Silent Scream of Malaysian Elderly: A Case Study in Noble Care Ageing Centres

The rich tradition of dignified ageing is exceedingly wearied away in developing countries, including Malaysia. The present study describes stories of the elderly associated with their physical, psychological and social experiences regarding immediate surroundings, friends, family and the society residing in the Noble Care Malaysia, established welfare and human services Organisation, helping the deserving members of the community. The qualitative research methodology is adopted. The data is collected through five in-depth life history's narrative of the elderly with chronic diseases. The study explains stories of the elderly in connection to familial neglection and abandonment for social awareness about ageing and older citizen feelings. This paper proposes some necessary measures to be addressed for graceful, proactive and gracious ageing.

citizen. During the year 1991-2010, the age group 60 and above shows a drastic increase in Malaysia and doubles from 1 million to 2.2 million. Reports predicted the rise of about 7 million or 17.6 % of the expected population of 40 million by 2040 (Md Isa et al., 2020). In 2005, 7 % of the elderly population was expected to be doubled by 14% by 2028. The improved life expectancy contributing to the older population growth as more elderly survive into older age. The increase in birth rate rose from 61.6% in the year 1970 to 74.4%. Moreover, the median population age increased to 27.8% in 2016 due to a better quality of life and living conditions. Hence, overall improved public health, education, progress and development led to aggregate longevity (Samad et al., 2017;Soong, 2016). Malaysia is a developing country where the phenomena of ageing grew significantly fast in a shorter period and becoming a significant challenge to the country as ageing is a continuous process, which brings various physiological and mental changes in the human body (Shenkin et al., 2014;Noor et al., 2019a).
An ageing population is a mixed group affected by health, non-health and societal factors (Samad et al., 2018). The increase in life expectancy may develop severe age-related conditions, issues and challenges that demand more and more well-equipped elderly care centres and nursing services (Chhetri, 2018;Noor et al., 2020a). The elderly home or Old homes strategy plays a vital role to look after the Malaysian aged population. Unfortunately, Malaysia lacks behind in terms of social and housing policies for the elderly compared to other developed countries. However, Malaysia has led down social and housing policy in the development plans since the preindependence period (1950)(1951)(1952)(1953)(1954) to the Eight Malaysian Plan (2001)(2002)(2003)(2004)(2005). Still, the need for old homes for the elderly is facing a lack of attention in Malaysia's development and housing plan (Phua et al., 2019;Noor et al., 2019b). The main question is; how to keep the elderly healthy and active as ageing criteria may vary from chronological deterioration to physical and psychological problems, i.e. less motivation, worsen eyesight, memory loss, and tendency to compare the present position with the past? (Phua et al., 2019;Noor et al., 2020b;Tohit et al., 2012;Park et al., 2018;Ursulica, 2016).
The history revealed that after the Second World War, Asia became the region with low fertility. Japan is considered a leader in this regard, along with southeast countries like Indonesia, Thailand, Singapore and Malaysia (Lai et al., 2019). Malaysia is a land that firmly believes in religion, traditions, moral values, and direct relationships. However, rapid technology advancement, mobility of rural residents to cities either leaving their elderly in their native homes or accompanying them towards cities, changing global context, desire for a small family and growth and development process are becoming the main reasons for the erosion of family norms, values and care of elderly parents these days (Phua et al., 2019;Noor et al., 2020a). Subsequently, older people live alone, susceptible to difficulties such as rejection, depression, and loneliness, and many have been abandoned and mistreated (Noor et al., 2020c). These are the older people who are forced to reside in some elderly care centres with various physical and mental health issues to be concerned about (Yasamy et al., 2013;Laceulla & Baaars, 2014;Noor et al., 2020b). Based on the present ageing trend, Malaysia is predicted to get ageing population status by the year 2025, which means that 15 % of Malaysia's entire population will be elderly (60 years and older) (WPP, 2019; Samad et al.,2017;Noor et al., 2020c). Hence, it will be one of the biggest challenges for Malaysia to manage an ageing society.
In line with this, Malaysia's Ministry of Health reported that the government fixed 8.39% of the National Budget that is RM 22.16 billion, to improve healthcare systems. According to the American Publication report "International Living", the Malaysian health care system ranked at number three among 24 countries. However, due to an increased number of elderly persons, medication cost has been increased along with better technological advancement in medical science (Mohidin, 2016). As Guerin et al. (2015) stated, although Malaysia's health care system is satisfactory, still issues regarding affordability and quality are getting worsen with time. Currently, 365 registered elderly care centres work in Malaysia's leading states (Noor et al., 2020c). These centres are categories either as public, private, and centres that come under religious organisations. The private sector is playing a dynamic role in providing care and help service to the elderly with a fee package of RM 1500 to 2500 per month depending upon the health condition and situation of the elderly (Noor et al., 2019a). In addition to these centres, many more unregistered centres are also actively operating throughout the country. Some are free of charge, and some with minimal basic charge, i.e. centres run by religious groups or communities in remote or rural areas (Md Isa et al., 2020). Few elderly care centres such as Noble Care provide holistic care, and quality services cost to cost with minimum margins of profit needed to be sustainable. Noble Care Malaysia is a welfare and humanity services organisation established to help the old folks and disabled society members.
138 Senior Citizens during Issues,Efforts The centre provides care services to support the Malaysian government's social responsibility program to provide residential care for homeless, elderly, needy older unprivileged people. The motto of Noble Care is "Care and Nursing Services for Poor Community." Noble Care started its services for the first time in 2010 and helped thousands of families suffering from challenges of caring for old folks in terms of medical, physical, and emotional needs. Noble Care's well-equipped model centres work and provide holistic care and quality services to aged and ailing community members. They specialise in providing care to the elderly suffering from severe illnesses such as stroke, coma, tube feeding, catheters, tracheostomy tube, gastrostomies, colostomy bags, terminal illness like cancer, etc. Noble Care has a dream to attend all those old folks unattended at their homes (Ejaz Ahmed, Personal Communication, NC, and October 2019).
The elderly require a home with freedom, liberty, and the ability to contact friends and family. It is essential to ensure that the voices of older citizens are heard in their families and societies. The majority of the studies described younger nurses' experience and confronted challenges towards ageing and the elderly (Abudu et al., 2019;Zivin 2013). However, limited studies were done on the experience and feelings of the elderly towards the ageing group and the transition of a young person to older in developing countries context (Appleton, 2002;Brown, 2009;Ismail, 2008;Keyes, 2017;Meriam et al., 2014;Mohiudin et al., 2016;Samad et al., 2017;Tohit et al., 2012). Pertaining to the ageing context, the Activity Theory of Ageing is associated with activeness. It highlights that getting active enhances life satisfaction and life span. The activity theory stresses ongoing social activities, which are becoming the main reason to keep the elderly vibrant and lively (Roy et al., 2005). Thus, It is essential to keep the elderly socially engaged by introducing new activities, hobbies interaction with a group of people to keep them psychologically fit (Bearon, Lucille, 1996). Activity Theory postulates that retiring may not be harmful if the person actively maintains his/her other roles in life. The tasks related to recreational, familial and community, and elderly must switch their roles according to the ageing process; hence, many functions are lost (NIA, 2010;Normala et al., 2014). Therefore, for attaining the proper social status, the older population must be physically and mentally active for structuring the social-related activities. With regards to this view, the present study explores the elderly experiences about getting older and problems faced by society and how they accept this reality of becoming older. Below mentioned the adopted methodology

