Pan American Health Organization

Aging and demographic changes

  • Introduction
  • The Americas Are Aging: a Window of Opportunity
  • Aging Beyond Demographics: the Search for Equity
  • Aging, Health, and Functional Capacity
  • The Public Health Response to Aging
  • Conclusion
  • References
  • Full Article
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Introduction

Between 2000 and 2050, the proportion of the world’s population aged 60 years and older will double, from about 11% to 22%. The absolute number of people 60 years and older is projected to increase from 900 million in 2015 to 1.4 billion by 2030, to 2.1 billion by 2050, and to 3.2 billion in 2100 (). Between 2025 and 2030, life expectancy in Latin America and the Caribbean (LAC) will increase to a projected 80.7 years for women and 74.9 years for men; in Canada and the United States of America, those numbers are projected to be even higher: 83.3 years for women and 79.3 years for men ().

The increase in life expectancy is due to several factors, including a decline in fertility rates and success in reducing fatal childhood diseases, maternal mortality, and mortality in older ages (). However, longer life expectancy is also a source of concern for policymakers; income growth may become harder to realize in countries with large populations of older people, and meeting the needs of a large elderly population will be especially difficult in low- and middle-income countries. It will be necessary to create economic and social institutions that provide income security, adequate health care, and other needs for the aging population (). An additional issue that policymakers are facing today is how to best define an older person. Terms used to define an older people include “the aged,” “the elderly,” “the third age,” and, in some cultures, “the fourth age” (). However, being “old” comes at different times to different people (). How to define older persons will remain a challenge because “the elderly, despite being a class, consist of individuals with unique life experiences, goals, and needs,” and because becoming older involves a change in capacity, social involvement, and physical and mental health ().

In response to these demographic transitions and concerns, the the Pan American Health Organization (PAHO) and the World Health Organization (WHO) have approved strategies and guidelines related to aging and health. In 2002, for the first time, PAHO Member States approved a resolution on health and aging (CSP26.R20). The Region of the Americas was the first WHO region to approve a strategy and plan of action on aging and health, in 2009(). In June 2016, the Organization of American States, with the technical support of PAHO and the Economic Commission for Latin America and the Caribbean (ECLAC), approved the Inter-American Convention on Protecting the Human Rights of Older People (). These instruments, which have been developed in the international context of health and aging, highlight the need for an innovative approach in the care of older persons. However, most of the countries in the Region still lack a holistic view of the demographic transition and do not provide an integrated approach to the care of older persons. The challenge posed by this change is viewed in a fragmented way, addressing the increased prevalence of chronic diseases, disability, and care dependency, or the consequent impact of these problems on health services, medication use, and long-term care. Therefore, it will be necessary to continue developing an integrated approach and working on comprehensive public health actions “to ensure healthy lives and promote well-being for all ages through universal health coverage including financial risk protection” ().

In the next decade, both population aging and individual aging will be major factors in modulating health needs, social security, and social protection, as well as the way in which these demands will be met. Despite the tangible implications of this aging trend for social security and public health, the Region still lacks a comprehensive vision of health for older persons. Knowledge about their health needs and care is not uniform, and most health systems lack indicators to monitor and analyze the impact of health measures. Coverage, continuity of care, and geographical, physical, economic, and cultural access to health services are inadequate, and the few persons who who do have access still do not receive services to meet their needs (). In this context, most experts agree that it is necessary to foster integrated health interventions () and to develop strategies that enable health systems to adapt to the new demographic and epidemiological realities ().

The Americas are aging: a window of opportunity

WHO’s Global Strategy and Plan of Action on Ageing and Health highlights the importance of demographic changes and how the changes will drive new challenges for public health and offer opportunities and a window for action created by the “demographic dividend” to be experienced during this decade (). The term demographic dividend refers to the dependency ratio in the population (i.e., the proportion of children aged less than 15 and adults over 59 years, compared with persons aged 15–59 years). The demographic dividend occurs when the dependency ratio drops substantially (Figure 1) due to the large pool of adult workers with low fertility combined with a relatively small group of dependent older people. Such a situation offers a “window of opportunity” to make investments in strengthening the country’s education, pension, and health systems (). The demographic dividend will span a much shorter period of time in countries with large pools of older persons than for those countries in the Region whose populations are still younger (). In the next decade, the extended work life of older people and their active participation in productive activities will require a review of the point at which they might be considered a “dependent” segment of the population.

Figure 1. Total child and old-age dependency ratios under different projection variants in LAC, 2010–2050

Source: United Nations Populations Division, Department of Economics and Social Affairs (DESA), population estimates and projections 2008 revision. Available from: http://www.un.org/en/development/desa/population/.

