Rita Issa won second prize in our Michael Pittilo Essay Prize 2012. Here is her essay.
In the context of constricted health budgets and a rapidly growing population of service users with multiple long term chronic conditions, what strategies can we as health practitioners use to encourage healthy ageing?
The UK is getting older. Increasing longevity and decreasing birth rates will see the proportion of people over 65 rise from one-sixth of the population today, to one-quarter of the population by 2050(1).
With 72% of over 75’s reporting long standing illness (2), the pressure on public services will be felt twofold: a greater proportion of the population will be outside working (thus taxable) age and will be most likely to have multiple long-term chronic conditions.
How can we ensure that this population stays as healthy as possible in order to minimise the economic and social impact, and, how can we do so amidst constricting health budgets and health system restructuring?
The most straightforward answer, identified by the World Health Organisation (WHO), would be to target and treat the modifiable risk factors of the most prevalent and costly chronic diseases (3). However, with the definition of good health as ‘… a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity’ (4), interventions must encompass psychosocial as well as physical health. In addition, the link between social and economic inequality and poor health must be acknowledged and challenged as a barrier to healthy ageing.
Targeting risk factors for chronic conditions
The WHO has developed a ‘4 by 4’ strategy to target non-communicable diseases (3). Four conditions – cardiovascular diseases, cancers, chronic respiratory diseases and diabetes – account for a high treatment burden on patient and service providers, significant morbidity and 60% of all deaths globally. However, these diseases are also to a certain extent preventable. Eliminating four risk factors – tobacco use, unhealthy diet, physical inactivity and harmful alcohol use – may prevent up to 80% of heart disease, stroke and type II diabetes, and over a third of cancers (3).
Health practitioners have a number of tools at their disposal through which risk factors for chronic conditions can be targeted – education, the benefit of community links and the scope for policy change. These efforts should not focus on older populations alone. After all, healthy ageing should start young, and healthy practices at any age will help reduce the risk of chronic disease. Consultations can be exploited for opportunistic history taking and education. For example, with more than 20% of the population still smoking (5) and the effects of smoking felt most in old age, health practitioners can monitor smoking status, inform of dangers and direct to relevant cessation services.
Health practitioners can utilise their position to recommend beneficial services. Twice weekly Tai Chi has been shown to statistically improve balance, functional mobility and fear of falling in women over 65 years (6). Knowledge of such services in the community can have a significant impact on morbidity, hospital admissions and quality of life.
All doctors, especially those working in public health, can have some impact on the broader determinants of health by proposing and lobbying for policy change. In addition to informing of the new ‘change 4 life’ programmes and other local services, public health measures can go further to ensure healthy diets, with legislated restrictions on salt, trans-fatty acids, saturated fats and free sugars. Like smoking, advertising and sponsorship by the food industry could be limited and the success of the traffic light system could be used more widely.
Mental and cognitive health
Healthy ageing should encompass more than physical health and the EU paper on healthy ageing (7) advocates the need for additional mental health strategies. Depression affects up to 15% of people over 65 and the prevalence of chronic conditions is up to 3 times higher in this group (8). Cognitive impairment such as dementia disproportionately affects the elderly, representing a major care-giving and financial challenge (8). Early identification by health practitioners is essential for effective support and treatment of mental and cognitive health. In addition to targeted clinical care, evidence has shown that continued mental stimulation, be it through crosswords to playing a musical instrument, can be protective for cognitive decline. Therefore, coordinated care between the health practitioner and community will enable a holistic approach to a multi-faceted problem.
Holistic and coordinated care
Many of the risk factors for the most common conditions in ageing populations are shared. This means an integrated strategy can be implemented to target all risk factors at once, with significant benefit in multiple disease areas that justifies worthwhile investment even amidst constricted health budgets. Community interventions that use education or environmental change to promote and facilitate behaviour and lifestyle change, have been shown to be beneficial for addressing particular health problems (9). Social relationship-based interventions have been shown to enhance quality of life, functioning and survival (10, 11). Coordination between clinicians, services and charities will ensure targeted and comprehensive support.
One example is ‘Partnerships for Older People Projects’, which promotes ‘health, well-being and independence whilst preventing or delaying the need for higher intensity care’ (12). Here, a sustainable shift away from institutionalised interventions to earlier intervention within the community has shown cost effectiveness whilst improving quality of life. Similarly, projects introducing ‘social clubs’ for the elderly have increased participation, facilitated access to health and social services, reduced social isolation (a significant risk factor for non-communicable disease) (9) and can be used as a platform to address health promotion and the four mentioned risk factors. By addressing circumstances more common to the elderly – social isolation, lack of support and stress – morbidity and mortality from chronic conditions is reduced and cognitive and mental health are improved (9).
Next steps in ageing and multiple chronic conditions
Medicine will need to reflect and adapt to shifting demographics. For example, health professionals may be competent in treating chronic illness in isolation, but continuous research is needed on how to treat patients with ‘multimorbidities’ (14). The ‘Commission on Dignity in Care for Older People’ reports shortfalls in care of the elderly, ranging from nutrition to dignity, and recommends that medical school selection incorporates compassion as well as competency (15). Along with professional and clinical adaptations, technology will also need to evolve, and it could be technology that truly does provide cost-effective and successful solutions to ageing populations (16). For example, it is likely that screening for chronic conditions will become more sensitive and specific, resulting in early, accurate diagnosis and targeted treatment. It is evident that ageing cannot be addressed in isolation by clinicians, public policy or technology companies, and that active and encouraged collaboration will increase the chance of finding solutions for this complex issue (13).
The broader determinants of healthy ageing
As health practitioners aware of modifiable ris
k factors and their impact on population health, there is one overriding risk factor that is rarely addressed. The principal determinant of health status within a country is the degree of income inequality17 and social status is the overriding risk factor for chronic health conditions. The difference in life expectancy between the richest and poorest in the UK is 7 years; the difference in disability free life expectancy is 17 years18. The Wanless report (19) argued that if a nation were to extend ‘the compression in morbidity’ from the highest socioeconomic groups to the rest of the population, this would assist healthy ageing free of multiple chronic conditions and reduce the demands created by an ageing population.
There is ambiguity over the role of medicine and the scope health practitioners have to make change by addressing the broader determinants of health. Individual health practitioners who target risk factors alone must be sensitive to context and understand that wider structural issues may be at play. However, the Marmot review’s central message is that a healthy population depends on action beyond the individual health practitioner (18). Collaboration between health providers, social services and charities is essential to ensure comprehensive, far-reaching and positive change. The UK faces restructuring of both health and social care through implementation of the Health and Social Care bill and widespread austerity measures (20). Though entering a time of constricted health budgets, divestment in the sick and poor in society will inevitably lead to social decline and a subsequent economic burden. Therefore, it must be in our patients’ best interest, but also that of the nation, to utilise our position as health practitioners and strive for policy and outcomes that redress social and economic inequality.
Healthy ageing should start young. Health practitioners who screen for disease and target modifiable risk factors can ensure early intervention and delay or prevent chronic disease. However, successful ageing encompasses more than just physical health and should include functioning, social inclusion and quality of life (10). Shared responsibility with local services and new approaches designed to improve community-based interventions will enable comprehensive mental, cognitive and social support. Amidst constricting health budgets, this shift from institutionalisation toward community intervention is also preferable in terms of economic burden. It is important to remember that social and economic inequality is the greatest determinant of health, and to try as health practitioners to find ways to redress this. Finding solutions for the increasing burden of an ageing population will require true collaboration; between clinicians, community services, policy-makers and in technological advancement.
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