Perspective Chapter: Geriatric Care in Africa

Abstract

There are an increasing number of people that are aging. This is also common in Africa. Therefore, they need specialist care from various categories of health care workers and other professionals on geriatric medicine and gerontology. There are few geriatricians in Africans. This is because there are few training centres in the continents. Also, most of the geriatricians are trained on the other side of the continent overseas.

1. Introduction

As human beings are born, the aging process begins. There are many phases of life from being a neonate, infant toddler, adolescent, teenager, young adult, youth and then old age. As people age, there are challenges and problems associated with aging including health. The health needs of the elderly need to be cared for by medical doctors specially trained to care for the elderly persons who require special communication skills. Old age is a period in the lives of the elderly for rest after a long life of activity and service [1]. In some communities and societies, socio-cultural referents are used to define old age such as family status if the person has become a grandparent, physical appearances such as the appearance of gray hair and wrinkles [2].

Geriatric medicine is still a new medical specialty in most parts of the world; like any other career choice, there are still gaps in the knowledge, awareness and uptake as a profession [3, 4]. The elderly face a lot of challenges [5] physically, medically, socially, economically and otherwise. Geriatric medicine differs from typical adult medicine because it focuses specifically on the unique needs and health challenges of older adult [6]. There is generally a paucity of specialized healthcare services for the elderly in Africa, some of the reasons may be lack of training in most African countries, unawareness of the peculiar needs of the elderly and lack of human and material resources [7]. Geriatric medicine is important because most doctors deal with elderly patients no matter their specialty [8, 9].

Globally, the population is aging. It is therefore necessary that aged persons are healthy and physically active [10]. This longevity is due to several factors such as good sanitation, access to good healthcare, more people are getting educated, healthy eating and access to funds to provide the necessities of life. Some persons may become less physically active when they age. However, there is a connection between being less physically active and becoming frail [11]. Aging takes place throughout the lifetime, as it creates an opportunity to improve and preserve the physical, health, mental well-being and improve the quality of life. The aging of the population leads to various challenges, which may be economic and social. Also, the health of the person getting older may be affected as the elderly is predisposed to certain illnesses. Governments globally need to set up the right policies that will address the challenges faced by the aged [11]. Some senior citizens are discriminated against in their communities in Africa especially if they are women and childless. Other social challenges senior citizens encounter in Africa are social isolation, elder abuse, neglect and abandonment. This is common because nursing homes and long-term care facilities are not common in Africa. Even in communities where they are available, they are underutilized. Geriatric care cannot be complete without the provision of long-term care facilities [12]. The populace needs to be educated and enlightened on the need for long-term care [12]. This is because the long-term care will provide relief for family members who have elderly persons that are frail or cannot carry out the activities of daily living by themselves or need assistance. Elderly persons in Africa generally encounter several difficulties in which their health, well-being and mental state are affected [13]. This is due to health system inadequacies and lack of care for older persons and unavailable long-term care facilities for older persons. Older persons in Africa are well respected [14]. Older women perform other roles in Africa especially carrying for their grandchildren especially if the mother of their grandchildren has passed away [14]. They are employed as babysitters and nannies. Sometimes they travel overseas to care for their grandchildren so that their children can go to work and not pay for child care.

As times are changing, many young people are getting formal employment, there will be an increased demand for long-term care facilities inform of nursing homes to care for the elderly [12]. This will help the elderly to maintain good health and access social support. Though, even the available nursing homes in some African communities are underutilized. This is due to several factors, people are not aware of their existence, beliefs and myths about nursing homes and discrimination and humiliation of people who take their elderly ones to nursing homes [15]. Some of the nursing homes in Africa are managed by religious organizations. In Africa, elders are cared for by their offspring, grandchildren and extended family members [12, 14].

2. Population aging

Population aging is a worldwide phenomenon with economic and social consequences, and it follows a decline in both birth and death rates [5, 16, 17, 18, 19, 20]. Globally, there is an increase in the number of elderly persons who will require geriatric care [5, 8, 17, 18, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30]. They make up a large number of the population in every country. This worldwide increase in the number of aged persons will increase the importance of the geriatric medicine specialty [26]. This is because old age comes with certain challenges, and chronic illnesses will become a major global public health challenge [19]. The increase in longevity is linked to the reduction in the death rate due to improved health systems and interventions [18, 28, 31].

