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Understanding Elder Abuse in India: Contributing Factors and Policy Suggestions

• Published: 09 November 2022
• Volume 17 , pages 5–32, ( 2024 )

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• Priya Maurya   ORCID: orcid.org/0000-0002-5923-7884 1 ,
• Aparajita Chattopadhyay   ORCID: orcid.org/0000-0002-1722-4268 1 ,
• Smitha Rao   ORCID: orcid.org/0000-0002-6788-001X 2 &
• Palak Sharma   ORCID: orcid.org/0000-0001-8870-9097 3  

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Elder abuse is a multifaceted public health issue. The aim of this study is to provide a concise overview of elder abuse among adults age 60 and above, at the national and state levels in India. The main objective of this research is to examine the prevalence and determinants of elder abuse in light of the latest available data, with an emphasis on working status of older adults. Further, we explore the relative importance of distinctive factors explaining the gendered differential in elder abuse. This study also suggests some strategies to address the problem of elder abuse. Data from the 2020 Longitudinal Ageing Study in India indicates that although the overall prevalence of elder abuse is relatively low in India (5.22%), wide state-level variations prevail. Women, working older adults (especially working women), those under the age of 70, those with greater household assets, those not in a marital union, those staying in rural areas, and those in poor health have significantly higher chances of abuse than their counterparts. Both wealth and education must reach a critical level to curb abuse. Differences in economic factors explain only 10% of the gender gap in elder abuse prevalence. Sociodemographic factors alone account for around 29%, and health-related factors contribute to 28% of the gender differential in elder abuse. We argue for widespread protective policies and targeted program interventions to address elder abuse in India.

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Data availability.

The data used in this study is freely available and easily accessible for researchers through IIPS LASI Study ( https://www.iipsindia.ac.in/lasi/ ).

Social learning theory posits that violence is a learned behavior that may be passed down intergenerationally. Social exchange theory explains that elder abuse may occur because of the victim’s dependence on the abuse and vice versa. Feminist theory argues that elder abuse is the product of patriarchal family. structure. Examining the psychopathology of the caregiver theory would include looking at how an abuser’s behavioral characteristics contribute to elder abuse. For instance, caregivers who consume alcohol and experience depression and anxiety are more likely to use physical and verbal abuse against an elder. Symbolic interactionism assumes that people view and react to elements or situations according to the subjective meanings they attach to those elements. Everyone attaches their own meaning to every other object, and this meaning is created or modified through social interactions involving symbolic communication with other people. Hence, the perception and interpretation of an object is not always the same for all people.

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Acknowledgements

The authors are grateful to the International Institute for Population Sciences (IIPS), Harvard T. H. Chan School of Public Health (HSPH), and the University of Southern California (USC) for providing access to the data for this research. The data themselves are available for public access through IIPS LASI Study ( https://www.iipsindia.ac.in/lasi/ ). The authors also acknowledge Ministry of Health and Family Welfare (MoHFW), National Institute on Aging (NIA/NIH), USA, and United Nations Population Fund, India, for financially supporting the survey. We would also like to thank Todd Manza for extensive copyediting support. We are grateful to IIPS, Mumbai for providing access to the published research papers. Further, we show our gratitude to the Editorial board of the journal and the reviewers as their comments improved the paper significantly.

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Maurya, P., Chattopadhyay, A., Rao, S. et al. Understanding Elder Abuse in India: Contributing Factors and Policy Suggestions. Population Ageing 17 , 5–32 (2024). https://doi.org/10.1007/s12062-022-09399-x

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• 19 January 2022

Tackling the crisis of care for older people: lessons from India and Japan

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People exercise with dumb-bells at a health promotion to mark Japan’s Respect for the Aged Day in Tokyo. Credit: Toru Hanai/Reuters/Alamy

How to finance and deliver care for a population that is ageing fast is a politically fraught subject. In the United Kingdom, for example, many Westminster analysts say that Prime Minister Theresa May lost her governing majority in 2017 in response to her proposed social-care reforms, dubbed a ‘dementia tax’ by political opponents. In September 2021, the administration led by her successor, Boris Johnson, was criticized over its social-care policy for raising the rates of national insurance, a social-security tax paid by working adults and their employers, in a bid to raise £36 billion (US$48 billion) to fund long-term social care.

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Living arrangement of Indian elderly: a predominant predictor of their level of life satisfaction

• Binayak Kandapan   ORCID: orcid.org/0000-0003-2749-8235 1 ,
• Jalandhar Pradhan   ORCID: orcid.org/0000-0001-5998-0363 1 &
• Itishree Pradhan   ORCID: orcid.org/0000-0002-7886-7638 1  

BMC Geriatrics volume  23 , Article number:  88 ( 2023 ) Cite this article

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This article aims to examine the level of life satisfaction (LS) among Indian older adults and to determine whether their living arrangement is one of the potential determinants of their level of LS.

Data was drawn from the first and most recent wave of Longitudinal Ageing Study in India conducted in 2017–18. Using the Satisfaction with Life Scale, the level of LS was assessed for 30,370 elderly aged 60 + . Bivariate analysis was carried out to see the variation in the level of LS across elderlies with different socio-demographic characteristics. To investigate the association between LS and living arrangements and the selected socio-demographic factors multinomial logistic regression model was fitted.

The findings reveal that 25.4% and 45.5% of the elderlies have reported having a low and high level of LS, respectively. Living alone was associated with low level of LS. Co-residing with a spouse was associated with a higher likelihood of reporting high level of LS. The study also found that having both spouse and children as coresident increases the likelihood of reporting high level of LS (RRR = 3.15, 95%CI = 2.3–4.28). Elderly with self-reported poor health, limitation in more than two activities of daily living and presence of depressive symptoms were significantly associated with reporting low level of LS. However, being diagnosed with more than three chronic illnesses was associated with high level of LS (RRR = 1.41, 95%CI = 1.25–1.59). Older adults with the following characteristics were more likely to report a lower level of LS: male, 60–64 years old, no or few years of schooling, unmarried, working, rural resident, living in a poor household, Scheduled Caste and Tribe.

The level of life satisfaction in Indian older adults is significantly associated with their living arrangements, thus suggesting that the LS of older adults could be facilitated through interventions that consider their living arrangements. Older adults with various personal and household characteristics were identified as vulnerable groups, who should be the prime targets of the existing welfare policies.

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Introduction

India has the world’s second-largest elderly population and one of the world’s fastest growth rates in the elderly population [ 1 ]. India would only take three more decades to double its 60 + population, which is projected to reach 289.5 million in 2050 from 139.6 million in 2020 [ 2 ]. The country’s growing elderly population poses a significant challenge in improving the older citizens’ quality of life. Because, with ageing, people face special challenges such as a reduction in physical function, cognition, personal autonomy and engagement in social activities [ 3 , 4 ], making them dependent on others for their daily activities and requirements. Indian older adults predominantly reside with their immediate family members, and they receive the highest social support and care from them when in need [ 5 , 6 ]. Nevertheless, the blend of urbanization and western culture and children relocating overseas due to rapid globalization has been affecting the family system and the living arrangements of older adults in India [ 1 , 5 , 7 , 8 ]. As a result, the proportion of older adults co-residing with their children is declining sharply in India [ 2 ]; this has also led to fewer intergenerational households, which makes the provision of household-based social support more challenging [ 9 ]. Furthermore, the decline in fertility rate and increase in longevity are elevating the elderly dependency ratio in the country, which is estimated to increase from 15.9% in 2020 to 28.2% in 2050 [ 2 ]. With this exorbitant growth rate of the older adult population and an increase in the elderly dependency ratio, the change in the living arrangements poses a serious concern about the older adults’ overall well-being.

