How to meet the challenge of ageing populations
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d3815 (Published 20 June 2011) Cite this as: BMJ 2011;342:d3815All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
The challenges and contributions of ageing populations extend beyond
EU borders1(Fahy N, et al. BMJ. 2011;342: d3815 doi: 10.1136/bmj.d3815) to
middle and lower income countries where the majority of older persons
worldwide reside. As of 2011, 63% of the world's 537 million persons aged
65-plus years lived in countries in less developed regions.2 About 121
million older persons live in Europe as compared to 37 million in Africa,
287 million in Asia, and 42 million in Latin America and the Caribbean.
By the year 2031, the population aged 65-plus globally will exceed 1
billion, with 71% living in less developed countries. This translates into
168 million persons in Europe, 73 million in Africa, 587 million in Asia,
and 88 million in Latin America and the Caribbean. Clearly, ageing is
poised to become the next public health challenge globally and not just
for the EU.
Without comparable health data, much less information about the
impact of ageing populations on health care and social support systems, we
use life expectancy as a proxy for population health. Life expectancy and
the years of healthy life expected (HALE) is considerably lower in less
developed countries than in more developed countries.
The most recent World Health Organization estimates for healthy life
expectancy at birth (2007) reveals a mean of 66.8 years for persons in its
European region, 45.4 years in its African region, 56.8 years in the South
-East Asian region and 67.3 years in its American region.3 The
differences are less pronounced for persons aged 60 years, with HALEs of
16.0 years for older persons in Europe, 10.6 years in Africa, 11.6 years
in South-East Asia, and 16.4 years in the Americas. Regardless of where
you live, if you reach 60 years, you have considerable time remaining in
good health, contributing to your family and community. Recent reports
from the United Kingdom and New Zealand suggest a considerable net
positive contribution to society from populations aged 65 years and
older,4 or at least a decoupling of the attribution of rising health care
costs to ageing populations.5 This accounting of contributions in higher
income countries include pension costs, something accessible to only a
minority of persons in many lower income countries suggesting a larger
positive contribution in lower income than higher income regions. The
challenge will be to maintain subsequent cohorts of older adults in good
health for extended periods of time through lifestyle interventions such
as better nutrition through the life course, engaging in adequate amounts
of physical activity, stopping tobacco use and the harmful use of alcohol,
the early detection and management of hypertension and chronic
noncommunicable diseases and promoting well-being.
Adding two years to healthy life expectancy is a significant
challenge, even for European countries with well-funded health systems and
adequate health care force. Countries in Europe as well as in other
regions would benefit substantially from speeding up the application of
science to practice, but with a very different starting point in lower
income countries. Health infrastructure and health worker retention
remains a concern in many countries.6 Access to health care and health
professionals are required before health technologies can be applied. A
concerted multi-sectoral effort that goes beyond health systems
strengthening will be required. The United Nations High Level Summit on
Non-Communicable Diseases7 in September 2011 will be an opportunity to
highlight the role of ageing as the major driver of this epidemic and the
need to have a life course perspective if real gains have to be made.
Access to timely information is crucial to establishing the baseline
from which to measure improvements or interventions that would increase
the healthy years added to life expectancy. Recent data collection
efforts across middle and lower income countries, like the Study on global
AGEing and adult health (SAGE),8 along with several national and multi-
country studies on ageing, have established baseline health levels,
determinants and outcomes as well as health care utilization.3 The use of
common methodologies will allow valid cross-national comparisons. This
should also be coupled with enhanced geriatric training and retention of
health care professionals.6,9 The innovative partnership in Europe on
healthy ageing, a welcome initiative, could be informed by evidence from
outside the boundaries of the EU and could, in turn, provide the impetus
for similar efforts in low and middle income countries where the challenge
of ageing also looms.
Reference
1. Fahy N, McKee M, Busse R, Grundy E. How to meet the challenge of
ageing populations. BMJ. 2011 342:d3815; doi:10.1136/bmj.d3815
2. United Nations Population Division. World Population Prospects:
The 2010 Revision. New York: United Nations. 2011.
3. World Health Organization. World Health Statistics 2011. Geneva:
WHO. 2011.
4. WRVS. Gold age pensioners. Valuing the socio-economic contribution
of older people in the UK. Cardiff: United Kingdom. 2011.
www.wrvs.org.uk/Uploads/Documents/gold_age_report_2011.pdf
5. Bryant J, Sonerson A. Gauging the cost of Aging. Finance and
Development. 2006;43(3).
www.imf.org/external/pubs/ft/fandd/2006/09/index.htm
6. World Health Organization. The World Health Report 2006: Working
Together for Health. WHO: Geneva. 2006.
