THE WORLD HEALTH ORGANISATION (WHO) predicts that by 2050 the global population of those aged 60 years old and above will be approximately 2.1 billion, double of what it is today.

An accelerated and sizeable ageing population is also an exigent issue for Malaysia. Figure 1 illustrates a projection of an approximate 2% increase every five years, where eventually, by 2040, those aged 60 and above would constitute 19.8% of the country’s total population.

Penang’s ageing population is estimated to grow at an even more alarming pace. Population estimates for 2021 show that Penang is one of the states in Malaysia that is most vulnerable to the effects of an ageing community, with 14% of its population aged 60 and above.[1] By 2040, they are projected to make up 26.2%, or more than a quarter, of the state’s population.

An increasingly ageing population has consequences on a country’s social and economic structures, among them, increased dependency ratios, increased pressures and burdens on the health, social and welfare systems, housing problems as well as other issues that affect the quality of life.[2] The availability, accessibility and quality of healthcare and general care facilities, as well as optimal living arrangements for the ageing are matters of great importance in ensuring that older adults are best provided for.

In Penang, the welfare and wellbeing of older adults are seen as vital and are integrated into the Penang2030 vision, which aims to retain and develop Penang’s reputation as an attractive home for the young and the old. One of its pillars, namely to increase liveability to enhance the quality of life, inspires policies regarding the enhancement of welfare and care systems for older persons and the promotion of active ageing. The state also advocates for a sustainable active ageing policy that is primarily focused on addressing the issues of an ageing society, from improving care facilities to increasing the participation of older adults in their own community.

In an interview, Dr. Alan Ch’ng, a geriatrician who was trained in Singapore categorises older persons into three broad groups: those who are still able to work, travel and exercise are considered active or robust. There are also those who are vulnerable, frail and less mobile but still able to perform daily functions. Those who are bed-bound and immobile are considered dependent. These different groups require different services and levels of care, and he emphasises the importance of catering accordingly to the ageing community’s varied needs.

Aged care facilities in Penang are mostly privately operated or run by non-governmental organisations (NGOs), including religious bodies. It goes without saying that costs vary with each type of care and service. NGO and charity-run facilities such as the Penang Home for the Infirmed and Aged as well as the Little Sisters of the Poor have very strict entry requirements and often only cater to those who are destitute and alone. The options of care and services available for older persons are categorised into nursing homes, retirement homes/living, day care centres and home-based care.

Nursing homes are staffed with health professionals such as nurses and physiotherapists, and are intended for those who do not need to be hospitalised but are unable to be cared for at home. Care is provided around the clock.

Retirement homes and retirement living services are aimed at the segment of older adults who are still relatively healthy, independent and mobile, are able to perform day-to-day tasks when it comes to their personal care. Food catering, recreational activities and access to healthcare services are typically provided.

Congregate retirement homes are where older persons live and socialise together within the same building and premises. This newer concept of retirement living[3] consists of a housing complex where both assisted care and independent living are provided within their own separate units.

Day care centres, as the name suggests, are non-residential and provide day care for older persons. It is regarded as a safe space for them while their family goes to work or attends to other vital chores. The social aspect is a big part of day care centres for older persons and offers structure to their activities in addition to keeping them physically and mentally active.

Home-based care is provided in one’s own place of residence by health and caregiving professionals. This type of care allows older persons to primarily remain in the comfort of their own homes, and for those who are still mobile to maintain their independence with some assistance.

Challenges of the Aged Care Industry in Penang

As Penang’s population continues to age, more health and care facilities targeting the ageing community will be needed. Is Penang’s current aged care industry able to fulfil the ever-growing demand? Tan Soo Siang, the co-founder of Hope Geriatric Lodge, a premier facility that provides residential and nursing care for older adults, opines that the current demand is outweighing the supply.  

“In the past, older people were often cared for by the women in the family. But as more and more women join the workforce, the demand for caregivers is increasing.” Tan also points out that aged care facilities are severely lacking in certain districts, for example, in Barat Daya. “There is a lot of room for the industry to grow,” she expresses, “especially when it comes to day care centres for older persons.”

Ong Li Ting, the founder of Avenue Medihome Care Centre, shares some differing thoughts. She feels that the current number of nursing homes in Penang is well-equipped to handle the needs of older people, and that the industry is fairly competitive. “As a matter of fact, I also feel that the quality of nursing and retirement homes is on the rise, which bodes well for the industry and the ageing population in Penang.”

However, she agrees with Tan that more day care centres are needed to cater to those who are still relatively healthy and mobile. She points out that not every older adult needs round-the-clock supervision and care, and she feels that day care centres are better for their mental psyche.

On the other hand, Dr. Ch’ng highlights the lack of care facilities specifically for dementia patients. “Most nursing and residential homes here are not equipped or trained to handle residents with dementia, as they may have behavioural changes that can be challenging to manage.” He says that only a small number of care homes in Penang are willing to accept patients with dementia. Hope Geriatric Lodge and Avenue Medihome are two, but on the caveat that the patients do not suffer from psychosis and are non-violent.

Another challenge faced by aged care facilities is the issue of licensing. At present, there are many agencies and departments involved in the process of obtaining a license for an aged care facility, and sometimes the communication is not as clear as it should be. Ong expresses some frustration in this regard, as it has been a three-year wait for Avenue Medihome to get its license. She is not the only operator who struggles with this. “If the process is easier, more players will enter the industry and it will be a good thing.”

In the absence of available and/or suitable live-in facilities, some turn to the option of home care. Homage is a platform that focuses on providing home- and community-based care for older persons and those who need assistance with daily living. Jeffrey Leong, the Northern General Manager for Homage, disclosed that 75% of their customer base are older persons aged 75 years old and above. The care provided is tailored to suit their needs based on discussion and consultation between the client and Homage’s care advisors.

