Healthy Ageing – a Challenge for Europe Union Member States and EFTA-EEA Countries

BY 2025 ABOUT one-third of Europe’s popula- Co-funded by the European Commission, the tion will be aged 60 years and over and there will three-year (2004–2007) Healthy Ageing project Healthy Ageing be a particularly rapid increase in the number of aims to promote healthy ageing among people people aged 80 years and older. The countries aged 50 years and over. It involves ten coun A CHALLENGE FOR EUROPE of Europe must develop strategies to meet this tries, the World Health Organisation (WHO), the challenge. Promoting good health and active European Older People’s Platform (AGE) and societal participation among the older citizens EuroHealthNet. The goal is exchange of know- – AGEING HEALTHY will be crucial in these strategies. ledge and experience among the European TheHealthy Ageing – a Challenge for Europe Union Member States and EFTA-EEA countries. report presents an overview of interventions The main aims have been to review and analyse on ageing and health. It includes suggested existing data on health and ageing, to produce a recommendations to decision makers, NGOs report with recommendations and to develop and practitioners on how to get into action to a comprehensive strategy for implementation of promote healthy ageing among the growing the report findings and the recommendations. number of older people.

The report also presents different countries’ EUROPE FOR CHALLENGE A policies/strategies for older people’s health, summaries of reviews on the effectiveness of interventions for later life, and a number of examples on good practice projects promoting healthy ageing. Data about the health of older people is presented.

Swedish National Fax +46 8 566 135 05 Report R 2006:29 Institute of Public Health E-mail [email protected] ISSN: 1651-8624 Distribution Internet www.fhi.se ISBN: 91-7257-481-X SE-120 88 Stockholm Healthy Ageing – A Challenge for Europe PROJECT PARTNERS: CONTRIBUTORS TO THE HEALTHY AGEING PROJECT: AGE, European Older People’s Platform healthPROelderly, Austrian Red Cross, Austria EuroHealthNet SPF Santé Publique, Sécurité de la chaîne alimentaire WHO, World Health Organization, Ageing and Life Course et Environnement, Belgium Austrian Health Promotion Foundation, Austria VIG VZW, Vlaams Instituut voor Gezondheidspromotie, Belgium National Institute of Public Health, the Czech Republic Ministry of Health, Bulgaria The Health Development Agency,England (until July 14th 2005) Ministry of Health, the Czech Republic Middlesex University, England (from October 19th 2005) Ministry of Health, Cyprus Folkhälsan – an NGO for public health and health promotion, Age Institute, Finland Finland Finnish Centre for Health Promotion, Finland Università Degli Studi Di Perguia, Italy Finnish Institute of Occupational Health, Finland NIGZ, Netherlands Institute for Health promotion and Disease, GeroCenter Foundation for Research and Development, Finland the Netherlands Ministry of Social Affairs and Health,Finland The Norwegian Directorate for Health and Social Affairs,Norway National Research and Development Centre for Welfare and (until July 21st 2005) Health, STAKES, Finland Norwegian Knowledge Centre for the Health Services, Norway University Of Jyväskylä, Finland (from October 1st 2005) Direction Générale de la santé, France Ministério da Saúde Direcção Geral da Saúde, Portugal Bundeszentrale für gesundheitliche Aufklärung,Germany NHS Health Scotland, Scotland Federal Ministry of Health, Germany SNIPH, The Swedish National Institute of Public Health,Sweden Social Science Research Center Berlin, Germany Ministry of Health, Hungary Icelandic Institute of Public Health, Iceland Ministry of Health and Social Security, Iceland National Council on Ageing and Older People, Ireland Institute for Cognitive Science & Technology – National Research Centre of Italy, Italy Health Promotion State agency, Latvia Ministry of Health, Latvia National Centre for Health Promotion and Education, Lithuania Ministry of Health, Welfare and Sport, the Netherlands Verwey-Jonker Institute, the Netherlands National Council for Senior Citizens, Norway Health General Directorate, Portugal Ministry of Health, Poland National Institute of Hygiene, Poland Public Health Authority, the Slovak Republic Ministry of Health, the Republic of Slovenia National Institute of Public Health of the Republic of Slovenia, the Republic of Slovenia Stockholm County Council, Centre for Public Health, Sweden Ministry of Health and Social Affairs,Sweden Stockholm Gerontology Research Center, Sweden Umeå University, Sweden THE HEALTHY AGEING PROJECT IS Department of Health, United Kingdom CO-FUNDED BY THE EUROPEAN COMMISSION. Wales Centre for Health, Wales, United Kingdom

The views expressed by the individuals who have contributed to this Report do not necessarily reflect official policy of the participating organisations.

© The Swedish National Institute of Public Health R 2006:29 ISSN: 1651-8624 ISBN: 91-7257-481-X Illustrator: Ninni Oljemark, Kombinera Graphic design: Typoform AB All figure layouts redesigned by Typoform AB Print: NRS Tryckeri AB, Huskvarna 2007 Contents

7 Preface Environment 44 Lifestyle factors 45 8 Executive Summary Physical activity and nutrition 45 Injury prevention 47 13 CHAPTER 1. Introduction Substance use/misuse 50 Health promotion can improve older Use of medication 53 people’s health 15 Forthcoming European statistics 54 Improved health – a determinant Country codes 56 of economic growth 16 References 56 Definition of healthy ageing 16 Aspects of becoming older 16 61 mAjor topics Autonomy late in life to achieve personal control 16 Major Topics of the Healthy Ageing Project 62 Maintaining balance in a changing life situation 17 Disability in ageing 17 63 CHAPTER 3. Retirement and pre-retirement Health promotion 18 Increased participation of older workers needed 65 Involving older people 18 Work ability – a holistic concept 66 Ethical aspects 19 General recommendations 66 Cultural aspects 19 Methods to prolong working life 67 Inequality in health 20 Preparing for retirement 68 Gender and ageing 21 References 68 Framework for the Healthy Ageing project 22 References 27 69 CHAPTER 4. social capital Effectiveness of interventions 72 29 CHAPTER 2. Volunteer work 72 Statistics on older people and health Social support 72 Challenges due to demographic change 31 Interventions for preventing social isolation Demographic change 31 and loneliness 73 Migration 32 Summary of findings 73 Average life expectancy 34 References 74 Healthy life expectancy at 60 years 34 Health status in the EU countries 35 75 CHAPTER 5. Mental health Health among older people in the European Union 35 Those affected often neglected 78 Fewer working people to support more older people 36 Effectiveness of interventions 79 Health and inequality 36 Psychotherapeutic and psychosocial interventions 79 Inequalities between age groups 36 Prevention or reduction of depression 79 Statistics concerning the major topics 37 Interventions for caregivers 80 Retirement and pre-retirement 37 Summary of findings 81 Social capital 40 References 82 Mental health 43 83 CHAPTER 6. Environment 113 CHAPTER 10. Substance use/misuse Outdoor mobility 85 Tobacco 115 The technological environment 85 Health effects 115 Climate changes 85 Oral smokeless tobacco 115 Excessive cold and excessive heat 86 The benefits of stopping smoking 115 Air quality 86 Effectiveness of interventions 116 Effectiveness of interventions 87 Summary of findings 117 Housing improvement and health gain 87 Alcohol 117 Housing improvement and reduction of injuries 87 Effectiveness of interventions 118 Summary of findings 88 Risk of coronary heart disease 118 References 88 Falls/fall injuries, functional and cognitive impairment 118 89 CHAPTER 7. Nutrition Injuries and health benefits 119 Factors that may influence eating habits 91 Summary of findings 119 A positive attitude to food 92 References 119 Effectiveness of interventions 93 Prevention of osteoporosis 121 CHAPTER 11. Use of medication and cholesterol concentrations 93 and associated problems Dietary patterns and cancer risk 95 Medication error or non-compliance 123 Long-term weight loss 95 Inappropriate prescribing 124 Summary of findings 96 Interactions 124 References 96 Adverse drug reactions 124 Other drug-related problems 124 97 CHAPTER 8. Physical activity How to improve the quality of medication use 124 Effectiveness of interventions 100 Conclusions 125 Interventions to increase physical activity 100 References 126 Exercise and its health effects 100 Progressive resistance training 100 127 CHAPTER 12. Preventive health services Primary care-based interventions 101 Health literacy 130 Summary of findings 101 Effectiveness of interventions 130 References 102 Vaccination 130 Home visits 130 103 CHAPTER 9. Injury prevention Summary of findings 132 Community interventions 105 References 132 Violence towards older people 106 Effectiveness of interventions 107 135 CHAPTER 13. Good practice Multi-factorial fall risk assessment Examples of good practice 137 and management 107 Experience from good practice 140 Physical activity in relation to injuries/falls 108 Conclusions 142 Community interventions against falls 108 List of good practice examples 143 Withdrawal of psychotropic drugs 109 Austria 143 Preventive medical devices 109 England 143 Summary of findings 110 The Czech Republic 143 References 110 Finland 144 Italy 144 Netherlands 145 Norway 146 Scotland 146 Sweden 147 Mental Health Well-being in Later Life Programme, Scotland 148 Three interlocking strands 148 Family and friends – a key issue 149 References 149 151 CHAPTER 14. Health promotion for older Sweden 185 people is cost-effective Wales 186 What is cost-effectiveness? 153 Health data 186 Examples of cost-effectiveness Respondents’ comments 186 in programmes for older people 154 Does a policy contribute to health development? 187 Physical activity 154 Conclusion 188 Preventive home visits 154 Hip-fracture prevention 154 189 CHAPTER 17. Reflections on work done Are older people’s programmes cost-effective? 155 Statistics 191 Are there problems when applying Literature 192 cost-effectiveness to older people? 155 Good practice 193 Conclusions 158 Policies 194 References 159 Turning evidence into practice 194 References 195 161 CHAPTER 15. International policies WHO and UN policies 163 197 CHAPTER 18. Recommendations Health 21 – Health for all Core principles of healthy ageing 201 in the twenty-first century 164 Policy 201 Healthy Cities 164 Research 202 WHO active-ageing policy framework 164 Practice 202 The UN Madrid International Plan Priority topics for action 202 of Action on ageing 166 Conclusion 166 205 Contributions EU strategies and processes in relation to healthy ageing 167 209 Apendices Legal mandate of the European Union 167 Appendix 1. Life expectancy The ‘Lisbon process’ 167 in EU/EFTA/EEA countries 210 EU institutions 168 Appendix 2. Relation of Gross DG Health and Consumer Protection 169 Domestic Product (GDP) to average life expectancy in EU/EFTA/EEA countries 212 Social affairs and equal opportunities 169 Appendix 3. Healthy life expectancy EU policies on age discrimination 171 (HALE) in EU/EFTA/EEA countries 213 Conclusion 172 Comments on the HALE method 214 References 172 Appendix 4. Employment rate in EU/EFTA/EEA countries 215 175 CHAPTER 16. Policies in European countries Appendix 5. Literature Review on Healthy Ageing 216 Questionnaire for healthy-ageing policy 177 Appendix 6. Official statistical sources Summary of policies 178 on older people and health 219 The Czech Republic 178 Appendix 7. Abbreviations 226 Denmark 178 England 179 Finland 179 France 180 Germany 180 Hungary 181 Italy 181 Lithuania 181 The Netherlands 182 Norway 183 Poland 183 Portugal 183 Scotland 184 Slovak Republic 184 Spain 185

Preface healthy ageing | preface | ageing healthy

he consequences of demographic change for public health throughout the European Tin Europe, with the continuously growing Union. With this report we have taken a step older population, is a huge challenge. European forward in the development of health promo- societies need to increase knowledge about how tion among older people. Our intentions are to promote good health among older people so that this will contribute to and inspire future as to promote health and quality in later life work. The next step will be to implement the stages and to prevent costly and negative im- results into national and European policy and pacts effects on the population as a whole. practice. Policy-makers need good outlines on which We wish to thank the Project Group, the to make decisions, based on research and good Steering Group, the authors and those who have practice. This in turn requires that the “bridge” reviewed and made comments on the Report between research and public policy is open for their hard work and valuable contributions. and constructive. Practitioners and NGOs also They are all listed on the Contributions page. need to know about evidence and good prac- We are also very grateful to the European tice in healthy ageing. This is why in 2003 the Commission, DG Health and Consumer Pro- Swedish National Institute of Public Health, tection, for financial support of the project with the support of the European Commission within the EU Public Health Programme for and twelve partners including the WHO, AGE, 2003–2008. EuroHealthNet and Member States’ public Finally we would like to welcome you to health institutes, ministries and universities visit our website www.healthyageing.nu, where initiated the “Healthy Ageing“ project under summaries of this Report are available in dif- the EU Public Health Programme. ferent European languages, along with more The Healthy Ageing project has mapped and information on the project. analysed facts and evidence concerning health promotion for people aged fifty and over. It has considered statistics, policies/strategies, good practice and the literature. Finally a set of Stockholm, December 2006 recommendations on promoting older people’s health has been drawn up in co-operation with Gunnar Ågren Karin Berensson the project partners and ministries responsible Director General Project Manager Executive Summary

The challenge of Healthy Ageing The Project’s definition of healthy ageing The need for healthy ageing is a challenge to all Healthy ageing is the process of European countries. By 2025 about one-third optimising opportunities for physical, of Europe’s population will be aged 60 years social and mental health to enable older and over, and there will be a particularly rapid people to take an active part in society increase in the number of people aged 80 years without discrimination and to enjoy an and older. This will have an enormous impact independent and good quality of life. on European societies. There are powerful arguments for invest- This Report brings together information from ing in health as an objective in its own right. the Healthy Ageing project: literature on in- Health is also an important determinant of tervention, statistical data, examples of good economic growth and competitiveness. Invest- practice and facts about policies and strategies ing in healthy ageing contributes to the labour for healthy ageing. It also proposes recommen- supply, decreasing the likelihood of early re- dations. National implementation will take tirement. place in the European countries. Co-funded by the European Commission, the three-year (2004–2007) Healthy Ageing Major topics and cross-cutting themes project aims to promote healthy ageing The Healthy Ageing project has a holistic among people aged 50 years and over. It approach and takes into account health determi- involves ten countries, the World Health nants influenced both by society and its policies Organisation (WHO), the European Older as well as the individual. The project partners People’s Platform (AGE) and EuroHealth- have agreed to focus on ten major topics. Most Net. The goal is exchange of knowledge are broad and interact with each other and and experience among the European Union with the following cross-cutting themes: socio- Member States, acceding countries and EFTA- economic determinants, inequalities in health, EEA countries. gender and minorities. • Retirement and pre-retirement. Employers • Nutrition. Considerable gains in terms of and employees alike need to take responsi- mortality and function could be achieved bility for the health of the older members if older people adopted a healthier lifestyle

of the workforce so that these can work to with healthy eating habits. Obesity and summary executive | ageing healthy higher ages. “Work ability” is a holistic con- overweight are associated with unhealthy cept including a balance between work and dietary habits and lack of physical activity. personal resources. • Physical activity. The broad benefits of physi- Anticipatory social interventions concern- cal activity for older people are well docu- ing pre-retirement have positive effects and mented and associated with improved length contribute to empowerment. and quality of life. People tend to become • Social capital. A high level of social capital progressively less active as they get older. enhances a person’s sense of belonging and • Injury prevention. The three leading causes of well-being. Providing opportunities for older death due to injury in older people in Europe people to do voluntary work among seniors are self-inflicted injuries, falls and road traf- improves the quality of life of the volunteers fic injuries. Exercising balance and strength- and those who receive the services. Low so- ening muscles reduce falls in older people. cial capital correlates with mortality. Strained family relations are risk factors for • Mental health. Ageing is a gradual process the abuse of older people or for violence. and there is much we can do to promote good • Substance use/misuse (tobacco and alcohol). mental health and well-being in later life. Par- A majority of smoking-related deaths in the ticipation in meaningful activities, strong per- EU occur in older people. Smokers who stop sonal relationships and good physical health at the age of 65–70 halve their excess risk are key factors , while age discrimination has of premature death. Smoking cessation re- a negative impact. Poverty is a risk factor for mains the most effective method of altering mental ill-health. the smoking-induced disease risk. • Environment. Air pollution is responsible for Health problems caused by alcohol use a great burden of environment-related dis- disorders are often under-detected and mis- eases and its effects are especially adverse on diagnosed among older people. people already in poor health. Global climate • Use of medication and associated problems. change may have a widespread impact on the Older people are the largest per capita users older population in the future, due to more of medication. The risk of adverse reactions episodes of extreme weather. Accessible green increases with the number of individual areas allow older people with poor mobility drugs taken. Lack of overall knowledge or disability to spend time outdoors, which is of what medicines and treatment a patient an important determinant of good health. is receiving is an important explanation of drug problems. As well under-use, over-use The relationship between belonging to a 10 and unsuitable combination of medication minority group and ageing and health needs are other common problems. Some prob- more exploration. lems can be avoided through the inclusion of older people in clinical trials. Policies and strategies Most European countries have policies and strat- • Preventive health services. Older people with egies for healthy ageing according to a question- low socioeconomic status or from ethnic naire designed by the Healthy Ageing project. minorities may find access to health services The policies are either separate or included in difficult. They also may have low “health lit- general health policies. The majority of the poli- eracy”; that is, they may know significantly cies was on health and promoting the health of less than other people about disease and how older people, rather than care of older people. to maintain good health. Health literacy is a Most policies do not refer to health data. Poli- more meaningful predictive factor than edu- cies seldom allocate funds for health promotion, cation for older people’s use of preventive which may hinder local implementation. services, and has implications for the design There is a need to involve older people in of interventions. planning, and to promote positive images of Cross-cutting themes. Inequality in health is ageing, avoiding any arbitrary focus on chron- best illustrated by the gap in life expectancy be- ological age. tween people from low socioeconomic groups and those from high ones. Health inequality Good practice projects starts early in life and persists in later life. In The sixteen ’good practice’ projects presented healthy-ageing strategies, health promotion in this Report indicate the importance of sus- should give priority to addressing the health of tainability, i.e. transforming projects into pro- the more disadvantaged older people. grammes, and collaboration by people through- Poverty is an important socioeconomic out the community. Most of the projects are health determinant, with negative effects on considered suitable for implementation in health, life expectancy, disease and disability. other countries. Women living alone often risk poverty in later Social capital and physical activity are the life because their lifetime earnings are less than most common major topics in the ‘good prac- those of men, as are their pension entitlements. tice’ projects. Often in combination, they may Gender has to be taken into account when lead to improved physical health and the al- planning and implementing health promotion. leviation of loneliness. The key issue is how to Women live longer than men in all European persuade people to change habits, especially countries but report more psychological symp- those who for cultural, social and/or economic toms and consult health professionals more often reasons are least inclined to do so. Gender has and receive more treatment than men do. Men also to be considered: men are more difficult to and women need to be motivated differently to motivate to participate in activities than women participate in health promotion activities. are. The ‘good practice’ projects suggest that involving people from the target group in the planning and implementation phases may em- 11 power the less motivated and encourage their

participation. summary executive | ageing healthy

Is health promotion for older people worthwhile? The usual cost-benefit model with consumption versus production discriminates against people with low incomes, such as pensioners. Including “senior production” (care of grandchildren, voluntary work etc) makes cost-effectiveness analyses fairer. Cost-benefit analyses of programmes relevant to older people indicate that the programmes lead to improved quality of life and decreased health care consumption. The potential health gains of a prevention programme are greater in the older population than among young people.

Recommendations on policy, research and practice The recommendations in this Report on policy, research and practice are based on the findings of the project and on the following core principles: • older people are of intrinsic value to society • it is never to late to promote health • equity in health • autonomy and personal control • heterogeneity 12 healthy ageing | introduction 13 C H A P T E R 1 ntroduction I 14 healthy ageing | introduction 15 - - - -

Health promotion is defined in the Ottawa

to increase their level of control over, and to improve, their health. It represents a compre hensive social and political process. It entails action to strengthen individuals’ capabilities skills and to and change unsatisfactory so cial, environmental and economic conditions and public on impact their alleviate to order in individual health. Participation is essential for sustaining health promotion. Health promotion and preventive measures, and a positive approach to ageing, would help to improve the quality of life for older people. Successful planning for an ageing society re quires a comprehensive national, regional and local strategy. Health promotion can improve older people’s health Health promotion has an important later in diseases Many ageing. role healthy ensuring in life are preventable and health promotion can con chronic with people older that ensure even ditions and disabilities can remain active and independent, preventing institutionalisation and declining health. Evidence indicates that it its improve and life lengthen to possible be may healthy, remain can people older that so quality active, independent and productive (3). Charter (4) as the process of enabling people

- - - -

emographic trends are a key factor for the for factor key a are trends emographic future of the European Union. The num ntroduction

One task of the Healthy Ageing project is to is project Ageing Healthy the of task One I promotion and promotion to interventions study practical to prevent health hazards such as falls and de A pression. third task is to the present findings on their effectiveness and make these findings policymakers. and practitioners to accessible Ageing”. review current practices and policies for older people’s health across Europe. Another is to review the literature on evidence-based health of knowledge on healthy ageing is a challenge for European countries. The European Com mission has highlighted the importance of this issue in its EU Public Health Programme, and for support approved Commission the 2004 in the three-year multinational project “Healthy 2004. Life expectancy is projected to increase years five by and men for years seven almost by for women between 2005 and people, 2050. aged 65 Older to 79 years, will increase by (2). time of period same the during cent per 44 exchange the increase and improve to need The bers and proportion of older people in the pop the in people older of proportion and bers birth decreasing of because growing are ulation rates and increasing life By expectancy. 2014, there will be 33 per cent more people aged 80 in were there than EU present the in above and D Improved health lives and at the same time, at societal level, 16 – a determinant of economic growth contribute to larger growth, lower depend- Improved health is associated with national ency burdens and substantial cost savings in wealth; but it is only more recently that the con- pensions and health. They therefore represent tribution of better health to economic growth win-win strategies for people of all ages.” (7) has been recognised. There is evidence that The Healthy Ageing project has formulated improved health can promote earnings and the its own definition of healthy ageing which takes supply of labour. Poor health, on the other hand, into account equity in health and an independ- increases the likelihood of early retirement. All ent life of good quality. these provide powerful arguments for investing in health, both as an objective in its own right THE PROJECT’S DEFINITION OF HEALTHY AGEING and because it is an important determinant of Healthy ageing is the process of economic growth and competitiveness (5). optimising opportunities for physical, social and mental health to enable older people to take an active part in society Definition of healthy ageing without discrimination and to enjoy The phrases “healthy ageing”, “successful an independent and good quality of life. ageing” and “active ageing” have become increasingly common in research protocols and policy documents. An example from the World Aspects of becoming older Health Organization (WHO) states: “Active Autonomy late Ageing is the process of optimizing opportu- in life to achieve personal control nities for health, participation and security The notion of healthy ageing also includes au- in order to enhance quality of life as people tonomy. This right to self-determination is an age”(6). The fourth phase (2003–2007) of the essential aspect of human dignity and integrity. WHO Healthy Cities programme includes a Autonomy for older people ought to be pro- definition of healthy ageing. It adopts a rights- moted by preventing the restrictions and limits based approach that recognises the rights to imposed upon that right by their communities equality of opportunity and treatment in all and by themselves. respects, particularly as people age. The crux of autonomy is personal control, According to the European Commission’s the perception of having control over one’s self contribution to the Second World Assembly and the capability of defining one’s own needs on Active Ageing, active-ageing involves “an and acting upon that understanding. Indepen orientation towards active-ageing policies and dent living means not only doing things for and practices. Core active ageing practices include by yourself but also being in control of how life-long learning, working longer, retiring things are done. later and more gradually, being active after re- People must be given the space and the tirement and engaging in capacity-enhancing opportunity for self-realisation and for self- and health-sustaining activities. Such practices development. This can happen only if the in- aim to raise the average quality of individual dividual can share in decisions that essentially healthy ageing | introduction 17 - - - - – physical Environment – social Individual’s goal proﬁle BALANCE SOURCE: HEIKKINEN, 2006. (12) The balance between capacity, goals and The balance between capacity, repertoire Individual’s isability in ageing increase in life expectancy and the resulting in and the resulting in life expectancy increase presum are people older of number the in crease people older of number the increasing also ably with disabilities. Disability means difficultyor dependency in carrying out daily self-care ac home own one’s in independently living tivities, de Disability roles. social essential playing and Figure 1. environment. timising the available resources and by using compensatory measures. balance Further, may be enhanced through improvement in social support and by reducing physical obstacles to action (13). Because individual goals capacity, and environment are interrelated, these three in simultaneously considered be to need factors the promotion of healthy ageing. D Functional decline and disability seem to be typical, uncomfortable features of ageing. The ------

governance (8). Competence also concernsCompetencealso governance(8). - Decline Decline in personal resources may be pre The notion of this kind of balance offers a References also used in the text above: (9, 10) (9, above: text the in used also References One way of constraining older people’s free people’s older constraining of way One aintaining balance for example, changes in lifestyles or by medical in lifestyles changes for example, and rehabilitative interventions. Goal attain ment may be assisted by focusing on the most important meaning-bearing elements, by op to one’s ever-changing life situation and this tends to disturb any balance achieved. adaptation may include various actions. This vented or reduced and capacity restored by, desirable goals and select appropriate means satisfaction lies in of realising these. Individual (11). the balance between capacity and goals start for further development of the concept of health in ageing. Balance involves adaptation Ageing for most people means, by definition, the eventual decline in personal, physical, cog nitive and social resources This or in capacity. turn affects the ability to acquire and process information. One’s personal resources include the also ability to make decisions about also needed for healthy ageing. ageing. healthy for also needed M in a changing life situation mation is given in a way that understandable, is they will not be deprived readily of their freedom of choice and can be exposed to un necessary external control. freedom of choice is Clearly, concern for older people’s greater the implementation of the decision. dom of choice is to withhold the information they require for making choices. If people are not informed about possibilities for improving health or available treatment; or if the infor concern him/herself and the competence for self creases quality of life and increases the risks of Health promotion 18 hospitalisation or admission to nursing home, home help and premature death. The socioeco- Involving older people nomic burden of disability is great (14). Opportunities for self-realisation and for self- Approximately 20 per cent of people aged development can be compromised if experts 70 years or over, and 50 per cent of people and authorities plan and implement health aged 85 and over report difficulties in the basic promotion objectives and programmes for activities of daily living. A decline in e.g. mo- older people “top-down”. This ‘paternalistic’ bility, muscle strength, balance and cognitive approach, which often also imposes limits performance is also common (15). and restrictions on the right to self-determin The most widely-used conceptualisation of ation, could be reduced by enabling people to disability proceeds from pathology to the gen- have their say about the values, objectives and eration of organ and body-system impairments. methods of health promotion. Effective health This leads to functional limitations in the or- promotion is often a matter of combining the ganism as a whole and finally to disability (16, best interests of the individual and of the com- 17). The disablement model has been widely munity: the common good. used in research into ageing, and empirical evi- Modes of work with older people depend dence is accumulating on the progression from on environmental and cultural contexts. Non- disease or trauma to disability. governmental organisations concerned with A modification of the disablement proc- ageing and old age, and organisations of senior ess takes into account both the psychosocial citizens, can be included as partners in health and the medical aspects of late-life disability. promotion. This approach is appropriate for It looks at broader risk factors in the physical initiatives to improve the physical environment and social environment that also contribute and social support for older people in the form to disability. Identical physical and medical of e.g. safety, mobility, transport, recreation, life- conditions may result in different patterns of styles, social relationships and access to nature. disability, depending, for example, on the indi- Health promotion can also be strengthened vidual’s home conditions or family structure. through the active participation of the target At the same time, similar types of disability group. This approach, health promotion by may arise from different types of ill health. the people, assumes that attempts to change The fact that disability is unequally distributed attitudes and behaviour will succeed best when suggests a distinct sociogenic component (18). activities are planned “bottom-up” by older Prevention of disability in late life has become people themselves. This approach can include a major public health concern, a key area of helping older people to care for themselves ageing research (12) and a target for the devel- through life-long learning, for example univer- opment of effective policies and programmes. sities for older people, adaptation of information technology and involvement of interest groups of older adults as partners in health healthy ageing | introduction 19

- - - Similarly, the Similarly, understanding and practice of Consistent with cultural theories of age in in research to examine for example depression cross-cultural to due results different yield may depression. of concept the in differences great vary to seems fitness physical for exercise ly between older adults in different countries. Additional knowledge is required about cross- the benefits of different behaviour andhealth reflect are differences the addition, In practice. ed in people’s hopes and expectations about how they want and are able to live, how they want to die, how they work their way through life, how and when they learn, and how they ageing of reality the about feel and comprehend important create differences These age. old and ageing. in promotion health for challenges ing, many studies have shown how important it is that health promotion programmes and interventions are in agreement with the target group’s cultural norms, perceptions and self- exist differences cultural Significant awareness. between ethnic and cultural minority groups metro between classes, social between also but politan areas, and between rural and areas. urban Contextual factors may either help or hinder health promotion, in ‘troublesome’ or differences community neighbourhoods: ‘better’ used scales The capital. social termed is what in Cultural aspects differences in many aspects Significant cultural cross-cultural in example, for appear, ageing of gerontology studies. These differences appear people, old and ageing towards attitudes the in in the cultural-moral visions of relationships roles the in states; and families persons, among of beliefs, spirituality and and health, of religion perceptions in disease; regarding and health in cultural norms and perceptions regarding - - - References also used in the text above: Health promotion programmes for healthy Health promotion should focus on the most The concepts of health and illness and the maintaining control of their lives and allow for allow and lives their of control maintaining informed consent. (19–21) ageing are justified when they: are basedscientific on research, are communicatedgeneral to the public in an easily enable understood individuals to make way, changes while still essential and generallyessentialacceptedobjectives,and but also take into account specific issues related to older persons. These include a slightly differ entset ofvalues, lower levels ofeducation and income and a growing burden of disease and disability. ties and the general public. Young people, for example, evaluate their health on the basis of symptoms whereas older people put emphasis on functional capacity. ognised as positive, health involvesfundamentalcontradictionsvalue and promotion also ethical questions. value systems on which basedmaydiffer between individuals, authori the objectives are result in significant benefits such as increased average life healthy expectancy life expectancy), improvements in the (and quality particularly of life and savings in health costs. While these services outcomes are generally rec ageing with studies among older people and to develop links between the experts and the benefit they are working. people for whose Ethical aspects Healthpromotion programmes arebelieved to promotion. A further line is to increase know ledge about health promotion and healthy cultural differences as well as cross-cultural and poor health status and the level of educa- 20 universals, to prevent stereotypes and promote tion and income of older people. Those with health promotion. poorer education, a lower occupational class References also used in the text above: (12, or smaller incomes tend to die younger, and 22–27) to have, during their briefer lives, a higher prevalence of most types of health problems. An explanation of this persistence of health Inequality in health inequalities at an older age can be sought in Inequality in health is generally defined as the the people’s past lives. This means that present existence of systematic differences and varia- inequalities are the net effect of a lifetime of tions in health status between different socio- socioeconomic differences and exposure to un- economic groups. The differences are socially favourable material, psychosocial and behav- produced and unfair (28), and include: ioural risk factors (31). Certain groups of older people such as dis- exposure to unhealthy, stressful living and • advantaged or vulnerable persons, those facing working conditions, social exclusion, older migrants, refugees or the • inadequate access to essential health and homeless are even more prone to ill-health and other public services, disabilities, and therefore need special atten- • health-damaging behaviour where the de- tion (32). This raises the question of how far gree of choice of lifestyle is restricted, and health services are prepared for, and adequate- ly responsive towards, the needs of these older • health-related social mobility involving the tendency for sick people to move down the groups. Most national health care systems in social scale. Europe are ill-equipped to address the needs of the ageing members of their populations, let The existence of health inequalities is best alone the more vulnerable of the older groups illustrated by the gap in life expectancy be- (33). Richer people make more use of preventa- tween people from low socioeconomic groups tive and specialist care than poorer – who make and those from high ones. In many European more use of emergency hospital care (34). countries, men in higher socioeconomic groups Adequate access to good-quality health can expect to live up to six years longer than services for older people with lower socioeco- men in lower ones (30). In terms of ‘healthy nomic status is however not the only measure life expectancy’ the gap between the poorest necessary to reduce the health inequalities they groups and the richest is even bigger. In the experience. To reduce inequalities, any healthy- Netherlands, for example, it is 14 years (29)! ageing strategy should concentrate more on the Health inequalities start early in life – even disadvantaged than on the better-off. Strategies before birth due to differences in pre-natal should include special measures and approaches conditions – and persist into old age. For most to reach out effectively to disadvantaged groups specific causes of death, inequalities tend to be of older people. Measures that have proved larger among men (30, 31). There are direct effective in promoting the health of socially connections between self-reported morbidity excluded people include outreaching, home healthy ageing | introduction 21

- - - - was a re

. The MERI research has shown that researchthat shown hasresearch MERI The The gender difference in life expectancy is live alone than older disabled men are. Older women may report more psychological symp toms than men do. Another fact is that older women in the MERI countries make more use treatment medical and consultations medical of than do older men. carried out in twelve European countries. European twelve in out carried on older women as groupisstill inadequate. Approximately an every independent target fifth person in Europe now is a woman aged 50 years or older. In almost countries all studied, the women twelve more men often present than generalised symptoms pain, such arthritis as and arthrosis, ment or visual osteoporosis. At the impair same time older women are more affected by disorders caused by injuries and falls. Given these facts, there self-perception are reasons why older women’s the in men older of that than worse is health of MERI countries also smaller when years lived with disability are taken into account. Women’s longer life means in many cases a longer life with chronic suffer women Older disease. incapacitating and longer and are highly dependent. At the same time older disabled women are more likely to The EU-co-funded MERI project sponse to demands by scientists, associations knowledge more for governments national and of the living conditions and problems of older empir the improving for needed is This women. for work policy, and public for social basis ical and by for and associations national European encouraging future research on older women while also raising general awareness of older was project MERI The circumstances. women’s - - - - g in age nd a r e nd The gender aspect is evident in life expect Thus older women run a higher risk of pov In In short, tackling health in inequalities later http://www.own-europe.org/meri e 1. ancy and cause-of-death. Women have a higher a have Women cause-of-death. and ancy life expectancy than men, although longer life better in years more to lead inevitably not does health. reduced participation in the labour However, market. some countries are adapting their systems by adding pension rights for periods of care of children or dependent elderly or dis abled people (36). widely across the EU. In most countries they are designed to replace earnings from work as a result of lifelong contributions rather than awarding benefits to all older peoplebasis on the of residence. Women’s entitlements are significantly lower than men’s due to their living conditions. Gender-based differences in accompany conditions living and opportunities the individual through life. erty than older men do. Pension systems differ perspective on older people and example health, on for the biological and social aspects of ageing and on living conditions. But gender perspec gender special a necessitate differences tive: women as a group and men as a group, and comparisons between and women’s men’s ageing strategy. ageing G There is a lack of knowledge about the gender and other low-barrier activities that involve (35). and empower participants socioeconomic underlying the improving and life in disadvantaged people for older determinants should be situations at the core of any healthy visits, intercultural mediators (for older grants) or mi experience experts, self-help groups In the majority of the MERI countries older In addition, there are major structural deter- 22 women pay more attention to health issues than minants, including environmental and socioeco- older men do and they show healthier habits nomic strategies. concerning alcohol and tobacco. Older women also tend to be more aware of healthy nutrition Health determinants and major topics than men are. In Europe, obesity is less com- The Healthy Ageing project focuses on the dif- mon among older women than among older ferent levels of health determinants: those de- men. Nevertheless, older men more often take termined by society and political policies and part in physical activities and sport, although those determined by individuals themselves. the number of older women doing physical ex- The many important issues for older people ercise is increasing in many countries (37). include: older people living in rural areas; per- Note, however, that enormous social and sonal finances; technology and health; internet cultural changes are going on in Europe and all access; technical aids in the home; responsive- over the world. The fact that older women to- ness of health care to older people; sexuality; day drink more alcohol than did previous gen- cultural activities and oral health. erations requires new knowledge. The increase However the project has agreed on ten major in overweight might afflict men and women topics important for promoting healthy ageing. differently. Most are broad and include subtopics: injury prevention, for example, includes violence.