Henriques et al. [ 10 ] propose four domains of well-being in the nested model: subjective (happiness and LS); health and functioning (biological and psychological); environmental (both material and social environments); and values and ideology (the moral and ethical perspective of an external observer and evaluator). However, in the recent decade, policymakers and social scientists have been more inclined towards subjective measures of well-being to define and measure the welfare of individuals and the nation as a whole, because good health and economic conditions alone cannot make people happy and satisfy [ 11 ]. There is no doubt that no matter what personal and socio-economic characteristics one has, the main goal of the majority of people throughout the world is to be happy and satisfied with the life they lead [ 12 ]. Both happiness and LS are the subjective evaluation of one’s life; while happiness is affective feelings, LS is the cognitive evaluation [ 13 ]. Happiness is mostly based on emotional judgments, while LS is a cognitive assessment of the discrepancy between what you want and what you have; happiness is quite transitory, while LS tends to be stable (although it is sensitive to major events and changes in life conditions) [ 14 ]. Researchers consider LS as the measure of evaluated well-being because it requires the evaluation of one’s life events and experiences over relatively long periods [ 13 , 15 , 16 ]. Moreover, it is often considered as a common indicator of the overall well-being of a person [ 17 ], and a key index for measuring societal progress [ 18 ].

LS is more appealing to researchers assessing the quality of life of older adults because it is a more cognitive and stable phenomenon [ 11 , 14 ]. For older adults, it is a multidimensional issue that is influenced by various objective life conditions, personal traits, and psychological characteristics [ 14 , 19 ]. Previous studies in both developed and developing countries have identified a number of common predictors of LS in older adults, which include marital status, gender, employment, family ties, physical and mental health, social network, social support, wealth, participation in spiritual and religious events, education, social group, and caste in case of India [ 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ]. In India, the existing studies on LS or similar concepts such as happiness and quality of life particularly focused on its association with socio-demographic factors [ 25 , 30 ], social networks and support [ 26 , 29 , 31 ], change in living arrangements [ 32 ], household headship [ 33 ], and caste [ 34 ]. Yet the above studies have also found that living arrangement is a fundamental factor for LS of Indian older adults [ 20 , 22 , 25 , 27 , 29 , 30 , 32 , 33 ]. However, none of these studies has extensively studied living arrangement as a significant predictor of LS except for Nagargoje et al. [ 29 ], who studied mediating effect of living arrangement in the relationship between social participation and life satisfaction.

A person’s living arrangement generally indicates with whom the person resides. For older adults, it can be alone, with a spouse, with their children, with a spouse and children, or with others [ 35 ]. And it cannot be ignored while discussing the LS of older adults in a country like India, where collectivist culture has remained as an important feature right from ancient times [ 6 ]. Studies indicate that the majority of Indian older adults co-reside with their immediate family members, and they have better health and well-being compared to those who live without their family [ 1 , 4 , 5 , 6 , 32 , 36 ]. The most crucial aspect of living with family members is that kin provides financial, personal care and emotional support, help with day-to-day activities, and health awareness [ 4 , 5 , 6 , 28 ], which have a significant impact on LS. But, alarmingly, a higher proportion of the perpetrators of crime against older adults are the immediate family members, relatives, neighbours, and caregivers [ 37 ]. Moreover, about 56.3% of the caregivers feel that the burden is mild to moderate, while 15.1% feel it is a severe burden to take care of dependent older adults [ 38 ]. Thus, these literatures may also indicate that older adults may not receive the same level of care and attention they had devoted to their ageing parents and parents-in-law. In these cases, dissatisfaction and sometimes even resentment seeps in when there is a gap between what one expects and what one gets.

In addition to the above discussion, other reasons that compelled the researchers of this study to investigate whether living arrangements is a predominant predictor of LS of Indian older adults are as follows: (i) living arrangement of older adults is significant in achieveing the sustainable development goal 3: “ensuring healthy lives and promoting well-being for all at all ages” [ 39 ]; (ii) the factors that were important in predicting LS of older adults in one country may not be relevant to their counterparts in another country. This is because even people in similar economic and non-economic circumstances may use different benchmarks or scales to evaluate their well-being, owing to differences in sociocultural norms and the relative value placed on various achievements [ 11 ]; and (iii) the paucity of research on living arrangement and LS of Older adults in the Indian context.

Data and methods

The present study has used the first and most recent wave of the Longitudinal Aging Survey of India (LASI), 2017–18 data. LASI has collected detailed information on healthcare practices, health behaviour and risk factors, healthcare utilization, and various demographic and socio-economic characteristics. In addition, information on older adults’ perceptions about their life, living arrangements and family relations was also collected from a 31,464 nationally representative adults population aged above 60 (referred to as older adults) in India [ 35 ]. Among those older adults, only 30,370 (Male-14,553; Female-15,817) responded to the questions about life satisfaction, and they were considered for the analysis in this study. The detailed sample selection procedure is presented in Fig.  1 .

Sample selection flow chart

Study variables

Dependent variable.

In this study, the level of LS is considered as the main outcome variable. The Satisfaction with Life Scale (SWLS) was used to assess the level of LS among older adults. The scale was designed to assess an individual’s cognitive evaluation of overall LS [ 40 ]. The SWLS has good internal consistency and test–retest reliability [ 41 ] and is one of the most frequently used scales in subjective well-being research [ 13 ]. The SWLS is a very simple, short questionnaire made up of only five statements: “(i) In most ways, my life is close to ideal; (ii) the conditions of my life are excellent; (iii) I am satisfied with my life; (iv) so far, I have got the important things I want in life; and (v) if I could live my life again, I would change almost nothing”. A scale was assigned using the 7-point Likert scale (ranging from 1 = strongly disagree to 7 = strongly agree), indicating the respondents’ agreement with the five statements regarding LS. And an overall score was constructed by summing up the scales assigned for those five statements; therefore, the possible range of scores ranges from 5 to 35, with a score of 5–9, 10–14, 15–19, 20, 21–25, 26–30, and 31–35 indicating that the respondent is “Extremely Dissatisfied”, “Dissatisfied”, “Slightly Dissatisfied”, “Neutral”, “Slightly Satisfied”, “Satisfied”, and “Extremely Satisfied” with life, respectively [ 42 ]. However, for simplicity of computation and interpretation, we clubbed the seven levels of LS into three: (i) Low includes extremely dissatisfied, dissatisfied, and slightly dissatisfied; (ii) Medium includes neutral and slightly satisfied; and (iii) High includes satisfied and extremely satisfied. Hence, the scores for low, medium and high levels of LS are 5–19, 20–25, and 26–35, respectively.

Independent variable

Living arrangement was the independent variable in this study. We focused on conceptualizing it by building on earlier research [ 4 , 5 , 36 , 39 ] and based on the categories as classified in LASI, 2017–18. The classification of living arrangements of older adults was of five mutually exclusive groups: (i) living alone – those living on their own; (ii) living with spouse only – those living only with their spouse; (iii) living with spouse and children – those living with their spouse and children; (iv) living with children only – those living with only children but not spouse: (v) living with others only – those living with the persons who are neither their spouse nor their children. It is to be noted that the other members (members excluding spouse and children) may also be co-residing in living arrangements (ii), (iii) and (iv); but in cases where an older adult who have co-residents but they are neither his/her spouse nor his/her children, the living arrangement is categorized as (v) living with others only.

Control variables

Aside from living arrangements, researchers have identified several variables that have been consistently linked with LS, including health, socio-economic status, education, and financial contentment [ 24 , 43 ]. The individual characteristics selected for this study were sex (male and female), age group (60–64, 65–69, 70–74, and 75 +), years of schooling (no education, 1–4, 5–9, 10–14, and 15 +), marital status (married, widowed, and never married/divorced/separated/deserted), and working status (not working and working). The health indicators include self-rated health (moderate, good, and poor), limitation in activities of daily living (ADL), limitation in instrumental activities of daily living (IADL), number of chronic diseases (0, 1, 2, and 3 +) and depressive symptoms (Yes/No). Household characteristics include place of residence (rural and urban), social group (scheduled caste [SC], scheduled tribe [ST], other backward class [OBC] and Non-SC/ST/OBC), religion (Hindu, Muslim, Christian, and Others) economic status (middle, poor, and rich), and Region (North, West, Central, East, North-east, and South).

