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Indian Journal of Gerontology
2008, Vol. 22, No. 1. pp 27 -34
Benign Prostatic Hyperplasia, Prostatic Cancer and Penile Dysfunctions in Elderly :
A Hospital Based Study
S.V. Joshi, U.V. Salvi-Mahadik and H.L. Dhar
Medical Research Centre, Bombay Hospital,
Mumbai 400 020
Benign prostatic hyperplasia (BPH) is one of the most common diseases affecting the health of the aging male population. To study the clinical presentation of BPH, prostate cancer and penile dysfunction and to evaluate the urodynamic efficacy and safety of transurethral ressection of prostate (TURP) in elderly patients having symptoms of obstructive benign prostatic hypertrophy, 335 elderly patients with various urogenital disorders were retrospectively studied. Prostate specific antigen was estimated for the purpose of prostate cancer along with other parameters. Odds ratio was used to compare categoric variables between groups where appropriate. Of the 335 patients with various urogenital disorders, BPH was predominant as compared to prostate cancer and penile dysfunction. Maximum number of patients belonged to 60-70 yrs age group. Most common symptom in BPH group was weak stream (54.66%). Main associated diseases were hypertension (31.68%), ischaemic heart disease (21.11%) and diabetes (21.11%). Complications were very few. Mortality (6.9%) was noted only in prostate cancer. Biochemical parameters were also normal in most of the patients in all the groups. Lower mortality may be due to active treatment for low and intermediate risk prostate cancer. Early detection / surgical intervention and intake of endogenous antioxidants (Vitamins A, C, E and Betacarotene)may be responsible for low incidence of prostate cancer in Indian elderly.
Keywords: Benign prostatic hyperplasia, Hospitalized elderly, Prostate cancer, Risk factors
Aging male reproductive system can give rise to clinically relevant manifestations, such as benign prostatic hyperplasia (BPH), prostate cancer (PCa) and erectile dysfunction (ED) (Cattolica et al., 1997; Bobe et al., 2006). Benign prostatic hyperplasia is one of the most common diseases affecting the health of the aging males (Doll et al., 1994). Increasing life expectancy of men together with the introduction of prostate specific antigen (PSA) as a screening tool have both contributed to a rising number of elderly men with a diagnosis of prostate cancer (Waldert M. et al., 2006).
To study the clinical presentation of BPK prostate cancer and penile dysfunction and to evaluate urodynamic efficacy and safety of transurethral ressection of prostate (TURP) in elderly patients having symptoms of obstructive benign prostatic, hypertrophy
335 elderly patients with various urogenital disorders were retrospectively studied. Diagnosis of BPH was established on the basis of uroflowmetry, ultrasonography to map out size of prostate, transition zone, amount of residual urine, and international prostate symptom score (IPSS). Prostate specific antigen was estimated for the purpose of prostate cancer along with the other parameters. Data was expressed as the mean ± SD for basic parameters. Odds ratio was used to compare categorical variables between groups where appropriate.
Out of a total of 335 elderly patients with various urogenital disorders, 161 patients were diagnosed as BPH, 29 as prostate cancer and 5 as penile dysfunction. Other dysfunctions included renal calculi, ureteric calculi, renal cancer and non functioning kidney. Maximum number of patients belonged to 60 70yrs age group (57.76%), followed by 71 80 (32.30%) while only 9.94% belonged to higher age group (81 to 90 years) (Table 1).Most common symptoms in BPH group were weak stream (54.66%), followed by frequency (53.52%), intermittency (31.68%), retention (31.68%), incomplete emptying (29.191/o), urgency (27.95%), straining (21.12%) nocturia (8.07%) and incontinence (4.97%) (fig 1). None had irritation. The obstructive symptoms were primary cause for referral to specialists including surgery. In our series, 103 (63.97%) patients had undergone transurethral prostate resection and 3 (1.86%) prostatectomy. Main associated diseases were hypertension 31.68%, ischaemic heart disease 21.11%, and diabetes 21.11% (Table 2).
