One of the many challenges India is facing with its changing demographics – the numbers speak for themselves – is that a large proportion of senior citizens are living alone, either as couples, or as individuals
In India, a country that has had traditionally strong family-based structures, with multiple generations often living under a single roof, this is a relatively new phenomenon, one that senior citizens, their families and communities at large are coming to terms with.
Experts say that frameworks and policies for senior citizens in India – the Centre recently said that a new national policy on senior citizens is in the draft stages – must take this fact into consideration, as it impacts not just the physical health of the elderly, but also their emotional, social and financial health, as well as their safety.
Living alone
According to the Longitudinal Ageing Study in India (LASI), Wave 1 (2017-18), 5.7% of those aged 60 and above lived alone, compared to just 1.4% of those aged 45 to 59. And this number has not just risen — up from 2% in 2011 — it is rising, says T.V. Sekher professor and head, Centre for Ageing Studies, International Institute for Population Sciences, Mumbai.
Seniors living with their spouse and children comprised 40.6% in 2017-18, while for the younger age group, the number stood at 74.2%. Southern India, where for the most part, family planning measures were implemented more successfully than in the north, and where therefore there are lower total fertility rates, is ageing faster and is living alone significantly more too. Prof. Sekher says the numbers in Tamil Nadu and Kerala stand at around 15%. Add to this, the migration of young people to different parts of the country or abroad for work, men and women losing their spouses to death or separation, and the number of aged persons living by themselves is only bound to increase, he says.
In general, says Anupama Datta, head, policy research and advocacy, HelpAge India, an NGO that works for the cause of disadvantaged older persons, there are more senior citizens living alone (as couples and individuals) in urban India compared to rural parts of the country. Rurally, she says, a number of families continue to live in joint set ups, whereas in cities, smaller family structures are becoming increasingly common.
There is a gender angle to this as well – more older women live alone compared to older men, 4.5% women, compared to 1.8% men, according to LASI, possibly accounted for by the fact that women have a longer life expectancy.
The impacts
On the face of it, living alone – as a couple or an individual – may not seem like it has a direct impact on health and wellbeing. However, experts say it can have a number of effects on people. The foremost of these is loneliness.
“There is evidence of loneliness having an adverse effect on human beings across the lifespan: from the young to the elderly,” says P.T. Sivakumar, professor and head of geriatric psychiatry, NIMHANS, Bengaluru. When elderly people experience loneliness, when the quality of their interactions with other people is not optimal, this can lead to depression, which can contribute to cognitive decline and dementia, he says. “Social isolation and chronic stress are known to have an effect on cognition,” he adds. Depression, Dr. Sivakumar, points out, can lead to secondary effects as well, such as alcohol and substance abuse, further adding to negative health impacts. In many cases, adds Ms. Datta, elderly people are not able to even articulate how lonely they feel, and even if they want to, they have no one to articulate it to.
Another major effect of living alone is stress. This can be due to a number of factors, including dwindling finances and worries over safety. Studies have shown, says Dr. Sivakumar, that the prevalence of depression and mental health issues is higher in low-income groups. Rates of crimes against older citizens are on the rise: In 2022, as per the National Crime Record Bureau report, 28,545 cases were registered as crimes against senior citizens, a 9.3% increase compared to 2021. And, stress is a well-known risk factor for a number of diseases including heart disease, high blood pressure, strokes, sleep problems, digestive problems as well as depression and anxiety among others.
“Elderly women in our society are generally not used to living by themselves,” says Ms. Datta. “This, in itself, gives them a feeling of insecurity, an inability to quickly respond to challenges. They do not know whom to trust and whom not to, making day-to-day issues also challenging. Money is a problem – both not having it, and not knowing how to manage it, as culturally, women are not encouraged to know how to deal with money, making for a certain amount of dependence on someone else. Since in our country there are more widows than widowers, this is a huge issue.”