Globally in 2017, the number of persons aged 60 years and above was 962 million, and this figure is expected to double by 2015 [2, 18, 20]. Population aging will have an impact on healthcare delivery both positively and negatively as there will be a shift from acute to chronic diseases associated with old age and the likelihood of a shortage of healthcare workers specially trained to look after the aged [19, 32, 33]. Like any other group of individuals in society, the aged require constant interaction with people around them [5]. Generally, in most societies and cultures including Africa, it is expected that older people are relieved from normal labour and allowed rest from active economic activities [1]. The aging population is of great concern for the health sector as health challenges are common among the elderly [17, 34] with different patterns of presentation which therefore requires special medical skills [8, 35].

3. Demography of elderly persons in Africa

It is not news that there are older persons in Africa. Worldwide, it is estimated in 2019 that there were 1 billion persons who are 60 years and above [36]. However it is estimated that this number will rise to 2 billion by 2050, there is also speculation that there shall also be an increase in the number of people that will live up to 80 years and beyond [37]. The number of older persons is increasing dramatically, especially in countries that are still developing. Most of which are African countries [38]. It is estimated by the United Nations that by the year 2045, there will be more people that will be over the age of 65 years which will outnumber the number of persons that will be below 15 years [38]. Older persons in recent times consist of a significantly larger population. In Africa, it was estimated in 2009 that 53.8 million individuals are aged 60 years and above [38]. Generally, few persons are trained in geriatric medicine and gerontology to care for the aging population in Africa.

4. Who is an elder?

The elderly are also known as senior citizens, the aged, older persons and elder statesmen. There is no precise and accurate definition of who is an elder [39] as there are different definitions for the elderly by several international organizations, and it varies from society to society [40]. The United Nations agreed that the cut-off age for an older person is someone who is 60 years and above [1, 2, 41], while the World Health Organization defines an elder to be 65 years and above [42, 43]. Most developed countries have accepted the chronological age of 65 years as a definition of elderly individuals [5, 42, 44]. In some countries, the definition of old age is linked to the age of retirement from the government civil service [5, 21]. For instance, the cut-off age for elderly persons in Nigeria is 60 years as this is the age for retirement from the Nigerian federal and state civil service. Though with the various definitions of old age or who is an elder, there is no general agreement on the age when a person becomes old [5].

5. Aging in Africa

Older persons play important roles in African societies as the African cultural systems give them high status [45]. They preserve cultural values, transmit knowledge and skills, dissolve conflicts and disagreements and also educate the young [2, 46]. The typical older adult in developing countries lives in poverty [7]. In some African countries, the kin of elderly people accuse them of witchcraft that they are the cause of misfortunes in the family [29]. This is worst for elderly women who do not have any living child; sometimes these older women are ostracized, tortured or even killed [29].

Over half of persons aged 60 years and above in Africa resided with a child either their biological children or grandchild [23] as the family and friends care for older persons [46]. Older persons in most African societies are accorded much respect [46]. Sometimes older persons are not called directly by their names. They are called mama, for women and papa or baba for men depending on the country. They are addressed as mothers or fathers irrespective of whether they have children or not. In Nigeria, there are different tribes and each tribe has a prefix added to the name of an older person. Among the Ibani people of Grand Bonny Kingdom and Opobo in Rivers State, Nigeria, the prefix ‘Ada’ is used for older men and ‘Aya’ for older women. Among the Igbo tribe of Eastern Nigeria, the prefix ‘Dede’ is used for older men and ‘Dada’ for older women. Baba is the prefix used for older men among the Yoruba people of Western Nigeria. It is an insult and also seen as a sign of disrespect in most African countries to address an older person directly by their names. The respect of older persons is also seen in several cultures including greeting and acknowledging them. For instance, among the Ibani tribe of southern Nigeria, a man must remove his hat when greeting an elder especially if the older is a man. Among the Yoruba, an older person is greeted by a female kneeling down or a male prostrating on the ground. This shows that Africans hold the older person in high esteem and these traditions have been passed down from generation to generation.

In Africa, the chronological definition of the older person sometimes causes some problems as due to illiteracy, most dates of birth are not recorded [5, 40]. Sometimes historic events are used to estimate the age. In some African countries, aging is associated with retirement and the receipt of pension [1]. Though not all African older persons have been involved in formal work, older persons in Africa are involved in transmitting oral, culture and traditions from one generation to another [2]. In Africa and other countries, senior citizens may be perceived as burdens due to their disability or dependence [21].

