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Round Table
Healthy
aging and the quality of life
Ian Darnton-Hill
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The size of the elderly population, both in numbers and as a proportion of the whole, is increasing rapidly in most parts of the world. This trend, together with other deep changes in society, has made traditional ways of understanding and accommodating the aging process inadequate. Surveys suggest that economic security, psychosocial well-being, and a sense of being in reasonably good health are the most important values to aim for.
Never before have so many people lived for so long (l). Already, in 1992, 18% of Sweden's population and about 13% of the populations of Japan and the USA were over 65 years old. In Japan, which has an average life expectancy of 79.1 years, it is anticipated that approximately 25% of the population will be over 60 years old by the year 2020. Aging, previously regarded as an emerging trend mainly in the industrialized countries, is now recognized as a global phenomenon. In 1990 more than half (55% of 176 million) of the elderly population of the world were living in the so-called developing world; by 2025, the proportion is expected to be 65%. Besides the increasing numbers of people over 65 years old, there are now many more who live considerably longer. Already, over 2% of the population are over 80 years old in countries such as Australia and New Zealand, and over 3% in Japan and Western European countries, and this is the portion of the population that will grow most quickly in the coming decades.
A major difference between countries has been the rates at which they have moved from having a relatively young population to being what is called an "aged society". In France, for example it took 115 years for the proportion of elderly people to double from 7% to 14 %, and it was predicted that this doubling would occur in Japan in only 25 years, between 1970 and 1995, but in fact it happened even more quickly, in about 20 years.
The ever-increasing number of elderly people means that questions concerning the quality of life in the extra years will continue to attract increasing attention and resources in the future. The quality of life in the elderly has come to be seen as depending mainly on socio economic security, psychosocial well-being, and perceived health.
Socio economic security appears to be a critical factor for countries and individuals alike. Countries with a gross national product of less than US$ 7000 per capita (in the early 1980s) have been found to be unlikely to have anaverage life expectancy exceeding 70 years. After a certain point, however, increasing affluence appears to produce little further change in life expectancy without social and other changes. Increased food availability has likewise been shown to be associated with increasing life expectancy, but with an upper limit, after which further increases in dietary fat intake may actually be associated with a reduction in life expectancy due to an increase in cardiovascular diseases and probably some cancers.
It has been persuasively argued that where the gap between the richest and the poorest sections of a community is smaller, average life expectancy is higher. Thus it appears to be the scale of income difference and the resulting sense of disadvantage within a society that affects average life expectancy more than affluence as such. In fact, the relative health status of the less advantaged groups has grown worse as the income gap has increased
When one's external and internal environments are understandable, meaningful and manageable, life satisfaction is positive. When they are unstable, or are considered likely to become so, life dissatisfaction increases.
in countries such as Australia, the United Kingdom and the USA, and there is concern that the same trend will soon be seen in China. In the United Kingdom, money and class were found to be important determinants of the quality of life before death as well as length of life. The implication of this is that even though middle-class people are living longer than people in lower socio economic groups and therefore might be expected to have more ill-health, they, in fact, also have less ill-health in the year before dying than those in poorer groups. It has been consistently found that about two-thirds of the variation in mortality rates in both developed and developing countries is related to the distribution of income in the nation's population (2).
Level of income and health status are the two most consistently found variables associated with life satisfaction among elderly people. A study on the role of elderly members of Filipino families found that a strong economic position within the household endowed individuals with more power than other household members, regardless of age or health status. Feelings of loneliness were correlated in the WHO-commissioned four-country study on aging not only with marital status, but also with the subject's current economic situation, socio economic status, physical health and physical and social functioning, associations that come up again and again in considerations of the quality of life in elderly people (3).
One of the effects of aging populations will be the drastic change in the ratio of people working to those retired, which will have fallen from approximately 6:1 in 1990 to 3:1 in 2030 in Japan, though less marked in less affluent populations. This will presumably lead to a shortage of wage-earners, who will increasingly have to come from women who previously stayed at home, and older people, including those above the current retirement ages. If this projection is correct, the current fear that many young people will never have the opportunity of being in the workforce may eventually turn out to be ill-founded.
