Elderly – WMA – The World Medical Association

Adopted by the 73^rd WMA General Assembly, Berlin, Germany, October 2022

PREAMBLE

The ageing of the population due to increased life expectancy is one of the main challenges of many health systems given the increasing amount of resources needed to provide healthcare for the elderly population. This puts a strain on these systems, since ageing often causes a higher demand for care, with a high dependence on medical, pharmaceutical and hospital services. On the other hand, older people are perceived as recipients of help, care and financial support, which is inaccurate, as they make significant contributions to the well-being of their environment, which has a high social value.

The increase in longevity must be accompanied by appropriate quality-of-care standards, promoting health, reducing risk factors, and providing accessible and sustainable quality health and social services that are accessible, affordable, sustainable and which are of quality.

Biological age should never be used as a basis for discrimination, although it can be a relevant factor in medical decision-making. Reference to age can therefore be professionally sound.

Health discrimination in elderly patients

Elderly individuals experience all kinds of discrimination with one of the main types of discrimination being related to health. The elderly may be perceived as a burden on the healthcare systems and their financial sustainability. Elderly individuals are not uniquely responsible for the increase in healthcare costs in developed countries. There are other factors that play a key role in healthcare costs, such as the improvement in standards of living, accessibility to health services, quality of care and the use of new technologies.

Rationing of certain costly and time-consuming diagnostic or therapeutic procedures or particular settings that have a certain more expensive intensity of care is more common in the elderly population. Clinical trials often exclude patients of a certain age, even if they meet the criteria for enrolment.

Age has become a barrier when putting patients forward for certain interventions. The reasons tend to be physical; however, these may be underpinned by economic motivations, such as the recovery time being higher which increases the length of hospital stay, or by arguing that there are scarce resources and that elderly people have a shorter life expectancy.

There is consensus that from a physiological and psychological point of view, the determining factors for health in ageing patients are intrinsically linked to gender; therefore, the solutions need to address the differences between genders in order to reduce inequalities.

Health discrimination experienced by elderly individuals may have a negative impact on their physical, mental and social well-being and contributes to deterioration in their quality of life, loss of autonomy, confidence, safety and an active lifestyle, in turn, decreasing their levels of health. Is therefore a complex topic that requires the involvement of professionals, institutions, healthcare systems and authorities. Dealing with such discrimination requires awareness and coordination aided by moral and legal principles.

The need for a holistic approach

Healthcare systems do not always adapt to the changing population needs, as may occur with some hospitals, designed to care for adult patients with acute illnesses yet not elderly patients with chronic illnesses.

An increase in longevity must be accompanied by the highest quality-of-care standards, and should promote health, reduce risk factors, and provide accessible, sustainable and quality health and social services. Emphasis should be on patient-focused medicine that heals, cares for, alleviates and comforts.

The ethical duty of physicians

In line with the WMA Declaration of Geneva, physicians must strive to improve the health, well-being and quality of life for all patients without any forms of discrimination towards the elderly.

RECOMMENDATIONS

Recalling its Declarations of Geneva and of Lisbon on the Rights of the Patient, and its Statement on Ageing, the WMA makes the following recommendations:

To governments, medical associations and physicians

As priority actions, to defend the human rights and health of all individuals, including the elderly, as well as to ensure that their dignity is respected;

To governments

Develop appropriate and non-discriminatory healthcare policies for the elderly based on the efficient use of available healthcare resources;
To establish measures to eradicate discrimination against elderly individuals in healthcare;
Provide sufficient resources which ensure adequate healthcare for elderly individuals;

To the WMA, its members and the medical profession in general

To commit to eliminating all forms of discrimination due to health and age;
Promote training for primary care physicians on how to approach health problems in elderly individuals;
Promote development of the geriatric specialty or supplementary post-graduate training and increase of the number of physicians in this field, an increase of the number of physicians in this speciality and an adequate number of geriatric departments in hospitals and consultants, in order to ensure the availability of comprehensive care for elderly individuals;
Raise awareness and take action against discrimination of elderly individuals;
Promote ethical, responsible, effective and efficient practices for treating the elderly;
To set ethical standards that aim to prevent discrimination against any individual due to age;
To actively try to include elderly patients in medical scientific research;

To physicians

Not limit or impede patients’ autonomy on the basis of their age;
Provide healthcare of scientific and human quality according to good medical practice to all patients, without any discrimination;
Not apply limitations solely based on age in protocols for diagnosis and treatment;
To report any discrimination against the elderly that is observed in healthcare.

