We must now adapt to our changing circumstances, while recognising that ‘there is no health without mental health’.
Growing old is often associated with the 3Ds — decrepitude, dementia and depression. Related pessimism is pervasive in the community and even at home. When the Chinese Women’s Association opened the first day-care centre for dementia in the Henderson district in Singapore in November 1986, Mrs May Wong, the President, suggested naming it a Social Centre to eschew the stigma.
With the social transformation of Singapore medicine, there are now more research publications on ageing and mental health.1 Starting at the old, crowded flats around Chinatown, the research has expanded to include many new housing estates around the island.
For our team, it has been an odyssey, beginning with epidemiological surveys, then interventional studies and now translational research.
40 years ago, the retirement age in Singapore was 60 years and life expectancy at birth was 74 years. Today, the retirement age is 67 and life expectancy at birth is 84 years. The increase in life expectancy places Singapore ahead of the United States and the United Kingdom. While the increase in life expectancy is evidence of good healthcare policy that any country should be proud of, the number of elderly people today is a phenomenon never seen in the short history of Singapore. We must now adapt to our changing circumstances, while recognising that ‘there is no health without mental health’. 2
Be an ageless senior
NTUC Health’s Active Ageing Centres provide a range of community- based activities that help seniors stay active, learn new things, make friends and give life to old passions. Seniors are also encouraged to give back with their time, experience and skills. Mdm Chu Siu Lin, 83, volunteers as a dance instructor at the centre and brings her passion for Chinese dance to her fellow seniors. Source: NTUC Health website
AGEISM IN THE WORKPLACE
In 1986, the National University of Singapore’s (NUS) Department of Psychological Medicine conducted the first of four epidemiological studies on the mental health of elderly people in Singapore as part of the World Health Organization’s (WHO) Global Study of Dementia. Before this study, we knew very little about dementia in Singapore and misconceptions were common. The first study conducted in Chinatown made it evident that not all elderly people above 65 years old will have dementia. Less than 3% of people had dementia, while the prevalence of depression was much higher at 5.7%. This was highlighted in a lecture I delivered at the United Nations’ World Forum on Mental Health in New York on 8 October 1999.3
After the completion of the WHO study, we started the first Memory Clinic in Asia at the National University Hospital (NUH) in 1990, comprising a team of a psychiatrist, neurologist, geriatrician, nurse and psychologist. Studies on caregivers’ stress, health cost and the natural history of dementia were carried out at the NUH Memory Clinic.4
The second epidemiological study was conducted at Toa Payoh in 1995 with the collaboration of the Singapore Action Group of Elders (SAGE). This was the vision of Dr Lim Chan Yong, President of SAGE.5 Together with Mr Henry Lim, President of the Gerontological Society, we formed a research enterprise at the SAGE Centre for the Study of Ageing (SAGE-CENSA). Most of the elderly in this central district were locally born and their forebears came to Singapore much earlier, unlike the Chinatown cohort who emigrated after the Second World War. They were financially more comfortable and lived in bigger apartments compared to the crowded flats in Chinatown.
Finding the way home
As part of the Alzheimer’s Disease Association’s Wayfinding Project, Kebun Baru community comes together to paint dementia-friendly murals of ang ku kueh, White Rabbit candy, satay, tangyuan and other retro household items on HDB void deck walls to help elderly find their way home. Source: Joyce Sim / Facebook
What age is too old to keep working?
At 92, Mdm Leong Yuet Meng of Nam Seng Wonton Noodle House is one of Singapore’s oldest hawkers. Although she is no longer cooking at the stall, she still plays an active role by sourcing the ingredients, making the wantons and taking orders. Photo: REUTERS / Edgar Su
In 1995, I was on sabbatical leave at the National Institute of Mental Health (NIMH), in the US. While there, I was invited to write a chapter for an NIMH book on elderly suicide. When we conducted research on data from Singapore, we were surprised to discover that the suicide rate for Chinese men was very high.6 In response to this, the Gerontological Society and SAGE-CENSA started a series of public seminars in both English and Chinese on depression and suicide prevention. More day-care centres were also initiated by the Ministry of Community Development, the Ministry of Health and the National Council of Social Service. With greater awareness and more human resources available for eldercare, we noticed a gradual fall in the suicide rate.
The third epidemiological study took place in 2001. The National Mental Health Survey of the Elderly was a joint effort of the Institute of Mental Health (IMH) and the NUS Department of Psychological Medicine. As the CEO and Medical Director of IMH, I was glad to receive a grant of S$300,000 from the National Medical Research Council (NMRC) for this survey. The study was delayed by the SARS epidemic, but it was eventually completed after a three-year delay, under the guidance of Professor John Copeland from the United Kingdom. After this study, we felt that we had sufficient data on the prevalence of dementia in Singapore and shifted the focus of research to interventional studies, wherein researchers test interventions and assess their impact.
The quality of life and life expectancy of dementia patients could be improved through the stabilisation of chronic illnesses... together with lifestyle changes, including diet, exercise, gardening, music- reminiscence and art activities.