In the shorter term, however, this could be a source of conflict between unemployed younger people who want to work and older people who want to go on working, a similar conflict to the one women faced when they started entering the workforce in significant numbers.
The current trend in Europe appears to be for people to take early retirement, although in countries such as Japan, 40% of men take a second job after retirement. There are marked differences in labour force participation rates between elderly men and elderly women, and between developed and developing countries. For example, rates range from less than 2% of elderly men in the workforce in Austria to 85% in Malawi. For women, rates range from 1% in some developed countries to 29% in the Philippines (1). In contrast to elderly men's declining work participation rates, rates among older women in developed countries have been rising or holding steady.
A study on employment, social networks and health in retirement Years found that continued employment into old age was generally associated with higher morale, happiness, better adjustment, longevity, larger social net- works and, no doubt partly because of these, to better perceived health (4). In the context of health promotion there is therefore support for the idea that the retirement age should be flexible, with the capability of each individual judged in relation to the specific demands of his or her job. A review of studies made in Finland, Japan, the United Kingdom and the United States cited evidence suggesting that "the accepted conventions about ageing are overly pessimistic and that older workers offer many advantages to industrial employers through their experience, attitudes, and commitment", and that rates of absenteeism were actually lower among older workers (5).
In Canada, it was found that those who aged successfully were those who had reported greater satisfaction with life when questioned 10 years earlier, and who had made fewer demands on the health care system. Not being widowed or entering a nursing home were also shown to be predictive of successful aging in this study (6).
Mortality has been found to be lower if an elderly person is married, and higher if single, divorced or widowed, suggesting perhaps the importance not only of the family, but of day-to-day social interaction. The positive effects of social support have also been demonstrated by means of intervention studies and at1east three epidemiological studies have shown that being in a network of family and friends is associated with a lower risk of mortality. Higher age-specific mortality rates among widowed people than among married people have been consistently reported, although it appears that excess mortality in this group peaks during the first six months of bereavement and declines thereafter.
At the same time there is some evidence, although not as strong as is often claimed, that the break-up of traditional households has meant the abdication of care of the elderly by their families, although even in the more "westernized" countries of the Western Pacific region of WHO, the family is still the greatest single source of support and the main focus of activity for the elderly. Much research on modernization and aging has sup- ported the hypothesis that the status of older people declines as a society becomes modernized. This tendency has been attributed to many factors such as modern mass education, the decreased importance of land as a source of power, increased proportion of the population being aged, the emergence of the nuclear family, retirement, residential segregation between the generations, social differentiation, and rapid changes in the social structure and cultural values.
However, in the Republic of Korea, where traditional values regarding the elderly are reinforced by Confucianism emphasizing filial piety and strong obedience to parents, investigators found that younger elderly people who were married, lived in rural areas, and had modem attitudes and highly educated children were more likely than others to have power in family decision-making. In a study in the Philippines the younger elderly had greater input into family decisions than did the older elderly. While this could simply mean that authority declines with age, it was thought more likely to be because of other factors differentiating the two age groups. If so, this would argue against the contention that the impact of modernization upon the social status of the elderly is necessarily negative (7).
Preference among the elderly themselves for being separated from their children and having an independent household seems to be increasing (7,8). In a survey of the elderly in Canada, Germany, Japan, the United Kingdom and the USA it was found that although most elderly people enjoy close family ties, they wish to remain independent even in the face of serious illness. In these countries, but
Older workers offer many advantages to industrial employers through their experience, attitudes, and commitment.
not Japan, moving in with a son or daughter's family was not a popular option, and even institutional care ranked higher. Unlike in the USA where private nursing homes are more widely accepted by old people (41 % ), only 5% of the Japanese elderly want to stay in such a home if they become physically unable to care for themselves. In the Republic of Korea, 61% of those questioned (compared with 15% in Germany) said living with their offspring was or would be an ideal situation. However, this is a large decrease from the figure of 83% given in 1981. In Europe, there is also considerable disparity. For instance, the number of people of over 65 living in institutions ranges from 11% in the Netherlands to 1% in Greece.
