Ask the Expert- Challenges and Opportunities in an Ageing Society Mahendra Gonsalkorale

Challenges and  Opportunities in an Ageing Society

Mahendra "Speedy" Gonsalkorale

I like to reproduce my Reunion Presentation in Sept 2012 as it is even more relevant now. There is a short update addendum at the end.

This is a summary of the Lecture delivered by Dr Mahendra Gonsalkorale at the 50th Anniversary Reunion Academic session of the Medical Entrants of 1962 in Sri Lanka on September 1, 2012.

The World population is growing rapidly. From an estimated 2.5 billion in 1950, it reached 6.1 billion in 2000 and is projected to grow to 8.2 billion in 2025. It took over 4000 years to reach 2 billion but it will take less than 75 years to quadruple that number. Sri Lanka’s current population of just over 20 million will grow to 23 million by 2030. People are also surviving longer at all ages and increasingly achieving old age. Increased life expectancy is a Global phenomenon. Correspondingly, due to the decrease in fertility rates, there is less than the expected numbers of younger people, and the net result is a change in the age distribution pyramid from the familiar broad-based, gradually tapering shape as in the mid 60s and before, to one with a relatively narrower base with a “fat” middle (the older people) and a taller shape (because of the persistence of the very old).
 

 

 The proportion of elderly people in all countries is increasing. From about 4-10% just 50 years ago to 15-20% now and expected to increase to 25-30% in the mid 2000s. In Sri lanka, there are about 1.9 million over the age of 60 (10%) and this is expected to increase to 4.5 million (25%) by 2040. There are currently around 40 million over 65s in America compared to 23M just 50 years ago. Within the over 60s, there is a massive increase in the very old. The balance between the older and younger is affected and this will significantly affect the care of older people and the financing of pensions.

1 More old people and less (proportionately) young people means

2 More age-associated diseases such as dementia (Alzheimer’s), cardiovascular diseases, degenerative neurological disorders, cancer, arthritis and related disorders, chronic respiratory disease, and other chronic diseases.

3 Increase in disability levels in the population

4 Less people to support and care for older people.

5 Large increases in health and social care costs. 

The burden of Dementia is one of the most worrying concerns for the future. The WHO estimates that worldwide, nearly 35.6 million people live with dementia. This is expected to double by 2030 (65.7 million) and more than triple by 2050 (115.4 million). The vast majority of these will be elderly.

Dementia affects people in all countries, with more than half (58%) living in low- and middle-income countries. By 2050, this is likely to rise to more than 70%. The WHO observes that only eight countries worldwide currently have national programmes in place to address dementia.  

This may all sound very negative, but there is a more optimistic view to be taken, and with greater preparation and anticipation of need, the lives of both the elderly and the young could be enhanced. Older people can have a better quality of life, and the young can look forward to a time of fulfilment and relative leisure when they become old. 

Some of the challenges that need to be met are the following. 

(1)  Meeting health, social and housing needs. These are also fuelled by rising expectations, technological advances which are often costly, medical breakthroughs and other factors

(2)  Resourcing  (financial and other)  the demands of an ageing population who consume more resources, with the added factor of a relative decrease  in economically productive young wage earners

(3)  Evolving a society devoid of intergenerational disputes and replete with respect and love - a cohesive, equitable and productive society, with the wisdom and maturity of old age, balancing the exuberance of youth. Today’s young are tomorrow’s old; all have a stake. 

These challenges could be met by adopting various measures such as, 

(1)  A major shift in attitudes and perceptions of what it means to progress through life from birth to death, getting rid of the negative image of old age, utilisation of a range of skills and talents of old people set free from the need to pursue active employment, greater involvement in voluntary work, providing support for children and grandchildren.  

(2) When the retirement age was set years ago, the expectation was that retired people would live on average about 5 years more before they die according to life expectations at the time. This has changed over the years and at present, retired people can expect to live at least a further 10 years or more. This has major funding implications and current pension arrangements are not sustainable and the concept of retirement needs to be reviewed. The Shakespearean concept of 3 score years and 10 is outmoded and a good model is one of the 3 ages, the first is one of growing up and learning, the second is one of adulthood with employment, marriage and parenthood and the third age is one of gradual withdrawal from active employment with pursuit of leisure. These are blend into each other. 

(3)  Forward planning to meet the demands of a large increase in the number of old people.  

(4)  Change emphasis from a Disease Model to a Preventive model. The aim is to ensure that longevity is matched by a long disability-free period and not by the nightmare scenario of prolonging life by extending the period of disabled life that often precedes death, using the old adage, “add life to years and not years to life”.

 (5)  Towards this end, the message is that living a healthy life when you are young has to be promoted to achieve a healthy old age.

Among the suggested measures are:- 

•  control of hypertension,

•  attention to a proper diet, weight control

•  regular mental and physical exercise

•   correction of lipid abnormalities

•   smoking cessation

•   correction of abnormalities of heart rhythm, such as atrial fibrillation

•  Social interventions, such as libraries, heating allowances, and free health checks, need funding but will produce long-term savings and benefits.

•  Imaginative housing and home care schemes

•  Incentives such as low-cost or free recreational facilities and transport for older people  

(6) Creative use of new technologies, e.g., telemedicine, smart homes, and house robots.  

(7) Suitable national and international legislation to protect older people. 

(8) It is also suggested that we need to rethink our attitude to death and prolongation of life. The largest proportion of the total healthcare budget spent per person is at the end of life.

Death is as inevitable as life and without death, life cannot be sustained. Death is not a failure; accept death with dignity and equanimity.  

In conclusion,  

We must change how we think about our lives and progress from birth to death.

We have to re-engineer the concept of retirement

We need to devote more resources towards dementia research

We need to fight against ageism and paternalism. We must escape from the concept of A World for the Young to a World for All.

We need to harness the immense potential of technology and remain optimistic.

Addendum on 6th April 2024

As ageing was regarded as a “natural” process, not much energy was devoted to its underlying mechanisms. In other words, nobody seriously considered altering the ageing process through manipulative processes.

With the outlook for longevity improving, curiosity about the ageing process itself was aroused. Why do animals age? What are the genetic and environmental causes? Is it possible to slow down or even abolish the ageing process? Will a change in the rate of ageing reduce age associated disease?

Studies into the ageing process have made big advances recently. The genetics of ageing, the role of stem cells, the role of inflammation, and changes in fat metabolism are just a few. We are yet to see implementable strategies to change the ageing process in Humans although there are some promising animal experiments.

Of those still alive in our batch, we are all over the age of 75. The time when many of the actions we could have (and should have taken) is sadly now gone. BUT…

It is never too late to institute lifestyle changes and take therapeutic measures if indicated.

Wishing to slow the ageing process is not mainly about living longer but about living healthier and happier for longer. (as shown in the famous Fries Compression of morbidity graph above)