (1992) in a study of self-concept and successful ageing among medical men found significant changes in the self-concept of the elderly that affected their adjustment and life satisfaction.
In another study, Jamuna and Reddy (1993) found that self-concept in widowed women was negative. But, as age and length of widowhood increased women accepted and adjusted to the situation. Maladjustment was found to be related to certain personality factors such as introversion-extroversion, neuroticism, and dependency (Hussain & Narain, 1996).
Anantharaman (1980b, 1981b) investigated the self-concept and its relationship to adjustment. Those with negative self-concept had good adjustment and life satisfaction. Chadha (1991) found significant differences between institutionalized and non-institutionalized in their self-concept. The elderly (60 years to 75 years) from urban areas (Hasnain & Kapoor, 1997) showed positive self-perception and satisfied adjustment (Anantharaman, 1980b). Patri (1996) found that the elderly had more negative self-evaluations. There was no difference between the institutionalized and non-institutionalized elderly in their self-evaluations.
Social Supports and Networks
The groups or individuals in the social and family settings to whom the elderly relate themselves socially and emotionally, constitute the old person's social support network (Jamuna & Ramamurti, 1991). They provide the older person a sense of belonging and a feeling that they are available to extend help and support especially at times of need. They constitute the social network of the senior citizen. The degree of social support enjoyed by the older people can be assessed and the nature and extent of support network enjoyed can be plotted through sociometric analysis (Chadha et al., 1990; Gangrade, 1985; Jamuna & Ramamurti, 1991; Willigen et al., 1996).
As an individual grows older, several of his friends (particularly those older to the person) with whom he shared his life experiences pass away. This reduces the number of people to whom they can meaningfully relate themselves, making them feel somewhat alone or lonely—a normal occurrence in old age (Ramamurti, 1989b; Ramamurti & Jamuna, 1995).
Empirical studies on social supports and networks cover several aspects, for example, on tool construction (Chadha, 1990; Jamuna & Ramamurti, 1991; Subramanyan, 1989) and on methodology (Willigen & Chadha, 1990). A number of variables have been studied related to social supports (Jamuna & Ramamurti, 2000b; Jamuna et al., 2001; Ramamurti & Jamuna, 1999). Understanding social networks is necessary to maximize its strengths, in minimizing its strains, and to provide better care (Gangrade, 1985). Gender differences and marital status were related to social supports with the married women having better social networks (Chadha et al., 1990; Jamuna et al., 2004).
The researches on social supports have been devoted to examining the stress buffering properties of supportive social relations. Meaningful social supports help to reduce the effect of life events in the retired, working and non-working males (Dhillon & Arora, 1992). It reduces the feelings of the intensity of problems in the family and community living elderly as well. Depression was negatively related to social supports (Balakrishnan, et al., 1991; Chadha, 1994). Lower life satisfaction was related to lower social supports, both in the institutionalized and the non-institutionalized elderly (Arora & Chadha, 1995). Social networks help manage crisis better in joint families than in other families (Gangrade, 1985, 1996). There is a complex relationship between social support networks, functional competence, and subjective well-being of the elderly (Prakash, 1998, Umadevi, 1991, 2002).
Different kinds of support networks exist for different types of help-seeking behaviour (Kapoor & Kumar, 1996). In traditional patri-local societies, which are in transition, social support networks are related to living arrangements (Kumar, 2003; Maruthakutti, 1997). Social supports provide social security and alleviate stress in crowded residential colonies (Rao, 2000; Singh, 1993; Sinha, 1999). Social supports have implications for formal and informal relations (Chadha, 1993; Kumar, 2003; Phillips, 1994; Ushasree, 2000; Willigen & Chadha, 2003) and social networks help in feelings of well-being and functional competence (Umadevi, 1991).
Health behaviour refers to any behaviour in an individual that directly or indirectly contributes to physical or psychological health. In common parlance, it includes awareness of the characteristics of health and disease, motivational and attitudinal aspects pertaining to health, observance of hygienic practices related to health. The health of the elderly not only depends upon biological and disease factors but also on the awareness of the principles of health and hygiene and a strong motivation to practice the principles of health in daily life (Bagga & Sakurakar, 2000; Devi & Bagga, 1997; Dey & Soneja, 1999; Gunthey & Mathew, 1997; Joshi, 1971; Ramamurti, 1996a; Reddy, 1996a; Savita & Darshan, 1999; Umadevi, 2002; Vermani & Darshan, 1999).
It is the practice of principles of health and hygiene that directly leads to the maintenance of health in old age. Empirical studies have shown that in the first instance there is inadequate awareness of healthful and hygienic practices and presence of certain unscientific and irrational beliefs. This has been attributed to conditions of poverty and lack of education. Moreover, awareness of healthful and hygienic practices does not guarantee that they will be practised. The elderly may not be able to observe them not only due to lack of adequate motivation but also because of the absence of conducive environment at home, as the elderly are dependent on others for their living needs and they may not be in a position to demand and implement healthful and hygienic practices (Ramamurti, 1996a). Empirical findings have shown that health behaviour is directly related to the condition of the incumbent's subjectively reported health (Jamuna & Ramamurti, 1990; Ramamurti, 1997b; Ramamurti & Jamuna, 1992a; Umadevi, 2002).
Due to increased automation in different spheres of life, the scope for physical activity is reduced. Therefore, the important steps in community interventions to improve the health status of the elderly is to promote greater awareness and activities of healthful practices, not only in the elderly but also in the caregivers of the elderly and the family members with whom the elderly stay (Jamuna, 2004; Jamuna & Ramamurti, 2000a; Ramamurti, 2004; Reddy, 1996a, 1996b; Reddy & Ramamurti, 1995; Savita & Darshan, 1999; Shah, 2004; Shah & Prabhakar, 1996).
Attitudes towards health determine the general health of older persons. Locality, socio-economic status, education levels and some personality factors influence attitudes towards health. Knowledge, attitudes, and practices pertaining to health not only vary among individuals but are also poor in the rural elderly (Reddy, 1996a, 1996b; Venkateswarlu et al., 2003). Psychological factors like locus of control, knowledge of health practices, and certain personality factors influence health attitudes during old age (Reddy, 1996b).
A related aspect to health behaviour is the motivation to improve the personal competence of the elderly. It has four aspects that need to be taken care of, that is, physical health, psychological health, social health, and economic health (Ramamurti, 1996a, 2003a, 2004; Reddy, 1996a). The importance of physical exercise to promote physical and psychological fitness is not gaining its due importance especially due to sedentary lifestyles (Bali, 1997; George, 1999; Hasan, 1998). All these aspects need to be incorporated in one's lifespan much earlier than the onset of old age. This is because competence in old age is the end result of practices that were carried out in the earlier years of the person's life course (Bhatla, 2000; Chakraborti, 1997; Ramamurti, 1996a, 2004).
Disability in Later Life
Recent reports on the disease profiles of the elderly in India show that there is a health transition-taking place, that is, from communicable diseases to non-communicable diseases. Ageing is associated with impairments in various body systems that may be the result of disease or degenerative changes. Impairments lead to disabilities. Disability is a major concern for many of those who have crossed 65 years. Arthritis, osteoporosis, and vascular disorders are common disabling disorders in old age.
A comprehensive tool for the assessment of physical and psychological disability and the psychological attitude to personal disability was constructed as part of a project (Ramamurti et al., 1997). Some of the disabilities included were visual disability, hearing disability, speech disability, psychological disability, and locomotor disabilities (Jamuna & Ramamurti, 1990; Ramamurti et al., 1997). The NSSO report (1998) on the aged indicates prevalence rates per 1,000 of various types of disability viz., visual (rural-270/urban-240); hearing (rural-148/urban-122); speech (rural-35/urban-32); locomotor (rural-111/urban-87); amnesia (rural-105/urban-70). The influence of certain variables like gender, financial status, marital status, living conditions, quality of social supports, personality etc., on disability during old age were reported to be important (Jamuna & Ramamurti, 1990; Lalitha, 1995; Sugunamma, 1993; Umadevi, 1991; Ushasree, 1997).
The studies on disability show that the prevalence rates of disability have been higher for females than for males in both rural and urban locales (Guharoy, 2004; Jamuna & Ramamurti, 2000b; Prakash, 2003b). Results suggest a dire need to change lifestyles in preserving health and effective functioning in old age through interventions (Vinod Kumar, 1998). Experience in India shows that social support provided in various forms to individuals help them in adhering to medical regimens, faster recovery, and more effective rehabilitation (Jamuna & Ramamurti, 2000a; Ramamurti & Jamuna, 1992a; Ramamurti et al., 1992a; Umadevi, 2002).
The World Health Organization (WHO) (1995) defined health to include not only physical health but also psychological health and social health. Health does not just mean mere absence of disease but refers to a state of full fitness and a positive state of well-being. The clinical study of mental disease/health-like physical disease may fall in the medical domain of psychiatry. Strictly, it may fall outside the purview of this review. But mental health has a positive connotation, which includes a state of well-being (Prasad et al., 1996). The volume of research output in the area of positive mental health in the elderly has not been much (Nagar, 1998).
One of the earliest well organized and executed study on mental health in the elderly was sponsored as a task force study by the ICMR under the direction of Rao (1987). About 89/1,000 of the elderly are mentally morbid but the availability of mental health services falls very much short of the need. There are an estimated 15,000 psychiatrists, 500 clinical psychologists, and a similar number of psychiatric nurses to serve the mental morbidity cases among all age groups.
Among the mental ailments of the elderly, dementia and depression top the list. Comorbidity is a normal feature of all mental conditions. Though biochemical and neurological changes may be the important cause, psychosocial factors are no less significant particularly in the neurotic conditions as causative and contributive factors (Bhogale & Sudarshan, 1993; Prakash, 2004; Ramachandra & Sathianathan, 1986; Rao, 1997, 1998, 2004; Rao & Madhavan, 1983).
Though forgetting is a common symptom that is reported by the elderly, dementia refers to a more severe form of forgetting that has a pathology behind it (Lalitha & Jamuna, 2004b; Rajkumar, 1995; Ramamurti, 1990b; Rao, 1997). Senile Dementia of Alzheimer's Type (SDAT) is a well-known clinical syndrome of memory dysfunction that accelerates with ageing and is characterized by impairment in orientation, memory, and cognition and other behavioural changes. It has been routinely assessed as part of psychiatric investigation (Rao, 2004). Rajkumar (1995) reported a prevalence rate of 27 per 1,000 in urban and 35 per 1,000 in rural population for all types of dementia of which about 40 per cent were diagnosed as SDAT. More males than females suffered from this. Its prevalence in the 75 years+ age group is more than in the 65 years to 74 years age group (Rajkumar, 1995). The low prevalence may possibly be due to the small proportion of the population living well into late old age when it usually manifests.
