Expert Interviews:
The State of Aging and Health in Europe
Suzanne Wait, PhD, is Director of SHW Health Ltd, a UK-based consultancy focused on health policy and health outcomes. She is also Advisor to the International Longevity Centre-UK (ILC-UK). She co-authored the report, The State of Aging and Health in Europe.
Suzanne, what were some of the most notable findings around aging from the report?
The first is the numbers. In Europe by 2050, one third of people will be over the age of 60, as opposed to 13% under 16. The fastest growth is in the “oldest old” or people over the age of 80. The same trend is applicable to the US, where today there are 17 million people between 75 and 85, but in 40 years there will be 30 million, with 2 million over 100. So our society is going to look very, very different than it does today.
Secondly, it no longer makes sense to talk about a “typical” older person. People in their 60s or 70s may be incredibly different from people in their 80s, and one 80 year-old may be very different from the next. However, most statistical databases lump all people over the age of 60 or 65 together under the label of ‘older people’. There is a real need for more disaggregated data – by age groups, gender, socioeconomic status, culture and ethnicity.
It follows that using age as the natural cut-off for medical decisions, like cancer screening or surgical procedures, probably makes less and less sense. Of course age is an easy, clear-cut criterion, but we have to consider that people over a given age will vary significantly in terms of their chances of benefiting from certain interventions. Ideally, an individual assessment would be done each time. The problem is that much of medical training is based on precedent, so it takes a long time for practice to change and assumptions about what is ‘appropriate’ for given age groups to evolve.
How do you define healthy aging?
An operational definition could be “healthy aging is developing and maintaining the optimal level of physical, cognitive, social, and emotional well-being and function through old age.” The big question is what the enabling factors toward healthy aging are. Access to appropriate care is important, but prevention and health promotion can also play a critical role. For example, a number of studies have found that changes in diet or stopping smoking even at the age of 70 can make a big difference to patient outcomes.
What are disease states that should be getting more attention in older adults?
I think depression and malnutrition are particularly important.
Between 10-15% of people over 65 have depression in Europe, and the US data is similar. People who are depressed have a much higher rate of all kinds of chronic diseases, as well as mortality. In older people, depression is much more frequent but is often dismissed as a natural symptom of old age. Depression needs to be taken seriously by physicians, social workers or whoever is actually seeing older people with signs of depression.
Similarly, there is a misconception that as people get older they naturally get thinner. It is true that malnutrition is more common in older people. The causes are both clinical – for example, it can be secondary to other diseases like cancer – and social. A person may have a mobility issue and so not be getting to the fridge enough, or be unable to do the shopping, or live alone so that the whole social ritual associated with meals is gone. The important point is that much of malnutrition is preventable. A study in Europe they found that the number of older people getting weighed systematically by their physicians was staggeringly low. Raising awareness amongst physicians and all those who come into contact with older people about the risks and signs of malnutrition is thus critical.
Now onto the financial impact, isn’t it true that a growing population of older people with multiple chronic conditions drives up cost?
Yes, the cost of care is likely to increase with the aging population, but an older person doesn’t necessarily cost more than a younger person. The assumption is that the older population of tomorrow is going to be as sick, or sicker, than the older population of today, because we’re basing our assumptions on what we see today. But a number of longitudinal studies from around the world have shown that current generations of older people are living much healthier and longer lives than previous generations.
This brings us to the debate over whether there is an “expansion” or a “compression” of morbidity. The expansion of morbidity assumes that people are living longer, but they’re living longer in bad health. The compression of morbidity means that people are living longer, but they’re starting their years of morbidity much later, so instead of getting sick at 60, they get sick at 70, or 80. There’s a lot of evidence that we are starting to see a compression of morbidity. So the premise that because there are more older people, they are sicker isn’t necessarily verified by the existing data.
Are you suggesting that we put too much focus on the financial impact of an aging population?