Data and Methods
Qualitative methodology is considered the best approach to discovering and exploring a new area-developing hypothesis (Miles & Huberman, 1994). This study is exploratory research that involves qualitative data collection methods by utilising the self-administered questionnaire (Bernand, 2002) with an openended questionnaire. Several researchers suggested that exploratory research is useful for defining a set of investigative questions that can guide a detailed research design (Easterby et al., 2008). Thus, the Qualitative Research Interview explores the social unit's perception of getting an individual answer. A qualitative research strategy was adopted for this study, and the researchers used participant observation and an in-depth interview technique. The research design plays an essential role in answering the research question (Clough et al., 2014;Hall et al., 2016). The present study adopted interpretivism as a philosophical stance associated with people's experience (Creswell, 2013). The data collection was done by field study conducted in the Noble Care from August 2019 -October 2019. Currently, 35 senior citizens are residing in this centre (20 men, the 15 women). The purposive sampling technique was used, and the researcher selected five cases (three women, two men). Thus, based on the population characteristics, only those who were able to respond correctly were included; as of the rest, about 30 were bedridden, suffering from chronic diseases, mentally unstable or paralysed. The interviews were conducted in three native languages (Malay, Chinese, and Indian) and later transcribed in English. The interviews lasted about 45 minutes to one hour and later on summarised in the form of narrative. Murray (2018) stated that narrative analysis is associated with participants' stories based on their experience and analysed by qualitative research method (Riesman, 2008). Below mentioned the demographic details of participants. Table 1 depicts the profile of the participants. The details show that out of five participants, two males and three females were interviewed for the present study. The majority of the participants skewed towards Malay ethnicity (2), followed by Chinese (1) and Indians (1) and one belonging to other nationality. Regarding qualification, two of the participants have a diploma certification, two having a bachelor's degree, and the remaining one has a master's degree. The marital status of participants shows married (2), unmarried (1), widow/widower (1), and divorced (1). The age of participants skewed towards 75onwards (2), 65-75 years (2), while 55-65 years (1).

