According to Flores, by 2020, there will be more than one billion elderly persons in the world and most of them will live in LMIC countries. In Bangladesh it is projected that the number of elderly persons will be double from 7.8 million in 2001 to 16.2 million by 2025 (BBS, 2009). Due to decline of fertility, mortality, rising of life expectancy at birth and changing of prevalence of communicable diseases to non-communicable diseases Bangladesh is now currently going through both epidemiologic and demographic transitions (Caldwell et al, 1990 & US Census Bureau, 2010). As a result the number of older people is increasing and non communicable diseases are emerging especially among the older persons in the low income countries like Bangladesh. People of the low socioeconomic status are suffering from several adverse medical conditions which are now-a-days defined as "Multi-morbidity or co-morbidity" (Van Den Akker, Buntinx & Knottnerus, 2002). In Bangladesh the overall prevalence of multi-morbidity is 53.8% among the elderly people and Female sex was associated with a higher prevalence of multi-morbidity among this population (Khanam et al, 2011)
Already World Health Organization (WHO) declared that in the next two decades the world will face a dramatic transition in the health needs, as a result of epidemiological transition. In the country like Bangladesh the people of low socioeconomic condition are suffering from chronic diseases like arthritis, hypertension, diabetes, impaired vision, hearing impairment, thyroid dysfunction, cardiovascular diseases, cerebro-vascular diseases, stroke and obesity (Karar, Alam & Streatfield, 2009). This will affect significantly environmental, economic, social, and health consequences in national level, especially for the low income countries whose are not prepared for this circumstance.
In South-East Asia Region, NCDs - which include heart disease, stroke, cancer, chronic respiratory diseases and diabetes - are estimated to account for half of annual mortality (54%) and burden of disease (47%) (WHO, 2005 & WHO, 2008). In South-East Asia Cardiovascular diseases are contributing the major part of mortality and morbidity also rank among the top ten causes of death in Bangladesh (Ghaffar, Reddy, & Singhi, 2004 & WHO, 2004). The prevalence of diabetes has risen more rapidly in South-East Asia than any other large region in the world. A recent estimation shows that the number of people with diabetes in Bangladesh will increase from 1.5 million in 2000 to 4million in 2025 (King, Aubert, & Herman, 1998). This rapid rise of prevalence of diabetes in South- East Asia is much more comparing with any other part of the world. In Bangladesh a recent household survey estimated that tobacco-related illnesses are responsible for 16% of all deaths in the country (WHO, 2007). Recently Dementia is accounted as health problem of elderly people. It is estimated that 35 million people currently living with dementia globally and 58 percent of them live in low- and middle-income countries like Bangladesh. Eastern Asia and southern Asia will see dementia growth rates more than double in the coming 20 years (The Daily Star, 2011).According to the above sifting of epidemiological profile, the preventable risk factors including tobacco, unhealthy food habit, sedentary life style, physical inactivity, and alcohol consumption are becoming an increasing problem in Bangladesh. As a result the life style and NCD-related risk factors in Bangladesh increase in NCD prevalence and deaths. So the government of Bangladesh should focus on NCD risk factors and should take immediately for preventing NCDs in elderly by life course approach.
Formal and informal care for elderly
Formal care for elderly:
In Bangladesh older people depend on their family members mostly for care. Very few supports are available in the public programs. People who are involved in public sectors are eligible for pension and provident fund after retirement. People who work at private sector also have the option of contributory provident fund. But these pensions are not adjusted correspondingly to cover inflationary effects of the currency and as a result of this pensions can't help elders to meet the needs after retirement (Jesmin & Ingman, 2011).
In Bangladesh only three forms of services are currently available for the elderly: Old Age Allowance Program (OAAP), assistance for widows and old homes. But the annual allowance is very small amount to help the elder persons to get any kind of financial security. For older people, the government of Bangladesh has built one old home in each of the six administrative areas of the country. These homes provide food, clothing, and medical care free of charge. But in our culture children are criticized by the society if they leave their parents to an old age home. Most commonly sought healthcare provider for elders in rural Bangladesh is a village doctor, a medical assistant or a community health worker. The economic status of a house is the determining factor of whether the person would seek treatment from a qualified allopathic practitioners or an unqualified folk healer (Ahmed, Tomson, Petzold, & Kabir, 2005). The elderly health is mostly neglected in our country. As most of the elderly people could not afford the formal health services in the country due to financial and physical barriers, the government should focus strongly on elderly health in the health policy and also focus on age friendly hospital and should provide subsidies for them in the health facilities not only in the government hospitals but also in the private hospital but public private partnership.
Informal care for elderly:
Majority of older adults in Bangladesh live with their children. Family members are the important part for providing care to elderly persons. On the other hand older members play important role in raising younger family members. Recently some studies show that elderly couples are increasingly living alone. Several factors are contributing to this new trend: the changing social norms, delayed marriage, new gender roles, and higher rates of marital dissolution and growing numbers elderly whose spouse has died (Kabir, 1999). Due to new cultural change and entry of the western tradition in familial bonding the elders are left in large scale social, health and economic insecurity (United Nations, 2007). For example, a study done by Dong, Simon, & Gorbien, (2007) conducted in a medical center found that 35 percent of their respondents in urban areas in China reported some form of elder abuse and neglect. No such study is available to measure the severity and extent of elder abuse and neglect in Bangladesh. It is assumed that the risk factors associated with elder abuse such as female gender, lower education, lower income all make the elder's in Bangladesh vulnerable to mistreatment and neglect by the family caregivers. Many elder women find themselves in multiple care giving responsibilities (Jamuna, 2003). Thus role overload and stress is a possibility for elder women as they care for the elder husband as well as grandchildren. Women at later years of life have to depend more on family support than the men.
