1. health and fitness

13TL1642_Beard
Viewpoint
LW
THELANCET-D-13-01642
S0140-6736(14)61461-6
Embargo: [add date when known]
Towards a comprehensive public health response to
population ageing
John R Beard, David E Bloom
Worldwide, populations are rapidly ageing. This
demographic shift presents both opportunities and
challenges. Most people aspire to live a long and healthy
life, and older people (defined as older than 60 years in
some studies and older than 65 years in others; appendix)
can be valuable economic, social, cultural, and familial
resources. However, ageing populations are also
associated with a shrinking workforce and higher demand
for health care, social care, and social pensions.
Evidence suggests that many of the challenges
associated with population ageing can be addressed by
changes in behaviour and policy,1 especially those that
promote good health in older age. However, so far, the
debate on how best to achieve these changes has been
narrow in scope.2,3 A comprehensive public health
approach to population ageing that responds to the
needs, capacities, and aspirations of older people and
the changing contexts in which they function is needed.
Several factors make development of a policy on
ageing difficult. First, the changes that constitute and
affect ageing are complex.4 These alterations only loosly
correspond to chronological age, which changes at a
steady rate, whereas the variations in functioning linked
with ageing are neither smooth nor well defined.5 As a
consequence, great inter-individual functional variability
is a hallmark of older populations; thus, policies to meet
the needs of older people should consider many
different subpopulations. For example, although some
older people might wish to continue to participate in
social and occupational activities to a similar extent to
younger people, less healthy individuals in the same age
group might need substantial health and social care and
have little capacity for social engagement. Encompassing
such diversity in a simple policy framework is difficult.
Second, this diversity is not random. Roughly 25% of
the heterogeneity in health and function in older age is
genetically determined,6 with the remainder dominated
by the cumulative effect of health behaviours and
inequities across the life course.7 Thus, someone born
into a poor family with limited access to education, or in
a marginalised cultural group, is likely to have poor
health in older age and earlier mortality. Recent findings
suggest that there might even be an association between
the ability to build financial security in older age and
decision making that maintains healthy behaviours.8
Policymakers need to ensure that their interventions
do not reinforce these inequities. For example, a
common policy response to increasing life expectancy
has been to raise the age at which pensions can be
accessed. This response is consistent with findings from
a US survey9 suggesting that a substantial proportion of
www.thelancet.com Vol 384
people want some form of work beyond traditional
retirement ages, with a preference for workplace
flexibility. However, there are widespread barriers to
employment at older ages, including negative attitudes
of some employers and restricted access to training in
new technologies. If these barriers are not addressed,
increasing the pension eligibility age might remove a
crucial financial safety net. Delayed access to a pension
might be particularly challenging for older individuals of
low socioeconomic status who, in addition to being
more likely to have substantial health problems, often
work in the most physically demanding jobs and have
the fewest alternative job opportunities. Ensuring both
economic sustainability and health equity will be a
formidable challenge in the development of a public
health response to population ageing.
Major knowledge gaps make overcoming these
complex challenges difficult. For example, although life
expectancy in older age is increasing in almost all
countries, this Series emphasises that the quality of these
additional years remains unclear.10 Incredibly, we cannot
yet tell decision makers whether people are living longer
and healthier lives or are simply experiencing extended
periods of morbidity.
Several major longitudinal studies now underway will
help to fill these knowledge gaps. However, the methods
of obtaining and interpreting information about ageing
and health also need to be reconsidered if we are to make
meaningful progress.
For example, this Series reinforces that, regardless of a
country’s income level, the major causes of death and
disability in older age are non-communicable diseases.
Much of this burden can be prevented or delayed, and
increasing emphasis is being given to early life strategies
of enabling healthy behaviours and controlling metabolic
risk factors. However, the risks associated with these
characteristics continue into older ages, although this
relation might attenuate, and strategies to reduce their
effect continue to be effective. Yet, despite clear evidence
of the importance of continued risk factor modification
into older age, surveillance of health behaviours in older
people is imperfect, and data that are available suggest
that behaviours that put older people at risk remain
widespread.11 A greater emphasis on the neglected areas
of health promotion and disease prevention in older age
may yield substantial benefits.