Adopted by the 67^th WMA General Assembly, Taipei, Taiwan, October 2016

PREAMBLE

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.

GENERAL PRINCIPLES

Medical Expenses

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.

Adopted by the 41^st World Medical Assembly, Hong Kong, September 1989,
editorially revised by the 126^th WMA Council Session, Jerusalem, Israel, May 1990,
and by the 170^th WMA Council Session, Divonne-les-Bains, France,May 2005,
reaffirmed the 200^th WMA Council Session, Oslo, Norway, April 2015 and
with minor revisions by the 227^th WMA Council, Helsinki, Finland, October 2024

PREAMBLE

Older people may suffer pathological problems such as motor disturbances and psychic and orientation disorders. As a result of such problems, older patients may require assistance with their daily activities that can lead to a state of dependence. This may cause their families and the community to consider them to be a burden and to subsequently limit or deny care and services.

Abuse or neglect of older people can manifest in a variety of ways: physical, psychological, emotional, financial and/or material, and medical. Variations in the definition of elder abuse present difficulties in comparing findings on the nature and causes of the problem. A number of preliminary hypotheses have been proposed on the etiology of elder abuse including: dependency on others to provide care and services; lack of close family ties; family violence; lack of financial resources; psychopathology of the abuser; lack of community support, and institutional factors such as low pay and poor working conditions that contribute to pessimistic attitudes of caretakers.

The phenomenon of elder abuse is becoming increasingly recognized by both medical facilities and social agencies. The first step in preventing elder abuse and neglect is to increase levels of awareness and knowledge among physicians and other health professionals. Once high-risk individuals and families have been identified, physicians can participate in the primary prevention of maltreatment by making referrals to appropriate community and social service centres. Physicians may also participate by providing support and information on high-risk situations directly to patients and their families. At the same time, physicians should employ care and sensitivity to preserve patient trust and confidentiality, particularly in the case of competent patients.

The World Medical Association therefore adopts the following general principles relating to abuse of older people.

General principles

Older people have the same rights to care, welfare and respect as other human beings.
Physicians have a responsibility to help prevent all forms of abuse of older patients.
Whether consulted by an older person directly, a nursing home or the family, physicians should see that the patient receives the best possible care.
If physicians verify or suspect ill treatment, as defined in this declaration, they should discuss the situation with those in charge, be it the nursing home or the family. If ill treatment is confirmed, or if death is suspicious, they should report the findings to the appropriate authorities.
To guarantee protection of older people in any environment, there should be no restrictions on their right of free choice of a physician. Medical Associations should strive to make certain that such free choice is preserved within the socio-medical system.
The World Medical Association also makes the following recommendations to physicians involved in treating older people, and urges all its constituent members to publicize this declaration to their members and the public.

RECOMMENDATIONS

Physicians involved in treating older people should:

make increased attempts to establish an atmosphere of trust with their patients in order to encourage them to seek medical care when necessary and to feel comfortable confiding in the physician;
provide medical evaluation and treatment for injuries resulting from abuse and/or neglect;
attempt to establish or maintain a therapeutic alliance with the family (often the physician is the only professional who maintains long-term contact with the patient and the family), while preserving to the greatest extent possible the confidentiality of the patient;
report all suspected cases of elder abuse and/or neglect in accordance with local legislation;
utilize a multidisciplinary team of caretakers from the medical, social service, mental health, and legal professions, whenever possible, and
encourage the development and utilization of supportive community resources that provide in-home services, respite care, and stress reduction for high-risk families.