Statistical method

Bivariate analysis was carried out to assess the distribution of Indian older adults by their levels of LS across the selected socio-demographic characteristics. Pearson’s chi-square test for independence was used to test whether or not there is a significant association between the levels of LS and the selected socio-demographic characteristics variables. To estimate the effects of living arrangements adjusted for a set of health, individual and household (HH) characteristics on the dependent variable, that is, the level of LS, a multinomial logistic (MNL) regression model was fitted using the “mlogit” function in Stata 14 software. Before considering the MNL regression model for the analysis, the proportional odds (PO) model was fitted considering the ordinal nature of the dependent variable; and the omnibus Brant test [ 44 ] of the PO assumption was conducted. The Brant test’s χ 2 (9) = 28.68, p  < 0.001, indicated that the PO assumption for the model was violated. And the assumption of the PO model also did not meet for any of the predictor variables. All the statistical analyses were carried out using the statistical software package Stata/SE, version 14.

The general MNL regression model for this study is specified according to Schmidt and Strauss[ 45 ]:

where \(Pr\left({Y}_{i}=j\right)\) denotes the probability of an individual ‘i’ being in the outcome category ‘j’ . ‘J’ is the number of categories in the outcome variables; in this case, it is 3, hence ‘j’ takes a value of 1, 2, or 3. ‘ \({\beta }_{j}\) ’ is the regression coefficient. Owing to the three categories of the dependent variable in the study, the model has two equations. The simplified equations are as follows:

Equation  2 represents the log odds (logit) of reporting medium level of LS relative to low level of LS. Similarly, Eq.  3 is for the log odds of reporting high level of LS relative to low level of LS. In both the equations, \(x\) is the type of living arrangement, and \(Y, H\mathrm{ and }Z\) are the sets of individual, health and household characteristics, respectively; and \({\alpha }_{k},{\beta }_{k}, {\delta }_{k},and {\gamma }_{k}\) are the respective slope coefficients, and \({\varepsilon }_{k}\) is the error term for the respective equations. In this study, the estimated parameters represent the RRR. An RRR > 1 indicates the likelihood of being in the comparison group (medium or high level of LS) relative to the likelihood of being in the referent group (low level of LS) for the comparison groups in the independent variable is higher than that of their referent group counterpart. In other words, the comparison group of the independent variable is more likely to report “medium/high level of LS”. Explained in another way, an RRR < 1 indicates that the likelihood of reporting “medium/high level of LS” relative to reporting “low level of LS” is lower for the comparison groups of the independent variable (e.g., living with a spouse, with spouse and children, and with others only) as compared to the referent group of the independent variable (e.g., living alone).

Table 1 presents the characteristics of the sample. More than two-fifths (43.5%) of the elderly were living ‘with their spouse and children’, more than one-fifth (26.7%) ‘with children and others’, and nearly one-fifth (19.5%) ‘with spouse and others’. About 52% are females, and 48% are males. More than half (53.4%) of the samples have not received formal education. One-third (33.7%) of the samples were widowed, and 64.3% were married. More than three-quarters (77%) of the sample reported moderate or good health, and about 46% had depressive symptoms. More than one-fifth (20.4%) of the older adults reported having at least one limitation in ADL, 43.5% reported having at least one limitation in IADL, and nearly one-fourth (24.6%) reported having at least two chronic diseases. Nearly two-thirds of the sample belongs to rural areas. OBC constitute 37.8%, while SC and ST share an almost equal proportion of the total sample. The majority of the sample were from Hindu households (73.4%), followed by Muslim (11.8%) and Christian (9.9%). Southern states have nearly one-fourth (24%) of the sample size.

Table 1 also presents the mean LS score across the sub-populations and the distribution of that sub-population by their LS levels. One-fourth (25.4%) of the 60 + population reported a lower level of LS, while 45.5% reported a high level of LS. From Table 1 , it is also clear that noticeable differences exist in all five household characteristics and in some personal traits such as years of schooling, marital status, self-rated health, limitation in ADL and IADL, number of chronic diseases, and depressive symptoms. In household characteristics, older adults from rural, SC, ST, Christian, and economically poorer households have reported low level of LS at a greater rate than their other counterparts. Among the regions of India, one in every three (34.9%) older adults in the southern region have reported a low level of LS, which is remarkably higher than in other regions. To help visualize more clearly how LS varies across the states and union territories of the country, mean LS Scores and the percentage of older adults who reported having low levels of LS for the states and union territories of India are provided in Figs. 2 and 3 , respectively.

Mean LS score of the older adults across the States and union territories of India, 2017–18

Note: The Map was developed by the authors using Stata software version 14.1, and the map was cross verified with the India map and its States and Union Territories’ boundaries as shown in the official website of Survey of India: https://indiamaps.gov.in/soiapp/ . State and Union Territories: ANI: Andaman & Nicobar Islands; AP: Andhra Pradesh; ARP: Arunachal Pradesh; AS: Assam; BH: Bihar; CG: Chhattisgarh; CH: Chandigarh; DL: Delhi; DNHDD: Dadra & Nagar Haveli, and Daman & Diu; GA:Goa; GJ: Gujarat; HP: Himachal Pradesh; HR: Haryana; JH: Jharkhand; JK: Jammu & Kashmir; KA: Karnataka; KL: Kerala; LDKH: Ladakh; LDP: Lakshadweep; MG: Meghalaya; MH: Maharashtra; MN: Manipur; MP: Madhya Pradesh; MZ: Mizoram; NG: Nagaland; OD: Odisha; PB: Punjab; PU: Puducherry; RJ: Rajasthan; SK: Sikkim; TE: Telangana; TN: Tamil Nadu; TR: Tripura; UK: Uttarakhand; UP: Uttar Pradesh; WB: West Bengal

Percentage of older adults with low level of LS across the States and union territories of India, 2017–18

Note: State and union territories: Same as in Fig. 2

Figure 4 shows the percentage distribution of older adults based on their levels of LS in different living arrangements. Compared to the other living arrangements, older adults who were living alone reported low level of LS at a more significant rate (41.8%), and older adults who were living with their spouse and children reported high level of LS at a larger rate (45.5%). Overall, a remarkably higher proportion of older adults who do not live with their spouse or children have reported low level of LS.

Percentage distribution of older adults by their levels of LS across the living arrangements, India, 2017–18

Results from the MNL regression model of LS are presented in Table 2 . The results are presented in terms of relative risk ratio (RRR) and its 95% confidence interval (CI). A RRR value of greater than 1 indicates that older adults from that category are more likely to report higher level of LS when compared with the elderly in the respective reference category. For instance, we found elderly co-residing ‘with both spouse and children’ were significantly more likely to report a higher level of LS (RRR for Medium = 2.46 & High = 3.15, p -value < 0.001), followed by those who are living ‘with their spouse only’ (RRR for Medium = 2.34 & High = 2.76, p -value < 0.001). Though compared to the older adults who were living alone, the RRR of reporting medium and high levels of LS is greater for elderly living ‘with their children only’, it is remarkably lower than the RRR estimated for ‘living with Spouse’ and ‘living with spouse and children’ living arrangements. The result also revealed that older adults who are living alone are significantly more likely to report lower levels of LS compared to the elderly in other living arrangements.

After applying the backward elimination method to eliminate the variables that did not show any statistically significant association, the final model (model-4) retained individual characteristics, health indicators, and household characteristics that are found to be significant determinants of LS, which are presented in Table 2 . The RRR revealed that female older adults are statistically significantly more likely to report a higher level of LS (RRR for Medium = 1.12 & High = 1.18, p -value < 0.001). Older adults who were older in age and who had higher schooling years were more likely to report higher levels of LS compared to their younger and lower schooling years counterparts. It is quite astonishing to note that widowed older adults are more likely to report medium or high levels of LS compared to married older adults (RRR for Medium = 1.39 & High = 1.58, p -value < 0.001). Working older adults are 10% less likely to report high level of LS (RRR for High = 0.9, p -value < 0.001).