Aging population and functional Ability:
Functional ability of a person has two major domains physical function and cognitive function. Due to increase of life expectancy in low-income countries like Bangladesh, there is a rise of morbidity for NCDs and also decline in functional ability in the elderly persons, both physical and cognitive.
Physical function is a complex and extensive area that can refer to the function of a specific organ or organ system, mobility, strength, or the ability to carry out everyday activities (Parker, 1994). According to World Health Organization (WHO) impairment is a problem in body function or structure such as a significant deviation or loss (WHO, 2001) and disability is a complex phenomenon, reflecting an interaction between a person's health conditions and the social and environmental context in which he or she lives (WHO, 2001). Although disability serves as an umbrella term for impairments, restrictions in activities, or limited participation, impairment may not always necessarily lead to disability (WHO, 2001). In Bangladesh functional ability depends on some socio-cultural and structural factors. Functional limitation during the process of ageing is a result of impairments caused by a number of pathological conditions and chronic diseases like diabetes, impaired eye function, hearing impairment, cardio-vascular diseases, lung diseases and dementia (Abrass, 1990). Unhealthy diet is also related with chronic diseases that lead to disability. Although age related decline in muscle strength is a gradual process, this may occur earlier in malnourished persons than in well-nourished persons (Manadhar, 1995). Reduced muscle strength is, in turn, found to be strongly associated with poor mobility (Lauretani et al, 2003). Dementia is also an emerging disease that affects elderly people and affects their family life, social relationships, psychological well-being, and level of independence (Barbotte, Guillemin & Chau, 2001). In the context of a low-income country, e.g. Bangladesh, persons with functional difficulties are often valued negatively by the society (Hosain, Atkinson & Underwood, 2002).
Very few organizations are working for improving functional ability in Bangladesh. Among the Sir William Beveridge Foundation is working for the home based care for the elderly people form improving the quality of life. This organization is also working with dementia in elderly people. They are developing long term approach for diagnosis and treatment of dementia of elderly people with severe distressing condition.
NCD programs in Bangladesh from life coarse perspective:
Low income country like Bangladesh is going through the Demographic and epidemiological transition as there is decline of birth rate and mortality rate and rise of life expectancy at birth. On the other hand there is transition from communicable disease to non-communicable disease especially in older age. Three major diseases like Cardio vascular diseases, Diabetes, and tobacco related diseases are contributing the major portion of NCDs among the elderly people (Bleich et al, 2011). After addressing this problem in Bangladesh there are 11 programs are going on. Among the 11 NCD programs only 3 programs are working for prevention detecting the risk factors and 2 for reducing the tobacco consumption and 1 for batter nutrition for preventing Diabetes (Bleich et al, 2011).
In Bangladesh a recent estimation shows that the number of people with diabetes will increase from 1.5 million in 2000 to 4million in 2025 (King, Aubert, & Herman, 1998). This rapid rise of prevalence of diabetes is much more alarming comparing any other part of the world. BIRDEM took good initiatives for supporting the diabetic patient and also nutrition program for preventing diabetes.
It is already demonstrated that weight loss achieved by an increase in physical activity and dietary change including reduction in total and saturated fat and increased dietary fiber can reduce the incidence of diabetes (Feskens, Loeber & Kromhout, 1994). For primary prevention of Diabetes Mellitus BADAS has taken some initiatives in Bangladesh which are cost effective. These initiatives include general practitioners, community leaders, school teachers, some media personalities, well-motivated and socially oriented persons as ambassadors and local religious icons for promoting the programs and preventing diabetes mellitus. BADAS also developed movie with appropriate massage to reach the general people. They also submitted a draft of National Policy for preventing Diabetes Mellitus type 2 to the government of Bangladesh.
BADAS has taken the following strategies to prevent type to Diabetes Mellitus. Those are (1) To provide structured education for primary prevention, (2) Provide intervention for pre-diabetic patient, (3) Conduct educational program for employees, (4) Conduct awareness campaign against smoking (5) Organize walkers, clubs, swimmer's club, and golf club etc.
In collaboration with University of Oslo, Norway and BADAS is running a diabetes prevention intervention study (DPIS) to observe the outcome of different intervention like lifestyle, metformin and glibenclamide and also by correcting micronutrient deficiencies in pregnant mothers to prevent diabetes among high risk group (both obese and under-nutrition) in Bangladesh. With those interventions, project already has developed a good number of mass awareness programs in community level, developed leaflets, posters and a Prevention Guide Book in local language. Focusing on all the high risk people in Bangladesh and Bangla speaking population living in different parts of the world, project has recently develop a user friendly web-site for easy access to create a mass awareness in national and international level as well disseminate their developments.
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