Healthy Ageing Review Paper 2018 Part B
Risk & protective factors of Healthy Ageing
Many chronic diseases are preventable and/or modifiable, and are not an inevitable part of ageing. Prevention and early intervention are fundamental to address the determinants of healthy ageing. These are important targets for health promotion and strategies to reduce the burden of disability and mortality in older age by enabling healthy behaviours and controlling metabolic risk factors that should continue across the life course.
For older people, benefits can be made by targeting modifiable risk such as:
- Reducing: smoking, alcohol and drug use; injury and falls;
- Promoting: physical activity, mental health, healthy eating; screening and early detection; maintenance of hearing, vision and oral health; safe sex; social inclusion and community connection.
Reducing the use of tobacco, alcohol, and other drugs
There is strong evidence that smoking is harmful to health. Quitting smoking at any time of life is associated with lowered health risks and improvements in quality of life (Beggs et al. 2007).
Alcohol is the most common drug used by older people with Australians aged 70 plus are most likely to drink daily (Australian Institute of Health and Welfare, 2014a). National data indicate that while risky drinking is declining in younger people, this is not the case in Australians aged over 50 years of age, highlighting a need for improved interventions for older Australians (R. Rao & Roche, 2017). While the current Australian alcohol guidelines indicate some benefits associated with light-to-moderate alcohol consumption (one to two drinks per day), these benefits may be outweighed by the increased risk of cognitive decline, falls, injuries and some chronic conditions, including liver disease associated with alcohol consumption in older adults, and interaction between alcohol and multiple medications (National Health and Medical Research Council, 2009) (Cousins et al., 2014; Pringle, Ahern, Heller, Gold, & Brown, 2005).
Cannabis is the most popular illicit drug used by older Australians (Australian Institute of Health and Welfare 2014a) with rapid increases noted in the baby boomers (55 – 75 years approximately) in recent years (Kostadinov & Roche, 2017). While medicinal cannabis may confer health benefits for older people, research is sparse in this area and cannabis use, medicinal or recreational, can carry significant risks including falls, negative drug effects, and increased risk of heart attacks for older people (Kuerbis, Sacco, Blazer, & Moore, 2014). However, the long-term effects of illicit drug use on cognitive health and function are still largely unknown(NSW Ministry Of Health, 2015).
The misuse of pharmaceuticals is another risk factor that needs to be reduced. Approximately 4.7 per cent of people aged 60 plus reported misuse of pharmaceuticals (using a pharmaceutical drug such as paracetamol, ibuprofen or codeine for non-medical purpose) in the previous 12 months (Australian Institute of Health and Welfare, 2014a). Opioids and Benzodiazepines misuse have been identified to be problematic in Australian aged care services with estimates suggesting that up to 4.4 per cent of residents have problematic use of medication (Li & Jackson, 2016) and that older women are especially vulnerable to problematic prescription drug use (Li & Jackson, 2016).
The over prescription of pharmaceutical drugs and their misuse represents a complex, and growing, problem, both in the general community as well as in older people, and requires a multifaceted approach to address this issue (Monheit, Pietrzak, & Hocking, 2016). There is growing recognition for the need for general practitioners, pharmacists and drug and alcohol services to collaborate to address systemic issues that lead to misuse of prescription drugs. Initiatives such as the Home Medicines Review, a Commonwealth program, can be undertaken by a GP and pharmacist, and has been found effective in the prevention, detection and resolution of medication related issues for older people (Castelino, Bajorek, & Chen, 2010). The Victorian Alcohol and Drug Association (VAADA) is a peak body representing alcohol and other drugs services in Victoria. They provide advocacy and information to organisations or individuals working in alcohol and drugs.
Reducing injury and falls
Falls are common in older people and increase with age (Australian Institute of Health and Welfare, 2017d). While not all falls are serious, falls in older people can have serious consequences, including injury and at worst, death. Falls result from the interplay between intrinsic (person-specific) and extrinsic (environmental) factors. Although falls are a common occurrence, they are not an inevitable part of ageing. Evidence supports the effectiveness of both single and multifactorial interventions, including strategies such as strength and balance exercise, reducing medications, and addressing vision impairment (Vieira, Palmer, & Chaves, 2016). Despite the evidence of effective interventions, the translation of this evidence into practice remains a challenge at both individual and population levels.
Promoting physical activity
Physical activity is essential for maintaining physical abilities, health and independence as people age (I. M. Lee et al., 2012). Research suggests that uptake of physical activity later in life confers significant health benefits (Hamer, Lavoie, & Bacon, 2014), including the lowering risk of cognitive decline and dementia (Middleton, Barnes, Lui, & Yaffe, 2010; Zheng, Xia, Zhou, Tao, & Chen, 2016). Interventions focusing on physical activity are highly beneficial to physical functioning, reducing falls, improving mobility, quality of life and mental health, lowering the risk of cognitive decline, and fostering increased social connectedness (Bauman, Merom, Bull, Buchner, & Fiatarone Singh, 2016; Carter et al., 2001; Pahor et al., 2014; Stewart et al., 2001; Vrantsidis, Hill, et al., 2014; Zheng et al., 2016).
