THE PROBLEMS AND EFFECT OF OLD AGE

CHAPTER TWO

LITERATURE REVIEW

2.1 Concept health as related to ageing.

Health is a concept that is not easily defined as it has several meanings depending on how one perceives it. The definition of health becomes even more complex when referring to the older people). For example, an older person suffering from diabetes or even hypertension when asked how he/she feels would say he/she is fine. Even in appearance, that individual may look fine, yet in actual fact this particular individual has a medical problem. The variety of definitions of what is ageing that emerged from the literature might also explain the complexity of defining health as related to ageing.

Thompson (1996:15) defines ageing as ‘growing old, giving the appearance of advancing age’. Keith (1982) defined old age as ‘a basis for sorting individuals into categories’, and he places the concept of old age or older person, in a social context.

However, Davies (1998: 21) defines ageing as ‘a progressive loss of adaptability with time so that the individual is less and less able to react adaptively to challenges from the external or internal environment’. This suggests that with time, the individual becomes progressively more frail and in need of increasing support to maintain his or her autonomy. Several countries (Apt, 1997; Irvine et al, 1986; Kennie, 1993; Roach, 2001) defined ageing in terms of the official retirement age and have used it as a measure to indicate the beginning of old age. However, this official retirement age varied from country to country. For example, people retire at 55 years in Nigeria, 65 in South Africa and 60 in the Democratic Republic of the Congo. Previously, all the people over the age of 60 years were grouped under the category of being old. However, it has been recognized that much diversity exists among different age groups, especially in late life (Eliopoulos, 2001; Irvine et al, 1986).

From a health perspective, old age begins around 75 years and above, and this is referred to as functional age, fourth age or biological age. Functional or fourth age is considered as the operational definition of old age as there is an increase in medical disorders and resultant physical and mental disabilities among this age group (Kennie, 1993). In terms of health measurement, ageing is mostly defined in terms of functional age (Haslett et al , 2002). Functional age is seen as being reliable as it evaluates age in terms of functional performance (Kennie, 1993; Roach, 2001). It is most commonly used world wide for decision- making in terms of investigations and interventions (Haslett et al 2002).

However, it is argued that functionality has different meanings and is measured differently in different cultural contexts (Keith,1982). Measurement and meaning of functionality depends on what is required for full social participation in various settings.

This raises difficulties in establishing markers that can identify the functional age (Kennie, 1993). In high economy countries or affluent communities of the low economy countries, the level of functionality could easily be assessed or measured by the ability to climb stairs, taking a bath or clipping toe nails (Keith 1982). The chores of the poor people in Africa, Nigeria, inclusive are numerous and tedious, and range from walking long distances to draw water or fetching firewood. This creates difficulty in using standardised and acceptable measures and indicators of functionality.

In statistical terms, ageing is defined in terms of the number of years one has lived (chronological age). Chronological age rarely occurs alone, and according to the literature, reliance on chronological age could be misleading. It is acknowledged that chronological age usually occurs along with other definitions, such as retirement, physical decline, or change in mental attitude (Keith 1982). Keith (1982) observed that, when functional age rather than chronological age is used as an indicator of old age, the transition to old age is gradual. As it is thought that people who regard older people as a useful resource rarely define age in chronological terms. As compared to those who feel that people over 65 years are a burden. Several authors (Eliopoulos, 2001; Kennie, 1993; Roach, 2001) have defined the older persons in terms of both chronological and functional age.

The WHO defines health as ‘a state of complete physical, mental and social well being and not just the absence of disease’. Whitehead (1995) suggests that the above definition of health is based on the understanding that the individuals’ health is influenced by several factors that are often categorised into biological, physical and social environment, personal life styles and health services. The author refers to these factors as ‘layers of influence’, as they can have a health promoting or health damaging potential depending on the personal behaviour and the way of life that individual adopts.

Authors (Fuller, 2000; Whitehead, 1995) agree on the fact that individuals do not live or exist in isolation. By ‘being in the world’, they interact with other people. These interactions expose people to different types of social and community influences, which may have a potential to damage, or promote health.

Mutual support is one of such positive factors that result from the interaction in the community. Mutual support is capable of sustaining the health of the older people in what could have been unfavourable conditions. Lack of support, may lead to social isolation of the individuals that may adversely affect their health.

Leininger (1985) agrees that the WHO definition suggests that the immediate environment is very influential in the maintenance of health. The author further agrees that the inseparable relationship between the subject and the lived world, make health and illness socially and culturally constructed. It means that the socio-economic and cultural conditions prevalent in the society have an effect on the general health outcome and standard of living pertaining to the members of that society.

Socio-economic factors for example may influence the individual’s choice of accommodation, employment, feeding and other social interactions.