Framework for the Healthy Ageing project The selected major topics are: The factors which influence health interre- • Retirement and pre-retirement late and many can be influenced. They can be • Social capital thought of as a series of layers . See figure 2. • Mental health First there are the close family relations such • Environment as children’s relations with adults, the social • Nutrition network and support from friends and neigh- • Physical activity bours and the community. • Injury prevention On the next layer come the lifestyle factors • Substance use/misuse (tobacco such as eating habits, physical activity, sleeping and alcohol) habits, alcohol and tobacco use. • Use of medication and associated There are also the material and social con- problems ditions in which people live and work. These • Preventive health services are determined by housing, education, social services, traffic, work environment, health care and others.

2. Background document to WHO Strategy paper for Europe “Policies and strategies to promote social equity in health” by Dahlgren and Whitehead (1991). healthy ageing | introduction 23 etc. e

Health services l

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n l ductio Literature Review on Healthy Ageing. The ageing population is a heterogeneous group on depend people older for determinants Health of group larger the within group age smaller the differ of fifty-year-olds The needs people. older 100. aged people of those from greatly e to 12, Preventive health services, are based on literature on the respective topics. For search inclusion criteria etc. see Appendix 5, strategy, food pro-

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e S G Tobacco t Housing - Un- employment Work environmen Health determinants. As As already pointed out, the major topics in Figure 2. also affects the social determinants. One per haps becomes more aware of nutrition when one is physically active; and the risk of injury may decrease when physical activity is com bined with good nutrition. in health, gender and minorities. They should be be should They minorities. and gender health, in determinants. health key as considered teract. For example physical activity is often hence and people other with together practised The cross-cutting themes considered by the pro the by considered themes cross-cutting The i determinants, socioeconomic are ject 24

Figure 3. Major topics for the Healthy Ageing project. ILLUSTRATION: NINNI OLJEMARK.

At any time point, a person aged 50 has been ence, social responsibility and responsibility for brought up and has lived differently from a family. The third age is the part of the pension- person aged 75 or 100, and they have reached er’s life which consists of work-free fi nancial very different phases of life. security without too many limitations due to Phases in life have been described in different illness and disability. The fourth age has limits ways, for example Laslett’s “four ages” (38). due to illness and disability and people become The second age consists of work, independ- dependent on other people again. healthy ageing | introduction 25 - - - With With better evidence, prevention could be cutting benefits. Itprovides a background and is a good basis for the Healthy Ageing project with its recommendations for the promotion of older people’s health at local, national and EU levels. It also discusses the potential promoting older for people’s health, focusing on recommendations for policy action, evidence- based health promotion and structural oppor people. tunities for health promotion for older more effective and life could be improved for the general population as well as for the more vulnerable older groups. A basis for the Healthy Ageing project “Proven Strategies to Improve Older People’s Euro the for Report Age a Eurolink is Health” recommends report The (42). Commission pean cross the highlights and approach integrated an

- - - - To give an example: men in many of the old To Eastern and Central European contexts also According to a report from the SwedishreporttheNa fromAccording a to Demands for health promotion differ greatly greatly differ promotion health for Demands EU Member States have a significantly higher life expectancy at ages 50 and 65 than men of States Member new the of many in age same the (see Appendix 1). Living conditions also differ European the in areas rural and urban between countries (41). many older people are poor. They face other kinds of problem than people in the Western EU countries, such as inadequate health and social services. access to heterosexual people is one of the reasons for these inequalities in health (40). people and the rest of the population between LGBT differ: older people’s circumstances are more difficult in many new Member States, where women between the ages of 45 and 64 report impaired mental well-being, compared to 16 per cent of women of the same age in the rest of the population. The authors of the report suggest that social discrimination against non- tional Institute of Public Health, a significantly a Health, Public of Institute tional larger proportion of bisexual lesbian, and gay, poorer in are people) (LGBT people transgender health than the rest of the population. Mental health in particular is significantly worse. As bisexual and lesbian of cent per 55 example an to consider include disability (39) and sexual The identity. link between sexual identity and health, for instance, is a subject that needs fur ther examination. generations of today tend to longer in expect better health than their parents’ gen to live eration did. in different groups, depending on gender, so factors Other ethnicity. and status cioeconomic The circumstances of a person aged 60 today differ from those of 20 years ago. The ageing 26 The Healthy Ageing project Aims Age group 50 and over The aim of the project is to promote To promote health and prevent diseases it healthy ageing in later life stages (people is important to start early in people’s lives. aged 50 plus). The project will focus on The Healthy Ageing project has defined the different aspects of health and promote age groups considered for the project as healthy ageing through the development those aged 50 years and older. It is based of an integrated and holistic approach to on WHO’s definition of people aged 50+ health in later life. The main aims are: as the target group when discussing older people. The EU uses the same age limit in • to review and analyse existing data on order to include older workers’ health and health and older people at both EU and health and safety policies at workplaces, Member State level and produce and which are also objectives for WHO. Howe- disseminate a report, ver, there are many different definitions in • to make recommendations for policy at the European countries. both EU and Member State level based on current evidence and practice for pro- Work outline for the project moting the health of older people while To achieve the aims, the project has re taking cultural differences into account, viewed and compiled: and • health data • literature on interventions • to disseminate the findings by develo- • examples of good practice ping a comprehensive strategy . • policies and strategies

Finally recommendations are suggested based on the findings of the Healthy Age- ing project.

3. A comprehensive strategy is a strategy that covers many sectors. healthy ageing | introduction 27 -

healthy aging: A nursing and community Inc.; 1993. perspective. St. Louis: Mosby, Wheeler J, Raphael D, Brown I, Bryant T, Herman R, Houston J, et al. How government policy decisions affect seniors’ quality of life: findings from a participatory policy study Canada. Can J Public carried out in Toronto, Health 2001;92:190-5. to health orientation. The Aging Male to health orientation. The Aging Male 2000;3(4):171-6. of outcomes Disability J. Guralnik M, Salive public for implications their and disease chronic eds. T, Prohaska M, Speers T, Hickey In: health. Johns MD: Baltimore, Aging. and Health Public 87–106. p. 1997. Press; University Hopkins Burden of disease network project. Disability and in Old Age. Final Report, Conclusions Recommendations. Jyväskylä: Jyväskylä University Press; 2004. among Nagi SZ. An epidemiology of disability adults in the United States. Milbank Mem Fund Q Health Soc 1976;54(4):439–67. LM, Jette AM. The disablement Verbrugge process. Soc Sci Med 1994;38(1):1–14. Rautio N, Heikkinen E, Ebrahim S. Socio- economic position and its relationship to phys ical capacity among elderly people living in Jyvaskyla, Finland: five- and ten-year follow- up studies. Soc Sci Med 2005;60(11):2405-16. Promoting Beckingham AC, DuGas BW. crucial distinctions. Gerontologist 1988;28 crucial distinctions. Suppl:10-7. adaptedness. Theor Med Pörn I. Health and 1993;14(4):295–303. and physical activity Heikkinen E. Disability models and approaches. in late life – research Aging and Physical European Review of Activity 2006;3:3–9. Heikkinen E. A Paradigm shift from disease Collopy BJ. Autonomy in long term care: some Collopy BJ. Autonomy 20. 14. 15. 16. 17. 18. 19. 11. 12. 13. 10. - - -

- - ces n e r e The functional competency of elderly at risk. Gerontologist 1988;28(3 Suppl):53-8. Family caregiving, autonomous and Cicirelli V. paternalistic decision making. Newbury Park, CA: Sage Publications Inc.; 1992. – Promoting economic and social progress in an ageing world; A contribution of the Euro Assembly pean Commission to the 2nd World on Ageing. COM(2002) 143 Final. Brussels: European Commission; 2002. Stanley B, Stanley M, Guido J, Garvin L. policy framework. Report No: WHO/NMH/ NPH/02.8 (http://whqlibdoc.who.int/hq/2002/ World WHO_NMH_NPH_02.8.pdf). Geneva: Health Organisation; 2002. Communication from the European Com Ageing response to World mission – Europe’s health to the economy in the European Union. health to the economy in the European Luxembourg: Office for Official Publications of the European Communities; 2005. Health Organization. Active ageing: a World Nicholaas G. Health Expectancy and its Uses. Nicholaas G. Health Expectancy and its London: HMSO; 1995. Health Organization, ed. Ottawa Char World ter for Health Promotion. Ottawa, Ontario, Canada; November 17–21, 1986 (http://www. who.int/hpr/NPH/docs/ottawa_charter_hp.pdf). of European Commission. The contribution sion – The demographic future of Europe – from from – Europe of future demographic The – sion 571 COM(2006) opportunity. to challenge 2006. Commission; European Brussels: final. K, Bone M, Bebbington A, Jagger C, Morgan tions. 2006. Retrieved 2006-05-03 from tions. 2006. Retrieved http://epp.eurostat.cec.eu.int/portal/page?_ pageid=1996,39140985&_dad=portal&_ schema=PORTAL&screen=detailref&product= Yearlies_new_population&language=en&root =/C/C1/C11/caa11024. Commis European the from Communication f 9. 8. 7. 6. 4. 5. 3. 2. 1. EUROPA – Eurostat: Population projec – Eurostat: Population 1. EUROPA Re 21. Callahan D. Setting limits : medical goals in an 33. Wait S. Age discrimination. UK: Alliance for 28 aging society. New York: Simon and Schuster; Health and the future; 2005. 1987. 34. Review of statistics for the OMC on health 22. Barnes D, Almasy N. Refugees´ percep- and long-term care, discussion paper for the tions of healthy behaviors. J Immigr Health ISG meeting. 12 October 2005: EC; 2005. 2005;7:185–93. 35. Stegeman I, Costongs C. Promoting social 23. Field D. A cross-cultural perspective on exclusion and tackling health inequalities in continuity and change in social relations in old Europe – an overview of good practices from age: Introduction to a special issue. Int J Aging the health field. EuroHealthNet; December Hum Dev 1999;48:257-61. 2004. 24. Katzke M, Steverink N, Dittmann-Kohli F, 36. Report on equality between women and men. Herrera R. The self-concept of elderly: a cross- Luxembourg: European Commission; 2005. cultural comparison. Int J Aging Hum Dev 37. Quality of Life and Management of Living 1998;46:171–87. Resources Key Action 6: The ageing popula- 25. Kickbusch I, ed. In: Proceedings of the 1st tion and disabilities. In: MERI-Mapping exist- World Ageing & Generations Congress 2005.; ing research and identifying knowledge gaps St. Gallen, Switzerland; 2005. concerning the situation of older women in 26. Moberg D. Research in spirituality, religion and Europe. Contract No. QLK6-CT-2002-30372. aging. J Geronto Soc Work 2005;45:11-40. Frankfurt am Main: ISIS – Institut für Soziale Infrastruktur and European Commission; 27. Uotinen V. Age identification: a comparison 2004. p. 76. between Finnish and North-American culture. Int J Aging Hum Dev 1998;46:109-24. 38. Laslett P. A fresh map of life : the emergence of the third age. London: Weidenfeld and 28. Whitehead M. The concepts and principles Nicolson; 1989. of equity and health. Copenhagen: Regional Office of Europe World Health Organization; 39. Ageing and Disability, ed. Disabled people 1990. are ageing – ageing people are becoming disabled. Graz (AT), South Conference Center 29. Herten LM, Perenboom RJM. Gezonde – Messecenter Graz; June 8–9, 2006 (http:// levensverwachting naar sociaal-economische www.ageing-and-disability.com/aad/index. status (Healthy life expectancy by socio-eco- php?seitenId=14&lang=en). nomic status). Leiden: TNO PG; 2003. 40. Roth N, Nykvist K, Boström G. [Health on 30. Mackenbach JP. Health Inequalities: Europe in Equal Terms? Health and Life Conditions Profile. Rotterdam, Netherlands: Department Among LGBT-people] Hälsa på lika villkor? of Public Health, University Medical Center Hälsa och livsvillkor bland hbt-personer. Rotterdam; 2006. Stockholm: Swedish National Institute of 31. Huisman M, Kunst AE, Mackenbach JP. Socio- Public Health, 2006:8; 2006. economic inequalities in morbidity among the 41. Lowe P, Speakman L. The ageing countryside: elderly; a European overview. Soc Sci Med the growing older population of rural England. 2003;57(5):861-73. London: Age Concern England; 2006. 32. European Commission. The health status of 42. Drury E, Walters R. Proven strategies to im- the European Union: narrowing the health gap. prove older people’s health. London: Eurolink Luxembourg: Office for Official Publications Age; 1999. of the European Communities; 2003. healthy ageing | statistics 29 C H A P T E R 2 people and health Statistics on older 30 healthy ageing | statistics 31

ge n to e cha

c i du ges aph n r e g ll mo The demographic effect of the post-war baby baby post-war the of effect demographic The e emographic change ha is is expected to grow just slightly before starting until to drop in 2025 2030. This trend is even greater when only the total working-age considered. is years) (15–64 population C D In Europe, the present 25 EU countries have 18.2 million inhabitants aged 80+, which is 4 per cent of the total population. In 2014 the corresponding number will be 24.1 (5.2 per cent) (3). About one-third of Europe’s million population will be aged 60 or over in aged those in increase 2025, rapid particularly a with 80 years and older (9). The number of older people aged 65–79 has increased significantly since 2000 and will do so until around 2050 (see figur 4). boom will start to decrease around 2030 and is to expected not disappear earlier than in the of middle the (10). The century EU population d ------

his chapter maps statistical data on health the and social circumstances of older The Healthy Ageing project has gathered The statistics presented in this chapter re people and health. plicants or associated countries. information on official statistical sources con For countries. EU in living people older cerning further information on statistical sources, see older on sources statistical Official 6 Appendix upwards (50+). Most of the comparable data stem from available statistics from and Eurostat the WHO. It has not been possible to find other statistics that cover all the 32 countries in Europe that are either Member States, ap from a sample of official sources on interna tional and European levels. In addition to us ing official sources of statistics, we also point project. out other data of relevance to this late to data on people of age groups from fifty T people living in the EU countries. The meth odology is descriptive, with the main purpose of presenting statistical data and related data Statistics on older people and health 100% 32 80+ 65–79 80% 50–64 25–49 15–24 60% 0–14

40%

20%

0% 1950 1975 2000 2025 2050

Figure 4. Population distribution in EU25 by age group (1950–2050). Source: Green paper – Confronting demographic change: a new solidarity between the generations (11).

Europe has the world’s highest proportion of Migration older women. Today there are approximately In 2004, the European Union registered 1.8 three women for every two men between the million immigrants. Significant net immigra- ages of 65 and 79, with over twice as many tion into Europe will continue for the next 15 women over the age of 80 (12). to 20 years. Eurostat’s projection is that around Ageing could cause a fall in potential annual 40 million people will emigrate to the EU be- growth in GDP in Europe by 2040 (11). The tween now and 2050. As many of them are of statistics show that countries with high GDPs working age, migrants tend to bring down the (rich countries) usually also have long life ex- average age of the population. However, the pectancy. Denmark and Ireland (both males longer-term repercussions remain uncertain, and females) and males in Finland and Belgium as they depend on the more or less restrictive are exceptions. Poland has a higher ranking in nature of family reunification policies and on life expectancy than their ranking in GDP per migrants’ birth patterns. Despite the current inhabitant. flows, immigration can only partially compensate for the effects of low fertility and extended Oldest and youngest populations life expectancy on the age distribution of the Sweden has the oldest population in Europe European population (13). in percentage of people 80 years and above, followed by Italy. Turkey has the youngest population, followed by Romania. Italy has the highest percentage of people aged 65 and over, while Albania has the lowest. healthy ageing | statistics 33 (11). generations

1960 2002 Change 1960–2002 1960 2002 Change 1960–2002

the

UK UK

SE SE

between FI

SK SK

SI SI

PT PT

solidarit PL

AT AT

new

NL a

MT MT

HU HU

LU change

LT LT

LV LV

CY CY

IT Males IT

Females

IE demographic

FR FR

ES ES

GR GR

EE EE

onfronting

DE DE

– C

DK DK

Life Expectancy at the age of 60 (1960–2002).

BE paper BE

EU-15 EU-15

reen EU-25 EU-25 : G 5 0 5 0 ource 10 25 20 15 30 Country codes are listed at the end of this chapter, see page 56. Country codes are listed at the end of this chapter, Figures 5 and 6. S 10 25 20 15 30 Average life expectancy Average life expectancy at birth is calculated 34 Important gains in life expectancy4 in the Euro- to increase by 1.1–2.7 years for males between pean Union have been realised between 1960 and 2004 and 2014. For females it is estimated to 2002, with the exception of men in the Baltic increase within the interval of 1.4–1.9 years States. For the future, demographers estimate during the same period. that the difference in life expectancy between men and women will narrow and that life ex- Healthy life expectancy at 60 years pectancy of men in the Baltic States will within Healthy life expectancy (HALE) is based on life a few decades improve towards the EU average. expectancy but includes an adjustment for time The increase in life expectancy is the result of spent in poor health. It is most easily under- drops in the mortality of all age groups and is stood as the equivalent number of years in full not limited to the very old. health that a person who has reached 60 years According to the figures above, between can expect to live based on current rates of ill 1960 and 2002 life expectancy at age 60 in- health and mortality (8). creased almost everywhere, except for men in The differences between the European coun- Latvia and Slovakia. The differences at the age tries in relation to healthy life expectancy are of 60 are smaller than at birth, for both gen- similar to those regarding life expectancy, but ders. It is also clear that during this period the there are some exceptions. Females in Spain gender gap in life expectancy has further in- and Switzerland live in good health longer than creased. Nevertheless the new baseline projec- anticipated from their life expectancy. Females tion assumes that this gap, measured in terms in France and Switzerland have the longest of life expectancy at birth, will start to shrink HALEs. The shortest HALEs for females are from 6.3 years in 2002 to 5.2 in 2050 (11). in Turkey. Iceland, Switzerland (14) and Sweden have For males, Iceland has the best situation the longest life expectancy at birth5 (80.2–80.6 followed by Sweden and Switzerland, but the years). Turkey has the shortest (68.7 years), difference is smaller than the difference in life followed by Estonia and Romania (71.2 years). expectancy. Sweden shows the best HALE The pattern of high life expectancy in EU 15, situation for males. The poorest situation is in especially women in France, and lower life ex- Latvia, followed by Estonia. (For more infor- pectancy in the new Member States is the same mation about the HALE method and figures as above at 50, 60 and 80 years (for more in- on healthy life expectancy in EU/EFTA/EEA formation on life expectancy in EU/EFTA/EEA countries, see Appendix 3.) countries, see Appendix 1).

4. Average years an individual can expect to live if the current mortality rates persist. 5. The average years a newborn infant can expect to live divided by the mortality in the infant’s birth cohort. healthy ageing | statistics 35 - - -

Males Females Total nion U Other , around , 40 around per cent have some diseases . 6 diseases Digestive 1970–2001 (17) as less than ‘good’, and 10 per cent rate it ‘poor’ ‘poor’ it rate cent per 10 and ‘good’, than less as and diseases chronic Self-reported poor’. ‘very or were more both than very common: symptoms two thirds having at least one chronic disease diagnosed during their lifetimes; and around 40 per cent reported two or more diagnosed chronic diseases. Similar numbers at least reported one, two or at disease more chronic current no symptoms. reported one-third Around Health among older people The prevalence of physical health among older problems people is high. According to the Eu in Retirement and Ageing Health, of Survey rope (SHARE) prob health to due limitation activity of degree lems, and almost 50 per cent report that they have some Around health problems. long-term health their rate 40 per of cent the respondents in the European ata - causes External 2002 – D health

diseases Respiratory data y

e . K es in s Malignant neoplasms tu statistics a

t ountri s c

ealth diseases h Deaths by selected cause and by sex, 1998, EU15. Deaths by selected cause and by sex, U Circulatory : H lt E SHARE has collected data on the individual life circumstances of about 22,000 persons aged 50 and over in 11 Euro SHARE has collected data on the individual life circumstances of about pean countries from Scandinavia to the Mediterranean. The EQLS also showed that age plays a key ea he 0% ource 40% 6. 20% 10% 30% 50% Figure 7. S EU15 for at least another two decades. EU15 for at least another two decades. role in e.g. long-standing illness or in disability. over or 65 aged people the of half than More illness long-standing a reported CC3 and EU10 except in Cyprus and Malta (15). or disability, ity of Life Survey (EQLS), shows that health status in EU10 and CC3 is generally poorer than in EU15 (15). Although older health status people’s and longevity in EU10 and CC3 probably will status health their improving, are not reach the level of that of older people in A comparison between the 15 States EU(EU 15) States Member new ten the and Member countries candidate three the as well as (EU10) Qual European the on based data using (CC3), H t all, or no symptoms at all. The most commonly Health and inequality 36 reported chronic diseases were arthritis, diabetes and heart disease; many respondents also re- Regarding self-reported morbidity, inequalities ported hypertension and high cholesterol, which persist into old age. After the age of 60, relative are important risk factors for heart disease and and absolute inequalities in, for example, self- other cardiovascular problems. The most com- assessed health, limitations in daily activities monly reported symptoms were pain, sleeping and long-term disabilities by income level and problems and swollen legs (16). level of education tend to decrease. However, The principal causes of death in the EU are they remain substantial until at least the sev- circulatory diseases and malignant neoplasms, enties for all health indicators, income-related together accounting for two-thirds of all deaths, health inequalities, socioeconomic position among both genders. Within the group of circu- and level of education (21). latory diseases, ischaemic heart disease (IHD) accounts for one in six of all deaths, and cere Inequalities between age-groups brovascular disease for about one in ten (17). While those of ‘productive age’ (25–64) enjoy relative financial security, children (under 16), Fewer working people youths (16–24), and the elderly (65+) are at to support more older people particular risk of poverty. The risk-of-poverty- The population of Europe is ageing because of rate7 in 1995 was considerably higher for these increasing life expectancy and a declining fertility groups than for the wider EU15 population rate. There will be fewer people of working age (37, 28 and 16 per cent higher respectively). to support those in retirement (18). The number The relationship between age and ‘risk of pov- of working-age people per pensioner will nearly erty’ extends to long-term poverty. According halve by the year 2050, from 3.5 to 1.8 at EU to the report “Social Exclusion and Unemploy- level (10). In other words, in 2050 there will be ment in the European Union”, the age groups two persons of 15–64 years per one person of under 24 and over 65 show an above-average 65+, compared to four at present (19). risk of persistent poverty.8 This overall trend Together with the declining birth rate of the is largely mirrored nationally, although the past 20 years, there will be a problem in re- degree to which these groups are likely to be cruiting qualified workers, and more workers disadvantaged varies noticeably from country will leave working life than will enter it (20). to country (22). The continuing growth in the number of work- Poverty has a negative impact on health and ers over 60 will not stop until around 2030, life expectancy. Lower-class people in the Unit- when the baby-boomer generation will become ed Kingdom, at the age of 65, have a lower life “elderly” (11). expectancy, by 2–2.6 years (women/men), than

7. EUROSTAT estimates a risk-of-poverty rate: the share of persons with an equivalised disposable income below the risk-of-poverty threshold, which is set at 60 per cent of the national median equvalised disposable income (after social transfers). This share is calculated before social transfers (original income including pensions but excluding all other social transfers) and after social transfers (total income). 8. The share of persons with an income below the risk-of-poverty threshold in the current year and in at least two of the preceding three years. healthy ageing | statistics 37 - - - Iceland Iceland has the rate highest employment for etirement and pre-retirement Retirement and average exit and age between average differ Retirement the age European exit average countries. highest the had Among Kingdom United males, by followed the years), (64.2 market labour the from (63.7 and years) Portugal (63.5 Sweden years). Among females, Romania reported the highest by Norway followed and (62.9 years), Ireland, Sweden (all at 62.8 years). factor for most people. The employment rate is is rate employment The people. most for factor also important regarding future income from pensions and the pension burden of generations, depending coming on a pension country’s system. Between 1997 and 2002 the employ ment rate increase for older workers was very similar to the increase in the overall rate, but in 2002 alone the rate for older workers went up by a significant5.4 per cent, leading to an increase in the overall rate of 1.3 percentage genders. both for points males and 50–64 years old females (93 and 82 countries. European the of respectively) cent, per The lowest employment rate among males is in Poland (47.2 per cent). The lowest rate for is years aged 50–64 in per (17.2 Malta females cent). For more information on employment rates among people aged 50–64 years 4. in Appendix EU/ see countries, EFTA/EEA Retirement at different ages differing differing sample sizes, which makes compari The sons difficult. data andpresented statistics below therefore lack many aspects of compa The statistical rability. sources of this data are taken from studies from various countries or different and projects research EU-related from databases. R risk health a as regarded often is Unemployment ------

g rnin cs i ce p on c

cs jor to ti a s m ti a In northern Europe, poor older people liv Inequalities in mortality persist into the he countries) countries) have been scanned for age-related statistics for the major topics of the project. Very few countries have this kind of statistics at present. The available data are from differ ent years, with different age groups and with St (30 Europe in Offices Statistical Central the All both in general and among older people. northern-central In Italy, the most economically single-person in live people older disadvantaged households (mainly women) and/or aged cou ples, while in southern Italy poor older people live in larger households (23). ing alone are concentrated in large cities. On the contrary, in the Scandinavian people in countries these circumstances live mostly the countryside. Southern in Europe shows a dif ferent geographical composition of poverty, oldest-old.Ingeneral, inequalities inmortality are smaller among women than among men. While the rate ratios among men decline rap idlyhigherat ages, theynotsoso,dododoor much less, among women. highestage-groupsbecomesmallertotend but at higher ages. On the other hand, relative in equalitiesincreaseconsistently advancingwith age and reach their highest values among the tries, similar gradients can be discerned. Poverty Poverty discerned. be can gradients similar tries, aggravates disease and disabilities among old people. The manifestations of disabilities and activi life in everyday of the loss independence ties are “crucial turning points”. The loss of a (23). importance considerable of also is partner their coevals in the upper social classes. As far as as far As classes. social upper the in coevals their coun other in possible are analyses comparable t The lowest average exit age among males was dicate that people over 55 years of age think 38 reported in Belgium with 58.6 years, followed about their own situation and its implications by Austria with 59.4 years and France with for their future more and more actively (24). 59.7 years. There are many reasons for older workers The Slovak Republic had the lowest average to leave their jobs. About one-third of inactive exit rate for females at 55.9 years, followed by people aged 55–64 report their main reason Poland at 56.4 years and Bulgaria at 57.5 years. for leaving their last job as normal retirement, One-fourth of Finnish men and one-third of but more than 20 per cent indicate early retire- Finnish women often think about retiring be- ment as the main reason, (around three million fore retirement age for medical reasons. About persons per year). Another important reason to 30 per cent of men and women continue to leave a job is long-term illness or disability. The work without thinking about retiring. Statis- standardised prevalence rate of work-related tics show that the deterioration of health and health problems increases with age (24). work ability particularly increases thoughts about retirement. Even though these statistics Pensions systems do not show the effects of economic factors, Pension systems contribute to around 60 per work-life quality issues or, for example, the cent of the total net income of older people. situation of the spouse or other close ones on Other incomes include other social transfers, thoughts of retirement, they nevertheless in- income from property and income from work

Figure 8. Main reasons for leaving last job or business for older workers aged 55–64 in the EU15 (per cent of all reasons given). Source: Towards a longer work-life, ageing and the quality of work-life in the European Union (24).

40%

30%

20%

10%

0% Normal Early Own illness Dismissed Other retirement retirement or disability or made reasons redundant healthy ageing | statistics 39 - - rotection P Other incomes Social transfers other than pensions Pensions ocial

S EU-13

UK volution P

. A (10) uture

F NL he In In most countries pensions systems are de

ensions – T

signed to replace earnings from work in exchange exchange in work from earnings replace to signed awarding than rather contributions, lifelong for to allbenefits on people older the ofbasis resi dence. Women’s entitlements are significantly lower than men’s due to their smaller labour- some countries However, participation. market pension awarding by systems their adapting are dependent children, of care of periods for rights (25). people disabled or people elderly L GDP, GDP, goes to old-age and survivors’ benefits. The main source of pension income is public pension schemes, and most expenditure old age for and survivors comes out of statutory pension schemes. It is financed out of social insurance contributions and general taxation. As older people are the largest beneficiaries of health and long-term care, they are the people who are most dependent on social protection systems (10).

P I - - -

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S F and

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% % % % Nearly 45 per cent of total social protection Despite this success, there are still cases 0% ource 40 20 80 60 from Figure 9. S spending in the EU15, or around 12 per cent of cent per 12 around or EU15, the in spending older women, who constitute two-thirds pensionersabove the age of 75. In some coun of olderamonghigher still are ratespoverty tries, people than in the total population, although the difference has narrowed (10). descendants or means-tested social assistance benefits. in which pension systems fail to provide ad equate minimum resources, especially for ful in meeting their social objectives and have them allowing independent, people older made to enjoy a prolonged period of their leisure working lives. The risk of after poverty in old age has also been greatly reduced, as has the number of people who have to rely on their (10). Over the past success remarkably been have systems pension few decades, Europe’s 120% 100% 80% 40 Women 70% Men

60%

50% Lisbon target for 55–64 aged workers employment rate in 2010 40%

30%

20%

10%

0% FI IT IE SI LT EL LV PL CZ CY EE SE ES PT SK AT FR LU NL BE DE DK UK HU MT EU-25 Figure 10. Employment rates (women and men aged 55–64 in EU Member States – 2004. Source: Report on equality between women and men (25).

Social capital groups. By contrast, in France and Belgium, Social capital is a community resource based on older age groups are better represented. In Den- individuals’ shared values, attitudes, behaviour mark and Sweden the older age groups are not and commitment to the community (26). Being only represented in organisations to the same a member of an organisation, active in a po- extent as younger ones, but the total member- litical party or charitable organisation, having ship of organisations is significantly higher than trust in others and voting in elections can be in the other European countries surveyed. regarded as promoting social capital and the Political activity (measured as having at- social cohesion of a society while strengthening tended a trade union, political party or politi- a person’s sense of belonging and well-being. cal action group meeting, or having attended a Providing help and being engaged in politi- protest or demonstration, signed a petition, or cal or charitable organisations and performing contacted a politician or public official over the voluntary work strengthens civil society struc- past year) is also unequally distributed. Such in- tures and is often regarded as promoting social volvement is most prevalent in the EU15, where capital and the social cohesion of a society. For 17 per cent of the population is active in one the individual, such commitment stabilises so- way or another. The relevant share of the popu- cial networks and is likely to promote a sense lation is lower in the EU10 (12 per cent) and of belonging and subjective well-being (27). even lower in the CC3 (9 per cent). Among the Membership of political or charity organisa- EU15, political involvement is most widespread tions among older people varies in the European in Sweden and Denmark. Latvia and Malta are countries. In Austria, Germany, Italy, Ireland the EU10 countries where political engagement and Portugal younger age groups are better rep- is most common. This pattern goes through all resented in organisations than are the older age age groups, although it is clear that the older age healthy ageing | statistics 41

geing project

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9 , 2006). ife ife L L AT AT Activity in a political or charitable organisation in 1999, percentage of individuals. Activity in a political or charitable organisation in 1999, percentage Social participation: membership of an organisation 1998, percentage of individuals. organisation 1998, percentage Social participation: membership of an ur une ur (J : E : E , 2006). EurLife is an interactive database on living conditions and quality of life in Europe. It offers data drawn from the EurLife is an interactive database on living conditions and quality of surveys conducted by the European Foundation for the Improvement of Working and Living Conditions and from other for the Improvement of Working and Living Conditions and from other surveys conducted by the European Foundation well-being of European published sources. The data provided deals with the objective living conditions and subjective Romania and Turkey. citizens. It covers the 25 current EU Member States and three candidate countries: Bulgaria, The European Community Household Panel. European value studies. une 0% ource 0% 5% ource (J Figure 12. S 40% 30% 20% 10% 60% 50% 80% 70% 9. 10. 11. project 20% 15% 10% 35% 30% 25% Figure 11. S Mean on a scale of 1 to 10 42 7 30–44 6 45–64 65+ 5

0 AT CZ FI IT NL PT UK

Figure 13. Trust in people 2003. Mean value on a scale of 1, ’You can’t be too careful in dealing with people’, to 10, ’Most people can be trusted’. Source: EurLife by ESS12 2002 and EQLS13 2003. Data processed by Hans ten Berg, Healthy Ageing project (June, 2006).