Table 1 : Demographic Data
Age groups 60-70 71-80 81-90 Total
BPH n 93 52 16 161
% 57.76 32.30 9.94 100
n 10 12 7 29
% 34.48 41.38 24.14 100
n 4 1 - 5
% 75.0 25.0 - 100
Table 2 : Co-morbid conditions
DM HT IHD TUPR Prostatectomy
BPH 33 51 34 103 3
n=161 20.50 31.68 21.11 63.97 1.86
Ca Prostate 5 8 2 7 2 n=29 17.24 27.58 6.89 24.14 6.90
Penile 1 - - 1 1
dysfunction 20 - 20* 20**
OR = 1.24 OR = 1.22 *Partial penectomy **Penectomy
DM : Diabetes Mellitus HT : Hypertension
IHD : Ischaemic heart disease TUPR : transurethral resection of prostate
Complications of BPH: Stricture urethra in 5 cases, one had urinary incontinence and other hypotonic bladder.
Biochemical profile : Anemia in 12.42%, hyperglycemia in 5.59%, raised urea in 8.83%, Creatinine in 21.74% LDH (18%), and PSA (2.48%) (Table 3).
Table 3 : Changes in Biochemical Parameters
Hb Blood Urea Creatin LDH PSA
BPH n 20 9 11 35 29 4
% 12.42 5.59 5.59 21.54 18.0 2.48
Prostate n 2 1 2 2 2 9
Cancer % 6.90 3.45 6.90 6.90 6.90 31.0
Penile n - 3 1 6 8 -
Dysfunction % - 8.33 2.78 16.66 22.22 -
Cancer prostate : In the present study, 29 cases of Ca prostate were hospitalized during one year and only 2 patients (6.9%) died during hospitalization. Diabetes was detected in 17.24%, hypertension in 27.58% and IHD in 6.89% (Table 2).
Biochemical profile: Anemia in 6.90%, hyperglycemia in 3.45%, raised urea in 6.90%, Creatinine in 6.90%, LDH 6.908%), and PSA (9.3 1%) (Table 3).
Penile dysfunctions : There were 6 patients admitted with Cancer of penis and 2 had erectile dysfunction. Diabetes was associated in 20% patients (Table 2).
Biochemical Profile : Twenty percent subjects showed raised urea, creatinine and LDH levels however, none of them had anemia or hyperglycemia (Table 3)
Mortality : None
The age specific prevalence of BPH was maximum in the 60 69 year age group. Similar findings were reported earlier (Ozturk A. et al., 2000). Although malignant tumours occur at all ages, cancer disproportionately strikes individuals in the age group of 65 years and above.
High incidence of prostate cancer has been reported from western countries (Wong YN et al., 2006). However, only 29 patients with cancer prostate were admitted during one year in our hospital and incidence was the highest (65.51%) in late seventies. Findings are similar to other study (7) Most common symptoms in BPH group was weak stream (54.661/6), compared to 33% reported by Garraway et al (8) while other symptoms viz intermittency (31.68%). incomplete emptying (29.19%), were low. Straining (21.12%) was also similar to those reported by Garraway et al series (8) however, symptoms like urgency (27.95%), incontinence (4.97%) were less in our series compared to Garraway et al., (1991).
None had irritation although Bobe et al. (2006) reported irritation as main clinical symptom, along with obstruction. (52.2%). On analysing repercussions on quality of life, that obstructive symptoms were found to be less tolerated: 65.7% compared to 9.41/6 of the group with irritation. Our results showed very low incidence of nocturia (8.07%) compared to 88. 1% in series of Bobe et al. (2006).
In treating BPH, we must bear in mind preferences of patients. They tolerate obstructive symptoms less, resulting in consultations of specialists and even opt for surgery (ibid).
Operative procedure was mainly Trans urethral resection of prostate in our study though laparoscopic radical prostatectomy and photoselective vaporization of the prostate for benign prostatic hyperplasia (BP14) were commonly quoted by other authors (Poulakos et al., 2006 and Murtagh J. et al., 2006).
In our series, diabetes was associated with prostate cancer in 17. 24%. However, diabetics appear to have a lower risk of prostate cancer in whites (Rosenberg DJ, 2002).
Hypertension (31.68%) and BPH coexisted however, higher incidence (46%) was documented in literature (Nicolas Torralba IA et a1.,2003). Lower urinary tract infection (66.37%) was shown to be associated with BPH (ibid) but, the incidence was low (9.94%) in BPH and 13.79% in prostate cancer in our series.
Hypertensives (OR 1.22) and diabetics (OR 1.24) appear to have higher risk of BPH than prostate cancer Rosenberg in his study of Whites documented similar finding (Rosenberg DJ, 2002) showing Incontinence after surgery for BPH represents a condition that requires careful evaluation. In our series, 4.97% was found to have incontinence values were significantly low compared to 42.8% reported by Theodorou et al. (1998) showing 41.1% had a simple type of incontinence and 16.1% remained unclassified.