Furthermore, regardless of how effectively noncommunicable diseases can be prevented or delayed,
many older people will inevitably be affected. Improved
systems are needed to provide chronic management
for, and adequately address the consequ­ences of, these
Department of Ageing and Life
Course, World Health
Organization, Geneva,
Switzerland
(Hon Prof J R Beard PhD); and
Harvard School of Public
Health, Harvard University,
Cambridge, [A: city correct?]
MA, USA (Prof D E Bloom PhD)
Correspondence to:
Hon Prof John R Beard,
Department of Ageing and Life
Course, World Health
Organization, Geneva 1211,
Switzerland
[email protected]
See Online for appendix
1
Viewpoint
disorders. One barrier to building these systems is the 1 probably not directly applicable to them. Innovative
lingering perception that this chronic disease burden is approaches are needed to bridge this gap, identify the
made up of individual diseases that are best managed optimum treatments for individuals with several
independently. In reality, older people are more likely to disorders, and minimise adverse drug interactions. Until
have multiple, coexistent, and inter-related problems, 5 these methods are developed and adopted, improvement
and this multimorbidity is commonly manifested in post-marketing research could provide some guidance.
Finally, population ageing is not taking place in isolation.
through a loss of function and the broad geriatric
syndromes of frailty and impaired cognition, Other broad social changes are transforming society and
continence, gait, and balance.12 Functional assessments these are interacting with ageing to affect social and
of these syndromes are better predictors of survival 10 intergenerational dynamics. Understanding the interplay
than the presence or number of specific diseases,13 so between these trends is crucial if policy makers are to
the fact that comprehensive assessment and make the best decisions to promote the health and
coordinated care provide the best outcomes in older wellbeing of older people.
Foremost among these factors is the changing situation
adults should not be surprising.14 Yet, informed geriatric
assessment and coordinated care remain the exception 15 of older people in society. However, in many parts of the
rather than the norm, and much research fails to world, policy often seems to assume a division of the life
course into a series of stages that is based on chronological
consider these more holistic perspectives.
Additionally, the importance of non-communicable age and social roles—typically student, working age, and
diseases in older age should not obscure other health retirement—that have little physiological basis. This rigid
issues. Although our understanding of the burden of 20 framework prevents the flexible types of participation
communicable disease in older age is poor, these older people are increasingly seeking9 and is exacerbated
disorders clearly remain an important cause of morbidity by ageist stereotypes of frailty and mental diminution.
and mortality in older populations, particularly in Effective health, social, and economic policy needs to
low-income and middle-income countries. However, acknowledge the changing aspirations of older people
outdated perceptions of behaviour in older age could 25 rather than reinforce outdated stereotypes.
limit both surveillance and response. For example, older
Additionally, typical household composition is changing,
people, particularly those who are unmarried, might not along with attitudes about the obligations and respon­
be regarded as sexually active, and are often excluded sibilities that might be expected of different generations.
from HIV screening programmes or advice on safe sex Increased spatial mobility and changes in family structure
practices. At the same time, individuals with HIV are 30 mean that, in many countries, older people are
living longer, increasing the likelihood that a sexually increasingly living alone or as part of a couple, rather than
active older person will face exposure to HIV via a in the larger, multigenerational households of the past.
potential sexual partner. Older individuals with HIV For example, in some European countries nearly 50% of
infection also need specific clinical management.15 For women aged 65 years or older live alone.18 These trends
services addressing the prevention and treatment of HIV 35 present challenges, since older people living alone have
and other infectious diseases to have maximum effect, less opportunity to share the resources typically available
they will need to adapt to changing demography.
in a larger household and might also be at increased risk
Although vaccination can reduce the burden of infectious of isolation, depression, and suicide.
disease across the life course, immune function,
Provision of care and support by families to older
particularly T-cell activity, declines with age. These changes 40 people with substantial functional decline is becoming
mean that the capacity to respond to new infections and more difficult because of changing household structures.