100% 30–44 45–64 80% 65+

60%

40%

20%

0 AT CZ FI IT NL PT SE UK CC-13 EU-15

Figure 14. Percentage of people aged 18 over who in 2003 voted in the last national election, percentage of electorate. Source: EurLife by EQLS. Data processed by Hans ten Berg, Healthy Ageing project (June, 2006).

12. European social survey. 13. European quality of life survey. healthy ageing | statistics 43

------Studies based on anxiety disorders diag In the ESEMeD, Italy remains the only are un-weighted (31). nosed according to current criteria common. are Estimates less of prevalence recentEuropean studies vary from 2 to 10 per in more cent. The ESEMeD study found that lifetime prevalence of any anxiety disorders in people per8.7 from ranged years cent65 over Ger in many to 15.9 per cent in France (31). The prevalence of depression in old age hasbeen widely studied across Europe. Defined in recentclassificatory systems, depressionmajor seems to be a relatively rare older disease among people. But when appear symptoms these considered, are all dromes depressive syn common among older people. The prevalence of depressive syndromes ascertained by cat egorical diagnosis varies between 7.9 per cent studiesthese ofmajority the cent, per 26.9 and giving results between 9 per cent and 15 per cent (31). country where mental the health older group’s pop general the of those than lower are scores ulation between 25–64 years old. The remain mental better have Spain, except countries, ing health for older people. The interaction is very significant. For major depression, prevalence ranged from 6.4 per cent in Germany to 16.1 per cent in France. These results should be in terpreted cautiously since the data presented lenges lenges when interpreting differences. There is no consensus in the literature about whether the prevalence of depression increases or de creases with age. This is partly because many people where institutionalised excluded studies on studies Regional predominate. oldest-old the differ seem to methodological reflect dementia differences. real than rather ences Depression and psychological distress ------Differing Differing definitions of mental health, and These results are in line with recentresearchwithline in resultsareThese The The EU15 population is the most trusting, ental health “The state of mental health in the European Un European the in health mental of state “The ion” – the Eurobarometer and the “European Disorders/ Mental of Epidemiology the of Study Mental Health Disability: a European Assess ment” (ESEMeD). Although both surveys are EU-designed, they pose methodological chal major concern (30). concern major com to difficult it make surveys, different many States. Member the between health mental pare report the in used are surveys EU-designed Two The ageing The of in ageing during the Europe population the coming decades will have many social ef amplified be will care health on effect The fects. de in dementia, increase by a disproportionate substance Increased illness. mental and pression abuse disorders and delirium will also be of The experience of hardship obviously leads to scepticism, suspicion, insecurities and a more self-centred attitude. M living conditions, success and, above all, so cietal conditions are decisive social trust (28). in With few exceptions, people generating with low income and especially those who are unemployed, in almost all the countries, port lower re levels of trust in other people (29). more more widespread in the EU15, where people are on average more affluentand less affected (27). disadvantages severe by on this subject, emphasising that individual whereas trust whereas is less in the EU10 and lowest in as the is trust a CC3. Social understood collec as a good social and powerful as tive property, an indicator of social capital. The trustworthi ness or the degree of trust within a society is groups are not as active in political or charitable charitable or political in active as not are groups (27). groups age younger as organisations Environment Exposure to particle matter14 (PM) in ambient 44 Air pollution is an environmental factor that air has been linked to various health outcomes greatly affects health in Europe and is respon- involving the cardiovascular respiratory sys- sible for the largest burden of environment- tems. The most severe effects in terms of overall related disease. Recent estimates indicate that health burden include a significant reduction in 20 million Europeans suffer from respiratory the life expectancy of the average population problems every day. The majority of them are by a year or more, and this is linked to long- children, older people or people with asthmatic term exposure to PM (33). Larger estimates of problems, people with cardiovascular diseases the effects of particles on mortality are found and the socioeconomically deprived (32). in warmer cities.15 It is generally accepted that

Figure 15. Loss in average statistical life expectancy attributable to the identified anthropogenic contributions to PM2.5 (fine fraction of particle matter) (in months) in Europe for emissions in 2000, the CLE scenario for 2020 and the MFR scenario for 2020 (calculated for 1997 meteorological conditions). Source: Health risks of particulate matter from long-range transboundary air pollution. European Centre for Environment and Health, WHO Europe 2005 (33).

Months 16 2000 14 MFR 2020 CLE 2020 12

0 Italy Spain Malta Latvia France Ireland Greece Poland Austria Finland Estonia Sweden Belgium Slovakia Hungary Slovenia Portugal Germany Denmark Lithuania Total EU-25 Netherlands Luxembourg Total EU-15 Total non-EU Czech Republic United Kingdom

14. Particle matter is an air pollutant consisting of a mixture of solid and liquid particles suspended in the air. These par ticles differ in their physical properties such as size and chemical composition. PM can either be directly emitted into the air (primary PM) or formed secondarily in the atmosphere from gaseous precursors. 15. 0.8 per cent versus 0.3 per cent increase in mortality per 10-_g/m3 change in PM10. healthy ageing | statistics 45 , - - - - 18 , ES 16 . 20 , , there are four different module on health status, ETS status, health on module Eurodiet and OMC 17 19 All these data are available, in some cases favour of the north, physical functioning in of favour fa functioning the physical north, vour of the The south). improvement observed the in pronounced more was status functional in (34). north the in than Europe of south also by age group, from the ECHI EU-HIS list TAT, WHO-HFA Physical activity and nutrition According to health: benefit which activity physical of aspects total amount regulates weight; short, intense activity induces fitness and being; moderate influencesexercise reduces morbidity by well- 30–50 per cent; and One fracture. of chance the weight-bearing and loss bone limits activity per walking day to appears be sufficient hour’s (35). demineralisation bone down slow to social functioning and self-perceived health and and health self-perceived and functioning social healthy of a combination particular, In lifestyle. Consid risk. mortality decreased factors lifestyle function and mortality of terms in gains erable ing could be therefore if achieved older people changed their lifestyle in a healthy way (34). The project also observed regional differences of of the south in favour (generally in nutrition pattern) clear (no health self-perceived Europe), and functioning (psychological functioning in - - - - The ECHI (European Community Health Indicators) project was carried out under the Health Monitoring Programme The ECHI (European Community Health Indicators) project was carried arranged according to a conceptual view on health and health determinants. Database, an outcome from a project of the European Health Interview & Health Examination Surveys (HIS/HES) health monitoring programme (1997–2002). Scheme (EU ETS). European Union Greenhouse Gas Emission Trading World Health Organization – Health for All database. Care, Discussion paper for the ISG meeting on 12 October Review of Statistics for the OMC on Health and Long-Term 2005, European Commission, 2005. and the Community Public Health Programme 2003–2008. The result is a list of ‘indicators’ for the public health field and the Community Public Health Programme 2003–2008. The result is a list of ‘indicators’ In total, the Healthy Life Expectancy (HALE) (HALE) Expectancy Life Healthy the total, In Figure 15 compares the national estimates of estimates national the compares 15 Figure ifestyle factors 16. mortality. The project mortality. also found relationships between cognitive physical, and psychological, cereals, fruits and vegetables), physical activity cereals, fruits and vegetables), physical (time spent, energy expenditure) and environ food etc.) air, ment (housing, water, project showed that a healthy ers lifestyle low the risk of all-causes and cause-specific gender), alcohol (alcohol-related deaths, total alcohol consumption, heavy drinking among adults etc.), nutrition and malnutrition (body mass index, overweight people by age group, of amount average calories, of number average MFR scenario (33). L There are today different ways of measuring aspects of life-style such as smoking ing-related deaths, regular smokers by age and (smok effects of PM reduced to the maximum feasi ble reduction (MFR). For most countries, the reduction expected under current legislation amounts to about half the difference between current effects and those persisting under the evidence that the effects are greater among the elderly (33). loss in life expectancy in the 25 EU countries for the year 2000 and predictions under for the 2020 current legislation (CLE), with the air pollution causes larger effects in members of sensitive population sub-groups. There is 17. 18. 19. 20. Both women and men tend to become progres- (36). Another study, from Sweden, shows that 46 sively less active as they get older. By late life, the level of vigorous activity decreases with only a small minority are active enough to ben- increasing age, while moderate activity and efit their health and well-being. A Norwegian walking increase with age (37). survey shows that 6 per cent of elderly men A person with a BMI21 between 25 and 30 is and women (65 years +) are physically active considered to be overweight and a person with at the level recommended (30 minutes or more a BMI of 30 or more is considered as obese. of at least moderate-intensity physical activity Overweight and obesity are regarded as the or- on most, preferably all, days of the week) (68). igin of serious public health problems because The prevalence rates are related to sociodemo- they increase the risk of premature death and graphic factors. The oldest-old (> 80 years), disability; but this issue is still controversial. those who have an illness and use medication, Obesity and overweight are associated with bad and individuals with lower levels of education dietary habits and a lack of physical activity and income are the least active segments of (38). BMI generally increases with age, peaking the population. Interestingly, small gender dif- in the middle-aged and in older age, who are ferences in the level of activity were obtained at greatest risk of health complications. The

Figure 16. Age- and gender-specific mortality rates for falls in the WHO European region, 2002. Source: Injuries and violence in Europe: why they matter and what can be done, WHO (40).

Deaths per 100,000 population 160 Males 140 Females 120

100

0 0–4 5–14 15–29 30–44 45–59 60–69 70–79 ≥80

21. Body mass index (BMI) or Quetelet Index is a statistical measure of the weight of a person scaled according to height. BMI is defined as the individual’s body weight divided by the square of the height, and is almost always expressed in the unit kg/m2, which is therefore often left out. BMI value can be calculated as: BMI= Weight (kg)/height x height (mxm). healthy ageing | statistics 47 -

Females Males etwork N 160 uropean E within 140 120

People aged 65 years of age and over are more more are over and age of years 65 aged People 100 severe severe because of and and osteoporosis frailty, once injured they are more to susceptible fatal complications and longer ill-health because of their diminished recovery Falls capacity. are a particular problem, and older people who ex perience them, as well as other injuries, have mortality. greater and stays hospital longer Non-fatal injuries account for more than 6.7 million hospitalisations in EU25 (1,500 life of years million 3.9 while people), 100,000 per (YLL) are lost due to injuries. injuries Finally, are the second cause of years of potential life and the EU25. lost in both the EU15 likely to be injured because of various medical problems and impairments of vision, gait and balance; their injuries are more likely to be 01/07/04 – 01/07/05 eport - - 80 R 60 mplementation I 40 y (EUNESE) echnical 20 T lderl E nterim Deaths per 100 000 population I 0 s y k e a n d m among Age-adjusted mortality due to fall injuries/100,000 people among elderly (65+ years) by gender in people among Age-adjusted mortality due to fall injuries/100,000 EU y Italy irst Spai Latvia France Irelan Greec : F Poland Austria Finland Estonia Sweden Belgium Slovakia Hungar Slovenia Portugal Germany Danmar Lithuani afet S Netherland ource njury prevention Czech Republic for Each year about 235,000 citizens of the Eu ropean Union lose their lives due to injuries. the EU-25, excluding countries with <1,000,000 inhabitants. the EU-25, excluding countries with <1,000,000 S I Figure 17. proportions are respectively 25.0 per cent and 8.8 per cent. Greece is the country where the proportion of overweight men and women of men for cent per 60 (almost highest the is 65–74 (38). women) for cent per 53 than more and of 65–74 years old are less overweight or obese obese or overweight less are old years 65–74 of than any citizens of the same age group from other European countries. Thus, 33.7 per cent of Norwegian men of this age group are over the women, For obese. are cent per 4.9 weight, increase corresponds to higher levels of free sugars and saturated fats in the diet combined Norwegians (39). activity physical reduced with United Kingdo Although people over 60 years of age make up Regarding data on the European Union, other 48 18.6 per cent of the population, they account important databases are provided by different for 28.2 per cent of injury deaths. The ageing injury surveillance systems in some EU count population of Europe implies that the injury ries, and at EU level there is the European problem is likely to increase (40). Home and Leisure Accidents Surveillance Sys- The injury mortality rate (age-standardised) tem (EHLASS), recently re-named the Injury in EU15 is about 39 deaths per 100,000 peo- Database (IDB). ple, while in EU25 it is about 45 deaths per 100,000 people. Nevertheless, the European Suicide Union, either as EU15 or as EU25 seems to be Suicide is still usually higher at ages over, one of the world’s safest regions. rather than under, 65years (exceptions include The country with the lowest injury mortality men in Ireland, and women in Ireland and is Spain. The three countries with the highest Luxembourg). Under the age of 65, the lowest injury mortality from falls are Hungary (which suicidal mortality cluster of countries includes may be partly explained by the high suicide Greece, Spain, Ireland, Italy, Portugal and the rates), the Czech Republic and Finland. United Kingdom and the highest includes Bel- The three leading causes of injury death in gium, Luxembourg and Finland. For males and older people in Europe are self-inflicted inju- females under or over the age of 65, the overall ries, falls and road traffic injuries (RTI) (40). EU trend is currently stable (41).

Figure 18. Standardised mortality rates for people over 65 by injury cause in the WHO European region, 2002. Source: Injuries and violence in Europe: why they matter and what can be done, WHO (40).

Deaths per 100,000 population 35

0 Road Falls Drowning Fire Poisoning Self- Inter- traﬃc inﬂicted personal injuries injuries violence healthy ageing | statistics 49 - -

Males Females , WHO (40). done

≥80 be

can

70–79 what

and Rates of suicide are higher in rural areas than than areas rural in higher are suicide of Rates

barbiturate barbiturate overdoses, jumping from a height and setting the to according varies firearms and the to determination succeed. Men tend to use (40). women than means violent more attempted it previously. Suicide may also be the be also may Suicide previously. it attempted espe illness, painful and severe of consequence increasingly become has person the when cially disabled. As many as one in four of those who attempt suicide have such an illness, particu larly older people. isolation social to due presumably areas, urban (46). Suicide rates increase during periods of economic recession and unemployment. The lethality and availability of the chosen suicide the The outcome. method influences of success pesticides, of ingestion hanging, as such methods 60–69 matter

- - - y the 45–59 y wh : 30–44 urope E in

15–29 violence

5–14 and

Age-and gender-specific mortality rates for suicide in the WHO European region, 2002. for suicide in the WHO Age-and gender-specific mortality rates 0–4 njuries : I Deaths per 100,000 population Deaths per 100,000 0 ource 40 Figure 19. S predictor: 10 per cent of those who attempt suicide will eventually do so fatally, although most people committing suicide have not (42, 43). Hopelessness can be associated with nine out of ten cases of suicide and alcohol (44). use Drugs also play an important part, a quarter of suicides involving alcohol abuse (45). A previous suicide attempt is also a good who commit suicide may have demonstrated factors: psychological following the of features major depression and mood disorders (12–15 per cent lifetime risk), schizophrenia person (10 and conduct per anxiety, risk), lifetime cent hopelessness and impulsiveness disorders, ality Risk factors for suicidal behaviour are numer ous, and interact. Apart from age and gender, biologi psychological, into divided be can they cal, social and environmental. Many people 20 10 50 30 60 Age-speciﬁc Mortality Rate per 10 000 50 50 1984 Latest 40 available year

0 ) UK (97) Italy (97) Spain (97) France (97) Ireland (98) Greece (97) Austria (98) Finland (97) Sweden (97) Belgium (95) Portugal (98 Germany (97) Denmark (96) Netherlands (97) Luxembourg (97)

Figure 20. Age-standardised suicide rates among 65-year-olds in the EU. Source: Final report of the European review of suicide and violence epidemiology (Eurosave) project (2002).

Substance use/misuse According to the Institute of European Food Tobacco Studies (IEFS) survey carried out in 1997 about Each year, half a million people in the EU die a third of European men in the EU15 and a from the effects of smoking, and half of these quarter of women were smokers. More than deaths occur in middle-aged or older people, a third of people aged 15 and over in Greece, ages between 35 and 69 – well below aver- Denmark, Italy and France smoked, while less age life expectancy. Deaths from smoking will than a quarter did so in Finland, Sweden and rise substantially over the coming decades as Portugal. changes in population structure and the delayed The European Commission’s own survey, impact of smoking on health come fully into ef- carried out in 1999, shows that in specific age fect. The highest percentage of smoking-related groups, the largest proportions of male smok- deaths is from cardiovascular disease. However, ers aged 55–64 were found in Spain (52 per lung cancer is the disease most strongly linked cent), and in Denmark aged 65 and over (39 to tobacco consumption, and death rates result- per cent). The smallest proportions of male ing from it are the best indicator of long-term smokers were found in Sweden in each age exposure (17). group from 15 to 64, and in Finland and then healthy ageing | statistics 51 41 43 43 46 41 34 45 37 33 35 28 19 23 35 39 37 32 33 33 29 31 UK 8 34 24 17 12 26 21 20 33 26 21 27 23 33 28 17 21 19 25 22 16 S 49 41 34 41 40 34 15 12 13 29 31 30 39 28 62 20 26 12 19 22 30 FIH : 8 6 44 46 24 14 20 16 25 66 27 55 39 55 30 29 11 20 28 33 P 47 42 43 47 45 26 11 17 39 50 63 50 57 51 21 36 35 18 26 30 38 A 45 34 42 34 20 11 15 29 32 39 26 33 39 36 37 36 23 32 37 27 31 NL . 22 7 44 14 45 43 42 34 34 19 39 33 38 25 36 30 33 35 38 39 29 50 L 24 34 45 14 24 34 10 15 23 29 38 22 30 33 33 20 32 35 35 20 27 I 1970–2001 34 41 48 32 13 21 27 30 37 35 55 38 23 31 36 27 31 38 27 32 32 IBL ata 5 43 34 46 49 41 22 12 53 53 56 51 52 50 31 36 22 28 25 38 53 F 2002 – D 8 5

47 49 54 46 43 46 45 46 49 28 37 52 29 18 11 50 38 65 21 E health

7 48 74 42 45 47 43 45 64 16 31 36 20 53 59 58 83 36 60 58 32 EL on

8 43 41 34 45 34 40 41 34 45 45 45 49 35 17 26 27 15 37 37 27 data D y e . K 44 44 41 34 43 40 48 49 29 35 39 36 38 35 32 55 32 38 21 35 33 DK 8 44 47 42 40 48 49 40 48 46 23 32 32 17 27 38 28 37 53 38 55 B statistics

34 40 46 45 41 46 42 43 40 41 28 16 20 27 25 10 28 37 35 38 38 EU- 15 Smokers, by age and sex, 1999. Smokers, by age and ealth : H Based on 1,000 individuals by country, distributed by age and sex, the Eurobarometer data are not considered to be distributed by Based on 1,000 individuals by country, exact and should be interpreted cautiously. emales emales emales emales emales emales emales otal Do you smoke? ource All 15–24 Males T Males F All F All 65+ Males F F All 55–64 Males 35–44 Males F All 45–54 Males 25–34 Males F All F All 22. Figure 21. S Figure 22. Total alcohol consumption (litres 100%/year) by gender and age. 52 Source: Alcohol in Post-war Europe. Consumption, drinking patterns, consequences and policy responses in 15 European countries (47).

Men Women Study countries Age-groups Total Index Total Index Ratio men/ consumption Total=100 consumption Total=100 women

Finland 18–29 8.2 117 2.9 121 2.8 30–49 6.2 89 2.2 32 28 50–64 6.8 97 2.4 100 2.8 Total 7.0 100 2.4 100 2.9

France 18–29 6.1 81 1.8 82 3.4 30–49 8.0 107 2.4 109 3.3 50–64 8.6 115 2.4 109 3.6 Total 7.5 100 2.2 100 3.4

Germany 18–29 4.3 81 3.2 133 1.3 30–49 6.1 115 2.2 92 2.8 50–64 5.2 98 2.1 88 2.5 Total 5.3 100 2.4 100 2.2

Italy 18–29 6.4 90 2.5 71 2.6 30–49 7.0 99 3.8 109 1.8 50–64 7.7 108 3.8 109 2.0 Total 7.1 100 3.5 100 2.0

Sweden 18–29 7.5 142 1.9 112 3.9 30–49 4.7 89 1.6 94 2.9 50–64 3.8 72 1.6 94 2.4 Total 5.3 100 1.7 100 3.1

UK 18–29 16.0 122 7.9 155 2.0 30–49 11.1 85 5.0 98 2.2 50–64 13.2 101 3.1 61 4.3 Total 13.1 100 5.1 100 2.6 healthy ageing | statistics 53 The The prevalence of inappropriate medication There are no reliable, comparable Europe- Potentially inappropriate medication use are not available. use varied substantially among countries. In the Czech Republic 41 per cent of home-care elderly patients were prescribed at least one large proportion of health care spending;is rising faster it than expenditure on any other area of health care (49). an-level statistics on the relationship between age and use of medicines. Statistics from the Swedish Pharmaceutical Association the distribution of prescribed show pharmaceutical expenditure by age group. people Clearly, use more prescribed medication at higher ages, a several in similar probably is that circumstance countries. among older people is a though common European problem, studies on the subject rare. Fiavolá are D et. al. (50) conducted a retrospective cross-sectional study of 2,707 elderly European eight in care home receiving patients ex- available all compared study The countries. plicit criteria for inappropriate medication use evaluation comprehensive most the generate to of this issue in cEurope, criteria where specifi high proportions of the regular given drinker, that in this age group 28 per cent of men and 55 per cent of women consume less than one are non-drinkers (48). drink per week or use of medication Many studies show that older people are the largest per capita users of medications associated with both physical and mental ability. Pharmaceutical expenditure accounts for a , 23 of regular consumption i.e. around 1 in in 1 around i.e. consumption regular of 24 units a day and 14 units a week for women. A unit equals 10 ml of pure alcohol: the amount the body can safely get units a day and 14 units a week for women. A unit equals 10 ml of pure alcohol: the amount rid of in an hour. summed across all alcoholic beverages. The The 1994 General Household Survey found There is great variety among the age groups limits’ relatively are These women. 14 in 1 and men 6 drinking occasions and the volume per occasion consumption is calculated as the product of the frequency of Total 23. a day and 21 units in one week for men and 2–3 Sensible limits of alcohol consumption should not exceed 3–4 units 24. groups. In Germany, the youngest group stands group youngest the Germany, In groups. out with a lower gender ratio (47). that 17 per cent ‘sensible of the exceeded over and men 65 aged women and 7 per cent of men consume 2–3 times more women alcohol do. In than the UK, it appears that gender differences are most pronounced among the oldest group, whereas the opposite seems to France, and Finland In Sweden. for case the be age three all between similar very are ratios the in Finland, Sweden and the UK the youngest group reports the highest consumption Germany France, in both while women, and men for consumption and peaks Italy, in the middle or oldest age group (except for German females). The table also shows that, in all age groups, due to the fact that smokers die earlier than non-smokers. Alcohol consumption total c gender-specifi of terms In est prevalence is among the age groups 45–64 years, though in develop- some, the to due prevalence 15–24-year-olds, the among is higher ment of the smoking epidemic. The prevalence regarding smoking is also lower at higher ages aged 35 The and smallest over. proportions of female smokers were found in Spain, aged 55 and over along with France, aged 65 and over (17). high- the countries most In smoking. regarding in Sweden aged 65 and The over. largest proportions of female smokers were in Denmark Number of prescription items per inhabitant 54 90 Females 80 Males 70

0 0–4 5–9 90+ 40–44 45–49 10–14 20–24 30–34 50–54 60–64 70–74 80–84 15–19 25–29 35–39 55–59 65–69 75–79 85–89

Figure 23. Relationship between age and use of medicines reflected in number of prescription items per inhabitant – Sweden 2000. Source: EURO-MED-STAT – Library of European Union Pharmaceutical Indicators: Expenditure and Utilisation Indicators. Final version, March 2004 (49).

inappropriate medication compared with only ing and will hopefully lead in the long run to 16 per cent in Western Europe. Among the even more effective policy-making. This is one Western European countries, Finland and Italy reason why the European Commission has de- had a higher prevalence of potentially inappro- veloped a statistical technique, Response Con- priate medication use. The differences between version (RC), with strategies and harmonisa- countries probably reflect country-specific drug tion methodologies, to improve comparability. policies, care provision differences, inequalities Another solution to the problem of the lack of in socioeconomic background, differences in comparable data may be the consistent effort overall health conditions, and specific regula- taken by the European Union and the Member tory measures. States to further develop appropriate health monitoring. Commonly agreed methods, surveys and monitoring programmes with indica- Forthcoming tors should help Member States reach common European statistics socioeconomic and public health goals. With an ageing Europe it is important to im- The European Community Health Indicators prove and strengthen the knowledge about (ECHI) project was carried out in the framework health promotion concerning older people. of the Health Monitoring Programme and the Comparable data plays an important role re- Community Public Health Programme between garding increased knowledge of healthy age- 2003 and 2008. The result is a list of ‘indica- healthy ageing | statistics 55

- - - - Another Another important contribution to more important issue for the European Union and its Member States is the emphasis on health promotion for the European region’s ageing population so that the region can continue to flourish, withstand global competition and be a good society for all. also be a valuable tool for decision-makers and and decision-makers for tool valuable a be also effects the monitoring when stakeholders other policies. health of Healthy the is monitoring health comprehensive Ageing Sub-Network of the WHO Health European Network’s The Network. Cities Healthy fordevelop tools health are important profiles of and monitoring ment progress ac planning, should They health. community for countability and and provide should be readable, accessible old on information qualitative and quantitative This circumstances. living and health people’s er consists cities for Sub-Network guidance initial of a 75 proposing template grouped indicators sections: three into 1) population profile 2) health and social care systems 3) social picture Along with joint efforts to create ate structures for appropri health monitoring, the most as as well as several organisations and agencies. The project is bysupported financially the DG ”Public Health and Consumer Protection” of the European Commission. The main task is the preparation and publication of a ”Global Report on the Health Status in the European Union” that will cover at least years. the It intends to past provide a ten coherent picture of and population European the of health the of should It determinants. and time-trends related ------, with the EU-SILC is the percent the is EU-SILC the with , 25 Review of statistics for the OMC on Health and Long-Term Care, Discussion paper for the ISG meeting on 12 October Review of statistics for the OMC on Health and Long-Term 2005, European Commission, 2005. The EUGLOREH Project started in 2005 and and 2005 in started Project EUGLOREH The The European Community Household Panel Household Community The European The “Open Method of Coordination” 25. data sources, see Appendix 6). Appendix see sources, data will be in completed 2008. Its members are 25 EU Member States plus Iceland and Norway, health health and the quality the of health. However, specific circumstances of people aged 50+ are not yet being studied in these fields, although this will probably be possible in a future EU- SILC (for more information on the European age age of households risking poverty due to care nat circumstances these people older For costs. urally remain of great importance, influencing inequality in health, using commonly agreed in agreed commonly using health, in inequality studied, be to indicator important One dicators. etc region by ditions (EU-SILC). This continuous survey cov survey continuous This (EU-SILC). ditions for conditions living and income on statistics ers coun in European of household types different countries European the EU-SILC, the With tries. and social exclusion intend to address poverty, on so far. They follow developments regarding on so far. second A care. elderly and health pensions, e.g. cycle (2004–2006) is in progress. (ECHP) was in 2005 replaced with a new in Con Living and on Income Statistics strument, element in the method is to establish quantita benchmarks and indicators qualitative and tive tailored to the needs of Member best comparing of means a as involved, States sectors and decided been have indicators Eighteen practices. nants of health and health interventions. interventions. health and health of nants Coun European the by introduced was (OMC) cil in Lisbon in March 2000. It was designed to help Member States progress jointly in the reach the Lisbon goals. One reforms needed to tors’ of public health covering demographic and and demographic covering health public of tors’ socioeconomic factors, health status, determi Country codes References 56 EU25 1. EUROPA – Eurostat: Total employment AT Austria rate of older workers. 2006. Retrieved B or BE belgium 2006-05-03 from http://epp.eurostat.cec. CZ Czech Republic eu.int/portal/page?_pageid=1996,39140985&_ CY Cyprus dad=portal&_schema=PORTAL&screen= DK denmark detailref&product=Yearlies_new_population& EE Estonia language=en&root=/C/C4/C41/em014. FI or FIN finland 2. EUROPA – Eurostat: Relative median F or FR france income ratio for persons aged 65 years and D or DE Germany over. 2006. Retrieved 2006-05-03 from EL Greece HU Hungary http://epp.eurostat.cec.eu.int/portal/page?_ IE or IRE ireland pageid=1996,39140985&_dad=portal&_sche IS iceland ma=PORTAL&screen=detailref&product=SDI I or IT italy _MAIN&language=en&root=/sdi/sdi_as/sdi LV latvia _as_pen/sdi_as1100. LT lithuania 3. EUROPA – Eurostat: Population projec- LU or L luxembourg tions. 2006. Retrieved 2006-05-03 from MT malta http://epp.eurostat.cec.eu.int/portal/page?_ NL netherlands NO norway pageid=1996,39140985&_dad=portal&_ PL Poland schema=PORTAL&screen=detailref&product= PT Portugal Yearlies_new_population&language=en&root SK Slovakia =/C/C1/C11/caa11024. SI Slovenia 4. EUROPA – Eurostat: People by age ES Spain classes. 2006. Retrieved 2006-05-03 from SE Sweden http://epp.eurostat.cec.eu.int/portal/page?_ UK or Gb united Kingdom/Great Britain pageid=1996,39140985&_dad=portal&_ schema=PORTAL&screen=detailref&product= CC3 Yearlies_new_population&language=en&root BG bulgaria =/C/C1/C11/caa15632. RO romania 5. EUROPA – Eurostat: Gross domestic TR turkey product at market prices. 2006. Retrieved 2006-05-03 from http://epp.eurostat.cec. EU15 15 EU Member States (pre May 2004) eu.int/portal/page?_pageid=1996,39140985&_ EU25 EU Member States (post May 2004) dad=portal&_schema=PORTAL&screen= EU10 new Member States that joined the detailref&language=en&product=Yearlies EU in May 2004 _new_economy&root=Yearlies_new_economy/ B/B1/B11/daa10000. healthy ageing | statistics 57

Profile. Rotterdam, Netherlands: Department of Public Health, University Medical Center Rotterdam; 2006. M, Aaheim HA. Social Exclusion and Twena Unemployment in the European Union: Report 2005:01. Current and Future Trends. Oslo: Center for International Climate and Environmental Research; 2005. Europe: first results from the Survey of Health, Europe: first results from the Survey ageing and retirement in Europe. Mannheim: Mannheim Research Institute for the Econo mics of Aging (MEA); 2005. health. Eurostat. Health statistics : key data on Luxembourg: Office for Official Publications of the European Communities; 2002. of European Commission. The contribution Union. health to the economy in the European Luxembourg: Office for Official Publications of the European Communities; 2005. Social situation observatory demography monitor 2005. Contract reference No: VC/2004/0334. The Hague, Netherlands: and European Observatory on Demography the Social Situation; 2005. in an Boukal C, Meggeneder O. Healthy work ageing Europe: a European collection of measures for promoting the health of ageing employees at the workplace. Frankfurt am 2005. Main: Mabuse-Verlag; Health Inequalities: Europe in Mackenbach JP. development. OECD Factbook : economic, development. OECD social statistics. Paris: environmental and OECD; 2005. – First European Quality of life in Europe 2003. Dublin: European Quality of Life Survey Improvement of Living and Foundation for the Conditions; 2004. Working A, Mannheim Alcser KH, Börsch-Supan Aging Research Institute for the Economics of (MEA). Health, aging and retirement in Organisation for economic co-operation and Organisation for economic 22. 17. 18. 19. 20. 21. 15. 16. 14. -