Results
Below is the summarised interview in the form of narratives based on participants' experiences and reasons behind their disrupted lives. Almost all of the stories are painful and downhearted. The analysis subject demonstrates the reasons behind neglect and elderly experiences in their old age life. Thus, to fulfil the ethical standards, an anonymous name is used throughout the narrative analysis.

Case -1 (My Children betrayed me)
Case 1 was a 67 years old woman who passed the worst time after her husband died, and children's forced him to distribute property. The son left for abroad, and the daughter could not keep the mother in her home due to her husband. The lady passed a miserable life by begging on roads. The daughter also cut down from the woman. The woman recalled the days spent with her husband. Case 1 comments challenge that a man and woman in her old age face where children need the property and want to get rid of parents. She pointed out how it is painful to live without children, and she misses them very much. The life with a husband she reminisced about was the best period of her life as the husband was his most immense support. She expressed the old age of chronic diseases and wished to meet with her children before she dies. It is the miserable and painful condition of the elderly who need emotional support from family members. She left us with the question that am I ever missed by my children with tears in her eyes.

Case -2 (Once I was a Baker in a Hotel)
Case 2 was 58 years old woman single and was ditched by her boyfriend before coming to the centre. She was living with her brother and working in a hotel as a baker. She is getting support from her friend as she visits her and pays her fees. She explained: I am 58 years old and never married and was in love with someone. The guy betrayed me and left me alone. I have two brothers, and my parents died. Before I lived in my brother's house and got ill because of a stroke attack and could not earn for them, they kicked me out from home. I know how to bake, especially cakes, but now my body and brain are weak. I have worked in big hotels. I still miss my boyfriend. He promised to marry me, but he left me alone. I always used to buy gifts for him. I got a stroke, I was unable to talk, and then my family left me here. Nobody comes to meet me. I miss my brother's sons. I hope they will be grown up wisely now. My one and only friend come to meet me frequently, and she pays my fees too. I miss my boyfriend and wonder why he left me.
Case 2 highlights family members' neglecting behaviour towards their sister and unwillingness to pay her dues in the centre. They left her there and never came back to meet up with her. She misses the family and is thankful to her friend, who pays her monthly dues in the centre and sometimes visits her. This case let us ponder that sometimes family can act as an enemy while outsiders can be the ones an elderly can depend on wholeheartedly.

Case-3 (My husband divorced me when I got cancer)
Case 3 was 78 years old woman left by her husband when she got cervical cancer. She spent a few years with her mother, and then her mother passed away. She pays her dues independently without any burden on anyone and fighting a disease like cancer with courage and hope. She stated: I am 78 years old now. Once I used to work in a café as an accountant. I am excellent in calculations still. My husband divorced me when I got cervical cancer 15 years back. My mother was alive. I started living with my mother, and the day was passing good by taking care of her. One day she left me alone in this entire world. I have no siblings, and my father had passed away when I was so young. Luckily, I had my saving, so I decided to live here in this centre. Here at least, I can meet with people, and I always try to help them. You know I never tried to get married because I love my ex-husband too much. I still miss him because I am still living with the memories that he has shared with me.
Case 3 shows the spirit of an elderly how she is living her life in the centre by considering it as a blessing that she may meet here with people. She worked as an accountant. She has cervical cancer but trying to manage herself. Even with a fragile health condition, we have seen this courageous lady with a smiling face. Her true love keeps her alive with hopes.

