The Problems and Challenges of the Aging Population of Malaysia

At present, the number of Malaysians aged 60 years and above is estimated to be 1.4 million and is projected to increase to 3.3 million in the year 2020. The percentage of the population that is 60 years and over has also increased over the years - 5.2% in 1970, 5.7% in 1990 and 6.3% in the year 2000. In the year 2020, this percentage is expected to be 9.8% of the population. Between 1990 and 2020, the population of Malaysia is expected to increase from 18.4 million to 33.3 million - an increase of 80%. The aged population however is expected to increase from 1.05 million in 1990 to 3.26 million over the same period, an increase of 210%.

Apart from an increase in the aged population, the aged are also living longer as evidenced by an increase in life expectancy. As women tend to live longer than men, the disproportion between males and females therefore also increases with ageing. The sex ratio of men per 100 women will decrease from 90.1 in 1990 to 85.8 in 2020. The other feature on the demographic changes that is expected to occur in the aged population is in relation to urbanisation. The percentage of population in urban areas has increased from 24.5% in 1957 to 50.8% in 1990. Thus it is also expected that the proportion of the aged population be higher in the urban than the rural area and this change in the demographic pattern of the aged population will also influence the distribution of health care resources.

The elderlies are less healthy than the youngs, hence an increase in the proportion of the aged group is associated with an increase in the prevalence of ill health. The physical and social changes associated with ageing are combined with the debilitating effects of multiple, acute and chronic diseases. Fraility is often compounded by problems such as urinary incontinence, instability, falls and acute confusional states. Few elderly persons escape the accumulation of chronic pathologies as they grow older. Consequently, multiple pathologies resulting in multiple symptoms are a common phenomenon in the elderly. Incontinence, for example, is a common occurence and for those taking care of these people, it is a time consuming and sometimes, an unpleasant task. Alzheimer’s disease is also a common problem afflicting the elderly and is estimated to affect at least 5% of the population aged 65 years and above. The number of patients with this disease is expected to increase with the rise in the number of elderly population and this has important implications on the country’s resources.

Malnutrition is also expected to be a major problem in the elderly. This is due to changes in dietary habits, poor dentition and types and amounts of food consumed. With greater drug usage and poly pharmacy, the incidence of adverse drug reactions is more prevalent in the elderly. Physiological changes in the ageing kidney, memory deficits, altered eating habits and multiple drug regimes all contribute to make therapy more difficult in the elderly.

The health care system in this country is primarily geared towards short term care and hospitalisation. The elderly with their chronic diseases and problems require long term care. Rehabilitation from acute illness to help return the elderly patient to the level of premorbid function is often lacking in our hospitals. Thus the present health care system is thus inadequate and even inappropriate to service the elderly with their chronic diseases and disabilities. The trend currently is on prevention and primary health care as hospital based care is increasing in costs. Though Malaysia has quite a comprehensive medical and health care services for the general population, special programmes for the aged are lacking. This is in part due to lack of trained personnel in geriatric health care and also a lower priority being given to geriatric care.

With regard to prevention of diseases and disabilities in the elderly, healthy lifestyle promotion would benefit as a healthy young adult would normally continue to become a healthy elderly citizen if the healthy lifestyle practices are continued. This would minimise the incidence of illnesses and disabilities in the later years and enhance their independence in their daily living activities. Primary prevention should not be directed solely at the elderly but also at other age groups so that the benefits gained when young will facilitate healthy ageing.

Healthy ageing depends on health promotion and disease and injury prevention. Good health maintenance in early life and later years via a healthy lifestyle, avoidance of smoking and alcohol, prudent diet and regular exercise can help the elderly, including fewer doctor visits and fewer medications taken. Health education and counselling must be provided at all opportunities that ageing is not a disease and that early intervention treatment can prevent disability. Nutrition education should be carried out regularly as it is important to prevent nutritional problems. Secondary prevention is concerned with slowing down the disease process once it has begun and to prevent the occurrence of other problems, complications or deterioration. Active case detection is necessary through regular and frequent periodic medical examination to detect conditions that lead to chronic conditions so that early treatment is effective. Rehabilitation is important in illnesses that have occurred, with the intention to limit further deterioration of the condition and prevent further complications or relapses. Tertiary prevention is aimed at restoring function so that there is increased ability to achieve work, independence in self care and self respect.