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- mission – The demographic future of Europe COM(2006) – from challenge to opportunity. 571 final. Brussels: European Commission; 2006. Commission; 2005. Health. Wom European Institute of Women’s the health in Europe : facts figures across en’s European union. Dublin: European Institute Health; 2006. of Women’s Communication from the European Com tion from a Long-Term Point of View: Safe and Point of View: tion from a Long-Term Final. Sustainable Pensions. COM(2000) 622 Brussels: European Commission; 2000. Green Paper – Confronting demographic change: a new solidarity between the genera tions. COM(2005) 94. Brussels: European policy framework. Report No: WHO/NMH/ NPH/02.8 (http://whqlibdoc.who.int/hq/2002/ World WHO_NMH_NPH_02.8.pdf). Geneva: Health Organisation; 2002. Communication from the European Commis sion - The Future Evolution of Social Protec =SDI_MAIN&language=en&root=/sdi/sdi_as/ sdi_as_pen/sdi_as1110. The world health report: Changing history. Health Organization; 2004. Geneva: World Health Organization. Active ageing: a World erty rate for persons aged 65 years and erty rate for persons 2006. Retrieved 2006-05-03 from over. http://epp.eurostat.cec.eu.int/portal/page?_ pageid=1996,39140985&_dad=portal&_ schema=PORTAL&screen=detailref&product 2006-05-03 from http://epp.eurostat.cec. eu.int/portal/page?_pageid=1996,39140985&_ dad=portal&_schema=PORTAL&screen= detailref&language=en&product=Yearlies_ new_population&root=Yearlies_new_ population/C/C4/C41/em021. pov – Eurostat: At-risk-of EUROPA the labour force: total. 2006. Retrieved the labour force: total. EUROPA – Eurostat: Average exit age from exit – Eurostat: Average EUROPA 12. 13. 11. 10. 8. 9. 7. 6. 23. loegd, NRW. Report on Socio-Economic 33. Health risks of particulate matter from long- 58 Differences in Health Indicators in Europe: range transboundary air pollution. European Health inequalities in Europe and the situation Centre for Environment and Health, WHO of disadvantaged groups. Bielefeld: Institute of Europe; 2005. Public Health; 2003. 34. Bogers R, Tijhuis M, van Gelder B, Kromhout 24. Ilmarinen J. Towards a longer worklife – Age- D. Final report of the HALE Project, Healthy ing and the quality of worklife in the European Ageing: a Longitudinal study in Europe. Union. Helsinki: Finnish Institute of Occupa- Report 260853003. Bilthoven, Netherlands: tional Health, Ministry of Social Affairs and RIVM; 2005. Health; 2005. 35. Ferro Luzzi A, James WPT. European Diet 25. Report on equality between women and men. and Public Health: The Continuing Challenge Luxembourg: European Commission; 2005. – Working Party 1: Final Report. Eurodiet 26. Brehm J, Wendy R. Individual-level Evidence Reports:1: Eurodiet; 2000. for the Causes and Consequences of Social 36. Loland NW. Exercise, health, and aging. Capital. American Journal of Political Science J Aging Phys Act 2004;12(2):170–84. 1997;41(3):999–1023. 37. Hagstromer M, Bergman P, Bauman A, 27. Böhnke P, First European Quality of Life Sjostrom M. The international prevalence Survey: Life satisfaction, happiness and sense study (IPS): health enhancing physical activity of belonging. European Foundation for the Im- in Sweden. J Public Health 2006. provement of Living and Working Conditions. 38. European Communities. Health in Europe. Luxembourg: Office for Official Publications Data 1998 – 2003. 2005 edition. Luxembourg: in the European Communities; 2005. Office for Official publications of the European 28. Delhey J, Newton K. Who Trusts? The Origins Communities. of Social Trust in Seven Societies. European 39. Strong K, Bonita R. The SuRF Report 1. Sur- Societies 2003;5(2). veillance of risk factors related to noncommu- 29. Nauenburg R. Euromodule – Towards a Euro- nicable diseases: Current status of global data. pean Welfare Survey. Social Science Research Geneva: World Health Organization; 2003. Centre Berlin (WZB), Research Unit Social 40. Sethi D, World Health Organization. Regional Structure and Social Reporting, Volumes Euro- Office for Europe. Injuries and violence in module data tables; 2004. Europe: why they matter and what can be 30. Draper B. What is the effectiveness of old-age done. Copenhagen: Regional Office for Europe mental health services?: Health Evidence Net- World Health Organization; 2006. work; 2004. 41. European Commission. The health status of 31. The State of Mental Health in the European the European Union: narrowing the health gap. Union. European Communities; 2004. Luxembourg: Office for Official Publications 32. Environment and health. Report No 10/2005. of the European Communities; 2003. Copenhagen: European Environment Agency; 42. Mackenbach JP, Bakker M. Reducing in 2005. equalities in health: a European perspective. London: Routledge; 2002. 43. Ehab E, Tuppo DO. Smoking and the Older Person. Clinical Geriatrics 2005;13(8). healthy ageing | statistics 59

Jama 2005;293(11):1348-58. March 2004. E, Gambassi G, Finne- Fialova D, Topinkova Carpenter I, et al. Soveri H, Jonsson PV, Potentially inappropriate medication use among elderly home care patients in Europe. Studies. Retrieved 9/4/2006 from http://www. ias.org.uk/resources/factsheets/elderly.pdf – The Library of European EURO-MED-STAT Union Pharmaceutical Indicators: Expenditure and Utilisation Indicators. Final version. consumption, drinking patterns, consequences consumption, drinking patterns, consequences and policy responses in 15 European countries. Health: Public of Institute National Stockholm: 2002. International; Almqvist & Wiksell Institute of Alcohol Alcohol and the elderly. Retrieved 09/12/2006 from http://corp.aadac. Retrieved 09/12/2006 com/alcohol/the_basics_about_alcohol/ alcohol_seniors.asp. Promoting Beckingham AC, DuGas BW. healthy aging: A nursing and community Inc.; 1993. perspective. St. Louis: Mosby, Alcohol in Postwar Europe: Norström T. Abuse and Alcoholism; 1988. Retrieved Abuse and Alcoholism; 09/12/2006 from http://pubs.niaaa.nih.gov/ publications/aa02.htm. of Alberta. An Agency of the Government The ABCs. Alberta Alcohol and Seniors: Commission; 2003. Alcohol and Drug Abuse Bethesda, MD: National Institute on Alcohol Bethesda, MD: National Alcohol Alert No. 2: Alcohol and Aging. Alcohol Alert No. 2: 50. 49. 48. 46. 47. 45. 44. 60 healthy ageing | introductionl 61 ajor topics M 62 Major Topics of the Healthy Ageing Project

Chapters 3 to 12 of the Report are each dedicated to one of the ten major topics that have been the focus of the project. The ten chosen topics interact with each other and with the cross-cutting themes: socioeconomic determinants, gender, minorities and inequalities in health.

Chapter 3. Retirement and pre-retirement

Chapter 4. Social capital

Chapter 5. Mental health

Chapter 6. Environment

Chapter 7. Nutrition

Chapter 8. Physical activity

Chapter 9. Injury prevention

Chapter 10. Substance use / misuse (tobacco and alcohol)

Chapter 11. Use of medication and associated problems

Chapter 12. Preventive health services healthy ageing | introductionl 63

C H A P T E R 3 etirement and pre-retirement R 64

The Healthy Ageing project suggests that policymakers, NGOs and practitioners consider the following priorities for action when working with older people:

Increase the participation of older workers and the quality of their working lives using new management concepts. Keep a balance between personal resources and work demands and do not tolerate age discrimination. Prevent illness in the workplace, promote healthy lifestyles and a supportive and stress- free transition from work to retirement. healthy ageing | retirement and pre-retirement 65 - - tenance tenance n

Proposed Proposed financial changes in the transfer

of of good health up to a higher age. This means to have will employees and employers both that take for responsibility the health of the ageing workforce. In most European countries work place health promotion has already provided system system can work only in the long term. This needs to approach with be addi supplemented the be to needs aim general The measures. tional of extension work ability and the mai

- - - nomic nomic o

etirement ing-age population and ing-age population the future shrink he he actual relationship between work socioec by and affected strongly is ageing k For search strategy, inclusion criteria etc. see inclusion criteria strategy, search For

ncreased participation R and pre-retirement tion tion and employment rates of older workers (2). in This attention has considerable received (3). documents policy EU and national recent is is because the early-retirement systems of the past twenty years were intended to create jobs for younger workers. Given the ageing of the wor is generally issue policy the current ing thereof, as formulated a need to increase the participa I of older workers needed how are to debating countries Many European finance their statutory pension systems. This Instead 35 of aged Instead those between and 45 years being in the as majority at in present, 25 years time the will be majority aged 60 between and preparing or retired either be will They years. 70 retirement. for developments developments and policies. The demographic for in are trends new Europe posing challenges ageing workers, for enterprises, for and schemes for the system as social security pension a whole (1). By 2030 there will have been a dra population. the of structure the in change matic Appendix 5, Literature Review on Healthy Ageing. Appendix 5, Literature T E As work ability is a balance between work and As work ability is a balance 66 personal resources, people search for such a balance between work and personal resources, people search for such through their entire working life. The balance can a balance through their entire differ in different phases of life. working life. The balance can differ in different phases of life. good examples. One is a recent collection of Finnish research shows that in 60 per measures presented by the European Network cent of people older than 45 years work abil- for Workplace Health Promotion (ENWHP) ity over the 11 years studied remained good for promoting the health of ageing employees or excellent. It decreased for 30 per cent and at the workplace (4). These measures and inter- increased for 10 per cent. ventions are also being increasingly evaluated An important element in practice is age man- (5), though at the time of writing reviews or agement. Age management means managing meta-analyses which will underpin the evidence both the staff’s work ability and the success of statements in this report are not yet available. the organisation or enterprise: it is the everyday management and organisation of work from Work ability – a holistic concept the viewpoint of the employees’ life courses and Finland is a leading country in the area of resources (5). work ability (6). A severe labour shortage has led to a new ‘work ability’ concept, a holistic General recommendations concept that the Finnish government has been Using data from a European study of work promoting since 1998 to keep older people in environment conditions in 1995 and 2000, the workplace and retain their knowledge and Ilmarinen (5) has formulated overall recom- experience. The concept is based on the balance mendations concerning workplaces, personal between a person’s resources and the demands resources and society. These recommendations of their work. A person’s resources consist of can be seen as an agenda for the kind of Eu- health and ability, education and competence, ropean-level intervention and policy measure and values and attitudes. Work covers the work we need. Along with these recommendations environment and the community, as well as the he argues for holistic development through a actual contents, requirements, and organisa- new type of co-operation between the parties tion of work. Management is also associated involved. with work. Ilmarinen’s recommendations for workplaces Work ability has been described as a concept concern the work environment, demands, with several levels. The basic level is health and tasks, supervision, hours and age discrimina- physical, psychological and social functional cation. Physical exposure (to heat, cold, noise pacity. The second level consists of professional etc.) must still be decreased for ageing em- knowledge and skills. The third level contains ployees, as should physical work demands. values, attitudes and motivation. The fourth The psychological work environment should level represents work and its related factors. be developed to achieve an inspiring and chal- healthy ageing | retirement and pre-retirement 67 ------and younger workers. Some Some workers. younger and differences are well docu based are many but mented differences differences between older on on stereotypes. The interac negative negative factors characterise tion tion between age, work and

ing ing attention. Both positive and

The most important condition for older In occupational health and workplace health health workplace and health In occupational Ageing involves many physical and mental ethods to prolong working life related related changes and the relationship between clear. not is demands job and changes these employees to work longer is good health. Ex amples here are: promotion of exercise an active lifestyle, healthy and food, limited use of alcohol, a non-smoking policy and measures to reduce work stress for older employees (4). of healthy lifestyle (and work) are needed. needed. are work) (and lifestyle healthy of older promotion, workers and the relationship increas receiving are ageing and work between (7). understood fully not and complex is health changes and there is huge variation between Some individuals. variance is deter genetically differences to attributed be can much but mined, Physical lifestyles. example for factors, social in strength declines with age and ageing can also for affect mental example work-related ability, information processing. However, people de velop coping strategies to compensate for age- M Fairly ‘traditional’ work-related and development career- measures can be taken. and During experience of results the years few next the task include These accumulated. be will practice adjustment and change, job rotation, perma nent education, adjustment of working hours, policy demotion and age more comprehensive ing workforce policies (1). However develop area new the from, examples good and in, ment ------between individuals. Ageing involves many and there is huge variation physical and mental changes physical and mental changes - The social recommendations are: altering Recommendations Recommendations concerning ageing work of working life; improvement of service systems systems service of improvement life; working of for ageing employees; securing the right to life- long learning; and developing working life in an age-positive direction as a common goal for people of all ages. ping management’s poor treatment of ageing people; reducing the costs of ageing in work ing life; developing new methods to working shorten hours and reduce workload; preparation better for retirement in the latter stages into account in working-life management; their management; working-life in account into work ability and well-being should be support ed by measures which are monitored; and cooperation between parties should be improved. stop reality; reflect to ageing towards attitudes be supported and developed multidimensionally; ageing employees should be more life-long learning opportunities; the basic offered values of ageing employees should be taken of illness on work should be reduced; remain ing work ability should be better used; the risk of occupational disease should be prevented; or reduced cantly signifi functional capacity should ers’ personal resources are broad. There is need a to step up health promotion and encour age people to take more responsibility for their lifestyles; the prevention of illness in occupa tional health needs more investment; the effect own work should be improved;vidual supervision goodand age management indi have to be developed; individual and flexible work ing hours are needed; and there has to be zero tolerance in age discrimination. lenging workplace in which new things can be learned; the scope for employees to plan their The need for a healthy lifestyle and a preven- References 68 tive approach is also important in view of the 1. Feinsod R. Business case for workers age 50+: relevant social and medical developments, such planning for tomorrow’s talent needs in today’s as obesity, that will affect the workplace. competitive environment: a report for AARP. Washington DC: AARP; 2005. Preparing for retirement 2. Peulet J. Ageing and work in Europe. European Very little research has focused on preparing for Foundation for the improvement of Living and retirement, the transition from work to retire- Working conditions. Dublin; 2004. ment. This concerns the individual and his/her 3. Organisation for Economic Co-operation and social environment and the process of adjust- Development. Ageing and employment poli- ment to retirement. Good-practice examples of cies. Paris: Organisation for Economic Co- pre-retirement interventions have been demon- operation and Development (OECD); 2006. strated. On general principles it can be argued 4. Boukal C, Meggeneder O. Healthy work in that these anticipatory social interventions an ageing Europe: a European collection of have positive effects, and an evaluation study in measures for promoting the health of ageing England concludes that they are likely to contri employees at the workplace. Frankfurt am bute to a sense of empowerment (8). However, Main: Mabuse-Verlag; 2005. current literature reports no evidence on what 5. Ilmarinen J. Towards a longer worklife – Age- policy and practice can be developed (9). ing and the quality of worklife in the European Union. Helsinki: Finnish Institute of Occupa- tional Health, Ministry of Social Affairs and Health; 2005. 6. Maltby T. Ageing and the transition to retirement : a comparative analysis of European welfare states. Aldershot: Ashgate; 2004. 7. Wegman DH, McGee J, Ebrary Inc. Health and safety needs of older workers. Washing- ton, D.C.: National Academies Press; 2004. 8. Secker J, Bowers H, Webb D, Llanes M. Theo- ries of change: what works in improving health in mid-life? Health Educ Res 2005;20(4):392– 401. 9. Lethbridge J. Pre-retirement Health Checks and Plans: A Literature Review. London: Health Development Agency; 2001. healthy ageing | introductionl 69 C H A P T E R 4 Social capital 70

The Healthy Ageing project suggests that policymakers, NGOs and practitioners consider the following priorities for action when working with older people:

Encourage the participation of older people in the community. Increase educational and social activity group interventions targeting older people to prevent loneliness and isolation. Provide opportunities for voluntary work by older volunteers. healthy ageing | social capital 71

, of social contacts, of social contacts is more strongly more is contacts social of quantity quality associated with subjective well-being than having contact with adult children associations between life satisfaction quality and of contact are stronger for contact with adult children than with friendship. quality of higher socioeconomic status, better social integration and well-being, subjective higher with higher associated competence are income is more strongly subjective well-being than is education, correlated with the associated with subjective well-being than the having contact with friends is more strongly • been discussed by Pinquart and Sorensen (4) and the main findings ofgiven below: their analysis are • • • •

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he concept of social capital has been de construct useful a as literature the in bated In relation to ageing, the influences of socio of influences the ageing, to relation In Policymakers should take note of those The findings in the “Effectiveness of interven The findings in the

Social capital education in schools (1). economic status, social network and compe tence on subjective well-being in later life have tion and better health. initiatives that successfully capital when they generate plan interventions to tackle social problems such as deteriorating standards of of social capital can increase the levels in other in levels the increase can capital social of aspects (1). For example, investment in educa tion and training might have the potential to improve communication skills, enhance self- confidence, improve job prospects people access and give to better housing, better nutri (1, 2). Social capital in the Putnam tradition falls within the boundaries of political science and economics but it has recently been associ ated with positive health outcomes and with aspect one in Investment (3). promotion health to be applied to the study of health and health- and health of study the to applied be to in described is capital Social behaviour. related democracy, local as such characteristics of terms citizenship, civic engagement, social cohesion, trust networks, community relationships, social of others in the community and social support Literature Review on Healthy Ageing. Literature Review on T E on assessments made tions” section are based search original papers. For by the authors of the 5, inclusion criteria etc. see Appendix strategy, • for older men, the relationship between socio- unmarried, with a mean age of 71. The major- 72 economic status and subjective well-being is ity of studies described volunteer programmes stronger than for older women, which used face-to-face help or direct help to • social network has a higher influence on the the client. subjective well-being of females, Twenty-nine studies reported outcomes for the older volunteers. Most older volunteers had • for older groups, the association between scored higher on quality of life measures than social network and subjective well-being is those in the control group. Those engaged in a greater; the same is true for happiness and direct helping role derived greater benefit than competence, those engaged in more indirect helping roles. • socioeconomic status is more important for There was also a greater effect from counselling- the subjective well-being of the young-old type volunteering than from other helping than for the old-old. roles such as mediation, advocacy or informal A correlation exists between low levels of social referral. Nine of every ten clients who received capital and mortality that is mediated by income counselling from older volunteers reported inequality. The latter is thought to damage experiencing more improvement on outcome social cohesion and integration; it also leads to measures such as diminished depression than lack of social support within the community, those who did not receive services from an characterised by social isolation, which in turn older volunteer. contributes to premature mortality (5). The authors conclude that the evidence suggests that interventions providing opportunities for older people to do voluntary work improve Effectiveness the quality of life of those who volunteer. Such of interventions interventions also reduce depression in older One meta-analysis, one systematic review and people who receive services including visits and a literature review are reported in this chapter peer counselling from an older volunteer. Face- on certain aspects of social capital relevant to to-face volunteer approaches had greater effect older people. The aspects include volunteer than indirect helping approaches. work, social support and social isolation and loneliness. Social support Greenwood et al. (7) reviewed observational Volunteer work studies with over 100 participants from the The meta-analysis by Wheeler et al. (6) investi general population to examine the role of gated and assessed the benefits of volunteer social support and life stress on coronary work for older volunteers as well as for the heart-disease mortality. Older male and fe- people they serve. Older people are referred to male participants up to the age of 97 were as ‘seniors’ or ‘elders’ in the paper. Thirty-seven included. Methods of assessing life stress and studies were identified, using a wide range of social support in the included studies varied. databases that were conducted in the US and Studies had assessed life stress and social sup- Canada. Most volunteers were white, female, port by means of objective measures (e.g. life healthy ageing | social capital 73

- - - - voluntaryworkundertaken olderby volun the effectiveness reducing of mortality from heart disease, social due to the inconsistency in support the measures used in in studies to define psychological factors (7). teers increases mental well-beingvolunteerthosewho improves and menthe among tal health of older people who receive the services (6), and educational and social activity group inter ventions that target specific groups can pre vent social isolation and loneliness among older people (8). • discussion groups for adult daughters who were who daughters adult for groups discussion primary as carers such input and therapeutic/educational a other involving types of mental- activity with people older for groups discussion health problems. Six of the eight interventions ineffective provided one-to-one social sup port, advice and information, or health-needs assessment. Summary of the findings There is evidence to suggest that: • • There is inconclusive evidence for: The findings indicate thateffective nine interventions of were the group ten with activities an educational or support input. Group groups support bereavement included activities for recently widowed led as older well as people, professionally-led counselling/ peer-

- - - This review found that both life stress and lack of that both life stress and This review found

social support had an influence on coronary heart diseases. had an influence on coronary social support This review found that both life stress and nterventions for preventing three three as “service and provision” one as “com interventions. development” munity ies ies published between 1970 and 2002 in any language were included. Most were conducted in the USA and Canada. Thirty studies were usinga identified wideand range of databases, 17 in included interventions these studies were categorised as “group”, ten as “one-to-one”, point out that international policy and national national and policy international that out point health strategies are increasingly recognising the of importance tackling social and isolation to loneliness well-being improve older people’s and of quality stud outcome life. Quantitative I social isolation and loneliness investi (8) al. et Cattan by review A systematic gated the effectiveness of interventions to health-promotion prevent social isolation and loneliness among older people. The authors compared with that of normal review people. The also highlights the measures inconsistency used in to definefactors in the studies included. the psychological and both had a stronger influence on coronary incidence initial on than mortality disease heart of clinical disease. The authors state that the lack of social support increases coronary heart disease mortality by up to four times when involving the individual’s to stress). emotive response lack of social support had an influence oncor onary heart diseases. However, lack of social support had a greater influence than life stress events scale) or subjective measures (e.g. measures References 74 1. Putnam RD. The Prosperous Community: Social Capital and Public Life. The American Prospect 1993;4(13). 2. Putnam RD. The Strange Disappearance of Civic America. The American Prospect 1996;7(24). 3. Gillies P. The effectiveness of alliances and partnerships for health promotion. Health Promotion International 1998;13:1-21. 4. Pinquart M, Sörensen S. How effective are psychotherapeutic and other psychosocial interventions with older adults? Journal of Mental Health and Aging 2001;7(2):207-43. 5. Cooper H, Arber S, Fee L, Ginn J. The influence of social support and social capital on health. London: Health Education Authority; 1999. 6. Wheeler JA, Gorey KM, Greenblatt B. The beneficial effects of volunteering for older volunteers and the people they serve: a meta- analysis. Int J Aging Hum Dev 1998;47(1): 69-79. 7. Greenwood DC, Muir KR, Packham CJ, Madeley RJ. Coronary heart disease: a review of the role of psychosocial stress and social support. J Public Health Med 1996;18(2): 221-31. 8. Cattan M, White M, Bond J, Learmonth A. Preventing social isolation and loneliness among older people: a systematic review of health promotion interventions. Ageing and Society 2005;25:41-67. healthy ageing | introductionl 75 C H A P T E R 5 ental health M 76

The Healthy Ageing project suggests that policymakers, NGOs and practitioners consider the following priorities for action when working with older people:

Address the wider determinants, such as social relationships, poverty, discrimination, that influence mental health and well- being in later life. Raise awareness of mental issues relevant to older people, such as depression and dementia. Increase the provision of psychotherapeutic and psychosocial interventions for older people. healthy ageing | mental health 77

- is . Age discrimination is the

Discrimination in later life. Participation in important for meaningful good mental health and well- activity being in later life. Older people want to say make contributions they to society, but they often face barriers to participation in public and private life. There is much we can do to ensure that we experienced prejudice of type common most people older and over, and 55 aged people by say that it has a mental negative health. Eliminating it effect would help to on their promote good mental health and well-being of loved ones, increasing depression and forget and depression increasing ones, loved of coping of range a used Interviewees (1). fulness strategies to stay active and engaged life. later in and functioning of levels high maintain to stay mentally healthy and fit as we grow older. Studies of older views people’s and experience (3) point to the importance of action on the following themes: 1. 2.

- - -

For search search For .

ental health ental health is a resource that enables us to grow and learn and experience life

Ageing Ageing is a normal, gradual process that is The stigma associated with mental health The findings in the “Effectiveness of interven The findings in the

sions of ageing (1). Subjective older people health rate (how their own health) declined only slightly in old age (2). people However, older have negative views of some related changes such as declining health, death ageing- detection, diagnosis, treatment, care and sup port to recovery or end-of-life care. people older with Interviews change. by marked show that most of them had positive impres problems is very powerful and must be taken into account when discussing mental health in mind in keep also must We life. later to relation the whole spectrum of mental health services, from promotion and prevention, through to M productively and fruitfully, and is able to make to able is and fruitfully, and productively a contribution to his Having enough things money, to do, places or to her community”. go, a comfortable place to live and people to turn to in times of trouble, all play a role in health. promoting and strengthening mental as enjoyable and fulfilling. TheWorld Health Organization (WHO) defines mentalas health “a state of well-being in vidual which realizes the indi his or her own cope with the normal stresses of life, can work abilities, can Literature Review on Healthy Ageing. Literature Review on M E on assessments made by tions” section are based papers the authors of the original 5, inclusion criteria etc. see Appendix strategy, The experiences of people growing older alcohol and substance misuse 78 with severe and enduring mental illnesses such disorders. Depression is the most common, affecting up to as schizophrenia are often neglected, and evidence one in seven people aged 65 and shows that they tend to have poor access to over. But dementia is perhaps social support and services. the most feared and the most researched. While the causes of 3. Strong personal relationships, for example depression are fairly well known, the with friends, family and pets, may provide causes of dementia and ways of preventing it crucial social support and also help to pre- are less understood (5). See also page 43. serve a sense of one’s social and familial role (1). Social isolation and loneliness are Those affected often neglected major risk factors for poor mental health. The experiences of people growing older with 4. Physical health. Older people consistently severe and enduring mental illnesses such as identify physical health as extremely impor- schizophrenia are often neglected, and evidence tant and inextricably linked to their mood shows that they tend to have poor access to and mental well-being. They emphasize the social support and services (5). Older people importance of physical activity and a good with alcohol and substance misuse disorders diet. Other evidence shows the mental health are also often neglected. More work is needed benefits of physical activity (4). to generate a balanced understanding of the full range of mental health conditions that may 5. Poverty is a clear risk factor for poor mental affect people in later life. health. Many older people have inadequate More attention needs to be paid to the views incomes, live in poor housing and are gener- and experiences of older people with mental- ally excluded from society. health problems, and carers. In 1989 Keller et More work is needed to strengthen the evidence al. identified the “lived experience” of people base for mental health promotion in later life who are growing old as a major gap in the (4) and to implement current knowledge and literature on ageing. Today, much of this gap findings. More work is also needed to change has been filled but another gap remains – the people’s perceptions. Mental health problems lived experience of older people with mental are not an inevitable part of the ageing process, health problems and their carers (5), and of mi- yet they are often treated that way by profes- nority groups within this population. Work is sionals and by older people themselves. Older also needed to ensure that the priority given to people may not draw attention to symptoms younger adults’ mental health needs is extend- of illness that they consider to be part of nor- ed to include older adults; only then will we be mal ageing (1). able to ensure that all older people are able to The mental health problems that may affect experience good mental health and well-being people in later life include depression, anxiety, in later life. dementia, schizophrenia, bipolar disorder and healthy ageing | mental health 79

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the studies. Fur the studies.

Therapists with advanced degrees and either and degrees advanced with Therapists In a systematic review and meta-analysis, Psychosocial and psychotherapeutic interven psychotherapeutic and Psychosocial with with nursing-home residents were associated with significantly greater improvement in self- reported psychological well-being community. the compared in interventions with professional experience or with those than effective more were experience, special geriatric train geriatric special no but degrees advanced ing, or those with no advanced degree. Prevention or reduction of depression Depression is often considered to be a major health issue for all population groups. How- ever there is a lack of focus on the prevention, depression of treatment non-drug and reduction people. older for particularly literature, the in Lawlor and Hopker (7) investigated the effec tiveness of exercise as an intervention in the management of depression for with above, and 18 aged people depression with nosed diag therapies, supportive interventions, psycho- educational interventions, activity promotion and cognitive training. improved significantly had people older in tions across well-being self-reported were associ interventions individual thermore, ated with significantly greater improvements in self-reported psychological well-being com pared with group interventions. Interventions

------ mental health and well-being in later life. Work is also needed to ensure that the priority ded to include older adults; only then will we be able to given to younger adults’ mental health needs is exten ensure that all older people are able to experience good

ess chological chological ntion y e n e rv e tiv scence, miscellaneous scence, miscellaneous i ec enhancing interventions and - The results of the analyses showed that re py had an above-average above-average an had py a trol and the behaviour cognitive r well-being well-being compared with remin treatments, psycho-educational interventions, Con training. cognitive and promotion activity impact on self-reported measures of ps ventions ventions in older adults significantlyimproved self-reported psychological well-being. There studies. all across participants 3,718 were laxation had greater impact than supportive psycho-educational psycho-educational treatments, activity treat Outcomes skills. cognitive in training and ments included depression, subjective well-being, life morale satisfaction, and The self-esteem. auth ors carried out meta-analyses and found that the psychosocial and psychotherapeutic inter comparing comparing an intervention group with a con trol group. The interventions evaluated were: cognitive behavioural therapy, reminiscence, psychodynamic approaches, relaxation, sup portive interventions, control enhancement, psychosocial interventions A systematic review by Pinquart and Sorensen (6) investigated the interventions psychosocial effectiveness other and of therapeutic psycho- targeting older adults with mental problems. This review identified 122 primary studies One meta-analysis, one systematic review with meta-analysis and two systematic reviews are reported in this chapter. Psychotherapeutic and Eff of int no upper age limit. Studies using any method of burden. Other outcome measures included care 80 depression diagnosis and/or covering all levels givers’ coping skills and social support. Car- of depression severity were eligible for inclu- egivers were predominantly spouses of people sion. Ten of the 14 studies included used the with dementia, female and aged 55 and above. Beck depression inventory. They found modest but significant benefits to Three studies included older people aged 60 caregivers, who reported reduction in psycho- and above. Two of the three were carried out logical distress, improvements in their own in the USA, the other in Canada. The interven- coping skills and knowledge and improvements tions lasted between six and 12 weeks. The in their relationship with the person they were three types of intervention covered were non- caring for. aerobic resistance training three times a week, Interventions were more likely to succeed walking near home with the experimenter three if they involved people with dementia and their times a week for 20–40 minutes and supervised families and were more intensive and modified to running twice a week. caregivers’ needs such as teaching Two of the three studies the caregiver skills. Successful found no statistically sig- Successful interventions interventions also included nificant difference in the also included practical support, practical support, structured effectiveness of the exer- individual counselling and structured individual counselling cise groups in comparison consistent, long-term, pro- with control groups and and consistent, long-term, fessional support. Brodaty standard treatments for de- professional support. et al. (8) suggest that care pression. One study found giver interventions can delay a statistically significant effect admission to a nursing home. between the exercise group (mean age 72.5; However, short-term educational programmes, walking near home) and the control group. single interviews, support groups alone and brief Lawlor and Hopker (7) reported that it was interventions that were not supplemented with not possible to determine from the available long-term contact were not effective. evidence the effectiveness of exercise in the Peacock and Forbes (9) conducted a sys- management of depression for all age groups. tematic review to investigate the effectiveness of interventions designed to enhance the well- Interventions for caregivers being of caregivers of older people with de- In a meta-analysis, Brodaty et al. (8) reviewed mentia living in the community. They reviewed 30 studies (34 interventions) excluding respite 36 studies categorised according to type of care, targeting caregivers of people with de- intervention: education, case management, mentia. Interventions included individual and psychotherapy and computer networking. The family counselling, support groups, education most commonly measured outcome was institu- and skills training. The primary outcome meas- tionalisation of the care recipient, followed by ures included psychological morbidity and death of the care recipient, perceived behaviour healthy ageing | mental health 81

- case management for caregivers increases the likelihood of using formal services such (9). as computer networking the effectiveness of exercise in the manage for all age groups (7). ment of depression • evidence for: There is inconclusive •

- - - - - givers' givers' e own own coping skills and relationship with the and (8), for caring are they person home residents (6), family and individual including interventions counselling, support groups, education and psy reducing in effective be can training skills psychotherapeutic and psychosocial inter ventions targeting older people significantly improve self-reported psychological well- being, specially when delivered to nursing- tion on dementia, were more effective than those that offered education alone. tutionalisation of the care recipient, tutionalisation of the use of computer networking improved decision-making confidence, education interventions that included train ing in coping skills, in addition to informa case management increased the likelihood of likelihood the increased management case using formal services, psychotherapy for caregivers delayed insti chological distress and improving car and improving distress chological • Summary of findings There is evidence to suggest that: • They suggest that when reliable resources are caregiving, of strain the with assist to available referring in invaluable be would managers case caregivers to these resources. Peacock and Forbes conclude that the use of computers for networking would particularly benefit caregivers living in rural communities. • • and use of formal services. and use of formal indicated that: Positive findings • disturbances in the care recipient, depression, caregiver caregiver strain, caregiver stress • References 8. Brodaty H, Green A, Koschera A. Meta-analysis 82 of psychosocial interventions for caregivers 1. Keller ML, Leventhal EA, Larson B. Aging: of people with dementia. J Am Geriatr Soc the lived experience. Int J Aging Hum Dev 2003;51(5):657-64. 1989;29(1):67-82. 9. Peacock SC, Forbes DA. Interventions for 2. Pinquart M. Correlates of subjective health in caregivers of persons with dementia: a system- older adults: a meta-analysis. Psychol Aging atic review. Can J Nurs Res 2003;35(4):88-107. 2001;16(3):414-26. 3. Third Sector First. Things to do, places to go – Promoting mental health and well being in later life. London: Age Concern and the Mental Health Foundation; 2005. Retrieved 20/11/2006 from http://www.mhilli.org/index. aspx?page=stage2promotion.htm 4. mentality. Literature & Policy Review for the Joint Inquiry into Mental Health and Well- being in Later Life. London: Age Concern England and the Mental Health Foundation; 2004. Retrieved 11/03/2006 from http:// www.mhilli.org/documents/Litandpolicyre- view-Fulltextofreport.pdf. 5. Godfrey M, Townsend J, Surr C, Boyle G, Brooker D. Literature and policy review on prevention and service provision: Mental health problems in later life. London: Age Concern and the Mental Health Foundation; 2005. Retrieved 20/11/2006 from http://www. mhilli.org/index.aspx?page=stage2services.htm 6. Pinquart M, Sörensen S. How effective are psychotherapeutic and other psychosocial interventions with older adults? Journal of Mental Health and Aging 2001;7(2):207-43. 7. Lawlor DA, Hopker SW. The effectiveness of exercise as an intervention in the management of depression: systematic review and meta- regression analysis of randomised controlled trials. BMJ 2001;322:763-7. healthy ageing | introductionl 83 C H A P T E R 6 Environment 84

The Healthy Ageing project suggests that policymakers, NGOs and practitioners consider the following priorities for action when working with older people:

Improve access to safe and stimulating indoor and outdoor environments for older people. Access to technology should be considered as well as the impact of climate change, excessive heat/cold and storms. healthy ageing | environment 85

