GOOD HEALTH ADDS LIFE TO YEARS

Global brief for World Health Day 2012

 World Health Organization 2012 All rights reserved. Requests for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to WHO Press through the WHO web site (http://www.who.int/about/licensing/copyright_form/en/index.html). The boundaries and names shown and the designations used on maps in this document do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specic companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Design by: Services Concept, Geneva Photo credits. Cover and page 5: Karsten Thormaehlen; pages 8 and 12: HelpAge International/ Antonio Olmos; page 22: HelpAge International/Wang Jing; page 25: WHO/T. Halvari Printed by the WHO Document Production Services, Geneva, Switzerland This publication can be downloaded from http://www.who.int/world_health_day/2012 Document number: WHO/DCO/WHD/2012.2

Foreword
Population ageing is a global phenomenon that is both inevitable and predictable. It will change society at many levels and in complex ways, creating both challenges and opportunities. On the one hand, older people already make a signicant contribution to society, whether it is through the formal workforce, through informal work and volunteering or within the family. We can foster this contribution by helping them maintain good health and by breaking down the many barriers that prevent their ongoing participation in society. On the other hand, towards the end of life, many older people will face health problems and challenges to their ability to remain independent. We need to address these too, and do it in a way that is affordable and sustainable for families and society. Good health must lie at the core of any successful response to ageing. If we can ensure that people are living healthier as well as longer lives, the opportunities will be greater and the costs to society less. This great demographic challenge of the rst half of the 21st century therefore demands a public health response, and WHO has identied this as a priority for the Organization. Numerous determinants of healthy and active ageing lie beyond the health system. They also start to exert their inuence at earlier stages in life. Our response, therefore, needs to tackle issues across the life course and in many social spheres. But the health sector, too, needs to adapt. Overwhelmingly the health challenges in older age are the consequence of noncommunicable disease. We need to develop health systems which can provide the chronic care that these diseases and their risk factors require. This global brief takes a fresh look at existing health data and draws on some exciting new work to help us better understand exactly what these needs are. It identies action we can all take. It is now up to the global community to take up the challenges it identies and truly add life to our increasing years.

Dr Margaret Chan Director-General World Health Organization

Note on terminology
This brief approaches ageing from a life-course perspective. Rather than articially categorizing life into stages such as middle age or old age, it assumes that we age from the moment we are born. Nevertheless, for statistical purposes it is often necessary to divide populations into age groups. The analyses we have used generally apply 60 years and over as a statistical cutoff, however, for various reasons, some analyses refer to populations of different ages such as 50 years and over, 65 years and over or 80 years and over. Recognizing the differing experiences of these subpopulations helps us better understand the ageing process and to appreciate the continuum of life.

KEY
points
Population ageing is a global phenomenon that is now occurring fastest in low- and middle-income countries. While Europe and Japan were among the rst places to experience population ageing, the most dramatic change is now occurring in countries such as Cuba, the Islamic Republic of Iran and Mongolia. Population ageing is inextricably linked with socioeconomic development. Typically, as a country develops, more people survive childhood and childbirth, fertility falls, and people start to live longer. These changes in turn reinforce development. But they are also the drivers behind population ageing. Unless societies adapt in ways that foster the health and participation of older people, this inevitable demographic transition may slow down future socioeconomic advances.
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key
points
While ageing presents challenges to society, it also creates many opportunities. Population ageing will challenge society by increasing demand for acute and primary health care, straining pension and social security systems and increasing need for long-term and social care. But older people also make important contributions as family members, volunteers and as active participants in the workforce. They are a signicant social and economic resource, and longer life expectancy means a greater opportunity to contribute to society. Where the balance lies between these challenges and opportunities will be determined by how society responds. Fostering good health in older age is central to the global response to population ageing. Poor health, negative stereotypes and barriers to participation all currently marginalize older people, undermine their contribution to society and increase the costs of population ageing. Investing in health lessens the disease burden, helps prevent isolation and has broader benets for society by maintaining the independence and productivity of older people. Poor health in older age is not just a burden for the individual but also for their families and for society as a whole. The poorer the family or the setting, the greater the potential impact. Loss of good health can mean that an older person who was previously a family resource may no longer be able to contribute and may, instead, require signicant support. The cost of their health care can impoverish the whole family. This burden is spread inequitably. Those with the least resources, or who live in the poorest areas, are most at risk. The main health challenges for older people are noncommunicable diseases. The impact of these conditions is two to three times greater for older people in low- and middle-income countries than for people in high-income countries. Even in the poorest countries, the greatest health burdens for older people come from diseases such as heart disease, stroke, visual impairment, hearing loss and dementia. Older people often experience several of these health problems at the same time. Current health systems, particularly in low- and middle-income countries, are poorly designed to meet the chronic care needs that arise from this complex burden of disease. For example, while ischaemic heart disease and stroke are the biggest causes of years of life lost, and high blood pressure is a key treatable risk factor for these diseases, only between 4 and 14% of older people in a recent large study in low- and middle-income countries were receiving effective antihypertensive treatment. Instead of treating younger populations with single curative interventions, health systems will need to adapt to ensure high quality, safe care, beyond the hospital setting, for older populations who often have several chronic diseases and disabilities. Ageing is interrelated with other major global trends such as urbanization, technological change and globalization. Just as migration and urbanization are changing social structures and relationships, longer life expectancy will inuence the way people live and plan their lives. Approaches based on 20th century social models are unlikely to be effective in this rapidly changing environment.