The perceived role of women is another area of change. In most countries, women are more likely to survive to older ages than men, to be lonely, and to be economically disadvantaged. Even in societies in which women are seen to have a considerable degree of independence, the burden of care of the elderly, especially the infirm elderly, still rests predominantly on the females in the household. This is even more the case in many Asian societies. Studies by the Japanese Ministry of Health and Welfare have shown how nursing of the aged is expected to be shouldered mainly by women, including the aging spouse herself. However, change is rapidly occurring, and although the responsibility may still be thought of as belonging mainly to daughters and daughters-in-law, it may just not be possible if these women have full-time jobs, if the housing is too confined or if there is geo- graphic separation. In Singapore for example, women in the labour force rose from 44% to 50% in just a decade. This, together with the changes in the workforce mentioned above, will have considerable implications for the individuals, families and finances involved in health care of the elderly in the near future.
Differing expectations also strongly affect psychosocial well-being. In a comparative study of the elderly on different continents, it was found that only 10% of' the elderly in the United Kingdom were living with their families, but only 11% of them felt neglected by their children, whereas in the Republic of Korea 41% felt neglected although 61 % actually still lived with their families. In a European survey of the elderly, 1% of the Danes, 7% of the Britons and 9% of the Americans questioned described themselves as often lonely. As might be expected, those who were married were less lonely than those who were widowed, divorced or separated. Although not strictly comparable because of possible methodological differences, 24% of Fijians, 22% of Koreans, 10% of Malaysians and 7% of Filipinos have been reported as being often lonely. A study made in the USA indicated that numerous variables, such as subjective and objective health, education, financial satisfaction, having a role to play and feeling integrated, significantly correlated with life satisfaction. However, the combined effect of two variables, namely feeling of loneliness and isolation from the family and levels of sociocognitive skill, accounted for 49% of the variability in the life satisfaction of elderly people (9).
As in physical health, psychosocial perceptions and effects are the outcome of a lifetime of experience and development. When asked about their own assessment of their health and life satisfaction, many older people said they did not feel or believe that growing old was necessari1y "all down hill". When one's external and internal environments are understandable, meaningful and manageable, life satisfaction is positive. When they are unstable, or are considered likely to become so, life dissatisfaction increases.
The most important single non-biological factor affecting the health of an elderly person appears to be his or her economic condition; next comes nutrition, and then level of education (10). At the same time, health has been found to have the largest effect on life satisfaction, followed by subjective integration and financial satisfaction. It was noted above that health status and level of income were the two variables most consistently associated with life satisfaction among elderly people in general. In the very elderly at least, physical health status has been found to be a stronger predictor of emotional well-being in relation to life satisfaction than social networks.
Although about 80% of older people are quite capable of carrying out the activities needed for daily living, older people are statistically more likely to suffer ill-health than those under 60 years of age. Not only will they have more ill-health but many will have more than one condition that is disabling or in need of treatment. Health problems which significantly affect older people include incontinence, chronic pain, arthritis, deafness, periodontal disease, osteoporosis and hypertension. Although the diseases to which an elderly person is prone are not peculiar to 1ater 1ife, they take on specific characteristics when they occur in later life. An elderly person's illness is a compound of a particular disease and the effects of the aging process, plus, all too frequently, the pharmaceutical drugs which have been prescribed for various impairments. In western countries, for example, approximately a third of the people aged 65 years and over, and three quarters of those aged 75 years and over, take medication regularly.
Researchers taking the approach of looking at "successful agers" found that they were less likely than all others to have ever smoked. There was also some evidence that they were less likely to have either abused or completely abstained from alcohol, and less likely to have been severely over or underweight. One such study was on a cohort of over 5000 men of Japanese ancestry living in Hawaii. Those who developed coronary heart disease, stroke, cancer or a variety of other conditions, were more likely to have higher blood pressure, be obese, smoke cigarettes, consume alcohol at higher levels of intake than the others, and
Although Filipinos reported higher levels of satisfaction with their health status than other countries, they also had the highest prevalence of health problems.
have abnormal serum glucose, uric acid and triglyceride levels. Years spent in Japan was a factor positively associated with disease-free outcome in the trial period, but was presumably related to environmental and lifestyle factors in Japan.