- he technological environment for the older generation than for the younger. Technology may not be accessible, affordable or acceptable to older people (3). Climate changes Global climate change may have a widespread future, the in population older the on influence due to more episodes of extreme weather (4). dependent than others on they where to close recuperation having and recreation areas for live. Pleasant design of these areas is therefore of particular significance (2). T Developments in technology influence all pub lic domains and private life – and how older people can cope with Older people these need developments. encouragement and to time become accustomed to the world ever-changing of technology, “social functionality”. This challenge of adjustment is often greater

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oth indoor and outdoor affect the environments ability of an older person to

Accessible green areas and time spent out The naturally reduced mobility of older The findings in the “Effectiveness of interven The findings in the utdoor mobility

doors have been highlighted determinants of good health in as Sweden’s new important public-health policy. Older people with poor more are disabilities with persons and mobility transport “clearly demonstrate that the demonstrate “clearly transport decline entirely an not is life late in mobility outdoor in voluntary retreat from the being world. less or more are Instead, people it elderly that means and impairments health with cope to compelled (1). circumstances” external adverse they spend more time at home or doing out door activities. Many older people would like to be more mobile and active (1). public or private of lack the with together people out in this area. O Older people travel around in their local area no have they because people, younger than less need to travel in connection with work, and stay active, participate in and contribute the community. Environmental to improvements have a direct effect on the quality of life of an older person and also on his or her caregiver. However, more research needs to be carried B

Literature Review on Healthy Ageing. Literature Review on Environment E on assessments made by tions” section are based search papers. For the authors of the original 5, inclusion criteria etc. see Appendix strategy, With advancing age, the efficiency of the body’s fall. Some guidelines for the as- 86 heat-regulating mechanisms declines, placing sessment and emergency care of older people with hypothermia many older people at high risk of cold discomfort are given in this paper. and hypothermia, even in warm environments. A worldwide trend towards more hot and humid summers One focal point will be how infrastructural dis- raises concern for the health of our older turbance affects social service systems and vul- populations. Older adults are more vulnerable nerable population groups. There is a need to to heat illness than younger people because of examine the local consequences for the health, this thermoregulatory mechanism dysfunction, social care and security of older people in the chronic dehydration, medications, and disease. event of extreme weather episodes. Information is often provided for caregivers to Older people are often more dependent on enable them to protect their patients from heat the function of social service systems and often illness (7). It also discusses age-related changes rely on them for their daily care. Today many in the thermoregulatory system’s response to older people receive care at home. During an heat, risk factors, assessment criteria, preven- extreme weather episode such care will probably tive measures, and first aid for victims of heat be more difficult to distribute, while the need exhaustion and heat stroke. for it will no doubt increase. Such was the case, for example, during Sweden’s ‘Gudrun’ storm Air quality in 2005 when electricity, telephones and heating People are more likely to develop certain ill- systems were cut off. The storm also disturbed nesses at higher ages. Air pollution causes traffic and hampered rescue operations (5). cardiovascular and heart disease, cancer and lung disorders. The greatest negative impact is Excessive cold and excessive heat from particulate matter such as large particles With advancing age, the efficiency of the (PM10), fine particles (PM2,5), and ozone. body’s heat-regulating mechanisms declines, They originate in transport and combustion. placing many older people at high risk of cold People already in poor health (respiratory-, discomfort and hypothermia, even in warm heart- and cardiovascular disease) are more environments. Unfortunately, the thermoregu- adversely affected by air pollution than others. latory problems of the aged have received Air pollution is a global matter because insufficient attention in the education of care- substances are spread through atmospheric givers (6). As a consequence, some routine exchange and winds. Therefore international procedures in the care of frail older people agreements play a significant role in nego- may inadvertently cause cold discomfort and tiations about targets and limit values for the increase the risk that core temperature will reduction of air pollution (8). healthy ageing | environment 87

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the significant secondary data they 26 Of the intervention studies among older peo older among studies intervention the Of The authors argue that many people are en cupboards, putting covers on electric sockets, to potential risks. potential to Housing improvement and reduction of injuries A systematic review et by al. Lyons (10) of the determine to sought literature scientific existing whether alteration of the indoor environment reduces injuries occurring in the home. After reviewing found twenty-eight published studies and one unpublished. These they divided clusters based on a primary population model: into three children, older people and the general popula tion. ple, none demonstrated a decrease in injuries due to risk reduction, although two showed a reduction in falls that could be associated to hazard reduction. couraged to change their indoor environment (‘fixtures and fittings’) by installing locks on to the variety of methodologies and outcomes used, and problems with study methodologies. measuring in difficulties many experienced They the health outcomes of housing interventions. between the The two relationship is influenced example, For interactions. and factors many by it is the more groups vulnerable in the general the unem sick, such as the elderly, population, in time most spend who mothers, single ployed exposed more therefore being homes, their side

------The results of this review indicated that housing mental health; but they can also have adverse effects. improvements can generally improve health, specifically s ess ntion e n e rv e tiv ec Selection criteria: randomised controlled trials, non-randomised controlled trials, controlled before-and-after Selection criteria: randomised controlled trials, non-randomised controlled studies and interrupted-time-series studies. The authors found it quite The key interventions were: medical prior 26. statement of the effect of housing improvements due in rent increases and cause e.g. distress; and the original residents when relocated may not benefit from the improvements. difficult to produce a clear ogy was also used. The results of this review indicated that housing generally improve improvements health, specifically mental can health; but they can also have adverse effects. Housing improvements reported in studies on re-housing and regeneration can also result ity re-housing; energy re-housing; efficiency community regeneration advances; and re furbishment (ibid. p. 2). The prospectivewerestudies mainthese in usedmethods research or retrospective measures of health and use of the control groups. Qualitative methodol suggesting an increased interest in producing data on how housing might improve health. popu whole the from drawn were Participants lation including older people. focused on determining how housing improve housing how determining on focused ments could improve health in the population as a whole. The authors searched the interna tional literature, identifying nineteen studies, the earliest from housing 1936. intervention studies Fourteen were ongoing identified, Two Two systematic reviews are reported in chapter. this Housing improvement and health gain The systematic review by Thomson et al. (9) Eff of int installing grab rails, removing rugs and im- References 88 proving lighting in hallways or other falls haz- 1. Mollenkopf H, Marcellini F, Ruoppila I, ards. It is logical to consider that changes in the Tacken M. Ageing and outdoor mobility: a indoor environment, good house design and European study. Amsterdam: IOS Press; 2004. layout can reduce injuries; but there is still a 2. Nyquist Brandt Å, Watson G. The significance lack of significant scientific evidence. An older of the outdoor environment for older people person’s fall, injury or fracture can be caused and persons with disabilities living in special by several factors. The cause of the fall, the service accommodation. Stockholm: Swedish lack of reaction, the impact and the weakness National Institute of Public Health; 2005. of their bones are all important and contribute 3. Mollenkopf H, Fozard JL. Technology and the to an older person sustaining an injury. Good Life: Challenges for Current and Future The authors suggest that global injury re- Generations of Aging People. Annual Review search and the gerontology community should of Gerontology and Geriatrics 2003;23:250-79. collaborate to design and implement studies of 4. McMichael AJ, Woodruff RE, Hales S. Climate sufficient size, rigorous design, and acceptabil- change and human health: present and future ity to participants, to answer these important risks. Lancet 2006;367(9513):859-69. questions. 5. Carlsson-Kanyama A, Dreborg K-H, Hedberg See also Chapter 9, Injury. L, Jonsson D. [Health impact assessments in risk and vulnerability assessments. Study on Summary of findings climate changes and extreme weather episods.] There is inconclusive evidence that: Hälsokonsekvensbedömning i risk- och sår- barhetsanalyser. Förstudie om klimatför- • housing interventions can have a positive ef- ändringar och extrema väderhändelser. Report fect. Although they may generally improve R 2006:04. Stockholm, Sweden: Swedish health and specifically mental health in certain National Institute of Public Health; 2006. cases, they can also have a negative effect on 6. Worfolk JB. Keep frail elders warm! Geriatr health. Thus for example housing improve- Nurs 1997;18(1):7-11. ments can also result in rent increases and 7. Worfolk JB. Heat waves: their impact on the have an adverse effect on people’s health by health of elders. Geriatr Nurs 2000;21(2):70-7. causing distress (9), and 8. Swedish National Institute of Public Health. changes to the indoor environment can reduce • The 2005 Public Health Policy Report. Report injuries in older people due risk reduction, as R 2005:44. Stockholm, Sweden; 2005. an older person’s fall, injury or fracture can 9. Thomson H, Petticrew M, Morrison D. Housing involve several confounding factors (10). improvement and health gain: a summary and systematic review. Occasional Paper Number 5. Glasgow: Public Health Sciences Unit; 2002. 10. Lyons R, Sander L, Weightman A, Patterson J, Jones S, Lannon S, et al. Modification of the home environment for the reduction of injuries. The Cochrane Database of Systematic Reviews 2003;(4). healthy ageing | introductionl 89 C H A P T E R 7 utrition N 90

The Healthy Ageing project suggests that policymakers, NGOs and practitioners consider the following priorities for action when working with older people:

Promote healthy food and eating habits among older people, with an emphasis on low intake of saturated fats and high consumption of fibre-rich foods, green vegetables and fruits. healthy ageing | nutrition 91 - -

caused by ageing and

can have side-effects that affect appe affect that side-effects have can

actors that may can influence older people’s appetite and eating and appetite people’s older influence can habits. Medicines tite, sense of taste and smell and the ability to digest food. Examples of such side-effects in clude dryness of the mouth and constipation. rily mean poorer health. Retained body weight body Retained health. poorer mean rily in older people can be seen as an indicator of sound health (2). F influence eating habits The conditions in which older people live can sometimes lead to isolation, hear perhaps and/or because sight impaired have alone, live they or friends of loss The (3). incontinent are or ing a spouse, or depression, can lead to loneliness adopt to people cause subsequently may which poorer eating habits: they lose interest in food and cooking and therefore eat too little. Physiological changes problems as a result of disease and treatment - - - -

For search strategy, strategy, search For .

utrition ood and eating habits have medical, psychological, cultural and social nutritional, Even though older people’s energy require General dietary recommendations on what The findings in the “Effectiveness of interventions” The findings in the

N important as a person gets older. Special atten important as a person gets older. tion needs therefore to be paid to the balance between energy and nutrients. Among older people, higher body weight does not necessa ment is lower than need younger for essential people’s, nutrients is their just as high or sometimes even higher. The nutrient density of food, i.e. its nutritional content in relation to its energy content, becomes increasingly prepare their food with as little cooking fat as possible. Other important dietary components include vitamin D and calcium, especially con sidering the high prevalence of osteoporosis and hip fractures. we should eat to feel well are also relevant and relevant also are well feel to eat should we important for older people. They should, for example, not choose food that has a high salt or sugar content, but they should choose soft good with food choose fats, hard of instead fats carbohydrates and large amounts of fibre, and aspects. Good nutrition also plays a significant a plays also nutrition Good aspects. part in the well-being of healthy older people and in delaying and reducing the risk of con tracting disease (1). Review on Healthy Ageing. Review on Healthy F E assessments made by the section are based on papers authors of the original see Appendix 5, Literature inclusion criteria etc. Taste is experienced through a combination of smell, are good for the metabo- 92 taste and sight. If one of these senses deteriorates, lism, help retain body weight, and keep people a person’s experience of food is also negatively affected. active and in good spirits. Many older people can not Disabilities can reduce people’s ability to eat manage large amounts of food at a time. unaided, and their sense of taste and smell. Im- Three main meals and two-to-three snacks a paired sight, for example, can make it difficult day are appropriate. One important considera- for a person to see what he/she is eating. tion is that mealtimes are experienced as something positive; that they provide both pleasure Sense of taste diminishes with age. Taste is ex- and fun. A positive attitude towards food is perienced through a combination of smell, taste enhanced by being able to enjoy a good meal and sight. If one of these senses deteriorates, a in peace and quiet, in a pleasant environment person’s experience of food is also negatively with friends. Food and social relationships are affected. Sweet and sour are the tastes that de- interlinked and if older people are left alone, teriorate first, leading older people to perceive they may well lose interest in food. Evaluation their food as sour and bitter. The sense of smell of experiments where older people cook food deteriorates before the sense of taste. in teams and eat together show that this can be Poor teeth can have a negative effect on a per- a way of stimulating both good eating habits son’s ability to chew. Fungal infections in the and social contact. A person who loses interest mouth can lead to pain while eating. Good oral in food risks a vicious circle. hygiene and medical treatment are important The results of the HALE project (2) empha- here. sise the importance of older people retaining Throat-muscle coordination can deteriorate, body weight whilst maintaining their blood resulting in food getting stuck in the throat. pressure and cholesterol levels within recommended limit values (RR <140 mmHg and Lack of exercise can decrease a person’s appe- cholesterol <5mmol/l). A “Mediterranean” diet tite. is recommended for older people, with an em- Dementia and depression are often associated phasis on low intake of saturated fats and high with poor intake of energy and nutrients. consumption of fibre, green vegetables and fruit. A positive attitude to food The HALE project also recommends that It is important that food gives people all the lifestyle should be the starting-point of health- nutrition they require. It is also important to promoting interventions. Changing eating hab- spread mealtimes throughout the day, as this its can create synergy effects, for example on helps to utilise the nutrients in the most effec- social functions, risk of overweight and some tive way. Put rather simply, regular mealtimes forms of cancer (2). healthy ageing | nutrition 93 - - - - -

The Swedish Council review established vitamin D, decreasing the risk of hip-fracture, was recommended for elderly women (5). and cholesterolCouncil Swedish the concentrationsby report a of summary a In on Assessment Technology in Health Care (5) meta-analysis, and review systematic a on based the report findings indicate that eating habits are associated with bone-density and fractures with osteoporosis. The report suggests when that considering cost-effectiveness of treat ments, it remains important to assess whether, is it fracture, non-vertebral of prevention the in supplementation calcium combine to necessary with administration of vitamin D, or whether – at least in high-risk individuals – vitamin D alone may be effective. The aim of the evalu ation was to check systematically for scientific evidence of effectiveness for differing outcome measures. the during sunshine and daylight of lack a that winter for people living in Scandinavian coun tries causes nutritional vitamin D deficiency. and calcium with combined treatment Medical results suggest that policy and environmental strategies may promote physical activity and good nutrition. The authors suggest that fur ther research is needed to determine the long- term effectiveness of policy and environmental interventions with various populations and to identify the steps necessary to successfully im plement such interventions. Prevention of osteoporosis ------Several of the studies showed that labelling heart- foods were selected. healthy foods in restaurants, grocery stores and vending machines significantly increased the rate at which those - s ess ntion e n e rv e tiv ec Several of the studies showed that label Literature searches included studies con A site-specific literature review of policy and that sales of targeted food items were higher the during price-decrease interven tion than during the health- message intervention. The ling heart-healthy foods in restaurants, cery stores and gro vending machines significantly increased the rate at which those foods were selected. One intervention, comparison albeit with group, no showed campaigns, educational campaigns in also They involving newspapers. and television classes, activation, and organisation community cluded social marketing, and programmes containing environmental interventions for nutrition. These studies used policy approaches or to promote environmental good nutrition. They focused on providing primary and secondary prevention and health-promotion interventions using several approaches such as mass-media promote cardiovascular health. The review also review The health. cardiovascular promote summarised recommendations. ducted from 1970 to 1990. Forty-eight stud ies were identified. There were participants of all ages including those aged 50 and above. by Matson-Koffman et al. (4). The aim to was review selected, recent environmental and policy interventions designed to increase physi cal activity and improve nutrition as a way to reduce the risk of heart disease and stroke, and Three meta-analyses, one systematic and reviews systematic two meta-analysis, with review are reported in this chapter. a literature review environmental interventions was conducted Eff of int Malnutrition and low weight increase the risk in men enrolled in the Veterans Administration 94 of osteoporosis and fractures caused by osteo study. Mean duration of treatment was 4.8 porosis. The review also suggests that a high years. Primary prevention was defined as any intake of vitamin K in nutrition is associated investigation in which criteria for participants’ with reduced risk of hip-fractures. Increased in- eligibility omitted a history of coronary dis- take of calcium before menopause affects bone ease. Mortality included deaths from coronary density. High intake of vitamin A is associated heart disease, cancer and causes not related to with reduced bone density and increased risk of illness. The rate of mortality from coronary hip-fracture for both women and men. heart disease tended to be lower in men receiv- The systematic review by Gillespie et al. (6) ing interventions to reduce cholesterol concen- included 21 studies, of which 20 trations than that in control were randomised controlled Malnutrition and low subjects (p=0.06), although trials regarding prevention total mortality was not af- of falls. The results indicate weight increase the risk of fected by treatment. that almost all estimates of osteoporosis and fractures Analysing the drug trials treatments are based on single caused by osteoporosis. separately showed that the studies and therefore uncer- treatment for lowering choles- tainty remains about the efficacy terol concentrations significantly of regimens which include vitamin D or vitamin reduced mortality from coronary heart disease. D analogues in fracture prevention. In one of Milne et al. (8) examined the evidence for the the studies included in this systematic review effectiveness of nutritional supplements contain- the administration of vitamin D3 with calcium ing protein and energy for older people at risk of co-supplementation to frail elderly people aged malnutrition. Their systematic review comprised 80 and over living in sheltered accommodation 49 trials with 4,790 participants and examined was associated with a reduction in hip-fracture the evidence from trials for improvement in nu- incidence. The conclusion was that vitamin D3 tritional status and clinical outcomes with extra with calcium co-supplementation appears to be protein and energy supplementation. Weight effective and might be considered in fracture change benefited from energy and protein sup- prevention for frail elderly people. In other plementation compared with that of control groups, a fracture prevention programme using groups. There was no evidence of improvement vitamin D or vitamin D analogues cannot yet be in clinical outcome, functional benefit or short- confidently recommended. ened hospital stay with supplementation. Muldoon et al. (7) investigated the effects The trend was still towards a slightly shorter of lowering cholesterol concentrations on total stay for patients who were given supplements. and cause-specific mortality. Their meta-analysis To provide functional benefit the gain should included six randomised controlled primary- be in muscle mass. Milne et al. (8) recommend prevention trials. The participants, mostly further trials focusing on older people’s quality white, in five trials had mean ages ranging be- of life, well-being and functional ability. tween 45 and 51 years, with a mean age of 65 healthy ageing | nutrition 95

- - maintenance than those that exercised did less. The analysis of long-term weight-loss maintenance indicated that weight-loss 4 maintenance or 5 years after a structured weight- loss programme averages cantly cantly greater weight-loss 3 kg or 23 per cent of initial initial of cent per 23 or kg 3 ercised more had signifi- -

weight-loss, representing a sustained sustained a representing weight-loss, Six studies reported that groups that ex- Primary outcome variables were weight-loss necessary for successful weight maintenance. weight successful for necessary significantly between women and men. significantly between women and of 3.2 in per After weight cent. body reduction very-low-energy diets or weight-loss of 20 kg or more, individuals maintained significantly more weight-loss than after diets or hypo-energetic weight-loss of required lessis research further thanthat suggest authors 10 kg. The lifestyle the sustain to individuals most enable to changes in physical activity and food choices maintenance in kilograms, weight-loss main tenance as a percentage of initial weight-loss, and weight-loss as a percentage of initial body weight (reduced weight). Twenty-nine studies met the inclusion criteria. Successful -low- very energy diets were associated with significantly greater weight-loss maintenance than success ful hypo-energetic balanced diets at all follow- ups. Weight-loss maintenance did not differ ------cancer through diet. The authors argue that it - is unlikely that a major cancer is unlikely that a major cancer stantial potential for preventing stantial potential for preventing the risk factors; but there is sub in practice by varying only one of in practice by varying only one prevention effect will be achieved prevention effect will be achieved - - . The authors suggest that there that suggest authors The . 27 Participants’ ages were not given in the paper, but were kindly supplied by E. Riboli. Participants’ ages were not given in the paper, ietary patterns and cancer risk ong-term weight-loss and 59. 27. The meta-analysis by Anderson et al. (10) ex amined the long-term weight-loss maintenance of individuals completing a structured weight- aver The States. United the in programme loss age ages of the participants were between 50 likely that a major cancer prevention effect will effect prevention cancer major a that likely be achieved in practice by varying only one of the risk factors; but there is substantial poten tial for preventing cancer through diet. L other lifestyle factors such as smoking, alcohol and physical activity have role a in preventing cancer. The authors argue that it is un in prospective studies the imprecise dietary meas urement and limited vari ability of dietary intake within each cohort. Many might be many reasons for the discrepancies, such as recall and selection in -control case studies, or tistically significant in the meta-analyses of the cohort studies (9). Participants’ age range was years 80 to 40 cally the evidence from case-control and pro spective studies on intake of fruit and vegeta bles and cancer risk. They found a significant risk reduction associated with vegetables for many cancers, while only the protective effect of fruit on lung- and bladder cancer was sta D meta-analyti summarised (9) Norat and Riboli Summary of findings 4. Matson-Koffman DM, Brownstein JN, Neiner 96 There is evidence to suggest that: JA, Greaney ML. A site-specific literature review of policy and environmental interventions • vitamin D3 with calcium co-supplementa- that promote physical activity and nutrition for tion is effective in the prevention of fractures cardiovascular health: what works? following a fall in frail older people, Am J Health Promot 2005;19(3):167-93. • intake of vegetables is effective in reducing 5. Hagenfeldt K, Johansson C, Johnell O, cancer risk significantly among those aged Ljunggren Ö, Möller M, Mørland B, et al. 40–80 years (9), and Osteoporosis – prevention, diagnosis and • five years after completion of structured treatment. Report number: 165. Stockholm, weight-loss programmes, older people with Sweden: The Swedish Council on Technology an average age of 50–59 can maintain a Assessment in Health care; 2003. weight-loss of more than 3 kg and a reduced 6. Gillespie LD, Gillespie WJ, Robertson MC, weight of more than 3 per cent of initial body Lamb SE, Cumming RG, Rowe BH. Interven- weight (10). tions for preventing falls in elderly people. The Cochrane Database of Systematic Reviews There is inconclusive evidence for: 2003;(4). • the effect of lowering cholesterol concentra- 7. Muldoon MF, Manuck SB, Matthews KA. tions on total mortality in men with a mean Lowering cholesterol concentrations and age of 65 (7), and mortality: a quantitative review of primary prevention trials. Bmj 1990;301(6747):309-14. • the effectiveness of nutritional supplements 8. Milne AC, Potter J, Avenell A. Protein and en- containing protein and energy for older ergy supplementation in elderly people at risk people at risk of malnutrition in improving from malnutrition. The Cochrane Database of functional status and in reducing the length Systematic Reviews 2005;(1). of hospital stay (8). 9. Riboli E, Norat T. Epidemiologic evidence of the protective effect of fruit and vegetables on cancer risk. Am J Clin Nutr 2003;78(3 References Suppl):559S-69S. 1. Unosson M. Malnutrition in hospitalised eld- 10. Anderson JW, Konz EC, Frederich RC, Wood erly patients. Doctoral dissertation. Linköping, CL. Long-term weight-loss maintenance: a Sweden: Linköping University; 1993. meta-analysis of US studies. Am J Clin Nutr 2. Bogers R, Tijhuis M, van Gelder B, Kromhout 2001;74(5):579-84. D. Final report of the HALE Project, Healthy Ageing: a Longitudinal study in Europe. Report 260853003. Bilthoven, Netherlands: RIVM; 2005. 3. Steen B, Nilsson K, Robertsson E, Ostberg H. Age retirement in women. II. Dietary habits and body composition. Compr Gerontol [A] 1988;2(2):78-82. healthy ageing | introductionl 97 C H A P T E R 8 Physical activity 98

The Healthy Ageing project suggests that policymakers, NGOs and practitioners consider the following priorities for action when working with older people:

Increase the level of physical activity among older people in order to reach the international recommendations of 30 minutes or more of, at least, moderate-intensity physical activity on most, preferably all, days of the week. healthy ageing | physical activity 99 - Physical activity, Physical preferably activity, weight-bearing, Finally, physically inactive people are at greater risk of developing depression than those than depression developing of risk greater physically while (10), active physically are who active persons may have reduced risk of devel oping Alzheimer’s disease (11, 12), and older people who are physically active report higher levels of well-being and physical function than the less active do (13). contributes to increased bone density and can it ele thus counteract osteoporosis. Moreover, vates physical function (improving endurance, strength, balance and mobility) to levels which living independent of years more guarantee can (8, 9). - - - -

- For search search For .

he importance of physical activity emerges in public-health issues ranging from dis Moderate physical activity on three-to-five Physical activity is associated with improved with associated is activity Physical The findings in the “Effectiveness of interven The findings in the

falls and fractures such as muscle weakness in over of level poor and balance poor limbs, the through improved be all can fitness physical all physical activity (7). occasions per week with a duration of 30–60 blood reducing in effective be to seems minutes evidence strong is there Moreover, (5). pressure that regular physical activity has a beneficial for factors Risk (6). sensitivity insulin on effect physically inactive run twice as great a risk of developing cardiovascular diseases as who are physically active (2). Exercise those reduces blood pressure (3). Lack of physical activity is also a modifiable risk factor for stroke (4). benefits of physical activity for older people are people older for activity physical of benefits well documented. length and quality of life, and plays an impor tant role in maintaining health and effective function in older people (1). People who are ease prevention and enhancement of a healthy lifestyle for all to the maintenance of an inde pendent lifestyle in later life stages. It has been best “the is activity physical frequent that stated preventive medicine” for old age. The broad T

Literature Review on Healthy Ageing. Literature Review on Physical activity E on assessments made tions” section are based original papers by the authors of the 5, inclusion criteria etc. see Appendix strategy, The most consistent positive effects were observed The effect was greater in studies 100 in strength, aerobic capacity, flexibility, walking and that measured exercise duration and in studies with a time inter- standing balance, with over half of the studies that val of less than 90 days between examined these outcomes finding positive effects. interventions and behaviour measurement. The findings sug- There is evidence from epidemiological gest that group-delivered interventions studies that physical activity may prevent or should encourage moderate activity, incorpo- postpone the onset of dementia (11). How- rate self-monitoring, target only activity, and ever the few intervention studies in this area encourage centre-based activity; and also that report great difficulties in separating the effect patient populations may be especially receptive of physical activity, as physical activity almost to activity interventions. always occurs together with mental activation and social stimulation. One recent study shows Exercise and its health effects that activities including all these three compo- Keysor and Jette (9) evaluated how far exer- nents, physical, social and mental activity, are cise among older adults improves function and the most likely to have a protective effect on prevents or decreases disability. Their review dementia (12). included thirty-one experimental and quasi- experimental aerobic and resistance exercise interventions. The participants were at least 60 Effectiveness years old and varied in health status. Exercise of interventions sessions lasted 45–60 minutes and were per- One meta-analysis, one systematic review and formed two-to-three times per week. The dura- two literature reviews are reported in this tion of the interventions ranged from 2 to 18 chapter. months, with most lasting 2 to 3 months. The most consistent positive effects were observed Interventions to increase in strength, aerobic capacity, flexibility, walk- physical activity ing and standing balance, with over half of the Conn et al (14) conducted a meta-analysis to study studies that examined these outcomes finding interventions to increase physical activity among positive effects. Of the studies that examined ageing adults. Their meta-analysis included 43 physical, social, emotional or overall disability studies that measured the activity behaviour outcomes, most found no improvements. of at least five participants aged 60 years or over. The effect was greater when interventions Progressive resistance training targeted activity only, excluded general health Latham et al. (7) conducted a Cochrane re- education, incorporated self-monitoring, used view to investigate the effect of progressive centre-based exercises, recommended moder- resistance training (PRT) on physical disability, ate intensity activity, were delivered in groups, functional limitations and impairment in older used intense contact between interventions and people. PRT is defined as ‘a strength-training participants, and targeted patient populations. programme in which the participants exercised healthy ageing | physical activity 101 - - - - - based, are effective in increasing - lengthy counselling in increasing physical activity for older people (15), and theory-basedphysical activity interventions are not more effective than those interven tions not based on explicit theories of be haviour change in older people (15). tive in increasing physical activity in older people including e.g. smoking, diet, alcohol (14, 15), exercise among older adults is effective in increasing strength, aerobic capacity, flexi walking and standing balance (9), bility, progressive-resistance training is effective in increasing strength in older people and in producing a positive effect on some func (7), tional limitations such as gait speed primary-care-based interventions consisting professional health a by given advice brief of effec are materials written by supported and tive in increasing physical activity among older people (15), interventions consisting of referral exercise to specialist and targeting an individuals are effective in increasing physical activity among older people (15), interventions consisting of brief counselling (3–10 minutes) may be as effective as more interventions incorporating self-monitoring and regular contact with specialist, an exercise promoting moderate and centre intensity, physical activity in older people (14), (for factor single a of consisting interventions to compared only) activity physical example multiple-risk-factor interventions are effec • • • • • • Summary of findings to suggest that: There is evidence • • - - - - cal activity interventions were no more effec of theories explicit on based not those than tive behaviour change. short term than multiple-risk-factor interven tions (including e.g. smoking, diet, The alcohol). results also indicate that brief counselling (3–10 minutes) may be as effective as lengthier counselling in increasing physical activity for older people. And finally, theory-based physi participants aged between 18 and years 50 aged adults only included studies Four 75 years. and Interventions older. tailored to participant characteristics and offering written materials to patients showed strong activity-only results. interventions fared Physical- better in the for increasing physical activity and made recom made and activity physical increasing for mendations for integrating successful strategies with practice. Their review consisted of both randomised controlled trials (nine studies) and quasi-experimental studies (six studies) with functional limitations such as gait speed. functional limitations Primary care-based interventions Eakin et al (15) summarised the literature (15 studies) on primary-care-based interventions this resistance was adjusted training throughout programme’. The the review included 66 randomised studies with 3,783 participants of mean age appears PRT 60 to years be or older. an effective intervention to increase strength in older people and has a positive effect on some their muscles against an external force that was that force external an against muscles their and participant, each for intensity specific at set References 11. Fratiglioni L, Paillard-Borg S, Winblad B. An 102 active and socially integrated lifestyle in late 1. Shephard RJ. Gender, physical activity, and life might protect against dementia. Lancet aging. London: CRC Press; 2002. Neurol 2004;3(6):343-53. 2. Powell KE, Thompson PD, Caspersen CJ, 12. Karp A, Paillard-Borg S, Wang HX, Silverstein Kendrick JS. Physical activity and the incidence M, Winblad B, Fratiglioni L. Mental, physi- of coronary heart disease. Annu Rev Public cal and social components in leisure activities Health 1987;8:253-87. equally contribute to decrease dementia risk. 3. Whelton SP, Chin A, Xin X, He J. Effect of Dement Geriatr Cogn Disord 2006;21(2):65-73. aerobic exercise on blood pressure: a meta- 13. Spirduso WW, Cronin DL. Exercise dose-re- analysis of randomised, controlled trials. Ann sponse effects on quality of life and independ- Intern Med 2002;136(7):493-503. ent living in older adults. Med Sci Sports Exerc 4. Wendel-Vos GC, Schuit AJ, Feskens EJ, 2001;33(6 Suppl):S598-608; discussion S9-10. Boshuizen HC, Verschuren WM, Saris WH, 14. Conn VS, Valentine JC, Cooper HM. Inter- et al. Physical activity and stroke. A meta- ventions to increase physical activity among analysis of observational data. Int J Epidemiol aging adults: a meta-analysis. Ann Behav Med 2004;33(4):787-98. 2002;24(3):190-200. 5. Fagard R. Exercise characteristics and the 15. Eakin EG, Glasgow RE, Riley KM. Review of blood pressure response to dynamic physical primary care-based physical activity interven- training. Med Sci Sports Exerc 2001;33 (6 tion studies: effectiveness and implications Suppl):S484-S92. for practice and future research. J Fam Pract 6. Borghouts LB, Keizer HA. Exercise and 2000;49(2):158-68. insulin sensitivity: a review. Int J Sports Med 2000;21(1):1-12. 7. Latham N, Anderson C, Bennett D, Stretton C. Progressive resistance strength training for physical disability in older people. The Cochrane Database of Systematic Reviews 2003;(2). 8. Cyarto EV, Moorhead GE, Brown WJ. Updat- ing the evidence relating to physical activity intervention studies in older people. J Sci Med Sport 2004;7(1 Suppl):30-8. 9. Keysor JJ, Jette AM. Have we oversold the benefit of late-life exercise? J Gerontol A Biol Sci Med Sci 2001;56(7):M412-23. 10. Camacho TC, Roberts RE, Lazarus NB, Kaplan GA, Cohen RD. Physical activity and depression: evidence from the Alameda County Study. Am J Epidemiol 1991;134(2):220-31. healthy ageing | introductionl 103 C H A P T E R 9 njury prevention I 104

The Healthy Ageing project suggests that policymakers, NGOs and practitioners consider the following priorities for action when working with older people:

Initiate safety promotion and injury prevention, including programmes against violence and suicide, at all relevant policy levels. The individual approach should include physical and nutritional aspects, careful prescription of psychotropic drugs, and safe housing. healthy ageing | injury prevention 105 - history of any fall in the previous year, four or more prescribed medications, disease, diagnosis of stroke or Parkinson’s reported problems with balance, and use the without chair a from rise to inability arms. of one’s Another factor important in falls preventing is adequate nutrition, see Chapter 7, Nutrition. 7, Chapter see nutrition, adequate is Community interventions serious most the among are injuries Fall-related and most common medical problems experi enced by older people. Every third woman in the County of Stockholm who reaches the age of 80 years either risks eventually incurring a • • • • • The presence of three or more of factors the increases the risk of fall in above the next six months (3). ------

For search search For .