key
Increasing longevity may even lead us to rethink the way we view old itself. With people living 10 or 20 years longer, a range of life options that would only rarely have been achievable in the past become possible. There is no simple magic bullet solution to the challenges of population ageing, but there are concrete actions that governments and societies can take now (Table 1).

points

Table 1. A life-course approach to healthy and active ageing

Promoting good health and healthy behaviours at all ages to prevent or delay the development of chronic disease. Being physically active, eating a healthy diet, avoiding the harmful use of alcohol and not smoking or using tobacco products can all reduce the risk of chronic disease in older age. These behaviours need to start in early life and continue into older age.

Minimizing the consequences of chronic disease through early detection and quality care (primary, long-term and palliative care). While we can reduce the risk of chronic disease through a healthy lifestyle, many people will still develop health problems in older age. We need to detect metabolic changes such as high blood pressure, high blood sugar and high cholesterol early and manage them effectively. But we also need to address the needs of people who already have chronic disease, care for those who can no longer look after themselves and ensure that everyone can die with dignity.

Creating physical and social environments that foster the health and participation of older people. Social determinants not only inuence the health behaviours of people across the life course, they are also an important factor in whether older people can continue to participate. It is therefore important to create physical and social environments that are age-friendly and foster the health and participation of older people.

Reinventing ageing changing social attitudes to encourage the participation of older people. Many current attitudes to ageing were developed during the 20th century when there were far fewer older people and when social patterns were very different. These patterns of thinking can limit our capacity to identify the real challenges, and to seize the opportunities, of population ageing in the 21st century. We need to develop new models of ageing that will help us create the future society in which we want to live.

THE DEMOGRAPHICS
of ageing
Why are populations ageing?
In many ways, population ageing can be viewed as a direct consequence of socioeconomic development. While the experience of each country will vary, common patterns emerge. As living conditions improve and access to health care increases, mortality during childhood and childbirth falls. This is typically followed by falling birth rates as families become aware of the greater likelihood that their children will survive, and as women gain more control over their fertility. The lag between falling mortality and falling fertility creates a temporary increase in the proportion of children in the population. As this generation moves into traditional working ages, it reinforces economic growth.

THE DEMOGRAPHICS
But this population bulge eventually moves into older age and, if fertility rates remain low, the proportion of older people in the population increases. This trend is accelerated by increasing survival in older ages. In more developed countries, child and maternal mortality rates have plateaued at very low rates and their future ageing will be increasingly driven by longer survival at older ages. This will lead to greater proportions of people aged more than 80 years in the population. These changes dramatically shift population structures from a dominance of younger age groups, to one where all age groups are more equally represented (Figure 1).

of ageing

Male

China: 1990

Figure 1. Changing population age structure for China 1990-2050

Female

100+ 95-99 90-94 85-89 China: 1990 Male 80-84 75-79 100+ 70-74 95-99 65-69 90-94 60-64 85-89 55-59 80-84 50-54 75-79 45-49 70-74 40-44 65-69 35-39 60-64 30-34 55-59 25-29 50-54 20-24 45-49 15-19 40-44 10-14 35-39 5-9 30-34 0-4 25-29 70 60 50 40 30 20 10 0 20-24 0 10 15-19 Population (in millions) 10-14 5-9 Source: U.S. Census Bureau, International Data Base. 0-4

Female

20

30

40

50

60

70

70

60

50

40

30

20

10

10

20

30

40

50

60

70

Population (in millions) Source: U.S. Census Bureau, International Data Base.