None of the patients in our series were on statin drugs and were not associated with risk of prostate cancer overall but was associated with a reduced risk of advanced (especially metastatic or fatal) prostate cancer (Platz EA et al., 2006).
TURP in relieving urinary obstruction due to BPH, offers some advantages in terms of catheterization and hospital stay (Gallucci M. et al., 1998) Our results shows that TURP is the safest procedure (Cattolica EV et al., 1997 and Doll HA et al., 1994) with no deaths in BPH group. Hargreave et al. (1996) reported the relative risk of late mortality after TURP compared with open prostatectomy was 1.13 after controlling for age and the presence of a diagnosis of cancer.
Penile dysfunctions is a part of aging male reproductive system (Sampson N. and Schulman CC, 2000) however, only 5 patients had penile dysfunction in our series and no association between diabetes and hypertension was noticed.
During hospitalization, mortality was found to be 6.90% amongst prostate cancer while none in BPH and penile dysfunction group. PSA levels were significantly higher in prostate cancer group compared to BPH. Age is generally considered to be a key prognostic factor in terms of therapeutic decision making, perhaps as important as PSA level and Gleason score. Even in men over 70 years, treatment without curative intent may deprive frail patients of years of life (Waldert M. et al., 2006).
Lower mortality may be due to active treatment for low and intermediate risk prostate cancer in elderly men aged 65 to 80 years.(Wong et al., 2006). Early detection by PSA and early surgical intervention and intake of endogenous antioxidants (Vitamins A, C, E and Beta carotene) might be responsible for low incidence of prostate cancer in Indian elderly (McHedlidze M. et al., 2006).
Thanks are due to Sonali Pandloskar for the statistical analysis and record section for making the datasheets available.
Bobe Armant F, Buil Arasanz ME, Allue Buil Al, Morro Grau A, Maxenchs Esteban M, Gens Barbera M. (2006). Benign prostate hyperplasia. Need to evaluate quality of life in the therapeutic process. Aten Primaria. 38(7) : 387-91.
Cattolica EV, Sidney S, Sadler MC.(1997). The safety of transurethral prostatectomy: a cohort study of mortality in 9416 men. J Urol. 158 : 102-104.
Doll HA, Black NA, Mc Pherson K.(1994). Transurethral resection of the prostate for benign prostatic hypertrophy : factors associated with a successful outcome at I year. Br J Urol 73 : 669-80.
Gallucci M, Puppo P, Perachino M, Fortunato P, Muto G, Breda G, Mandressi A, Comeri G, Boccafoschi C, Francesca F, Guazzieri S, Pappagallo GL. (1998).Transurethral electrovaporization of the prostate vs. transurethral resection. Results of a multicentric, randomized clinical study on 150 patients. Eur Urol. 33 : 359-64.
Garraaway WM, Collins GN, Lee RJ. (1991).High prevalence of benign prostatic hypertrophy in the community. Lancet 338 : 469-471.
Hargreave TB, Heynes CF, Kandrick SW, Whyte B, Clarkeb JA. (1996). Mortality after transurethral and open prostatectomy in Scotland. Br J Urol. 77 : 547-553.
McHedlidze M, Shioshvili T. (2006) Influence of antioxidants on the development of benign prostatic hyperplasia. Georgian Med News 140 : 23-7.
Murtagh J, Foerster V. (2006). Photoselective vaporization for benign prostatic hyperplasia. Issues Emerg Health Technol 95 : 1-4.
Nicolas Torralba JA, Tornero Ruiz J, Banon Perez V, Server Pastor G, Lopez Cubillana, P, Perez Albacete M. (2003). Relationship between hypertension and clinical cases of benign prostatic hyperplasia. Arch Esp Urol 56 : 355-358.
Ozturk A, Serel TA, Kosar A, Kecelioglu M. (2000). Prevalence of benign hypertrophy of the prostate in Turkish men hospitalised in urology. Prog Urol 10 : 568-70.
Platz EA, Leitzmann W, Visvanathan K, Rimm EB, Stampfer MJ, Willett WC, Giovannucci E. (2006). Statin drugs and risk of advanced prostate cancer. J Natl Cancer Inst 98: 1819-1825.
