India’s ageing crisis demands urgent action, warns Himachal doctor

India Ageing Report 2023, published by the United Nations Population Fund (UNFPA) and the International Institute for Population Sciences (IIPS), projects that the proportion of Indians aged 60 and above will rise from about 10.5 per cent of the population in 2022 to 20.8 per cent by 2050, amounting to roughly 347 million people. The population aged 80 and above could grow by around 279 per cent.

I believe the question is no longer whether India will age, but whether it will do so with dignity or neglect.

Ageing changes the nature of healthcare. A younger patient may suffer an acute illness, receive treatment and return home. An older person, however, may live with several conditions simultaneously, including hypertension, diabetes, cardiovascular disease, chronic lung disease, arthritis, sensory impairment, cognitive decline, frailty and depression.

Data from the Longitudinal Ageing Study in India (LASI) shows that, among Indians aged 60 and above, about 32 per cent report hypertension, 14.2 per cent diabetes and 8.3 per cent chronic lung disease. Stroke affects 2.7 per cent, while cardiovascular disease affects roughly one-third.

Yet our healthcare system remains organised around diseases rather than people. An older patient does not experience five separate diseases; he or she experiences one life.

A cardiologist may treat the heart, a diabetologist manage blood glucose, an orthopaedic surgeon address the knee and a neurologist investigate memory loss. But who takes responsibility for the whole person? India needs integrated, continuous and person-centred geriatric care.

Older people in rural India face a cruel paradox: a heavy burden of chronic disease coupled with limited access to diagnostic facilities and specialists. The result is often not an absence of disease, but an absence of diagnosis. Hypertension may go undetected for years. Diabetes may be discovered only after complications such as neuropathy, kidney disease, visual impairment or heart problems emerge. Breathlessness may be dismissed as ‘old age’ until the underlying disease has advanced. Community Health Centres (CHCs) in rural India face an overall shortfall of about 79.5 per cent in the required number of specialists. For an older person, every kilometre matters. A referral can mean lost wages, transport costs and physical exhaustion.

Decentralising diagnostic services is more important than simply building larger hospitals. Primary care must be equipped to detect hypertension, diabetes, anaemia, kidney dysfunction, nutritional deficiencies, chronic respiratory disease, sensory impairment, depression, cognitive impairment and frailty. Older people should not have to become critically ill before the healthcare system notices them.

Fragmentation disguised as sophistication

Urban India has more specialists, but not necessarily better care. Older patients may move from one specialist to another, accumulate prescriptions, undergo repeated investigations and receive treatment focused on individual organs, without anyone taking responsibility for their overall wellbeing. I call this fragmentation disguised as sophistication.

The consequences include polypharmacy, duplicate tests, conflicting prescriptions, unnecessary procedures and high out-of-pocket expenditure.

Older people need a care coordinator, whether a physician or a geriatric team, who can see the complete picture, prioritise problems, rationalise medicines, assess functional ability and cognitive health, involve family members and plan follow-up care.

India has long taken pride in its tradition of family care. But migration, urbanisation, smaller homes, longer working hours and settlement overseas are changing that arrangement. Millions of older parents now live apart from their children. Money can be transferred and medicines ordered online, but technology cannot replace human presence.

Who takes a parent to hospital at midnight? Who notices missed doses of medication? Who recognises forgetfulness or a change in breathing? Who sits beside an older person when they are frightened? These are questions of

India Ageing Report 2023 highlights vulnerabilities associated with poverty, widowhood, rural residence and dependence, particularly among older women. Financial support and emotional care are not interchangeable.

Elder abuse does not always leave bruises. It can take the form of humiliation, denial of treatment on the grounds that ‘there is no point spending at this age’, control over pensions or abandonment of a dependent parent. Such abuse often remains invisible because victims may depend on those responsible for it. The law provides a framework for protection, but no legislation can replace a culture of respect.

From geriatric wards to a geriatric society

India has the National Programme for Health Care of the Elderly and the Maintenance and Welfare of Parents and Senior Citizens Act. These provide a foundation, but the response must extend beyond hospitals and legal safeguards.

The answer is not merely to build more geriatric wards, but to create a geriatric society.

Primary care must be redesigned around the needs of an ageing population, with screening for frailty, falls, cognitive impairment, depression, malnutrition, sensory impairment and polypharmacy.

Essential medicines and diagnostic services must be available at the primary-care level.

Home-based care, rehabilitation, physiotherapy, palliative care and assistive services must be expanded.

Public transport, pavements, buildings and toilets must be accessible to older people and those with disabilities.

Preventing disability is as important as treating disease.

Healthcare policy often focuses on hospitalisation, but much of the care older people need is outpatient-based. This includes consultations, medicines, diagnostic tests, physiotherapy, spectacles, hearing aids, dental care and transport. A hospital admission may occur once a year, but medicines for chronic conditions are often needed every day. Public financing must therefore cover outpatient care for chronic conditions. No older Indian should have to choose between food and essential medicines.

Digital health can connect villages, Primary Health Centres, district hospitals and tertiary-care facilities. But technology must remain a tool, not a substitute for human support. An 80-year-old may own a smartphone and still need help using it.

Community Health Officers, Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives (ANMs) and primary-care teams can help bridge the gap between technology and older citizens.

The deepest problem is cultural. Ageing is often portrayed as decline, while older people are viewed as dependent or burdensome. But retirement does not end citizenship, old age does not diminish dignity, and dependence does not erase rights.

The older generation built families, institutions and communities. Its members are not asking for charity, but for the right to age with dignity.

Five principles must guide India’s response to ageing.

First, detect diseases early through accessible, well-equipped primary care. Second, integrate healthcare rather than relying on fragmented, organ-specific treatment. Third, protect household finances by covering medicines, diagnostics, rehabilitation and long-term outpatient care. Fourth, support families through day-care services, respite care, home-based healthcare and community support. Fifth, safeguard the dignity and rights of older people by making abuse, exploitation and abandonment both socially unacceptable and legally actionable.

India takes pride in its demographic dividend, but that dividend has an expiry date. Today’s young worker will become tomorrow’s pensioner.

The true measure of development lies not only in hospitals, highways or economic growth. It lies in whether an 80-year-old woman living alone can obtain her medicines; whether an elderly farmer can reach a doctor without having to sell part of his harvest; whether a widower can live without fearing dispossession; whether a frail grandfather can cross a road safely; and whether an ageing parent can ask for help without feeling like a burden.

India must prepare to become an age-friendly republic. The ageing crisis is not someone else’s future. It is already arriving.

— The writer is MD (Medicine), Regional Hospital, Kullu