Case-4 (I gave my whole life to my son, and he left me like garbage)
Case 4 was 82 years old man who looks after his son ever since his wife passed away when the son was only two years old. Son ditched him and left him alone. The man got a stroke and experienced a miserable life before reaching to centre. He said: Case 4 portrays the feelings of a man who raised his son as a mother and father both. He was ditch as the son sold all his property and left him alone. Due to shock, the man got a stroke and lived the rest of his life, waiting for his son to call him and take him back home one day. This type of mental trauma the elderlies are facing in centres because of their family neglect or misbehaviour. This case reflects an elderly's lonely life with full hopes to finally meet his loving son without hatred.

Case-5 (What to do when my wife left me alone)
Case 5 was 69 years old man who got paralysed and lost one leg. The wife and children left him alone due to his poor health condition. He got help from one of his friends, who sometimes visit him. The man was heartbroken due to his wife and children's behaviour when he could not earn money. They left him alone: He mentioned: All of them left me alone. I cannot tell my siblings that my own family left me alone without thinking that I was paralysed. One of my friends helps me, and he comes some time to meet me and brings fruits and gifts for me. I am very heartbroken. Is this the world of money only? Why are relations so meaningless? I do not talk much here, but I am feeling happy to tell you my story. I want to tell all children to care for their parents and save them from this loneliness and sadness.
Case 5 highlights the pain of a man left by his wife and children due to his poor health condition, but a friend helps him. The man expressed his pain and requested the new generation to save their parents from this loneliness. He left us with this question about the world is with you when you are physically healthy and earning a lot. He also sadly uttered about the meaningless of relationship.
Based on the findings, the conceptual framework is developed. Figure 1 demonstrates the economic, social, physical, and living experiences and conditions in the transition to ageing; and how the elderly population is affected by health, non-health, and societal experiences which lead to issues related to economic, family care and support, health issues, residential aspects, and community care.  Ageing and Social Policy,9(2) 145 The family is the most significant support for the elderly. The majority of older people go down with their mental and physical health problems, fewer movement activities, and societal neglect.

Discussion
The cases mentioned above explained how familial neglect, physical and psychological issues, compelled them to take shelter in elderly care centres. However, older people desire to live in their own homes or family neighbourhoods. Case 2 and 5 getting support from friends community in the form of a few visit to them, submission of dues, bringing gifts and flowers, but still, the participants miss the emotional support from family members and longingly reminisce their past lives. Most of the elderly in the centre suffer from severe health decline due to their family's absence of emotional support. It is the ground reality that older people's happiness lies in fulfilling the physical and emotional needs of the elderly. The family is the most significant support for the elderly. Society is also responsible for elderly care and utmost importance; it is not only families' responsibility. In societal norms, elderly care must be lined up by families (Yasamy et al., 2013;Lai et al., 2019). Thus, maintaining proper care of the elderly quality of life and ideal health condition is crucial. The ideal health status of the elderly is associated with the fulfilment of their basic need, which comprises healthy life, physical damage safeguard, and continuity of middle life circumstances throughout for active ageing. However, due to less or no emotional support from the families, the elderly experienced a dull, meaningless, and miserable life (Abudu et al., 2019;Noor et al., 2021;Roy et al., 2005;Singh, 2014). These negativities will end up killing their desire to live and gradually deteriorate their health condition.
In this modern era, attitudes towards the elderly generally tend to be negative, resulting in verbal, emotional, somatic, and financial abuse (Singh, 2014;Tohit, 2012;Normala et al., 2014). In order to preserve a caring society, every neighbourhood community could play a significant role in providing a safe living area for the elderly and inculcate a caring culture in younger generations so that every child will care for and love their parents unconditionally. Community care refers to the community's services like daycares centres, hospitals, clubs, counselling centres, home help, meal on wheels, and home nursing (Phua et al., 2019;Noor et al., 2020b). It is the community's foremost responsibility to train the family members, neighbours, and friends of the elderly to care for their elderly at home properly. Moreover, elderly clubs can play a remarkable role in keeping older people healthy and making them busy in many extracurricular activities such as art and craft, cooking classes, games and puzzles, aerobics. Senior citizen clubs play a significant role in cutting down the loneliness of the elderly population by providing group exercise classes, walking, gardening, and book clubs (Park et al., 2018;Phua et al., 2019;Tey et al., 2015). Case 3 findings revealed some different facts about her happiness in the centre as she gets a chance to meet with people even with severe illness. One of the main reasons is that she is financially stable and has savings and not economically dependent on anyone. She misses her mother as after her divorce, she lived with her mother, and now she considers the centre her own home. It shows case 5's positive attitudes towards living in the centre.
Healthy ageing is multi-layered, associated with economic, social, physical, and living experiences interlinked with a person, friends circle, family, and society as a whole. The social experience of the elderly demonstrated the perception towards aged people by considering them useless, worthless, shame on being old and abandoned, humiliated, and social burden (Park et al., 2018;Noor et al., 2020c). It gives painful feelings to the elderly that they have nothing left for social life. Similarly, bedridden elderly suffer from serious health complications such as bedsores, digestive and respiratory issues, and severe depression attacks. This suffering will continue to be plaguing them until the last moment of their lives. One of the most significant issues that are becoming very common these days and associated with severe depressive features among the elderly is dementia. Dementia affects memory, and subsequently, the memory will affect emotions (Noor et al., 2020c, Phua et al., 2019Soong, 2016). The memory dis-functioning leads to remembering sad things more than good things, making the elderly most heartbreaking. The physiological disorders make them more prone to loneliness compounded with lesser activities to cope with ageing actively.
Based on these narratives, the economic, social, living, and physical experience of the elderly are main core observant areas, which leads to specific health conditions of the elderly, including dementia, cancer, increase in the number of falls, hypertension, and diabetes mellitus. These living experiences of the elderly are becoming the reason for depression, anxiety, and psychotic disorders. Regarding the social needs of the elderly, more attention in terms of humanity and cultural need should be paid as the main obstacles in social interaction is deteriorating health conditions, poverty, and less access to services which may be eliminated by assisting the less privileged. It is imperative to organize activities such as exercise classes, puzzle games, life story exercises in centres for the elderly that are beneficial for their mental and physical health and crucial for social interaction.