Physical illness was associated with mental disorders in 50 per cent of cases (Menon et al., 1971). In an analysis of 227 patients, ideas of reference (93 per cent), suicidal tendencies (66 per cent), restlessness (53 per cent), anxiety (60 per cent), sleeplessness (57 per cent) were associated with physical morbidity (Rao, 1981, 1991). A host of factors were found to be associated with mental health as revealed in empirical studies (Prakash, 1995, 2004; Verma & Kohli, 1982). Social- and family-maladjustments were associated with psychological ill health (Pathak, 1982; Sinha, 1989–90). There was an association between life events and psychological stress, with the old-old people experiencing more life events (Harinikumari & Prakash, 1986; Lalitha, 2000c). More knowledge and information than available now is needed on prevalence and causes of mental disorders in India (Rath, 1989).
Anxiety that increases with age was associated with many mental conditions (Dubey et al., 1992). Hypochondriasis and depression were influenced by personal culture and life experiences of the incumbent (Singh, 1992). Older women had higher prevalence of mental disorders including Alzheimer's (Murphy, 1994; Patel et al., 1998). In addition to gender, marital status, habitat, and level of support systems were also related to mental health of elderly (Sharma, 1999).
Frustration and Stress
As an individual steps into old age, the tell-tale signs of ageing (e.g., greying hair, failing fitness, and bodily symptoms, social distancing by the young, expecting retirement and reduced income) may become threats to the ego, self-esteem, and self-image of the elderly. Many elderly have felt frustrated that they were not able to be as efficient as earlier. In a study using picture frustration stimuli, it was found that the elderly developed negative feelings (extrapunitive or impunitive) of reaction to picture frustration (Ushasree, 1994).
Successful coping to the stress of ageing is an important aspect in late life (Dhillon & Chhabra, 1992; Ramamurti, 1997b). A study of how senior executives respond to stress was carried out by Srikanth Reddy (1990) who found that successful coping to stress was characterized by following cognitive- and problem-oriented approaches (Reddy, 1987; Reddy & Ramamurti, 1987, 1991, 1992). In a study of stress reaction to old age among the rural elderly, Kumarreddy (1989) found that taking the help of others and information seeking were predominant coping styles, while emotion-focused response was less frequent. Several elderly had resigned themselves to their state of affairs and did not complain. Many conditions associated with the onset of ageing may themselves cause stress. Thus, ageing itself can be a source of stress to many and can cause anxiety (Ramamurti, 1989b).
There are not many national mental health promotion programmes for the community living, and hardly any for the elderly as such (Bansal, 2000). Low socio-economic status has been considered a factor that acts as a stress in old age and indirectly contributes to poorer mental health (Ramamurti, 1989b). It is common knowledge that stresses and strains associated with retirement, loss of status, and deficient coping with the signs and symptoms of ageing do contribute to the vulnerability of the elderly to mental morbidity (Khetarpal, 1995–1996). Therefore, there is a need for mental health promotional programmes for the elderly. A few studies on mental health needs and problems in the elderly are available (Moudgil, 1986; Ramamurti & Jamuna, 1993c; Satyavathy & Murthy, 1979; Sharma, 1999). But we need community intervention studies to promote mental health of senior citizens as preventive measures (Gautam & Pant, 1997; Singh, 1988; Sinha, 1994). The health professionals operating at Primary Health Centers (PHCs) level need to be trained in mental health promotion in the community and schemes of intervention in order to promote positive mental health (preventive) not only in the elderly but in all individuals across their lifespan.
Loneliness is a feeling that one is psychologically and socially isolated and without a perceived social network. As the elderly outlive their peers there is a substantial loss of age mates causing a constriction in the number of people to whom the elder can relate. The elderly feel that they are excluded in social interactions and not given sufficient attention resulting in a feeling that they are unwanted (Anuradha & Prakash, 1991). It is not unusual for an older person to feel lonely even when in the midst of people (e.g., Chadha et. al., 1992; Nair, 1970; Parthasarathy, 1975; Patel et al., 1999, 2000a, 2000b; Prakash, 2003c; Rathi & Mrinal, 1996; Srigowri, 1994; Suparna et al., 1993).
Several researchers have addressed the problem of feelings of loneliness in old age. Some have used scales of loneliness. A widely used tool in the study of loneliness is UCLA scale (Chadha & Singh, 1996; Jamuna, 1992b; Prakash, 2003c; Srigowri, 1994). Loneliness was influenced by perceived lack of control of supports and neuroticism (Jayakumari & Kalanidhi, 1993; Patel, 1998). Social interaction and socialization of the old, good social networks and proper rehabilitation can reduce loneliness (Anjum, 2000; Banerjee, 1997; Sinha, 1971). Those in institutions felt lonelier than the community living elderly (Ramamurti & Jamuna, 1997).
The empirical findings showed that a majority of those women who were confined to the home and those who were poor felt lonelier than others (Nandakumari, 1991; Parthasarathy, 1975). Studies carried out on religious sub-groups showed that Hindus experienced more loneliness than Muslims and Christians for reasons not clear (Bhogle, 1991). Age differences suggest that loneliness increased steeply in old age (Guha, 1992). Loneliness was more in the neglected elderly and the spouseless elderly (Kumar, 1998; Rathi & Mrinal, 1996). Men felt lonelier compared to women (Patel et al., 1999, 2000a). The elderly perceived that loneliness was an unwanted situation (Chadha et al., 1992; Lalitha & Jamuna, 2004a; Prakash, 2003c). Religious activities, hobbies, and social activities may reduce the feeling of loneliness. Living in a joint family reduces the feelings of loneliness (Nair, 1970) and death anxiety (Asgarali & Broota, 2000; Patel et al., 2000b; Ramamurti & Jamuna, 1992b).
Elder Care—Psychosocial Issues
Old age is generally characterized by frailty, disability, and dependency. In such conditions seeking the help of others in the activities of daily living (ADL) may become necessary. In a broad sense, this act of helping the elderly with physical, psychological, and financial assistance (for that matter any type of support or assistance rendered) may be termed as caregiving behaviour.
In India, elder care is rooted in a soil of ancient culture and a hoary tradition. But over the years, like a windswept terrain these traditions have been exposed to erosion by a host of social and technological changes that occurred in the post-independence era (after 1947) like modernization, urbanization, consumerism, individualism, migration, and the breakdown of joint families (Bhathacharjee, 1992; Bose, 1995; Bose & Gangrade, 1988; Gangrade, 1988, 1996; Jamuna, 1995a, 1997a, 2003a; Ramanathan & Ramanathan, 1994; Sivan, 1991). The traditional joint family consisting of members of different generations living together having common business or land holdings with shared family and occupational responsibilities is fast on its way out. Joint families are being replaced by nuclear families or at best extended families (Singh, 1994). Fewer aged parents stay with their married children. A recent analysis (Singh, 2003) states that in India less than 15 per cent of all families are joint families (even less in urban areas). According to Cowgill (1974), modernization brings in its wake several changes that are detrimental to the care of the elderly, though Palmore and Kenneth (1974) view that Japan suffered less from such influences.
Added to this is the situation of a burgeoning elderly population and a constricting younger generation in India, who will constitute the future caregiving generation (Devi, 2000). As a result, caregiving is fast becoming an acute problem of immense dimensions (Coco, 1993; Jamuna, 1995b, 1997a, 1999a, 2001a, 2002, 2004; Nagar, 1987; Pai, 1988; Ramamurti & Jamuna, 2002a).
In Indian culture, elder care is predominantly a feminine function, for example, the care of a husband by the wife, and of elders in the family by the daughter-in-law/daughter in the family. It is rarely that a man assumes this role (e.g., care of the wife by her husband) (Basu, 1998; Jamuna, 1987b, 1999a, 2002, 2003a). It is also evident that more care receivers are women. Thus, there is a feminization of elder care (Basu, 1998; Jamuna, 1987b; 1995a, 1999b; 2001b; Jamuna & Ramamurti, 2000a). Essentially, caregiving involves a dyadic interaction between the caregiver and care receiver that is influenced by the interpersonal perceptions of the dyad members, that are determined by a host of dynamic factors (Jamuna, 1999a, 2004; Jamuna & Ramamurti, 1999; Jamuna & Reddy, 1992; Jamuna et. al., 2003; Reddy & Usharani, 1996).
Caregiving would become mechanical, if it is bereft of the psychological components. Thus, caregiving implies a delicate dyadic relationship (of service to others) essentially between the caregiver and the carereceiver (as between a baby and its mother) (Jamuna, 1987b, 1990, 1992b, 1996, 1997a, 1997b). A factor that determines the quality of care rendered is the interpersonal relationships between the caregiver and the carereceiver (Jamuna, 2001a, 2002, 2003a, 2003b; Jamuna & Ramamurti, 1999, 2000a; Singh, 1995; Sivakumar, 1999; Sundaram, 1999; Vidyarthi, 1995).
A model of caregiving (see Fig. 3.2) was suggested on the basis of the empirical evidence gathered by studies in the area of elder care (Jamuna, 1995b) portraying the factors governing it, namely, caregiver-receiver interpersonal perceptions, motivation, time availability, skill, and resources of caregiver, task complexity, values, individual personality factors, work overload, family dynamics, subjective stress, care receiver's level of disability, family support, and caregiver's physical and mental health (Ghatak, 1999; Jamuna, 1993, 1996, 1997b, 2004; Ramamurti, 1992b; Ramamurti et al., 1992a; Somasundaram, 1990).
Figure 3.2: Constituents of Dyadic Interperceptions and Quality Care.
Source: Jamuna, 1995b
Caregiving is a psychologically and physically taxing task, more so when the care receiver is disabled. When the demands of the situation overstretch the resources of the caregiver, it leads to stress in the caregiver and in extreme cases to burnout (Jamuna & Ramamurti, 2000a). Caregiver stress management is a well-researched area in the US (Kosberg et al., 1990; Zarit, 1990) and its management in the Indian situation was successfully tried through field interventions. Group- and individual counselling involving the caregiver, carereceiver, and their family was found to be useful in managing elder care effectively (Jamuna, 1987a, 1992b, 1997a, 2000a, 2004; Jamuna & Ramamurti, 1993, 2000b; Johri, 1982).