alls result in significant health problems for older people and also affect society in njury prevention Appropriate and effective intervention re Not all the causes and risk of falls are prevent are falls of risk and causes the all Not The findings in the “Effectiveness of interven The findings in the

ment tool is described by Nandy et al. (3). The tool is based on the existing systematic review of community-based prospective studies iden tifying risk factors for falling. Five risk factors were identified: men as they are more fragile in later life: they are more likely to have e.g. osteoporosis and less muscle strength (2). assess An falls. of risk the of assessment quires able, but most can be modified by intervention. by modified be can most but able, The two main target groups are: older people liv people older and homes own their in living ing in institutions. Both groups need specific than vulnerable more are Women intervention. and life itself. Physical mental health deterioration and fear health of falling impairment, people from walking and experi prevent older encing social contact to a greater extent than the injury from the fall itself (1). general due to high treatment costs. Falls also result in significant morbidity and mortality among older people. Injuries, long-term hospi talisation, rehabilitation and loss of autonomy ending with institutionalisation are all factors that lead to deterioration in health, well-being F

Literature Review on Healthy Ageing. Literature Review on I E on assessments made tions” section are based original papers by the authors of the 5, inclusion criteria etc. see Appendix strategy, hip fracture or has already had such an acci- Risk factors for abuse of older people include 106 dent (4). Prospective studies have reported that strained family relationships as a result of stress 30 to 60 per cent of community-dwelling older and frustration as the older person becomes adults fall each year, with approximately half more dependent on others; and social isolation experiencing several falls (5). In population- because of physical or mental infirmities. based fall-prevention programmes several Where institutional care standards are low measures are introduced as a package across and the staff are generally poorly trained, the an entire community or a large part of it. relationships between staff and residents are The WHO “Safe Communities” model for difficult and of poor quality. Psychological the prevention of injury in whole populations and physical violence from the emotional ex- has been accepted around the world as a model haustion of staff is significantly related to the for coordinating efforts to improve safety and number of working hours and to depersonali- reduce injury (6). Over 100 com- sation (8). Neither sex nor age munities throughout the Fall-related injuries are are correlated with violent world have been formally behaviour. Interventions designated as “Safe Com- among the most serious and should concentrate on the munities” by the World most common medical problems training and work envi- Health Organization. The experienced by older people. ronment of staff caring Safe Communities ideology for older people (8). Older refers to safety that can be men are as much at risk of achieved through integrated, collaborative efforts abuse as women, but in those cultures or so- that are implemented in a supportive social, cul- cieties in Europe where women still have an tural and political environment. The emphasis inferior status, older women are at higher risk in these programmes is on collaboration, part- of abuse or neglect (9). nerships and community capacity-building that Prevention of and intervention against is the core of the Safe Community model. violence towards older people are a very sensitive issue and depend on the culture and the Violence towards older people legal environment of each country. Screening Violence towards older people has many ill- in health care settings is accepted in different health consequences including injuries. Violence ways among health professionals (10). has many forms – physical, psychological and One finding of the WHO “Missing Voices” economic abuse or neglect. Older people are project is that older people perceive abuse subjected to all kinds of violence in families mainly as neglect, violation and deprivation. and in care facilities including health-care set- “Missing Voices” is a project co-ordinated tings. A case-control study on violence among by the International Network for the Preven- older people in nursing homes examined resi- tion of Elder Abuse (INPEA) and explores dent-to-resident violence resulting in injury (7). the knowledge and experience of two target The authors suggest that injured residents are groups: health-care professionals and older more likely to “put themselves in harm’s way”, people themselves. A global strategy developed to be verbally aggressive, and to be cognitively to combat violence against older people in- impaired. cludes recommendations for prevention: healthy ageing | injury prevention 107 ------

ess ntion e n e rv e tiv ec intergenerational solidarity and the pro to and prevent the problem. some population subgroups particularly vul particularly subgroups population some nerable to elder abuse: the very old, and women those capacity, functional limited with the poor, motion of a culture rejecting violence critical are for preventing elder abuse, and all countries should develop structures and services (health, social, legal protection, po respond appropriately that etc.) referral, lice ulti-factorial fall risk Multi-factorial fall risk assessment and man agement was the most effective. Exercise pro risk the on effect beneficial a had also grammes of falling. Eff two meta-analyses, with reviews systematic Two re one review, literature one reviews, systematic of community reviews two and of reviews view chapter. this in reported are interventions M assessment and management of A review and forty systematic meta-analysis trials controlled randomised among older peo ple aged 60 by and Chang over was conducted the effec was to assess The purpose et al. (12). tiveness of multi-factorial risk assessment and the in as reducing an intervention management risk of falling. Four types of were intervention fall compared: multifactor risk and assessment management, exercise programmes, environ education. and modification mental • • • of int - - - - - education) and through media (combating stigma, de-stereotyping older people, tack ling taboos etc.), cultural context mandatory for fully under standing elder abuse, many sectors of society must be involved, particu a have workers primary-health-care larly important role, education and dissemination of tion informa both in formal sectors (professional legal frameworks missing, similar structural issues, and research to obtain more information people. evidence on violence against older and themselves and on their own behalf, role of media: to change the negative image of older people, structural solution: need for strong protec tive law, improved health care plans and inter-generational inter-generational relationships to minimise social isolation, older people’s training for professionals in social services health and law, care, empowerment of older people to act for schools on how to perceive older adults as to society, positive contributors awareness and educational programmes for older people to help them to rights, know their awareness and educational for the general programmes public through media and • • • • Global Prevention of Elder Abuse calls for abuse elder of prevention the at aimed action (11). The following points were stated for consideration: • While“ Missing Voices” (10) was research- was (10) Voices” Missing While“ oriented, the Toronto Declaration on the • • • • • • • • The results suggest that health promotion policy for in- (14) found that Tai 108 vesting in community fall-prevention programmes is effective Chi or other exercises which exercise bal- in reducing falls and fall-related injuries in older people. ance were also effective. Muscle strength- Gillespie et al., (2) in their systematic review ening combined with balance of 62 randomised trials designed to minimise retraining, individually prescribed at home by the effect of, or exposure to, risk factors for fall- trained health professionals, and 15 weeks of ing in older people, found that multidisciplinary Tai Chi courses, were effective. interventions targeting multiple risk factors are effective in reducing the incidence of falls. Community interventions against falls Home-hazard assessment and modification by a Marks and Allegrante (1) investigated the health professional may reduce falls, especially effectiveness of community fall-prevention pro- among those with a history of falls. grammes in reducing the incidence of falls and See also Chapter 7, Nutrition. fall-related injuries. In their review of reviews, they point out that one in three people over 65 Physical activity in years annually in the US will experience a fall, relation to injuries/falls and that this will result in significant fall-related Nine observational epidemiological studies injuries that constitute an important and costly and 12 randomised controlled trials (RCTs) of public health problem. The review included exercise programmes were examined by Gregg nine meta-analyses on interventions for pre- et al. (13). Physical activity (defined as bodily venting falls in older people and 23 published movement produced by skeletal muscles that reports on community-based interventions to results in energy expenditure) was associated reduce the risk of falls using multi-factorial ap- with a 20–40 per cent reduction in the risk of proaches. Of the 23 reports, 15 were conducted hip fracture among sedentary individuals. Epi- in countries other than the U.S, such as Aus- demiological studies suggest that a higher level tralia, Canada, France, Holland, New Zealand, of physical leisure activity prevents hip fracture. Scotland, Spain and the United Kingdom. Results from RCTs suggest that certain exercise However, the authors made suggestions for programmes may reduce the risk of falls. health promotion policies: Sherrington et al. (14) analysed systematic re- 1) To provide support for community-wide views and three randomised controlled trials of implementation, by well-trained personnel, the effectiveness of various physical-activity or of specific evaluative and screening- pro exercise-intervention strategies for the preven- grammes for identifying individuals at risk; tion of unintentional falls among older people. The authors suggest that a targeted, supervised 2) To give high priority to individuals at high risk home exercise programme concentrating on of falls, for example those who are sedentary, strength and balance, exercise and walking physically compromised, or those who have practice can prevent falls among older people recently experienced important life events. living in their own homes. Sherrington et al. healthy ageing | injury prevention 109 ------to older people. There was associ consistent but small ation between use of most prescribed inappropriately classes of psychotropic drug psychotropic of classes tropic medications are often and falls. Gillespie et al. (2) in (2) al. et Gillespie falls. and

Acceptability by users of the protectors There was no significant reduction in hip- of hip fracture. No important adverse effects compli but reported were protectors hip the of ance, particularly in the long term, was poor. remains a problem, due to practicality. The discomfort authors and concluded that hip protectors may only help prevent hip fracture liv fracture of risk high very at people those in ing in institutional care. their systematic review suggest that withdrawal withdrawal that suggest review systematic their of psychotropic medication decreases risk of falling among older people. Preventive medical devices randomised 14 of review systematic Cochrane A compared trials controlled quasi-randomised or users of with hip a protectors group to control prevent in protectors of effectiveness the assess (16). people older in fractures hip ing in living people older among incidence fracture with care institutional in those For homes. their a high background incidence of hip fracture, hip protectors appear to reduce the incidence Withdrawal of psychotropic drugs A systematic review Leipzig and et al. (15) meta-analysis examined the effectiveness by neu or antidepressants, hypnotics, sedative/ of and 60 aged people among falls in use roleptics over. Forty epidemiological studies were ana trial). controlled randomised a was (none lysed were people older in falls for factors risk Several prevent potentially as was none but identified, able or reversible as medication use. Psycho - - - - hip fracture. hip Epidemiological studies studies Epidemiological suggest that a higher level of of level higher a that suggest physical leisure activity prevents prevents activity leisure physical - See also Chapter 6, Environment. practitioner in the intervention community versus the control community. pre- versus post-intervention medically-treated medically-treated post-intervention versus pre- fall-related injury incidence in the interven tion community, change in incidence of fall-related injury re ported as having been treated by a medical McClure McClure et al. (5) re all programmes supports the preliminary claim the supports preliminary all programmes to the approach pre that the population-based can and effective is injury fall-related of vention practice. health public of basis the form Despite the methodological limitations of the evaluated studies reviewed, the consistency of across injuries fall-related in reductions reported • • meta-analysis. meta-analysis. Participants aged 65 years and The unit over. of for analysis these prospective The community. was the entire trials controlled review made two comparisons for each study included: change. 23 viewed population-based the for interventions on studies people. older in injuries fall-related of prevention The studies were too to heterogeneous permit dwelling older people at high risk of falling, and can lead to more efficient use of limited social resources to improve both individual health and community environmental intervention strategies that combine various intervention elements for preventing falls and fall-related injuries offer important social and economic gains. They suggest that such efforts are likely to reduce morbidity and mortality rates attributable to falls among community- Marks and Allegrante also argue that system atic efforts to implement risk-assessment and Summary of findings References 110 There is evidence to suggest that: 1. Marks R, Allegrante JP. Falls-prevention • home-hazard assessment and modification programs for older ambulatory commu- by a health professional may reduce falls, nity dwellers: from public health research to especially in those with a history of falling health promotion policy. Soz Praventivmed (2), 2004;49(3):171-8. • a multi-factorial fall-risk assessment and 2. Gillespie LD, Gillespie WJ, Robertson MC, management intervention is effective in re- Lamb SE, Cumming RG, Rowe BH. Interven- tions for preventing falls in elderly people. The ducing the risk of falling among older people Cochrane Database of Systematic Reviews aged 60 and over (12), 2003;(4). a higher level of physical leisure activity • 3. Nandy S, Parsons S, Cryer C, Underwood M, prevents hip facture and certain exercise Rashbrook E, Carter Y, et al. Development and programmes may reduce the risk of falls preliminary examination of the predictive va- (13), lidity of the Falls Risk Assessment Tool (FRAT) • Tai Chi courses and other ways of exercising for use in primary care. J Public Health (Oxf) balance and strengthening muscles, individ- 2004;26(2):138-43. ually prescribed at home by trained health 4. Hokby A, Andersson R, Andersson SS. A professionals, are effective in reducing falls community intervention program targeting the in older people (14), elderly in Stockholm county. Scand J Rheuma- tol Suppl 1996;103:115-8; discussion 9-22. • community fall-prevention interventions are effective in reducing falls and falls-related 5. McClure R, Turner C, Peel N, Spinks A, Eakin E, Hughes K. Population-based interventions injuries in older people (1, 5), for the prevention of fall-related injuries in • careful prescription or withdrawal of psy- older people. The Cochrane Database of Sys- chotropic drugs decreases the risk of falling tematic Reviews 2005;(1). among older people (15), and 6. Spinks A, Turner C, Nixon J, McClure R. • hip protectors help prevent hip fracture in The ‘WHO Safe Communities’ model for the older people at very high risk of fracture and prevention of injury in whole populations. living in institutional care; but there is a lack The Cochrane Database of Systematic Reviews of evidence for older people living in their 2005;(2). own homes (16). 7. Shinoda-Tagawa T, Leonard R, Pontikas J, McDonough JE, Allen D, Dreyer PI. Resident- to-resident violent incidents in nursing homes. Jama 2004;291(5):591-8. 8. Evers W, Tomic W, Brouwers A. Aggres- sive behaviour and burnout among staff of homes for the elderly. Int J Ment Health Nurs 2002;11(1):2-9. healthy ageing | injury prevention 111 - protectors for preventing hip fractures in older people. The Cochrane Database of Systematic Reviews 2005;(3). Sport 2004;7(1 Suppl):43-51. ME. Drugs Leipzig RM, Cumming RG, Tinetti review and falls in older people: a systematic and meta-analysis: I. Psychotropic drugs. J Am Geriatr Soc 1999;47(1):30-9. Parker MJ, Gillespie LD, Gillespie WJ. Hip cal activity, falls, and fractures among older cal activity, adults: a review of the epidemiologic evidence. J Am Geriatr Soc 2000;48(8):883-93. Physical Sherrington C, Lord SR, Finch CF. activity interventions to prevent falls among Sci Med older people: update of the evidence. J Mojica WA, Maglione M, Suttorp MJ, et al. Maglione Mojica WA, in Interventions for the prevention of falls older adults: systematic review and meta- analysis of randomised clinical trials. Bmj 2004;328(7441):680. Pereira MA, Caspersen CJ. Physi Gregg EW, Declaration on the Global Prevention of Elder Declaration on the Global Prevention Abuse. 17 November 2002: WHO/INPEA; 2002. Morton SC, Rubenstein LZ, Chang JT, the recommendations of the World report on of the World the recommendations Health Geneva: World violence and health. Organization; 2004. Missing voices: Health Organization. World on elder abuse. Geneva: views of older persons WHO/INPEA; 2002. The Toronto Health Organization. World Preventing violence: a guide to implementing Preventing violence: Butchart A, World Health Organization. Health Organization. Butchart A, World 15. 16. 14. 13. 12. 10. 11. 9. 112 healthy ageing | introductionl 113

C H A P T E R 1 0 Substance use/misuse 114

The Healthy Ageing project suggests that policymakers, NGOs and practitioners consider the following priorities for action when working with older people:

Promote smoking cessation and the reduction of harmful alcohol consumption among older people. healthy ageing | substance use/misuse 115 - - ral smokeless tobacco he benefits of stopping smoking healthy life expectancy. Epidemiological stud ies have shown that smokers who stop when they are 65–70 years old halve the excess risk of premature death (11). O Oral smokeless tobacco and Swedish snuff are carcinogenic and increase the risk of mortality from cardiovascular diseasee including myo cardial infarction (10). T Every second smoker dies prematurely those who do and lose an average of 13 years in - - - - -

- For search search For . o

acc

The association between smoking and vari Cigarette-smoking begins in adolescence but adolescence in begins Cigarette-smoking The findings in the “Effectiveness of interven The findings in the ob

cidents (7), impotence (8) and eye disease (9). es, gastrointestinal diseases and osteoporosis among other disorders. ous health issues is described e.g. in numerous 4), (3, risk fracture bone as such papers review peripheral arterial disease (5), cancer (6), ac Smoking is associated with increased risk, in of some contracting cases 10–20 times greater, 40 or more different diseases. Smoking causes disease pulmonary obstructive chronic cancers, (COPD), pulmonary diseases, vascular diseas causes death and disability predominantly at smok by caused rate mortality The ages. older age (2). ing increases steadily with advancing Health effects and with smoking acknowledged as a leading cause of death in both developed and develop ing countries, tobacco use is to be regarded as one of society’s biggest ill-health issues for all ages (1). T With almost 1.3 billion smokers world-wide

Literature Review on Healthy Ageing. Literature Review on Substance use/misuse E on assessments made tions” section are based original papers by the authors of the 5, inclusion criteria etc. see Appendix strategy, Effectiveness analysing the association of behavioural fac- 116 of interventions tors with maintenance of health in older populations. The findings indicate that behavioural Two systematic reviews and one literature re- determinants for which there was evidence of view are reported in this chapter. an association with healthy ageing included D. M. Burns (2) reviewed smoking control, not smoking, being physical active, maintain- presenting selected data from epidemiological ing weight within moderate ranges and moder- and behavioural literature that describes and ate alcohol consumption. quantifies smoking among older people and Combining positive health behaviour, high their disease consequences. The review shows physical activity and not smoking increased that the absolute rate of disease incidence and the chances of healthy ageing. Ex-smokers and mortality due to smoking increases steadily with never-smokers with a high level of physical ac- increasing age and the duration of smoking. tivity were two-and-a-half times more likely to Cardiovascular disease is the most com- age successfully than their sedentary counter- mon cause of excess mortality among younger parts. A lower consumption rate also predicted smokers; lung cancer is most common at ages healthy aging (12). over 60 years and at older ages the excess Ketola et al. (13) undertook a systematic death rate from chronic obstructive pulmonery review of randomised controlled trials of lifestyle disease equals that for car- interventions (diet, exercise, diovascular disease. Older Older smokers are smoking cessation, reduction smokers are less likely to at- less likely to attempt to quit of alcohol intake) in work- tempt to quit smoking but smoking but are more success- ing-age adults followed-up are more successful than for one year or longer. The ful than younger smokers if younger smokers if they do purpose was to assess the attempt quitting. The bene they do attempt quitting. effectiveness of lifestyle fits of cessation are proportion- interventions in reducing car- ately somewhat less among older people and diovascular disease risk factors, morbidity and manifest themselves more slowly than among mortality. However, people aged over 65 were younger smokers, but cessation remains the excluded. Twenty-one single-factor and 21 most effective way of altering smoking-induced multi-factor interventions were analysed by out- disease risks at all ages, including the overcome. The study found 18 studies on smoking sixties (2). cessation that were analysed and four of them Countries are implementing healthy-ageing were effective: one in 4–14 targeted participants policies to improve the quality of older people’s stopped smoking. lives. To broaden the evidence base for such In secondary prevention, both single and policy development, focusing on those who multi-factorial lifestyle interventions reduced age well, Peel et al. (12) conducted a systematic morbidity and mortality, and multi-factorial review to present the existing evidence regard- approaches reduced cholesterol levels. Primary ing behavioural determinants of healthy age- (original) prevention reduced risk factors effi ing. The review included longitudinal studies ciently, especially when the intervention was healthy ageing | substance use/misuse 117

- - - evity evity (16). g In a global perspec where the positive health prescribed prescribed medications, and over greatly decrease life. of quality all tive, there is no country conditions, conditions, interfere with effects of alcohol outweigh alcohol of effects

illness, illness, worsen other medical the negative effects. The ECAS The effects. negative the

adults. Alcohol misuse can cause serious serious cause can misuse Alcohol adults. ently mixing alcohol with other ways that are harmful, drugs in excessively alcohol use to begin people some for the first time in their later years. some seniors have used alcohol excessively of their lives, throughout most others drink at low levels but are inadvert study (17) showed increased mortality when alcohol-consumption increased and decreased mortality when consumption decreased. This applied to all diagnoses except mortality from • Drinking per se is not physically or medically light- fact, In adults. older among even harmful, example (for consumption alcohol to-moderate healthy among day) per drink one of average an especially benefits, health have can adults older with regard to heart health and lon promote also may amounts moderate in Alcohol However, and relaxation reduce social anxiety. alcohol misuse is associated with negative health effects, numerous especially among older graphic as graphic older people are the fastest-growing segment of the population. The second is that psychologically biologically, differ people older younger (14). and socially from people older among problems alcohol general, In (15): categories three into divided be can • •

------

quality of life. Alcohol misuse can people.

greatly decrease overall cause serious illness, worsen with prescribed medications, and other medical conditions, interfere misuse misuse people people -

instruments and dia and instruments

alcohol

ol h o associated associated with not c

There There are two compelling reasons to study ing and with ex-smokers and never-smokers a high level of physical activity are two-and a-half times more likely to age successfully than their sedentary counterparts who are past and never-smokers with a low level of physical activity (12). smoking cessation remains the most effec disease risk at all ages, including those over the age of 60 years (2), and non-smoking is associated with healthy age tive method of altering the smoking-induced the altering of method tive alcohol consumption and alcohol-related prob and alcohol-related consumption alcohol lems among older people. The first is demo gnostic criteria are geared to younger to geared are criteria gnostic are able health Further, problems. in older they are often misdiagnosed, and detected under- screening as tiatives related to alcohol-use disorders tend to disorders to related tiatives alcohol-use groups. age younger on focus However, disorders are common among older people and Al Substance misuse has problem among older adults becomeas well as young a people. Media growing attention and public health ini • • and should target high-risk patients with mul cardiovascular disease. tiple risk factors for Summary of findings to suggest that: There is evidence multi-factorial. The authors concluded that in multi-factorial. The optimally be multi-factorial terventions should heart-coronary diseases (no effect) and suicide Falls/fall injuries, functional 118 (a relationship only in the Nordic countries). and cognitive impairment See also chapter 2, Statistics. A systematic review by Reid et al. (18) examined potential relationship(s) between alcohol consumption and: Effectiveness 1) falls or fall injuries, of interventions 2) functional impairment, One meta-analysis and two systematic reviews 3) cognitive impairment, and are reported in this chapter. 4) all-causes. The criteria for selecting the studies were: Risk of coronary heart disease The association between consumption of beer, 1) enrolled participants 60 years of age and wine, and spirits and the risk of coronary heart older; or disease was investigated by Rimm et al. (16) 2) included a broader age range of participants in a systematic review of 12 ecological stud- (e.g., 50–80 years of age) and reported ies, three case-control studies, and ten separate stratum-specific results for older sub-groups prospective cohort studies. The 12 ecological (i.e., 60 years); or studies examined the association between per 3) enrolled predominantly older participants capita consumption of specific alcoholic drinks i.e. mean age 65 years and above. and mortality from heart disease across coun- Twenty per cent of the 84 studies demonstrated tries in men and women aged from 55 to 64 harm associated with increased alcohol expo- in ten studies and 35 to 64 and 35 to 75 in sure, 70 per cent found no association between the other two. These studies showed a strong increased alcohol use and any of the selected inverse association between consumption of outcomes, and 10 per cent reported benefit wine and mortality from heart disease. The from greater alcohol use. Formal meta-analy- association for spirits and beer was weaker or ses could not be performed due to large varia- non-existent. Wine was therefore more effec- tions in the measurement of both exposure and tive in reducing the risk of mortality than beer outcome variables. or spirits. The prospective cohort studies found The results of the study by Reid et al. indicate the same association between risk of heart that the magnitude of risk posed by alcohol use disease and moderate wine, beer and spirits for falls or fall injuries, functional impairment, consumption. The results conflict, case control cognitive impairment, and all-cause mortal- studies finding no one type of drink more car- ity among older adults remains uncertain. Al- dio-protective than the others. though a substantial minority (20 per cent) of studies demonstrated harm, most studies (80 per cent) found The conclusion from this recent work is to no association or benefit beware of drawing far-reaching conclusions regarding associated with increased the protective effects of moderate drinking. alcohol exposure. healthy ageing | substance use/misuse 119 ------ces n e r e Klaver CC, Klein BE, et al. Risk factors for age-related macular degeneration: Pooled find ings from three continents. Ophthalmology 2001;108(4):697-704. ciated with smoking: a meta-analysis. J Intern ciated with smoking: a meta-analysis. Med 2003;254(6):572-83. of Law MR, Hackshaw AK. A meta-analysis and cigarette smoking, bone mineral density risk of hip fracture: recognition of a major effect. Bmj 1997;315(7112):841-6. ML, JA, Bartelink EM, Teijink Willigendael Boiten J, Moll FL, et al. Influ Kuiken BW, ence of smoking on incidence and prevalence Surg of peripheral arterial disease. J Vasc 2004;40(6):1158-65. Buiatti E, Saracci J, Boffetta P, Tredaniel smoking and gastric R, Hirsch A. Tobacco Cancer cancer: review and meta-analysis. Int J 1997;72(4):565-73. Leistikow BN, Martin DC, Jacobs J, Rocke for DM, Noderer K. Smoking as a risk factor accident death: a meta-analysis of cohort stud ies. Accid Anal Prev 2000;32(3):397-405. TO, Osgood ND. The link between Tengs smoking and impotence: two decades of evi dence. Prev Med 2001;32(6):447-52. Assink J, Klein R, Mitchell P, Smith W, opment goals and tobacco control: an oppor opment goals and tobacco Geneve: World tunity for global partnership. 2004. Health Organization; smoking among the Burns DM. Cigarette and the benefit elderly: Disease consequences of health promotion of cessation. The science 2000;14(6). L. Fracture risk asso Mosekilde P, Vestergaard Esson KM, Leeder SR. The millennium devel Esson KM, Leeder f 4. 5. 6. 7. 8. 9. 2. 3. Re 1.

------hol consumption among healthy older adults adults older healthy among consumption hol long increasing and health heart improving in evity (19), due to the recent controversy on 21). (20, studies in reported issue this about the magnitude of risk posed by alcohol alcohol by posed risk of magnitude the about impair functional injuries, fall or falls for use ment, cognitive impairment, and and (18), all-cause adults older among mortality alco light-to-moderate of effectiveness the for for the effectiveness of wine consumption in reducing the risk of mortality compared with that of beer or spirits (16), Recent reviews of epidemiological studies in The main finding indicated that light or njuries and health benefits • • Summary of findings There is inconclusive evidence: • misclassification (21). The conclusionthis recent fromwork is to beware of drawing far- reaching conclusions regarding the protective effects of moderate drinking. co-morbidity of alcohol and medication was not considered in the studies meth of number a raised have field alcohol the odological concerns. These primarily address problems related to confounding (20) and to moderate alcohol consumption (e.g. an aver age of one drink per day) among healthy older adults can have health benefits, especially with regard to heart health and longevity; but the gated the involvement of alcohol in non-traf fic injuries among older adults. They selected 65 medical-examiner studies present also reporting was Alcohol fatalities. non- traffic-injury in 47 per cent of homicides and 29 per cent of suicide deaths. I A meta-analysis by Smith et al. (19) investi 10. Cnattingius S, Galanti R, Grafström R, 18. Reid MC, Boutros NN, O’Connor PG, Ca- 120 Hergens M, Lambe M, Nyrén O, et al. [Health dariu A, Concato J. The health-related effects Risks of Swedish Snuff] Hälsorisker med of alcohol use in older persons: a systematic svenskt snus. Stockholm: Swedish National review. Subst Abus 2002;23(3):149-64. Institute of Public Health; 2005. A 2005:15. 19. Smith GS, Branas CC, Miller TR. Fatal non- 11. Sachs DPL. Cigarette smoking – health effects traffic injuries involving alcohol: A metaanaly- and cessation strategies. IN: Mahler DA (ed) sis. Ann Emerg Med 1999;33(6):659-68. Clinics in Geriatric Medicine: Respiratory 20. Naimi TS, Brown DW, Brewer RD, Giles WH, Diseases, vol 2, pp. 337-62. Philadelphia, PA: Mensah G, Serdula MK, et al. Cardiovascular WB Saunders, 1986 and Vetter NJ, Charny M, risk factors and confounders among nondrink- Farrow S, Lewis PA. The Cardiff Health Sur- ing and moderate-drinking U.S. adults. Am J vey. The relationship between smoking habits Prev Med 2005;28(4):369-73. and beliefs in the elderly, J Publ Health 1988; 21. Fillmore K, Kerr W, Stockwell T, Chikritzhs T, 102: 359-64. Bostrom A. Moderate alcohol use and reduced 12. Peel NM, McClure RJ, Bartlett HP. Behavioral mortality risk: systematic error in prospec- determinants of healthy aging. Am J Prev Med tive studies. Addiction Research and Theory 2005;28(3):298-304. 2006:1-31. 13. Ketola E, Sipila R, Makela M. Effectiveness of individual lifestyle interventions in reducing cardiovascular disease and risk factors. Ann Med 2000;32(4):239-51. 14. Alcohol Alert No. 2: Alcohol and Aging. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism; 1988. Retrieved 09/12/2006 from http://pubs.niaaa.nih.gov/ publications/aa02.htm. 15. An Agency of the Government of Alberta. Al- cohol and Seniors: The ABCs. Alberta Alcohol and Drug Abuse Commission; 2003. Retrieved 09/12/2006 from http://corp.aadac.com/alcohol/the_basics_about_alcohol/alcohol_seniors. asp. 16. Rimm EB, Klatsky A, Grobbee D, Stampfer MJ. Review of moderate alcohol consumption and reduced risk of coronary heart disease: is the effect due to beer, wine, or spirits. Bmj 1996;312(7033):731-6. 17. Norström T. Alcohol in postwar Europe: consumption, drinking patterns, consequences and policy responses in 15 European countries. Stockholm: Swedish National Institute of Pub- lic Health: Almqvist & Wiksell International; 2002. healthy ageing | introductionl 121

and C H A P T E R 1 1

se of medication U associated problems 122

The Healthy Ageing project suggests that policymakers, NGOs and practitioners consider the following priorities for action when working with older people:

Problems associated with the use of medications can be avoided by the systematic use of quality indicators for drug use and better co-ordination among care providers. Surveys of therapies and the inclusion of older people in clinical trials will also help. healthy ageing | use of medication and associated problems 123 - - - -

In addition to these problems, some medi edication error or non-compliance intake also occur such as duplication and in take of wrong dosage. Many attempts been made have to diminish medication errors and improve compliance. So no far, ideal solution to these problems has been found. cines used today by older people have not been been not have people older by today used cines tested in this age group. It is obviously neces sary to test new medications in the group who will use them most. M Many patients do not adhere scribed to drug their regimen. Among pre symptom-free patients on long-term treatmentsometimes missed, doses while among are those using several different medications, errors in drug - -

se of medication and

he literature on the and use associated problems is extensive. The of medication accessibility to doctors, pharmacies, difficul pharmacies, doctors, to accessibility ties in opening drug packages, interactions with other treatments – herbal medicines. inappropriate prescribing, interactions, adverse reactions, use of drugs carrying risks, of lack to due under-use example for others, The drug-related problems can be catego medication error/non-compliance, For search strategy, inclusion criteria etc. see inclusion criteria strategy, search For

is undergoing is an important explanation of the the of explanation important an is undergoing is meet. might patient older an problems drug • patient a therapies all of overview an of lack The • • • • • rized as follows: • problems problems in the These elderly. include adverse medicines. of under-use and reactions drug World World Health Organisation (WHO) has in its publication Priority Medicines for Europe and (1) the the summarized World recent literature a of burden disease the of nature and size the on drug-related of and diseases geriatric of number T

E Review on Healthy Ageing. appendix 5 Literature U associated problems Inappropriate prescribing admissions due to ADR varies from around 124 Many older people are prescribed drugs be- four per cent in young people to 16 per cent cause of their symptoms and not on the basis and even more in older people. A meta- of a diagnosis. The consequence might lead to analysis suggests that ADR rank between the inappropriate therapy. This has been shown fourth and sixth cause of death in hospitalised for benzodiazepines and NSAIDs28 and other patients. The percentage of preventable ADR preparations. Another example of inappropri- in the elderly ranges between 28 and 51. In ad- ate prescribing is when the prescriber has not dition to human suffering, the costs of ADR taken into account the patient’s renal function are considerable. or weight. Other drug-related problems Interactions Under-use of medication is an under-esti- Studies of the importance of drug-disease inter- mated problem but occurs frequently among actions are contradictory, but there is evidence older patients. It can be explained in several that the most common potential drug-disease ways: interactions involve calcium-channel blockers 1) There are older patients who do not contact in patients with heart failure; aspirin in those a physician for their health problems; with peptic ulcer disease, and beta-blockers in 2) There is under-prescribing by physicians; those with diabetes mellitus, peripheral vas- 3) There are economic barriers; and cular disease/Raynaud`s disease, or chronic 4) There are unsuitable formulations and other obstructive pulmonary disease. practical obstacles. The author(s) argue that drug-drug interactions such as the combination of antibiotics and warfarin, or NSAIDs and warfarin, constitute How to improve the a problem; but a smaller one than drug-disease quality of medication use To improve the quality of medication use in interactions and problems linked to the dura- older people, quality indicators for drug use tion of drug use. by such people have been developed. Hanlon Interactions between drugs and herbal medi- et al (5) list the quality indicators that can be cines have recently attracted much interest. of use during routine therapeutic auditing of Thus extracts from St. John’s wort (Hypericum the care of older persons: perforatum) interact with digoxin and anti depressants (2, 3) and ginseng with warfarin in • drugs to avoid, for example long half-life healthy subjects (4). benzodiazepines, • drug-disease interactions, for example beta- Adverse drug reactions blockers in patients with chronic obstructive The risk of adverse drug reactions (ADR) in- pulmonary disease (COPD), NSAIDs in pat creases with the number of individual drugs ients with heart failure, NSAIDs and steroids patients are using. The percentage of hospital in patients with peptic ulcer diseases,