The elderly also known as older persons or senior citizens are persons aged 60 years and over [47]. Some others define the elderly as persons aged 65 years and above. In Nigeria, 60 years is used as this is the age of retirement from the Nigerian government civil service. Few other professionals in Africa retire above the age of 60 such as judges and lecturers.

Elderly persons are well respected as they are believed to be full of wisdom. During family and community conflicts, they are made head of locally constituted panels to deliberate on issues that range from marriage disputes, sibling rivalry and land disputes. Their verdicts are respected and taken as the final even if the decision is not reasonable. Most elderly persons in Africa do not have any form of pension or retirement benefits. They are cared for by their family members who are their biological children, nephews and nieces, community members and sometimes members of religious organizations. Therefore, they need social support as this will in turn affect their health and psychological well-being, mental health, quality of life, independence, interpersonal relationship and personality [48]. This is because social support will reduce boredom and loneliness. There will also be a reduction in elder abuse, neglect and mental health problems such as anxiety and depression.

In sub-Saharan Africa, most elderly women are not unemployed, therefore, they do not benefit from any form of social security, and hence, they are vulnerable [13]. Older persons in Africa are sometimes accused as the cause of misfortunes that happens or is experienced by their siblings and sibling children, especially if the older person is a woman and childless.

Older persons tend to retire to their rural areas and villages when they retire from formal employment. Social amenities of life are absent in most African villages such as electricity, good pipe bore water and in recent times the internet and mobile telecommunication services. They do not have access to healthcare when they retire to the village as most of the healthcare facilities in Africa are located in urban areas and cities. The elderly are sometimes termed as witches and wizards that possess spiritual powers to inflict evil on whomsoever they want.

6. Education and training in geriatric medicine in Africa

Doctors who are specialists in geriatric medicine are known as geriatricians. There are few hospitals in Africa that provide special care for the elderly with a unit division or department of geriatric medicine. Such units are manned by doctors who have either trained abroad either in Europe or the United States of America in geriatric medicine or generalist either internal medicine physicians or family doctors with interest in caring for the elderly. There is a dilemma in Africa if generalists with an interest in caring for the elderly should be referred to as geriatricians.

Globally, there are few geriatricians. In a study among medical graduates to find out those interested in geriatrics in medical schools in the United Kingdom, only 0.9% (0.4% males, 1.3% females) after 1 year of qualification and 1.5% (1.2% males, 1.9%) females after 5 years were interested in becoming geriatricians [26].

Geriatrics is not relatively popular among medical students [9], especially in Africa where most medical students are not even exposed to geriatric medicine in medical school. In another study in South Africa, only 6.6% wanted to specialize in geriatric medicine [16].

Geriatric medicine is a relatively new medical subspecialty in most parts of the world including Africa [16, 49]. It is complex to train as a geriatrician [50]. Unlike many other physicians who have a high proportion of older patients in their practice, geriatricians place a high premium on improving the function of their patients and not just treating the disease [51]. Globally, there are several models of specialty training to become a geriatrician [6]. Some doctors enrol in residency training in geriatric medicine. Another career pathway is to complete the residency in either internal medicine or family medicine depending on what is obtainable in the country and then train in a 1 year clinical fellowship [6]. Another career pathway is to complete a postgraduate degree that is Diploma, Masters or Doctor of Philosophy (PhD) in geriatric medicine [6]. Another pathway which is that some African doctors have done is to write the diploma in geriatric medicine examination of the Royal College of Physicians of London. In Canada, only candidates certified by the Royal College of Physicians and Surgeons of Canada in internal medicine may be eligible for certification in geriatric medicine [52].

In most countries, geriatric medicine is hardly included in undergraduate training [16]. This may be due to the lack of geriatricians. Specialization in geriatric medicine has traditionally been within internal medicine but a trend in some countries is for geriatricians to be trained within family medicine [16]. Medical training should embrace a multidisciplinary perspective team with particular attention given to the special care needs of the elderly persons reflecting the fact that they include medical conditions unique to this age group [30]. Development of geriatric care should be enhanced in undergraduate and also at postgraduate levels of training [26]. A Diploma in Geriatric Medicine is awarded by the Royal College of Physicians of London. The examination is designed to give recognition of competence in the provision of care of older people to general practitioners, trainees, middle-grade doctors working in non-consultant career posts in departments of geriatric medicine and other doctors with interest in or responsible for the care of older people [53]. Some Africans have passed this examination.

