Populations around the world are ageing due to increased life expectancy and falling fertility. These shifts have been driven by improved healthcare, better infrastructure and medical innovations. But why do so many people struggle to see this as a good thing?
The WHO’s recent World report on ageing and health recasts the “problem”. Rather than pointing the finger at older people and stereotyping them as a burden, the Report says the real challenge has been the failure of society and social institutions to adapt to these changes.
Rather than pointing the finger at older people and stereotyping them as a burden, the Report says the real challenge has been the failure of society and social institutions to adapt to these changes.
After all, society easily coped with life expectancy rates rising from mid 40s to 60s in past centuries and has always seen this as a positive. And why do we find this adaptation difficult? – the place to start is our ageist stereotypes. These tend to fall at two ends of the spectrum: we either assume that all older people are frail and dependent on the rest of society or else that they are healthier than previous generations and should all be engaged as active members of the workforce until the end their seventh decade. The fact is that some will be frail, some will be robust enough to work full time into quite advanced age while most will be somewhere in the middle.
The fact is that some will be frail, some will be robust enough to work full time into quite advanced age while most will be somewhere in the middle.
These stereotypes underpin many misconceptions of older age can and do lead to bad policy.
For example, one of those incorrect assumptions is that older people cost more money in terms of healthcare and will place unsustainable pressures on health systems. Yes, people do tend to have more health problems as they get older, but studies have shown that the majority of the extra cost comes from services provided in the last 18 months of their lives. Somewhat counter intuitively, just because people are living longer does not mean more people are within the last 18 months of life. Indeed, in the UK, while slow population ageing continues, the proportion of people in this high cost period is falling. We also know that the relationship between increased healthcare costs and advancing age varies between different healthcare systems. Costs are much higher in provider driven, fee for service systems or when a large proportion of older people die in intensive care units. Systems that offer alternative services such as long term care and palliative care are much less costly and may have better outcomes. And how many of us really want to die in intensive care anyway?
Older people can be very resilient but we also know that small issues, if ignored, can have a major impact on their quality of life. So for example, good dentistry is very important in older people if they are to maintain good nutrition. Technology and supportive devices can also help people who have lost some capacity to adapt and compensate for these losses.
While families will generally be the mainstay when older people need long-term care and support, it is also wrong to think they can carry the burden alone. In countries like China and Iran where some of the fastest ageing populations is occurring, far fewer older people now live in multi-generational households than 30 or 40 years ago. This means providing this care, and the reciprocal care older people often provided to younger generations, is much harder. Moreover, family care is most often provided by women, who now have different career expectations than in the past. These social norms have changed very quickly so governments need to be careful not to assume current social mores will continue unchanged.
Around the world, I don’t think that any country has developed a perfect system but some are closer to the ideal than others. In the UK, there are already a number of coordinated care pilot projects which are looking at better integration of health and social care. One limitation is that while studies show that this leads to older people receiving better care, the financial implications are less clear. We need more evidence to persuade decision makers that this the way forward.
If we can change the way that health systems are designed, we can achieve the results we need, but this will take political will. We need to bridge knowledge gaps and look at what people really want in old age.