Generally speaking, when the family is indicated as a care provider, one has in mind the role of the spouse, daughters-in-law, the daughter, and other relatives. In this arrangement women predominate as caregivers (Jamuna, 1987b; Pattanaik, 1999). Very rarely do men take on this role in the Indian setting. Traditionally it is the daughter-in-law of the family who assumes this role. In such situations the prejudices of mother-in-law and/or the daughter-in-law towards each other become a critical factor in determining the quality of care. Dual careers of the son/daughter-in-law (or) the daughter in the family, raises the stress of these persons as caregivers. If the daughter-in-law is also the primary caregiver and is employed, she may find it difficult to judicially apportion her time and effort among her professional obligations, the care of elders, care of children, and attending to other domestic responsibilities such as cooking, house keeping, etc., (Jamuna, 1993, 1995b). This renders her position unenviable (Suresh, 1998).
The elder care situation in the coming years in India is bound to turn acute and problematic if adequate preventive steps are not taken. As the material- and non-material resources as well as the attitudes towards elder care by adult children are showing signs of deterioration (Jamuna, 2003b; Siddh, 1990; Sivasankar, 1991), it is necessary to plan concrete steps to protect the role of the family in elder care (Bali, 1994, 1996; Barusch, 1995; Ghei, 1980; Jamuna, 2003b, 2004; Jamuna et al., 2003; Kumar, 1994, Ramamurti & Jamuna, 1990, 2002a, 2002b).
The community around too has not assumed any major role in eldercare except in support to the norm of family care of the elderly (Phillip, 1994; Fanning, 1994; Krishnan & Santhana, 1991; Nagesh, 1992; Nair, 1991; Puri, 2000; Sivakumar, 1999). However, in a few Indian states (e.g., Maharashtra) federations of senior citizens organizations are spearheading active care of elderly. The community can play a significant role by organizing neighbourhood caring networks and community homes for elderly particularly in rural areas (Jamuna, 1993; Jamuna et al., 2003). The state as such cannot assume responsibility of elder care because the cost of supporting 70 million elderly even partially would become a prohibitive expenditure consumig the lion's share of the national budget. Hence the family, the community and non-governmental organizations may have to play a major role with support from the government (Ghei, 1980; Kuthiala, 1994; Muttagi, 1997; Ravi, 1989; Thakur, 1990).
Organizing supplemental elder care services (meals on wheels, home care services, respite care, help lines) cannot be delayed any more (Jamuna, 2004; Ramamurti, 2004). Many middle class old people are choosing to stay by themselves or join ‘pay and stay’ homes rather than in old age homes (OAHs) for destitutes (Jamuna et al., 2003). Real estate developers are offering programmes of ‘own your flat’ for seniors in metropolitan and other urban areas which resemble the concept of Independent Living localities in the US. Some corporate construction companies are starting to provide housing for the elderly using the Retirement Communities Model. Even pay-and-stay facilities for the elderly are on the increase in many cities and towns, and are turning out to be good commercial propositions.
Some private organizations for example, heritage hospitals and senior services at Hyderabad are offering model services for the elderly such as dial-a-driver, meals on wheels, companion services, home health checkups, etc. (Gangadharan, 2003). This development is gradually paving the way for the elderly to seek alternate care avenues (self-care, hiring home care services, care in OAHs, etc.). The conditions of family care are fast changing (Basu, 2002; Jamuna, 2004; Jamuna et. al., 2003; Kalyani, 2000; Ramamurti, 2003b; Ramamurti & Jamuna, 2002a; Udaysen, 1998). Countries like the US, UK, and Australia have a wide variety of such supplemental care services for the elderly (Hunt, 2003). A study of the psychological and social interactions among the elderly occupants of these residential establishments is becoming an area of recent research interest (Jamuna, 2004; Ramamurti, 2002).
Psychological Issues in Institutional Care
When family care, self care, or care by relatives and friends fail or become problematic, resort to care or residence in OAHs is an alternative for many (Christopher, 1992). Care in nursing homes, hospitals, etc., are sought when the older person is sick or disabled, but owing to their high cost and lack of good insurance facilities they do not become viable alternatives in India. Most OAHs in India admit the elderly only if they are functionally capable of taking care of themselves (Ramamurti, 2001a; Ramamurti & Jamuna, 1997).
Several studies of residents of OAHs are available especially on their reasons for entering the home and on the life experiences of the residents. Some of the reasons given by the older people entering OAHs were destitution, poverty, neglect, and abuse in the family, incompatibility between care dyads, migration of the younger generations, incapacitation of the caregivers or desire of the elderly to be independent of the family and to not become a burden on it (Ara, 1995; Bhatia & Kau, 1995; Dhillon & Poudwal, 1992; Ganesh, 2000; Jamuna, 2000b; Kalavar, 2003; Kalavar & Jamuna, 2002; Liebig, 1998; Mishra, 1986; Ramamurti, 2001a; Ramamurti & Jamuna, 1997; Swati, 1968).
Interactional problems are not only seen in families but also among the residents of (either pay and stay or destitute) OAHs. Institutional care and rehabilitation help to modify and facilitate old people's earlier adjustment (Sasi & Sanandaraj, 1982). Conflicts are not unusual among the residents of OAHs either pay-and-stay or destitute. The conflicts may be among the residents themselves as well as between the staff of the OAHs and residents on a variety of issues (Ramamurti, 2001a; Ramamurti & Jamuna, 1997).
Comparisons of the problems of residents of OAHs with those who were community residents showed that the common problems of the former were: feelings of alienation, loneliness, boredom, marginalization, inadequate social supports, unwantedness, worry about the future, poor QOL, disability, sickness, and dependency (Jamuna, 2000b; Lalitha, 1997b; Liebig, 2003; Mathew, 1997). The findings on the problems vary among the investigators (Borah, 1989; Gomathi et al., 1981). The life experiences of those living in institutions have an impact on their self-concept and personality (Anantharaman, 1980c; Jayakumari & Kalanidhi, 1993; Patri, 1996). The managements of the OAHs generally complain of inadequate resources, and lack of support from governmental agencies, dearth of care staff (managerial and professionals), poor community involvement, excessive attention-seeking behaviour from residents, difficulty in managing conflicts among residents, etc., (Jamuna, 2000b; Ramamurti, 1991b; Ramamurti & Jamuna, 1997).
Studies show that the demand for residence in OAHs is on the rise (Ara, 1995; Mishra, 1968, 1986; Ramamurti & Jamuna, 1997). More and more people are seeking admission into OAHs, as an alternative living arrangement (Arora, 1995; Barreto, 1980). This is all the more so as the baby boomers move up in age as a consequence of demographic transition and reach old age. They will have fewer young caregivers than the elderly of today, a situation that will impel the elderly towards self-care or care in OAHs (Bhatla, 1993a; Ramamurti, 2001a; Ramamurti & Jamuna, 1997). The state, due to other pressing financial priorities would not be able to contribute substantially towards individual elder care. The role of NGOs needs to be encouraged as a major provider for the elderly (Joy, 1998; Khan, 1989; Ramamurti, 2001a).
Many elderly have sought residency in OAHs hoping for a better life there than with their families or living alone (Cathuria, 1996; Kalaver & Jamuna, 2002). But the QOL in many of the free- or low-payment homes leaves much to be desired. Only the elderly in the higher echelons of society, who join the pay-and-stay OAHs, enjoy a satisfactory QOL. Standards of maintenance need to be evolved and strictly enforced through state monitoring, so as to give the elderly who stay there a square deal. The benefits of technology in designing an elder-friendly environment and providing gadgetry for use by the elderly in OAHs and other residences have to be ensured, for example, provision of ramps instead of stairs, railings to hold on sides of the walls or corridors, and provision of non-slippery flooring in baths and toilets, better lighting on stairways and walkways (Jamuna, 2000b; Liebig, 1998; Prakash, 2000; Ramamurti, 2001a; Ramamurti & Jamuna, 1997).
Care of the Sick
Care of the sick and the disabled elderly is a special area that demands training of the caregiver to be able to meet the demands of the care receiver (e.g., care of the bedridden/acutely ill, orthopaedically severely disabled) (Bhatla, 1998; Chandra, 1997; Hall, 1993; Jamuna, 1992b; Ramamurti, 2001a; Supple, 1987).
There are also those who may not only be physically disabled but are also disabled psychologically. The dementia patient is a case in point as they may suffer from poor memory as well as somatic affectation due to brain pathology (Bhatia, 1998; Malhotra, 1999). These individuals need constant care which is highly taxing for the caregiver (Chandra, 1997). Even in these conditions, the role of the family is primary because nursing home costs are prohibitive. This results in stressful situations for members of the family (Rajkumar et al., 1995). Therefore, there is every need to train family caregivers. The training requirements for dementia caregivers may differ from the training requirements for the acutely sick or orthopaedically disabled. It is not only the primary caregivers who need counselling but also the supporting family members (Bhatia, 1995; Jamuna & Ramamurti, 2000a; Prakash, 1999c; Puri, 2000; Rajkumar et al., 1996a, 1996b; Reddy, 1998). In these matters an integrated approach to training care and counselling has been emphasized (Rajkumar et al., 1996a; Sundaram, 1999; Yadava, 1997).
The opposite of good caregiving is neglect and abuse of the elderly. It is particularly influenced by such factors as poor caregiver-carereceiver interpersonal perceptions and strained interpersonal dynamics. Other competing interests in the caregiver that displace caregiving functions are stressed feelings, a selfish orientation, lack of altruistic feelings, economic and housing problems (Gangrade, 1996; Jamuna, 1994a, 1995b; 2003a). Both, physical and psychological abuse are reported by individuals in dealing with the elderly. Abuse is seen not only in family settings but also in other settings (e.g., in travel, in work and social interactions). It could be latent, covert, or open and aggressive (Bambawale, 1996, 2004; Jamuna 2000b, 2003b, 2004; Liebig, 2003; Malathy, 1998; Rao, 1999).
Empirical data indicate that elder abuse is on the rise (Bambawale, 2004). Abuse of the elderly may take many forms. It consists of verbal assault, threats of violence, physical assault, derogatory naming, demeaning commentary, loud talking, exploitation, wilful neglect and confinement (Bambawale, 1996, 2004; Kumar, 1998; Padmasree, 1991; Peretti & Majcen, 1991).
The assessment of elder abuse is a tricky process. The abusing person may cover it up and present a pleasant front to the investigator. Also, the elderly who suffer abuse are afraid of the dire consequences of complaining against the abuse and hence paint a ‘no problem’ picture to the investigator (Jamuna, 2003a). Therefore, its investigation is fraught with difficulty. The result is that the prevalence of elder abuse cannot be correctly assessed as only few are reported (Aggarwal, 1999; Deviprasad, 1997; James, 1996; Jamuna, 2003a; Rao, 1997). Studies show that the economically and physically dependent are at a higher risk than others (Mahajan, 1992; Sreenivasan, 1998; Ushasree & Basha, 1999).