Some authors (Irvine et al, 1986; Kamwengo, 2001; Kennie, 1993) argue that the WHO definition lacks an operational precision upon which specific preventive and health promotional strategies for the older persons can be based. It is believed that the emphasis on social well being and ‘a complete absence of disease’ as suggested by the definition, could mean provision of goods or services that should keep the older persons more content. It should however be noted that achievement of this level of health is accompanied with a variety of costs to many of the individuals concerned.

It is believed that the social and economic environments in many African countries (high level of poverty, the effects of HIV/AIDS, limited infrastructure) do not allow access to the necessary resources to achieve anything approaching ‘a state of complete physical, mental, and social well-being’. Therefore, they support that a framework for considering the various possibilities for action and how they may contribute to the attainment of health and active ageing is required.

Fuller (2000) suggested that the concept of health maintenance as a way of contributing to achieving health and active ageing. The author argued that it is vital to maintain good health as it helps to maintain well-being and quality of life.

Maintenance of good health enables the older people to maintain autonomy in order to continue making active contributions to society even in this later stage of life. However, the author argues that health maintenance is based on the concept of health and the ability of an individual to maintain desired health status. Maintenance of health is complex, as it requires a balanced state of the internal and external environment. By being in the world, people are always interacting with the changing environment.

2.2 Theories explaining ageing

The complexity of the ageing process has led theorists in exploring several factors, both internally and externally to try and explain ageing. No single theory to date can fully explain ageing or the causes of ageing (Roach, 2001). In the continued efforts to try and explain the causes of ageing and the ageing process, several laws and theories have been suggested. Eliopoulos (2001) pointed to the fact that most of the proposed ageing theories only offer varying degrees of universality, validity and reliability.

Despite, this variety of theories trying to explain ageing, there is a common understanding amongst most of the theorists (Eliopoulos, 2001; Hall et al, 1993; Roach, 2001; Robert & Hofecker, 1990) that:

• ageing is a universal process;
• it is a progressive and irreversible process, both in structure and function;
• all living beings age;
• beings under the point of reference emerge from the same type of organism;
• ageing is influenced by several intrinsic and extrinsic factors and;
• ageing is debilitating and resulting not only in losses but also in gains.

In this section, three categories of ageing theories (the fundamental bio dynamic or natural law, biological theories and psycho social theories) were reviewed. These theories are summarized in Table 2. Most of these theories arise from the understanding that people grow and develop physically, emotionally and socially during their human life in order to realise their full health potential (Stoyle, 1994).

2.2.1 Fundamental bio dynamic or natural law of ageing

The fundamental bio dynamic or natural law explains the ageing process as a ‘linear fashion’ of ‘emerging, changing and vanishing. It views ageing of man as destiny, as he has to return home into ‘being’ and acknowledges that ageing starts with conception (Robert & Hofecker 1990:7). The natural law argues that the individuals are born, grow and attain optimum vitality. But with advancing age, vitality begins to fade and eventually death takes place. Kennie (1993:7) recognizes that, there is a decline in physiological functioning in almost every organ and system, particularly after the eighth decade of life. This leads to decrease in the homeostatic reserve. The decrease in the homeostatic reserve leads to the body’s failure to respond to pathogenic diseases, and maintenance of adequate homeostasis.

The fundamental biodynamic law is associated with the preservation and the deprivation principles or laws. The preservation principle is also referred to as the law of preservation and applies to the period between birth and the optimum of vitality (Robert & Hofecker 1990). It is reinforced by the disposable stroma theory that suggests that ageing is as a result of failure of body cells to repair random environmental damage (Hall et al, 1993; Robert & Hofecker, 1990). The deprivation principle or the law of deprivation extends from the phase of optimum vitality to death (Robert & Hofecker 1990: 3). It is more associated with biological ageing, as the processes of ageing are more conspicuous in this stage. People begin to show attributes that society associates with old age. Functional deficits and death take place mainly in this phase of life (Robert & Hofecker, 1990).

However, effects of the law of preservation are present in all stages of life, including the deprivation phase of life, as life has to continue throughout the senescence. But as one grows older, the influence of the law of preservation decreases and the effects of the law of deprivation increases. This causes an increase in the age-specific death rate seen with advancing age (Robert & Hofecker, 1990). The theory supports the Gompetz’s law, which advocates that the percentage of surviving decreases with time and the chance of death increases with age (Redfern & Ross, 1999). In the final analysis, this fulfils the law of negation.

2.2.2 Biological theories of ageing

Biological theories suggest that, ageing is a natural process that is thought to be as a result of cell changes over a period of time. As a natural process, biological ageing proceeds irreversibly in structure and function from earlier, to the later stages of life (Irvine et al, 1986; Stoyle, 1994). The most commonly used theories are discussed in this section and include the genetic factor's theory, the cross-linking theory, the free radicals theory, the auto- immune reactions theory, and the wear and tear theory.