By international standards, Canada and the United States, in which some 20.7% of their population is at least 60 years of age, are already “old.” The aging of this population has taken place gradually over a period of 50 years. In contrast, in LAC, the number of persons 60 and older is expected to climb from 59 million to 196 million between 2010 and 2050. As shown in Figure 2, in LAC, the growth of the aging population will occur in a severely contracted interval of 20 to 30 years ().

Figure 2. Percentage change in the proportion of adults aged 60 or older in the Americas, for North American and for Latin America and the Caribbean (LAC), 2000–2015 and 2015–2030

Data Source: United Nations. World population prospects: the 2015 revision. New York: UN, Department of Economic and Social Affairs, Population Division; 2015.

Currently, people over 60 comprise about 13% of the population in the Caribbean, 12% of the population in South America, and 9% of the population in Central America. In contrast, by 2050, approximately 25% of the population of LAC will be 60 years and older (). These demographic trends will continue in the Region in the next 25 years and will be associated with a decrease in the proportion of children (aged 0–14) in the population, leading to drastic changes in the aging index (i.e., the ratio of older people to people under the age of 15) ().

In 2010, there were approximately 36 older persons for every 100 children in LAC. The projections indicate that this trend will reverse as of 2036, and by 2040, there will be 116 older persons for every 100 children younger than 15. With regards to the Caribbean, by 2040, the aging index could reach 142 older persons for every 100 children ().

Figure 3. Young children and older persons as a percentage of the population of the Americas: 1950–2050

Source: He W, Goodkind D, Kowal P. U.S Census Bureau, International Population Reports, P95/16-1, An Aging World: 2015. Washington, D.C.: U.S. Government Publishing Office; 2016.

Life expectancy in the Region has increased by 21.6 years, on average, over the last 60 years and will continue to increase during the rest of the century. The octogenarians of the second half of this century have already been born, highlighting the importance of substantial investment in population health throughout the life course (this topic is discussed further the section “Building health throughout the life course“) (Figure 4).

Figure 4. Probabilities of survival to ages 60 and 80 among the 1950–1955 and 2000–2005 birth cohorts, by sex, for Latin America and the Caribbean (LAC) and for North America

Data Source: United Nations. World population prospects: the 2015 revision. New York: UN, Department of Economic and Social Affairs, Population Division; 2015.

While investment throughout the life course is imperative, the reality is that LAC will have to adapt much more quickly to the growth of the aging population at much lower levels of national income compared to the experience of higher-income countries in North America (). Unless there is unprecedented economic expansion, countries in LAC will generally experience rapid aging combined with increasing pressure for pension coverage that is already deficient for older people (). It is therefore essential that the Region develops a new paradigm of aging that views longevity as a period that continues to be productive and is characterized by self-care and involvement with family and community (). It is increasingly recognized that many countries in the Region will need to increase social security funds for older people, such as contributive and noncontributive public pensions. Additionally, removing the stigma of old age is essential for developing different approaches and ensuring not only the financial security but also the health and social protection of older people in a broad and equitable fashion ().

Not only can individuals expect to live much longer than previously, but families and communities are changing, too. Traditionally, the well-being of older people relied on support provided by younger relatives. Culturally, it was considered the responsibility of adult children to protect and care for parents. However, a significant shift has occurred in this norm due to changes caused by urbanization, migration, changes in living arrangements, increased life expectancy, and a rapid decline in fertility. These changes mean there will be fewer older people living with, or in proximity to, adult children who are able to provide support and care for them (). In countries with a younger population, the majority of older persons still live in multigenerational households; however, as populations age, the percentage of older persons living alone increases. In Central American countries, for example, only 10% to 23% of older adults live alone, while in Uruguay and Argentina over 50% live alone. By definition, as populations become older, fertility declines and life expectancy increases (). Only about one-third of adults in LAC receive income from pensions; as a result, material support for old age is still dependent on the extended family. Furthermore, rapid aging is occurring in a fragile institutional environment, i.e., in which the bulk of sources that guarantee minimum levels of social and economic support (such as old-age pensions) are being reformed or, in some cases, eliminated (). As families become smaller, it is conceivable that adult children will have to ration available resources in support of three and even four generations (). Thus, in LAC, a highly compressed aging process will take place in the midst of rapidly changing intergenerational relations and fragile public social protection structures, affecting pensions and access to health ().