It is not an easy task in the Indian cultural setting to draw up strategies for preventing elder abuse or minimizing the severity of its manifestations (Kapur, 1997; Savithrivaithi, 1996). Essentially, such efforts are to be directed at reducing the prejudice between the caregiver and carereceiver and promoting favourable interpersonal perceptions (Jamuna, 1996, 2003a, 2003b, 2004; Padmasree, 1991; Vaswani, 1997). The care receiver's appreciation of the acts of caregiving behaviour reinforces good caregiving and improves the attitude of care providers. This apart, creating awareness of the value of caregiving and treating it as a noble act may reduce negative feelings towards caregiving. Additionally, improving infrastructure facilities for caregiving, and providing support and respite care to the caregiver may reduce the burden of caregiving and consequently downplay the latter's negative attitude and vexation towards the task of caring (Bambawale, 1996; Jamuna, 1999b; Shah et al., 1995). It could be useful if the media plays a facilitative role in promoting favourable attitudes towards elder care (Jamuna, 2003b, 2004; Ramamurti & Jamuna, 2002b).
As individuals grow they marry and start a family. Children born to them become the next generation (second generation). The second generationers too grow up and start their own families and beget children, who become the subsequent generation (third generation) and so on. The times and contexts in which each generation of children grows up vary and thus their impact varies with the generations (Ramamurti, 2001b). Each generation is conditioned by a different ‘period’ in which they grow up, and as a consequence are likely to imbibe different perceptions (Anantharaman, 1979c, 1984), attitudes (Reddy, 1984b, 1990b, 1995, 1997), values (Reddy, 1985) and behaviour; these cause generational differences (Bhave, 1970; Gangrade, 1978; Jamuna et al., 1991a; Kanwar & Bharadwaj, 1991; Ramamurti & Jamuna, 2002b; Reddy, 1983, 1985, 1987; Reddy & Ramamurti, 1988; Ree, 1970). These generational differences (or similarities) affect inter-generational relationships (Anandalakshmy, 1972; Madan, 1969; Malick, 1986; Ramamurti & Jamuna, 2002b). The number of generations that are contemporaneous in a family vary. For instance, in 1880 when the average life expectation was low at 30 years there could only be at best two generations (parents and their children) and when this life expectation grew to 50 in the 1950s another generation would have been added. But today in many Western countries with life expectation rising to 70 (in India it is 65), three generations co-exist. In countries like Japan where life expectation is over 80 years, four generations co-exist making inter-generational relationships richer but more complex. But, in Africa many members of intermediate generation are missing that is mostly the grandparents and grandchildren are present while the parents who were afflicted by AIDS became deceased, leaving the grandparents caring for the grandchildren (Imhof, 1986).
While studying inter-generational relationships some special aspects need to be assessed, for example, the degree of support that is extended across the generation, the strength of such inter-generational bonds and their determining factors, the economic value of intergeneration transfer, etc.
With modernization and social change family structures have been changing. The types of marriage (legal or non-legal), divorce, widowhood, remarriage, all have significant effects on intergenerational relationships and transfers (Bengtson & Lowenstein, 2003).
In all inter-generational interactions, there are transfers between the generations that may be either material (wealth, property, etc.) or non-material (e.g., affection, care, values, traditions, etc.). Such transfers may be reciprocal (a service is rendered expecting a return immediately or later) between parents (who care and rear their children) and their adult children. Alternately, the service may be viewed as obligatory as when children care for the elderly or vice versa as a matter of duty or obligation (Antonucci & Jackson, 2003). This latter inter-generational expectation largely prevails in the Indian culture, while a reciprocity view is seen more in Western cultures.
Inter-generational relationships take on a special significance in a family setting where an older person resides (Bhagban, 1994; Bhai, 1998; Gangrade, 1985; Nayar, 1998; Ramamurti & Jamuna, 2002b). The attitudes held by the caregiving younger generation towards the aging and the aged influence the care providing behaviour of the younger generation (Kalyani, 2000; Reddy, 1997). The negative attitude of the young towards ageing or the elderly may reduce the quality of their caregiving behaviour towards the elderly in the family (Dube, 1986; Reddy, 1997; Warty, 1970). In a family situation, there may be several aspects that may cause conflicts between the older people and younger ones (Dutt, 1987; Mukherjee, 1972; Shah, 1969); for example, inheritance or partitioning of parental property, opposition to the disciplinary and authoritarian role of the older person towards the young, or other restrictive practices (Chadha & Singh, 1996; Sengupta, 1973). Inasmuch as the older and the younger generations are conditioned by different time periods in their childhood, their lifestyles, values etc., may differ somewhat (Bhai, 1998; Gangrade, 1988, 1999; Gangrade & Singh, 1971; Reddy, 1992) which in turn may become the cause for inter-generational distance or the ‘generation gap’ (Dave, 2002; Jamuna, 2001b; Ramamurti, 2001b; Ramamurti & Jamuna, 2002b; Reddy, 1985).
The attitudes of the younger generation (inter-generational attitudes) towards elder care were examined at two different periods of time, in 1984 and again in 1994 (Jamuna, 1997a, 2003b). The younger generationers, in the 1984 study, had more favourable attitudes towards elder care than the younger generationers in 1994. Deterioration in the attitudes to elder care was noticed. 53 per cent of the younger generationers of 1984 favoured home care but only thirty three per cent of the younger generationers of 1994 favoured home care (Jamuna, 1991a, 1997a, 2003b; Jamuna et al., 2003; Ramamurti & Jamuna, 1984).
Traditionally, a negative attitude between caregiving daughter-in-law and the care receiving mother-in-law is known to exist. Apart from the perception between the daughter-in-law and mother-in-law, there is also the contribution from the ‘generation gap’ between them, as they belong to two different generations (Jamuna, 1991a; Jamuna et al., 2003; Reddy, 1987; Sinha, 1972, 1979). The older woman's (mother-in-law's) attitudes might have been conditioned by the ‘times’ when she was young, as contrasted to the attitudes of the daughter-in-law who grew up during a later period. Each of them applies the standards of judgement appropriate to their period and as a consequence there is bound to be a conflict of views (Jamuna, 1991a, 1996, 2001b; Jamuna et al., 2003; Mathur, 1994; Ramamurti & Jamuna, 2002b).
Personal attitudes also affect interactions between the older and younger individuals in a variety of settings other than those of the family context (Anantharaman, 1980e; Ramamurti, 2001b; Swarnalathamma, 1992). For example, in an office- or work-setting, the interaction between older and younger employees could be affected and be the cause of negative perceptions of each other and of the social distancing between them (Bhingradiya & Kamala, 1997; Jamuna & Reddy, 1992; Nair, 2001; Prakash, 2001; Ramamurti, 2001b; Ramamurti & Suryanarayana, 1981; Rikhye & Chadha, 1998). It could even lead to open conflicts. The ageistic stereotypes, namely, rigidity, conservatism, slowness, uncouth appearance, etc., attributed to the old comes in handy in branding the elderly (Reddy & Ramamurti, 1988; Tiwari, 1999). These occur despite the salutary effects, if any, of the traditional regard and respect for the elderly in India. In sum, the ‘generation gap’ between the younger and older generations is a significant factor that affects their interrelationship, often contributing to negative interperceptions.
Other Psychological Issues of Significance in Later Life
One of the significant variables in the study of individual differences is gender and this holds good even in ageing. Distinct gender differences have been observed in many aspects (biological and psychological) of lifespan development. But ageing changes in women have been emphasized to the extent that ‘gender ageing’ generally connotes women ageing (Ramamurti, 2004).
Apart from the biomorphological differences between the sexes, a demographic fact that is apparent has been that, by and large, women seem to outlive men. The average life expectation, both at birth (e0) and at 60 years of age (e60) is higher for women than for men in many countries (Ramamurti & Jamuna, 2002a). Same is the case even for ‘disability free’ life expectancy in older years (Guharoy, 2004; Jamuna, 1995a; Umadevi, 2002). The cause, though not clearly specified, seems to point to the protective role of the gonadal hormones, estrogen and progesterone, in women, though lifestyle factors, for example, incidence of stress, and effective coping to it have also been implicated (Ramamurti, 2004). A slightly higher proportion of women than men seem to suffer from dementia and depression (Rajkumar, 1995; Rao, 2004). A few studies using the animal model have shown that supplementation of these hormones, have prolonged their lifespans (Thakur, 2003).
Adopting gender-specific roles, contributes significantly to sex differences in behaviour. Role expectancies, cultural norms and attitudes have a cumulative impact on the individual. Despite being a patriarchal society, traditionally, the Hindu woman has been eulogized and described as an embodiment of shakti (goddess of energy). In wedlock, as a spouse she is given a participant role in the discharge of family responsibilities and, her role is portrayed in ancient Sanskrit verse as Karyeshu Daasi, Karaneshu Manthri, Bhojyeshu maatha, Shayaneshu rambha. Yet, discrimination and prejudice against the girl child and social exploitation of women has been pointed out and a case made out for women empowerment (Bambawale, 1999; Jamuna, 1999b).
In traditional India, when a husband dies the wife becomes a widow. Her status, as a widow changes to an unimportant, dependent position. Socially she is ostracized, marginalized, and derogated so much that in some communities she is even regarded as a ‘bad omen’ at religious and auspicious social functions (Ramamurti, 1989g; Reddy & Jamuna, 1992; Reddy et al., 1992). The older widow thus suffers from triple jeopardy namely widowhood, womanhood, and old age (Jamuna et al., 1991b, 1998). A social stigma exists for widowed women to remarry, whereas, it is not so for men (Lalitha & Jamuna, 2003, 2004a). Many philanthropist and religious organizations run homes for widows, for example, at Brindavan, near Agra and at Varanasi. The quality of their life in these homes may not be satisfactory (Liebig, 2003).
Widowhood (loss of spouse) affects both old men (widowers) and old women (widows). Studies comparing their status and problems have shown that older widows experience loss of status, loneliness, alienation, anxiety towards their future, negative self-feelings, diffidence, and dependency (Chakravarty, 2001; Jamuna, 1999b; Jamuna & Ramamurti, 1988a; Jamuna & Reddy, 1993; Jamuna et al., 1991b; Ramamurti, 1989g; Reddy et al., 1992, Sureender et al., 1996, Sushma et al., 2002). Older widowers experienced reduction in status, minimized support from family and friends, dependency, loneliness, etc. (Ghufran, 1998; Lalitha, 1994, 1997a; Lalitha & Jamuna, 2003, 2004a). But, on the whole women, unless very sick, could find many useful home-making and grandparenting roles more easily than men (Jamuna, 1999b; Lalitha & Jamuna, 2003).
