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Learning objectives
After studying this chapter, you should be able to:
define healthy ageing and describe the current models of healthy ageing
understand the determinants of healthy ageing
identify the major health problems experienced by older people
identify strategies for promoting health among older people
understand the role that knowledge translation plays in promoting health in older people.
‘Ageing Well at Home with Broadband’ was a proof-of-concept project conducted by the National Ageing Research Institute and aimed to promote social inclusion and assist older adults to remain active at home via a ‘virtual’ exercise class. Using interactive gaming technology via the National Broadband Network (NBN), older adults and an exercise instructor, all in separate locations, were linked to each other to enable participation in real-time interactive exercise sessions.
Five older people living in an NBN roll-out area were provided with a Microsoft Kinect for Xbox 360, which included a Kinect 3D motion-tracking camera, the Xbox console and Avatar Kinect software, as well as six months of internet connection. After some trialling of the software with older volunteer consultants, the participants started training including how to turn on the system, how to navigate through the various menus and how to log in to the exercise class at the appropriate time. Training consisted of individualised, guided instruction in written and face-to-face formats.
Participants selected and customised avatars to ‘represent’ them in the exercise class, which they really enjoyed. During the exercise class the participants and instructor could see and hear each other’s avatars and see them moving. The exercise session consisted of warm-up activities, upper body movements and a cool-down. At the end of the very first virtual real-time exercise class for older people, participants laughed and cheered!
Older people loved it, especially the novelty and anonymity of using avatars. It did not matter if they were in their pyjamas or their house was untidy as no one could see that. So what were the challenges?
The software and hardware was ‘off-the-shelf’ and was not specifically designed with the older person in mind. The Avatar Kinect software was only able to show upper body movement on the screen because its original purpose was for ‘chatting’ rather than showing full body movement. Another challenge was that the sound echoed as each signal would be repeated through each console so earpieces were needed.
The participants required extensive training. Having a manual was not sufficient: in-home and then real-time phone support was needed, partly because it was not possible to predict all the problems that would arise.
Overall the project demonstrated the feasibility and benefits of establishing a virtual exercise class for older people using technology that incorporates 3D motion sensor tracking (Kinect) and uses software to connect people in their own homes (Avatar Kinect). The aim of teaching older people to use technology was achieved with the end result that weekly exercises classes could be run by an instructor for a group of participants, each in different locations. Key features that ensured the success of the project included allowing participants to meet each other in real life before meeting ‘virtually’ to create a sense of common purpose, and collaborating closely with older people, technology partners, government and researchers to ensure that any problems that arose could be solved. Not least, the use of technology produced physical benefits as it increased the exercise challenge, mentally and physically, in an enjoyable way.
What does the future look like? With the rapid expansion in technology that is occurring, there are many possibilities. However, as this project demonstrates, technological solutions, including those aimed at increasing physical activity and social connection, should be developed in conjunction with older people and take into consideration their needs, abilities and preferences.
Introduction
Healthy ageing is gaining momentum as an important goal for all societies experiencing population ageing. This chapter presents the public health issues relevant to the wellbeing of older people, now and in the future. Knowledge derived from research is of little value unless it is put into practice. The final sections of this chapter focus on guidelines for health promotion programs and the concept of knowledge translation which bridges the gap between research and policy/practice.
By mid-century, the number of Australians aged 65–84 years is expected to more than double, from 3.1 million in 2015 to seven million in 2055, representing approximately 18% of the total population at that time (Commonwealth of Australia, 2015). A rapid rise in the number of Australians aged over 85 years will also occur over the next 40 years, from about 500 000 people in 2015 to two million in 2055 (Commonwealth of Australia, 2015). The proportion of the total population represented by this age cohort will increase from 2 to 5% over this period. However, within the older population, the largest change from 2015 to 2055 will be in the number of centenarians. A ninefold increase in people aged over 100 years, from about 4500 to 40 000, is projected (Commonwealth of Australia, 2015). Population ageing is a result of increased life expectancy (lower mortality) and decreased fertility rates (Commonwealth of Australia, 2015).