Healthy aging in the Region will be determined by the availability of age-friendly policies and programs that create sustainable environments to allow older persons and their families to live with dignity and a high quality of life. The time to act is now, while most countries still have a window of opportunity (). The stage is set: the current older population in the Region grew up with a wide range of privileges and disadvantages that have resulted in sharp differences in life expectancy, longevity, and health. Therefore, the current policy challenge is to invest in necessary interventions to reduce health inequities in adults who are older, and to improve conditions that promote healthy aging and equity by building the infrastructure that is needed to address the continued expansion of the older adult population that will occur during the next decade ().

Aging beyond demographics: the search for equity

“When we are old, it is hard to do things; age takes over and we are no longer able to work like before… [I] don’t have the strength to do the things I used to do, my children are all gone; what can I do? Perhaps it is time for me to die.” (An indigenous older person in the qualitative study on aging in Ecuador)

The impact of aging extends to practically all spheres of life. It is especially evident in its economic, social, and public health spheres, and in family and personal life. The Political Declaration and Madrid International Plan of Action on Ageing () approved in Madrid in 2002, defined three priority areas: integrating older people into development strategies; providing enabling environments for aging and older people; and promoting the health of older people. These three priorities are now very much in force in the Region. The pursuit of equity through the life course is imperative for healthy aging (see “Building health throughout the life course“). Almost 50% of the older people interviewed for the Salud, Bienestar y Envejecimiento (SABE) study said that they did not have the financial means to meet their daily needs, and one-third did not have a pension or a paying job (). In developed countries, approximately 75% of the older population receives some pension; in LAC, only 40% of older people do. There is a significant difference between the genders, too; 11% of older men and 25% of older women have no income of their own (). The level of schooling among older people is lower than that of the general population, and they have very high illiteracy rates. Ill health in old age is not inevitable, and there is a demonstrable association between ill health and social and health conditions. In the United States, 77% of people over the age of 65 report they are in good health. In LAC, however, less than 50% of people over 60 describe their health as good. Furthermore, women in LAC say that they are in poorer health than men.

Inequality and indigenous populations

Studies in Ecuador and Peru offer a window into the experience of aging among indigenous populations in rural areas, which have high rates of extreme poverty. In Peru, in a sample of low-income “younger olds,” defined as the beginning of old age (), 61% reported that they had good or very good health, with no significant difference between rural and urban areas. However, among people 75 or older who lived in rural areas that percentage dropped to 48%. In contrast, in urban areas, 61% of those 75 and older reported they were in good health (). This difference is consistent with the number of self-reported chronic conditions untreated or unmanaged in rural versus urban areas and in the percentage of individuals who report difficulties with instrumental activities of daily living (). In a qualitative study of an indigenous population in Ecuador, aging is most frequently associated with the loss of capacity to do physical work and with dependence on others to meet basic needs ().

Figure 5. Percentage of older persons reporting good or very good health by age, and rural/urban residence

Source: ESBAM 2012. Ministry of Development Social Inclusion –General Department of Monitoring and Evaluation.

Aging, health, and functional capacity

With time, and especially after having reached a peak of development, humans experience important biological changes at the cellular and molecular level that lead to a decrease in the capacity of organs and systems. This is reflected primarily in a loss of reserve capacity, but eventually the changes also lead to a loss of functional capacity, exponentially increasing the risk of becoming ill or disabled, or dying. However, it is clear that all people do not age in the same way; although genetics is involved, aging is also determined by many positive and negative influences during the life course (). The development of geriatrics and gerontology in the last decades has allowed for a better understanding of the processes of health and aging and their relation to disease ().

The World Report on Ageing and Health defines healthy aging as “the process of developing and maintaining functional abilities that enable well-being in older age. Functional abilities are the health-related attributes that enable people to be and to do what they have reason to value; it is made up of the intrinsic capacity of the individual, relevant environmental characteristics and the interactions between the individual and these characteristics” ().

Ensuring healthy population aging begins before birth and continues throughout the life course. The challenge for policymakers today is to address increases in chronic conditions and frailty among older persons, as well as continuing to improve health along the life course. But addressing longevity requires systemic changes in health care systems; what works when the health care system focuses on primary prevention of noncommunicable diseases and on curing acute conditions does not necessarily work when the aim is to maintain health and functional capacity in adults and older adults with chronic conditions. These changes need to be informed by the diversity of health, disease, and functional trajectories that occur during the last four decades of life ().