Studies on the contemporary status of older women have painted a somewhat poor picture of them (Jamuna, 1989b, 1999b; Karkal, 2000a; Prakash, 1996b; Ramamurti, 1989g). The women elderly are regarded as a vulnerable group, disadvantaged on various counts (Jamuna, 1995a, 1999b; Ramamurti & Jamuna, 1994b). The current concern is on how to empower them and improve their overall status.
In essence, comparisons of aged men with aged women, show that the woes of the aged woman have been researched more than of the man. Her condition, especially if she is a widow, has been described as an appalling one—helpless, alienated with negative self-regard—and as stressful (Jamuna, 1990, 1994a; Jamuna et al., 2004). Wherever the spouse is alive, the ageing losses seem to be partly compensated by the companionship of the spouse (Jamuna, 1984; Jamuna & Ramamurti, 1984). The absence of the spouse makes the situation difficult and problematic. Individual- or group psychological counselling through intervention, providing empowerment, and financial security have been found to improve their lot (Jamuna, 1995a, 1999b; Ramamurti, 1986, 2003a). The media too needs to highlight this situation and suggest solutions.
The Psychological Concerns of Rural Elderly
Urbanization and migration as part of modernization have pushed most of the younger people away from the villages, while most of the elderly whose economic base is agriculture have continued to remain in the rural areas. For those who had migrated early in life to urban environments and grown old there, have adapted themselves to urban lifestyles. But the major chunk of the elderly continues to languish in rural locales steeped in poverty, illiteracy, and ignorance. Traditional practices, beliefs, and habits of life that have been handed down the generations are the assets of the rural elderly.
Despite the rural elderly constituting a majority, research studies on them have not been many (e.g., Bali, 1997; Bhingradiya & Kamala, 1997; Bose & Saxena, 1964; Dandekar, 1975; Jamuna, 1989b; Jamuna et al., 1991b; Ramamurti & Jamuna, 1992b, Reddy, 1989; Reddy, & Ramamurti, 1990; Sureender et al., 1996; Yadava et al., 1996). The NPOP has exhorted planners and programmers to focus their attention on the rural elderly. In practice, it is not known how many of these programmes and good intentions have reached the doorsteps of the rural families where elders reside (Ramamurti, 2004).
A useful study, entirely on the rural elderly in India, was undertaken by Muthayya and Anisuddin (1992) which was funded by the Ministry of Welfare, Government of India. The rural elderly were found to be less educated and economically poor and only a few owned property compared to their urban counterparts. They expressed need for better medical care, financial support, social recognition, and opportunities for greater participation in civic life. By and large, the rural elderly reported satisfactory health except for poor vision, hearing, and joint stiffness (Muthayya, 2004).
The elderly felt that traditional values such as respect for elders, courteous behaviour, honesty and hard work were slowly disappearing in the younger generations. The elderly needed economic support and easier medical help through mobile medicare units. They opined that though they were consulted on matters regarding marriage, and organization of social and religious events they were not given due importance in family decision-making in day to day matters. Most of the rural elderly (69 per cent) had no remunerative jobs or vocations and had to spend much time sitting idle at home. Only attending to grandchildren, if such a need was present was an avocation. Older women, however, had more useful roles to play in home making than men (Muthayya, 2004).
Religiosity and Spirituality
The importance of the religious and spiritual activities of the elderly has been widely reported in Western literature. The significance and benefits of participation in religious/spiritual activities towards the well-being of the elderly were well-quoted in ancient as well as modern Indian writings (Tilak, 1990). Ancient Indian texts prescribe prayer, and participation in religious meetings in old age to obtain spiritual liberation. The early realization of the role of religion was reported to result in a decrease in religious faith whereas later realization in an increase in religious faith (Soodan, 1970). Prayer and meditation are mentioned as a means for ensuring mental peace and securing salvation (moksha) (Jamuna, 1989c; Ramamurti, 2004; Singh, 2002).
Spirituality/religiosity offers emotional succour in old age. When an older person relates his woes to God, it acts like catharsis. Also, the utterance of prayers relieves anxiety and promotes an emotional feeling of surrender. There is a beneficial relationship between religiosity and fear of death as people grow older (Sharma & Jain, 1969). There is dire need to instil good values and maintain the moral code in the elderly (Bhatla, 1993b). Socio-economic status is a significant factor influencing lifestyles and religiosity (Dhillon & Kumar, 1992). The elderly who realize the transient nature of physical reality, who appreciate the eternal character of the soul, and who believe that their actions can change the final outcome of their spiritual-self are better situated to cope with life (Rastogi, 1996; Singh, 1989).
Religiosity has also been related to adjustment, mental health, and QOL in the older years (Dave, 1999; Dhillon, 1996; Jamuna, 1989c; Ramamurti & Jamuna, 1993a; 1994a; Singh, 1995, 1996, 2002; Ushasree & Basha, 2003). Older people tend to be more religious than the young (Rao, 1993). Those elderly who live with their families were more religious than those living in institutions (James, 1990; Karna & Panjiar, 1987). Greater interest and participation was seen among the elderly in these activities compared to their younger counterparts (Ramamurti & Jamuna, 1993a, 1994a, 2004). Even young students showed a tendency to model themselves after their old parents on religiosity (Singh, 1985).
Older people were found to be rendering excellent service to the community and were leading purposive, joyous lives by properly harmonizing material and spiritual values to matching their practical life (Banerjee, 2000; Leder, 1996; Sarma, 1994). Developmental models of Western religiosity were not found to hold good for the Indian elderly (Thomas, 1991, 1992, 1993). Women and the rural elderly exhibited great interest in devoutness and religiosity (Jamuna, 1991b; Karna & Panjiar, 1987). Widowers were significantly less religious than widows for reasons not clear (Ghufran, 2000).
Leisure Time Utilization
In later adulthood, persons relinquish some of their earlier roles and responsibilities or retire from their occupations either mandatorily or voluntarily. As a result, ample free time (leisure) becomes available to them. In Western settings, leisure time in old age is filled through recreational or other useful activities. It is part of their preparation for old age. In India, for most people leisure time planning in old age was not a concern, probably because the average life expectation was not very high. Also, till recently most elderly lived in joint families or with their adult children and shared the work in home making, domestic chores or caring for and attending to grandchildren. However, in recent years, with the increase of life expectation at 60 years being about 15 years, and with joint families dwindling, spending these years meaningfully is receiving the attention of gerontologists (Ramamurti, 2004).
The desire to spend leisure usefully plays a vital role in motivating the elderly to participate in various types of leisure-time activities (Prakash, 1999c; Ramamurti, 1956; Sullivan, 1997). Sharma (1969), Verma (1982), Ganesan (1991), and Kohli and Verma (1997) state that the present time is an age of creative leisure. There is an increase in significance of leisure to personal identity and QOL in the elderly. Middle class males and females engage most frequently in solitary- or family-based activities after retirement. Males were most likely to be engaged in activities outside of family context (Chadha et al., 1991a). Involvement in leisure time activities like religious and household work, and interaction with family members, neighbours and relatives had no impact on personal happiness. However, socially active retirees lived very satisfying and productive lives after retirement (Mishra, 1992, 1993). Preference towards productive and satisfactory leisure time involvements have been found to steadily increase in the elderly with advancing age (Basu, 1996).
The main activities that elderly spent their time were reading newspapers (if literate), watching TV especially for political news, and games and sports, and religious serials, listening to music (Bambawale, 1997; Kanwar & Chadha, 1997; Srivastava & Saksena, 1995), helping in home making and domestic chores, attending to grandchildren (if in extended families) or simply sitting and resting (Jain, 1989–1990; Praveenkumar, 1992; Singh et al., 1982).
Perception of Personal Future
As old age is characterized by sickness, frailty, and disability, many individuals become apprehensive of their own (personal) future. Some grow anxious and worry about the future, while others may worry about death (Ramamurti, 1971, 1989c). For many, the process of dying and the preceding disability may be the cause of their concern rather than the event of death itself (Usha, 1985; Usha & Ramamurti, 1988). Another significant and related aspect is about one's self-perception of personal futurity. Studies of perception of personal future have shown that a majority of older persons view their future with some anxiety. They are personally concerned about sickness and resulting disability that may befall them in their later years. The elderly do not seem to plan their future for long spans of time (not exceeding a few years). Some even evade talking or thinking of their personal future (Gangireddy, 1971; Ramamurti, 1971, 1989c).
According to Ramamurti (1989c) perception of future consists of two categories. One refers to the general perception of future events (e.g., future of the world around or some other non-subjective aspect). The other refers to the perception of one's own future (called personal futurity). As one grows and ages there may be changes in the perception of their personal future. In younger years, a major part of their lifespan is before them to be thought of and fantasize about, that is, their education, marriage, married life, raising a family, profession, job, etc. But, as the person enters old age (or in the post-retirement phase of life), many feel that there is not much to achieve or aspire for. Some may feel confident of the future while others feel depressed. This appears to depend on their pleasant or unpleasant past experiences. It is common for many elderly to plan for short periods (about 5 years at a time), as they are unsure of how long they would live (Ramamurti, 2004).
Death anxiety among the elderly, that is, on how people perceive and confront death is a well researched area in Western gerontology (the US and Europe). Terminal illness is one condition that may be relevant to the application of Kubler-Ross's stages in preparing for death (Kubler-Ross, 1969). Counselling individuals on meeting and resolving how to face death is a specialized skill (Ramamurti, 1989c).
Ramamurti's (1971) study on attitudes towards death showed that there were wide individual variations on the expressed attitude to death among elderly. Thirty-one per cent of the elderly stated that thought of it does not worry them, 29 per cent said they were somewhat worried, particularly as there were many unfinished things remaining to be completed, 18 per cent of the sample were not happy to discuss the subject and 22 per cent said they never gave a serious thought to it though it came to their mind on and off. They believed that it is like discarding an old body and starting a fresh new life somewhere else (rebirth).