Conclusion
The narrative of the elderly residing in the Noble Care centre implicates the real picture of loneliness, sadness, pain, and disregard from familial neglection, abandonment that leads to the increasing percentage of mental illness and chronic diseases among the elderly population. Ministry of Health Malaysia, Institute for Public Health (2015) statistics revealed that 30.3% elderly population are facing hypertension, 47.7% have hyper cholesterol anaemia, and 17.5% have diabetes mellitus. These figures are not to be ignored since they could indicate the silent suffering among elderly patients. Hence, healthy and active ageing demands social engagement, familial support, and community care. Thus, the elderly need to be mentally vigorous for social interaction, indulging themselves in different hobbies and interests, and may be able to take responsibilities rather than lose themselves in the dark side of ageing. Positive thinking and an active body will help them establish an affirmative relationship with action, social status, and life satisfaction. Practically, the elderly care centres provide living support to the elderly. In contrast, emotional support is needed from family, and it will help the elderly cope with ageing in a gracious manner. Their inner sadness and silent screams will no longer be captured in their weakening and vulnerable heart if the balance of support, care, love, and well-equipped facilities are surrounding their lives at all times. They also can share their laughter and concern with the people they can trust and rely on at the centre. Hence, the present study stresses that social policies emphasise familial interaction, support, and care system for healthy and graceful ageing in Malaysia. This study's findings may benefit the policymakers, i.e. the government, who are keen on reducing oldage costs to improve the elderly life standard concerning accommodation, health condition, safety, and security. In addition, the entrepreneurs and caregivers at the centres could benefit from this study by getting a more indepth understanding of the real feeling and thinking of the elderly involved in this study. The participants' heart-wrenching stories may reflect other elderlies' loneliness and painful life journey as well. Thus, the entrepreneurs and caregivers can try their best to learn how to be closer, more caring and understanding of each elderly under their personal care. Ultimately, the elderly happiness and satisfaction will ensure their centres' sustainability in the long run. However, this study comes with a limitation that lies in the fact that only five participants could be interviewed, and only one centre involved. Thus, future studies should cover more centres and more participants to get a broader view. Finally, it is in the best hope the findings could also guide policymakers to advocate social welfare policies emphasising moral education on welfare and care of the elderly.