In LAC, birth cohorts that reached 70 after the year 2000 are unique in that they are largely the product of public health interventions that increased childhood survival. This cohort was exposed to infectious diseases and early malnutrition that may contribute to the late onset of chronic conditions and frailty. Evidence that early childhood conditions affect adult health is mounting fast (). Empirical data as well as theoretical arguments () highlight four factors in early childhood that may influence later health: () conditions that developed in utero or shortly after birth may remain latent for long periods and may be expressed in late adulthood as chronic conditions (); () illnesses during early childhood may directly cause the late onset of some chronic diseases such as heart disease and rheumatic fever; () recurrent bouts of infectious diseases during early childhood and the processes of sustained inflammation in later life may cause the early onset of coronary heart disease; and () socioeconomic conditions in early childhood could have harmful health effects in a person’s later years (see Building health throughout the life course ).

Achieving the goals of healthy aging is “not simply a case of doing more of what is already being done or doing it better. Systemic change is needed” (). Aging is and will continue to be a driver in public health for decades to come. Population aging in the Region is not only a matter of increased number of people 60 and older, but the increased combination of multiple chronic conditions, recurrent infectious diseases, and geriatric conditions that include diminishing muscle mass, changes in sensory and cognitive functions, and a decline in immune functions. However, the current public health and health care systems were developed around a different set of demographic and epidemiological imperatives and are seriously unprepared to address the needs and priorities of a fast-growing older population (). Regardless of socioeconomic conditions in the Region, life expectancy at the age of 60 may now mean another 18 to 23 years of life can be expected. People aged 80 and older are the fastest growing population group in the Region (). This is an unprecedented reality, and their presence will affect existing paradigms of public health and health services.

About two in three older persons have a chronic condition, including arthritis, asthma, chronic respiratory conditions, diabetes, heart disease, and hypertension (). The prevalence of two or more concurrent chronic conditions increases with age (). As the number of chronic conditions in an individual increases, so do the risks of poor functional status and otherwise unnecessary hospitalizations.

The resource implications of addressing multiple chronic conditions are immense. In the United States, 66% of total health care spending is directed toward care for the approximately 27% of Americans with multiple chronic conditions (). The 2015 World report on ageing and health describes a systematic review of studies in seven high-income countries, which concluded that more than half of all older people are affected by multimorbidity for which the prevalence increases sharply in very old age (). Even though we lack information in LAC about the prevalence and impact of multiple chronic conditions, the increasing life expectancy and the aging LAC population will dramatically increase the need for health systems to change from a “young” system of care to a mature system that deals in large part with the effect of multiple chronic conditions in an older population.

The aging population will experience greater functional loss, dependence, and demand for care, and despite the visible implications that this phenomenon will have for social security and public health in the next 10 years, the Region still lacks a plan for long-term care. This scenario also requires that health care confront new prevention and treatment challenges. Health systems and services should prepare in a timely way to respond to the growing health care needs caused by those conditions and should not be focused only on cures or avoiding death. By 2020, the prevalence of severe disabilities affecting this population group in LAC will increase by 47%. In the year 2010, dementias were responsible for an estimated global cost of US$ 604 billion; in the Americas alone, the total estimated cost was US$ 235.8 billion ().

Preventing blindness in older persons

The aging process is frequently associated with declines in sensory functions that can have important implications for the well-being of older people and their families. Much of this dependence can be completely prevented with health interventions. Untreated sensory changes affect not only quality of life but also the level of dependency and disability, with the associated costs of caring for someone who becomes disabled in old age. In order to achieve universal access to health, health systems must develop simple interventions aligned to the health needs of older persons, including improved access to intraocular lenses used in cataract surgery. These lenses can make the difference between healthy aging and premature dependency on others. Cataracts that are not corrected by surgery continue to be the most common cause of blindness for three million people in the Americas. In Latin America, cataract surgery performed by the public sector or by NGOs costs about US$ 300; cataracts that go uncorrected cause 58.0% of blindness in Peru and 66.4% in Panama. In the United States, the 13-year societal cost perspective for the financial return on investment (ROI) for first-eye cataract surgery was US$ 121,198, a 4,567% gain over 13 years. The direct ophthalmic medical cost for unilateral cataract surgery in 2012 was US$ 2,653 ().

The public health response to aging

Poor health is not inevitable in old age, but a long life of good health is not a given. Older people have accumulated a lifetime of risk factors associated with multiple chronic conditions in addition to the physiological changes of old age. Faced with a long-lived population, it is necessary for public health systems to develop an approach focused on functional capacity and health, in addition to disease management.

Whether or not we are able to promote healthy aging and support the intrinsic capacity of older adults to maintain functional capacity will depend on how well we achieve systemic changes in the health care system. In turn, how well we promote healthy aging, in spite of multiple chronic conditions, will determine the cost of population aging and the capacity of the health system to respond to the health needs of the entire population.