vaccinations decreases in later life—a tendency known as This challenge is exacerbated by the increasing proportion
immunosenescence. Furthermore, an age-related increase of older people compared with younger family members
in serum concentrations of inflammatory cytokines— and by internal and external migration of younger
known as inflammaging—has been linked to a broad 45 generations. This change in balance is even evident in
range of outcomes including frailty, atherosclerosis, and sub-Saharan Africa, where the HIV epidemic has
sarcopenia. Fresh consideration of these trends might removed potential support for nearly 1 million older
provide innovative interventions for older age groups in people that would have been normally forthcoming from
the future.16
younger generations.19
A more comprehensive understanding of population 50 These changes are stimulating increasing debate on
ageing starts with research. However, many established the roles of government and family in providing the
mechanisms for development and assessment of clinical social care many older people need. Changing gender
interventions have not been adapted to population ageing. norms add a further layer of complexity to this debate.
Despite being the most frequent users of many drugs, In most cultures, traditional carer roles are assigned to
older people are generally excluded from clinical trials.17 55 women. This role limts their capacity to engage in the
Yet, their altered physiological status means that the formal workforce, which [A: sentence changes ok?]
evidence we extrapolate from younger populations is places them at greater risk of poverty, abuse, and poor
2
www.thelancet.com Vol 384
Viewpoint
health in older age, while reducing their access to 1 To optimise trajectories of functioning, health
quality health care, social care services, and pensions. systems could be redesigned to better provide
The increasing participation of women in the workforce coordinated and informed geriatric services that enable
will help overcome this inequitable burden and will older people, as much as possible, to age in place (eg, at
have great benefits for socioeconomic development, but 5 home or in the community). Ideally, these services
it will also challenge traditional familial roles and would be seamlessly linked with social and long-term
restrict families’ capacity to provide informal care at the care to provide a continuum of care that extends from
same time that demand for it is growing. New, the community to, where indicated, institutionalised
sustainable models of care that balance the role of care. Core services would include prevention and early
family and government, and that overcome gender 10 detection of disease, acute and chronic rehabilitation,
provision of assistive devices, and palliative care. The
inequities, are urgently needed.
Advances in information and communications importance of each of these services would differ
technology, assistive devices, medical diagnostics, and between settings, dependent on demographics and
interventions offer much promise. For example, the level of socioeconomic development.
advent of wearable devices that can continuously monitor 15 Although few low-income and middle-income
physical activity may rapidly transform our understanding countries have established such a continuum of care,
of functional trajectories and their determinants. However, there is an opportunity for existing health services to be
if the benefits of technological advances are to be fully adapted to better meet the unique needs of older
realised, designers must also better understand the people.20 These adaptations might include basic geriatric
changing needs, capacities, and aspirations of older 20 training for all health staff, or practical steps such as
people. A greater focus on how these innovations might reducing queuing time for frail older people. Diagonal
meet the specific needs of older people in low-income and approaches—an integration of vertical models that focus
middle-income countries is also needed.
on a disease and horizontal models that focus on
Thus, an effective public health response to population health-care delivery systems—might also be considered
ageing must take into account the diversity in the 25 to meet emerging needs (eg, control of hypertension) by
health, social, and economic circumstances of older building on existing services (eg, chronic HIV care).
people, the disparities in the resources that are available
In all settings, greater attention will need to be given to
to them, concurrent social trends, changing aspirations, building and supporting an appropriately trained
and knowledge gaps. How can such a response be workforce, including both formal and informal carers.
achieved? First, health needs to be viewed in a way that 30 Relying on international health worker migration is
is relevant to all older people. In view of the likelihood problematic since it can simply shift shortages from
of comorbidity and the centrality of geriatric syndromes more to less developed countries. Strategies to retain
in older age, a conceptual framework that focuses on older health workers, and perhaps to recruit and train
functioning rather than disease would probably be most older people as new health workers, will therefore be
relevant. Public health policy for ageing could then be 35 important. For those entering the workforce, a greater
designed to maximise levels and trajectories of emphasis on geriatrics in core medical training
functioning in older age and the ability of older people curriculums, along with a rethinking of the culture of
to do the things that are important to them regardless of many clinical services that treat older people as generic
their functional capacity.
