Three medical professionals from the geriatric fraternity in Western medicine presented papers at the seminar themed ‘Responding to the Global Challenge of an Ageing Population – an international perspective,’ held at the BMICH recently. Sponsored by the Gamani Corea Foundation, the seminar was headed byDr. Mahendra Gonsalkorale, retired consultant in geriatric medicine and Clinical Director for Elderly Care, Hope Hospital, Salford Royal Hospitals NHS Trust, Salford, Manchester and former Associate Lecturer in Geriatric Medicine, University of Manchester, UK. 
When one of them said, “some consultants here are in the habit of scoffing at elderly patients who seek their advice, saying, ‘a case of old age, natural phenomenon and no cure’; next time you hear this, tell them to treat you instead of such contemptuous rudeness,” reminding me of an instance where a leading Ophthalmologist mocked and ridiculed a former Octogenarian on the basis of his age. He even used a quotation from the ‘Guttila Kavya,’ the 15th century satire, to support his mockery. He had no respect for the ‘emotional life of the elderly.’ The story was published in the media. I quote [in the words of the victim] from the Island newspaper of August 1, 2013. 

“Recently I saw a leading Ophthalmologist to seek a cure for my dwindling eyesight. The Specialist examined my eyes and declared, “mata mahalu wayase beriya veena gaayanaa perase” and his assistants giggled in response. Despite my discomfiture about that reaction, I explained that I was spending about four or five hours at the computer every day and the Specialist replied that the state of my optical nerves showed that such performance was unbelievable. No remedy was recommended and to my request for enhancing my reading vision, I was asked to see an optician. As I left, the Specialist was repeating the Guttila lines, creating another ripple of chuckles, much to my embarrassment. The question, “If so, of what use is your medicine?” was uppermost in my mind but I did not give expression to it out of courtesy.” [unquote] 

This anonymous Ophthalmologist who is ‘blind’ to medical ethics [leading in making money?], is certainly not learned in manners. He has tarnished the image of the noble profession and set a bad example to his assistants. A sense of lethargy and alienation is generally associated with old age. Loss of loved ones and friends of the same age; loss of status and of a role adversely affect the elderly. Six centuries after Ven. Wettewe Thera created Guttila Kavya which carriedthe above lyrical piece, it became a popular text in school literature classes. Guttila, the ageing maestro, becomes pessimistic having to compete [by a royal decree] with Musila, his own pupil from a different territory, who challenged the teacher after learning the intricacies of playing the violin [veena] from him. The story, a Jataka fable, portrays Guttila as the veteran palace musician who withdraws to a forest abode away from the harsh world to avoid competition. 

Hippocratic oath and GMC guidelines

A senior consultant approached by the writer said dignity and respect for patients were considered by the GMC to be of great importance and a whole section was devoted to it in its handbook. The few Musilas[not to be confused with the Sinhala term ‘Moosala’]of local medical profession should be reported to the GMC-UK that is responsible for regulating all stages of medical education as well as maintaining intimate contact with the royal colleges regarding the good standing of consultants (specialists); and deal firmly and fairly with doctors whose fitness to practise is in question. 

“The moral test of government is how it treats the elderly; those who are in the shadows of life; the sick, the needy and the handicapped.”- Hubert H. Humphrey - 

"Some consultants here are in the habit of scoffing at elderly patients who seek their advice, saying, ‘a case of old age, natural phenomenon and no cure’; next time you hear this, tell them to treat you instead of such contemptuous rudeness"