The World report on ageing and health provides three key reasons to act. The first reason is the rights of older persons: an approach to health based on human rights means that health “embraces a wide range of socioeconomic factors that promote conditions in which people can lead a healthy life and extends to the underlying determinants of health, such as food and nutrition, housing, access to safe and potable water and adequate sanitation, safe and healthy working conditions, and a healthy environment” (). In addition, this approach recognizes that older persons’ autonomy, participation, and integration into the community are central to their well-being (). The second reason is to foster sustainable development: promoting older persons’ contribution to development promises to lead to a more equitable society. Healthy older adults contribute to the community in numerous ways. Conversely, lack of access to health care may lead to avoidable hospitalizations and loss of functional capacity, which in turn requires the care and resources of family members. The third reason is the economic imperative: based on the continuous contribution older people make to individuals, family, and the community, WHO presents a new paradigm.

The World report on ageing and health takes a novel approach to the economic implications of older populations. It states that “rather than portraying expenditures on older persons as a cost, these are considered as investments” (). These investments include expenditures in an integrated health system aligned to the needs of older persons, long-term care, and age-friendly environments. As with any other investment, doing what is known to work to improve and maintain functional capacity will yield a sustainable return on the investment. The public health response will suggest how some of these investments may be prioritized.

The Multisectoral Action for a Life Course Approach to Healthy Ageing: Draft Global Strategy and Plan of Action on Ageing and Health () defines five priority areas to concentrate the public health response to aging. One of the first steps in implementing the plan includes developing indicators with core baseline data to be used in monitoring progress in each of the priority areas and to document progress towards planning for a decade of healthy aging during 2020–2030 (). The identified priorities represent an important road map for the public heath institutions in America.

Commitment to action on healthy aging in every country

The WHO strategy recognizes that fostering healthy aging requires leadership and commitment. To enable all people to live a long and healthy life calls for a multisectoral approach with strong engagement from diverse sectors and different levels of government. Collaboration is also needed between government and nongovernmental actors, including service providers, product developers, academics, and older people themselves. A key step to fostering action must therefore be to build local, regional, and international coalitions to develop a shared understanding of the issues involved.

Much of the investment to foster healthy aging will also have direct benefits to other population groups and will tend to strengthen a country’s commitment to the Sustainable Development Goals. For example, multisectoral leadership will ensure that all actions to improve healthy aging foster the ability of the elderly to make multiple contributions in an environment that respects their dignity and human rights, free from gender- and age-based discrimination, and it promotes the social, political, and economic inclusion of all, irrespective of age. Within this framework, the rights of older persons become an important driver for meeting regional goals for sustainable development, human rights, and universal access to health. The Inter-American Convention on Protecting the Human Rights of Older Persons, adopted at the 45th regular session of the Organization of American States General Assembly (), recognizes the need to address matters of old age and aging from a human rights perspective, provides a framework to address and ensure those rights, and highlights the need to eliminate all forms of age discrimination in the Americas.

Several countries in the Region have developed at least one public policy tool (law, national plan, specific policy, or program) to address aging and/or specifically aging and health. The task ahead is to ensure that all public policy instruments develop indicators and core data for monitoring implementation and evaluating effectiveness. Therefore, a priority must be to strengthen Member States’ capacity to develop, monitor, and evaluate public policies for healthy aging.

Developing elder-friendly environments

Environments that are elder-friendly help to foster healthy aging in two ways: by supporting the building and maintenance of intrinsic capacity across the life course and by enabling greater functional ability so that people with varying levels of capacity can do the things they value ().

Whether or not individuals are able to function depends not only on the person’s intrinsic capacity, such as strength, musculoskeletal function, and other conditions that induce physiological limitations, but also on the individual’s environment and access to supportive services and devices. For example, a person who has difficulty walking one block due to osteoarthritis may be able to function independently with a combination of (a) appropriate assistive devices, such as a cane or walker, that compensate for decreased intrinsic capacity, and (b) a proven regimen of physical activities that supports and improves intrinsic capacity. Thus, healthy aging is framed in a way that focuses both on strengthening or maintaining intrinsic capacity and creating supportive environments and technologies.