Male

China: 2050

Female

100+ 95-99 90-94 85-89 China: 2050 Male 80-84 75-79 100+ 70-74 95-99 65-69 90-94 60-64 85-89 55-59 80-84 50-54 75-79 45-49 70-74 40-44 65-69 35-39 60-64 30-34 55-59 25-29 50-54 20-24 45-49 15-19 40-44 10-14 35-39 5-9 30-34 0-4 25-29 70 60 50 40 30 20 10 0 20-24 0 10 15-19 Population (in millions) 10-14 5-9 Source: U.S. Census Bureau, International Data Base. 0-4

Female

20

30

40

50

60

70

Source: 60 U.S. Census Data 70 50 Bureau, 40 International 30 20 Base. 10

10

20

30

40

50

60

70

Population (in millions) Source: U.S. Census Bureau, International Data Base.

THE DEMOGRAPHICS
of ageing
Global trends
Population ageing is taking place in every country, although each country is at a different stage of this transition. Figure 2 shows how the proportion of older people is increasing across the globe. While the shift to older populations started in wealthy regions such as Europe and North America, it is now low- and middle-income countries that are experiencing the greatest change. By 2050, 80% of older people will live in these countries. Chile, China and the Islamic Republic of Iran will have a greater proportion of older people than the United States of America. These trends are also evident for the oldest age groups. In the middle of the 20 th century there were just 14 million people on the whole planet aged 80 years or older. By 2050, there will be 100 million living in China alone, and 400 million people in this age group worldwide. Figure 2. Global ageing trends
Percentage of the total population aged 60 or over, 2012

Percentage aged 60 or over

0 to 9 10 to 19 20 to 24 25 to 29 30 or over

Percentage of the total population aged 60 or over, 2050

Percentage aged 60 or over

0 to 9 10 to 19 20 to 24 25 to 29 30 or over

Source: United Nations (2012, forthcoming) Population Ageing and Development 2012, wall chart. Department for Economic and Social Affairs, Population Division, New York. Calculated from the data of United Nations (2011) World Population Prospects 2010, ST/ESA/SER.A/306. Note: The boundaries shown on these maps do not imply ofcial endorsement or acceptance by the United Nations.

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THE DEMOGRAPHICS
For countries such as France and Sweden, population ageing has taken many years. For countries that are now experiencing the same transition, it is taking place much more rapidly. Thus, while it took more than 100 years for the share of Frances population aged 65 or older to increase from 7% to 14%, countries including Brazil, China and Thailand will experience the same demographic shift in just over 20 years (Figure 3). This gives them much less time to put in place the infrastructure to address the needs of this older population.

of ageing

Figure 3.  The speed of population ageing. Time required or expected for population aged 65 or older to increase from 7% to 14%

1860 14%

1880

1900

1920

1940

1960

1980

2000

2020

2040

Percentage of Population Aged 65+

7%

United Kingdom of Great Britain and Northern Ireland

United States of America

Japan

Republic of Korea China Thailand

Sweden

France

Source: Kinsella K, He W. An aging world: 2008. Washington, DC: National Institute on Aging and US Census Bureau, 2009.

Brazil

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THE EPIDEMIOLOGY
of population ageing
Life expectancy
One statistic that is commonly used when discussing population ageing is life expectancy at birth. This is dened as the average number of years that a newborn could expect to live if they were to pass through life exposed to the death rates prevailing at the time of their birth. Life expectancy at birth is a measure of both survival at younger ages and how long survivors tend to live. Table 2 shows life expectancy at birth for different WHO regions. The disparity of almost 20 years in life expectancy at birth between highincome countries and low-income countries partly reects greater longevity in richer

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THE EPIDEMIOLOGY
countries, but is also heavily inuenced by the higher risk of dying at an early age, generally from communicable (infectious) disease in poorer countries. We can gain a different perspective on population ageing by examining the number of additional years that someone who has already reached the age of 60 might expect to live. This life expectancy at age 60 is a better measure of longevity than life expectancy at birth, and the variation between countries is less marked. A 60-year-old woman in sub-Saharan Africa can expect to live for another 14 years, while a 60-year-old woman in a high-income country can expect to live 25 years (Table 2). However, life expectancy at 60 in high-income countries is increasing twice as fast as in low- and middle-income countries, and almost three times as fast as in sub-Saharan Africa.

