Monica Ferreira

Linking Ageing to Development Agendas in Sub-Saharan Africa: Challenges and Approaches

International calls and frameworks for policies on ageing in sub-Saharan African countries, encapsulated in the UN Madrid Plan of Action on Ageing (2002) and the African Union Policy Framework and Plan of Action on Ageing (2003), have resulted in little concrete policy action. The lack of progress calls for critical reflection on the status of policy debates and arguments on ageing in the sub-region. In a context of acute development challenges and resource constraints, the paper links the impasse in policy action to a fundamental lack of clarity about how rationales and approaches for policy on ageing relate to core national development agendas. It then explicates four steps required to elucidate these connections, namely: (a) A full appreciation of key aspects of mainstream development agendas; (b) identification of ambiguities in calls for policy on ageing; (c) pinpointing of key perspectives, arguments and queries for redressing the ambiguities; and (d) addressing ensuing information needs. We argue that advocacy and research on ageing in sub-Saharan Africa need to consider the framework proposed in the paper urgently, in order to advance policy and debate on ageing in the region.

Stroke outcomes in a socio-economically disadvantaged urban community

AIMS To determine survival, disability and functional outcomes of stroke patients following their discharge from an acute stroke unit in an urban community with limited rehabilitative resources. METHODS Stroke patients were recruited from a district hospital in Cape Town and followed-up for 6 months. Clinical characteristics, demographic and socioeconomic data, and disability and function as measured by modified Rankin Score (mRS), modified Barthel Index (mBI) at recruitment and 3 follow-up visits, were recorded. RESULTS The study included 196 patients. Median age was 60 (IQR 51-69) years, 135 (68.9%) were female, 57.7% black, 42.3% coloured, and 45 (23%) died within 6 months. At discharge, median mBI score was 7 (IQR 3-12) and median mRS 4 (IQR 3-5). In the multivariate regression models, only function (mBI OR 0.88, 95% confidence interval (CI) 0.79-0.96, p < 0.0001) and disability (mRS OR 2.34, 95%CI 1.20-4.54, p < 0.0001) were independently associated with risk of death. Shack housing was independently associated with moderate or severe disability (odds ratio 3.42, 95% CI 1.22-9.59, p = 0.02). Despite limited rehabilitation resources, 67% of survivors had mild to moderate disability at 6 months. CONCLUSION Apart from initial stroke severity, risk factors for poor survival were a severe disability category and the presence of impaired swallowing at discharge. Shack housing was independently associated with poor functional outcomes. These findings should be helpful in allocating home-based care and inpatient rehabilitation resources to high-risk groups to improve outcomes.

A minimum data set on ageing and older persons in sub-Saharan Africa: Process and outcome.

Relatively scant knowledge is available on the situations of older persons in sub-Saharan Africa. Reliable and accessible demographic and health statistics are needed to inform policy making for the older population. The process and outcome of a project to create a minimum data set (MDS) on ageing and older persons to provide an evidence base to inform policy are described. The project was initiated by the World Health Organization and conducted in Ghana, South Africa, Tanzania and Zimbabwe. A set of indicators was established to constitute a sub-regional MDS, populated from data sources in the four countries; a national MDS was produced for each country. Major gaps and deficiencies were identified in the available data and difficulties were experienced in accessing data. Specific gaps and constraints against the production and access of quality data in the sub-region are examined. The project and outcome are evaluated and lessons are drawn. Tasks for future phases of the project to complete and maintain the MDS are outlined.

Management of older patients presenting after a fall − an accident and emergency department audit

BACKGROUND It is common for older patients to present to accident and emergency (AE) departments after a fall. Management should include assessment and treatment of the injuries and assessment and correction of underlying risk factors in order to prevent recurrent falls. OBJECTIVES To determine management of older patients presenting after a fall to the AE department of Groote Schuur Hospital in Cape Town, South Africa. METHOD Hospital records were reviewed for a random sample of 100 patients aged 65 years and older presenting to the AE department after a fall, between December 2001 and May 2002. RESULTS The mean age of the sample was 78.6 years (range 65-98 years); 72% of subjects were female. History of a previous fall, and history of drug or alcohol intake, were recorded in less than 20% of cases. Blood pressure and pulse rate were recorded in approximately 90% of cases, and pulse rhythm and postural blood pressure in 2%. Examination of the musculoskeletal system was done in 86% of cases and that of other systems in less than 50%; cognitive assessment was conducted in less than 30%. Radiological investigations were performed in 89% of cases, glucose and haemoglobin in 32%, renal profile and electrocardiogram in 5%, and urinalysis in 4%. Three-quarters of the patients were referred for further management: 52% to orthopaedic surgery, 12% to other surgical subspecialties, 6% to the general medical department, and 6% to other hospitals and clinics. No referrals were made to geriatric medicine, physiotherapy or occupational therapy. CONCLUSIONS In managing elderly patients after a fall, the AE department focused on injuries sustained. Little effort was made to establish and manage risk factors, hence to prevent recurrent falls. Guidelines are needed for the management of such patients in AE departments.