In this context, multisectoral leadership, commitment, and resources at the local level are essential. A WHO global network of age-friendly cities and communities in the Region of the Americas would provide numerous examples of how coordinated action among municipalities and various public and private sectors can improve life for older people. The goal of age-friendly communities is to foster the autonomy and engagement of older people as well as to ensure access to transportation, housing, outdoor spaces, communication and information sources, employment, community support and health services, and encourage social and civic participation, respect, and social inclusion (). No sector can be solely responsible for promoting and supporting the ability of older persons to function and continue to contribute to society. Member States should collect and use age and socioeconomic disaggregated information on older people’s functional abilities and should assess the effectiveness of and identify gaps in existing policies, systems, and services in meeting the needs and rights of the older persons ().

Prevention of falls

Extensive evidence indicates that falls and the risk of falls can be reduced through systematically identifying risks and taking actions that include a combination of clinical and community-based interventions. Engaging older adults in strategies that help prevent falls is cost-effective (). Interventions that strengthen intrinsic capacity and technologies and environmental changes that compensate for decreasing intrinsic capacity can prevent many risks that result in falls (). Public health interventions to prevent falls should be evidence-based. Interventions are grouped into three categories: exercise-based, home modification, and multifaceted interventions that address a combination of risk factors ().

Table 1. Seven risk factors of effective fall interventions

Risk factor Modifiable by:
Lower body weakness Targeted strengthening exercises
Vitamin D deficiency Vitamin D supplementation
Difficulties with walking and balance Physical therapy intervention and mobility-assisted devices
Polypharmacy Medication review
Vision problems such as cataracts Timely cataract surgery and vision aids, as needed
Foot pain or poor footwear Foot care
Home and environmental hazards Home and environment are made age-friendly

Adapted from: Centers for Diseases Control and Prevention. Preventing falls: a guide to implementing effective community-based fall prevention program. Atlanta: CDC; 2015 ().

Aligning health systems to the needs of older populations

In order to ensure that older people have universal access to health, systemic changes are needed because old age does not mean simply living more years. It is a new phase in human development (). A health care system that is aligned to the health needs of older adults has policies, plans, and programs to improve or maintain functional capacity, manage multiple chronic conditions, and provide services and support for long-term care ().

With the longevity of the population, new challenges will appear as health systems address the health needs of adults in their 60s, and older adults present different problems related to health and frailty that have significant impact on the capacity of health systems across the Region. A system aligned to the needs of older people has the capacity to address the problems that matter to them: chronic pain; difficulties with hearing, seeing, walking, or performing daily or social activities; and depressive symptoms. Primary care services are still focused on diagnosis and treatment of diseases, but most problems that older people bring to the clinics are not necessarily identified as “diseases” in the traditional sense. Primary care personnel are not trained in nor do they receive much guidance in recognizing and managing health problems identified by older people. Nor are they able to identify community resources and the extended-care team needed to respond to the health issues of older persons. A focus on prevention requires that the health team better understand the intimate relationship that exists between intrinsic capacity, environment, and the technologies used to compensate for the normal losses that occur as part of the aging process.

Primary prevention focuses on four risk factors: harmful use of alcohol, unhealthy diet, physical inactivity, and tobacco use. These factors are important throughout the life course not only to prevent but also to manage noncommunicable diseases. Epidemiological data in the Region show that a significant number of adults and older adults will live with a chronic disease such as diabetes, lung and heart diseases, arthritis, and cancers for an average of 30 to 40 years (). Teaching older people how to be healthy, and how to live healthy lives even with these chronic diseases, is essential.

A WHO framework of integrated, people-centered health services sets forth a vision in which “all people have equal access to quality health services that are co-produced in a way that meets their life course needs…” (). The framework defines the concept of “co-production of health” as “care that…implies a long-term relationship between people, providers, and health systems where information, decision-making, and service delivery become shared” (). A health service aligned to the needs of older persons has the necessary human resources, technologies, and community partners to be able to assess risks and symptoms. Unlike acute care, where treatment is usually short and definitive, ongoing treatment and monitoring chronic conditions require productive interactions between health professionals and the individual with the chronic conditions. Person-centered care requires active participation in self-care management and promotes a partnership in improving and maintaining health. In the life of a typical person living with a chronic condition, health care system interventions take no more than a few hours a year. The rest of the time the patient is responsible for self-care management. Outcomes are determined not by the short time in the doctor’s office but by the daily behaviors of the individual. To achieve the goals of person-centered care, the health system needs to support the self-care management (for more information see the box Self-care programs) of individuals living with chronic conditions. Evidence-based programs are those that have been rigorously tested in controlled settings, proven effective, and translated into practical models that can be implemented at community sites. Primary health care services should seek to adopt evidence-based programs that provide skills and practice to older adults in the co-production of health ().