of population ageing

Table 2. Life expectancy at birth and at age 60 by WHO Region

Life expectancy at birth 2009

Life expectancy at 60 years Annual average rate of change 2000-2009 (%) 0.5% 0.3% 0.7% 0.4% 1.0% 0.1% 0.5% Annual average rate of change 2000-2009 (%) 0.5% 0.3% 0.5% 0.4% 0.7% 0.2% 0.6%

WHO Region

Male (years)

Female (years)

Male 2009 (years) 18 14 21 16 19 15 19

Female 2009 (years) 21 16 24 18 23 18 22

World Africa Americas Eastern Mediterranean Europe South-East Asia Western Pacic

66 52 73 64 71 64 72

71 56 79 67 79 67 77

Source: World health statistics 2011. Geneva, World Health Organization, 2011.

Premature death
One way of characterizing the importance of different diseases is to look at the deaths they cause and to calculate the number of years each person might have lived if, instead, they had been able to survive to older age. Rather than identifying an arbitrary age (such as 70 years) before which a death might be considered premature, epidemiologists can use the highest observed life expectancies as the ideal. Theoretically this ideal is reachable with current technology and resources since it is already being achieved in at least one country. Death at any age younger than this ideal can be considered premature, and this can be quantied as Years of Life Lost depending on how many years earlier than the ideal it occurred. Since Years of Life Lost analyses of the whole population are heavily inuenced by survival rates in younger age groups, these are not very good at helping us understand the important causes of death in older age. Just as life expectancy at age 60 is useful

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THE EPIDEMIOLOGY
of population ageing
in understanding survival patterns in older age, examining the Years of Life Lost for people aged 60 and over is a better measure of the major diseases that cause death in older age groups. This is important since it helps us to prioritize the issues on which we need to focus if we are to better address the health of older people in all countries. Figure 4 shows the 15 greatest causes of Years of Life Lost for people aged 60 and over by different country income group. Regardless of the level of economic development, the three biggest causes of premature death are noncommunicable diseases: ischaemic heart disease, cerebrovascular disease (stroke) and chronic obstructive pulmonary disease. Since this analysis is calculated for every 100000 older people (rather than by the absolute number in each country), it also allows us to compare the relative impact of each of these conditions in different settings. It shows that the burden of premature mortality from noncommunicable diseases in older people is, in fact, even higher in low- and middle-income countries than for high-income countries. Thus, among the same number of older people living in low- or middle-income countries, more than three times as many years are lost to stroke than in high-income countries. More than twice as many years are lost to ischaemic heart disease and more than four times as many to chronic obstructive pulmonary disease.

Figure 4.  Years of life lost due to death per 100000 adults aged 60 years and older by country income group

Thousands 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 Hypertensive heart disease Cerebrovascular disease Stomach cancers Colon, Rectum cancers Ischaemic heart disease Trachea, Bronchus, Lung cancer Nephritis and renal disease Chronic obstructive pulmonary disease Lower respiratory infections Cirrhosis of the liver Oesophagus cancer Breast cancer Tuberculosis Diabetes Liver cancer Low-income countries Middle-income countries High-income countries

Disability
Older people experience higher rates of disability that reects an accumulation of health risks throughout their life course. WHOs Global Burden of Disease (2004) estimates show that prevalence of disability increases with age and suggest that more than 46% of people aged 60 years and over have disabilities. The disability prevalence among older people in low-income countries is higher than in highincome countries, and higher among women than among men.

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THE EPIDEMIOLOGY
Population ageing is therefore likely to lead to an increase in demand for health care and social support. The extent of this increase will be heavily inuenced by whether these trends remain the same or change with increasing longevity. If these patterns stay the same and a 75-year old in 2050 experiences the same level of disability as one in 2012, the increase in demand will be much greater than if the added years of life are healthy. Understanding which of these scenarios is occurring is therefore fundamental if we are to plan effectively for the future. Unfortunately, despite very clear evidence that people are living longer, we do not yet know whether these added years are necessarily healthier. Even if the onset of disability is delayed, increasing numbers of the oldest age groups, those most at risk of disability, will inevitably result in increased demand for long-term care. The Organisation for Economic Co-operation and Development has therefore concluded that it would be unwise for policy-makers to expect that reductions in severe disability among older people will offset increased demands for long-term care. There is clearer information on the current causes of disability in older age. Figure 5 shows the burden of disability by country income group using the concept of Years Lost due to Disability (YLD). YLDs are calculated from the incidence of nonfatal disease and a weight factor reecting the severity of the disease. Using this approach, the four biggest causes of disability (visual impairment, dementia, hearing loss and osteo arthritis) are the same in low-, middle- and high-income countries, although the ranking changes by income setting.