Yes. I think there’s a lot of panic that with all these older people our healthcare systems are never going to be able to accommodate them and our Medicare bills are going to explode. You can’t dismiss all this, but there’s too much focus on the quantity of care and not enough thought given to the quality. We have to consider what needs to be done to ensure the aging population receives better prevention and care in order to live longer and healthier lives and also to avoid the devastating financial impact on our health and social care systems.
That said, the aging of the population has huge ramifications for the configuration of our health care services and human resources needs. We will need a significant shift towards enabling older people to live in the community, manage their chronic conditions over time and maintain their independence as long as possible. This will require better training of all those involved in treating older people – primary care clinicians, nurses, social workers – but also an increase in personnel and services that are at the interface between clinical and social care. So a huge change in services is going to be needed. Whether this is going to be more expensive remains to be seen.
What are best practices you’re seeing?
The first is the provision of truly integrated care and the removal of the historically-based and artificial divide between what is healthcare and what is social care. There are quite a few examples in Europe of great initiatives where an older individual living in the community has one centralized needs assessment done, and then based on that assessment, a multidisciplinary team comprised of a primary care physician, nurses, social care, etc., offers services commensurate with those needs. This ensures a patient-centered or individualized, as opposed to a one-size-fits-all , approach.
There are also some interesting policy initiatives. For example, in France, Alzheimer’s disease was recently added to the list of long-term chronic conditions for which patients get their medications for free. In the US, the closing of the so-called Medicare donut hole is also a huge step forward. And the FDA’s recommendation to drug manufacturers to include more older people in clinical trials in its Guidelines to Industry is a critical step to ensuring that recommended dosing regimens are suitable to people of all ages, not just those aged 18-60 without co-morbidities who have traditionally been included in clinical trials.
What should we be doing more of?
Better training is needed across all health and social care staff who work with older people. For example, GPs need to be better able to recognize the signs and symptoms of Alzheimer’s disease in order to diagnose it early. Very often, older people will present with comorbidities, so it’s necessary to take a holistic approach, because the Alzheimer’s symptoms may almost be masked by other symptoms that present at the same time, and they may present differently than in a younger patient.
We also need to improve continuity of care. For example, when a person is discharged from hospital with a hip replacement, someone needs to ensure he has the appropriate support and care to recover appropriately at home, so he doesn’t end up in hospital again. Also, it’s important to provide sufficient information so he can continue his care at home.
Let’s come back to the trend to try to keep people in their homes. Keeping people at home assumes there are caretaker structures in place. What is the impact on the elderly caretakers, and the strain there? Are there any studies looking at this?
There definitely is recognition of the strain on the carers– both physical and emotional, in research as well as policy circles. In the UK, carer associations have been quite successful at lobbying for recognition, and across Europe there are pilot projects in which carers are given some financial compensation for respite care. In Scotland, older people receive a sum of money to allocate as they see fit to get the services they need. And there are lots of other interesting initiatives.
The challenge I see with the policies increasingly focused on keeping people in their homes, although it’s a laudable goal, is that it makes so many assumptions, primarily that the spouse of the sick older person is in a position to drive them to appointments, buy the food, clean the house, and do everything else. What happens if that person gets sick? Just coordinating the multiplicity of agencies providing the services that an older person may need as he becomes older and frailer can be utterly daunting and exhausting. We need to make sure that appropriate support is available to help these informal carers and not underestimate their needs.
Of course, it’s important to keep in mind that there’s no one answer and we’re still trying to figure all this out. Nobody has the right to be prescriptive when we’re talking about how people spend their later years. It would be a huge mistake to say “this is what we should be doing and everyone should be growing older in their homes.” Well, some people don’t want to grow older in their homes. I think it would help if we all recognized that aging is a dynamic process. While you suddenly hit the age of 65, you don’t suddenly become old; your body doesn’t suddenly become decrepit; you don’t suddenly become dependent. And accepting that requires a huge change in mindset in all of us.