The belief that there is a continuity of the soul and that on leaving the body at death it finds a newborn body somewhere else (death here but being reborn elsewhere) may relieve the aged of some of their fears or worries of personal annihilation at death (Ramamurti, 1987, 1989c; Ramamurti & Jamuna, 1990). Hindu cultural view holds that the soul is immortal and that there is rebirth after death (Banerjee, 2000; Dhillon, 1996). Religious faith and attitudes to death cannot be properly understood without taking into account meanings that are shared by individuals through particular religious and cultural beliefs (Beg & Zilli, 1982). Poor health was an important criterion for desiring death while the healthy elderly stated that they were not afraid of death (Mathew, 1998). As a whole, studies in India on death anxiety or attitude to death are few and far between (Gangireddy, 1971; Narayanan, 1990; Patel et al., 1998, 2000b; Ramamurti, 1989b).
SUCCESSFUL, HAPPY, AND PRODUCTIVE AGEING
In broad terms, the aim of successful ageing is to make it a happy, satisfied, and contented period with few woes. This state of well-being in old age has been christened differently by different authors, depending on the context and the variables that go to make it.
Life satisfaction (Havighurst, 1957; Neugarten et al., 1961), active ageing (Anantharaman, 1979a; D’ Souza, 1993), successful ageing (Paintal, 1976, 1978; Ramamurti & Jamuna, 1992b), and productive ageing (Jamuna & Ramamurti, 1989a; Ramamurti, 2003a) are terms that generally connote similar meanings. The term life satisfaction has been in use for some time. It boils down to a subjective self-rated feeling of contentment and satisfaction with one's own life. Early studies in India on life satisfaction appeared in the late 1960s and extensive work has been done in this area (Anantharaman, 1976, 1980a; Ramamurti, 1968b, 1970a). Most persons used the Life-Satisfaction Indices A and B developed by Neugarten et al. (1961). Both measure levels of satisfaction with past events and a general view of their earlier years. It has been adapted to suit local conditions (Anantharaman, 1980a; Jamuna & Ramamurti, 1988b; Ramamurti, 1989a, 1991a).
A number of variables were found to be associated with life satisfaction. Ramamurti (1970a) found a decline of life satisfaction around the 55th year, and also beyond the 61st year. Self-perception of health and functional abilities, self acceptance, attitudes to ageing, satisfaction with familial- and social interaction, economic security, perceived flexibility of behaviour, and belief in karma and re-birth philosophy were found to be significant contributants to life satisfaction with one's present life (Ramamurti, 1989a, 1992c; Ramamurti & Jamuna, 1993d). Jamuna (1989a) found higher self-acceptance and life satisfaction in women of upper caste groups compared to women of scheduled caste groups. Social supports, a positive life review, a fair amount of physical and mental activity, roles, self-concept, self-confidence, living arrangements (Ramamurti, 1989e); quality of social supports and networks, education level, health status and disability, work status, socio-economic status, and living arrangements were found to be related to life satisfaction (Anantharaman, 1980d; Kaur & Khumar, 1993; Ramamurti, 1989a, 1991a; Ramamurti & Jamuna, 1984, 1993c, 1995; Ramamurti et al., 1991).
Gurudass and Lakshminarayanan (1989) stated that men with their spouse living had high life satisfaction. Bhardwaj et al. (1991) found that distorted cognition and activities negatively correlated to life satisfaction significantly. Chadha (1991) and Chadha et al. (1991a, 1992) discovered that males and females differ significantly with regard to life satisfaction. Hosmath (1992) and Hosmath et al. (1993) found that life satisfaction differed in elderly and younger subjects. Those elderly who were living separately had good life satisfaction compared to those living with married or unmarried children. External locus of control, mental health and adjustment (Ramamurti & Jamuna, 1992b), values of creativity, altruism as against seeking power, wealth, status (Ramamurti, 1987; 1989a, 1989e, 1991a) were associated with life satisfaction. Chadha and Arora (1995) showed lower life satisfaction and social supports in the institutionalized elderly than in the home-bound elderly. Khetarpal (1995–1996), Mathew (1997), and Prakash (1996a) enquiring into the health and life satisfaction of the elderly reported that subjective life satisfaction decreased with increasing age. Low life satisfaction has been associated with increase in physical complaints pertaining to vision and locomotor disabilities.
Some times life satisfaction was used synonymous to good adjustment, mental health, psychological well-being, etc., (e.g., Bali, 1999; Bhatia, 2002a; Jamuna, 1992a; Jamuna & Ramamurti, 2000b; Jamuna et al., 1999; Nathawat, & Rathore, 1996; Nandini, & Parvathi, 1996; Prakash, 2003a; Ramamurti, 1989e, 1991a). The life satisfaction concept continues to be in vogue with studies to assess its determinants (e.g., Bakshi & Sandhu, 2002; Gaonkar et al., 2003; Mathew, 1997; Ramamurti, & Jamuna, 1993c; Ushasree, 1989; Vijayashree, 1989).
Successful ageing is another term used to connote good coping to ageing changes. An important determinant of this is the acceptance of changes consequent on ageing as normal and not to become apprehensive (or) anxious about them. Happiness and contentment in old age stem from a graceful acceptance of ageing changes.
Here again a host of variables were studied in relation to successful ageing in India namely good adjustment, life satisfaction, mental health, a sense of well-being, etc. (Jamuna, 1988, 1994b; Ramamurti, 1987, 1989d). There were significant correlates of successful ageing. Self-perceptions of physical health, belief in karma, self-acceptance of ageing changes, flexibility, belief in after-life and social supports were found to be the important determinants of successful ageing (Ramamurti, 1991a, 1992c; Ramamurti & Jamuna, 1992b). A number of psychosocial and other factors were considered in relation to it as contributants or as predictors of successful ageing (Baltes & Smith, 2003; Ramamurti, 1989e; 1991a).
Many felt that old age is not a period when people should disengage, withdraw, accept the inevitable and fold up. On the other hand, they viewed that the right response to ageing was to fight it and continue their activities as vigorously (actively) as possible. It is borne out of the viewpoint that if the body and mind were well exercised and kept active, ageing could be slowed down. Different people offer different sets of suggestions on how to keep active (Bhatia, 2002b). Some of these were active involvement in rearing children to help them to grow up and settle down, help the people around them in their daily chores, keep body and mind well exercised, and use physical and mental capabilities to serve the community (Chaudhary, 2001; Ramamurti, 1989d).
It is further believed, that active ageing is an important component of healthy ageing (Bagchi, 2000; Ramamurti, 1996c). A significant way of doing it is to keep physically and mentally active (Kumar, 1998; Ramamurti, 1989d; Sachdev, 1998). Several conferences and seminars were conducted in India in recent years on the theme of ‘Active Ageing’ and the proceedings published (e.g., Chaudhary, 2001) reflecting the recommendations of the Second World Assembly on Ageing held at Madrid in April 2002, in this regard (UN Report, 2002). Some Indian studies on the correlates of ‘Active Ageing’ are also available (Roy & Chakraborti, 1999; Singh, 1995).
Productive ageing has been used synonymously with active ageing with the modified meaning that activities should be productive and useful to oneself and others (Jamuna & Ramamurti, 1989a; Khan & Maqbool, 1998; Ramamurti, 1997c, 2003a). It also means that individuals keep themselves useful, and learn to be self-dependent in old age (Bhatia, 2002b; Ravindrakumar, 2002; Tyagi, 1999). The elderly can contribute voluntarily to community development through social service (Ramamurti, 2003a; Yesudian, 1999). There is little empirical information on how the elderly are currently engaged in productive activities.
PSYCHOSOCIAL CHARACTERISTICS OF LONG LIVED INDIVIDUALS
In view of changing demographic structure, the study of longevity and factors associated with it gained its momentum in recent decades. In the twentieth century alone, about 30 years have been added to the average life expectancy. While there is evidence to suggest a predominant role for genes (family longevity) and other biological factors, it cannot be denied that lifestyle and psychosocial factors also contribute to longevity. Most of the work on this comes from the US and Europe.
A few Indian studies were also carried out relating psychosocial factors to longevity, for example, the Tirupati Centenarian Study (Ramamurti et al., 1996a, 1996b; Sudharani, 2000). Data collected through detailed case studies and interviews of centenarians showed that they hailed from families where ancestral members generally lived long lives (above 80 years). Most of them belonged to the middle economic class. Physically they were slim (not overweight) and active for their age. They consisted of both vegetarians and non-vegetarians and ate a variety of foods. They did not in their past, suffer from major diseases, were not hospitalized, and had only visual and hearing defects. They were largely self-dependent in ADL till a few years back. Most of them were widowed. They also passed through the usual problems and losses in their lives. They generally coped with such setbacks and took them in the stride. They enjoyed good social relationships, were God-fearing in outlook. They always took a positive and confident view of life (Jamuna & Ramamurti, 2000b; Jamuna et al., 2001; Kiranmayi, 1993; Ramamurti et al., 1996a).
Two major research projects were executed relating psychosocial factors to longevity [an ICSSR funded study (Jamuna et al., 2001) and an UGC funded project (Jamuna & Ramamurti, 2000b) covering several sets of variables]. Long-lived individuals including centenarians constituted the sample. The studies showed that some variables such as physical- and psychological activity levels, flexibility of behaviour, and significant social supports were associated with long-life. There were more women than there were men in the oldest-old group, most of them hailing from rural areas and belonging to middle-income families with history of long-lives. Most of the long-lived persons lived with their children and grandchildren and helped them in their daily chores. Spiritual orientation, belief in the Hindu concept of karma, God-fearing nature was common in many. Temperamentally, they were calm and did not show agitation or stress, and were mostly satisfied with their lives. They reported that they had not at any time suffered from serious ailments. Though frail, they wanted to attend to their needs themselves (with a little assistance). Long living individuals who expressed good life satisfaction had better social supports, a positive life review, a fair amount of physical and mental activity, and were self confident in most of their affairs (Jamuna et al. 2001; Jamuna & Ramamurti, 2000b).
The aforementioned studies were mostly on cross-sectional samples examining the characteristics of the old-old and oldest old and comparing them with a young-old group in the 60 to 70 age group. No doubt, prospective studies with a panel of older persons, who could be followed up at regular intervals may provide results that are more reliable. However, the findings from these major research projects are highly suggestive and provide lead data that would be of help in planning appropriate prospective studies of older people.
Active life, physical exercise, peace of mind, personal hygiene, balanced diet consisting of milk, vegetables, fish and fruit, a normal sex life, avoidance of drugs and smoking, and a happy outlook may contribute to longevity (Ali, 1975; Jordan, 1997; Saibaba & Rammurthy, 1998; Srivastava, 1976; Wasir, 1996). Vedantham (1975) made a census survey of centenarians in A. P. (special report). Baweja (1992), based on the Tirupati Centenarian Study (Ramamurti et al., 1992b) concluded that the level of physical work in their lives was just right, neither too burdensome as with the poor, nor too little as with the rich. Most centenarians were calm and unflappable in dealing with family crises (Ramamurti et al., 1996a, 1996b).
