New voices: Live long or live well?

It is not uncommon these days to hear or read a story in the media about the increasing number of older people in our country. Unfortunately, these stories tend to focus on the negative aspects of ageing and the challenges this population will present to society in the not-too-distant future. Some of the most frequently mentioned problems stem from the increased health and social care needs of older people, due to age-related disease and disability putting pressure on services. Other worries are centred on the economy and how we as a society will financially support an increasing proportion of older people in the population.

An ageing population is not an issue for the UK alone, but for countries across the globe. In previous centuries decreasing mortality was fuelled by improvements in housing, hygiene, education and medicine, all helping to reduce mortality in early life. In modern times, improved survival rates beyond 65 years of age have driven the increase in life span (Oeppen & Vaupel, 2002). At the same time, birth rates have slowed, meaning that older people form a larger proportion of society than ever before. These demographic changes have the potential for long-lasting political, social and economic implications for society (e.g. Restrepo & Rozental, 1994).  

The good news that we can expect to live longer than any generation before us must be tempered with the knowledge that these extra years may be spent in poor health (Lara et al., 2013): with greater age comes greater incidence of age-related disease and disability. Older people tend to require more frequent and lengthier hospital admissions, as well as more support in the community, adding pressure to healthcare and social services.  

In response to population ageing, and the societal challenges it gives rise to, researchers across the disciplines are examining not just how to increase life span but how to improve 'health span'. One approach has been to examine evidence from longitudinal cohort studies that look at the characteristics of people in later life. These cohorts are large groups of participants who have been followed up over the years, with various measurements made of their health and wellbeing, and ultimately age-related diseases and age of death. The problem for this area of research is that different studies have different ideas about what exactly healthy ageing is. For example, is healthy ageing a long life, a disease-free life, a good quality of life or the ability to remain independent in later life? In some of the literature, people who achieve a long life span have been divided into 'survivors', those who live a long time but with a long period of disease or disability before death; 'delayers', who avoid age-related disease or disability until near the end of their life span; and 'escapers' who live to an old age without any major illness or disability (Kivimaki & Ferrie, 2011).

Some studies have aimed to improve health span by using targeted lifestyle-based interventions designed to modify health behaviours in order to keep people healthier for longer. However, in order to be sure that these interventions are working, we need ways to measure how healthily someone is ageing. As yet, there are no gold standard measures of healthy ageing, but there are easily obtainable, cost-effective and widely acceptable ways to measure ageing outcomes, such as biomarkers (Barron et al., 2015).

But what about the views of older people themselves? A relatively small amount of work has been done to look at older people's opinions of healthy ageing, but results so far do show discrepancies between what academics and older people themselves think. For example, Hung et al. (2010) compared definitions of healthy ageing given by academics and older people and found that academics focused on physical health, mental health and social functioning, while older people's definitions mentioned more aspects such as independence, adaptability, finances and spirituality. The researchers also looked at cultural differences in what mattered to older people and found that some aspects of healthy ageing were valued more highly in some cultures than in others. Preliminary results from my own research support the idea that people change their opinion about what is important for healthy ageing as they get older, with older people placing more importance on wellbeing than younger people and less importance on mood and ways to measure ageing. New research is now under way to see if the aspects of healthy ageing that older people report as important tally with measurements made in scientific studies.

The problem with not knowing how best to define healthy ageing is that studies that try to evaluate healthy ageing are all measuring different things. This means that different studies cannot be compared fairly. Studies that aim to produce estimates of how many older people are achieving healthy ageing tend to come up with widely varying estimates depending on whether it is the older people who say how well they think they have aged, or whether the researchers classify older people's ageing based on whatever the definition on healthy might be. In studies that look at how older people rate themselves, estimates of healthy agers are much higher, sometimes threefold higher, than when researchers decide what percentage of older people have met their healthy ageing criteria.

One reason for this discrepancy between how the research community and older people define and estimate healthy ageing is the approach that they take to the subject. Older people who take part in these studies are from all walks of life and have widely varying backgrounds. Academics working on this aspect of ageing, on the other hand, tend to be mainly from the field of biomedicine and have a tendency to focus on disease and physical decline rather than more multidimensional aspects such as quality of life.

An ageing population need not be seen as burden for society. Policy makers need to consider the implications of an ageing population carefully so that proper plans can be made for the future in respect to provision or care for older people. They also need to change how older people are perceived with more focus on the wealth of experience they have to offer rather than cost associated with age-related decline. However, people also need to be responsible for their own future. A wealth of information is available to the public about health behaviours and lifestyle choices that will help to maintain good health into later years. People are now more educated about their own health and are interested in what changes they can make, for example to diet and exercise, to age healthily (Phelan & Larson, 2002). Because of this, to live to a great age is no longer the goal it once was. Quality of life is just as important as length of life, if not more so.

The scientific community can also play a part in changing the way ageing is perceived. Finding ways to increase the span of a human life is an admirable goal, but researchers need to take into account the aspects of healthy ageing that matter the most to older people and find ways to condense any age-related disease and disability into as short a time as possible at the end of life so that quality of life is preserved. We need multidisciplinary researchers to bring novel approaches to an area that has so far been dominated by the biomedical approach.

When I began my postgraduate research looking at healthy ageing, reading articles about age of disease onset and age of mortality was very impersonal. Now, after seeing relatives live a long life but also endure a long period of low quality of life, the facts and figures in a journal article are much more meaningful. If you had asked me at the start of my PhD studentship whether I would want to live to an old age the answer would have been an obvious yes, but now I know it is not so clear cut. Very few of us are likely to reach an old age with no experience of age-related disease, so while increasing life span is a commendable goal for the scientific community, I would much prefer to increase health span, and enjoy my life to the fullest no matter how long it lasts.

Evelyn Barron is a PhD student at Newcastle University
[email protected]

References

Barron, E., Lara, J., White, M. & Mathers, J.C. (2015). Blood-borne biomarkers of mortality risk: Systematic review of cohort studies. PLoS ONE, 10, e0127550.
Hung, L., Kempen, G.I.J.M. & De Vries, N.K. (2010). Cross-cultural comparison between academic and lay views of healthy ageing: A literature review. Ageing and Society, 30, 1373–1391.
Kivimaki, M. & Ferrie, J.E. (2011). Epidemiology of healthy ageing and the idea of more refined outcome measures. International Journal of Epidemiology, 40, 845–847.
Lara, J., Godfrey, A., Evans, A. et al. (2013). Towards measurement of the healthy ageing phenotype in lifestyle-based intervention studies. Maturitas, 76, 189–199.
Oeppen, J. & Vaupel, J.W. (2002). Broken limits to life expectancy. Science, 296, 1029–1031.
Phelan, E.A. & Larson, E.B. (2002). Successful aging: Where next? Journal of the American Geriatrics Society, 50, 1306–1308.
Restrepo, H.E. & Rozental, M. (1994). The social impact of aging populations: Some major issues. Social Science & Medicine, 39, 1323–1338.