The differential impact of social-pension income on household poverty alleviation in three South African ethnic groups

Social pension programmes play a key role in old-age support systems through their ability to reach vulnerable older persons. Pension income helps to sustain households affected by extreme poverty and vulnerability, by providing resources for spending that protects against vulnerability, and thereby they facilitate economic and social development. Under apartheid, South Africas citizens were categorised according to race, and persons classified as Asian, black and coloured (mixed race) had less access to the opportunities and resources available to whites. Parity in the amount of social pension benefits paid to beneficiaries in the different ethnic categories was achieved only in 1993. The Non-Contributory Pensions and Poverty Study (NCPPS), conducted in Brazil and South Africa, has assessed the impact of social pension income on household poverty alleviation. This paper draws on the findings of the South African survey to analyse the differential effects of pension income on household poverty alleviation in three ethnic-geographic groups. Its data show a pervasive social and economic gradient of disadvantage among the groups, with rural-black households being most disadvantaged, urban-coloured households least disadvantaged, and urban-black households in between. The impact of pension income on household poverty alleviation has a similar pattern. The paper concludes with a discussion of the implications of the findings for the achievement of equity through informed policy interventions.

Profile and management of patients at a memory clinic

Increasing longevity and a growing older population are being accompanied by a higher prevalence of dementia and concomitant demand for care. In this connection, the University of Cape Town/Groote Schuur Hospital (UCT/GSH) Memory Clinic provides a valuable service to patients, families and health professionals. High levels of behavioural and psychological symptoms of dementia need expert tertiary level assessment and management. Public education on dementia, early referral for assessment by primary care health professionals, and advanced training of health professionals are needed to encourage early recognition and appropriate management. Community-based care services too are needed to support caregivers of cognitively impaired older individuals.

Status report from South Africa

ConclusionIn their lifetime, older blacks have experienced discrimination and disadvantages that have discouraged healthy life-styles and economic and subjective well-being. The family support system and a non-contributory pension system have helped overcome some of the negative effects. South Africa’s Reconstruction and Development Program, which tends to favor youth over the elderly, poses a threat to existing service provision but also promises greater empowerment of the elderly and the benefits of a community-driven comprehensive family care system.

Geriatric Medicine in South Africa—a Cinderella subspecialty?

Population ageing is a worldwide phenomenon and follows a decline in birth and death rates. Longevity and a greater number of people living to an advanced age are a major achievement for humankind. However, a consequence of the demographic shift is an escalating demand for health care as a result of increases in chronic and age-specific diseases and disabilities. The transition is more rapid in developing countries, which also have fewer resources than the developed countries to meet the challenges of an ageing population. Geriatric Medicine (GM) is a relatively recent subspecialty but has been well-established in a small number of tertiary institutions in South Africa since the 1980s. The first chair of geriatrics was installed at the University of Cape Town but was frozen by the provincial government in 2000. Nonetheless, the Division of Geriatric Medicine at that institution remains the leading geriatrics focal point in the country. The University of KwaZulu-Natal has the only other chair, and only two or three other institutions, notably the University of Stellenbosch, have a geriatrics unit.

Ethnic differences in rates and causes of falls in an urban community-dwelling older population in South Africa

To the Editor: Falls are a major cause of disability, morbidity, and mortality in older persons. Incidence rates of falls reported for non-Caucasian populations are approximately half those for Caucasian populations in high-income countries. A variety of risk factors, including ethnicity, have been suggested as causative factors for falls. Despite potentially serious consequences of falls for older individuals, little is known of the extent and gravity of the problem in South Africa. A study was undertaken to determine prevalence, incidence, and consequences of falls in a multiethnic, urban, community-based population aged 65 and older.

PREVALENCE OF FALLS IN AN URBAN COMMUNITY-DWELLING OLDER POPULATION OF CAPE TOWN, SOUTH AFRICA

OBJECTIVE Falls are a major cause of disability and mortality in older adults. Studies on falls in this population have mainly been conducted in high income countries, and scant attention has been given to the problem in low and middle income countries, including South Africa. The aim of the study was to establish a rate for falls in older adults in South Africa. DESIGN A cross-sectional survey with a 12-month follow-up survey. SETTING Three purposively selected suburbs of Cape Town: Plumstead, Wynberg Central and Gugulethu. PARTICIPANTS Eight hundred and thirty seven randomly sampled ambulant community-dwelling subjects aged ≥ 65 years grouped according to ethnicity in three sub-samples: black Africans, coloureds (people of mixed ancestry) and whites. MEASUREMENTS Data were collected on socio-demographic and health characteristics, and history of falls using a structured questionnaire and a protocol for physical assessments and measurements. RESULTS Of the total baseline (n=837) and follow-up (n=632) survey participants, 76.5% and 77.2 % were females with a mean (S.D) age of 74 years (6.4) and 75 years (6.2), respectively. Rates of 26.4% and 21.9% for falls and of 11% and 6.3% for recurrent falls, respectively, were calculated at baseline and follow-up. Fall rates differed by ethnic sub-sample at baseline: whites 42 %, coloureds 34.4% and black Africans 6.4 % (p=0.0005). Rates of 236, 406 and 354 falls per 1000 person years were calculated for men, women and both genders, respectively. Recurrent falls were more common in women than in men. CONCLUSION Falls are a significant problem in older adults in South Africa. Effective management of falls and falls prevention strategies for older people in South Africa, need to be developed and implemented.