vessels of single-organ disease, is essential.20,21
This approach has several strengths. Fostering 40 Finally, since functioning is inextricably linked to
functional capacity can take place at all stages of older context, a comprehensive public health strategy would
age, and before, and is a worthwhile goal even for the need to take into consideration the physical and social
frailest or most cognitively impaired people. This environment. In recent years, several interventions have
process would also lead to a thorough consideration of been developed to create environments that foster active
the contextual factors—including issues of equity—that 45 and healthy ageing. These include the WHO Global
are so fundamental to wellbeing in older age, and will Network of Age-Friendly Cities and Communities,
probably encourage the development of the more which now has over 200 members responsible for almost
coordinated systems of health and social care that best 100 million people.22 Not all the resulting strategies will
address the needs of older people.
need complex policy measures. For example, older
Such coherence is absent from most policy 50 people repeatedly identify simple aspects of the urban
approaches, which insufficiently address key aspects environment, such as access to public toilets and seating
of heterogeneity among older populations.3 Instead, in public spaces, as crucial to their social engagement.
For development of this comprehensive public health
policies often emphasise either the need to minimise
the economic costs of population ageing—more recently response a rigorous evidence base that can serve to
by maximising the labour participation and net 55 counter entrenched stereotypes and identify the most
contribution of older people—or the goal of meeting the cost-effective strategies for the future is needed, followed
by mechanisms to ensure this evidence is translated into
needs of the most vulnerable.
www.thelancet.com Vol 384
3
Viewpoint
policy and practice. Some obvious knowledge gaps that 1 5
urgently need to be filled include our understanding of
the actual and potential contributions and costs of older 6
populations; changing patterns of morbidity in
older populations; optimum clinical interventions 5 7
in older age, especially pharmacological interventions;
optimum ways to manage comorbidities and complex
issues such as frailty; quality of the additional years 8
engendered by increased life expectancy; and effect of
strategies to create more age-friendly environments. A 10 9
good start would be to extend the collection and analysis
of routine data to older ages and both institutional and 10
home settings. Identification of the best way to obtain
relevant data on functioning will also help.
11
This Series is a useful step towards filling many of 15
these gaps. Recent work started by WHO will also help;
the World Health Assembly has agreed to prioritise work 12
on ageing and to develop a World Report on Ageing and
Health, followed by a Global Strategy and Action Plan.
13
Such progress will build on existing initiatives, such as 20
projects on knowledge translation in Ghana and China,
to help establish evidence-based policy on ageing and
14
health. World demographics are changing: our thinking
and research, and their manifestations in policy, have to
change with it.
25
15
Contributors
JRB and DEB contributed to the design, content, and writing of this
Viewpoint.
16
Declaration of interests
We declare no competing interests.
30 17
Acknowledgments
We thank many colleagues who reviewed the paper in part or in whole for
their advice, particularly Jeffrey Adams, Des O’Neill, Jean-Pierre Michel,
Larry Rosenberg, Aki Kuroda, and Laura Wallace. The views expressed in
18
this manuscript are those of the authors and do not necessarily represent
the views or policies of WHO or any other organisation with which the
35
authors are affiliated or from which they derive financial support. DEB’s
work on this Series was supported by grant P30AG024409 from the
National Institute on Aging to the Harvard School of Public Health.
References
19
1 Bloom DE, Canning D, Finlay J. Population aging and economic
growth in Asia. In: Ito T, Rose A, eds. The economic consequences 40
of demographic change in east Asia. Chicago: University of Chicago
Press, 2010: 61–89.
20
2 Lloyd-Sherlock P, McKee M, Ebrahim S, et al. Population ageing
and health. Lancet 2007; 379: 1295–96.