Similarly, in health indicators, self-reported poor health (RRR for Medium = 0.73 & High = 0.64, p -value < 0.001), limitation in more than two ADLs (RRR for High = 0.79, p -value < 0.001), and presence of depressive symptoms (RRR for Medium = 0.63 & High = 0.34, p -value < 0.001) were significantly associated with reporting a lower level of LS. It is quite astonishing to note that older adults diagnosed with 3 or more chronic conditions were significantly more likely to report high level of LS (RRR for High = 1.41, p -value < 0.001), but less likely to report medium level of LS (RRR for High = 0.85, p -value < 0.001).

In HH characteristics, elderly from ST HH (RRR for Medium = 0.73 & High = 0.66, p -value < 0.001), SC HH (RRR for Medium = 0.84 & High = 0.76, p -value < 0.001), economically poor HH (RRR for Medium = 0.91 & High = 0.77, p -value < 0.05), and from southern region (RRR for Medium = 0.56 & High = 0.78, p -value < 0.001), were less likely to report medium or high level of LS. Elderly living in HH practising Christianity (RRR for High = 1.31, p -value < 0.01) and living in Western, Central and North-eastern regions were more likely to report high level of LS.

This study examined the association between living arrangements and the level of LS in Indian older adults aged 60 + , adjusting for the selected health indicators, individual characteristics, and HH characteristics. The findings suggest that the level of LS of the elderly is statistically significantly associated with their living arrangements. “Living alone” is significantly associated with reporting low level of LS, followed by “living with others only”. In agreement with Kooshiar et al. [ 20 ], this study indicates that living in the same arrangement with a spouse is associated with reporting a higher level of satisfaction. Possible explanations for these findings can be as follows: loneliness can adversely affect the LS of an individual [ 20 , 46 ]; and having spouse under the same roof provides a significant support system for the older adult —males can look after the finances and females can take care of health issues— [ 21 ]. Further, the study also found that having both the spouse and children as co-residents increases the likelihood of reporting a higher level of LS. This may be attributed to the presence of both spouse and children giving a feeling of having a complete family; and adult children usually shoulder their parents’ physical, mental and financial burden.

Concurrent with Singh & Singh [ 26 ], this study found no significant differences in the mean score of LS by the age and gender of the older adults. However, our study suggests female older adults were more likely to report higher levels of LS than males, and this finding is supported by Ng et al. [ 23 ]. Like the finding of Ng et al. [ 23 ], this study found an increase in the years of schooling is associated with an increase in mean LS score and a higher likelihood of reporting a higher level of LS, indicating older adults with “no” or “very few years” of schooling were more likely to report low level of LS. The possible explanation for this is that, post-retirement, an illiterate person, who was an unskilled worker, is less likely to receive a pension amount that can meet the exorbitant healthcare expenditures of an ill health older adults and the daily living expenditure of older adults in good health. This indicates financial insecurity may be higher among the illiterate and less educated elderly, due to which they may also be dissatisfied with the fact that they were once taking full responsibility for the upkeep of the house, but at present, instead of contributing to household expenses, they depend on the younger members. This study suggested low mean LS scores among the widowed and divorced/separated/deserted older adults. This may be because a negative event like the death of a spouse [ 47 ] and marital disruption causes a sharp decline in LS among older adults. Moreover, discrimination and negative labelling of people with a disrupted marriage are quite prevalent in Indian society, making them more vulnerable in their older ages, and to a significant extent, this affects their level of LS. Contrary to a previous study in India [ 29 ], our study found widow/widower are very more likely to report a higher level of LS compared to their married counterparts. This may be explained partially by the fact that widow shares a significantly higher proportion against the widowers in older adults with widowhood status; in India, widows may maintain economic independence by carrying on her spouse’s business and be accorded certain rights, such as entering guilds; and they may experience peace, and increase in their social participation and social support through attending religious and spiritual events. However, more robust research is required to determine the cause of such surprising findings.

The rate of reporting low level of LS is higher in older adults with more than two limitations in ADL or IADL, depressive symptoms and poor health. In line with previous studies [ 22 , 25 ], the MNL regression result showed that having limitations in ADL was significantly associated with reporting low level of LS, but no association between IADL and the level of LS was established. In contrast to our study, Hsu & Jones [ 48 ] found no significant association between physical function difficulties (ADL and IADL) and LS. Unlike the previous study [ 22 ], our study indicates that having more than three chronic diseases is associated with a higher likelihood of reporting a high level of LS. To determine the reason for such unexpected finding, more robust research is required. Concurrent with Ng et al. [ 23 ] and Lombardo et al. [ 18 ], this study indicates that reporting good health is associated with reporting high level of LS, and reporting poor health is significantly linked to low level of LS. Poor physical health was hardly related to lower life satisfaction, whereas poor mental health was strongly related to lower life satisfaction.

In line with Muhammad et al. [ 34 ], this study found that living in a rural setting, belonging to SC and ST communities, and living in poor households is significantly linked to low level of LS in older adults. This may be ascribed to the likelihood of living alone is higher among these older adults compared to their counterparts [ 36 ]. It is well documented that illiteracy is higher among the rural and SC/ST population, and a higher proportion of SC/ST lives in rural areas; not to mention living in rural areas or from a poor household abstains older adults from availing better healthcare provisions and other social welfare services meant for the elderly. Several previous studies have also suggested that older adults from economically poorer households are significantly more likely to report low level of LS as compared to their economically richer counterparts [ 18 , 22 , 23 , 48 ].

This study has the following limitations. First, it fails to draw any causal relationship between the LS and living arrangements due to cross-sectional nature of the dataset; hence, a longitudinal research design would be more precise to measure phenomena that changed over time. Second, while this study analyzed the association between living arrangement and LS, it did not investigate the factors that can influence living arrangements. Third, level of LS is assumed as the overall well-being of the elderly in this study; however, several factors, such as the mood or the surrounding environment when the interview was taken, in some cases influence the responses to items used for measuring the level of LS [ 49 ]. Further, LS is multidimensional; the perceived level of LS may vary from person to person based on individual expectations and requirements; moreover, recent events can also significantly impact evaluating life as a whole.

The findings of this study showed that living with a spouse and children was the most common type of living arrangement for older adults in India as in other Asian countries. In India, co-residing with a spouse and living specifically along with a child was associated with a higher level of LS, and living alone was associated with a lower level of LS. The study also revealed that living arrangements could be assumed to be a crucial predictor of the LS of older adults in India. Significant socio-demographic disparity persists in the form of older adults’ satisfaction with their lives. Older adults with few years of schooling, with a disrupted marriage, from rural areas, belonging to poor households, SC and ST communities, and southern regions have reported low satisfaction with their lives.

The study identified various older adult groups with a higher likelihood of having a low level of LS. Thus, the existing welfare policies for older adults need to be redesigned to address the issues that hinder enhancing the satisfaction levels among these older adults. Early study indicates that the economic independence of the older population is a crucial indicator of their well-being, but nearly three-fourths of the older adults are economically dependent [ 1 ]; the Government needs to focus on financial incentives to ensure economic security. The number of older adults living alone is also increasing significantly, and they are more likely to have a low level of LS. Hence, there is a need to promote co-residence through policies, special care and provision to provide an enabling environment and to track the overall well-being of older adults living alone or at risk of becoming alone in the near future, such as older couples staying alone.