Poulakis V, Witzsch U, de Vries R, Dillenburg W, Becht E. Laparoscopic Radical Prostatectomy in Men Older than 70 Years of Age with Localized Prostate Cancer: Comparison of Morbidity, Reconvalescence, and Short Term Clinical Outcomes between Younger and Older Men. Eur Urol. 2006. Dec 14
Rosenberg DJ, Neugut Al, Ahsan H, hea S. (2002). Diabetes mellitus and the risk of proatatic cancer. Cancer Invest 20 : 157-165.
Sampson N, Untergasser G, Plas E, Berger P. (2007). The ageing male reproductive tract. J Pathol 211 : 206-218.
Schulman CC. (2000). The ageing male : a challenge for urologists. Curr Opin Urol 10 : 337-342.
Theodorou C, Moutzouris G, Floratos D, Plastiras D, Katsifotis C, Mertizotis N. (1998). In continence after surgery for benign prostatic hypertrophy : the case for complex approach and treatment. Eur Urol. 33 : 370 -375.
Waldert M, Djavan B. (2006). Prostate cancer in the elderly patient Ann Urol (Paris) 40 : 336-341.
Wong YN, Mitra N, Hudes. G, Localio R, Schwartz JS, Wan F, Montagnet C, Armstrong K. (2006). Survival associated with treatment vs observation of localized prostate cancer in elderly men. JAMA 296 : 2733-4.
Wu SL, Li NC, Xiao YX, Jin J, Qiu SP, Ye ZQ Kong CZ, Sun G, Na YQ. (2006). Natural history of benign prostate hyperplasia. Clin Med J (Engl) 119 : 2085-2089.
Indian Journal of Gerontology
2008, Vol. 22, No. 1. pp 35-42
Epidemiology of Disability Among Geriatric Population in the Semi Urban Area of
Mangalore City, Karnataka
K.S. Ganesh, A. Yadav, B.S. Sajjan and M.S. Kotian
Department of Community Medicine, Kasturba Medical College
The paper aims to determine the prevalence and socio demographic correlates of disability, associated co-morbid chronic conditions and needs assessment of the disabled among geriatric population. A cross sectional study was carried out from July to October 2006. 120 subjects in geriatric age group were randomly selected from Boloor, Mangalore city, Karnataka. All the individuals aged 60 years and above in the selected houses were interviewed and examined. The data was analysed statistically. Prevalence of disability was found to be 65.8%. Speech and loco motor disability were more common. Prevalence of disability was found to be 90.9% among 80 years and above age group. Around 1/3 of the disabled had chronic co morbid conditions. None of the disabled received Speech therapy, Vocational training and Job placement. Disability in this area is an important public health problem among geriatric population. There is an ample scope for community based rehabilitation of the disabled also.
Key words : Epidemiology, Disability, Geriatric population
Disabled individuals in the community face many social problems. They are perceived only in the light of their infirmities. The incidence of disabilities is higher in developing countries than in the industrialized ones. However, in developing countries, people with disabilities have a shorter life span. As health services in developing countries improve, survival rates will increase. When infant and child mortality rates diminish, the overall survival shows an upward trend and the proportion of elderly people in the population increases (WHO, 1989).
In India around 10% of the population is affected with some disabilities (Barbotte E. et al., 2001; Sharma, A.K. and Praveen, V. 2002). Expectation of life at birth for males and females has increased considerably in recent years. In India it is projected to be 67 years for males and 69 years for females in 2011-2016. Projections beyond 2016 made by United Nations has indicated that 21% of the Indian population will be above 60 years of age by 2050 which was 6.8% in 1991.The contribution of elderly populations to demographic figures is increasing day by day. Increasing problems of health care, psycho-social, personal and socio-economic factors associated with the elderly further overwhelms this (Prakash, R. et al., 2004).
Disability among the elderly certainly is not a new problem. The high prevalence of chronic conditions in the elderly, coupled with the dramatic shift occurring in the age structure accounts for increasing concern about disability among the elderly as a public health problem. Knowledge of chronic diseases or conditions in and of itself, however, does not directly inform us about level of disability. Direct information is still needed on the nature and extent of disability in the elderly population (Alan M.J. et al., 1981)..
Though disability is the commonest problem, very few community based studies had been conducted in India to understand the problem. No similar study had been conducted in the past among geriatric population in Mangalore city of Karnataka. Considering this background, the present study was conducted in order to determine the prevalence of disability among geriatric population in Mangalore city, Karnataka.