INTERVENTIONAL RESEARCH
In 2010, we launched the Jurong Ageing Study, now widely known as the Dementia Prevention Programme (DPP), as an interventional research project. Drawing from our experience in the NUH Memory Clinic, we found that the quality of life and life expectancy of dementia patients could be improved through the stabilisation of chronic illnesses — such as diabetes mellitus and hypertension — together with lifestyle changes, including diet, exercise, gardening, music- reminiscence and art activities.7
In 2011, the research team moved to the Jurong Point Shopping Mall to be part of the Training and Research Academy (TaRA). Thanks to the generosity of the Lee Kim Tah family, we have a piece of real estate in this popular shopping mall. The initial donation of S$10,000 from Mr Henry Lim was followed by a generous gift of S$1.8 million from the Kwan Im Hood Cho Temple. The tagline of this research is ‘Preventive Medicine in the Community by the Community for the Community’. The cohort of about 1,000 elderly people is spearheaded by Dr Feng Lei, the Assistant Professor of Research, and Associate Professor Rathi Mahendran. This longitudinal study provided invaluable data on ageing in an urban community.8
The 5-year outcome of the DPP showed dementia prevalence at 3% and depression at 4%.9 The Ministry of Health has stated that the prevalence of dementia for people above 60 years is 10%. Although we do not presume that DPP will prevent all dementia, if we could reduce the prevalence by a modest 10%, that will be equivalent to 10,000 cases. The cost-benefit of care will be tremendous for the family and healthcare service, while delivering quality-of-life benefits to individuals.
The busking duo who went viral
For Davidson Teo, 63, and Gillian Goh, 67, busking has become a way of life and a motivation to get through trying times. When Gillian lost her sister to cancer, long-time friend Davidson invited her to busk with him to help her cope with her grief. The duo, Silver Hype, made their debut at Hougang Mall and instantly became a TikTok sensation. Source: Must Share News
CHALLENGING AGEISM
Our research has debunked some of the myths about ageing. In the Jurong study, the prevalence of only 3% tells us that dementia is not common.
Today, many people still consider growing old to be odious. Notwithstanding, the quest for longevity continues and the ‘threescore years and ten’ belief is now obsolete. It is an incontrovertible fact that not all elderly people become demented, but ageism still permeates subtly. We must do something about this.
In the first study, Chinatown’s elderly seemed to have adjusted well in retirement and carved out a niche for their social life. In their reflection, there was satisfaction with home and family. Tolerance and perseverance were their stock-in-trade and they found solace in friendship. They valued relationships and although some were living alone, they had assistance from their neighbours who were of the same dialect group and many had come together from the same village in China.10
The Toa Payoh and Jurong elderly were mainly locally born and lived in better housing estates, but they did not seem to know many people in the neighbourhood. However, in the Jurong Ageing Study, we noticed that the elderly who participated in the DPP made more friends and increased their social connectedness. They have begun to rebuild their socio-ecological network like in the old days of living in the village.
The therapeutic power of gardening
The National Parks Board (NParks) has developed the Therapeutic Horticulture Programme that is especially beneficial for the elderly and persons with dementia. Activities such as plant propagation, leaf collage, gardening and growing of edible sprouts are organised in various NPark's therapeutic gardens. Source: NParks / Facebook
In the past ten years, we changed the paradigm of medical research in Singapore. With a team anchored at a shopping mall and donations from the public, we conducted interventional studies in the community. The DPP — later renamed the Age Well Everyday (AWE) programme — became a tripartite partnership of NUS, the People’s Association and the National Parks Board, and expanded to include eight more centres around Singapore. In this translational research model, elderly volunteers are trained to organise and teach the programme to other elderly participants, thereby empowering them into their golden years.
At the Jurong Ageing Study, we surveyed the first batch of baby boomers born in 1946. Of these ‘new-olds,’ many are educated and working full-time or part-time. They should be viewed as valuable human resources—assets that could benefit the community. The potential of this burgeoning group is phenomenal and the challenge for policymakers is to harness their energy.11
PROF KUA EE HEOK
Prof Kua Ee Heok is an Emeritus Consultant and Tan Geok Yin Professor in Psychiatry and Neuroscience at the National University of Singapore (NUS). He practises at Mind Care Clinic at Farrer Park Medical Centre. Prof Kua was a member of the World Health Organization (WHO) Research Team for the Global Study of Dementia and has published 30 books on ageing, addiction and mental health. He is Editor-in-Chief (with Norman Sartorius) of the new 7-book series ‘Mental Health and Illness Worldwide’. His novel, ‘Listening to Letter from America’ is used in a course on anthropology at Harvard. He has been invited by the United Nations in New York to address the World Assembly on ‘Depression — the hidden illness’.
AUGUST 2023 | ISSUE 11
THE ART, SCIENCE AND GOOD NEWS OF AGEING
- Kua EH, Kua PHJ (2016). The social transformation of Singapore medicine from 55 years of the SMJ. Singapore Medical Journal (in press).
- Kua EH (1992). A community study of mental disorders in elderly Singaporean Chinese using the GMS-AGECAT package. Australia and New Zealand Journal of Psychiatry, 26: 502-506.
- https://www.who.int/data/gho/data/major-themes/health-and-well-being
- Kua EH, Tan CH, Tan SL, Ko SM, Lee KS (1997). The NUH Memory Clinic. Singapore Medical Journal, 38: 112-115.
- Kua EH, Ng TP, Goh LG (2004). Long Lives. Armour Publishing, Singapore.
- Kua EH, Ko SM, Ng TP (2003). Recent trends in elderly suicide rates in a multi-ethnic Asian city. International Journal of Geriatric Psychiatry, 18: 533-536.
- Kua EH, Mahendran R (2022) Ageing with Dignity. Write Editions, Singapore.
- Rawtaer I, Feng L, Fam J, Kua EH, Mahendran R (2015). Psychosocial interventions with art, music, tai-chi and mindfulness for subsyndromal depression and anxiety in older adults: a naturalistic study in Singapore. Asia-Pacific Psychiatry, 7: 240-250.
- Kua EH, Mahendran R (2022) Ageing with Dignity. Write Editions, Singapore.
- Kua EH (1986). Shades of Grey. Asiapac Books, Singapore.
- Kua EH (2012). Ageing Baby Boomers. Write Editions, Singapore.
