building a society for all ages

Second World Assembly on Ageing Madrid, Spain 8 -12 April 2002

Advancing health and well-being into
old age: the case for active ageing

"We are in the midst of a silent revolution. It is a revolution that extends well beyond demographics, with major economic, social, cultural, psychological and spiritual implications. And it is a revolution that hits developing nations harder than others, and not just because the majority of older persons live in developing countries, but because the tempo of ageing there is already - and will continue to be - far more rapid."
United Nations Secretary-General Kofi Annan

Population ageing raises many issues for policy makers, and providing affordable health care is one of the most important. Will a proportionately smaller number of working adults be able to provide the support that older people need? Will large numbers of older people bankrupt our health care and social security systems? How do we help older people remain independent and active? How do we best balance the role of the family and the state when it comes to caring for older people who need assistance? How can we best make use of older people's wisdom, experience and talents? Now that people are living longer, how can we improve the quality of life in old age? How can we afford to grow old?

There are those who say that we just can't.

Better health, better ageing, better living
But the World Health Organization suggests that we can afford to get old-if countries, regions and international organizations enact policies and programmes that enhance the health independence productivity and security of older persons. In all countries-but in developing countries in particular-measures to help older people remain healthy and economically active are a necessity, not a luxury.

Older people spend more of their income on health than any other need or activity. The average overall cost of health care due to ageing alone is expected to increase by 41 per cent between 2000 and 2050, which will represent an increase of 36 per cent for developing countries and 48 per cent for developed.

The challenges presented by a growing ageing population must be addressed at the global, national and local levels. In developed countries and in countries in transition, meeting these challenges will require innovative planning and substantive policy reforms. Developing countries, most of whom do not yet have comprehensive policies on ageing, face the biggest challenges of all. Failure to deal with demographic imperatives and rapid changes in disease patterns can have far-reaching negative consequences for government budgets and individual well-being. The time to act is now.

In 2000, 62 per cent of those aged 60 and over lived in less developed regions. By 2050, this will increase to 80 per cent. However, socio-economic development in the developing world is not keeping pace with population ageing.

Rapid ageing in developing countries will be accompanied by dramatic changes in family structures and roles, as well as in labour patterns and migration. Urbanization, smaller families, and more women entering the formal workplace mean that many fewer people will be available to care for older people when they need assistance.

· In France, it took 115 years, from 1865 to 1979, for the proportion of older persons to more than double, from 7 to 17 per cent,

· In China, it is expected that it will take only 27 years, from 2001 to 2027, for the proportion of older persons to double from 7 to 14 per cent.

Rapid population ageing will lead to increasing and changing demands on health care systems. In older societies, health care systems will have to adapt to increasing proportions of the oldest old.

Disability and the double burden of disease
As nations grow older, and as living and working conditions change, patterns and types of diseases also shift. This shift will hit developing countries the hardest. Even as these countries continue to struggle with malnutrition, complications from childbirth, and infectious diseases such as HIV/AIDS, malaria and tuberculosis, they will also have to face the rapid growth of non-communicable diseases. This "double burden of disease" will strain already scarce resources to the limit.

Chronic illnesses, such as heart disease, cancer and mental disorders, are fast becoming the world's leading causes of death and disability, including in the developing world. In fact, according to the World Health Report 2001, non-communicable diseases now account for 59 per cent of all deaths globally.

In both developed and developing countries, chronic diseases are significant and costly causes of disability and reduced quality of life. An older person's independence is threatened when physical or mental disabilities make it difficult to carry out the basic activities of daily living such as bathing, eating, using the toilet and walking across the room, as well as shopping and meal preparation.

The likelihood of experiencing major disabilities dramatically increases in very old age, and within the age group of 60 years and over, adults over the age of 80 are the fastest growing group. But disabilities associated with ageing can be prevented or delayed. In many developed countries, there has been a marked decrease in the amount of age-related disability over the last 20 years. This reduction of disability in older persons considerably lessens the burden and expense of care-giving. The good news is that the onset of disease and functional decline can be prevented or slowed. As individuals grow older, the status of their health becomes more diverse. A life course perspective offers a better way of looking at how to maintain optimal health and well-being into old age.