Self-care programs

Self-care or self-management requires processes that are designed to assist with behavioral changes and empowerment. Research has shown that patients can learn and change behaviors at any age. Programs specifically designed to improve patients’ self-efficacy, such as the Stanford University Chronic Disease Self-Management Program, have been used with adults of all ages and have proven effective in changing patients into proactive self-care managers. In a meta-analysis of 25 years of research findings, the Centers for Disease Control and Prevention concludes that, “At the population level, these interventions could have a considerable public health effect due to the potential scalability of the interventions, the relative cost to implement them, wide application across various settings and audiences, and the capacity to reach large numbers of people” ().

It must be a priority to retool the health care work force to deliver care centered on older persons and to create and use evidence-based programs to best promote healthy aging. In a 2007 Regional meeting, an informal survey was conducted in which 85% of the focal points who participated acknowledged not having any formal training in either gerontology or geriatrics. A “geriatricized” work force is one that has been provided with training in healthy aging and has basic skills and tools to develop elder-centered plans and programs aligned to meet the health needs of older persons and their families. It is a work force that understands elder-care priorities, that focuses on functional capacity, and that can avoid preventable complications. To fill this training gap, PAHO’s Regional Program on Health and Aging, in collaboration with other academic partners in the Region, has developed a 420-hour certificate in “Management of Aging and Health Programs.” It combines 40 weeks of total immersion and online training in a flexible format that is rich in tools and promotes online group learning. Since 2007, more than 250 individuals from 25 countries in LAC have completed the program.

In 2000, with the support of PAHO, the Latin American Academy of Medicine of Older Persons (Academia Latinoamericana de Medicina del Adulto Mayor, ALMA) was established to create a network of faculty members in medical schools across the Region for teaching geriatrics and for training medical students and primary health care doctors in the specialty of geriatrics. ALMA provides ongoing education and now has 220 faculty members from 16 Latin American countries. In 2005, ALMA published a guide to teaching geriatrics in general medical education ().

Despite these advances in training, rethinking the primary care work force for the 21st century for extremely fast aging scenarios requires a different approach to the education and training of the existing work force and to the expanded role the care team will need to assume to ensure universal access to person-centered care. There will be a growing need for nurses, physical therapists, dietitians, community health workers, and health educators who are trained in population health with a focus on diverse populations from birth to age 100 ().

Developing sustainable and equitable systems for long-term care

Families are the main providers of unpaid care in LAC: in particular, women account for 90% of all unpaid care providers. Family caregivers cut back up to 20% on paid work to provide care to older persons (). About 43% of caregivers, mainly informal/family caregivers, show symptoms of depression and anxiety; it is estimated that compared to non-caregivers, caregivers have twice the risk of heart disease and injuries. In addition, when care is provided in conditions of poverty and when caregivers have no training, resources, or social or institutional support, elders are at increased risk of morbidity; furthermore, the elderly who are being cared for are at increased risk of neglect and abuse by their overwhelmed caregivers ().

In the next decade, health systems must integrate medical, social, and supportive care in a more efficient way. A health system aligned to the needs of older adults develops elder-driven care plans and is aligned with the goals of both the older person and his or her family. This means that they have alternatives to hospitalization and institutionalization, and access to long-term care support and services designed to maintain health and functional capacity for as long as possible during a life phase that is marked by frailty and dependence.

Long-term care

“System of activities undertaken by informal caregivers (family, friends, and/or neighbors) and/or professionals (health, social, and others) to ensure that a person who is not fully capable of self-care can maintain the highest possible quality of life, according to his or her individual preferences, with the greatest possible degree of independence, autonomy, participation, personal fulfillment, and human dignity” ().

For people who live into old age, maintaining health and avoiding crises requires a very different health care system than the existing model. Just one generation ago, people rarely survived into frail old age. For those who survived, someone in the family was always able to provide care. But for millions of families caring for a loved one, this is no longer a simple affair. Urban settings are not elder-friendly, fewer children are available and able to provide care, and long-distance caregiving have all changed the dynamics of living into old age with supportive environments. When there are no options for caregivers, caregiving crises result in otherwise preventable, long-term, costly hospitalizations.

In a young society, one becomes accustomed to people dying of a terminal illness with a relatively short period between the onset of the fatal disease and death. However, in an aging society, there is a new phase in the life course for those who live into old age: frailty. In this phase, no terminal illness is identified, and the decline of functional capacity, speech, and ambulation may be prolonged for as many as 6 to 8 years ().