7. Geriatric care in Africa

Formalized care for the elderly is not adequate and well developed in Africa. There are few geriatricians in Africa including few training centres dedicated to the training for geriatric medicine. However, there are few training centres in African countries such as South Africa. In Nigeria, the training in geriatric medicine is still new and only a few hospitals are accredited by the West African College of Surgeons for the training of geriatricians in Africa. This is done after success in the junior residency emanations. Most geriatricians working in Africa have been trained overseas. In developed countries, some other doctors who have an interest in the care of the elderly but do not have the opportunity to have specialist training in geriatric medicine have attended refresher courses in geriatric medicine. There are family doctors and physicians who have gained their experience in geriatric medicine by interest in the specialty and devoting their time and energy to caring for the elderly. Most African societies are becoming urbanized, and this is affecting the care of older persons making them vulnerable, dissolution of the structure of the family and lack of access to good healthcare [13]. Even with experience in caring for older persons, their knowledge will be limited because they do not have any specialists training in geriatric medicine [38].

In a study conducted by Dotchin et al., on the services and training in geriatric medicine in Africa, in most African communities, there are limited specialist healthcare services for older persons [38]. Several medical specialties are encompassed in geriatric medicine such as family medicine, internal medicine, emergency medicine, surgery and dermatology. Geriatric medicine as a specialty is not taught in medical schools [38]. Governments in developing countries have an important role in the provision of healthcare for elder persons [12]. The governments need to enact policies and laws that will protect the vulnerability of senior citizens. Care of the elder citizens is not of importance to the policymakers in most African countries.

There are few geriatric centres or units in Africa. This may be because there are few training centres for geriatric medicine in Africa. In Nigeria, for instance, as at the time of writing this book, there is the Tony Anenih Geriatric Centre at the University College Hospital, Ibadan; Care of Elderly Person’s Unit (CEPU) at the University of Port Harcourt Teaching Hospital and the Geriatric Unit at the University of Benin Teaching Hospital, Benin City, Edo State. The Geriatric Unit of the University of Benin Teaching Hospital was created in October; 2013 [7]. Other Nigerian hospitals have a special clinic for older persons but are not organized by the hospital management as a geriatric unit or department. In the face of limited resources, it is possible to establish a functional geriatric unit and achieve best practices in resource-limited settings by investing in improving available human resources and infrastructure [7].

In Nigeria, there is no organized training for geriatric medicine but doctors with an interest in caring for the elderly practice geriatric medicine and care for the health needs of the elderly. This includes family doctors and physicians. Anesthetists with an interest in geriatric medicine practise geriatric anesthesia. Few Nigerian doctors have trained to be geriatricians in the United Kingdom and the United States of America or have passed the diploma in geriatric medicine examination of the Royal College of Physicians. In March 2016, the University College Hospital, Ibadan, Nigeria, organized a 2 week certificate course on geriatric medicine to train family doctors and physicians in geriatric medicine. This introductory training to geriatric medicine has been done for some years after the maiden one.

Nursing homes are long-term care facilities for vulnerable groups of people for example children, motherless babies, the disabled, mentally retarded and the elderly. These are not common in Nigeria as most Nigerian nursing homes are established and managed by religious organizations and/or non-governmental organizations. Institutional homes for the elderly have their problems, therefore the residents need medical care. In Africa, due to the culture of the people, the elderly resist being kept in a home either as daycare or for long-term care instead they are to be taken care of by their children or other relatives [54]. This is also applicable to Nigeria as the Nigerian elderly are still cared for by their families [55]. One of the reasons why in countries such as Nigeria, the elderly person will not be kept in a long-term home is the belief that the elderly will place a curse on whoever brings the idea and support any placement in the long-term care facility or children or other family members [55].

Sometimes, some of the residents of the nursing homes are abandoned and neglected by their relatives. In this modern day, where young people both men and women have to be involved in circular work or businesses that keep them away from home, specialized long-term institutions are necessary to care for the vulnerable groups of people in the society including the elderly.

8. Conclusions

There are a rising number of people getting older and living up to 60 years and above. This group of people in Africa is faced with several challenges, and they are prone to vulnerability. They are faced with health and social problems. This is worst for women who are single as they are sometimes ostracized and even called witches. There are few geriatricians in Africa; however, most countries are developing strategies for various forms of training in geriatric medicine such as postgraduate courses, fellowship, refresher courses and workshops. There is need for more research on the elderly in Africa. The different states in the African continent should enact policies and laws to protect senior citizens in Africa.