When it comes to men, the issues are somewhat different, she says: “Older men are more socially and emotionally isolated. In families in India, relationships with children and relatives are often mediated through the wife. In families with only sons, the situation is even more challenging. After the wife dies, isolation of the elderly man is very likely. They have a decreasing number of friends in an already small circle, making the emotional void in them much deeper. In fact, a lot of elderly women express this fear to us: ‘If I die before my husband, who will look after him?’ This too, is an important aspect of elderly care that needs to be taken into consideration.”
Compounding all of these factors is the fact that the health of the elderly is not given much importance. “In limited resource settings, the first priority is given to the health of the children – if there is an issue there, the whole family contributes; when it comes to the health of older persons, not so much. Apart from some amount of neglect by the family, there is also self-ageism at work here: senior citizens often delay going to the hospital due to worries about money and access,” says Dr. Sivakumar.
Lack of caregivers
Caregiving is another crucial aspect: traditionally, says Prof. Sekher, in the joint family system, the elderly were taken care of by younger members of the family, primarily by women, generally the daughters-in-law.
“Now, increasingly, that structure is no longer there, the number of daughters and daughters-in-law has come down drastically and even when present, they may not want to commit to caregiving or may not be able to, due to other priorities. In our country though, for the most part, the elderly expect to be taken care of, and when this does not happen, their health deteriorates,” he says.
The system in India, says Merita Joseph, chapter head, Dignity Foundation in Chennai, an NGO working to improve the lives of senior citizens, is still not geared toward professional caregivers, unlike in the West. “This creates a gap in service: there simply aren’t enough trained geriatric staff and where available, they are not cheap, making them unaffordable for many.
The usual thing to do is to employ a domestic helper who also does the caregiving. Even when there is a professional caregiver, sometimes the mindset is such that families expect household chores to also be taken care of, which is not optimal,” she says. She adds that in their experience, the rates of dementia are going up alongside the increase in the numbers of senior citizens living alone.
There simply aren’t enough trained geriatric staff and where available, they are not cheap, making them unaffordable for many | Photograph used for representational purpose only
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Barriers to self-reliance
It is inevitable as one grows older, for social circles to diminish, for connections to be fewer than in the past. But even with this reality, experts say, the barriers to socialisation in India, especially for women, are many, compounding the loneliness of those already living alone.
“The challenge with our society,” says Dr. Sivakumar, is that there are not many avenues for elderly people to come together, particularly for those with physical and minor medical issues. In urban settings, some senior citizens have access to facilities such as parks and clubs, but the vast majority of seniors in our country do not. The lack of senior-friendly and accessible environments, lack of access to transport and sometimes even the fact that they may be on the third floor of a building with no lifts or ramps and are therefore confined to their homes, all add to the barriers. Loneliness in these cases, has a reciprocal effect on physical health; sometimes, doctors cannot differentiate between the cause and the effect, due to the complex relationship between the mind and the body,” he points out.
For women, Dr. Sivakumar adds, the barriers are even more. “In our culture, in the previous generation, men had more access to social interactions and groups, as primarily, men would have worked and women would have stayed at home. There are fewer women-only groups: some residential societies and other city-based networks have them, but in tier-2 towns, and in suburban areas, where there may be fewer peer groups, the avenues for interactions are lower,” he says. Prof Sekher adds: “Many women find satisfaction in religious or spiritual activities, but mobility and financial challenges are bigger issues for them and can pose barriers even to these activities.”
When it comes to health, the barriers are many and complex: travelling to a health facility in itself is a challenge. A recent study in The Lancet Regional Health Southeast Asia, ‘Miles to go before I seek: distance to the health facility and health care use among older adults in India’ found that that older adults, on an average, travelled a distance of 14.54 km to seek outpatient services and 43.62 km for inpatient care respectively. It noted that both out-patient and in-patient care utilisation was high (73% and 40% respectively) when the healthcare facility was within 10 km. As the distance increased, a commensurate decline in the out-patient utilisation was observed. For women, those living alone, and those with low education and income, this decline was more pronounced.