28. Non-steroidal anti-inflammatory drugs healthy ageing | use of medication and associated problems 125 - - - Through the use of the essary laboratory costs. above-mentioned above-mentioned quality reactions and fewer unnec indicators, drug problems in

the elderly might be avoided. the elderly might are the consequence of medication error or non-compliance, inappropriate prescribing and interactions, and can be avoided by the use of quality indi cators for drug use, therapy survey and the trials. inclusion of older people in clinical come key public health issues which should be a high priority issue in the promotion of good people. health and quality of life among older Conclusions problems: drug-related that evidence is There • • There comes a day when frailty and diseases (including co-morbidities) become Therefore use. a drug extensive to turn in leading reality, be safety, patient and drugs, of use rational the

Many older people are prescribed drugs because because drugs prescribed are people older Many drug-drug interactions, for example anti logy is a resource to address this problem. Electronic records can alert to, and thereby prevent, medication errors. This can result in better prescribing, fewer adverse drug a patient is involved with is an important explanation of the drug problems an older patient might meet. For medical professionals involved in a patient’s this reason all treatment should agree on all the therapies involved. Advanced information techno inclusion of older people in clinical may trials provide important information about dosage, efficacy, long-term effects, dosage regimes and safety of drugs. Survey of therapies The lack of an overview of all the therapies Inclusion of older people in clinical trials Inclusion of older people in clinical Some medicines used today by older people have not been tested in this age group. It is obviously necessary to test new medications in the group who will use them most. The required monitoring, for example Interna ACE inhibitors. two NSAIDs, and INR, Ratio, for warfarin, Normalized tional tests thyroid function in taking patient levo thyroxine, electrolytes in patients taking biotics and warfarin, NSAIDs and warfarin, biotics and warfarin, drug duplication, for example more than of their symptoms and not on the basis of a diagnosis. diagnosis. a of basis the on not and symptoms their of The consequence might lead to inappropriate therapy. inappropriate to lead might consequence The The value of using these indicators is now being tested in a number of countries. Other measures to be et al (1) are: Willemen taken according to • • •

• • References 126 1. Willemen M, Jansen P, Leufkens H. Pharma- ceuticals and the Elderly. In: Kaplan W, Laing R, eds. Priority Medicines for Europe and the World. Geneve: WHO; 2004. 2. Johne A, Brockmoller J, Bauer S, Maurer A, Langheinrich M, Roots I. Pharmacokinetic interaction of digoxin with an herbal extract from St John’s wort (Hypericum perforatum). Clin Pharmacol Ther 1999;66(4):338-45. 3. Fugh-Berman A. Herb-drug interactions. Lancet 2000;355(9198):134-8. 4. Yuan CS, Wei G, Dey L, Karrison T, Nahlik L, Maleckar S, et al. Brief communication: Ameri- can ginseng reduces warfarin’s effect in healthy patients: a randomised, controlled Trial. Ann Intern Med 2004;141(1):23-7. 5. Hanlon JT, Lindblad CI, Hajjar ER, McCarthy TC. Update on drug-related problems in the elderly. Am J Geriatr Pharmacother 2003;1(1):38-43. C H A P T E R 1 2 Preventive health services 128

The Healthy Ageing project suggests that policymakers, NGOs and practitioners consider the following priorities for action when working with older people:

Make preventive health services such as vaccination accessible to older people, paying special attention to frail older people. Consider preventive home visits under certain conditions. Take health literacy into account when working with older people. healthy ageing | preventive health services 129 - - - Older people can experience various barri administrative (complicated regulations), and physical (no public transport), cultural (lan guage, religion) or psychological and (lack social of social support to seek medical care). Measures to reduce age discrimination and to enhance access to preventive health services should therefore be further investigated and addressed in healthy ageing strategies. ers when accessing preventive health services. Older people with low socioeconomic status or from ethnic minority groups, ple, for have poorer exam cancer outcomes, which also partly due to lower rates of is screening (4). Older patients may have to wait longer or are less likely to receive appropriate treatment. In addition, the barriers may be financial (high advance payments, out-of-pocket payments),

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The findings in the “Effectiveness of interven The findings in the t is important to continue enable to live independently older in their people own to

tions” section are based on assessments made tions” section are based search For by the authors of the original papers. etc. see Appendix 5, inclusion criteria strategy, Literature Review on Healthy Ageing. Preventive health services E Denmark people over the age of 75 are legally entitled to home visits (2). A similar law exists in Australia, also valid for inhabitants over 75 the of members of exception the with old, years Aboriginal people who are entitled to regular home visits from the age of 55 (3). maling in the improved and rate north mortality reduced a example of Sweden shows for health-related quality of life in the group older of people (see chapter 14, Health promo tion for older people is cost-effective). In care to older people is through regular home visiting (1). The proven effectiveness of home visiting is not unambiguous, as the result of the literature review in this But there is evidence chapter of good results from this shows. intervention. A home visit project in Nord- older people to need long-term people should receive appropriate support and care. Older should also be encouraged to make adequate use of preventive health services. One example of promoting health and delivering preventive I homes. Health promotion and measures are preventative necessary for delaying the onset of illness and dependency that eventually lead Health literacy educational tools can be used. Jacobson et 130 Primarily used in health care to help patients’ al (10), for example, showed that a simple, understanding of health care information, inexpensive, low-literacy educational leaflet the concept of health literacy is increasingly significantly increased both pneumococcal becoming an issue in health promotion. Health vaccination rates and discussions with the literacy can be defined as “the capacity to health care provider about the vaccine in an obtain, interpret and understand basic health elderly, low-literate, minority population. information and services and the competence to use such information and services to enhance Effectiveness health” (5). The concept of health literacy is therefore closely related to the concept of of interventions empowerment. One meta-analysis, one meta-analysis with Survey results (6–8) indicate that health meta-regression analysis, one systematic review literacy is lower among older age groups. with meta-analysis, one systematic review and This has enormous importance because of this one review of community interventions are group’s high prevalence of chronic disease. A reported in this chapter. relationship is found between health literacy and knowledge of chronic disease (9). Older Vaccination people with inadequate health literacy know Influenza can cause serious illness and death significantly less about their chronic disease among individuals aged 65 and above (11). than those with adequate literacy. Health pro- Vaccination against influenza is associated with motion and patient education need to consider reductions in hospitalisation for heart disease, health literacy skills. Even in well-educated cerebrovascular disease, pneumonia, influenza older people, communication methods should and the risk of death. Strategies to increase be adapted to a poorer comprehension of vaccination levels include reminder systems; written health care information (7). mass mailing reminders encourage people aged Older people with inadequate health literacy 50+ to receive an influenza vaccination, and are more likely to report failure to receive they are cost-saving (11). vaccinations and cancer screening (8). The level of education was not a significant predic- Home visits tor of use of preventive services. It appears that Reviews on the effectiveness of home visiting health literacy, rather than level of education, programmes for older people have produced is a more meaningful predictive factor for older discrepancies in findings due to different people in their use of preventative services (8). methodological approaches; therefore reviews This has important implications for the have reported both inconsistent and consist- design of interventions to increase the use of ent evidence of effectiveness for some outcome preventative health care. If older people with measures (12). low literacy skills are less likely to receive The systematic review by van Haastregt et vaccinations or cancer screening, then strate- al. (13) investigated the effectiveness of home gies such as reminder systems and low-literacy visiting in improving the health of people aged healthy ageing | preventive health services 131

- - - - Regarding home care interventions that tend beyond home visits, ex Hughes et al. (15) suggested have that home care on impact significant a has acute hospital use and sig nificantly reduces hospital readmission days, small-to-moderate with effect sizes. Hughes et al. (15) meta-analysed 22 studies been neglected. care might otherwise have on home care selected from a significant reduction. Over people whose need for hospital hospital for need whose people

was

Stuck et al. (14) conducted a meta-analysis status in older people. Meta-analysis showed no overall significant reductionhome admissions but meta-regression analysis in nursing- suggested that in trials with more than visits, nine there visits preventive that showed meta-analysis all, had little effect on functional status. an initial 412 references. Home-care interven tions may include, besides visits, installation of emergency alarm systems, adult day care or foster care. and meta-regression analysis of 18 European and North American trials effect to of evaluate preventive the home visits on home nursing- admissions, mortality and functional reducing mortality and admission to long-term to admission and mortality reducing meta-regression the However, care. institutional analysis by Stuck et al. (14) only found such effectiveness after nine visits. Elkan et al. (1) found no significant reduction in the number of admissions to hospital, explained which by could increased be admission of older

- - - - Reviews on the Reviews on the evidence of effectiveness reviews have reported both inconsistent and consistent for some outcome measures. for some outcome measures. programmes for older people programmes for older people effectiveness of home visiting effectiveness of home visiting have produced discrepancies in have produced discrepancies dological approaches; therefore dological approaches; therefore findings due to different metho - The systematic review and meta-analysis None of the trials of 15 studies by Elkan et al. (1) assessed the effectiveness of home visits to people aged 65 in effective was visiting Home above. and years evidence of effectiveness This approach. methodological their is measure for any outcome the with re did for not any allow combination (14) al. et Stuck and (1) al. et Elkan e.g. of sults analyses. meta-regression and meta-analyses on population selection and compliance. In addi tion, they comment that the wide range and multi-dimensional nature of intervention types may have further weakened the strength of the review’s findings. The reason for of the failure van Haastregt et al. to find any consistent and inconsistent between trials. The authors report that the trials generally failed to provide details on delivery, of mode its including intervention, the reviewed reported negative any effects of inter vention. The effects observed of appeared home to visits be modest following five categories: psychosocial functioning, physical function, falls, admission to institutions and mortality. this review, six were carried out on populations on out carried were six review, this aged 75 or over, and the remainder covered In nine trials, the interven those aged over 65. tions lasted more than two years and in seven Out year. a visits two least at of consisted they come measures included the 65 and over living in the community for a wide a for community the in living over and 65 in identified trials 15 the Of outcomes. of range Summary of findings References 132 There is evidence to suggest that: 1. Elkan R, Kendrick D, Dewey M, Hewitt • vaccination against influenza is effective in M, Robinson J, Blair M, et al. Effectiveness reducing hospitalisation for heart disease, of home based support for older people: cerebrovascular disease, pneumonia, influ- systematic review and meta-analysis. Bmj enza and the risk of death (11), 2001;323(7315):719-25. • home-care interventions for older people, 2. Danish Law. [Law about preventive home- extending beyond home visits, are effective visits to older people] Lov om forebyggende in reducing the number of days spent in hos- hjemmebesøg til ældre m.v December 1995: pital readmissions (15), Lov nr. 1117 af 20/12/1995 §1–3. • home visits can have modest effects in reduc- 3. Byles JE, Francis L, McKernon M. The experi- ing mortality, and the evidence is stronger ences of non-medical health professionals undertaking community-based health assess- for younger populations aged 73–78 years; ments for people aged 75 years and over. but not for older populations aged 80 and Health Soc Care Community 2002;10(2):67-73. above (13, 14), and 4. Mandelblatt JS, Yabroff KR. Effectiveness • home visits are effective in reducing admis- of interventions designed to increase mammo- sion to long-term institutional care/nursing graphy use: a meta-analysis of provider-targeted homes for older people (14), and the evidence strategies. Cancer Epidemiol Biomarkers Prev is stronger when older people are followed 1999;8(9):759-67. up with more than nine visits. 5. U.S. Department of Health and Human There is inconclusive evidence for: Services: Office of Disease Prevention and Health Promotion – Healthy People 2010. • the effectiveness of preventive home visits in Nasnewsletter 2000;15(3):3. improving the psychosocial functioning of older people (1, 13, 14), 6. Baker DW, Gazmararian JA, Sudano J, Patterson M. The association between age and health • the effectiveness of home visits in improving literacy among elderly persons. J Gerontol B physical functioning or reducing physical Psychol Sci Soc Sci 2000;55(6):S368-74. decline in older people (1, 13, 14). However, 7. Gausman Benson J, Forman WB. Comprehen- in trials including multidimensional assess- sion of written health care information in an ment and follow-up visits, meta-regression affluent geriatric retirement community: use analysis has shown reduced functional of the Test of Functional Health Literacy. decline, but not in other trials (14). Gerontology 2002;48(2):93-7. 8. Scott TL, Gazmararian JA, Williams MV, Baker DW. Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Med Care 2002;40(5):395-404. healthy ageing | preventive health services 133

Impact of home care on hospital days: a meta analysis. Health Serv Res 1997;32(4):415-32. admission and functional decline in elderly admission and functional decline in elderly people: systematic review and meta-regression analysis. Jama 2002;287(8):1022-8. FM, Hughes SL, Ulasevich A, Weaver Manheim L, Kubal JD, et al. Henderson W, E, de Witte LP, Crebolder HF. Effects of Crebolder HF. LP, E, de Witte living preventive home visits to elderly people Bmj in the community: systematic review. 2000;320(7237):754-8. CE, Stuck AE, Egger M, Hammer A, Minder home Beck JC. Home visits to prevent nursing of home visiting or home-based support for of home visiting or home-based support WHO older people? HEN Synthesis Report. Health Evidence Regional Office for Europe’s Network (HEN); 2004. van Rossum van Haastregt JC, Diederiks JP, controlled trial. Jama 1999;282(7):646-50. controlled trial. Jama CL, Berg GD, Thomas E, Silverstein S, Neel utilization service medical Reducing M. Mireles control by encouraging vaccines: randomized led trial. Am J Prev Med 2004;27(4):284-8. Elkan R, Kendrick D. What is the effectiveness disease. Patient Educ Couns 2003;51(3):267- disease. Patient Educ 75. DM, Morton FJ, Thomas Jacobson TA, Ray S. Use of a low- Offutt G, Shevlin J, tool to enhance literacy patient education rates. A randomized pneumococcal vaccination DW. Health literacy and knowledge of chronic Health literacy and knowledge DW. Gazmararian JA, Williams MV, Peel J, Baker MV, Gazmararian JA, Williams 15. 14. 13. 11. 12. 10. 9. 134 healthy ageing | good practice 135 C H A P T E R 1 3 Good practice 136 healthy ageing | good practice 137 - - - ce ti ac r p ood g of es l p m a Staff working with the direct target group The sixteen projects address the promotion in people older all target projects the of Nine with an intervention group and a control group. control a and group intervention an with One includes all residents of three homes for projects are nationwide and older people. Two one is connected with a trade union. are mostly volunteers and public-health pro fessionals, health visitors carers of and older people, but other professional professional groups may also be involved. Researchers are transformed into programmes or with integrated continuing operations. One example is the description of the Scottish Mental Health Later Life programme. in and Well-being Ex The examples of good practice serve as illus trations of interventions that are successful, transferable and sustainable ways of promot ing healthy ageing. The aim is not a complete overview of good demonstrate practice. much know-how and new The ideas examples on how to cope with the ageing process in an active and positive way. of healthy ageing in later stages of life (50+). They reflect creative solutions to at least one major problem and inequality in health. the community. Six are scientifically designed

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ood practice in health promotion is based on evidence: statistics, research and ex Sustainability when working with public The Healthy Ageing project has collected NGOs play an important role, as the many

The range of factors affecting health means Good practice questionnaire sent to the The result is project presented below (see also partners. www. healthyageing.nu). health is of great importance. Many examples of good of practice are the intended to be voice and promote the interests of older people older of interests the promote and voice projects several presents Union, European the in on the Healthy Ageing website. sixteen examples of good practice using a housing and the facilities and environment, education. See community also Framework page 22. examples in this field show. Platform Older (AGE), People’s which aims to The European volving most sectors, and operating at all lev els of society. People making changes in their daily lives is a vital component, but their abil ity to make these choices is often determined by issues that are harder for an individual to influence, such as access to work, quality of perience from projects, programmes etc. This chapter seeks to show good practice from EU Member States. action is required across all policy areas, in G responsible for the planning and implementa- into Swedish society and to show methods to 138 tion of projects. The projects are mainly funded maintain control and psychological well-being. locally, regionally or nationally with budgets The Hambleton Strollers Working for Health for two-to-three years. is another example of equity, as it aims to en- The present Report describes the aims and courage sedentary, disadvantaged and older the outcomes of the sixteen examples of good individuals to take up walking. practice. A full description of the examples, and the questionnaire, are published at www. Some examples from the projects healthyageing.nu. • older people act as peer counsellors for fellow citizens, The most common major topics • art, exercise and therapeutic writing are used Most projects cover several major topics/health in group psychotherapy to empower and determinants. The most common are “social socially activate older people, capital” and “physical activity”. Most of the • health visits to elderly immigrants, 60 + and projects where social capital is a major topic use to older people 75 +, physical activities such as walking for solving problems related to loneliness and coping • day centre for elderly immigrants, physically with ageing. Three projects focus • self-reflection and self-perception as an inte- on social capital and mental health. One aim grated project part, is to alleviate loneliness by creating psycho- • local telephone help lines for older people, social groups for rehabilitation. Another is to • “Third Age Popular Universities” for train- empower older people to participate in health ing and education, programmes and activities. Two projects focus solely on physical • turning local circumstances (winter, snow, activities. The Norwegian project seeks to prove ice) into a resource by opening a privately- scientifically the importance of correct train- owned heated football stadium for walking ing for physical strength, fitness and balance during icy winter months, and at identifying appropriate testing equip- • arranging transport to sports or cultural ment for measuring its results. The Dutch activities, project, using earlier scientific research, is dis- • engaging e.g. local shopkeepers to inform seminating results to all regions. Seven projects on exercise and nutrition at the local super- focus on injury prevention in connection with market, physical activity. They regard injuries and falls • organised walks and “walk packs”, as mostly connected to individuals rather than to the environment. One project has a municipal • production of "map walk" leaflets for inde- technical department as a collaborator. pendent walks. From an equity point of view a project such as Bozorgan Day Centre is interesting as it aims to promote health and well-being for older Iranian women, and their integration healthy ageing | good practice 139

------Older people participating in the projects Projects aimed at alleviating loneliness may barriers. Integration demands new efforts from efforts new demands Integration barriers. the and community, empowerment may influ consump the reduce and positively health ence tion of social and health services. Programmes focusing on “health literacy” have in improved eating resulted habits and an increase in physical activity. Evaluation and outcomes A careful description of a project, objectives and its activities, gives a aims, fair basis for exchange of experience and is a prerequisite for quality transparency, assurance and evalu ation. Quantitative and qualitative methods, in combination or alone, are most often used in the projects. Measuring before two and projects four in done was intervention and after had external final evaluations. Questionnaires, analy cost-utility and interviews health-profile ses were used. whether care health less consumed exemplified the project focused on physical, educational or social activities. There was also a decrease in mortality in groups offered home visits by health care visitors. lead to cognitive improvement and improved psychological well-being, especially for older immigrants with severe cultural and language reduces the need for specialised home-care serv home-care specialised for need the reduces and effective cost is It care. institutional and ices benefits quality of life. sav indicates project Braveheart The health-economic the of analysis ings in hospital beds through implementation of the project. The cost-analysis of preventive home in savings showed Sweden in visits home care, in-patient care and emergency visits to general practitioners.

- - - - Collaboration and shared responsibility be Cost benefit analyses cost-benefit no projects the of eight In were carried out. The Keep Walking people older project in activity physical that concluded tween a local municipality, health care and a special group for discussions, project progress reports and suggestions for improvement seem to benefit the management of activities. and definition approach of qualityscientific standards. Reference project’s the to made also was with randomised controlled trial and review of application systematic A board. ethics an by sophisticated quality quality. project increase management/assurance probably could methods Nine projects did not on answer quality the management question assurance. The referred rest to systematic teamwork, supervision, process evaluation, external evaluation, docu mentation, continuous monitoring, reflection and want different kinds of activity, need dif fering encouragement to participate or require more effort. People with a disability must also be given special consideration. Quality management assurance Six projects give special attention to gender and gender to attention special give projects Six such, as gender-sensitive not Though inequality. one project addresses inequalities in health for older people, including migrant seniors, with low socioeconomic status. People often need promoting healthy ageing demonstrates efforts the to take up the challenges involved in activating older people physically and stimu lating them socially. Inequalities Innovative perspective The variety of activities offered in the projects Transparency and documentation by getting people to know their surroundings. 140 The analysis of transparency and documenta- “Walking” is then also about finding suitable tion is positive. The original grant application paths and interesting places away from traffic submitted by the programme/project(s) sets and providing self-help information. Walking out the aims and objectives. The results – as programmes may improve both physical and far as they are available, depending on how far mental health and can lead to new friends, but the project has progressed – are presented in invitations have to be active or they will reach reports and /or as scientific papers. Not all the only the already enlightened. Safety during documentation is in English. outdoor wintertime activities requires special efforts when the target group is older people Potential for replication and transfer with decreased functional capacity. The examples of good practice have been It may take a long time and hard work to in- piloted locally, and in some cases similar volve the least motivated people – often also the projects are being implemented in other parts most needy – in activities. “Open” programmes of the country. Most of the projects are con- with focal points such as “women’s get- sidered suitable for replication and transfer togethers”, “men’s breakfasts” and “regulars’ to other European countries, account taken tables” (for men and women caring for some- of cultural and other environments. Detailed one at home) may prove successful in this project descriptions, transparency, scientific respect but need to be combined with actively approach and links to international networks inviting those who do not attend. such as the WHO Healthy Cities project increase The gender perspective demands special the potential for replication and transferability. attention. Women and men have different health needs and different ways of dealing with Experience from good practice health issues. More must be learned of how How to involve the least motivated men relate to health promotion and what issues One crucial question for health promotion is they judge are the most important. Women are how to motivate people to change their be- usually more interested in taking part in health haviour. This is especially so for those who promoting activities and special consideration for cultural, social and/or economic reasons must be taken in programme design so as to lack motivation. Most of the healthy-ageing make men feel at home. projects seem sensitive to this issue, involving volunteers or people from the target group in their planning. Awareness has increased about how to motivate passive and sedentary older people to adopt a healthier lifestyle. Many examples of good practice focus on walking, but their aim is not only to improve physical health but also to alleviate loneliness and create “social capital” healthy ageing | good practice 141

- - - - - Training Training manuals, teaching materials for Partners for healthy-ageing projects can be Problems to overcome Lack of money and weak support from politi usual most the were decision-makers and cians problems mentioned in the project question naires. It is important to and work strategically involve politicians and decision-makers early in the process of defining and planning How to disseminate the messages The more effort that is invested semination in of the knowledge dis about the project, the more likely it is to reach the general pub lic and get support from opinion leaders and the media. Publication of articles in the local other and lectures and discussions public press, known messages the making of ways are events among politicians, organisations and people, who then may older act as pressure groups on their own behalf. Internet the and pamphlets volunteers, and staff knowledge professional transfer to used be can to non-professionals and interest them in the programme. Develop resource and press local the lists in activities advertise topics, for the get the project “branded” so that people can recognise and identify with it. And “translate” research papers into messages understood by ordinary people. issues are considered. For professionals and politicians, cooperation with trained volun teers is an inexpensive way of disseminating messages: the collaboration affords valuable way the and group target the about know-how disseminated. messages are best organisations for the retired, study trade unions, organisations, churches, Lions Clubs, etc. sports associations,

------Collaboration between professional staff Many of the projects were set up in col are well-founded. An important task for pro fessional staff is to point out at risk target or with groups special needs. They may also ensure that knowledge is evidence-based and that ethical, cultural, scientific and technical finished. and trained volunteers benefits both parties: the volunteers gain new knowledge and assurance that their knowledge and arguments the people as volunteers and participants. Volun teers committed to the programme, dedicated staff members and target-group participation were of crucial importance for the success of the projects. Some project groups even con tinued to meet when the actual project was volunteers interacted with the target group of older people. The voluntary organisations felt to priority gave organisations public when that the project, this then also stimulated them to older many attracted turn in which participate, partnershippossibilitytheaction,long-and of term financing increases. Agroup may specialbe needed project for reporting and dis cussions about progress. laboration with voluntary organisations, and to the development and implementation of a healthy-ageing agenda. A politically and supportive strong management group, sharing the responsibility between the and the municipalitylocal health care district, encourages as the European Commission, European NGOs European Commission, European the as and the WHO seems to give projects a higher status and a better chance nised at national, of regional and beinglocal levels. A recog city’s successful application to the WHO for healthy-city status could prompt commitment Collaboration for health promotionsuch organisations international with Affiliation for a project. Referring to successful projects in Conclusions 142 other areas or countries or membership of an The 16 projects presented indicate the impor- international network may help to create more tance of sustainability in public health work. status for the project – and for those deciding The possibility of transforming projects into to set it up. Difficulties related to project man- programmes should be included in the planning. agement and collaboration with other institu- Collaboration at several levels is needed for tions may be alleviated by careful planning effective health promotion. Most of the projects and clear division of responsibilities. “Project are viewed as replicable in other countries. fatigue” is not unusual in municipal depart- The most common major topics in the ments and health care: it is important to fit the projects were social capital and physical ac- project into the normal forms of activity. This tivity, often in combination. They may lead may also ensure a life beyond the time frame of both to improvement of physical health and the project. alleviation of loneliness. When evaluating A problem that can only be dealt with projects targeting physical activity, it may be through information and education is the important to look outside the direct goals and length of time needed for behaviour change, measure how people interact and make friends, and that change requires multi-level collabora- thus contributing to “social capital”. tion. One example is how attitudes to smoking The key issue is how to motivate people to have changed during the past twenty years. Re- change habits, especially those who for cultural, sults of health promotion also take a long time social and/or economic reasons are least moti- to prove, and are difficult to prove statistically. vated. Older people may be very sensitive to Increased well-being affects the development suggestions for lifestyle changes from younger of disease and thus has consequences for the people. Gender, too: men are more difficult to economy of health care. Many diseases that motivate to participate. The projects suggest can be prevented by a healthier life style take a that involving people from the target group in long time to develop, so decreases perhaps can- the planning and implementation phases may not be seen in statistics until after many years. activate the less motivated and encourage their Health promotion is – and should be – an participation. ongoing activity: new target groups will always Cost-benefit analyses of programmes - acti appear, outside the current aims of the activity vating older people indicate that they benefit and the age of the target group. It is important quality of life and reduce the consumption of to involve older people in the planning and health care. implementation of projects and to rely on their knowledge and experience when designing activities. One challenge of the Healthy Ageing projects is the issue of empowerment: how powerful older people are allowed to be when dealing with their own health and well-being. healthy ageing | good practice 143

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participation and great interest of residents residents of interest great and participation Regi activities. project in staff and Health, People’s Older on ference homes for newsletter in information lifestyle media. regional in and people older for two-thirds of the participants a reported health condition which could improve through exercise, fifty-five per centsince walking of frequency their increased of the walkers have joining the scheme, “socialising" was a significant reason for joining the scheme. The learned walkers where to walk have and with whom. Walk packs will help with this, but assessment has yet been carried out. no improved food intake in A homes for Region. older Bohemia North the in people to encourage sedentary, disadvantaged and older individuals to take up walking. England Outcome According to the Health Walk naire: Question • • Outcome • Hambleton Strollers Walking for Health The aim is • • •

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or more information, see www.healthyageing.nu F epublic R

behaviour from passive survival to active control and enabling them to participate in social activities. to improve life expectancy, health quality of and life for the elderly by improv ing their health literacy, changing their become a hot topic in political discussions political in topic hot a become and in local and provincial government planning. that the target groups participate in work groups and in the programmes, that target group members participate in training and qualifying activities, and that health promotion for the elderly has to create a healthy environment by sus taining the programmes developed. to develop and test initiatives to promote healthy ageing in a community through setting participation of target groups, gender equity also considered, and he Czech ist of good practice examples Austria The aim is • The Healthy Region of North Bohemia – Add Years to Life and Life to Years • • Outcome The project is still in progress but some ex pected outcomes are: The aims are • Promoting healthy ageing in a community setting • • t L

finland italy 144 Research and development project AUSER RisorsAnziani – ONLUS self- for geriatric rehabilitation/Loneliness management of services and action of the elderly The aims are The aim is • to develop social promotion and solidar- • to alleviate loneliness among the elderly ity activities, especially for the elderly and and to improve their quality of life. between generations, • to improve quality of life and relation- Outcome ships with other people, • loneliness was alleviated among elderly • to maintain and develop active cognitive persons in the intervention groups, skills, • intervention group members showed • to create, in collaboration with public in- more improvements in health, cognition, stitutions, structures for social networks psychological well-being and number of and family support services in the neigh- new friends than controls did, and bourhood, and • the group continued to meet after the • to promote active citizenship with re- direct intervention. sponsible participation of citizens in order to defend human rights. Keep Walking Outcome The aim was The project has not yet been evaluated. • to improve functional capacity, quality of life and autonomy among frail 75 + people living at home by increasing their Older people opportunities to walk and move outside as resources for the community their homes. The aim is • to shift attention from the elderly person Outcome as a service and intervention beneficiary • the aims of this action research project have been well achieved, to a person with experience, skills, com- • outdoor mobility among the target group petence, practical and theoretical abilities, remained constant or improved, history and wisdom – a resource for the • services were developed for the target area, the town and the whole community. group, outdoor mobility environments Outcome produced new ideas (benches for resting, The project has not yet been evaluated. slower traffic lights, accessibility), social support models were improved (outdoor and shopping companions were established and trained), and • outdoor mobility was included in home care planning and could be ordered in the same way as meal services. Netherlands 145 Groningen Active Living Model (GALM) • referrals were mostly to a general practitioner, dietician, optician, audiologist or

The aim is practice good | ageing healthy elder care consultant, • to get non-active or insufficiently active • experienced health did not change after seniors (55–65 years) to become and the intervention, stay active. Orientation towards healthy • loneliness decreased, seniors as well as those suffering from a • younger seniors were more likely to chronic disease and/or physical handicap. change their health behaviour than older Outcome seniors, and • the pilot studies proved that the GALM • evidence of early diagnosis of health prob- Strategy encourages sedentary seniors to lems and growing self-reliance. be more active physically, and • the project had positive effects on endur- In Anticipation of the Golden Years ance, fitness, leg-power, dynamic balance, litheness in shoulders, BMI and nutrition. The aim was • to improve pro-active competencies and stimulate investment in a (personal) future Periodic Preventive and prepare for aging. Senior Health Screening Outcome, process evaluation The aims were • attendance rate was satisfactory and the • for older persons to get insight into their applicability of the techniques used was own health and how to age healthily shown. using early and periodic screening, health education and, if necessary, referral to Outcome, effect evaluation relevant health professionals, and • participants’ pro-active coping competen- • as sub-aims, individual and joint health cies and approach to preparing for aging profit; increase in client’s self manage- improved significantly. Results remained ment; possible shifting of use of home- stable three months after completion of care provision; staying healthy as long as the intervention, and possible; social participation. • no negative side-effects in terms of wor- rying or negative mood, nor generalised Outcome effects on self-efficacy. • most advice was given on high blood pressure, cholesterol, weight, fluid intake and physical activity. The proportion of participants who followed up on the advice given was 74–91 per cent, • when advice was given on high blood pressure, blood pressure became lower, norway • to increase the information and guidance 146 Study A: Effects of a multi-factorial available to help participants make life- training programme on physical fitness style changes to improve well-being, and physical function in a group of older • to enable participants to make more people informed choices, • to increase independence and improve the The aim was well-being of participants in community • to determine the possible effects of a life, and multi-factorial training programme on • to reduce the likelihood of hospital admis- physical fitness and physical function for sion. a group of older persons ≥65 years living at home. Outcome • the aims are being achieved for those join- Study B: Comparison of the effects of ing the programme. Behaviour changes high-power-machine strength training include increased physical activity and and functional strength + balance train- improved dietary habits, and ing on functional and traditional muscular • greater awareness and understanding of strength in a group of older individuals diagnosis and medication; benefits from (≥65 years). the social element of meeting others with The aim was similar health issues. • to determine the possible effects of high- power-machine strength training and Stirling Healthy Ageing Project functional strength + balance training The aim was on functional and traditional muscular • to maximise the current and future health strength in a group of older individuals and well-being of people over 50 years in (>65 years). the Stirling area through involvement of Outcome local citizens, local and national organisa- Study A – preliminary results: tions and partner members of the WHO • the training group achieved significant Healthy Cities (WHO HC) Network. (P<0.05) increases in walking speed, aero- Outcome bic endurance and muscle strength, and • the aim of creating a partnership approach • the training group also reported increased between agencies and the WHO HC ADL function and decreased pain experi- project, together with the involvement of ence. older people has been achieved, and Study B – Analysis under way. • improvement in health and well-being will Scotland be assessed once action areas have been developed and implemented. Braveheart The aims are • to increase participants´ awareness of their illness and help them achieve a healthy lifestyle, healthy ageing | good practice 147

health and prevent illness. been have changes social or environmental noted as the social networks have grown; people have got to know each other and learned from each other – social capital has grown. to develop supporting environments for older people to facilitate the development of social networks, to develop co-operation municipality, health between care the district, adult educational associations,organisations, etc to voluntary foster environments for supportive older people reduce health inequalities, to help to increase pensioners’ awareness existing of the importance and social old and new both with lifestyle a of soon-to-be networks, involving participation and in fluence on their lives to promote health, and to broaden the competence of care staff to include systematic efforts to promote was three times as high in group, group as in the intervention the control deaths were half the expected compared to those number with no intervention. During a group. either follow-up in remained effect no project, three years post- (See also Chapter 14, Health promotion for older people is cost effective). the percentage of emergency visits to GPs Outcome • Well-being for older persons in Kristianstad The aims are • • • • • • - - - anxiety gradually decreased, especially enza increased, reduced inpatient care at nursing homes as well as home care, hospital and among the women, the numbers reporting frequent or con stant pain decreased, the percentage vaccinated against influ people and to test the economic feasibility economic the test to and people above persons to visits home preventive of 75 years. to show how a health-economic analysis can be carried out with a focus on older the aims have been achieved and there are there and achieved been have aims the clear changes in the behaviour of the tar get group, there are social changes as well. these women’s life in Sweden to prolong health, sustain the desire to live, enhance feelings of security and maintain control and psychological well-being. to promote health and well-being for older for well-being and health promote to into integration their and women, Iranian and Swedish society, during opportunities and methods show to Sweden Outcome • • Two Two visits per year were made during two years. professionals Two (one district nurse and one social worker) made the visits. Cost-utility analysis of preventive home visits in Nordmaling The aim was • • Outcome The aims were • The Bozorgan day centre • • • •

Mental Health Well-being The programme aims to improve the health 148 in Later Life Programme, and well-being of older people across Scotland Scotland by bringing together evidence of effective promotion of mental health, disseminating Sustainability is of great importance in public the evidence and acting as a catalyst to assist health work. A good example of a health- changes in practice and policy. promotion programme targeting older people is the Scottish Mental Health Well-being in Three interlocking strands Later Life Programme. The programme has three main interlocking The Mental Health and Well-being in Later strands, which have been overseen by a multi- Life Programme by the Scottish Executive is agency national steering group, meeting informed by research (1, 2) as well as consul- three times annually. Sub-groups have been tation (3), with older people, practitioners, developed to support the three key areas of academics and policy makers at both national the programme: and local levels.