This was a community-based cross sectional study carried out over a period of 4 months from July to October 2006. The study was conducted at the semi urban area of Mangalore Municipal Corporation, which consists of 60 wards and population of 3,99,565 according to 2001 census. Boloor, a semi urban area which covers a population of 12,880 spread over 2 wards were covered. Sample size was estimated for infinite population by using the formula 4pq/d2, where prevalence was taken as 20%. Required precision of the estimate (d) was set at 10%. Using the above formula, the sample size was estimated for all the age groups to be 1600. After adding non response error of 10%, an additional 178 subjects were included. Thus the sample size for all the age groups became 1778. Taking proportion of geriatric population as 6.8%, the sample size of geriatric population in our study was found to be 120. The study population comprised individuals in the geriatric age group, which included 60 years and above age group.
The study was conducted by making house to house visits selected with simple random technique, interviewing and examining all the eligible subjects. A prerequisite for the eligibility was membership in the household, defined as all persons who are biologically related with the other members and eating from a common kitchen. If a designated person could not be contacted or not cooperative during three separate visits, then the subject was considered as non-respondent.
Socioeconomic status was assessed by modified Uday Parik Scale. Disability was assessed as per the criteria laid down by WHO (Dey, A.B., 1999). Mental disability was assessed by Indian Disability Evaluation and Assessment Scale (IDEAS) developed by the Rehabilitation Committee of Indian Psychiatric Society (Report, 2002). Needs assessment of the disabled was assessed based on the instrument designed on the lines of questionnaire taken from Action Aid India (Thomas, M. and Pruthvish, S. 1993).
The data collected was tabulated and analyzed by using the Statistical Package for Social Sciences (SPSS) version 11.5 for windows. Findings were described in terms of proportions and percentages. Univariate analysis was carried out separately for each factor. Chi square test was carried out to test the differences between proportions. The probability level of less than 0.05 was considered as significant.
All the 120 subjects were available for the final analysis (response rate, 100%). The overall prevalence of disability was found to be 65.8% (79). The most common type of disability was speech (45, 57%), followed by Loco motor (39, 49.4%), Hearing (17, 21.5%), Mental and Visual (14 each, 17.7%) disability.
The prevalence of disability was marginally higher among males (66.7%) than that of females (64.1%). It was comparatively less among (60-69) years age group (54%). This was followed by (70-79) years age group (76.1%) and 80 years and above age group (90.9%) and it was found to be significant (x2=9.2, p=0.01). The prevalence of disability among subjects of nuclear family was marginally less (64.4%) than that of Joint/Extended family (66.7%), but majority of the disabled (50) belonged to latter category. The difference was not found to be significant with family type, socioeconomic status and marital status (Table 1).
Table 1 : Prevalence of disability according to socio demographic variables (N=120)
Socio demographic Subjects Number Prevalence x2, p variables examined of disabled (%)
Gender Male 81 81 66.7 0.1,
Female 39 25 64.1 0.8
Age group 60 -69 63 34 54.0 9.2,
(years) 70-79 46 35 76.1 0.01*
80 and above 11 10 90.9
Family Nuclear 45 29 64.4 0.1,
Joint/Extended 75 50 66.7 0.8
Socio Low 48 32 66.7 2.9,
economic Middle 52 37 71.2 0.2
status High 20 10 50.0
Marital Ever Married 117 76 65.0 1.6,
Status Never married 3 3 100.0 0.2
* P value less than 0.05 is considered as significant.
Majority of the disabled had Hypertension (34) followed by joint pain (32), Diabetes (25), Backache(16) and others like Asthma/COPD, Fits, Heart Problems (Table 2). Around 1/3 of the disabled (36.7%) were assessed, while 27.8% of them got medical/surgical treatment. Even though majority (78.5%) of the disabled felt that they required Aid/appliance, only 17.7% of them received them. None of the disabled received Speech therapy, Vocational training and Job placement (Table 2).