- Life expectancy
the average number of years a person can expect to live, usually from birth. It is based on age and gender-specific death rates.
This demographic situation is not unique to Australia. The United Nations (2013) projects that, globally, the number of people aged 60 years or over will increase from 841 million people in 2013 to more than two billion in 2050. In 2013, two-thirds of the world’s older population lived in developed countries. However, the growth rate of the older population in developing countries will rise dramatically and outpace that of developed regions. By 2050, almost 80% of older people will live in less developed regions (United Nations, 2013).
What is healthy ageing?
Healthy ageing defined
Ageing is the ‘process of growing old’ (Oxford Advanced Learner’s Dictionary, 2015). Although there are commonly used definitions of old age, there is no general agreement on the age at which a person becomes old. Calendar age or the age at which one can begin to receive pension benefits are often used to mark the beginning of old age (World Health Organization, 2015). This assumes that chronological age equals biological age, yet at the same time it is generally accepted that these two are not necessarily synonymous. There are wide variations in health status, participation and levels of independence among older people of the same age. Gender and culture and social factors also need to be considered. Currently, 60 years is the United Nations’ standard to define older people (United Nations, 2013).
The phrase ‘healthy ageing’ has become commonplace in mainstream and scientific literature because of increasing interest in the wellbeing and independence of the growing proportion of older adults. There are many definitions of healthy ageing, which is also known as successful ageing (Bowling & Dieppe, 2005; Bowling & Iliffe, 2006; Rowe & Khan, 1997), active ageing (Bowling, 2008; World Health Organization, 2002), positive ageing (Kendig & Browning, 1997) and productive ageing (Kerschner & Pegues, 1998). However, it is accepted that healthy ageing involves more than just physical or functional health. Since 1948, the World Health Organization has defined health ‘as a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity’ (World Health Organization, 2011, p. 1). Further, active ageing is ‘the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age’ (World Health Organization, 2002, p. 12), allowing people to ‘realize their potential for physical, social and mental wellbeing throughout the life course’ (World Health Organization, 2002, p. 12).
Models of healthy ageing
Bowling and Dieppe (2005) proposed three broad models of successful ageing. The first model, based on biomedical theories, defined successful ageing as the presence of high levels of physical and cognitive functioning. The second model emphasises psychological resources, life satisfaction and social functioning (Bowling & Dieppe, 2005). The third model is based on older people’s perceptions of successful ageing (Bowling & Dieppe, 2005). To the first two models, lay views add having a sense of humour, learning new things, financial security, productivity and spirituality. Upon further investigation, Bowling and Iliffe (2006) found the multidimensional lay model to be most predictive of successful ageing (measured using self-reported quality of life). Taken together, these papers provide a strong argument for a holistic approach and for including older people’s views when defining successful or healthy ageing. The models have been the foundation upon which other frameworks for healthy ageing have been developed, such as the Madrid International Plan of Action on Ageing (United Nations, 2002) and World Health Organization’s ‘Active Ageing’ framework (World Health Organization, 2002).
World Health Organization’s ‘Active Ageing’: a policy framework
In 2002, the World Health Organization Ageing and Life Course Programme developed a policy framework to inform discussion and formulate action plans to promote healthy and active ageing (Kalache & Gatti, 2003). The framework takes a life course perspective on ageing, acknowledging that older people are not a homogenous group and that individual diversity tends to increase with age (World Health Organization, 2002). World Health Organization (2002) states that ‘to promote active ageing, health systems need to take a life course perspective that focuses on health promotion, disease prevention and equitable access to quality primary health care and long-term care’ (World Health Organization, 2002, p. 21). In this framework, optimal functional capacity (for example, muscle strength, cardiovascular fitness and balance) is the goal from childhood to old age (World Health Organization, 2002).
- Life course
all stages of life, from early life to adulthood and old age.