According to the three panellists at the seminar, the next most important point to get across is the change in the age structure of the population. In other words, the number of people in various age bands at (any) one period. The most dramatic change is the absolute increase in the number of old people at any time compared to previous years. The relative number of employed youth will decrease, mainly due to increased life expectancy and reduced fertility rates. Low fertility and extended life expectancy are likely to continue, with potentially severe economic implications due to fast-rising pension, health and social care costs. These changes will affect both the state and private sectors. 
They say, Sri Lanka is one of the fastest-ageing countries in the world, with a significant proportion of the population aged 60 years or older projected to jump from 12.5% to 16.7% in 2021. Even though such demographic transition affects many countries, the speed of change is particularly dramatic for Sri Lanka. 
The next important point is that within this rise in the old, there are spectacular increases in numbers surviving to extreme old age (i.e. 80 years and above). According to projections, this age group will treble, growing from 126.5 million to 444.6 million from 2015 to 2050. 
Coming back to the Guttila-Musila duel, though highly-talented, Guttila suffered from psycho-social issues faced by the elderly. Musila’s first encounter was with visiting businessmen from Baranasiwho were well acquainted with maestro Guttila’s performance;as the author puts it in poetic sarcasm —‘Unimu vena sadathei…Nodattemu gayana karathei,’ how they had responded to Musila’s inquiry on their impassiveness [they presumed he was only tuning it…] 

Myths painting a negative image 

Dr. Gonsalkorale believes we have a lot of old people because good doctors keep them alive. His research has revealed that doctors have improved life expectancy by reducing deaths, mainly of the youth. 
“Dementia awaits us all. We will all get demented if we live long enough. Age associated illness does increase and Alzheimer’s disease is one such example but not all old people will develop Alzheimer’s although a high proportion of them would develop Dementia in various forms. They are more likely to have medical problems,” he said.

Old age 

Dr. Gonsalkorale said they have more disabilities. “They need support for independent living. They are more likely to be retired and dependent on pensions. Greater need for adaptive transport, recreational facilities, adaptive housing produces, financial demand on the state.  

Services 

Acute medical care, stroke and orthogeriatric services, older persons assessment units and rehabilitation (hospital based), general surgical and psycho-geriatric liaison and specialist clinics. 
TIA clinics, Parkinson’s, Rapid access clinics (TREAT), cognitive impairment clinics, community services, frailty hubs, day hospitals, care home outreach services and the Proactive Elderly Care Team (PECT).  

Solutions 

Accept the reality - we will have a large elderly population with correspondingly high costs of care. Do everything possible to maintain their health with sound preventive policies. Make them as productive as possible by finding roles for them in society which are mutually beneficial. 

Responsibilities  

Dr. Gonsalkorale recommends the following; 
Eyesight - cataracts, spectacles, hearing aids. Better sign-posting - large print leaflets. Improved sanitary facilities - more toilets in the right places. Easier access for walking frames - wheelchairs. Education of younger people on needs of the elderly. More tolerance and understanding (for instance, recognizing sluggishness in thought, memory, digesting new information in a humane way). If the older person has mental and/or physical problems that need institutional care, they are at greater risk and the state must have policies in place -- quite apart from meeting basic healthcare needs. Sufficient care for elders to remain at home, sheltered care, residential homes, nursing homes and hospices elderly attuned hospital care. Comprehensive Geriatric Assessments (CGA), efficient geriatric units and multi-disciplinary teams. 

Funding 

The team suggests accountable, audited and monitored funding. Best use of money available. Response and discharge teams. Rapid assessments – community and hospital. 
“The ageing population will certainly challenge public and private budgets in many ways, but through a combination of reduced consumption, postponed retirement, increased asset holdings and greater investment in human capital, it should be possible to meet this challenge without catastrophic consequences” --Ronald Lee, Professor of Demography and Economics at the University of California, Berkeley and Chair of the Centre on the Economics and Demography of Ageing. 
When Musila visited Baranasi, there remained only Guttila’s blind mother and father who asked him to wait until their son returned. Seeing the master’s veena, he tries to play. The blind parents [not so blind as our Ophthalmologist] who assumed rats were nibbling the strings, spelled out the lines written by a poet of the 15th century — “Su, soo yayi atha gesu sekayen.”

"Accept the reality - we will have a large elderly population with correspondingly high costs of care. Do everything possible to maintain their health with sound preventive policies. Make them as productive as possible by finding roles for them in society which are mutually beneficial"