2.2.3 Genetic factors theory

The genetic factors theory suggests that life is programmed in the genes before birth and that people are born with biological clocks that determine the specific life span. It supports that genes control ageing, and that control occurs at the cell level. It is believed that the longer the life span, the greater the cell divisions. Some theorists believe that there is a growth substance that fails to be produced causing cessation of cell growth and reproduction. Others hypothesize that there is an excessive production of the ageing factor, which accelerates the ageing process (Eliopoulos, 2001; Roach, 2001; Stoyle, 1994).

2.2.4 Cross-linking theory

The cross-linking theory proposes that cellular division is threatened as a result of a chemical reaction. It maintains that a cross-linking agent attaches itself to a deoxyribonucleic acid (DNA) strand preventing normal parting of the strands during mitosis. According to this theory, cross-linking agents accumulate over a period of time, and they form dense aggregates that interrupt with intracellular mechanism. Interruption of the intracellular mechanism leads to the impairment and failure of the body’s organs and systems due to poor homeostasis (Eliopoulos, 2001; Roach, 2001). The failure of the intracellular mechanism is thought to be responsible for ageing.

2.2.5 Autoimmune system theory

The autoimmune system theory suggests that the changes that take place in the immune system as people grow are responsible for ageing. There is substantial evidence that several physiological changes take place in the immune system. Some of these changes cause several deficiencies in the immune system (Eliopoulos, 2001; Stoyle, 1994). The thymus and the bone marrow are the primary organs of the immune system. The ageing process affects these organs. The size of the thymus decreases with age affecting the production of the T-cell differentiation. The level of the thymus hormone also decreases to an extent that it becomes undetectable in the blood of persons older than 60 years and above (Eliopoulos, 2001).

The body is protected by the humoral immunity from cancer and viral infections. Humoral or acquired immunity is what is referred to as the cell-mediated immunity. Lymphocytes (T- lymphocytes and B-lymphocytes) are the active agents of acquired or humoral immunity. Both lymphocytes come from the stem cells, and are manufactured in the bone marrow. T cells are responsible for the cell-mediated immunity as they protect the body from diseases by destroying foreign cells directly. The T cells stimulate other cells to assist in the immunity. It is the T cells that are responsible for initiating a rapid immune response when repeated invasion occurs. The reduction in the thymus hormone leads to bone marrow stem cells inefficiency, and reduction in the production of T cells (Eliopoulos, 2001; Roach, 2001).

These changes render the body incapable of fighting disease or infection. It is these changes in the immune system that are thought to be responsible for the older peoples’ predisposition to certain infections and perhaps to the high incidence of cancers suffered in old age (Irvine et al, 1986).

This theory suggests that failure of the immune mechanism, leads to the accumulation of disease in the body, and this in itself is a cause of ageing. The theory also maintains that, the body misidentifies aged, irregular cells as foreign agents and attacks them. The changes that take place in the immune system are thought to be responsible for the correlation of disease and ageing. It is difficult in most cases to separate the effects of ageing from the effects of disease. As disease and ageing compound each other. Survival becomes impossible without a well-functioning immune system.

2.2.6 Psycho social theories of ageing

The psychosocial theories of ageing explore the mental processes, behaviour and feelings of persons throughout the lifetime (Eliopoulos, 2001; Stoyle, 1994). Ajila & Adegoke (2001) refer to psychosocial theories as theories of adjustment to ageing. Ageing is associated with chronic ill health, disabilities, retirement, and, in most cases reduced income. Retirement also leads to increased free time from formal employment but increased caring responsibilities of looking after the grand children. The psychosocial theories therefore, do explore how the older persons adapt to those pressures. The psychosocial theories include the disengagement theory, the activity theory, the continuity theory, and the stress adaptation theory.

2.2.7 Activity theory

The activity theory as the name implies, is the opposite of the disengagement theory. It advocates that people should remain involved and be active members of society, taking on roles and responsibilities (Eliopoulos, 2001; Redfern & Ross, 1999; Roach, 2001). This theory is positive as it promotes healthy and active ageing. It maintains that people should maintain their middle life age activities. Evidence shows that those who maintain their middle life age activities leave a more satisfying life.

2.2.8 Continuity theory

The continuity theory is concerned with personality and culture. It suggests that as people age they become more predictable in their behaviour and would like to continue with their roles. However, personality and culture plays a major role in determining the relationship between the levels of activity and life satisfaction. The theory suggests that, the older people have certain beliefs, norms, attitudes, expectations and behaviours that differentiate them from the younger age groups (Eliopoulos, 2001; Roach, 2001).