7. General Assembly of the United Nations. High-level Meeting on Non-
communicable Diseases. 2011.
http://www.un.org/en/ga/president/65/issues/ncdiseases.shtml
8. World Health Organization. Study on global AGEing and adult health
(SAGE). www.who.int/healthinfo/systems/sage
9. International Federation of Medical Students' Associations, World
Health Organization. Teaching Geriatrics in Medical Education II. Geneva:
WHO. 2005. www.who.int/ageing/projects/TeGeMe_II.pdf
Competing interests: No competing interests
Perhaps the most important emphasis missing from the editorial on the
European initiative on innovation and ageing (1) is the potential for
advances in the gerontological sciences to positively influence how
healthcare is delivered to an ageing Europe. The effectiveness of this
approach has been underlined by a recent Cochrane review which shows that
acute geriatric medical care in hospitals increases the likelihood of
surviving and living at home at six months by 25%, an effect size
equivalent to that of stroke units (2). This effect relies on
gerontological nursing, an informed multidisciplinary team and specialist
geriatricians to work, and is a potent metaphor for the many gains that
gerontological insights and expertise add to the care of older people in a
wide range of settings.
Unfortunately, despite advances in promoting geriatric medicine,
gerontological nursing and related age-attuned disciplines, there are
glaring gaps in widespread availability of these competencies across
Europe (3), and health policies for older people from major forums such as
the OECD or the World Economic Forum show worrying evidence of
gerontological illiteracy (4). Even the European Observatory's own report
on the responsiveness to health systems to ageing (5) omits the importance
of training in gerontology and geriatric medicine for those in primary and
seconday care, even though this was an important objective of the United
Nations' major blueprint for ageing societies, the Madrid International
Action Plan on Ageing.
Happily, the forthcoming European Observatory summer school mentioned
in the editorial (www.observatorysummerschool.org) has a generous
representation from geriatric medicine and gerontology among the faculty,
and hopefully will facilitate cross-fertilization of the ever more
critically important sciences of ageing with those of public health and
health-care delivery.
References
1) Fahy N, McKee M, Busse R, Grundy E. How to meet the challenge of ageing
populations. BMJ 2011;342:d3815.
2) Ellis G, Whitehead MA, O'Neill D, Langhorne P, Robinson D.
Comprehensive geriatric assessment for older adults admitted to hospital.
Cochrane Database Syst Rev 2011;7:CD006211.
3) Michel JP, Huber P, Cruz-Jentoft AJ. Europe-wide survey of
teaching in geriatric medicine. J Am Geriatr Soc. 2008;56:1536-42.
4) O'Neill D. Dialogue at Davos for an aging society. J Amer Geriatr
Soc (in press).
5) Rechel B, Doyle Y, Grundy E, McKee M. How can health systems
respond to population ageing? www.euro.who.int/en/what-we-do/data-and-
evidence/health-evidence-network-hen/publications/2009/how-can-health-
systems-respond-to-population-ageing.
Competing interests: A number of members of the Executive and Academic Boards of the European Union Geriatric Medicine Society will be on the faculty of the forthcoming European Observatory summer school
Thing is though, according to the recently published report by the
College of psychiatrists into the drinking habits of older people (which
has had scorn heaped upon it by the C.E. of SAGA and provided loads of
opportunities for twittering fun by especially retired people with time to
listen to R4 this a.m. (instead of rushing to work)), too many of us seem
to be drinking ourselves into an early grave to worry much about being
productive in the sense you probably mean. There are though other
definitions of a useful and productive retirement, including showing others
how how lovely it is to enjoy greater leisure, whether tripping (over) to
the pub to catch up with the news, have a laugh, share various sorrows and
joys, not to say enjoy the effect of a drink or two - or helping to run
any of the myriad of other activities retirement offers after a lifetime
of work. There are of course the thousands of unpaid hours of looking
after all sorts of others in retirement to think about. Most importantly:
Who is going to make the tea for the kids afer school if grandma and
grandad and all the retired people are still working?
Competing interests: No competing interests
Fahy er al. mention the broad range of solutions and interventions
available to the EU partnership in order to reduce the burden of disease
on an ageing population. However, I feel an important counterpoint has not
been considered. It may be argued that high-income countries have reached a
plateau in life expectancy where further investment is likely to bring
little return, but also, that the effect of increasing life expectancy
would be to increase the numbers of the unproductive retired thereby
creating a vicious cycle that can only be broken by raising the retirement
age.
Competing interests: No competing interests
The frailty phantom
Editor:
We agree with the editors about the increase in the number of oldest people in the
world carrying global consequences, economic and social, and for health
systems; those consequences will exaggerate in the future.
We must promote active and successful ageing in order to diminish the
effects that disability and dependence frequently have on older people.
Frailty, a clinical syndrome associated with non-successful ageing,
increases its frequency in older adults in developed
countries, with adverse health outcomes such as disability,
institutionalization, dependence and death. The prevention and detection
on time of frailty syndrome must be one of the future interventions if we
want to minimize its consequences.
It is clear, that present and future strategies to face
demographic ageing cannot be only in a geriatric form: we have to give to
other specialists the attributes and lineaments of geriatricians, with
special focus on healthy life style promotion, and also consider the
frail elderly person as a target point for geriatric care (1).
The culture of modern society is not to focus on the consequences of ageing. However, promoting health and activity in old age with integral education for everyone to prepare for ageing will help people to face this life stage without one of its ghosts: frailty (2).
Sincerely,
Julio C. Romero, Angel J. Romero
References:
1. Romero AJ. Current perspectives on health care for the older adult. Rev
Panam Salud Publica 2008; 24(4): 288-94.
2. Romero AJ. Frailty: an emerging geriatric syndrome. Medisur 2010; 8(6):
81-90.
Competing interests: No competing interests