A life-course perspective supports action in early life that will enhance health and well-being throughout life, and lessen disability. In adult life, ageing activities should support the highest possible functioning and prevent, reverse or slow down the onset of disease. In later life, activities should focus on maintaining independence, preventing and delaying disease and improving the quality of life for older people who live with some degree of illness and disability. Policies and programmes that focus on community-based development, health promotion, disease prevention and increasing productivity are relatively inexpensive but so far have received little attention. Policies that target the reduction of poverty and malnutrition will reduce both communicable and non-communicable diseases. Efforts in both areas can bring substantial benefits and reduction in costs.

Good choices, better results
Poor public health policies can result in processes that are disabling, and thus increase the needs of older people and lead to isolation and dependence. Good policies, however, can result in enabling processes that can restore function and expand the participation of older people in all aspects of society.

Injuries resulting from cars hitting pedestrians tend to be higher for older people than any other age group.

Policies that are age-friendly include efforts to provide well-lit streets and good transport systems, recreation services that offer exercise programmes for older people, educational services that offer life-long learning and literacy programmes, social services that can provide hearing aids or instruction in sign language, enabling rehabilitation programmes, cataract and hip replacement surgery, flu shots, and credit.

Time for a change of perspective on old age
Traditionally, old age has been associated with sickness, dependency, and a lack of productivity. Today, this traditional view is considered just plain wrong, and now, public policies must reflect this change in thinking. In fact, most people are quite able to adapt as they grow older and remain independent well into very old age. In developed countries, older persons continue to work in paid and unpaid work. Voluntary activities of older people make an important contribution to society. By encouraging and enabling their participation, and realizing their vast potential as resources, the problem of an ageing population can be transformed into the benefit of a mature one.

The feminization of ageing
Women tend to live much longer than men, and they are much more likely to be poor. As they live longer, they are more likely to suffer the disabilities that come with old age. And because of their lower status, their health needs are often neglected or ignored. Too often, health care systems and public officials pay less attention to and provide fewer resources, such as home health care instead of hospital care, for the alleviation of disabilities that often affect women.

As populations age, a range of ethical considerations will assume more importance and acquire more visibility. These include the allocation of resources, medical interventions related to the undue hastening or delaying of death, genetic research and manipulation, and a host of dilemmas linked to long-term care and the human rights of poor and disabled older citizens. Advocacy, ethical decision-making and upholding the rights of all older people must be central strategies in any plan on ageing.

Poverty and health are related. The poor of all ages everywhere suffer more disabilities and earlier deaths, and the very poor suffer the most. Each step up the socio-economic ladder adds healthy years to life. But structural inequities in both developing and developed countries can lead to the exclusion and impoverishment of older people, resulting in a lack of or unequal access to education, employment and health care. For older people who are poor, the consequences of earlier experiences are worsened through further exclusion from health services, credit schemes, income-generating activities and decision-making. In many cases, older people simply do not have the means to achieve dignity and independence, to receive appropriate care and to participate in civic affairs.

Growing older without growing old -active ageing

Active ageing is the process of optimizing opportunities for physical, social, and mental well-being throughout life, in order to extend healthy life expectancy, productivity and good quality of life into older age.

The World Health Organization (WHO) has promoted the idea of "active ageing," a concept aimed at supporting policies that will keep people active for as long as possible. Health, well-being and productivity at older age depend on a variety of factors, and through the right environment, people have a greater opportunity to enjoy a more productive life. These factors include:

· Gender and culture-gender can have a profound effect on such factors as social status, ways to access care, meaningful work and access to nutritious food. Cultural values and traditions determine to a large extent how a society views and treats older people.

· Health and social service systems should promote active ageing. They should educate, encourage and enable people to take control over their own health, including through disease prevention activities. Health and social services must be cost effective, and they must provide equal access, especially to older poor, and most especially, to those living in rural areas. It is important that health and social systems have built-in mechanisms that will ensure respect to older persons who are very sick and who are dying. The terminally ill must be allowed to die in dignity, in conditions that they themselves determine, to the condition allowed, and surrounded by people of their choosing.