of population ageing

Figure 5.  Years Lost due to Disability (YLDs) per 100000 adults over age 60 by country income group

Thousands 9 8 7 6 5 4 3 2 1 0 Dementia Cerebrovascular disease Ischaemic heart disease Chronic obstructive pulmonary disease Rheumatoid arthritis Cirrhosis of the liver Trachoma Vision Diabetes Parkinson's disease Osteoarthritis Depression Insomnia Hearing Dental High-income countries Middle-income countries Low-income countries

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THE EPIDEMIOLOGY
of population ageing
In low- and middle-income countries, visual impairments are by far the biggest cause of burden of disease, and this burden is more than three times that experienced by older people in high-income settings. These impairments are mainly due to refractive errors, cataracts, glaucoma and macular degeneration (Table 3). A signicant portion of these problems can be corrected or resolved at very little cost.

Table 3.  Years Lost due to Disability (YLDs) from visual impairment per 100000 adults over age 60 by country income group

Refractive errors

Cataracts

Glaucoma

Macular degeneration

World High income Middle income Low income

1869 762 1564 3919

1478 136 1816 2492

430 180 541 517

912 708 938 1118

An often-overlooked cause of disability is age-related hearing loss. Untreated hearing loss affects communication and can contribute to social isolation, loss of autonomy and is associated with anxiety, depression and cognitive decline. This physical and social handicap is often not appreciated by persons with normal hearing, and slowness in understanding the spoken word is often equated with mental inadequacy, causing the older individual to withdraw further and often remain aloof in order to avoid being labelled as mentally inadequate. Hearing impairment can lead to a loss of independence and the need for formal support services. Table 4 shows the absolute numbers of people affected by these common causes of disability by country income group. More than 250 million older people around the world experience moderate to severe disability. There are more than 40 million older people in low- and middle-income countries with signicant hearing impairment, while 32.5 million have signicant visual impairment from cataracts, and 39.8 million signicant visual impairment from refractive errors. Dementia is the greatest cause of years lost due to disability in high-income countries and the second greatest worldwide. More recent data suggests that, in 2010, there were 35.6 million people living with dementia globally, with 7.7 million new cases each year.1 Numbers of people with dementia will nearly double every 20 years, with much of the increase occurring in rapidly developing middle-income countries. Currently, 58% of people with dementia live in low- and middle-income countries, and this proportion is projected to rise to 71% by 2050.

World Alzheimer Report 2011: The benets of early diagnosis and intervention. Alzheimers Disease I nternational London, 2011.

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THE EPIDEMIOLOGY
of population ageing

Table 4.  Prevalence of moderate and severe disability in adults aged over 60 (in millions), by leading health condition associated with disability, and by country income group

High-income countries Visual impairment Hearing loss Osteoarthritis Ischaemic heart disease Dementia Chronic obstructive pulmonary disease Cerebrovascular disease Depression Rheumatoid arthritis 15.0 18.5 8.1 2.2 6.2 4.8 2.2 0.5 1.7

Low- and middle-income countries 94.2 43.9 19.4 11.9 7.0 8.0 4.9 4.8 3.7

The total burden of death and disability

The total burden of disease faced by older people is a combination of both premature death and poor health experienced during life. This concept is captured in a measure known as the Disability Adjusted Life Year (DALY). One DALY can be thought of as one lost year of healthy life and is calculated as the sum of both the years of life lost due to premature death and those lost due to disability. When applied to all ages, the leading causes of burden of disease (DALYs) are lower respiratory disease, diarrhoeal disease and depressive disorders. Examining the burden of disease in older ages gives a different picture (Figure 6). For older adults in high-income countries, the biggest causes of burden of disease are, in order of importance, ischaemic heart disease, visual disorders, dementia, cancers and stroke. For low- and middle-income countries, the biggest causes are ischaemic heart disease, stroke, visual disorders, and chronic obstructive pulmonary disease. All are noncommunicable diseases.
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THE EPIDEMIOLOGY
of population ageing