Table 2 : Needs of disabled (N= 79)
Types of needs Felt (%) Received (%)
Assessment 69 (87.3) 29 (36.7)
Medical/surgical treatment 70 (88.6) 22 (27.8)
Physiotherapy 25 (31.6) 11 (13.9)
Speech therapy 12 (15) 0 (0)
Aid/appliance 62 (78.5) 14 (17.7)
Vocational training 3 (3.8) 0 (0)
Job placement 0 (0) 0 (0)
Consistent with the economic and social changes in the country, geriatric population in India are increasing with a subsequent increase in chronic co morbid conditions. This has enhanced the risk of developing disability among geriatric population. Well documented studies to determine the prevalence and its epidemiological features are few. Some studies had taken only the physical disability and some others mental disability. Also, the data collected by health workers could not detect mild degrees of disability because of their limited knowledge and lack of training. As our study illustrates, both physical and mental disabilities are of great concern in this area. Age place a major role as determinant of disability. Chronic medical conditions are also more common among disabled.
The present study showed a higher prevalence of disability among geriatric population in comparison to prevalence in general (NSSO, 2003, Census 2001). This was because of detection of even mild degrees of disability in our study. Recent National Sample Survey Organization report in India showed the prevalence of disability among geriatric population as little as 6.4%. The widely differing prevalence of disability found in these studies was due to wide difference in the samples and definitions used for disability. Higher prevalence of speech disability was observed in our study in contrast to other studies (NSSO, 2003, Census, 2001). This is mainly because even mild degrees of speech impairment such as stammering, speaking with abnormal voice like nasal voice, hoarse voice and discordant voice is taken into consideration while assessing speech disability. Prevalence of loco motor disability was also higher in comparison to other studies. This is again because of inclusion of even mild loco motor disability in our study.
As the age advances, the prevalence increased significantly. Our study is consistent with the findings of other similar studies (Alan, M.J. et al., 1981). Marginally higher prevalence of disability among males is observed in comparison to other studies (Noveymony, M.A. and Raj J.S. 2003). The present study showed that 95% of the disabled were married and only 5% of them were unmarried in contradiction to other studies. In India, about 92% of the disabled lived with their spouse and/or other members in the family. But in the present study, 37% (29) of the disabled belonged to nuclear family. Others (50, 63%) belonged to Joint/Extended family. In view of the above, the aged disabled in this part of the country are well placed as far as the family life is concerned.
Various studies have shown that the prevalence of disabilities is found to be significantly high among the individuals suffering from chronic medical conditions (Dey, A.B. et al., 2001; Joshi, K. et al., 2003; Khan, J.A. and Khan Z, 2001). Even though majority of the disabled felt that they required Aid/appliance, only minority of them received them in contrast to other studies (Pal H.R. et al., 2000). None of the disabled received Speech therapy, Vocational training and Job placement. That shows that there is a large scope for community based rehabilitation for the disabled.
The present study can not depict the true picture of disability among geriatric population in the community as because of inherent limitations of cross sectional study. Besides, variation in the prevalence may occur due to the location of the area and other factors. There is also possibility of underestimation of mental disability because of inability of subjects to express their mental abilities such as self care, interpersonal activities, communication and understanding. There also may have been recall bias. Pure tone audiometry was not used while assessing hearing disability due to feasibility constraints. In spite of all these, one of the important strength of the study was that the data was gathered through a population based survey by community based clinicians, which gives more reliability of information than self reported information or lay reporting.
Disability among geriatric population in this area is an important public health problem. Speech and loco motor disabilities are the commonest types of disabilities. Effort should be made to start the Community Based Rehabilitation Programme for aged disabled among geriatric population in Boloor, a semi urban area of Mangalore city. This will require coordinated efforts by local, district and provincial authorities. Political will, public sector cooperation and assistance, financial support from nongovernmental and international organizations involved in rehabilitation is also essential. Special emphasis should be laid on care of aged disabled in our health care system. It should be incorporated to the general health services and training facilities for health workers should be made available.
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Barbotte E, Guellimin F, Chan N, Lorhandicap (2001). Prevalence of impairments, disabilities, handicaps and quality of life in the general population: A review of recent literature. Bulletin of World Health Organization 79(11): 1047-1055.
Dey AB (1999). Health care of the elderly: A manual for trainers of physicians in primary and secondary health care facilities. The World Health Organization, Ministry of Health and Family Welfare, All India Institute of Medical Sciences (India); New Delhi,1999.
Dey AB, Shubha S, Kalpana MN, Jhingan HP. (2001). Evaluation of the health and functional status of older Indians as a preclude to the development of a health programme. The National Medical Journal of India 14(3): 135-138.
Guidelines for evaluation and assessment of mental illness and procedure for certification (2002). Ministry of Social Justice and Empowerment, Government of India. New Delhi.