In a country where the population aged 60 years and over is growing faster than all younger age groups, it is important to continue exploring the scope of the problem by doing more robust research to address the issue of low LS and factors affecting older adults’ LS level. The study did not investigate any causal relationship, but this concern can be investigated with longitudinal studies, which is more appropriate for testing causality. Segregating “living with spouse”, “living with children”, and “living with spouse and children” that consider dependency of children (living with dependent children or independent children) and the health status of the spouse can give a more clear picture of the positive association of these two arrangements with the level of LS. Further research is warranted to see the factors that elevate the association between different living arrangements and the level of LS. This may help to enhance the existing welfare strategies to promote life satisfaction in older adults across all living arrangements.

Availability of data and materials

The study uses secondary data which is available in the public repository of International Institute for Population Sciences, Mumbai, which can be accessed by submitting the Data Request Form for Longitudinal Ageing Study in India (LASI), wave – I, 2017–18 available at: https://www.iipsindia.ac.in/content/LASI-data

Abbreviations

• Life satisfaction

Longitudinal Ageing Study in India

Satisfaction with Life Scale

Activities of Daily Living

Instrumental Activities of Daily Living

Scheduled Caste

Scheduled Tribe

Other Backward Class

Multinomial logistic

Proportional Odds

Relative Risk Ratio

Confidence Interval

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Acknowledgements

The authors are grateful to the Department of Humanities and Social Sciences, National Institute of Technology (NIT), Rourkela, for their support and encouragement, which helped improve this research paper. We are grateful to the editor and the two anonymous reviewers for their helpful comments and suggestions in improving the quality of this manuscript.

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Kandapan, B., Pradhan, J. & Pradhan, I. Living arrangement of Indian elderly: a predominant predictor of their level of life satisfaction. BMC Geriatr 23 , 88 (2023). https://doi.org/10.1186/s12877-023-03791-8

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• Older Adults

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Factors Associated With Social Isolation Among the Older People in India

Affiliations.

• 1 1 Department of Statistics, Prasanna School of Public Health (PSPH), Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India.
• 2 2 Department of Community Medicine, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India.
• 3 3 Department of Biostatistics, National Institute of Mental Health and Neuro Sciences, Dr M. V. Govindasamy Centre, Bengaluru, Karnataka, India.
• 4 4 Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Bhubaneshwar, Odisha, India.
• PMID: 30149767
• DOI: 10.1177/0891988718796338

Objective: To explore the factors associated with social isolation among older people using the data from Building Knowledge Base on Population Ageing in India (BKPAI) survey.

Methods: Multiple logistic regression and classification and regression tree (CART) analysis were used to identify the factors associated with social isolation using data from BKPAI survey. An individual was regarded as socially isolated if the response was "never" to all 4 activities in the last 12 months: (1) attending public meeting, (2) attending any group/club/organizational meeting, (3) attending any religious program, and (4) visiting friends or relatives.

Results: Among 9836 older people, 19.7% were observed to be socially isolated. From multiple logistic regression, age (odds ratio [OR] = 1.85 for age 80 to 89 years and OR = 2.67 for age ≥90), religion (OR = 0.54 for Christians compared to Hindus), duration of stay in current home (OR = 0.64 for 6-10 years compared to >10 years of stay), number of activities of daily living (ADLs) for which the assistance was needed (OR = 2.09 for 1 or 2, OR = 3.14 for 3 or 4, and OR = 12.05 for 5 or 6), and Alzheimer's disease (OR = 1.65) were identified as factors associated with social isolation. Number of ADL for which the assistance was needed and self-reported health status were the factors identified through CART analysis.

Discussion: Requiring help in performing ADL, advancing age, and Alzheimer's disease were the likely factors for socially isolation among elderly patients in this surveyed population.

Keywords: BKPAI; CART; India; older people; social isolation.

• Activities of Daily Living / psychology*
• Aged, 80 and over
• Social Isolation / psychology*
• Surveys and Questionnaires

ABUSE ON ELDERLY PERSONS IN THE COUNTRY

As per the Report of Longitudinal Ageing Study in India (LASI) (Wave-I) from Ministry of Health and Family Welfare around 5.2% of senior citizens surveyed reported ill-treatment/ abuse.

Details of crimes against senior citizens reported by National Crime Records Bureau for the years 2019, 2020 and 2021 are at Annexure-I . The Government of India is already implementing various initiatives to support and rehabilitate the elderly persons of the country, as given at Annexure-II .

Crime Head-wise Cases Registered (CR), Cases Chargesheeted (CCS), Cases Convicted (CON), Persons Arrested (PAR), Persons Chargesheeted (PCS) and Persons Convicted (PCV) under Crime against Senior Citizens during 2019-2021

Culpable Homicide not amounting to Murder

Attempt to Commit Murder

Attempt to commit Culpable Homicide

Simple Hurt

Grievous Hurt

Assault on Women with Intent to Outrage her Modesty

Kidnapping and Abduction

Criminal Trespass

Forgery, Cheating & Fraud

Criminal Intimidation

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New Delhi, May 9 (PTI) A new study that surveyed elderly people across India has found that nearly half of its respondents in urban areas do not visit doctors regularly due to financial constraints and logistical challenges and the corresponding figure for rural areas is over 62 per cent.

The study conducted by NGO Agewell had a sample size of 10,000. The organisation recently shared examples of some of the responses it received in the course of the survey.

It said Prabhkar Sharma, a 78-year-old resident of Agra who has been grappling with arthritis for a decade, found navigating hospitals for routine check-ups painful and difficult which often forces him to postpone essential medical visits.

“If there were door-step or mobile health check-up services… it would be very helpful for people of my age group,” he told the NGO.

In Ludhiana, 72-year-old Rajesh Kumar faces a different predicament, according to the study.

Dependent solely on his retirement pension, Kumar finds the exorbitant cost of healthcare services prohibitive, it added.

“If I had some mediclaim policy… perhaps I could afford better medical services,” the study quoted him as saying.

The study sought to shed light on the broader landscape of issues facing the elderly in India.

The NGO said that 48.6 per cent of elderly respondents of the survey in urban areas did not visit doctors regularly due to financial constraints and logistical challenges and the corresponding figure for rural areas was 62.4 per cent.

In urban areas, 36.1 per cent of elderly respondents reportedly claimed that they visit hospitals and doctors as and when required, the study added.

It also claimed that family dynamics played a pivotal role in this aspect as 24 per cent of the respondents of the survey lived alone.

This isolation exacerbates health concerns and underscores the need for community-based initiatives, the NGO said.

Among the elderly, health-related challenges emerge as the foremost hurdle hindering elderly participation in public and social life, it said, adding that marginalisation and financial constraints further compound these issues.

A total of 10,000 respondents were studied by 510 volunteers across 28 states and Union territories of India in the survey conducted in April 2024, the NGO said.

Among the respondents, 4,741 were from rural areas and 5,259 from urban areas, it added.

During the survey, the NGO said, more than 38.5 per cent of elderly respondents claimed that their current health status was poor or very poor.

Among the respondents, 23.4 per cent said that their current health condition could be termed as average, it added.

For approximately 54.6 per cent of the elderly respondents, their overall financial status was poor or very poor, the study said, adding that 23.3 per cent of the respondents claimed that their financial status could be termed as above-average. PTI UZM IJT

This report is auto-generated from PTI news service. ThePrint holds no responsibility for its content.

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Regulation of Long-Term Care Homes for Older Adults in India

Vijaykumar harbishettar.