Figure 6.  Disability Adjusted Life Years (DALYs) per 100000 adults over age 60 by country income group

Thousands 16 14 12 10 8 6 4 2 0 Hypertensive heart disease Stomach cancers Ischaemic heart disease Trachea, Bronchus, Lung cancer Colon, Rectum cancers Dementia Hearing loss Tuberculosis Diabetes Vision Chronic obstructive pulmonary disease Lower respiratory infections Cirrhosis of the liver Osteoarthritis Stroke

High-income countries Middle-income countries Low-income countries

Why is there such a marked variation in disease burden between countries? Partly, it may reect problems collecting comparable data. The differing burden for dementia, for example, may partly reect difculties in diagnosis in low- and middle-income countries. But another explanation is that the behavioural and metabolic risk factors for these chronic diseases (e.g. smoking) vary by country. Since we know the relationship between these factors and major diseases, it is possible to estimate the proportion of this total burden of disease that is caused by each risk factor. These estimates are shown in Figure 7. The biggest underlying risk factor observed in older people is high blood pressure which can explain 12-19 % of the total burden of disease in poorer countries. Other key determinants are smoking and high blood glucose levels.

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THE EPIDEMIOLOGY
of population ageing

Figure 7.  Proportion of DALYs in each country-income group caused by specic risk factors for adults over age 60

20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Low fruit/vegetables High blood glucose Physical inactivity Tobacco use High blood pressure Overweight/obesity High cholesterol Indoor smoke High-income countries Middle-income countries Low-income countries

In older people, the impact of almost all of these underlying causes are greater in low- and lower middle-income countries. This is in stark contrast to the widely held belief that these health risk behaviours, and the diseases they cause, are problems of afuence. Despite the importance of these risks, current approaches to their control in low and middle income countries do not appear to be succeeding. Analysis of over 35000 people aged 50 and over in the World Health Organization Study on Global Aging and Adult Health (SAGE) indicates that despite between 32 and 80% of older people having high blood pressure, only 4 to 14% were receiving effective treatment (Figure 8). Yet, WHO has identied multidrug therapy to those at high risk of cardiovascular disease as an evidence-based best buy with a cost of less than US$ 1 a year per person in lowincome countries. For lack of this basic care, the health and future of millions of older people and their families is currently at risk.

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THE EPIDEMIOLOGY
of population ageing

Figure 8.  Prevalence of hypertension and proportion effectively treated among adults aged over 50 and older across six countries

80 70 60 50 % Hypertensive 40 30 20 10 0
China Ghana Mexico South Africa Russian Federation India

% Controlled

Other challenges
Injuries, particularly falls, among the elderly are often unrecorded, but are frequent events which may start a downward spiral in health status, resulting in death or long-term care needs. Approximately 28-35% of people over the age of 65 fall each year, and this proportion increases to 32-42% for those aged more than 70 years. Falls may lead to post-fall syndrome, which includes increased dependence, loss of autonomy, confusion, immobilization and depression. Within the year following a hip fracture from a fall, 20% of older people will die. Yet falls may be prevented through a number of interventions including: clinical interventions to identify risk factors such as treatment of low blood pressure and treatment of correctable visual impairment; home assessment and environmental modication of risks; muscle strengthening and balance retraining; and, community-based group programmes which include fall-prevention education and exercises, such as Tai Chi, to improve balance and strength. Elder maltreatment is rarely recorded. Around 4-6% of elderly people have experienced some form of maltreatment at home. Maltreatment can lead to serious physical injuries and long-term psychological consequences. Multiple sectors can contribute to reducing elder maltreatment, including the social welfare sector (through the provision of legal, nancial and housing support); the education sector (through public education and awareness campaigns), and the health sector (through the detection and treatment of victims by primary health-care workers).

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THE EPIDEMIOLOGY
of population ageing

Other issues that are crucial for healthy and active ageing relate to mental health and wellbeing. While depression is identied as a signicant cause of disability and a likely problem in older age, social isolation and loneliness are not recorded in these databases. Social trends may be exacerbating these issues. For example, in some European countries, more than 40% of women aged 65 or older live by themselves. Facilitating social participation of older people can not only benet society, but can also help avoid or overcome the loneliness experienced by many older people.