Joshi K, Kumar R, Avasti A.(2003). Morbidity profile and its relationship with disability and psychological distress among elderly people in northern states. Int. Journal of Epidemiology 32(6): 978-987.
Khan JA, Khan Z. (2001). A study on the leading causes of illness and physical disability in an urban aged population. Indian Journal of Preventive and Social Medicine 32 (3&4): 121-127.
National Sample Survey Organization (2003). A report on disabled persons. New Delhi: Department of Statistics, Government of India.
Noveymony MA, Raj SS. (2003). A study in the family and socio-economic conditions of the persons with disabilities in Vallioor Panchayat Union. Asian Pacific Disability Rehabilitation Journal 5(1): 14-20.
Pal HR, Saxena S, Chandrashekar K, Sudha SJ, Murty RS, Thara R, et al. (2000). Issues related to disability in India: A focus group study. The National Medical Journal of India 13(5): 237-241.
Prakash R, Chaudary SK, Singh U. (2004). A study of morbidity pattern among geriatric population in the urban area of Udaipur, Rajastan. Indian Journal of Community Medicine 119: 35-40.
Sharma AK, Praveen V. (2002). Community Based Rehabilitation in Primary Health Care System. Indian Journal of Community Medicine 117 : 139-142.
The World Health Organization (1989). Training in the community for people with disabilities. WHO: Geneva.
Enabling the disables. (1999). Thakur Hariprasad Institute of Research and Rehabilitation for the Mentally Handicapped, Hyderabad.
Thomas M, Pruthvish S. (1993). Identification and needs assessment of beneficiaries in community based rehabilitation initiatives. Bangalore: Actionaid India.
Indian Journal of Gerontology
2008, Vol. 22, No. 1. pp 43 -52
Future Implications of the Dwindling Culture of Vertical Support for Retirees in Southwestern Nigeria
ADISA Ademola Lateef
Department of Sociology and Anthropology
Obafemi Awolowo University, Ile-Ife
Osun State, Nigeria.
This study examined, working with the philosophy of care among the Yoruba people of Southwestern Nigeria, the extent of care from the desired source(s) by 954 retirees in the said location between October 2005 and March 2006. Since the study was both reactionary and retroactive in nature, it did not limit focus to the immediate problems of care for the retirees but extended concern to possible accompanying problems of inadequate care of the retirees by children in the future. The study concluded that parochial but macro and Europocentric nature of past studies account for the persistence of retirees’ problem in Nigeria.
Key words : Social support, Support bank, Retirees.
The culture of social support describes a way of life involving a network of assistance among relatives, friends and organizations. Social support refers to the exchange of resources, material or nonmaterial, between at least two persons perceived by the provider or recipient to be intended to enhance the well-being of the recipient.
We can describe human beings as surviving on the culture of social support; and it is pronounced in modern societies which Emile Durkheim (1893) describes as bound and united by organic solidarity. He believes that heterogeneity and division of labour bring about interdependence and interdependence ensures harmony in modern societies. This is, however, not to construe an erroneous belief that it is only in modern societies where dependence, needs and a culture of assistance can be found. Every form or stage of living, from infancy to retirement and/or old age, is marked by a peculiarity of needs; and there is no stage in which self-sufficiency is attained for most members of the society. In another form, it can be concluded that needs, either in the economic, physical, social or psychological sense, characterize living. The needs of the individuals differ, however, either as a result of varied demands of stages of living, socio-demographic and economic characteristics of each person, among others.
Social support is also observable in all the four dimensions of human interaction; namely: cooperation, competition, exchange and conflict. For instance, Coser (1956) submits that even in conflict situation, cohesiveness, love and support are promoted within a group any time such a group is involved in a conflictual relationship with another group. That is, inter-group conflict promotes intra-group solidarity. Reference is usually made to the public plea by the traditional ruler of a warring community in Osun State that because of the disruptions of war, creditors should extend the periods of grace given their debtors. Additionally, they also appealed to those who had enough to lend fresh financial support during the period of war. It was a clear demonstration of support in the face of conflict.
As expressed earlier, social support can come in different dimensions but its flow is either vertical or horizontal in nature. Support may be expressed structurally (marital status, size of support network or frequency of social interactions)and/or functionally (offering emotional, informational or tangible support).
On the network of support, Quadagno (1999) points out that support networks can be described by the characteristics of the people with whom an individual has ties. Such characteristics may include age, sex, number of years of relationships involved and geographical proximity. She also stresses that networks of support involve exchanges over a life time. The simplest way to understand this is to think of a support bank; in which deposits are made early in the life course in anticipation of future needs, or withdrawals (Antonovsky, 1974).