· Economic factors: income, work and social protection - Many older people lack reliable or sufficient incomes. Active ageing policies must coincide with broader schemes to reduce poverty and increase the involvement of older people in income-generating activities. Older people can make productive contributions in paid, unpaid and volunteer work.

Families everywhere provide the majority of support for older people who require help. But governments will increasingly be called upon to provide social protection for older people who are alone and vulnerable. A balanced approach to providing social protection can enable societies who are willing to plan to be able to afford to grow old. The goal must be to recognize and harness the skills and experience of older people and to ensure adequate living standards for them.

· Factors in the physical environment. Physical environments that are age-friendly can make the difference between independence and dependence for some older people. Older people who can safely go outside and walk to a neighbour's house or to the park can increase fitness and mobility and are less likely to suffer from isolation and depression.

· Factors in the social environment. Social-support, opportunities for education and lifelong learning, and protection from violence and abuse are key factors in the social environment that enhance health, independence and productivity in older age. Loneliness, social isolation, elder abuse, illiteracy and lack of education and exposure to conflict situations greatly increase the risk for disabilities and early death.

· Personal factors. Three key personal factors in how well a person ages are biology, genetics and adaptability. Natural losses in some cognitive capacities can be compensated for by gains in wisdom, knowledge and experience. At the same time, the dictum "use it or lose it" does apply, and such losses of cognitive function can be reduced or prevented by practice, behaviour and participation - mentally and physically.

· Behavioural factors. It is never too late to change habits. Moderate physical activity and healthy eating can improve mental health and reduce the risk of chronic diseases, in addition to delaying functional declines. Malnutrition in older adults can be a source of special concern, particularly because of their reduced ability to absorb certain nutrients. Sufficient calcium, vitamins D and B12 are particularly important, but a balanced and varied diet is essential. Vitamin deficiencies in older persons can lead to severe dementia.

Quitting smoking, even in older age, can substantially reduce one's risk for heart attack, stroke and lung cancer. Alcohol use, at very low levels (less than a drink a day), may offer some degree of protection against coronary heart disease and stroke for people age 45 and over. However, the adverse effects of heavy drinking outweigh these benefits.

Moving Forward
Promoting health for older people is one of the main objectives of the Second World Assembly on Ageing. With the goal of promoting health and independence, greater productivity for older persons, and better social protection, the governments and representatives of civil society will work to adopt the standards that will guide the development of health policies geared for ageing populations.

Many of the policies needed to support "active ageing" are not specifically directed toward the health sector. These include efforts to make older people part of society, to allow them to work, and to allow them to fully participate in civic affairs. But certain health interventions aimed at older are necessary.

In an effort to reduce the incidence of major disease, guidelines on physical activity and healthy diet must be developed. Public awareness campaigns are needed to discourage tobacco use and the misuse of alcohol and drugs. Health and social service professionals must be trained to counsel older people on healthy activities, and special effort must be made to reduce the risk of social isolation. In addition, health professionals must be trained in the specialized care of older persons, which can require very different approaches and treatments than care for younger people.

Efforts are also needed to include older people in prevention and education efforts to reduce the spread of HIV/AIDS, and this can be done through the development of health and social service systems that emphasize health promotion and disease prevention.

There are other health-related issues that must be confronted:

· Providing cost-effective, equitable and dignified long-term care.
· Eliminating age discrimination in health and social service systems.
· Reducing inequities in access to primary health care and long-term care.
· Ensuring high standards and stimulating environments in residential care facilities.
· Ensuring that all people have the right to death with dignity.
· Endorsing policies that allow people to die where they choose, surrounded by whom they choose.
· Making cost-efficient treatments, such as cataract surgery and hip replacements, available to older people with low incomes.
· Increasing affordable access to medications.
· Encouraging a wide range of suitable housing options.

This article was based on information provided by the World Health Organization

For further information, please contact:

UN Department of Public Information
United Nations, Room S-1040, New York, NY 10017

Published by the United Nations Department of Public Information DPI/2264 March 2002

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