An examination of the lifestyles of the Japanese led to the conclusion that their high longevity is at least partly due to current eating habits: a ratio of approximately 1:1 for dietary animal to vegetable protein, retaining rice as the main dish, having one of the highest intakes of fish in the world, and reducing the amount of salt in the diet. Almost certainly, the still relatively low levels of saturated fat in the Japanese diet should be added. Even among the "westernized" inhabitants of Osaka, dietary fat was found to contribute only 23% of energy intake, compared with 42% in the United Kingdom. The ratio of unsaturated to saturated fat is 1.1: 1 compared with 0.34: 1 in Britain. The change to less (but still relatively high) salt and fewer preserved foods has also probably been responsible for the decrease in both stroke and stomach cancer in Japan.
In spite of all this, however, it may be that subjective perception of health, rather than actual health, is more important in terms of how elderly individuals feel about the quality of their life. In the four-country study mentioned above (3), at least half the subjects in all four countries reported feeling quite healthy, ranging from 50% in Korea to 84% in the Philippines. Except in Fiji, more females felt unwell than males. When asked about health problems or illness affecting functional ability, there were marked cultural differences with 59% of Fijians reporting such health problems,40% of Koreans and 25% of Malaysians. Although Filipinos reported higher levels of satisfaction with their health status than other countries, they also had the highest prevalence of health problems, which brings us back to questions of expectation. In a study of four European countries and Japan, it was found in all five countries, that becoming ill was the greatest fear of elderly people.
A WHO Scientific Group looking for a global end-point for epidemiological use, proposed maintenance of autonomy as the basic aim of healthy aging, and prevention of its loss as the objective of intervention programmes (11). Such interventions will require social support, public changes of attitude, and manipulation of the environment, in addition to activities directed to the individual.
It might even be said that the real aim of health promotion is to lead to "healthy dying". In western studies at least, older people mostly interpret this as remaining as independent as possible for as long as possible and as having as much control over their lives as possible. It would be interesting to know if societies in which old people expect to be cared for in the family setting attach equal importance to this factor of independence. It may be that a higher value is given to remaining productive within the family and maintaining respect as a source of guidance and wisdom. Many studies, however, have shown a remarkable convergence. As Rowe & Kahn observe, "lack of control has adverse effects on emotional states, performance, subjective well-being and on physiologic indicators" (12). The authors also found that undesirable events over which the individual had full control did not correlate with the index of emotional strain, whereas this was not so for undesirable events, over which the individual had no control.
The possibilities for primary prevention are somewhat reduced in old age, and the distinctions between primary prevention (avoiding or delaying the onset of diseases), secondary prevention (early diagnosis to stop the progress of disease), and tertiary prevention ,(adequate treatment of established diseases to diminish disability) become increasingly blurred.
Medawar has proposed that most diseases that afflict us from middle age onwards might simply represent "unfavourable" genes that have accumulated to express themselves in the second half of our lives (13). They are no longer subject to evolutionary pressure, as that only affects the earlier years, when we reproduce, so all types of haphazardly accumulated decay can assert themselves freely. In this argument, civilization, which has more or less wiped out famine and pestilence in most industrialized societies, is not the cause of our chronic diseases but has ,merely allowed our genes to express themselves and reveal what had been lurking within us for centuries. It is likely that the "western " chronic disease pattern already existed among the few relatively affluent people of the past, who were somewhat better nourished, and more exempt from infections, and therefore lived longer. If this is true, life style changes will be of little avail.
However, given the effect of lifestyle changes on cardiovascular and cerebrovascular disease prevalence figures, as well as the effects of class, socioeconomic advantage and education, I take me view that lifestyle factors are important, particularly with regard to individual behaviour in matters such as smoking, diet and physical exercise. Growing evidence supports me view that continued physical activity and good nutritional status are important determinants of physical and cognitive functioning. Studies suggest that
Increased food availability has been shown to be associated with increasing life expectancy, but with an upper limit, after which further increases in dietary fat intake may actually be associated with a reduction in life expectancy.
moderate exercise programmes improve me glucose intolerance and insulin resistance of older people and, together with avoiding the known risk factors of cigarette smoking, heavy alcohol intake and inadequate calcium intake, can also help in the prevention of osteoporosis.