The main aim in the care of the elderly is to maintain the quality of life by assisting them to have a full life for as long as possible. There are other factors apart from medical that influence the quality of life of the elderly - such as work, retirement, income, housing, family, community and leisure activities. Socioeconomic security contributes to the quality of life of the elderly. Level of income and health status have been found to be very closely associated with life satisfaction among the elderly. Work is an important factor in keeping the elderly healthy. As the proportion of the aged population increases with time, the ratio of people working to those retired is expected to fall. This would lead to a shortage of workers although could be alleviated by raising the the retirement age. Continued employment would result in higher morale, happiness, better adjustment, longevity, larger social network and better perceived health among the elderly. This could keep them healthier and decrease the burden on health care.

Women survive longer than men and usually also take care and nurse the elderly in the household. However, more and more women are entering fulltime employment or are not living near their elderly parents. This will definitely have an implication on health care for the elderly in the future. Institutionalisation of the elderly is quite common and acceptable in the west but not favoured here. With social changes such as migration, urbanisation, increased participation of females in the labour force, changes in family structures, the rapid increase in the number of aged expected in the future and the longer expectation of life, the number of elderly that would require institutionalisation can be expected to increase.

The existing institutions for the aged will not be adequate to meet this expected demand in the near future and so more institutions or homes for the aged would be required. Home care for the elderly is quite well developed in certain countries. Here, community programmes are helpful to families with elderly members. The aim is to provide health service for the non-ambulant and aged sick to help them be cared for in the community for as long as possible.

This would ensure the continuity of health care for patients discharged from the hospital. This would also train family members to take care of the elderly at home. Community services that enable the elderly to remain in the community include day centres, day hospitals, social clubs, rehabilitation centres, counselling and advice centres, transport services, home meals, meals on wheels, mobile libraries, volunteer schemes and home nursing. As for the cost of healthcare in Malaysia in general, in 1994 the amount spent on health care was about 2% of the GDP and is also about that figure at the moment. Considering that the US spend about 14% of the GDP on health and the G-7 countries spend between 5–8% of the GDP, Malaysian health care cost will also increase as we progress into developed nation status. The figure quoted of about 2% of the GDP is the amount for the Ministry of Health appropriations and does not include the private sector’s expenditure. Thus the health care cost in reality is more than 2% of the GDP if the private sector’s expenditure is also taken into account. As for the Ministry of Health’s allocation, it accounts for about 5% of the annual national budget or RM 2.6 billion and represents an allocation of RM 125 per capita. Of the allocation given, about 80% is spent on the hospital and health clinic services. It is estimated that about 20% of all admissions into hospitals are elderly patients and since these patients are usually admitted with serious, life threatening conditions which require intensive treatment and monitoring, treatment of the elderly patients takes a sizeable chunk of the budget allocated.

As the absolute and relative number of the elderly increases, it is only to be expected that the number of admissions of elderly patients into hospitals to also increase. More hospitals would be needed to be built and services which need to be introduced or further developed, especially in relation to the care of the elderly, would include rehabilitation and ambulatory and day care services. Retirement homes for the elderly is also an area of future development. Retirement homes would be ideal as they could live their independence and at the same time have the company of their same age groups and be secured by the fact that professional helpers are always around nearby.

In conclusion, the increase in the ageing population in this country is inevitable. The aged population has its own unique problems and will generate new challenges and demands on the health and social services. This undoubtedly requires a sharing of responsibilities between the government, private sector, non-governmental agencies and the community. We will all age and we will all require the services for the aged at some point in time.