21
3 Stephens C, Breheny M, Mansvelt J. Healthy ageing from the
perspective of older people: a capability approach to resilience.
22
Psychol Health 2014; published online April 29. DOI:10.1080/088704 45
46.2014.904862.
4 Kirkwood TB. A systematic look at an old problem. Nature 2008;
451: 644–47.
Steves CJ, Spector TD, Jackson SH. Ageing, genes, environment
and epigenetics: what twin studies tell us now, and in the future.
Age Ageing 2012; 41: 581–86.
Brooks-Wilson AR. Genetics of healthy aging and longevity.
Hum Genet 2013; 132: 1323–38.
González-González C, Samper-Ternent R, Wong R, Palloni A.
Mortality inequality among older adults in Mexico: the combined
role of infectious and chronic diseases. Rev Panam Salud Publica
2014; 35: 89–95.
Gubler T, Pierce L. Healthy, wealthy, and wise: retirement planning
predicts employee health improvements. Psychol Sci 2014; published
online June 27. DOI:10.1177/0956797614540467.
Age Wave. SunAmerica retirement re-set. http://www.agewave.com/
research/landmark_RetirementReSet.php (accessed Aug 1, 2014).
Crimmins EM, Beltrín-Sínchez H. Mortality and morbidity trends:
is there compression of morbidity? J Gerontol B Psychol Sci Soc Sci
2011; 66: 75–86.
Lloyd-Sherlock P, Beard JR, Minicuci N, Ebrahim S, Chatterji S.
Hypertension among older adults in low and middle income
countries: prevalence, awareness and control. Int J Epidemiol 2014;
43: 116–28.
Lee PG, Cigolle C, Blaum C. The co-occurrence of chronic diseases
and geriatric syndromes: the health and retirement study.
J Am Geriatr Soc 2009; 57: 511–16.
Lordos EF, Herrmann FR, Robine JM, et al. Comparative value of
medical diagnosis versus physical functioning in predicting the
6-year survival of 1951 hospitalized old patients. Rejuvenation Res
2008; 11: 829–36.
Ellis G, Whitehead MA, Robinson D, O’Neill D, Langhorne P.
Comprehensive geriatric assessment for older adults admitted to
hospital: meta-analysis of randomised controlled trials. BMJ 2011;
343: d6553.
Cordery DV, Cooper DA. Optimal antiretroviral therapy for aging.
Sex Health 2011; 8: 534–40.
McElhaney JE, Zhou X, Talbot HK, et al. The unmet need in the
elderly: how immunosenescence, CMV infection, co-morbidities
and frailty are a challenge for the development of more effective
influenza vaccines. Vaccine 2012; 30: 2060–67.
Gurwitz JH, Goldberg RJ. Age-based exclusions from cardiovascular
clinical trials: implications for elderly individuals (and for all of us):
comment on “the persistent exclusion of older patients from
ongoing clinical trials regarding heart failure”. Arch Intern Med
2011; 171: 557–58.
Central Statistics Office. Ageing in Ireland, 2007. http://www.cso.ie/
en/media/csoie/releasespublications/documents/
otherreleases/2007/ageinginireland.pdf (accessed mmm dd, yyyy).
[A: Please provide date accessed. Reference correct? I wasn’t sure what
you meant by “reference 71 in “Central statistics office government of
Ireland 2007”. Section 3.2 in this pdf shows a table of people aged 65
years or older who live alone]
Kautz T, Bendavid E, Bhattacharya J, Miller G. AIDS and declining
support for dependent elderly people in Africa: retrospective analysis
using demographic and health surveys. BMJ 2010; 340: c2841.
O’Neill D. A piece of my mind. To live (and die) as an original.
JAMA 2012; 308: 679–80.
WHO. Towards age friendly primary health care. Geneva: World
Health Organization, 2004.
Beard J, Petitot C. Aging and urbanization: can cities be designed to
foster active aging? Public Health Rev 2011; 32: 427–50.
50
55
4
www.thelancet.com Vol 384