Even when they do get to a healthcare facility, most in India are not designed for patients to visit alone – in the absence of a caregiver, the already complex system becomes even more so |Photograph used for representational purpose only
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Another barrier to healthcare is finances: most elderly people in the country do not have insurance policies, and even if they do, these generally do not cover outpatient expenses. “In our country, 26% of senior citizens have multiple non-communicable diseases – and this is only the diagnosed number. Medicines are expensive and financing healthcare is a big challenge. When it comes to inpatient care, most are completely dependent on family and if they are living alone, there may be no one to help,” points out Ms. Datta.
For those living alone, distance, lack of public transport facilities especially in rural areas, no one to take them in a private vehicle and not having the money to go or not having a relative who will pay for them, can all play a part in delays in seeking care. Even when they do get to a healthcare facility, most in India are not designed for patients to visit alone – in the absence of a caregiver, the already complex system becomes even more so, says Dr. Sivakumar. “There are no supportive interventions to encourage independence and mobility,” he notes.
At most healthcare facilities, interventions for mental health and elder abuse, two crucial issues facing the elderly, are not tackled, says Ms. Datta.
The path ahead
There is no going back: the country is not going to become younger anytime soon, and traditional structures of caregiving and support that are beginning to erode may not be able to be propped up. What is needed, say experts, is a number of interventions – both government and community-based – that can help with a comprehensive care system for senior citizens in the country, one that takes into account not just changing demographics, but changing family systems too.
There have been some developments in this area, but they remain small and unevenly distributed.
Interventions – both government and community-based – that can help with a comprehensive care system for senior citizens in the country is needed, say experts |Photograph used for representational purpose only
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File Photograph
For one, says Dr. Sivakumar, workplace interventions can be implemented: targeting and preparing retiring employees for life after, can help ease the process and navigate changes. “Teaching people how to cope – mentally and financially can help, and this has to start at least five years before retirement,” he says, adding that individuals in the unorganised sector too, need to be assisted.
Population-level and community-based interventions are known to work, he says. “Some models have demonstrated feasibility and utility, but these need scaling up. Just like anganwadis for children, there can be centres for senior citizens, but these have to be integrated with regular programmes, both in urban and rural areas. Resident welfare associations, rural panchayats and the government need to step in to create mechanisms and resources where people can be supported as these places have to be within reach and user-friendly,” he says.
Age-friendly environments, public transport and spaces – so the elderly can venture out with no fear – are also needed. “Dependence can create depression, apart from having a negative effect on the dignity of individuals,” Dr. Sivakumar says, and when elderly people feel they are becoming dependent they may choose to remain alone rather than go out, which adds to the problem.
The creation of resources remains a challenge – large-scale institutionalised care facilities such as those in other countries, may not work in India, says Prof. Sekher. Since the demand, however, for trained geriatric care workers will increase, this is perhaps an area that needs investment to be able to make it grow.
Active ageing
Societies must also encourage active ageing, says Ms. Joseph. This is defined by the World Health Organization as the process of optimising opportunities for health, participation, and security in order to enhance quality of life as people age. At Dignity Foundation, this involves getting together for exercise, yoga, art therapy and games, as well as for sessions on internet literacy, financial and legal services and even interactions with college students. “We have seen that residents who are involved tend to form groups and friendships and can then depend on each other for support. This helps stave off loneliness,” she says.
Awareness creation of their rights and privileges such as The Maintenance and Welfare of Parents and Senior Citizens Act, 2007 (MWPS Act), 2007 for instance — only 18% were even aware about the Act as per LASI — will help, Prof. Sekher says, adding that awareness about what to do in cases of elder abuse, cyber scams and how to stay safe, can all go a long way towards helping seniors staying alone feel more secure.
From the government end, the inclusion of those above 70 years in the Pradhan Mantri Jan Arogya Yojana (PM-JAY) insurance scheme is a welcome step, experts say, and while initiatives such as the national elderly helpline (14567) and other measures exist, more is needed, especially to help seniors access the services meant for them.
Apart from this, there is no contesting the fact that societal attitudes need to change to bring in more sensitivity among all sections of society.
“There are no easy solutions,” as Prof. Sekher says. We are going to live for more years. Are we going to live them healthily, physically and mentally? To do that, we need to put in the work.”