Access to family care is no longer the norm. Almost half of older adults live alone or with a spouse, not in a multigenerational family (). Intergenerational living takes place not only within households but also among generations regardless of living arrangements. The many SABE surveys consistently report a lifetime bidirectional distribution of resources going one way or the other in critical periods of life, with family relations often strained by illness and disability ().

Long-term supportive services at home are essential during this phase of life. The transition from being a healthy, functioning older adult to a frail, dependent adult is not as clearly defined as transitions in other stages of life, such as the transition from childhood to adolescence. However, these transitions are real, and society has to recognize that at the onset of frailty, the individual will need services from health care providers, family, and friends that are distinctly different from services provided to non-frail persons. Although the majority of older people will enjoy active and healthy aging until near the end of life, a significant number will suffer from dementia and other conditions that lead to disability, frailty, and the need of long-term care (see Box “The case of dementia” for more information regarding dementias). About 20% of people 65 and older will require long-term care services and support in order to perform activities of daily living ().

The case of dementia

Dementias are the most important contributor to disability and dependence among older persons. It is estimated that in the Americas the prevalence of Alzheimer’s disease and other dementias will double every 20 years, increasing from 7.8 million in 2010 to 14.8 million in 2030. The countries of LAC will be the most affected, where the number of people with dementias will increase from 3.4 million in 2010 to 7.6 million in 2030, surpassing the projected 7.1 million people with dementias in the United States and Canada. In 2010, the estimated cost of dementias in the Americas was US$ 235.8 billion ().

Dementias cause the second largest burden of years lived with disability (11.9%) (). The proportion of people needing care for dementias rises with age, from 30% of people between the ages of 65–69 to 66% of people 90 years and older. And unlike with other chronic conditions, people with dementias may need care beginning in the early stages of the disease and be increasingly dependent on caregivers as their condition worsens (). At the 54th Directing Council, PAHO approved Resolution CD54.R11, the Strategy and Plan of Action on Dementias in Older Persons; it urges Member States to strengthen the capacity of their health systems and health services networks in order to increase access to resources, programs, and services for people with dementias and their families ().

Improving measurement, monitoring, and research for healthy aging

The primary driver of change in public health is data. Public health addresses perceived threats to health when those threats are quantified and localized, and the action taken to address them needs to be driven by evidence: evidence of the threat to healthy aging; evidence that there are policies, interventions, and programs proven to improve healthy aging; and evidence that there is local capacity to adopt the policies, interventions, and programs with fidelity.

The Regional capacity to study aging and health issues has improved during the past 15 years. What is missing is a substantial effort to collaborate regionally in order to provide infrastructure and build capacity for analyzing and utilizing findings that support policies, plans, and programs that address the needs of the Region’s diverse, aging population. Strengthening the scientific foundation for policy-making that meets the challenges of healthy aging must be a priority for the Region ().

The goal for the next 5 years is for health systems throughout the Region to develop core indicators of health and functional capacity across the life course, segregated by sex and age groups, and representative of the population from birth to old age. The aim is to prepare and then adopt systemic changes that are needed for an aging population. With the support of PAHO, Member States will need to create a database that can provide indicators on healthy aging and that is focused on access to health and functional capacity, segregated by age groups and geographic areas. Local knowledge can then drive local decision-making in support of national plans. PAHO’s appointed multidisciplinary work group on aging research has a 5-year goal of ensuring that at least 40% of the Region’s countries will develop the capacity to manage a database on aging and health indicators and will be able to translate that research and data into evidence that can inform decision-making and public health interventions. The long-term vision is to use evidence, information, and research to help reduce inequalities in health and improve healthy aging, with a special focus on those who are at greatest risk of disability or premature death.

Conclusion

The next 5 years will require a major commitment by various sectors of government and society, including older people, to respond to the five key priorities for healthy aging. Member States will have many opportunities to exchange information, coordinate actions, and share lessons learned to support the development of healthy aging. The Region will need to strengthen national capacity to formulate evidence-based policies and programs. If the policies and programs are well crafted and implemented with an evidence-based approach, their cost will be a solid investment, and the return on that investment will be healthier older adults as a key step toward universal health.

Orienting health systems around intrinsic capacity and functional ability will require sustainably financed services, collaboration between sectors, and health and social systems that are aligned to foster healthy aging. Providing access to care and supportive services for people who live into old age will require substantial efforts to finance, create, and implement mechanisms to provide quality care. In general, the next 5 years will require collaboration among Member States, international development organizations, the scientific community, and all sectors of society, which will need to test a variety of approaches to further health and functional capacity in a rapidly aging, diverse population.

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Reference/Note:

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