Longevity studies from the West and East indicate that they are well organized and fully supported by institutions and the State (Ramamurti, 2002). Similar support and substantial encouragement for longevity studies in India are needed. Teams of people rather than individuals should undertake them. Such studies would yield valuable data that can be used to promote healthier and happier longevity.
QUALITY OF LIFE—PSYCHOLOGICAL CORRELATES
A term that is often used as a measure or marker of social and of national development is QOL of people. The World Bank often uses this index as a measure of development. The term acquired different connotations under different contexts and authors. It has come to mean several things: standard of living, living conditions, the extent to which needs of life are met, physical and psychological well-being, the level of satisfaction with one's living conditions, etc. In medical parlance, the term QOL has frequently been used to connote the level an individual is able to manage his/her ADL and feel a sense of well-being (Jamuna et al., 1999; Ramamurti, 1991c, 2001a).
The indicators of QOL can be categorized into several domains, for example, physical, psychological, social, financial, spiritual. The WHO used an omnibus definition of QOL that included a variety of categories. The WHO developed a special scale combining measures on several aspects. The WHO (1995) states that QOL refers to the individual's perceptions of their position in life in the context of culture and value systems and in relation to their goals, expectations, standards, and concepts. It includes physical health, psychological health, level of independence, social relationships, personal beliefs, and their relationships to salient features of the environment. The WHO definition consists of assessment of six broad categories viz., (i) physical domain; (ii) psychological domain; (iii) level of independence; (iv) social relationships; (v) environment and (vi) spirituality, religion and personal beliefs. The objective of the WHO has been to improve the QOL of the older person by raising the functional level of the various domains that constitute it.
Several studies in India were carried out to assess the QOL of the elderly and investigate the factors associated with it. The medical, psychological, and socio-economic status of individuals and their functional capabilities need to be improved to upgrade the overall QOL (Kumar, 1994; Prakash, 1991; Rajkumar et al., 1995). Chadha (1997) and Chadha et al. (1991b), and Katyal and Bector (1999) found that those who are living with their families, have cordial relations with their children, and spouse are self-sufficient. They have a positive frame of mind and have few problems relating to health. They feel less lonely, less helpless and were more satisfied with their life. They had more leisure activities than the institutionalized elderly. The elderly enhanced their perceptions of their QOL through life reviews (Pinto, 1994; Pinto & Prakash, 1996). Women, the old-old, and the rural in Delhi had economic, physical, psychological and social characteristics that suggested a poorer QOL than that of their counterparts in Tamil Nadu (Easwaramoorthy, 1993; Easwaramoorthy & Chadha, 1997, 1999). Improvement of living conditions particularly of the rural elderly in turn improves the QOL (Jamuna et al., 1999; Kaushik et al., 1997; Mohanty, 1997). Chadha (1997) suggests free bus passes, long-term fringe benefit schemes at national level, health care insurance at an early age, free medical treatment at the doorstep to improve the QOL of elders. Sreenivas (1999) has suggested several steps for improvement of the psychological QOL of retired sportspersons. Antony (1994) and Prakash (2000) state that assistive technologies could be effectively used for improvement of the QOL of the elderly.
Pannu (1994) and Sandhu (1998) explains the role of NGOs like HelpAge India who serve to improve the QOL of the elderly, and suggests that one should look after one's own elderly or adopt one if they do not have any. Gautam (1993) and Baradha (2000) suggest adoption of different strategies by multi-disciplinary groups for upgradation of the QOL of older people (Soneja, 2000). Disciplined daily living activities during one's working life leads on to a good QOL in later years. Neglecting middle age and calling themselves old before their time is to throw away the prize of life that they have almost won (Patnaik, 2000).
A few research projects were carried out in India to assess the correlates of QOL (Jamuna et al., 1999, 2001). The findings indicated that affect balance, psychological health, life values, social supports, (psychosocial variables) economic status, education, and locality (demographic variables) and physical health were related significantly to QOL. A model of contributants to good QOL was proposed (Jamuna et al., 1999). Interventions to promote the sense of well-being (QOL) by manipulating its critical contributants are of immense importance. It can be gainsaid that in addition to physical health, psychosocial variables play a significant role in promoting the sense of well-being popularly known as ‘quality of life’ (QOL).
RIGHTS AND RESPONSIBILITIES OF OLDER PEOPLE—PSYCHOLOGICAL IMPLICATIONS
The United Nations in its Declaration of Human Rights specified certain basic rights (e.g., right to live, right to equality, right to basic necessities, right to education, etc.) that are inalienable to human living and need to be guaranteed in governance. Awareness of these affects self-perception and attitudes to life. A large number of countries (including India) have incorporated them in their constitutions and/or statute books to ensure them to their peoples. Arising from this, ideas were generated that the older persons as a distinct group (mostly vulnerable), need to have their own set of rights. Accordingly, the International Federation of Ageing (IFA) deliberated on this and formulated a set of rights applicable to senior citizens. They are stated in an abridged form below:
Rights of Older Persons
(i) To obtain adequate food, water, shelter, clothing and health care through the provision of income, family, and community support and self-help; (ii) to work and to pursue other income-generating opportunities with no barriers based on age; (iii) to retire and participate in determining when and at what pace withdrawal from the labor force takes place; (iv) to access educational and training programmes to enhance literacy, facilitate employment, and permit informed planning and decision-making; (v) to live in environments that are safe and adaptable to personal preferences and changing capacities; (vi) To reside at home for as long as possible.
(i) To remain integrated and participate actively in the formulation and implementation of policies which directly affect their well-being; (ii) to share their knowledge, skills, values and life experience with younger generations; (iii) to seek and develop opportunities for service to the community and to serve as volunteers in positions appropriate to their interests and capabilities; (iv) to form movements or associations of the elderly.
(i) To benefit from family support and care consistent with the well-being of the family; (ii) to obtain health care in order to maintain or regain the optimum level of physical, mental and emotional well-being and to prevent or delay the onset of illness; (iii) to access social and legal services to enhance capacity for autonomy and provide protection and care; (iv) to utilize appropriate levels of institutional care which provide protection, rehabilitation and social and mental stimulation in a humane and secure environment.
(i) To exercise human rights and fundamental freedom when residing in any shelter, care and treatment facility, including full respect for their dignity, beliefs, needs, and privacy and for the right to make decisions about their care and QOL; (ii) to pursue opportunities for the full development of their potential; (iii) to access educational, cultural, spiritual, and recreational resources of society.
(i) To be treated fairly regardless of age, gender, racial or ethnic background, disability or other status, and to be valued independently of their economic contributions; (ii) to live in dignity and security and to be free of exploitation and physical or mental abuse; (iii) to exercise personal autonomy in health care decision-making, including the right to die with dignity by assenting to or rejecting treatments designed solely to prolong life.
Responsibilities of Older Persons
(i) To remain active, capable, self-reliant and useful; (ii) to learn and apply sound principles of physical and mental health to their own lives; (iii) to take advantage of literacy training; (iv) to plan and prepare for old age and retirement; (v) to update their knowledge and skills, as needed, to enhance the employability if labour force participation is desired; (vi) to be flexible, together with other family members, in adjusting to the demands of changing relationships; (vii) to share knowledge, skills, experience and values with younger generations; (viii) to participate in the civic life of their society; (ix) to seek and develop potential avenues of service to the community; (x) to make informed decisions about their health care and to make decisions about terminal care known to their physician and family. All these have an impact on an older person's lifestyle and behaviour. Apart from these universal declarations of the UN and IFA, the Constitution of India recognizes the needs of the elderly and holds the State responsible for making effective provisions. Apart from this, Section 125 of the Code of Criminal Procedure considers it the duty of an individual with sufficient means to maintain his father and mother who are unable to maintain themselves. There are several provisions in the Succession Act that entitles the elderly parent to a part of the property of his (or) her deceased child. As an outcome of the National Policy destitute old people need to be paid old age pensions. Senior citizens have been extended several concessions in travel, income tax, medical aid and in queuing (Gokhale, 2003, 2004).
THE RESEARCH EFFORT ON GEROPSYCHOLOGY—AN EVALUATION
The sustained development of any field of enquiry or a policy squarely rests on its research base, and is data-driven, an observation no less true of Indian geropsychology. Further, teaching, training, and innovative problem-solving lean heavily on research. Thus, it can hardly be denied that research is the breath of good development (Chandra, 1988; Ramamurti, 1996b, 2003b, 2003c).
Indian research on the psychology of ageing began slowly in the 1960s and picked up in the late 1980s. It still suffers from several teething troubles. As in other countries, in India too, socio-psychological and welfare research (that is conditioned by a dominant cultural milieu) is far ahead of the research in the biological and medical sciences. The latter suffer from several drawbacks such as paucity of funds and of trained work force. These apart, there are several other lacunae that afflict the Indian research effort (Ramamurti & Jamuna, 2000).
At the outset, poring over the four thousand and odd research articles, (especially those in the psychological and social sciences), to assess them with regard to representativeness of the population studied, the methodology and techniques adopted, their reliability and validity, and the utilization of the generated data, one gets the impression that things could have been far better than they are (Bali, 1995; Karkal, 2000b, Ramamurti & Jamuna, 1984, 1993c, 1995, 2004).
Taking the national effort in ageing research as a whole, it is found to be piecemeal, disorganized, and uncoordinated. It suffers from a lack of direction, goal setting, and the absence of an agenda for research thrust. This is largely because there is no national agency that is responsible to guide the research effort or coordinate it. Redressing this situation would be the first task cut out for the national organizations of academicians who need to take on themselves the responsibility of achieving the said objectives of good organization, coordination, and purposeful direction.
The data output of Indian research on psychology of ageing is rich and varied but poor with regard to theory building or theoretical interpretation. This aspect needs emphasis in efforts in the future. Evolving appropriate models to explain data trends would be useful (Ramamurti, 2003c).
For research to be useful, standards have to be imposed in each subject of research planning, and execution and reporting modalities established. Research, where the standards are watered down, is unauthentic, undependable, useless, and wasteful of resources and effort. Here again, academic geropsychologists have a role to play in formulating and specifying appropriate standards that are to be followed.