As we have seen, the continuing increases in life expectancy mean that questions about the quality of that longer life are becoming more important. The aim must be to compress me time of disability so that an ever-decreasing proportion of our longer lives is spent disabled or in ill-health. So far, it is unclear whether this is happening or not, partly because of methodological problems in examining the variety of factors leading both to increased life expectancy and to disability and ill-health. Also these probably differ from country to country. At present, women can expect to spend more years in a disabled state than men, but also to live longer. National longitudinal studies now taking place in an increasing number of countries are beginning to examine this important question, with all the implications it has for national health and long-term care systems.
Japan has concluded from its experience that strong health service programmes and check-ups starting in middle age reduce the demand for inpatient care in later life. However, considerations of cost-effectiveness are not currently a constraint in that country, and it is likely that such an approach is beyond the resources of all but a few. The cost, except in the case of a few specific medical conditions, generally does not appear to justify such an approach.
A possible obstacle for health promotion in this area is what older people consider appropriate behaviour. In Australia older people have reported feeling that participation in vigorous activities is inappropriate and becomes less acceptable socially with increasing age. It has also been found that the aspirations and expectations of older people for their own capacity and achievement tend to be low, and those perceptions are reinforced by the expectations of the rest of society. Reduced opportunities also reduce the activity levels of older people.
To sum up, enormous sociocultural changes caused by rapid economic development have brought with them many other changes, both positive and negative, not least in health and aging. Life satisfaction and the quality of life are determined by socioeconomic security,
At present, women can expect to spend more years in a disabled state than men, but also to live longer.
psychosocial well-being and perceived satisfactory health. In turn, health is governed by one's past life, genetic make-up and environment, as well as satisfaction with life, psychosocial well-being and socioeconomic security. All are intertwined and necessary, with their relative importance differing from culture to culture and person to person, but the factors remain remarkably similar.
Some have expressed the concern that tackling the emerging problems of the aged may, while necessary, further weaken the tradition of supporting and caring for them within the family. This view is sometimes taken in spite of the evidence that the expectations and preferences of the elderly may be changing towards increased independence. The outcome of the debate about the increasing costs of health care for the elderly will depend primarily on the cultural, political and ideological context in which particular service systems operate. It is extremely important but beyond the scope of this paper.
According to the findings we have just reviewed, efforts to meet the needs of elderly people should focus on three factors: their socioeconomic security, their psychosocial well-being, and their perceived health. Health promotion, in its broadest sense of working for healthy lifestyles and health-supporting environments, appears to have much to offer for well-being in aging. Increasing experience with aging populations will help us to decide exactly what are the most important points at which to intervene to ensure that the quality of life is optimized throughout life.
Finally, however, a whole new debate appears to be starting, about the danger that health promotion may encourage dependency in older people and reduce their perceived quality of life by nagging them about what they should be doing or not doing in terms of exercise, prudent diets, sensible drinking and so on. While there would be pay-offs in terms of longer life and better health if everyone did the "right" thing, my view is that such choices, once the information has been provided, must be made by the elderly person concerned.
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WHO's programme on Aging and Health
In April 1995 the World Health Organization launched a new programme on Aging and Health which is to include the following perspectives:
- Life course-approaching old age as part of the life cycle rather than a separate area of health care
- Health promotion-focusing on healthy aging
- Cultural setting as an important determinant of health in later life
- Gender differences in health and ways of living
- Ethical considerations which claim more attention as populations age, such as undue hastening or delaying of death, human rights, long-term care, and abuse.
WHO is being called on to provide worldwide leadership in the health dimensions of aging, which will become a dominant societal issue in the twenty-first century, Aging and Health will be a horizontal programme, working as a catalyst for action in other divisions of WHO, in the Regional Offices, in Member States, and in other agencies. Collaboration with academic institutions and nongovernmental organizations will be firmly established. Key programme components will be information base strengthening, policy development, advocacy, community-based programmes, training, and research. A global media strategy on healthy aging will be created.
- For further information, please contact Dr Alexandre Kalache, Aging and Health Programme, World Health Organization, 1211 Geneva 27, Switzerland.