Overall, Leong says, it is probably fair to say that an older person’s first preference would be to continue staying where they are instead of in a nursing facility or retirement home. Home care then becomes a viable option for those who want to be cared for and rehabilitated in the comforts of their own home. It is also more convenient, as family members continue to live with them and do not have to carve out time for visits.

Another pressing issue confronted by Penang’s aged care industry is a lack of professionally trained caregivers for older adults. On top of the shortage of certified caregivers, few are willing to accept professional training to work as caregivers.

“Avenue Medihome is willing to offer professional caregiving courses and training to those who are interested, but unfortunately, there are very few takers,” Ong concurs. Most health professionals such as nurses and physiotherapists would not choose aged care or nursing homes as their first choice of employment as hospitals often offer higher pay and better benefits.   

“The challenge is to make the career of caregiving more appealing,” states Leong. Caregiving is a noble job, he says, and with the growing needs of the ageing community, it is an evergreen industry. Leong hopes that those with an interest and passion for caregiving will step forward to receive training.

Unfortunately, the role of a caregiver is not a job that is often highly regarded, as most see it as a difficult job that generates little satisfaction. Caregivers are sometimes belittled and disrespected, and have had to endure rude behaviours from the families of the older persons, which makes an already demanding job even more challenging.

Leong also sees this happening among Homage’s care professionals, where there exists an unfortunate and unfair view of care professionals as domestic helpers. “This is an area that we really seek to improve with communication and education, and we have different initiatives planned.”  

Improving the Aged Care Industry in Penang

Ong hopes for a smoother and more straightforward process in terms of applications and licensing to set up aged care facilities. Though she admits that there have been ongoing sessions of discussions between the stakeholders and the government, she hopes that the government can play a bigger role to support the industry.

Meanwhile, Leong hopes to see more day care centres for older people. Currently, most of them are operated by NGOs with continuous engagement from the state government to establish more day care centres in each of the five districts in Penang and their respective constituencies.[4] The state government is also pushing for more federally funded Senior Citizens’ Activity Centres[5] to be established in Penang.

Dr. Ch’ng advocates for a proper system to rehabilitate those who have suffered from deconditioning due to acute illness and hospitalisation. Deconditioning is a complex process of physiological change following a period of inactivity, bedrest or sedentary lifestyle which results in functional losses in such areas as mental status and activities of daily living. “In Malaysia, there is a dearth of hospital beds. When older patients complete their treatment, they are usually discharged straight home for recuperation.” This means that the crucial step of rehabilitation is, more often than not, overlooked. Citing Singapore as an example, he continues that ideally, there should be several transitional care services between the hospital and home to ensure optimal rehabilitation and recovery for the patient. The aged care industry can fill in these gaps but it is still imperative for a proper and streamlined system to be in place, such as that illustrated in Figure 2.

When asked about the best practices of other countries, Tan thinks that Japan has an excellent system for providing and coordinating care for their aged community, although she acknowledges that it took years for the system to be implemented and perfected. Singapore’s Agency of Integrated Care, an agency that coordinates and supports care integration in addition to supplying information, is another model worth emulating.

Furthermore, synergy between all the stakeholders in the aged care industry as well as collaborative efforts between hospitals, nursing/residential homes and home care to create an ecosystem will strengthen the industry. Leong believes that the state government should take the lead in this respect. This is echoed by Dr. Ch’ng, who expresses the same wish for the state government to assume the role of the “conductor” in bringing all the players together and orchestrate the best ecosystem for aged care.  

More Than Just Physical Care

While physical care is important, the mental health of older persons must not be neglected. Tan specifically spends time preparing her residents when they arrive at Hope Geriatric Lodge, making sure their transition goes as smoothly as possible. Ong does this by letting residents participate in simple decision-making such as choosing what they want to wear or eat. “This gives them a measurement of control and is beneficial towards their mental health.”

Compassion, patience, love and knowledge are some of the most important aspects when it comes to aged caregiving. “Caregiving, at its core, is not just a job,” Leong explains. “One must have the passion and the patience to go the extra mile in providing the best care for those who need it.” Tan agrees and says that profits should not be the reason one enters the aged care industry. “At the crux of it, this industry is not hugely profitable when compared to other sectors. If you don’t have the compassion and the love, you won’t be able to last in the industry.”

Active ageing is another important component in the wellbeing of Penang’s older persons. Encouraging them to keep active, both physically and mentally, and engage themselves in social interaction with others will help to ensure a healthier process of ageing. Aged care facilities must also ensure their residents are given opportunities to remain as active as possible, for both their physical and psychological wellbeing.

Footnotes:

[1] Discrepancies in the figures are due to the usage of different data sets; Figure 1 wholly peruses the data found in Revised Population Projections, published in 2016, while the 2021 population estimate was taken from Current Population Estimates, published in 2021.

[2] Pastalan, L.A., cited in Tobi, S. M., Fathi, M. S., & Amaratunga, D. (2017, October). Ageing in place, an overview for the elderly in Malaysia. In AIP conference proceedings (Vol. 1891, No. 1, p. 020101). AIP Publishing LLC.

[3] Currently, there are two projects in the pipeline when it comes to retirement living: Penang Retirement Resort, situated in Timur Laut and Eden at Botanica.CT, to be constructed in Balik Pulau.

[4] Basyir, M. (7^th October, 2018). Penang to set up day care centres for senior citizens, retrieved from https://www.nst.com.my/news/nation/2018/10/418858/penang-set-day-care-centres-senior-citizens

[5] Also known as Pusat Aktiviti Warga Emas (PAWE), there are currently three centres in Penang.