The World Report on Ageing and Health

Today, for the first time in history, most people can expect to live into their 60s and beyond ( United Nations Department of Economic and Social Affairs [UNDESA], 2007 ). And those who reach 60 years of age can expect to live longer than ever before. When combined with marked falls in fertility rates, these increases in life expectancy are leading to the rapid ageing of populations around the world. These changes are dramatic, and they have profound implications for each of us as individuals, as well as for society more broadly.

Longer lives present many opportunities, and the article by Fried (2016) in this supplement makes a strong case that appropriate social investment can create a “third demographic dividend” for society. Yet, the extent of the opportunities that arise from increased longevity will depend heavily on one key factor: health. If people are experiencing these extra years of life with good physical and mental capacity, and if they live in enabling environments, their ability to do the things they value may have few limits. If these added years are instead dominated by declines in capacity and disabling environments, the implications for older people and for society are much more negative. Staudinger, Finkelstein, Calvo, and Sivaramakrishnan (2016) take up this issue and look specifically at the effects of work on health in later life.

Unfortunately, there is only limited information to suggest that older people today are experiencing these extra years in better health than previous generations ( Chatterji, Byles, Cutler, Seeman, & Verdes, 2015 ). Moreover, in many places, neither the policies nor the infrastructure is in place to ensure that the opportunities that arise from population aging can be realized. Public health action on ageing is therefore urgently needed. Yet debate on what this might comprise has been remarkably limited ( Lloyd-Sherlock et al., 2012 )

To progress action in this area, the World Health Organization (WHO) recently released the first World report on ageing and health ( WHO, 2015 ). Nearly 200 people contributed directly to the report, including authors of a series of background articles, many of which have been refined for academic publication in this supplement. Given the great diversity of issues that are relevant to ageing and health, it is not surprising that the scope of these articles is broad.

The report outlines a public health framework for action on Healthy Ageing that is built around the concept of functional ability. This is defined by the report as “the health related attributes that enable people to be and to do what they have reason to value”. The report emphasizes that this ability is determined by both the intrinsic capacity of the individual and the influence of the environments they inhabit. This builds on capabilities-based approaches used in other fields ( Anand, 2005 ). The report approaches the changes associated with ageing in the context of the entire life course, yet focuses on the second half of life. It describes some of the important underlying physiologic changes that can occur with age (for example, those outlined in the article by Blume-Peytavi et al. (2016) on skin) but also considers the disorders that become more frequent in older age and that can impact on functioning. These are largely chronic conditions, particularly noncommunicable diseases, hearing loss, and musculoskeletal disorders as discussed by Davis and colleagues (2016) and Briggs and colleagues (2016) , respectively.

Many of these can be prevented or delayed by engaging in healthy behaviors across the life course, and the benefits of these behaviors continue into later life ( Hrobonova, Breeze, & Fletcher, 2011 ). The article by Bauman, Merom, Bull, Buchner, and Singh (2016) highlights the importance of these ongoing influences, making a robust case for promoting physical activity among older adults. However, Bauman and colleagues also show how ageing influences the relationship of these behaviors to health and the importance of considering this when developing interventions to foster capacity and ability. Their article highlights how, for physical activity, this may lead to a shift in focus that gives priority to interventions that can help the retention of muscle mass and balance. Subtle shifts in messaging across the life course may also be required if these interventions are to succeed ( Notthoff & Carstensen, 2014 ).

Yet, even with effective health promotion strategies, many older people will still experience chronic disease and most likely more than one of them at the same time. Integrated person-centered care can ensure these are effectively managed, particularly if they are detected early enough. And even for people where these result in significant declines in capacity, access to medical and assistive technologies (see article by Garçon et al. (2016) ) and supportive environments can ensure that they can continue to live lives of dignity and continued personal growth.

These responses would fulfill the right to health and other related rights and fundamental freedoms of older people that are enshrined in international law, an issue expanded on by Baer, Bhushan, Abou Taleb, Vasquez, and Thomas (2016) . Yet, globally, breaching of these rights is almost the norm, as highlighted by the high prevalence of elder abuse. The article by Pillemer, Burnes, Riffin, and Lachs (2016) considers this issue—a problem that has devastating individual consequences and societal costs for which we are yet to identify evidence-based interventions that work.

But few places in the world offer the policies and infrastructure necessary to ensure older people can experience a long and healthy life. One challenge for decision makers is that when it comes to health, every older person is different. The report highlights how physical and mental capacity are only poorly associated with chronological age. Even in low- and middle-income countries, some 80-year-olds have physical and mental capacities similar to many 20-year-olds, whereas others experience significant declines in physical and mental capacities at much younger ages. Furthermore, this diversity of health state in older age is not random. As the article from Foebel and Pedersen (2016) states, genetic inheritance plays some role. But most of the variation is likely to result from personal factors such as our sex, ethnicity, and occupation, as well as the physical and social environments in which we live our lives. Together these influence opportunities and health behavior, and these impacts start from childhood and continue across life( Commission on Social Determinants of Health, 2008 ; Dannefer, 2003 ). The article by Sadana, Blas, Budhwani, Koller, and Paraje (2016) elaborates in detail the causes of health inequities across contexts and policy and research options for stimulating change.

