“We were older then, we are younger now”
Dr John Beard, Director, Ageing and Life Course
When is someone old?
One question that I am often asked is “When is someone old?"
The more I work in the field of healthy ageing, the more difficulty I have providing an answer. There are, of course, definitions that are used for statistical purposes – the UN has historically adopted 60 years as a cut-off. But the link between chronological age and the health and functional status of an individual is tenuous at best.
And many other factors may have just as significant an influence on an older person’s ability to do the things they value. For example, the attitude of business to employing older people is likely to have a very strong influence on whether they can continue to work. Similarly, the presence of disabled access public transport can help determine whether an older person gets where they want to go, regardless of any functional limitations they may have.
So this is not just a question for statisticians. I am 59 years old and have just welcomed a gorgeous son to my family. I seem to be in pretty good health. Next year my son will be 1 and I will be 60. Will I be old?
Increasing numbers of people the world over are likely to ask themselves the same thing. By 2050, the world’s population aged 60 years and older is expected to total 2 billion – up from 841 million today. Eighty per cent of these people will live in what are now low- or middle-income countries.
Our goal should be for long life in good health
This is a huge success for public health. But our goal should be for people not just to live longer, but to have healthier, more fulfilling lives.
To achieve this, much will have to change. Unfortunately, the information we have on what might work and what doesn’t is very limited. For example, while we know people are living longer, we do not yet know whether they are living those additional years in good or poor health. It seems likely this will depend considerably on where you live.
Dispelling outdated and “ageist” perspectives
We are not simply challenged by knowledge gaps. We are held back by myths that have emerged in an effort to fill these gaps. These often reinforce outdated and “ageist” perspectives on what getting older means for the individual and for society.
One example is the myth that providing health services for an ageing population will necessarily be unaffordable. This does not fit with the evidence which shows that the last 18 months of life place most demand on health systems, regardless of how old you are. And, interestingly, the costs of health care in the last 18 months of life appear to drop significantly when someone reaches 80, when conventional health services are often replaced by different forms of long-term care.
Furthermore, research suggests that while population ageing will certainly lead to an increase in expenditure on health care, the introduction of new technologies and treatments is likely to have a much bigger impact, as is the natural tendency for countries and individuals to spend more on health as they get richer. There are also many inefficiencies in most health systems that have an enormous influence on costs.
It is now becoming clear that the way we design services makes a difference too. Hospitals designed to manage individual diseases separately have much poorer outcomes for older patients than those that provide holistic and coordinated care. This is because as we get older, the health conditions we experience change. Young people may have single, curable disorders, but older people are more likely to experience chronic conditions, and experience more than one of them at a time.
Reinventing health systems
Instead of focusing on making current approaches more affordable, perhaps it would be more useful to invent systems that are not just sustainable but that can better meet these complex health needs. At their core, these systems would centre on the functional capacity and quality of life of the older person. One way of getting there would be greater use of comprehensive health assessments. These can identify all relevant health conditions and risks, but, rather than managing each of these separately, they would take into account underlying problems and prioritize the issues that are most important for the older person, both at that time and for the future.
This holistic starting point could be linked to an interdisciplinary team of providers that spans the full range of services the older person may require including prevention, acute and chronic care and long-term care. Sound too good to be affordable? In fact research suggests it may not just be better for the older person, but no more expensive for the health system.
A woman who lives near me here in Geneva is a good example of how this can work. She is in her eighties and started to lose weight, become anaemic and look very frail. She also lost a lot of energy. Her family doctor thought she may be getting depressed. It looked like she would require treatments for her depression, iron tablets for her anaemia and nutritional supplements. Her weakness put her at risk of falling and possibly a long and expensive hospital stay. Overall, it seemed like a downward spiral that was likely to result in admission to a nursing home. But a comprehensive assessment identified the real problem was with her teeth. When this was fixed she gained weight and strength, got her old energy back and is now babysitting for her great grandchildren. Ask her if she is old and she will say “heck no”.