Like the disengagement theory, this theory disadvantages the older persons as it promotes isolation and discrimination of the older people.

2.2.9 Stress adaptation theory

The stress adaptation theory argues that life cycle has not only a predetermined genetic programme that determines one’s life span, but the non-genetic factors (stressful life events, life style, behaviour, culture, and gender) also have a role in the ageing process. It suggests that stress does accelerate ageing due to the negative effects it has on people’s health. Long-term stress causes chronic fatigue, sleeping difficulties and high blood pressure (Kozier, Erb, Berman & Snyder, 2004). Life styles and behaviour play a major role in peoples’ lives as they determine one’s health status and the rate of ageing. Life styles and behaviour have a health promoting or health damaging potential depending on

the life style or behaviour one adopts.

2.3 Challenges Faced by the Elderly in the Urban Areas

Analysis basic needs including water, shelter, sanitation, child education, etc. To meet needs household members’ access resources or services (water, food, shelter, healthcare, electricity) the elderly required assets, especially financial capital. In urban settings, most access is gained through payment. In order to build financial capital, the urban poor have to engage in productive activities, e.g. selling labor or making micro- small business. But the involvement of the old people in productive activities was found to be extremely limited. Moreover, the amount of income obtained from such activities is also insignificant compared to total household consumption needs. There are barriers to accessing resources/services which for the poor usually fend or reduce the quality and quantity of resources accessible.

The qualitative study gives insight to the sources and linkages between the different livelihood sources. Private transfers from children to their parents or grandparents can be motivated by altruism, that is result from children’s concern over the living standards of their parents, or by the need to reward parents in exchange for services provided, for example child care. These types of supports are not common among the destitute old people in Addis Ababa. The factor for this outcome was found to be historical poverty at the child and adult life. They were poor, uneducated who mostly live on casual incomes. As a result they did not invest on their children and they fell in to protracted poverty. So those parents with higher levels of assets may show a higher incidence of in kind support from their children to the contrary the old people how are poor having little thing for themselves are obliged to care grandchildren. Of the 58 respondents 19 of them (33%) reported they are caring grandchildren ranging on to six children per respondent. But only two of them reports they receive regular remittance from children.

Overall the old people at the age of critically needed philanthropic support they painfully care siblings the expense of themselves. To this end, they try all possible sources of income, including beginning on street sides, religious institutions, etc to meet immediate basic needs. In sum like many developing countries, the old people in Addis Ababa suffer from intergenerational transmission of poverty. They are not entitled to the marginally available forms of social protection, due to absence of social pension program to non-contributors. This would imply the long distance to go way in reducing poverty and vulnerability among older people and their families.

Efforts undertaken to buffer elderly households against stresses and shocks, sickness, unemployment are inadequate or inappropriate. The average age was 73 during the survey. Out of total sample respondents, about 44% reported they were relatively healthy while remaining proportion were reportedly suffering from disability, sight problem/blindness, chronically ill, hypertension, diabetic, etc. meanwhile they received life skill and business skill trainings. The initiatives deserve credit because capacity building trainings could play a key role to prolong an active life and existing supports, though limited, are in line the activity theory of aging. When we look at the livelihood outcome, the social, physical and financial capital buffed after support are sadly minimal. The barriers, inter alia, include:

The amount of financial support- N30,000 per month, plus about N50,000 loan intended for business. The amount of loan may increase based on performance of the debtor. One type of business or income generating stream was renewing shanty houses thereby rent income. However, it is far from required amount. At the same time significant numbers of houses are owned by government (kebeles). This ownership type disallows any renovation or modification on the houses. It is also prohibited to rent out for second person. As a result only 2 sample respondents are finds to generate rental income from improved houses.

Training and financial supports provided by TSDA and NGO related with economic strengthening of the aged group targets the very old (above 80 years), who are also responsible to care grandchildren. Firstly, though it is theoretically sound, there is little evidence throughput the world to witness the success of similar interventions targeting similar age groups. Secondly, FGD participants felt that the goods and services supposed to be offered by these age groups are finds to be less completed in the prevailing market to generate livelihood sustaining incomes. A programmatic implication of the aforementioned result is that IGA initiatives should be designed in a way that suits the diversified needs of age and other vulnerable groups. Experience gained from other countries call for Introducing new types of models such as social entrepreneurship.

The type of support required are debatable whether protection against survival by providing immediate needs or trying to build their livelihood. The answer is both, but logically the immediate need should come first. When respondents asked about an experience of requesting external support 12 months back to survey period about 60% said ‘Yes’. The type of support asked by overwhelming majority (94%) of them food aid. Unfortunately, the response they received was “we do not have any’”, but some of them received ‘cloth support’.