Promoting healthy eating
As people age, physiological changes occur that may make it more difficult to meet optimal nutrition needs. These may include changes in appetite, hormone levels, disease and injury reduced mobility, medication and difficulty chewing and swallowing. Adequate nutrition is critical to healthy ageing. It is possible to improve dietary patterns and nutritional intake among older people, which in turn positively influences the burden of chronic disease in this population (Pietinen, Valsta, Hirvonen, & Sinkko, 2008; Tourlouki, Matalas, & Panagiotakos, 2009). The Australian dietary guidelines (National Health and Medical Research Council, 2013) provides guidelines for healthy eating for older people (but does not cover nutrition for frail older people). The evidence suggest that diets high in vegetables, fruit, whole grains, poultry, fish, and low-fat dairy products are associated with better quality of life and survival in older adults (A. L. Anderson et al., 2011).
Promoting mental health
Aged care residents, people in hospital, people experiencing multi-morbid conditions and/or dementia, carers, women, Aboriginal and Torres Strait Islander people, and migrants are more likely to experience mental illness in older age (Rickwood, 2008; Wells et al., 2014) (Australian Institute of Health and Welfare, 2013). Causes of mental illnesses are multi-modal and strongly influenced by both intrinsic factors (e.g. genetic predisposition) as well as environmental factors (e.g. socio-economic disadvantage, physical and social isolation) (Haralambous et al., 2009; Wells et al., 2014). Mental health symptoms can be masked or mistaken for physical health conditions. It is important for accurate and early diagnosis of mental health conditions to ensure appropriate treatment and supports are made available.
Similar to the overall population, a multidisciplinary approach is essential to addressing mental health problems among older people (B. Dow et al., 2010; Haralambous et al., 2009). Comparable to the treatment approaches in other age groups, psychological interventions are usually the first point of call and a combination of medical and psychological interventions may be employed in more resistant and/or severe cases (Royal Australian College of General Practitioners Silver Book National Taskforce, 2006). Other alternative approaches to treat depression are also gaining ground including physical activity (Lautenschlager, Almeida, Flicker, & Janca, 2004) and reminiscence and life reviews (Bohlmeijer, Smit, & Cuijpers, 2003).
Poor mental health is also linked to social isolation. Programs with proven efficacy targeting social isolation in older people include collaborative partnership approaches; involving older adults in planning, implementation and evaluation of programs; using evidence-based approaches; addressing local needs; using existing resources; and utilising volunteers (Department of Health & Human Services, 2016).
Promoting screening and early detection
Chronic illness and disease such as cancer and dementia can result in significant morbidity and mortality. The incidence of cancer increases with age, indicating the importance of screening over the age of 50, including for breast, prostate and bowel cancers (Australian Institute of Health and Welfare, 2017c). Early and regular screening can result in timely diagnosis, early intervention, and treatment, prolonging the lifespan of older Australians (World health Organization, 2018a). Although some chronic illnesses such as dementia are incurable, the condition can be treated and managed, so it is important to diagnose dementia early in older Australians to ensure quality of life is maintained.
Intervention design considerations
Entry points for public health interventions to promote healthy ageing should be identified and tailored to any age and across varying levels of capacity, sectors and services (United Nations, 2015; World Health Organization, 2002, 2016).
Public Health Framework for Healthy Ageing (WHO 2015)
The nature and scope of prevention may change according to the target population, their capacity, and the setting. The World Health Organisation developed this public health framework highlighting points for intervention (WHO, World Report on Ageing and Health, 2015, p.33).
In Australia, and Victoria, the overarching aim is to promote and improve health through health promotion and prevention strategies (for example, to avoid the development of chronic diseases) (Australian Health Ministers’ Advisory Council, 2017; Victoria State Government, 2015). As highlighted in Figure 2, intervention can occur at different points of illness progression, however it is ideal to prevent or reduce the risk of the development of illness which in turn will have significant impacts on the health and well-being of the individual long term (Australian Health Ministers’ Advisory Council, 2017; Victoria State Government, 2015).
Interventions aimed at older people with high levels of intrinsic capacity should focus on the maintenance and improvement of health (for example through lifestyle programs and environmental programs to encourage healthy lifestyle behaviours) (World Health Organization, 2015). Interventions need to be carefully tailored to the target community; for example, designing interventions for older people who are experiencing decline in intrinsic capacity means that the focus of intervention will shift from preventing illness occurrence to minimising the impact of the illness and further progression, as well as supporting and improving functional abilities (World Health Organization, 2015). For example, to improve limited physical capacity, interventions could improve the physical environment to be supportive of such decline (World Health Organization, 2015).