New research and evidence gaps

There are limits to the available data. In particular, they do not show how well all these needs are currently being met. Information on this is very limited, particularly in low- and middle-income countries. To overcome this knowledge gap, WHO is undertaking a longitudinal study of more than 40000 older people in six countries: China, India, Ghana, Mexico, the Russian Federation and South Africa (http://www. who.int/healthinfo/systems/sage/en/). Although in-depth analysis of the rst wave of data has not been completed, early results indicate major gaps.

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TAKING ACTION
on ageing and health
The burden of poor health is unevenly shared, with older people in low- and middleincome countries facing far higher rates of death and disability than in the rich world. Yet it is these same countries that have the most limited infrastructure with which to respond. Noncommunicable diseases are the overwhelming challenge, and all countries need to build health systems that can prevent and control these disorders. The evidence for how to do this is very strong.

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TAKING ACTION
Promoting good health and healthy behaviours at all ages to prevent or delay the development of chronic disease.
Since noncommunicable disease in older age is often the consequence of behaviours or exposures earlier in life, strategies need to be put in place that reduce these risks across the life course. Being physically active, eating a healthy diet, avoiding the harmful use of alcohol and not smoking or using tobacco products can all reduce the risk of chronic disease in older age. WHO has identied a set of evidence-based best buy interventions for tackling noncommunicable diseases that are not only highly cost-effective, but also feasible and appropriate to implement within the constraints of low- and middle-income health systems. These include preventive strategies such as taxes on tobacco and alcohol, smoke-free workplaces and public places, reduced salt intake in food and increasing public awareness on diet and physical activity.

on ageing and health

Minimizing the consequences of chronic disease through early detection and quality care
Early detection
A key approach is the early detection and management of noncommunicable diseases and their modiable risk factors. Given the heavy burden of cardiovascular disease, high blood pressure should be prevented and better managed. A recent study examined why people in Japan now live the longest, and possibly healthiest, lives.2 A major factor appeared to be control of hypertension through an efcient detection and treatment system combined with strategies to reduce salt consumption across the population. Yet, as shown in Figure 8, high blood pressure is very common in older people in lowand middle-income countries, and few are receiving effective treatment.

Chronic care
Even with a greater emphasis on health promotion and disease prevention, many older people will still develop noncommunicable diseases and the current generation of older people has immediate needs. All countries, therefore, need to develop sustainable systems of chronic care that ensure high quality, safe care, beyond the hospital setting. These must address the chronic nature of these problems and the coexistance of multiple diseases requiring multiple treatments. For example, many elderly patients in high-income countries can be taking up to 20 medications at one time, often resulting in adverse health effects due to drug interactions.

Long-term care
A key consequence of noncommunicable diseases is disability. Problems such as cataracts, refractory errors, dementia and osteoarthritis cause sensory, cognitive and physical impairments that limit an older persons ability to participate in society. Access to rehabilitation, assistive devices and living in a supportive environment can lessen this burden. However, many people will reach a point in their lives when they are no longer able to look after themselves. We need to make sure that these people have access to long-term care. In most countries, informal care, including family care, is the predominant model of support for older adults. But caregivers often experience high levels of strain, psychological problems and poor physical health. Moreover, as the relative number of older people increases and there is a decreased proportion of younger adults available to provide care, these models are unlikely to be sustainable. New models are needed which provide the necessary support for older people that are relevant to 21st century demographic and social patterns.

2 Ikeda N et al. What has made the population of Japan healthy? Lancet 2011; 378: 1094105.

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TAKING ACTION
on ageing and health
Palliative care
Many of the common causes of death in older age can be associated with pain and distress. We need to ensure that everyone can live with dignity until the end of their life. Yet in many countries, access to effective pain relief is extremely limited and millions lack access to any form of palliative care.