1 Padmashree Medicare, Vijayanagar, Bangalore, Karnataka, India.

Mahesh Gowda

2 Spandana Healthcare, Nandini Layout, Bangalore, Karnataka, India.

Saraswati Tenagi

3 Dept. of Psychiatry, Belgaum Institute of Medical Sciences, Belagavi, Karnataka, India.

Mina Chandra

4 Dept. of Psychiatry, Centre of Excellence in Mental Health, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India.

The rising aging population in India has led to an increased caregiving burden, and accordingly, the number of residential care facilities is also burgeoning. There is no regulatory framework or registration authority specifically for residential care homes in India. The article’s objective is to understand the need for a regulatory framework in India in the context of historic and global experiences in the UK, USA, and Europe. Although there is a lack of literature comparing the community home-based care and residential care, one study reported a preference for home-based care in the South Asian context. Elder abuse and deprivation of rights of seniors are common, and there is a need to bring in more safeguards to prevent these from the perspective of the older adults, their family members, the care providers, and the state. While the main priority of meeting care needs in long-term care is a challenge given the lack of trained care staff, the quality control mechanisms also need to evolve. A review of adverse incidents, complaints, and litigations also highlights the need for regulation to improve the standards and quality of care. The article explores lacunae of residential care facilities in the Indian context and provides recommendatory parameters for evaluating the quality of care provided. Relevant sections of the statutory new Mental Healthcare Act of 2017 in India could provide a regulatory framework ensuring rights and liberties of the residents are upheld. The authors propose a state-run model for elderly care homes and commencement of framing regulations appropriate to the Indian context.

Introduction

Demographic transition because of increased life expectancy 1 has led to the rise of aging population resulting in huge demand for care. At the same time, there has been a decline in traditional familial, social support because of a reduction in fertility rates, 1 small nuclear families, increased urbanization, a decline in traditional social networks, and migration of children to other cities and countries. 2 – 5 This has contributed to the burgeoning of residential care homes for older adults, globally and in India. 6

In 1980, there was a national average of 54 beds per 1,000 elderly in the USA, while older people aged 65 and over were 25.5 million. 7 Around 13% of people above the age of 85 years needed residential care in 2010. 8 A Dutch economic survey between 2007 and 2009 found residential care to be expensive than home-based care. 9 Resource limitations deter governments from operating elderly care facilities to meet the increasing demand, leaving the management of elderly care facilities to charities, nongovernmental organizations (NGOs), or the for-profit private sector.

The need to regulate the management of elderly care homes was recognized in Western countries. In 1984, the Department of Health and Social Security in England introduced the Registered Homes Act, Registered Care Home Regulations, Registered Homes Tribunal Rules, and a Code of Practice for residential care home life. 10 With the majority of homes in the UK being run by the private sector, the government had to step in and develop legislations, monitor through regulations, and ascertain the care needs and outcome of long-term care in these homes. 11

Unstructured, unaccounted growth of the number of residential care homes for older adults in India necessitates that similar regulations and regulatory framework would be required in India, 5 and this article aims to study the relevant regulations and legislation of older adults’ long-term residential care homes and explores the lacunae in the Indian system to make appropriate recommendations.

History/Evolution of Care Homes in Europe and the USA

The earliest available information based on record-keeping that began in the 1830s in the UK mentions English workhouses on average had 300-bed spaces. In addition to the aged and the sick, the workhouses had orphaned children, the unemployed, and other people with disabilities. After 1851, the number of people aged above 65 years gradually increased for the next 100 years, and by 1945, post-World War II, the workhouses transformed into geriatric homes. There was also a rise of older people in the so-called lunatic asylums. The older people were considered as inmates segregated from the community and under the care of institutional managers in a master–inmate relationship. Studies suggested that people generally were reluctant to use care homes because of the fear of loss of independence. Thus, the experience of such living showed that the issues of independence, privacy, dignity, and choices became important for the residents, making some older people reluctant to move to these homes. 12 Furthermore, the financial constraints led to identifying a so-called need or incapability for such admissions. Later, legislation divided older people who were ill to care under the health authorities and those needed care otherwise to be under local authorities or social services. 10 , 12

Registered Homes Act of 1984 and subsequent legislations led to defining quality of care and standards for care home. 10 , 12 Periodic inspections began after quasi-inspection bodies were established under each local authority. Over some time, these homes started to run as small businesses. 12 Entry criteria to care homes included conditional “needs” assessment and financial assessment by a social worker. 12 Gradually, the senior care has become an established business in the Western society.

History of Residential Homes for Older Adults in India

The first documented residential care facility for older adults in modern India dates back to 1814. It was founded in erstwhile Madras (current Chennai) where a friend-in-need society comprising British merchants and bankers started to house Anglo-Indians and domiciled Europeans in difficulties. 13 This was followed nearly 70 years later in 1882 when home for the aged was established in Kolkata by “Little Sisters of the Poor” as a focussed initiative from a Maltese man Asphar. 14 These two homes for the aged and needy provided shelter, clothing, and medical care.

The initial focus was on providing basic needs such as shelter and clothing for those capable of taking care of their personal or nursing needs but could not live independently. Several religious organizations also opened ashrams for the elderly, which provided basic care in a spiritual environment. It is only later that nursing care, nutrition, physical and mental health care were incorporated into the care facilities for the elderly. Currently, residential care homes for the elderly are a non-formal sector in India, and the exact official numbers are not available. Nevertheless, in 2009, HelpAge India estimated 1,176 senior living facilities, with Kerala having the highest (182), followed by West Bengal (164), and Tamil Nadu (151). 15 Tata Trusts and the United Nations Population Fund and NGO Samarth, surveyed on a sample size of 480 old age homes and 60+ senior living developments in 84 cities in 2018, concluded that these numbers were low when the actual demand is high. 16

Defining Residential Care Homes

Residential care homes involve caring for elderly persons who cannot manage themselves partially or wholly, supported by unregistered or unqualified support staff who have gained some experience. Care needs mainly involve personal, supportive care, as prompted or requested by the residents themselves. The term Nursing home is generally used when there is a nursing care need for the person with a medical ailment, usually provided by registered nurses. Some care homes are specialized in offering long-term rehabilitation care with the help of a multidisciplinary team involving specialists in medicine, psychiatry, neurology, speech therapists, dietician, physiotherapists, nurses, social workers, pharmacists, etc. for older adults with complex physical, cognitive, or behavioral problems. These are a step down from hospitals providing acute care. The need for such facilities is also increasing because of the high costs of hospitalization. Retirement homes are homes built by private builders in India as a community living where the neighborhood comprises older adults who buy or rent the property. Some of the risks of independent living are managed or aided by the retirement home society. These homes allow the elderly to live autonomously with privacy, exactly similar to living in their own house.

Home-Based Care Versus Residential Home Care for Elderly

A systematic review of studies from high-income settings concluded that there is insufficient quality published research to effectively compare institutional care with community-based care for functionally dependent older people. Institutional care may be associated with reduced risk of hospitalization, better activities of daily living, while community-based care may be associated with improved quality of life and physical function. The impact of both the care models on mortality, healthcare utilization, economic correlations, and caregiver burden needs further research. 17 A meta-synthesis of ten studies from USA, Europe, and Asia found that culture impacts the decision making for a residential care facility, adjustment process, and eventual adaptation there. 18

In the South Asian cultural context, home is the preferred residential setting. 19 The residential option is considered when there is no family member (or male offspring) or when the complex physical and mental health needs overwhelm the caregivers (respite care or long-term care) or when neglect or abuse by familial caregivers exists. 20 Hence, the conditions of elderly and their outcomes in-home care versus residential care home are not comparable in India.

A literature review from India reported that the experiences and perspectives of older adults living in residential facilities are heterogeneous. Several older adults residing in residential facilities view them favorably, citing security, medical attention, and a sense of independence. Still, most prefer their own homes and families despite having experienced neglect or abuse by them. The common stressors associated with living in residential facilities include difficulty in adjusting to the new environment and rigid time schedules, declining functional ability, separation from their family and community, social alienation, sense of powerlessness, and repeated witnessing of death and illness in such settings. 21

Health Concerns in Residential Care Homes for Older Adults and Their Implications

Older age is associated with multiple physical and psychiatric comorbidities. Assessment and management of comorbidities are major challenges for residential care providers. 22 The needs of the residents are complex and multisectoral, and one has to look at addressing various issues than one particular specific health need. 23 There is a lack of data on rates of comorbidities in Indian residential care facilities for older adults, but the trends are likely to be similar to residential care facilities in other countries.