Another key component of the active ageing framework is consideration of the broad determinants of health on the ageing process. Culture and gender are overarching factors because they shape the way one ages and influence all the other determinants. This framework also includes behavioural determinants, social environment determinants, economic determinants, health and social service system determinants, physical environment determinants and personal determinants. See the chapters in Part 2 of this volume.
- Determinant of health
a factor within and external to the individual that determine their health; the specific social, economic and political circumstances into which individuals are born and live.
When researchers at the National Ageing Research Institute embarked on developing the Healthy Ageing Quiz (Cyarto, Dow, Vrantsidis & Meyer, 2013), they asked older adults what healthy ageing meant to them.
Healthy ageing, as described by focus group participants, is ‘remaining independent and being able to enjoy life’ (Cyarto et al., 2013, p. 17). Most of the factors associated with healthy ageing identified in the academic literature were mentioned by older people. Of particular importance was engaging in physical and mental activities. Although physical health affected healthy ageing, it was the opinion of focus group participants that people could have health problems but still feel that they are ageing well. They also pointed out the multiple benefits of physical activity in working the mind, the body and providing social contact.
Relationships with family, friends and community were seen as key factors associated with healthy ageing. Participants mentioned developing and maintaining good relationships, making new friends, joining groups and even embracing in-laws. The importance of intergenerational contact was also highlighted.
‘Being productively and socially engaged, having a purpose’ (Cyarto et al., 2013, p. 17), and ‘being valued and respected’ (Cyarto et al., 2013, p. 17) were also mentioned by participants. In addition, participants highlighted the role of volunteering and replacing paid work with other meaningful activities, as well as establishing new contacts. Adaptation to changed circumstances and recognition of any limitations were also viewed as important.
Involving older adults in the development process ensured that the quiz included questions on the health and lifestyle factors that were important to those who would be completing the quiz, not just what was deemed relevant in published literature on healthy ageing.
Determinants of healthy ageing
Behavioural factors
Many aspects of healthy ageing can be influenced by individual behaviour change. Modifiable lifestyle factors include physical inactivity, smoking, being overweight or obese, heavy alcohol consumption, poor diet and hypertension (Australian Institute of Health and Welfare, 2014a; Hartman-Stein & Potkanowicz, 2003; Heikkinen, 2003; Peel, Bartlett & McClure, 2004; Rowe & Kahn, 1987; Seeman et al., 1994; Stuck et al., 1999; Valliant & Mukamal, 2001; Yates, Djousse, Kurth, Buring & Gaziano, 2008). All of these factors are associated with many of the chronic diseases that affect middle-aged or older Australians (Australian Institute of Health and Welfare, 2014a).
Psychosocial factors
Psychosocial factors, under a person’s control to some extent, have also been found to have a positive impact on ageing. These include autonomy and social support (Rowe & Kahn, 1987), being involved in social activities or groups, participating in work or volunteer opportunities and positive mental attitude (Seeman et al., 1994), maintaining an optimistic mental outlook and finding meaning in life (Hartman-Stein & Potkanowicz, 2003), effective coping strategies (Heikkinen, 2003) and marital stability (Valliant & Mukamal, 2001). Although positive health behaviours, both physical and psychosocial, are best implemented early in life, changes can improve health outcomes even if initiated in old age (Hartman-Stein & Potkanowicz, 2003; Peel, McClure & Bartlett, 2005).
Social factors
The social model of health argues that an individual’s health is not determined only by their behaviour and lifestyle choices but is also a product of social and economic determinants such as income, race, education, country of birth and gender, which may be beyond their control (Marmot & Wilkinson, 1999). Other aspects of the social model of health include stress, early life, social exclusion, employment, social support, addiction, food and transport. The social model of health states that improvements in health and wellbeing are achieved by addressing the environmental and social determinants of health in tandem with biological and medical factors (Marmot & Wilkinson, 1999; Victorian Government Department of Human Services, 2008).