Creating physical and social environments that foster the health and participation of older people.
While health and social care are crucial for older people, numerous determinants of healthy and active ageing lie beyond the health system. Some of these inuence older people directly. For example, living in a neighbourhood that is safe, and where other older people can be seen on the streets, might encourage older people to engage more frequently in community activities. But active ageing is a lifelong process, and these same neighbourhoods can also increase the likelihood of younger people being physically active. This is positive for their health and helps to ensure that when they, too, transition to older age, they do so from a stronger base. The WHO Global Network of Age-friendly Cities and Communities (http://www.who. int/ageing/age_friendly_cities_network/en/index.html) is taking practical steps to create physical and social environments that foster healthy and active ageing. Afliated programmes are in place in many countries including Canada, France, Ireland, Portugal, the Russian Federation, Slovenia, Spain and the United States of America. Individual cities such as Geneva, La Plata, Manchester and New York are also participating. Each of these has committed to a cycle of continual improvement to become more age-friendly. This includes strategies to improve both physical and social aspects of the environment including accessibility, transport, intergenerational links, societal attitudes and service provision. Many innovative models are emerging.

Reinventing ageing changing social attitudes to encourage the participation of older people.
Potentially effective strategies to foster healthy and active ageing can be undermined by a range of stereotypes that are often applied to older people. While we tend to view older people within our own family or personal networks in a positive light, older people in a more general sense are often viewed in negative ways. For example, a person may be considered too old to learn new skills, or too near retirement age to be worth retraining. Both of these attitudes make it harder for an older person to maintain the skills they need to make them attractive to a prospective employer. There are many ageist stereotypes that limit our capacity to really understand the challenges and opportunities of population ageing. They can also prevent us from identifying innovative solutions. For example, portraying older people as a burden rather than a resource leads us to think of ways to minimize the cost of ageing rather than to maximize the opportunity for older people to contribute. Viewing older people as out of touch stops us thinking of strategies that might better draw on their experience and knowledge. Some of these stereotypes will change as more and more older people start to live lives that vary from previous norms. Already older people make major contributions in elds as diverse as business, the arts and public service. This is likely to become much more widespread as populations age. But taking active steps to break down these negative beliefs will not only benet older people, it will reduce the costs of population ageing. It will also help us to build sustainable, cohesive, equitable and secure societies the sort of society which we may all want to be part of.

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RECOMMENDED
reading
From burden to best buys: reducing the economic impact of noncommunicable diseases in low- and middle-income countries. Geneva, World Health Organization/ World Economic Forum, 2011. Global population ageing: peril or promise? Geneva, World Economic Forum, 2012. World report on disability. Geneva, World Health Organization, 2011. World economic and social survey 2007: development in an ageing world. New York, United Nations Department for Economic and Social Affairs, 2007. Global age-friendly cities: a guide. Geneva, World Health Organization, 2007.
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Appendix 1. Methods and data sources used in this brief

This paper uses data for adults ages 60 and older from the Global Burden of Disease: 2004 update (GBD 2004). 3 World Bank income classications (2004)4 are used with WHO Member States classied as follows: high income if their 2004 gross national income (GNI) per capita was US$ 10 066 or more, middle income if their GNI per capita was between US$ 826- 10 065, and low income if their GNI per capita was less than US$ 825. The data required to estimate YLLs are number of deaths and standard life expectancies, whereas data required to estimate YLDs are incidence, disability duration, age of onset and distribution by disability weight. Disability weights, reected on a scale from 0 (perfect health) to 1 (death), can be found in Mathers et al (2006).5 For the purposes of estimating the burden of disease in older adults, analyses for this report were conducted without age weights or discounting, attributing similar value to years lost during the older ages. In 2009, WHO conducted analyses to assess the impact of 24 risk factors on the global burden of disease.6 For this report, 8 risk factors were selected based on their empirical association with diseases or conditions that cause the greatest loss of DALYs for older populations, namely heart disease, stroke, chronic obstructive pulmonary disease and diabetes. To assess the burden caused by each risk factor for countries in different income levels, the proportion of DALYs for each risk factor was calculated against the total DALYs for each of the three income categories. Burden estimates attributable to risk factors included the 3% discount and non-uniform age weights. A full description of the methods used can be found at http://www.who.int/ageing/en

The global burden of disease: 2004 update. Geneva, World Health Organization, 2008. Available at: http://www.who.int/evidence/bod

4 5

World development report 2004: equity and development. Washington, DC, World Bank, 2006. Mathers CD, Lopez AD, Murray CJL. The burden of disease and mortality by condition: data, methods and results for 2001. In: Lopez AD, Mathers CD, Ezzati M, Murray CJL, Jamison DT, eds. Global burden of disease and risk factors. New York, Oxford University Press, 2006:45240 (3).

Global health risks: mortality and burden of disease attributable to selected major risks. Geneva, World Health Organization, 2009.

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