To understand the care needs, the UK national census of care home residents survey (n = 16043 residents in 244 care homes) showed that medical morbidity with an associated disability was the cause for admission in over 90% of cases. Over 50% of residents had dementia, stroke, or another neurodegenerative disease. Around 76% of residents required assistance with their mobility, 71% were incontinent. Twenty seven percent had multiple issues of immobility, confusion, or incontinence. Only 40% of those in residential care were ambulant without assistance. It was concluded that care needs in long-term residential care homes were determined by progressive and chronic illnesses. 24 Similarly, up to two-thirds of residents in care homes in USA have cognitive impairment, with many diagnosed with dementia. 25

The care need issues imply residential care facilities for older adults need-specific adaptations for toilet facilities to ensure hygiene, nutrition planning taking into account specific nutritional needs of the elderly as well as individual comorbidities requiring customized diets, 26 physiotherapy and exercise to maintain range of motion, balance, endurance, strength, and flexibility 27 environmental adaptations for easy mobility and prevent falls, specific measures to prevent pressure ulcers in nonambulatory residents, 28 periodic medical consultation as well as immunization.

In addition, the elderly in old age homes have high rates of psychiatric morbidity. Indian studies have reported high rates of depression, anxiety, and psychotic disorder in residents of old age homes in addition to dementia. 29 – 31

Apart from pharmacotherapy, addressing the mental health care needs of the elderly residents may range from providing cognitive stimulation, pro-social environments, ensuring sleep hygiene to managing agitation and frank aggression. Effective nonpharmacological management can reduce the need of dosage of pharmacotherapy. 32 This requires specialized training. There are only a few centers like the National Institute of Social Defence under the Ministry of Social Justice and Empowerment, which runs courses in geriatric care. However, the number of human resources trained in this and similar settings is minuscule as compared to the requirements of residential care facilities. In addition, the requirement of trained manpower in multiple domains can escalate the cost of services. At the same time, there is no framework for periodic evaluation, inspections, certification, and recertification of such service providers.

Complaints and Litigations

Elderly care facilities in India do not have any formal mechanisms for feedback, appraisal, complaints, or grievance redressal. When the care becomes business, or there is no regulatory framework, there is always a scope for disagreements and complaints against the care-providers by the consumers, with scope for formal lawsuits. Some of the outcomes of such litigation may be beneficial for the residents. For example, malpractice litigation threats have led to an increase in registered nurse to staffing ratios. These may reduce issues like pressure sores among residents and improve quality. 33 High-risk malpractice lawsuits have also led to the change of managers of nursing homes. 33

Since there is no regulatory body or licensing authority, it becomes difficult for the residents and their families, as they are unsure of where to complain if there are disagreements over the care and the responses from care home management. Even for the care providers, it becomes difficult to prove their quality of care when there are no benchmark standards. In the absence of defined regulatory frameworks, complaints against residential care facilities or individual care providers in such facilities have been made to elder’s helpline or Human Rights Commission or the Local Health Authority. 34

Choking, wandering and related risk, falls and related injuries, physical or chemical restraints, malnutrition, pressure sores, medication errors are a common source of litigation against the nursing homes. 35 A study of claims against 1465 nursing homes in USA demonstrated that best-performing nursing homes providing quality care were sued less than low-performing ones. 36 Repeated ongoing complaints or litigations may lead to the closure of poorly performing ones. Thus, there is an incentive to improve business by improving the quality of care and having good working relationships with the residents.

Need for Regulation

Aging-related issues coupled with living in an institutional environment may impact individuals’ autonomy, especially if they have never experienced living in institutionalized spaces earlier. This issue was debated, and consensus that it can be a “relational autonomy” related to the care home policies. 37 , 38 The boundaries of assertive care versus boundary violation to depriving someone of their rights can lead to conflict and stress amongst residents and the staff in the absence of policies.

There is also a concern about complex biopsychosocial needs of the elderly not being met in some of the residential care facilities through oversight, neglect, or deliberate measures. Various stakeholders to address the needs are the care providers, family members and friends of residents, advocacy groups, and State Health Authorities and Departments of Social Justice. Independent regulators have been proposed to regulate older adults’ residential care facilities. 39 Furthermore, regulation requires laws, rules, and minimum standards for such facilities. Unfortunately, such a framework does not exist in India as yet.

In contrast, the Department of Health in the UK established National Care Standards Commission in UK 2002, which has powers to regulate and inspect under the Care Home Regulations (2001) and National Minimum Standards (2001). Standard setting, self-regulation as well government regulation are important. 40 Similar provisions are found in other high-income countries.

Case studies from high-income settings have also highlighted the challenges of over-regulation. The Ontario Nursing Homes Study concluded though the regulations and accountability scrutinizing objective was predominantly to improve quality of care, it, unfortunately, ended up increasing workload and paperwork. This meant reduced time to provide direct physical care and missing out on scrutinizing top management such as funding and staffing levels. 41 This indicates that any form of licensing or regulations will come with minimum norms to provide care that can only be scrutinized by examining the documentation in the resident records. Audits are likely to pick up deficiencies and therefore will further increase the workload. More human resources could be directed towards record keeping, and these issues of regulations not serving the real purpose need to be considered while preparing regulatory policies. Another study report from Quebec province, after regulation, found that some smaller care homes were closed; however, the quality of care provided by the private care homes saw improvement. 42

A survey on the status of old age homes in India was conducted by Tata Trusts and assessed 480+ old age homes and 60+ senior living developments in 84 cities, towns, and districts. The report concluded a wide gap between expectations and delivery of services at most elder care facilities, with no mechanism for evaluating the quality and appropriateness of the services leaving the elderly inmates vulnerable and providing no incentive for improvement of services to the facility owners and managers. 16

Quality of Care

Quality of care involves adequate and proper staffing, regular assessments, minimum standards, care planning and provision, appropriate management of behavior and psychological symptoms of dementia (BPSD), physical environment characteristics, innovations, and quality of care provided to residents. 25

A review of adverse events in skilled nursing care facilities in the USA who were medicare beneficiaries by the Office of Inspector General found 22% of the residents had adverse incidents. Half of them were preventable. 43 This was not different from previous studies showing poor safety culture and indicated a need for regular inspection.

In England, residential care for adults including for older adults is provided by public, not-for-profit, and for-profit organisations. A study of 15,000 homes showed that quality of care was significantly lower in the private for-profit organization that managed 74% of the total homes, with the highest quality in the not-for-profit charity organizations that managed 18%. Public sector managed only 8% of homes. The study concluded that regulation would help improve the quality of care. 44

There is attention being paid now for improving the residential care facilities for the elderly and those with dementia. The focus has been to ensure a safe environment, designs that will assist way-finding, orientation, navigation, and access to nature and the outdoors although there is an ongoing need to sensitize policy makers and construction firms on age-friendly design practices. 45

The only comparable initiative is by the Kerala Government Department of Social Justice, which has prepared a manual for old age homes. It describes in detail the procedure for designing and maintenance of old age home, admission procedures, mechanisms for the protection of residents, provision of basic services (food, health care), safety and security, caregivers, rules, procedures, documentation, and rights framework of inmates and family members. 46 No other Indian state has developed any such framework as yet.

Relevant Legislative Framework in India

The National Programme for the Health Care for the Elderly (NPHCE), National Policy on Older Persons (NPOP) in 1999, and Section 20 of the Maintenance and Welfare of Parents and Senior Citizens Act, 2007, all deal with provisions for health and social care of older adults. 47 NPHCE aims to provide accessible, affordable, and high-quality long-term comprehensive care services to the aging population and build a framework to create an environment for older adults to function well. However, both NPHCE and NPOP have not discussed the need for residential care facilities for older people and their regulations. According to the provisions of the Maintenance and Welfare of Parents and Senior Citizens Act of 2007, the responsbility of health and social welfare lies with the legal heirs. 48 The regional state government, where the responsibility of health lies as per the Indian Federal Structure, manages some of its citizens’ health and social needs, including senior citizens. The states may provide staff salaries or funding for training caregivers. Also, there are provisions in some of the regional governments to offer financial assistance to NGOs to run old age homes to take care of the elderly persons providing all the basic amenities and care protection to life.