In considering the social determinants of health and ageing, we need to recognise the cumulative or life course effect of these factors. For example, if deprived of the opportunity to complete secondary or tertiary education, a person may be unable to secure work, in turn affecting their income over the life course, and their ability to purchase real estate and therefore secure housing in older age. People with lower educational levels are more at risk of developing dementia in older age; they have poorer health literacy and are therefore more likely to develop and less likely to manage chronic health conditions (Ngandu et al., 2007). Other social determinants also have cumulative effects. For example, if a person grows up in a situation of domestic violence or abuse, they may have to leave home at an early age, interrupting schooling, perhaps leading to homelessness and drug addiction, which have long-term consequences for health (Brown, Kiely, Bharel & Mitchell, 2012).
In Australia, a particularly at-risk group due to social disadvantage is that of Aboriginal and Torres Strait Islander elders (see Chapter 16). Older Indigenous Australians, especially those living in rural and remote areas, have greater levels of socio-economic disadvantage and poorer health than non-Indigenous Australians (Australian Institute of Health and Welfare, 2015a). Generally, conditions associated with ageing, including chronic health conditions and dementia, affect Aboriginal and Torres Strait Islander people at a younger age. For this reason planning for aged care services for the Indigenous population starts at age 50 years, rather than 65 or 70 for non-Indigenous Australians (Australian Institute of Health and Welfare, 2015b). Although stereotypical views of Indigenous Australians have attributed the higher prevalence of dementia to alcohol abuse, in fact this is not the case. In 2008, the first rigorous study of dementia prevalence in Indigenous Australians of the Kimberley region of Western Australia (Smith et al., 2008) found the prevalence of dementia among older Indigenous Australians to be five times the national average. They found associations between dementia diagnosis and lack of formal education, smoking, stroke and head injury, but not alcohol consumption (Smith et al., 2008).
Homelessness among older people graphically illustrates the cumulative impact of poverty and disadvantage over time. Although often not old in terms of chronological age, long-term homeless people can suffer from health conditions associated with ageing from as early as 45 years of age.
In one of the few studies that has investigated the health of older homeless people, Brown et al. (2012) found that homeless older adults (average age 56 years) were more likely to have functional impairment, frailty, depression, visual impairment and urinary incontinence compared to the general older population.
A research project by Wintringham Specialist Aged Care in Melbourne, Australia showed what could be achieved when intensive psychosocial support was provided to older long-term homeless men and women with alcohol-related brain injury and associated challenging behaviours (Rota-Bartelink, 2012). Seven older men and women took part for six months in a supported residential trial that included intensive recreation, behavioural modification, and individualised drinking and smoking reduction programs. The ratio of staff to participants was 1.5 to 4, care was provided 24 hours per day and the approach was consistent with the Wintringham philosophy of a non-judgmental, tolerant and flexible approach to care. They found that quality of life and productivity improved at the same time as depression, anxiety and alcohol consumption reduced. They estimated that the government saved $30 per person per day compared to caring for this high-needs group in the community. This study suggests that when some of the social determinants of health, such as homelessness and lack of opportunity for productive engagement, are addressed positive health outcomes can be achieved even in later life. However, these intensive models of care require a high degree of taxpayer investment and homeless older people do not generally receive a great deal of public sympathy and support.
The health of older people
Life expectancy
Globally, there have been gains in life expectancy at birth since the 1950s (United Nations, 2013). Over the next 35 years, life expectancy is projected to increase from about 78 years to 83 years in developed countries and from 68 years to 75 years in developing regions (United Nations, 2013). In Australia, total life expectancy is estimated to be 95 years for men and about 97 years for women by 2055 (Commonwealth of Australia, 2015).
Opportunely, increases in life expectancy at birth have been matched by improvements in healthy life expectancy. This refers to the number of years spent without disability (Australian Institute of Health and Welfare, 2014b; Commonwealth of Australia, 2015).
- Disability
a physical, sensory, intellectual or mental impairment which, combined with social and environmental barriers, may limit a person’s activities and participation in society.
- Healthy life expectancy
the number of years a person can be expected to live in full health; often used as a synonym for ‘disability-free life expectancy’.
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