The importance of careful and thoughtful design, implementation and evaluation of interventions and programs to improve the health and well-being of Victorians across the life span cannot be understated (Department of Health, 2013). To this end, the Victorian State Government has released the Guide to municipal public health and wellbeing planning which aims to assist in the planning of programs and interventions to improve the health and well-being of the Victorian community.
Health promotion & prevention strategies
Health promotion and prevention strategies may be delivered in different settings and targeted at the level of the individual, the community, or the population. In this resource, primary prevention interventions are defined as actions targeting population, environmental, and systems level factors that influence healthy ageing. Secondary prevention interventions are defined as actions targeting the modification of risk factors (lifestyle and behavioural) for healthy ageing. Tertiary prevention interventions are defined as actions targeting the treatment and management of disease and rehabilitation (World Health Organization, 2018b).
- Primary prevention intervention: The age friendly city of Melville, Perth
The City of Melville in Perth, Australia became a member of the WHO Age-Friendly Cities network in 2010. Seniors and people living with a disability make up a significant part of the Melville Community.
The Melville Age Friendly Accessible Business (MAFAB) Network is an initiative of the businesses within the City of Melville, which was created to support businesses meet the requirements of an age-friendly city. Dementia was a disability that the MAFAB identified early on, and members wanted to gain a better understanding of the condition. MAFAB engaged with Alzheimer’s WA for education and resources, and a number of local cafes provided dementia training for staff.
There have been positive outcomes of this initiative. A retail centre within the city of Melville was awarded the 2016 WA Seniors Business Award, and recognised as the only retail centre in WA to implement strategies to provide outstanding services to older people. MAFAB regularly receive positive feedback on exceptional customer service for older people amongst its business members.
The changes made provide an environment that is more age friendly, improving accessibility for older people and supporting greater community participation.
The National Bowel Cancer Screening Program is a government-funded, population-based initiative that aims to minimise the incidence, illness, and mortality related to bowel cancer in Australia through early and systematic screening to detect cancers and pre-cancerous lesions.
The program invites older people aged 50 – 74 to screen for bowel cancer using a free, simple test at home. A free immunochemical faecal occult blood test (iFOBT) is sent by mail at regular intervals to eligible Australians.
Evaluation of the program suggests a reduction in morbidity and mortality resulting from bowel cancer (Australian Institute of Health and Welfare, 2017e).
- Tertiary prevention intervention: Diabetes Victoria Education
Diabetes Victoria represents and supports people in Victoria affected by all types of diabetes and those at risk.
Diabetes Victoria works with diabetes health professionals and educators, researchers and healthcare providers to minimise the impact of diabetes in Victoria.
As part of their role, Diabetes Victoria provide information and support to individuals who have been diagnosed with diabetes to help manage the symptoms.
Other intervention considerations
The Australian Commission on Safety and Quality in Health Care (2014) separates health literacy into individual health literacy and the health literacy environment:
- Individual health literacy is the skills, knowledge, motivation and capacity of a person to access, understand, appraise and apply information to make effective decisions about health and health care and take appropriate action.
- Health literacy environment is the infrastructure, policies, processes, materials, people and relationships that make up the health system and have an impact on the way that people access, understand, appraise and apply health-related information and services.
For older people, low individual health literacy is linked to poorer health and a higher risk of premature death. Barriers to health literacy are increased where there is disadvantage and vulnerability, such as lower education levels, low English proficiency and disability (Australian Commission on Safety and Quality in Health Care, 2014).
Adequate health literacy generally increases from 15 to 19 years up to 35 to 39 years, and then generally declines. More than 8 out of 10 older Australians aged 65 - 74 years do not have an adequate level of health literacy (Australian Bureau of Statistics, 2008). The differences may be due to health care participation expectations, cognitive decline, and length of time since, and level of, formal education (Australian Commission on Safety and Quality in Health Care, 2014).
Physical, psychological and social changes associated with ageing often increase the need to access health care services. Therefore, as people age it is important for them to have an adequate level of individual health literacy to be able to negotiate our complex health systems (Centre for Culture, 2015). It is also important for health services to reduce or eliminate the barriers to health literacy by addressing health literacy in a coordinated way. This includes embedding health literacy into organisational policies and processes; ensuring health information is clear and understandable and communicated effectively; and educating consumers and providers about health literacy (Australian Commission on Safety and Quality in Health Care, 2014; Centre for Culture, 2015). Understanding the way older adults learn and retain critical health information and establishing environments to best support this, such as collaborative learning and social support, is another important aspect of health literacy to consider (de Wit, 2018).
Interventions with a health equity lens
It is important to recognize that the older population is not a homogenous group, but rather one of great diversity and must be considered in terms of ethnicity, culture, sexual identity, degree of disability, and socio-economic status. In addition, while older people are categorised as those aged 60 years plus, this “group” spans some 40 years or more. There is a significant difference in the health of those in their 60’s compared to those in their 90’s, and many variations in between. Such diversity requires a complex and multi-faceted approach to meet the needs of older individuals, and to ensure equity across all segments of the community.
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