One way of maintaining fair standards of research work is to ensure that journals that publish the articles ensure that articles conform to certain basic requirements (such as topical relevance, sample representativeness, sound methodology, appropriate statistical analysis, and valid discussion and implications) for acceptance for publication. Expert peer review or approval is essential. Similar steps of screening, evaluation or audit may be applied to the approval of research projects and research reports. Redundant research has to be discouraged. Research work that is approved could be of pure- or of applied value especially of an intervention or demonstration type.
The foundation for good research, namely, a scientific attitude in experimentation and field study has to be inculcated early in prospective researchers, that is, at the master's level. The curriculum in geropsychology has to be fashioned to include a taste of a field/laboratory study, handson experience that incorporates and encourages a scholastic initiative, etc. This will provide the most essential professional insights into the subjects of study. Unfortunately, such programmes are not available in many institutions. The existing system needs to be revamped to provide ample representation for this type of experience. As part of this training writing, reporting and communication skills are to be imparted as many persons of the younger generation seem to be lacking in these areas.
Another aspect of research that needs attention is making available research findings to persons who need them and use them (e.g., other researchers in the field, policy makers, consultants, and teachers). Often research reports of significant and useful projects simply decorate shelves or fossilize on library racks. One cannot ignore necessity to appropriately document research findings and disseminate them widely among possible users. The benefits of research findings should be available to the scientist and the common man in the form of popular handouts. National datasets may be generated and made available to scientists as secondary sources of data.
The volume of research output in geropsychology is vast. It could best be integrated by a centralized national documenting agency which procures the publications, processes, categorizes and even summarizes them (abstract) not only in English but also in the regional languages. Anyone who needs information on a specified topic should be able to easily access it in this central location. Information on the availability of data at this centre also needs to be disseminated among prospective users. A Website or Web resource centre could be created for this purpose (Ramamurti, 2003b).
Another important aspect that should be addressed is to expose scholars to international literature in the field (Ramamurti, 2002). Many university and college libraries do not procure essential international journals, as they are prohibitively costly. A national centralized facility (e.g., NASSDOC) could procure these international journals with an electronic computerized access system in place, through which college libraries could access them at minimal cost. This facility would help scholars in reviewing the literature in the specific field in which they propose to launch their research study.
Geropsychological research, though four decades old in India, has not uniformly covered the various sub-areas. Certain areas have remained grey while a few areas have been intensively covered. The areas fairly well worked upon are adjustment, life satisfaction, general problems of ageing, the elder in the family and in the social context, implications of demographic changes, the elderly residing in institutions (OAHS, etc.), living arrangements, elder care issues, generational differences, retirement effects, and QOL.
Areas which need to be widely covered are cognitive aspects, personality studies, stress and conflict, service needs, elder abuse, policy-related issues, interventional studies, health behaviour, preparing for death, planning for retirement and ageing changes, methodology, behaviour modification techniques for the elderly, prospective (longitudinal) studies, person-environment fit, etc. There is dire need for team work and multidisciplinary research.
The aforementioned are some suggestions that universities, colleges, and agencies like the ICSSR can adopt and put into practice. Intense training in knowledge acquisition, research planning, methodology and execution has to be imparted to the student. It is only when these basic essentials are taken care of that the research effort in the country would ensure that a trained human resource becomes available.
THE FUTURE OF GEROPSYCHOLOGY
In the foregoing pages an attempt has been made to provide a bird's eye view of the developments in geropsychology in India. Most of the significant researches (though not all) have been included under appropriate categories. It is possible that some of them will not have found a place here. Certainly, this is not because of their insignificance but due to our oversight. Weightage has been given to empirical studies while downplaying theoretical and the popular exhortation. In an undertaking like this, it is possible that there may be some shortcomings but it is our hope that the reader takes kindly to them.
In the footsteps of other sciences, geropsychology too has set its sights on the welfare of the senior citizens. Research has tried to observe, record, and understand the behaviour of older people in their natural settings. The best of available analytical tools have been used to assess the correlated or determining factors that contribute to a good QOL in the elderly. The search for more of such variables and the effort to control them goes on so that we may give the older person a better QOL. Old age need not be viewed as a curse. It is only a phase of life, the end phase of life, for which the beginning was made. Let us join Robert Browning to view old age more positively as part of development and say ‘Grow old with me for the best is yet to be’.
Ageing is an ongoing process throughout the lifespan of an individual. As the individual progresses in life, the cumulation of earlier experiences continues to influence his present as well as future behaviour. In other words, the latent or patent behaviour at any point of time in the lifespan (e.g., old age) is the result of the dynamic interaction of all his past incidents and experiences. Viewed in this sense, succeeding patterns are dependent on the preceding events and their interrelationships, that is to say that determining the preceding events is the best way of determining later events in life. Notwithstanding genetic determination, both physical- and mental health in later life are constructions from the constituents of earlier events. It implies that the QOL in the later years depends on these earlier events.
Future research in geropsychology would do well to further delineate how life's later processes regress on past events of the elderly and devise ways and means of exercising control of these early events. As elsewhere, the best way of ensuring a good later life is to ‘catch them young’ and ensure such their early lifestyles would promote a disability-free, happy, and livelier longevity.
According to Baltes a gain/loss conception of development would mean that the life course is the product of growth (gain) and decline (loss), a mix of new adaptive behaviour and loss of a part of past capability (Baltes, 1987). Longitudinal data from the Berlin Aging Study on everyday functioning proposes that older individuals who are rich in sensory motor, cognitive, personality, and social resources exhibit fewer negative age trends than older people with poor resources (Baltes & Lang, 1997). Some others have emphasized that ageing is an ecological process involving organisms of particular genetic backgrounds interacting with particular psychosocial and physical environments. It is also added that it is difficult to classify all of human variance as solely biological, in view of the observation that nearly 30 years have been added to the human life expectation in the last century. Thus, the contribution of psychosocial ecology to longevity is not insignificant (Schroots, 1995).
Baltes and Baltes (1990) have given us the psychological lifestyle principle of selective optimization with compensation (SOC) as a normal mechanism of coping with the consequences of ageing. But there are limits to this process, and it may not be applicable beyond a certain level (Lang et al., 2002). Speaking at the Valencia Forum, Baltes (UN Report, 2002) pointed out that beyond this level, only interventions in molecular biology can offer hope by extending the human lifespan.
The mapping of the human genome and the processes of its expression have given us ample insights into their role in determining certain chronic disease processes that affect individuals particularly in their later years. Genetic intervention in this regard has progressed from a stage of theoretical possibility to one of practical probability in the not too distant future. By modulating genetic expression and the psychophysical environment, the severity of the contributory factors to the process of ageing can be mitigated and the whole process of ageing substantially retarded.
The Indian ethos, insofar as ageing is concerned has been unique, though some similarities can be found in other developing countries of Asia. The special contexts in which the process of ageing is occurring in India need to be examined and analysed in detail, the determining factors fitted into an appropriate model, and the role of behavioural variables delineated. One such model to explain human longevity in India (see Fig. 3.2) was proposed (Ramamurti, 1997c) and is presented in Figure 3.3.
It picturizes ageing as an ongoing lifelong process rooted in genetic prenatal foundations that interact with an ecosystem as it is expressed and constantly modified in the journey of a lifetime. They continuously interact as the organism develops across the lifespan to determine the end event. The quality, quantity, the duration of the impact of the factors impinging on the developing organism appears to fix longevity and the QOL in the older years. Longevity and QOL in the aged can be viewed as a dynamic weighted regression on a host of factors (internal and external) that impinge on the person as he/she passes through the lifespan (Jamuna et al., 2001; Ramamurti, 1997a).
When a large segment of the population is poor and resides in rural localities, the medical model of care services (as prevalent in Western countries) may be unsuitable as these services are prohibitively expensive. In its place, we have to consider a more appropriate modified social model of care services. Home care or community care with trained health care personnel providing assistive bedside help or home care is to be developed. Primary and secondary carers at home could be suitably trained to attend to the sick or disabled elderly. The psychological component in such cases, for example, good interpersonal altruistic behaviour has to be imparted to care providers and care recipients.
Among these services, psychological counselling services to the elderly and their families of various types to meet their needs has to be emphasized. Specialist professional training needs to be provided to handle specific problems or issues at a modest cost. Counselling apart, a wide variety of other psychological services could also be thought of. Interventionist services, to improve general social and intellectual competencies could be made available, for example, memory training, emotional intelligence training, and other efficient psychological training modules for these could be developed.
Figure 3.3: Model of Longevity.
Source: Ramamurti, 1997a
A significant aspect of population ageing that would affect the Indian scenario is the increased longevity of individuals. This development with regard to India is that in the near future there will be a large number of people above the age of sixty. Due to greater health awareness, better health practices, better control of disease and disability, and repair of diseased organs, most persons may be physically and psychologically able. Indigenous programmes for the effective and productive utilization of this increased human resource of older persons have to be drawn up and implemented. This will be a special challenge that has to be dealt with. The elderly could be organized to volunteer; self-help groups of such volunteers could not only take care of their own peers but also to lend a helping hand in local community development activities of others as well. The scope for such development is very vast if only imagination, innovation, and enterprise could be stretched a little.
Talking of intellectual- and physical fitness, there is much that India can offer as a resource. Meditation of various types and yogic exercises are available aplenty. You have only to name the condition and you have an appropriate exercise for it. There is plenty of scope for the adaptation of yogic techniques for improving intellectual functioning.
Research on the effects of transcendental meditation has reported beneficial effects on intellectual functioning. Further investigations on the effect of yoga, meditation, and intellectual function are strongly indicated (Chopra, 1995; Dhar, 1997; Ramamurti & Jamuna, 1992b; Rastogi, 1996; Umadevi, 2002). In the same way, spirituality should be considered an important contributor to the mental health and well-being of the older people. The WHO in a multinational study has identified spirituality as a significant component of QOL (WHO, 1995). This aspect has already been enlarged in a previous section on QOL. In view of this, geropsychology of the future could focus on our indigenous cultural heritage viz., yoga, meditation, and spiritual style of life.
The quest for a better insight into longevity or for that matter, in a larger sense, of life itself and its place in the scheme of things in the cosmos is as old as the human mind. The mind, however, has its own limitations, as any understanding gained by the mind is in itself a function of the nature of mental processes. Yet, we have learnt that concepts of time, space, and causality are themselves relative and the search for the absolutes may be like chasing mirages in this timeless universe. All that we see and notice around us is change, which appears to compose time. And ageing is change or rather, change characterizes ageing! Yet, science cannot become sterile and in the limited sense of a lifespan the search for happy, disability-free ageing (as a relevant one) goes on and will continue to go on. Geropsychologists have a definitive role to play in this endeavour.