build financial security in older age and decision-making that maintains healthy behaviours (Gubler and Pierce, 2014). Policy-makers need to ensure that their interventions do not reinforce these inequities. For example, a common policy response to increasing life expectancy has been to raise the age at which pensions can be accessed. However, there are widespread barriers to employment at older ages, including negative attitudes of some employers and restricted access to training in new technologies. If these barriers are not addressed, increasing the pension eligibility age might remove a crucial financial safety net. Ensuring both economic sustainability and health equity will be a formidable challenge in the development of a public health response to population ageing. A more comprehensive understanding of population ageing starts with research. Although life expectancy in older age is increasing in almost all countries, the quality of these additional years remains unclear. Are people are living longer and healthier lives or simply experiencing extended periods of morbidity? Several major longitudinal studies now underway will help to fill these knowledge gaps. However, the methods of obtaining and interpreting information about ageing and health also need to be reconsidered; many established mechanisms for development and assessment of clinical interventions have not been adapted to population ageing. Despite being the most frequent users of many drugs (and facing drug interactions), older people are generally excluded from clinical trials – yet the evidence we extrapolate from younger populations may not be directly applicable to their physiologies. Regardless of how effectively non-communicable diseases can be prevented or delayed, many older people will inevitably be affected. At the same time, the importance of non-communicable diseases in older age should not obscure other health issues. Although our understanding of the burden of communicable disease in older age is poor, these disorders clearly remain an important cause of morbidity and mortality in older populations, particularly in LMICs. Gr owi n g o l d t o g e t h e r Social determinants Population ageing is not taking place in isolation. Other broad social changes are transforming society and these are interacting with ageing to affect social and intergenerational dynamics. Understanding the interplay between these trends is crucial if policy-makers are to make the best decisions to promote the health and well-being of older people. Foremost among these factors is the changing situation of older people in society. However, in many parts of the world, policy often seems to assume a division of the life course into a series of stages that is based on chronological age and social roles – typically student, working age and retirement – that have little physiological basis. This rigid framework prevents the flexible types of participation that older people are increasingly seeking and is exacerbated by ageist stereotypes of frailty and mental diminution. Effective health, social and economic policy needs to acknowledge the changing aspirations of older people rather than reinforce outdated stereotypes. Provision of care and support by families to older people with substantial functional decline is becoming more difficult because of changing household structures. This challenge is exacerbated by the increasing proportion of older people compared with younger family members, and by internal and external migration of younger generations. This change in balance is even evident in Sub-Saharan Africa, where the HIV epidemic has removed potential support for nearly a million older people who would have been normally forthcoming from younger generations (see page 41). Changing gender norms add a further layer of complexity to this debate. In most cultures, traditional carer roles are assigned to women. This role limits their capacity to engage in the formal workforce, which places them at greater risk of poverty, abuse and poor health in older age, while reducing their access to quality health care, social care services and pensions. The increasing participation of women in the workforce will help overcome this inequitable burden and will have great benefits for socioeconomic development, but it will also challenge traditional familial roles and restrict families’ capacity to provide informal care at the same time that demand for it is growing. Conclusion An effective public health response to population ageing must take into account the diversity in the health, social and economic circumstances of older people; the disparities in the resources that Commonwealth Health Partnerships 2015 39 Communicable diseases Outdated perceptions of behaviour in older age could limit both disease surveillance and response. For example, older people, particularly those who are unmarried, might not be regarded as sexually active and are often excluded from HIV screening programmes or advice on safe sex practices. At the same time, individuals with HIV are living longer, increasing the likelihood that a sexually active older person will face exposure to HIV via a potential sexual partner. Older individuals with HIV infection also need specific clinical management. For services addressing the prevention and treatment of HIV and other infectious diseases to have maximum effect, they will need to adapt to changing demography. Although vaccination can reduce the burden of infectious disease across the life course, immune function, particularly Tcell activity, declines with age. These changes mean that the capacity to respond to new infections and vaccinations decreases in later life (immunosenescence). Technologies Advances in information and communications technology, assistive devices, medical diagnostics and interventions offer much promise. For example, the advent of wearable devices that can continuously monitor physical activity may rapidly transform our understanding of functional trajectories and their determinants. However, if the benefits of technological advances are to be fully realised, designers must also better understand the changing needs and opportunities of older age. A greater focus on how these innovations might meet the specific needs of older people in LMICs is also needed.
Commonwealth Health Partnerships 2015
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