Together the articles in this supplement highlight the complexity in the health and functional states experienced by older adults. They help raise fundamental questions such as what do we mean by health in older age, how do we measure it, and how might we foster it. The reconceptualization of Healthy Ageing provided by the report draws on many years of gerontological and geriatric research and debate to start to answer these challenging queries.

In building this public health framework for action, WHO looked to challenge many pervasive misconceptions. In particular, the report seeks

• to emphasize that action is urgent;

• to acknowledge the great diversity of health and experience in older age and the need for policy responses to reflect this rather than being built on ageist stereotypes of a “typical” older person;

• to shift conceptualizations of health in older age from a focus on the absence of disease in an individual to a focus on functioning and an acceptance that both the individual and their environments have a role in determining this;

• to frame Healthy Ageing as a process that takes place across the life course rather than as a state at a particular point in time, and that both policy makers and researchers should be interested in how we maintain optimum trajectories of functional ability and capacity across life and older age.

• to understand the cumulative impact of environmental determinants across life and to shape policy that looks to address disadvantage rather than reinforcing it.

The policy priorities it proposes are relevant for all older people, regardless of where they sit on their personal trajectory of Healthy Ageing . They emphasize the need to build supportive and enabling environments. These can help people build and maintain capacity (for example, a walkable environment may foster physical activity). But they can also provide a range of resources or barriers that determine whether people with a given level of capacity can do the things they feel are important. Thus, although older people may have limited capacity, they may still be able to get where they want and need to go if they have access to an assistive device (such as a walking stick, wheelchair, or scooter) and live close to affordable and accessible transport. This will require a coordinated response from many sectors and multiple levels of government to create age-friendly environments (housing, employment, transport, and social protection) to facilitate the ability of older people to age in a place that is best for them and to do what they value.

The report also recommends a better alignment of health systems to the older populations they increasingly serve. This requires a greater integration of services and shifts from disease-based reactive services to models of health care that prioritize the functioning of the older person as a whole, take account of the physiological trends and health conditions that may influence it, and consider the individual’s circumstances and ambitions.

And this integration of services must extend to the support and care needed by those older people with significant loss of capacity. Crucially, the report is very clear that “In the 21st Century, no country can afford not to have an integrated system of long term care.” Population and social trends mean it is no longer feasible, sustainable, or equitable for governments to leave this to families alone. This does not mean that this role should instead fall solely to governments, but if families are to provide adequate care and not be unreasonably burdened, at a minimum they need information that can allow them to fill this role, and have access to support such as respite care. Governments also need to put in place mechanisms to ensure the quality of the care that might be contracted by private care givers or in institutions. Positive responses from WHO’s “Member States” to the Report suggest that this new emphasis on the need to build systems of long-term care, even in the poorest countries, may result in much greater global attention to this neglected issue.

Finally, the report emphasizes the extensive knowledge gaps that form a major barrier to evidence-based policy development. There is little global consensus on even widely used terms in the field, and although longitudinal research and population surveys are increasingly common, the instruments they use are often not comparable and may not provide the information needed by decision makers. Most of the treatments offered to older people are derived from clinical research that excludes them and that fails to take account of the influence of the comorbidities most of them will have.

These recommendations will not be surprising to gerontologists and geriatricians. However, to date, policy related to older age in many countries has often prioritized cost containment over the investment needed to enable the human and social resource that is inherent in older populations. Moreover, policy can appear disjointed, reflecting a political polarization that portrays older people as either vulnerable and needing support, or robust and needing to contribute. Although each characterization may have legitimacy, they are simply the ends of a continuum of diversity, and broader policy responses are needed to encompass this heterogeneity in a coherent way.

We hope that the World Report and the articles in this special issue help progress work to achieve this. Certainly, the framework for action outlined in the report is designed to speak to all people at all stages in life and to look to how society can help them experience more positive Healthy Ageing trajectories. Moreover, rather than tell them what they should do, it looks to build their abilities to navigate the challenges and seize the opportunities of later life. As the report says, enabling these abilities is likely to be a sound investment in a future where older people have the freedom to live lives that previous generations might never have imagined.

The World report on ageing and health can be found at http://apps.who.int/iris/bitstream/10665/186463/1/978 9240694811_eng.pdf?ua=1 . To navigate the report—which features content from the articles in this supplement— Chapters 1 and 2 cover all the main ideas. The analysis of context and rationale for action in Chapter 1 is followed by the development and explanation of a Public Health Framework for Action in Chapter 2. Chapter 3 provides a comprehensive, stand-alone update of current knowledge on health in older age. It includes a review of demographic and epidemiological change; the characteristics of health in older age, including underlying changes as well as the health conditions of older people; changes in intrinsic capacity and functional ability; behaviors that influence Healthy Ageing ; and key environmental risks. Chapters 4, 5, and 6 can be read together. They take the Public Health Framework for Action (Chapter 2) as their starting point and examine in detail the implications for health care systems, long-term care, and age-friendly environments, respectively. Chapter 7—Next steps—sets out a menu of options for action applicable to countries at all levels of development. It is organized in four sections: aligning health systems to the needs of the older populations they now serve; developing long-term care systems; creating age-friendly environments; and measuring monitoring and understanding.