A systematic review indicated 48% of long-term care residents had dementia, within which 78% had BPSD and 10% had major depression. 49 Depression was found in one third and dementia in two thirds in care home survey in England. 50 In a study of the prevalence of health conditions of elderly in residential homes, 93% had a mental or behavioral disorder, including dementia 58% and depression 54%. 51 In a study of old age homes in Lucknow, it was found that depression was present in 37.7%, anxiety in 13.3%, and dementia in 11.1%. 29 Dementia, with its complications that includes BPSD, depression, anxiety, is common in care homes that need access to mental health care. Therefore, such residential care facilities fall within the purview of the Mental Healthcare Act (MHCA) 2017. According to Section 66 of MHCA 2017, any residential care home caring for person/s with mental illness comes under the definition of Mental Health Establishment (MHE). So, it must be registered with the State Mental Health Authority (SMHA). The SMHA needs to make regulations for the operation of MHE, including the minimum standards of facilities and services, the minimum qualifications for the staff personnel, and maintenance of a registry. There is no data in the public domain whether any residential facility for older adults with or without psychiatric morbidity has been registered under SMHA in any state. Admissions to care homes when they have locked facility when the older adult is not willing or not having competence to decide will have to be under the MHCA 2017. 52

National Accreditation Board for Hospitals and Healthcare Providers (NABH) Accreditation, a constituent of the Board of Quality Council of India, manages quality control and certifies hospitals in India. There is nothing specific for the long stay care homes, specific for the elderly 53 in NABH. The Union Ministry of Housing and Urban Affairs in 2019 developed guidelines for developing regulations for retirement homes 54 but there is no information in the public domain regarding the compliance of these guidelines by retirement homes.

Proposed Areas of Concern for Regulatory Framework (Also See Table 1 )

Authors’ Recommendations on Areas of Regulation

The prevalence of elder abuse is high in India and was found to be around 50%, which during the covid lockdown period went up as high as 71%, and the general factors found were increase in age and lack of formal education. 55 , 56 The elderly population is vulnerable, particularly when dependent and staying in institutional settings. WHO data on institutional elder abuse suggests that 64% of staff members perpetrated it in institutional settings. These acts include physically restraining inappropriately, depriving them of dignity, such as not changing soiled clothes or washing them, withholding or overmedicating them, and inadequate care to cause pressure sores.

The vulnerability of dependent elderly residents can increase the risk of abuse and neglect because of their physical and cognitive functioning limitations in addition to their fear and anxiety. 57 Examples include aggressiveness, yelling in anger, making threats, punching, slapping, kicking, hitting, speaking in a harsh tone or words, or humiliating. Neglect involves not providing food, water, assisting with toilet needs, or medicines. A report from Atlanta ombudsmen long-term residents program in 2000 found 44% of residents reported experiencing abuse. 58

The challenges faced by the staff of the care homes must be addressed by regulation, by ensuring the training needs are met. The majority of the staff members and almost half of them reported violent incidents towards them from residents or their families. They expressed that poor working conditions compelled them to offer inadequate quality of care for the residents. Many thought such incidents of violence happened during their duty as careworkers. 59 Staff training should include techniques and strategies to prevent and manage any form of violence from residents and their families.

When it was found out that the proportion of vulnerable patients or residents could not come under the purview of the Mental Capacity Act of 2005 of England and Wales, which could have impacted their human rights, another legislation called Deprivation of Liberty Safeguards was introduced. 60 This was to ensure the vulnerable elderly persons were not deprived of their liberty to safeguard rights under Article 5 of Human Rights Act and that most of the elderly care homes are locked facilities. No such provision exists in India.

Regulations can be state-mandated by an independent public body, or there could be forces of market competition or self-regulation with accreditation by service providers associations. 61 A Swedish study of the economics of care homes between 1990 and 2009 showed privatization with the associated increase in market competition significantly improved quality as measured by mortality rates. 62

The Karnataka Private Medical Establishment Act rules of the state of Karnataka from 2009 (amended 2018) includes details of the process of registration of private medical establishments, renewal, different types of hospitals, minimum standards for accommodation, equipment, facilities, staffing requirements and their qualification, and maintenance of records. The space requirement for the inpatients or examination room has also been mentioned. 63 However, the act does not include old age homes/elderly care facilities.

The study by Tata Trusts published in 2018 explored the need for minimum compulsory standards for infrastructure and management to ensure attention given to physical needs, safety and security, dignity and respect for elderly persons. Lack of regulation was evident, and they recommended compulsory registration, annual filings, and periodic inspections. They highlighted few broader themes in terms of home healthcare, personal supportive care, social activities, complaints and safeguards, environment, staffing, and management. In addition, they also highlighted the need for a third-party regulator and ombudsmen for safeguards, certification for staff, and establishing model care homes. 16

System in Place for Prevention of Elder Abuse

In December 2019, Indian Central Government proposed a bill to amend the Maintenance and Welfare of Parents and Senior Citizen Act, 2007, which proposes registration of senior citizens care homes/home care service agencies along with maintenance of minimum standards for senior citizen care homes. However, implementing the regulatory framework will be with nodal police officers for senior citizens in every police station and district-level special police unit. This framework is not satisfactory. 64

The authors propose that regulations for residential care facilities for older adults must define minimum standards for living, nutritional care, medical care, palliative, and end-of-life care. There should be ongoing staff training in elderly care, ethics and human rights, and documentation of medical management, including any adverse drug events/complications with an evaluation of care to help improve services. 65

There should be a system to report incidents. All staff members must be trained in filling the incident reporting form, which is to be regularly reviewed by the named senior clinician (see Table 2 ). Prevention strategies include public and professional awareness, training, screening before employing the staff of residential care home, and caregiver training on dementia. Mandatory reporting of abuse to a central independent agency is to be considered. Perpetrators need to be identified, and in the first instance, appropriate education, training program, and work should be supervized until confidence is built. If the abuse is severe, this may need to be informed to social services or senior citizen helpline for appropriate action by the judiciary. The homes may not record or report abuse may try to underplay the issue, for wary of receiving tag of a poor quality care home, despite the obligation to report. The managers of the care home must ensure there are enough safeguards. There could be regular monitoring of common areas with closed-circuit television recording, regular review of the residents, and feedback.

Proposed Minimum Standards

Long-term social care is also the responsibility of the state. Since the government alone cannot meet the huge demand in this area, policies to expand health insurance schemes to include long-term care in a residential care home can be considered.

There is a need for health and social care reforms to manage the rapid aging process, which may help expand services through home care or residential care. 66 With demand rising, India is likely to see more residential care homes in the future. Although MHCA 2017 has provided some legislative framework when the care home has any one or more residents with a mental disorder, it is not enough to regulate and safeguard the residents. The government authorities could take the lead and bring in geriatric experts, NGOs, private care providers, and the main stakeholders, the elderly community, and their children on board to ensure consultations and discussions take place periodically. Appropriate quality control measures in terms of registry, licensing, periodic inspections, and developing minimum standards for all kinds of old age homes should be instituted. At the same time, under-or over-regulation should be avoided. Until the regulations are formulated, the residential care homes must follow general work ethics, safeguard the human rights of residents, provide compassionate care, self-regulate by regular review of their care and impact, and handle complaints and feedback and work on the shortcomings. There must be an appropriate care needs assessment endorsed by specialists and attempts to provide home-based care before admission to residential homes. The government should take the lead by setting up model residential care homes to train the staff in as many regions as possible and then serve as a mentor to the private or NGO bodies.

Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The authors received no financial support for the research, authorship, and/or publication of this article.