The concept of support bank points to the fact that support systems are never one-sided; but reciprocal. And as people can gain or lose in their transactions with banks in the economic world, the same is applicable to an individual in the social support banks of life. There can be an instance where vertically, parents might have deposited greatly into the nurture and education of children only to be repaid by neglect or desertion from such children or, some of them in later life. This is an instance of loss in the support bank of the parents. At another time, help or assistance rendered to friends, workmates, members of the same religious association, and so on, may not be reciprocated by the beneficiaries and in this instance, one is losing out horizontally from the support bank of life. For clarification, support is horizontal when it flows from people of equal or almost of similar status such as age, educational attainments, among others. But, when it is between or among people of different statuses, especially age, such as parents to children, it is vertical; and this forms the core of the different foci of gerontologists on the issues of social support.
In the study, attempts were made to examine the relevance of children in helping needy, retired parents in Southwestern Nigeria; to project into the future relations of care between children and parents and to draw attention to likely accompanying problems of poor attention of care.
Review of Literature
In a pilot study on the possibilities and limits of care in seven European countries, Amann (1980) reported that open, and not institutional care was prevalent for the needy elderly in most parts of Austria, Denmark, Greece, Hungary, The Netherlands, Poland and Yugoslavia. Care giving in homes was also very common in Nigeria and other non-Western societies in the past. This was sustained for a long time by some traditional beliefs, resulting in promotion of care.
In the past, Nigerian elders were held in high esteem and were not allowed to suffer any neglect. This was also obtainable among the Chinese and the Kirghiz, a small community of 2000 people who lived in the high valleys of Afghanistan. Among the Kirghiz, the household head, called oey bashi, (the most senior male or, in the absence of a male, the most senior female), exercised complete authority over the household (Shahrani, 1981). Traditional Chinese culture also placed a high value on old age. The veneration of the old is always linked to values of Confucian religion, which emphasizes that parents should treat their children with zi, or nurturance, and that children should treat their parents with xiao, meaning filial piety or absolute obedience. To be xiao means showing one’s parents respect at all times, performing acts of ancestral worship when they die, and generating grand children to carry on the family name. Xiao extends beyond respect for one’s parents alone but includes deference to all elderly people. It is accompanied by many symbolic and conventional gestures such as speaking politely, deferring in conversation to those older than oneself, and never ridiculing or insulting the aged. It would be a shameful breach of xiao to neglect the needs of clothing, food, medical care of the elderly or to put them in a nursing home (Amoss and Harrel, 1981).
The Yoruba people, inhabiting the Southwestern Nigeria also had similar culture. They too had similar names/labels for individuals who met up or otherwise on the nurture and care of needy members of the family. Parents who shirk in the responsibility of nurture and care for the children are called abímáwò, that is, they can only bear children without giving attention of care. Children who abandon their parents in periods of needs too can be labeled ò?sánjú-o?mo?, that is, a wicked child; not holding any kind of love or pity for the parents or o?mo?-pò?-bí-o?sàn-bó? which likens such a child to an orange which drops from a tree top and bursts, thereby rendering itself useless.
In the past, the belief in ancestral worship ensured that elders were taken care of so that the living child would not suffer their wrath when the old died and were transformed into gods (Bussia, 1965 and Adisa, 2000). The extended living, premarital investigations, among others, created love towards the elders.
Generally, the care of the elders is dwindling as a result of many factors, some of which are examined in the next discussions.
There is a negative effect of poor political economy and modernization on the attention that the elderly receive in the contemporary times. Adisa (Ibid.) observed that there have been changes in the compositions and functions of families in Nigeria. It is not the importance of the values attached to rendering help to the needy members of the family that has gone down but also incapacities and variations in mode of living. For instance, the Yoruba adage that: bí òkété bá dàgbà tán, o?mún o?mo? rè? ni ó n? mún, meaning, an old rodent feds on the teats of the children, has become a niche. The political economy, which has made it difficult or impossible for the children themselves to be in dependent, has made the moral philosophy of living outdated. There are problems associated with unemployment, under-payment at work, and job insecurity which may make both the parent and the child double victims of retrenchment.
This study was carried out on the presumption that the retirees were receiving attention from younger members of their families just as their plight has been focused by the media in the recent times.
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