Adopted by the 67th WMA General Assembly, Taipei, Taiwan, October 2016
The world is undergoing a longevity extension at an unprecedentedly rapid pace. Over the last century, some 30 years have been added to global average Life Expectancy at Birth (LEB) – with more gains expected in the future. By 2050, LEB is projected to reach 74 years with an ever-increasing number of countries reaching 80 years and beyond. In 1950 the total number of people aged 80+ was 14 million – by 2050 the estimated number is 384 million, a 26-fold increase. The proportion of elderly will more than double from 10% in 2015 to 22% of the total population in 2050. These improvements are very variable; many of the poorest communities in all countries and a larger percentage of the population in the poorest countries have gained little in terms of life expectancy over this period of time.
The increase in longevity has been paired with a decreasing number of children, adolescents and younger adults as more and more countries experience Total Fertility Rates below replacement level, raising the average age in these countries.
The challenges of aging in developing countries are complicated by the fact that basic infrastructure is not always in place. In some cases, populations in developing countries are aging more quickly than infrastructure is being developed.
Longevity is arguably the greatest societal achievement of the 20th century but it could turn into a major problem during the 21st century. The World Health Organization (WHO) defines Active Ageing as “the process of optimizing opportunities for Health, Lifelong learning, Participation and Security in order of enhancing quality of life as individuals age”. This definition presupposes a life course perspective as the determinants that influence active ageing operates throughout the life course of an individual. These are social determinants of health and include behavioral determinants (life-styles), personal determinants (not only hereditary factors which are, overall, responsible for no more than 25% of the chances of ageing well but also psychological characteristics), the physical environment where one lives as well as broad social and economic determinants. All of these act individually on the prospects of active ageing but also interact among themselves: the more they interact and overlap, the higher the chance of an individual ageing actively. Gender and culture are crosscutting determinants, influencing all the others.
There is strong evidence that chronic diseases increase the use (and costs) of health services rather than age per se.
However, chronic conditions and disabilities become more prevalent with advancing age – therefore health care use and spending rise in tandem with age.
In many countries health care spending for older persons has increased over the years as more interventions and new technologies have become available for problems common in older age.
Effect of Ageing on Health Systems
Health care systems face two major challenges in the longevity revolution: preventing chronic disease and disability and delivering high quality and cost-effective care that is appropriate for individuals regardless of age.
In less developed regions the disease burden in old age is higher than in more developed regions.
Special Health Care Considerations
The leading diseases contributing to disability in all regions are cardiovascular diseases, cancers, chronic respiratory diseases, musculoskeletal disorders, and neurological and mental diseases, including the dementias. Some common conditions in older age are especially disabling and require early detection and management.
Chronic diseases common among older people include diseases preventable through healthy behaviors and/or lifestyle interventions and effective preventive health services – typically cardiovascular disease, diabetes, chronic obstructive pulmonary disease and many types of cancer. Other diseases are more closely linked to ageing processes and are not understood well enough to prevent them – such as dementia, depression and some musculoskeletal and neurological disorders.
While research may eventually lead to effective disability prevention or treatment, early management is key to controlling disability and/or maintaining quality of life.
Older persons may be more vulnerable to the effects of accidents within and outside the home. This will include risks when operating machinery such as road vehicles, but also risks from handling other potentially dangerous equipment. As older people continue to work these risks must be assessed and managed. Those who suffer injuries may have their recovery complicated by other medical vulnerabilities and comorbidities.
Considerations for Health Care Professionals
Health care for elderly people usually requires a variety of professionals working as an articulated team.
Education and training of health professionals to treat and manage the conditions common in the elderly are generally not sufficiently emphasized in undergraduate curricula.
Reducing Impact on Health Care
A comprehensive continuum of health services needs to be adopted urgently as population age. It should include health promotion, disease prevention, curative treatments, rehabilitation, management and prevention of decline, and palliative care.
Different types of health care providers offer these services, from self and family/informal care – sometimes in a voluntary capacity – to community-based providers and institutions.
Establishing Optimal Health Care Systems
Universal Health Care coverage ideally should be provided to all, including elderly people.
The vast majority of health problems can and should be dealt with at the community level. In order to provide optimal community care and ensure care coordination over time it is critical to strengthen Primary Health Care (PHC) services.
In order to strengthen PHC to promote active ageing, WHO advanced evidence-based principles for age-friendly PHC in three areas which should be considered: information/education/communication/ training, health management systems and the physical environment.
The health sector should encourage health systems to support all such dimensions of care provided to individuals as they age given the importance of health to ensure quality of life.
Specificities of Health Care
Many formal systems of health care have been developed with an emphasis on “acute or catastrophic care” of a much younger population, often focused on communicable diseases and/or injuries. Health systems should emphasize other needs, especially chronic diseases management and cognitive decline, when treating the elderly.
While acute care services are essential for people of all ages, but they are not focused on keeping people healthy or providing the ongoing support and care required to manage chronic conditions. A paradigm shift is needed to avoid treating chronic diseases as if they were acute conditions.
Medical conditions in older age often occur simultaneously with social problems and both need to be considered by health professionals when providing health care. Doctors, particularly specialists, should bear in mind that elderly patients may have other concurrent chronic diseases or comorbidities that interact with each other and that their treatment should not lead to inadvertent and preventable induction of complications.
When initiating a pharmacologic treatment for chronic disease in an elderly patient, prescribers should generally start low (doses) and go slow (increasing the doses) to accommodate the specific needs of the patient.
If the patient cannot decide for him/herself, due to the high prevalence of memory and cognitive problems in old age, physicians treating elderly patients should actively communicate with the family, and frequently with the formal caretaker, to better educate them about the patient’s health condition and about medication administration, in order to avoid complications.
When considering different therapeutic options, physicians should always seek to find out the wishes of the patient and recognize that for some patients quality of life will be more important than the potential results of more aggressive treatment options.
Education and Training for Physicians
All physicians should be appropriately trained to diagnose and treat the health problems of older people, which means mainstreaming ageing in the medical curriculum.
Secondary health care for the elderly should be provided as necessary. It should be holistic, including taking into consideration psychosocial as well as environmental aspects. Physicians should also be aware of the risks of elder abuse and measures to be taken when abuse is identified or suspected. (See the WMA Declaration of Hong Kong on the Abuse of the Elderly.)
Every doctor, particularly general practitioners, should have access to information and undergo training to identify and prevent polypharmacy and adverse drugs interactions that may be more common in elderly patients.
Continuing medical education on topics relevant to the ageing patient should be emphasized in order to help physicians adequately diagnose, treat, and manage the complexities of caring for an ageing population.