“Getting involved was When I was informed that the workshop the best thing I ever did” was going to take place, I couldn’t have “Sixteen years ago when I retired, I suffered been more pleased. Mental health has been badly from depression. I had worked all my the poor relation for too long, and the no- life since I was fourteen and now, suddenly, I tion of well-being – two simple words that had nothing to do. The first few months were mean such a lot – is vital for older people. wonderful – lots of ‘free time’ to go on bus But the thing that excited me most was that trips, go swimming and take long walks. But the workshop was giving older people like there was something missing. After a while, me the chance to talk about our hopes, all that ‘free time’ became my prison. I began our fears, our worries and our dreams. It to dread every day. It got to the stage where is those views and experiences that have I couldn’t answer the phone and didn’t want shaped the action plan that developed from to go out. I had lost my way, and the more I the workshop, and it is those views and ex- said ‘I can’t cope’, the more I believed it. periences that should now determine how My doctor could see what I couldn’t. I the action plan is brought to life.” needed something to do – to be part of the community again. I took the doctor’s advice, Nell McFadden, participant in a course to and the struggle to regain control of my life promote older people’s participation (1). started. It wasn’t easy and, like all of us, I still have my moments, but I now have my life back. healthy ageing | good practice 149

ces n e r e Report of a regional seminar programme, April–May 2004. Edinburgh: NHS Health Scotland; 2005. Mental Health Improvement: What works? A briefing for the Scottish Executive. Edinburgh: Health Education Board for Scotland; 2002. people’s perceptions. Edinburgh: NHS Health people’s Scotland; 2004. in Later life: Mental Health and Well-being by Mentality for Mental Evidence Review, Health Foundation and Age Concern Inquiry, 2004. Mental health and well-being in later life: Mental health and well-being in later life: older Mental health and well-being in later life: f family and friends, positive attitude, keeping active, maintaining capability and independence, and negotiating transitions – including financial security. amily and friends – a key issue 4. 2. 3. The most effective initiatives input. some had themselves people older which were ones in of influence positive the to points evidence The health mental on belief religious and spirituality in later life. The importance of individual and ability the and purpose of sense support, social to let go of one’s worries and responsibilities were also important (4). Re 1. F The key aim of the “Mental Health and Well- being in later life – older perception” people’s the highlight people older help to was research issues that affect mental health and well-being key issues were: in later years. The • • • • •

- - - - gathering the evidence and supporting the The programme aims to develop the exist Another example of capacity-building is A third example is support to interesting One part of the capacity-building efforts is practice, capacity-building (Health in Regional Later Interest Groups; Life Award Scheme; Education Small for Participation Project Courses), and resource development. knowledge transfer of evidence and good people are appropriately represented relevant publications. in all information and and training evaluation monitoring, planning, including to the projects, data collection, and communication. older that ensure and resources of portfolio ing and innovative work through a Small Projects Scheme. The projects have been funded Award on the basis that they involve tackle older health people, inequalities and ensure partner ship working; and are committed to evalua tion. The programme is providing support, Health in Later Life Regional Interest Groups. across established been have groups such Three Scotland. Education for Participation courses. The aim is to maximise older people’s contribution to partnership-working to ensure that the older person’s voice is heard and is effective, to en courage confidence, participation and feeling of community belonging. The programme is working in partnership with with partnership in working is programme The older people, policy voluntary organisations and academics. makers, practitioners, • • • 150 C H A P T E R 1 4 Health promotion for older people is cost-effective 152 – physical Environment – social Individual’s goal proﬁle BALANCE repertoire Individual’s

healthy ageing | health promotion for older people is cost-effective 153

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gained during 60 years The construction of QAL indholm : L QALY QALY is nowadays a common measure of ource maximum possible health benefit, for example (QALYs) years life quality-adjusted or years, life subject to overall limits sources”. on health-care re- one of into life of and quality life length bining single scale 24).(figure The axis vertical repre Quality weight 1.0 0.7 Figure 24. S health health gains. It is a composite measure com

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here will soon be millions of hundred-year- of millions be soon will here olds, a shortage of medical professionals ha “Most often, CEA is applied from a societal viewpoint or from the viewpoint of a national health care system. In this implied formulation, decision-maker is the an agent of society at large, and the objective is to achieve the be counted irrespectively of who the benefici ary and the payer are. In the context of health is maximisation welfare health, public and care replaced by health maximisation. One descrip tion of this process runs (1): a societal perspective that is based on welfare economics rooted in utilitarian The goal of society is philosophy. assumed to be the max imisation of Following utility. this view in the evaluation of health care programmes means costs and savings should that all health effects, W Cost-effectiveness analysis (CEA) considered to be a simple and straightforward is often tool for resource allocation. Most common is and, possibly, limited growth Serious consideration of of this scenario requires resources. that the cost-effectiveness of measures for pro moting health and preventing illness among older people to be better understood. is cost-effective T Health promotion for older people sents health-related quality of life. Time free than the costs. In a second, similar study re- 154 from disease is weighted 1, dead is 0 and time ported by Robertson (6), the cost was £ 121 of disease is below 1. The QALYs lived during per prevented fall. a given period are the product of the weighting Wilson reports a study where Yang-style tai and the length of the period. If an individual chi classes were given twice a week to nursing during one year suffers a disease weighted 0.7, home residents. Two hypothetical cohorts were the QALY = 0.7x 1 years = 0.7 QALY. compared and savings in health-care costs were Cost-effectiveness is usually reported as a larger than costs (7). Monro also reports a ratio, the cost per health unit (QALY, gained clustered, randomised community intervention life year etc.). The lower the cost, the better the to promote physical activity for people aged cost-effectiveness of the intervention. 65 and over. The intervention cost was about € 17 000 per QALY gained (8).

Examples of cost- Preventive home visits effectiveness in programmes The Nordmaling study (3) was a randomised for older people controlled trial with 200 healthy pensioners. After two years and four preventive home visits This section illustrates important features in they were compared with 350 controls. Morta measures that have been shown to be cost- lity and, in some respects, use of health care effective. The first example is five studies decreased in the intervention group. A cost- aimed at increasing physical activity among utility analysis showed a moderate cost per older people, analysed in a published review QALY, € 18 500. The analysis was made with (2). The second example is home visits among a societal perspective and a life time span. persons older than 75 years in Nordmaling, Sweden (3); the third is a programme for Hip-fracture prevention preventing hip fractures in Västra Götaland, Analysis of the hip-fracture prevention pro- Sweden (4). gramme “A safe and secure municipality” in Västra Götaland indicates that a comprehen- Physical activity sive information package can be cost-effective Several studies have investigated physical (4). The costs of taking care of the prevented- activity among older people. Munro compares hip-fracture patients would have been larger two hypothetical cohorts aged 65 and older (2). than the actual costs of the intervention. One did aerobics twice a week led by qualified Transferring the reduction in hip fractures the instructors; the other had no intervention. The whole Västra Götaland region, would reduce calculated cost per life year gained was £330. the costs for hip fractures from €60 million to Robertson reports a randomised controlled € 45 million. trial with 240 adults aged 75 years and older The studies reported here apply different (5). Individual home-based exercise was pre- health-economic models, but they all claim scribed and five home visits were made bya that the interventions studied are cost-effective. nurse over six months. For people older than This seems reasonable. The next section 80 years, the savings in health care were higher presents some general observations. healthy ageing | health promotion for older people is cost-effective 155

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r r g e he lyin t e As stated earlier, the societal perspective is Finally, Finally, is it reasonable to presume that recommended by most economists. However, is it that is view this against argument main the unfair to include personal income as a savings will doing so because calculations the in factor discriminate against people with low incomes, for example women, pensioners, ethnic groups and immigrants. strong competitors for their time. Ar When trying to understand the principles of cost-effectiveness analysis one starting point is the typical life-time pattern of consumption societies, western In 25). (figure production and around at market labour the enter people most Illness 60–65. age around retire and 20–25 age in a worker causes a production loss, health hence is a prerequisite for production. So if people can stay healthy or quickly return to health after illness, production will be greater. A socioeconomic analysis takes quence this into conse account, meaning that of the treatment cost is counterbalanced by increased production capacity, usually measured as the individual’s gross income plus employer-paid benefits. Project the youngest age group (30 years) had the than rate participation lower significantly a was later excluded from the older ones (9) and intervention. retired people, on opportunity average, cost for time devoted have to exercise a or other in health-creating the activities. Work lower informal sector, taking care of grandchildren and helping other older people are of course app to old

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es pe r e mm a r g old e Older people have more control of their own their of control more have people Older Given Given the general awareness of this age- the risk of illness is high, the incentives for participation in promoting activities may be significant, health the time cost is low. ro become more obvious when people see their own own their see people when obvious more become cancer. and strokes by hit being generation time and set their priorities according to their own values. In the Västerbotten Intervention of this – the older the patient is, the more cost- more the is, patient the older the – this of effective the treatment. to are likely more people older pattern, disease Reasons measures. other or advice with comply for a rapid change to a more healthy lifestyle age: a hip fracture, for instance, is more severe more is instance, for fracture, hip a age: the older the victim is. health gains Thus of the a prevention potential programme are greater in the older population. Drug example well-known a is hypertension of ment treat Most diseases correlate with age; the risk of disease increases with age as do quences.the conse The incidence diabetes, cancer etc. increases with age. At the of heart diseases, with decreases resistance biological time, same • • • erally that prevention among older people is people older among prevention that erally conditions some are there But cost-effective. that distinguish older people (say 65 older) and from the middle-aged people. These conditions indicate lower costs and better effects in the older group: In health care it is crucial to match ventions and target inter groups. An intervention proven to be cost-effective in group may not one necessarily work well in target all gen state to wrong be would it Thus others. Ar p 156 Consumption Production (paid) Individual’s goal proﬁle

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Figure 25. Production / consumption pattern during a lifetime. Source: Lindholm and Sahlén, 2006.

To some extent it also seems reasonable to In figure 26, unpaid senior production has include consumption in the analysis, and this been added to traditional paid production. The pattern is completely different from the produc- sum represents the age-specific values that could tion pattern (figure 25). There is an obvious in- be used in a health-economic evaluation. Even crease in the consumption of health and social if we quantify and use this senior production, care after retirement. Children also consume however, the entire production ability of older significant resources, mainly child-care and people will not equal that of their youngers. education. So production and consumption Bearing this in mind, it can be wise to make patterns do not follow each other, rather the health-economic evaluations in two steps: first opposite, in that typical individuals consume without production in the calculations and at the highest levels when their contribution to then with production. production is at its lowest levels. Thus, if the Including senior production (taking care of individual’s total contribution to production grandchildren, informal work in associations plus total consumption is included, most older etc.) just like other age groups’ production, can people would be regarded as net consumers make a difference in health-economic analysis. while most people of working ages would be The concept of senior production can also be regarded as net producers. viewed from a gender perspective. A large part It is arguably unfair to regard production of senior production is carried out by women, as non-existent when the target group is older, since women live longer and take greater respon- as production is included in other age groups. sibility for the care of spouses and children. Older people do much of social importance. Figures 25 and 26 illustrate one more impor- The fact that we do not usually include this tant phenomenon. If gained health is measured unpaid senior production in economic analysis in life-years or in quality-adjusted life-years, does not make it less important. the potential gain depends heavily on the age healthy ageing | health promotion for older people is cost-effective 157

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n . . Om det inte känns känns inte det Om ar bästa i 95 % % i 95 bästa ar Consumptio Production (paid) Senior production (unpaid) Total production rk ve Är det något smalt stående så stående smalt något Är det d. det det , , o Pr The Swedish Health Care Act, including The use of time measures can be defended

xt pain and suffering have a time dimension: the longer pain lasts the worse it chronic disease is. that can begin Imagine either in child a hood or in old age the from apart adult and child age. for identical The consequences are at onset. Most people would judge the condi time the since child, the for severe more as tion of pain is longer. A measure without a time the change that can be achieved by treatment. Cost (resources used in health be care) should taken into account gains. A but life-saving intervention will draw not on production resources during added life years. Sometimes these costs are included in analysis, health-economic sometimes not. Their relevance decision-making is still unclear in Sweden. to its preparatory works, does not consider that life years gained or quality-adjusted life years gained conflict with the principles of human international some However, need. and dignity literature has claimed that they do. with several arguments. One is the view that Har lagt till några färger några till lagt Har Te a

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erat och uttöjt och uttöjt erat Total production and its components. Total rger (anpassade ef (anpassade rger indholm 25 years : L vänd 1-spalt 74,5 mm vänd 1-spalt Discussions lead in many countries to the use the to countries many in lead Discussions ource Behåll fä sk att diagrammen från Utgå Men låt dem in omotiv helt an Figure 26: S not been interpreted in this way, as prioritising as way, this in interpreted been not acceptable are criteria some but allowed; not is income while acceptable is need not: others and health- that is interpretation authors The not. is should need of measure a as analysis economic try to estimate the severity of a condition plus of policy documents as guidance. In Sweden for Sweden In guidance. as documents policy of rules general gives Act Care Health the instance, for setting priorities in health care. The most is that universal human dignity prominent rule gives the same right to health care. This has collected through taxes or insurance premiums, premiums, insurance or taxes through collected and they should health be If fairness. distributed of according views widespread to analyses fail to meet them. thesedisregard may decision-makers fairness criteria, potential risks of unfairness when designing the the designing when unfairness of risks potential of purpose the is to consider analysis economic the analysis. The authors see health economic in mainly decision-making, to aid an as analysis for Resources health care are the public sector. of of the target group. The older the group, the to One gain. less way potential to these handle dimension would consequently be unfair A further argument for such a window is based 158 against the young. On the other hand a measure on uncertainty. In general, the more distant in lacking any scale of severity would be unfair to the future an event is, the less reliable are data people with serious conditions. Since serious predictions. Thus a window attaches all impor- conditions are more common amongst older tance to more immediate and certain data and people it would be unfair to them to exclude ignores distant and uncertain data. the dimension of severity. A second argument stresses that life itself is valuable and that people in general strive for Conclusions as long a life as possible. Older people are thus • There are very few cost-effectiveness studies lucky in that they have already lived a long life, of public health interventions with older while young people have not yet had the same people as the main target group. amount of the good “life”, and cannot be sure • However, some examples prove that pro- of ever achieving it either. This way of reason- grammes for older people can be very ing indicates that the value of a prevented death cost-effective. depends on age. In the context of older people, the cost- • The authors of this chapter believe there effectiveness analyst can expect to meet several are some basic biological (risk of illness), ethical dilemmas. One person can convincingly psychological (risk-awareness) and social defend the use of a time-dependent measure (lower-opportunity-cost-of-time) conditions but another can credibly criticize its use. A that distinguish older people (say 65 and possible compromise can be the use of a “time older) from the middle-aged. These condi- window”. Here the follow-up time is reduced tions point towards lower costs and better from life-long to, say, around five years. Within effects in the older group when public-health this window, all costs except production gained interventions are undertaken. are counted, as well as life years gained. After • There exists no consensus about the cost- the window, nothing is counted. Thus the max- effectiveness model. Some variants of cost- imal potential health gain is five years, even if effective analysis are unfair towards older a young life is saved. The window keeps a time people, for instance if production gains are dimension in health but restricts possible vari- counted for people of working ages. The ation to five years. authors suggest as a matter of principle a This idea resembles discounting, an estab- model that tallies with widespread views on lished technique in economics with the purpose fairness in health care use. This may result in of scaling down the weight of events in the different cost-effectiveness models in differ- future. Discounting allows a continuous ‘weight ent countries. reduction’ in future events – the more distant, the less value. A window is more radical in that all events up to our ‘five years’ have full and equal weight, while all subsequent events have zero weight. healthy ageing | health promotion for older people is cost-effective 159 - Cochrane T. Cost effectiveness of a community Cost effectiveness of a community Cochrane T. in over 65 year based exercise programme trial. J Epidemiol olds: cluster randomised 2004;58(12):1004-10. Community Health for health – On the L. Partnership Weinhehall care in a community role of primary health Umeå: Umeå Univer intervention programme. sity; 1997. Munro JF, Nicholl JP, Brazier JE, Davey R, Nicholl JP, Munro JF, 9. 8. - -

ces n e r e Outcomes Managements 2001;8:19-27. home exercise programme to prevent falls. 2: Controlled trial in multiple centres. Bmj 2001;322(7288):701-4. Chi for prevention C, Datta K. Tai Wilson of fractures in a nursing home population: An economic analysis. Journal of Clinical evaluation of a nurse delivered home exercise evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial. Bmj 2001;322(7288):697-701. N, Robertson MC, Gardner MM, Devlin McGee R, Campbell AJ. Effectiveness and economic evaluation of a nurse delivered vgregion.se/upload/Folkhälsa/hälsovinstprojek tet.pdf). Göteborg: Västra Götalandsregionen; 2004. Robertson MC, Devlin N, Gardner MM, Campbell AJ. Effectiveness and economic Report number R 2006:19. Stockholm: Swedish Swedish Stockholm: 2006:19. R number Report National Institute of Public Health; 2006. [”The Health Gain Project” – Public Health Economy and resource allocation.] Hälsovinst- hälso- projektet i Västra Götalandsregionen – ekonomi och resursfördelning. (http://www. a cost-effective exercise for the NHS? J Public a cost-effective exercise Health Med 1997;19(4):397-402. Sahlén K-G, Löfgren C, Lindholm L. of 65? [Is prevention profitable after the age Preventive care home visits in Nordmaling] Är det lönsamt med prevention efter 65? source allocation in health care organizations. source allocation in 1990;6(1): Assess Health Care Int J Technol 93-103. Davey R, Nicholl J. Munro J, Brazier J, could it be the over-65s: Physical activity for Weinstein MC. Principles of cost-effective re MC. Principles Weinstein f 7. 6. 5. 4. 3. 2. Re 1. 160 C H A P T E R 1 5 International policies 162 healthy ageing | international policies 163

- - - - - the corporate sector to achieve a healthier world, promoting health involves building healthy public policy, creating supportive environ ments, strengthening actions, developing local personal skills and re- community orienting health services. health is a positive concept that encompasses that concept positive a is health social and personal resources physical capacities, as well as health promotion goes beyond health care and requires “upstream” maintain investments and improve to health and prevent disease, health promotion focuses on reducing dis peo all enabling and status health in parities ple to achieve their fullest health potential, a range of political, economic, social, cul tural, environmental, behavioural and bio logical factors determine health, requiring the consider to sectors all in decision-makers health consequences of their decisions, of part the on required is action co-ordinated governments, communities, civil society and • The enduring principles of health promotion (2) that underpin all current policy approaches are that: healthy-ageing • • • • •

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O nternational policies Mounting evidence regarding the poten and the UN have and flexible proposed policy frameworks to comprehensive guide both the secure to nations developing and developed health and well-being of older persons. health-promotion model to policy on ageing, including the WHO Health Europe 21 and agenda the for Healthy Cities At the start programme. of the twenty-first during century, which the “longevity WHO the revolution” universally, agendas health will and social drive promotion remains the accepted health policy future. approach now and for the foreseeable tialities and challenges of ageing led to local, national and international application of the all”; and the 1986 Ottawa Charter for Health Promotion (2) which articulated a framework for action to promote health. This vision and mid-1980s, the since progressed has framework Promo Health for Charter Bangkok the as yet, tion in a Globalised World (3) affirms, health origins to the ‘pillars’ of health promotion, in cluding the 1978 Declaration of Alma-Ata (1) which first affirmed that health is a fundamen tal human right and called for multi-sectoral action to protect and promote “health for WH their trace policies healthy-ageing International I Health 21 – Health for local governments wishing to join the move- 164 all in the twenty-first century ment and call their city a “Healthy City” in In 1998, the 51st World Health Assembly en- political commitment, institutional change, joined WHO member nations to implement the capacity-building, partnership-based planning “Health-for-All Policy for the 21st Century” and innovative projects to improve health (6). through relevant regional and national poli- In the WHO EURO region, the programme cies and strategies. The countries of the WHO has evolved over four five-year phases. In EURO region responded by embracing a com- response to the Health 21 agenda, healthy mon policy framework for health develop- ageing became a core theme of the Phase IV ment. Based on thorough analysis of regional (2003–2007) Healthy Cities Network. health problems, the policy (4) set 21 targets The overall goal of the healthy ageing theme for improvement and outlined strategies to is to generate strong political commitment lo- implement change for the period 1998–2005. cally and to introduce policies and planning to “Healthy ageing” was Target 5. ensure a holistic and well-balanced approach Overall, it was recommended that Euro- to the health and care needs of older people. pean health policies should prepare people Becoming a “healthy-ageing city” involves for healthy ageing by means of systematically acknowledging the right of people of all ages planned health-promotion efforts and protec- to live a healthy, safe and socially inclusive life- tion of their health throughout life. The specific style and to enjoy equality of opportunity and strategies proposed were: treatment in all aspects. Strategies to attain a healthy city for all ages involve: • the provision of social, educational and occupational opportunities, as well as physical • fostering a positive attitude to growing old activities, throughout life and combating stereotypes • innovative programmes to maintain physical and negative attitudes to ageing, strength and to correct sensory and motor • promoting greater understanding between impairments at an early stage, generations, • outreaching by community health and social • adopting a life-course perspective that recog- services to support older people in their nises the influence of earlier life experience everyday lives, on health in later life. • consideration of older persons' needs and The cities involved in Phase IV are currently preferences in relation to housing, income developing local profiles of the health of older and other policy sectors to enhance their people for strategies to help them achieve the autonomy and social productivity. above goal.

Healthy Cities WHO active-ageing policy framework Since its inception about 20 years ago and WHO’s contribution to the 2002 Second development by the WHO EURO region, the World Assembly on Ageing, the Active Ageing Healthy Cities movement has spread to 1,000 framework (7) articulates a comprehensive cities worldwide (5). This approach engages health-promotion-based approach to ageing t Environmen – social – physical Individual’s goal proﬁle BALANCE repertoire Individual’s

healthy ageing | international policies 165

- - - Age e Older age the quality of life

uals

d and preventing disability Rehabilitation and ensuring Maintaining independenc

on in indivi In May 2005, the World Health Assembly reaffirmed its endorsement of the Active Age to States Member upon calling framework, ing develop, implement and evaluate policies and programmes to promote healthy and ageing active and directing the WHO to strengthen its ageing programme activities to support the policy vision. of functi with age. It takes into account the interplay between individual and external determining functional capacity from early life factors in to old age. The approach acknowledges multiple the and life-long determinants of health when framing integrated inter-sectoral policy strategies. Considering the diversity of experi ence and ability among the older action: people, of range the a proposes approach course life maintaining independence disability and for healthy preventing older persons, ing functional revers decline through rehabilitation following mild-to-moderate impairments, and ensuring quality of life for people irreversibly disabled or at the end of life.

- - - Range Adult life Disability threshold Maintaining highest Maintaining highest possible level of function , 1997. ickbusch older people as active con K

all and

A life-course approach to active ageing. alache Early life : K Growth and development Central to the WHO model is the life-course the is model WHO the to Central The term “active ageing” is preferred be ource social justice, with a strong gender perspective on health development strategies. approach (see figurethat older 27). people are This not one recognises group homogeneous and that individual diversity increases tributors to and beneficiaries of development. Consistent with the Policy for the 21st century”, the Active Ageing WHO “Health-for-All framework emphasises equity, solidarity and supporting flexible social roles regardless of age and viewing cause it conveys a more inclusive message than message inclusive more a conveys it cause healthy ageing – it encompasses participation civic and spiritual cultural, economic, social, in work. paid and activity physical just not affairs, Active ageing implies a “society for all ages”, Persons – independence, participation, dignity, Persons – independence, participation, dignity, active defines WHO the – self-fulfilment and care ageing as the process of optimising opportuni ties for health, participation and security so as age. to enhance quality of life as people Figure 27: S Older for Principles UN the on Building policy. Functional capacity The UN Madrid International • recognition of the vital importance of 166 Plan of Action on ageing families, intergenerational interdependence, Emerging from the World Assembly on Age- solidarity and reciprocity for social developing in 2002, the Madrid International Plan of ment, Action on Ageing (MIPAA) avoids the terms • provision of full health care, support and “healthy” or “active” ageing. Rather, it states social protection for older persons, that a “positive view of ageing” is an integral • recognition of the situation of ageing indig- aspect of the plan: “the aim… is to ensure that enous persons and the need to give them an persons everywhere are able to age with secu- effective voice in decisions affecting them, rity and dignity and to continue to participate in their community as citizens with full rights” • the harnessing of scientific research and ex- (8). Like the WHO Active Ageing framework, pertise and realizing the potential of technol- the MIPAA advocates an age-integrated society ogy to contribute to MIPAA goals. where older people contribute to, and benefit In sum, there is broad international consensus from, all aspects of social and economic devel- regarding the policy goals and strategies for opment. This vision of positive ageing is to be advancing the health and well-being of older achieved by inter-sectoral action to realize spe- persons. The comprehensiveness and flexibility cific targets in three priorities: securing the in- of these policy models, as well as their founda- clusion of older persons in the process and ben- tion in best-practice health promotion, make efits of development, advancing health and well- them widely useful. The aim now is to ensure being into old age, and ensuring enabling and their global implementation and the best supportive environments. possible health for older persons for as long as The MIPAA identifies the central themes present possible. in the 113 specific objectives. These include: Conclusion • full realization of all human rights and indi- International ageing policy frameworks vary in vidual rights of all older persons, their scope and emphasis, but all are founded • achievement of secure ageing, implying the on the basic and enduring principles of health eradication of poverty in old age, promotion. The strategies articulated by the • empowerment of older persons to fully and WHO EURO Health 21 framework focus on effectively participate in all aspects of soci- a life-course approach to promoting health etal life, for older age, as does the WHO Headquarters “Active Ageing” policy framework. Both the • the provision of opportunities for individual WHO Active Ageing model and the UN Madrid development, self-fulfilment and well-being International Plan of Action on Ageing pro- throughout life, pose comprehensive, multi-sectoral frame- • ensuring the full enjoyment of all rights and works to ensure full social integration, partici- the elimination of violence and discrimina- pation, health and security for older persons tion against older persons and, particularly, the inclusion of ageing in a • commitment to gender equality, global development agenda. A more concrete healthy ageing | international policies 167

- - - - isbon process’ L the the Broad Economic the main Policy instrument guide The for policies. Guidelines, economic coordinating States’ Member the lines for long-term sustainability of public To develop and formulate recommendations formulate and develop To In health and ageing, legislative competence he ‘ • Union can support stimulating innovative action and exchange their of policies through experience and good practice. on healthy ageing and make them relevant for European policy makers, it is important to un derstand how some of the European strategies and processes relate to healthy ageing. T All EU Member States have similar challenges with respect to economic growth and govern European 2000, in Lisbon In social progress. ments committed themselves to a strategy to “improve economic performance and generate jobs in a way that maintains social cohesion until 2010”. Since the European Union lacks the competence to develop legislation in this field, European leaders agreedOpen to Method of apply the Coordination (OMC). This method exists in the following parts Lisbon strategy: of the “A high level of human health protection shall be ensured in the definition and implementa tion of all Community policies and activities. Community action, which shall complement national policies, shall be improving directed public towards health, preventing illness human and diseases, and obviating sources of health…” danger to human belongs to Member States, but the European

- - - - g in nion U age cesses y h ro p lt nd hea a

es i eg t tion to a a l tr e s

The extended public-health mandate of the U egal mandate of the European that: for economic growth and social inclusion. This inclusion. social and growth economic for makes caring for older people and promoting healthy ageing an important area for the EU. European Union, based on the provisions of article 152 of the Amsterdam Treaty states The respect for democracy, equality, the human rule of law dignity, and re spect freedom, for human rights is one of the European foundations. Union’s The right to good health is a basic human right and also a prerequisite action and research programmes of the Commis the of programmes research and action sion (DGs). Directorates-General This chapter will further outline more important initiatives ageing. healthy to relevant programmes and L on on its legal mandate and with respect for the principle of The subsidiarity. ‘Lisbon strategy’ embraces many of the relevant areas such as employment and the social agenda. Important action is also taken by EU institutions via the E in r to the complex responds Union The European based strategies with population ageing an of ity where a sub-network of cities is settings-based developing strategies to promote strategic healthy consistent and accepted These ageing. approaches must now be implemented world goal of healthy ageing. wide to achieve the and settings-specific approach is emerging in the WHO EURO Healthy Cities movement, finances are aimed at reducing public debt Since 2005 the Broad Economic Policy Guide- 168 ratios to provide for the ageing of the popula- lines and European Employment Strategy have tion and designing and effectively implement- been merged. The OMC for social protection ing pension system reforms, for example by is maintained as a separate process. The OMC encouraging people to work longer, on pensions, inclusion and health and long- • the European Employment Strategy (EES), term care have separate national action plans. for promoting active ageing and delay- However, they will be combined in a European ing exit from the labour market. The EU Commission Joint Report once every three supports Member States’ measures and years. ensures the promotion of active ageing by The European Council has adopted (9) a coordinating national policies, financial new framework for social protection with a support and the exchange of experience. new set of common objectives for social inclu- Every Member State prepares a national sion, pensions and health and long-term care. reform programme, which is both a report- With respect to health and long-term care the ing and planning document. It describes objectives are as follows: how the employment guidelines are being • to guarantee access for all to adequate care implemented nationally and presents both and ensure that the need for care does not progress achieved in the Member State over lead to poverty; to address inequalities in the previous twelve months and measures access to care and in health outcomes, planned for the coming twelve months. • to promote the quality of care and adapt Social Protection, the main concern of a Social care to changing social needs, Protection Committee (SPC) established in • to ensure that care remains affordable 2000 and responsible for monitoring the so- and sustainable by promoting healthy and cial situation and the development of Member active lifestyles, good human resources, States’ social-protection policies. Social protec- good governance and coordination between tion covers: care systems. • promoting social inclusion, using an Open Method of Coordination (OMC) in combat- EU institutions ing social exclusion and poverty. Facilitated In developing European policies for healthy by the Commission, this OMC addresses ageing, several levels of action involve Euro- common problems, developing and ex- pean Commission officials, members of the Eu- changing policy responses across Europe. Its ropean Parliament (MEPs) and the European fundamental component is national action Council (national ministries). plans (NAPs), In the European Parliament, besides the po- • making pensions safe and sustainable, litical parties and regular committees such as the • ensuring high-quality health and long-term Committee of the Environment, Public Health care. The Commission body responsible for and Food Safety, there are intergroups, which this is the social protection committee in gather MEPs from different parties around one collaboration with the high-level group on specific issue of concern. One such group is health services and medical care. the intergroup on ageing, coordinated by the healthy ageing | international policies 169

------The overall aim of the is an elderly network on ageing and producing evidence based guidelines with recommendations – on EU, national local and levels – for potential field. actors It began in on this April 1, 2006 untiland December 31,runs 2008. In 2005, DG SANCO launched two consul Another Green Paper concerns the promo health. The project objectives are to expand an existing databank on European people, to assess older their health status and to investigate the associations environmental of data available with age groups of elderly, mortality in different morbidity and healthPROelderly-project is health to promotion for older people promotethrough EPIC healthPROelderly. Social affairs and equal opportunities DG Employment (DG EMPL) launch proposed PROGRESS, an integrated action pro to gramme for employment and social solidarity will programme the 2007–2013 Covering (14). address social inclusion, gender equality and non-discrimination. Its five sections each cor respond to one of the following themes: Active Ageing Community proposed new the in theme cutting is proposed Health Programme (2007-2013) (11). as a cross- tations of relevance to healthy ageing. One is a Green Paper “Promoting mental health, to Euro the for health mental on strategy a wards pean Union” (12). This is an incentive striving opportunities equal and health mental good for for the growing group of older people. tion of healthy diets and physical activity (13). Although very focused on preventing obesity discus Paper’s Green the people; young among sion of physical activity and nutrition clearly link to important elements of healthy ageing too. • •

- - main is a comparative and well-being, objectives are to improve workplace health and the well-being of the ageing workforce, to increase awareness among stakeholders of the needs of an ageing workforce, and to respond to their effects on workplace health Ageing and Nutrition analysis of existing data on nutrition and lifestyle of the ageing population in Europe, especially concentrating on the Member States, new EU Healthy work in an ageing Europe’s The European Commission is represented G Health and Consumer Protection • • Action Programme (2003-2008) improving (10) health for ing rapidly to information, health threats and health addressing respond determinants. co-funded several healthy ageing projects: DG SANCO has Technology and Innovation (DG RTD). Technology D DG Health and Consumer SANCO) Protection (DG implements the Public Health Commission’s Commission’s activities merit a more detailed description. Several Commission directorates- general (DGs) are relevant to healthy ageing, DG Health and Consumer SANCO), DG Protection Employment and Social Affairs (DG (DG EMPL) and DG Research, Development, by 24 Commissioners – cabinets, President and President cabinets, – Commissioners 24 by Directors-General and, as mentioned above, can act as a catalyst, facilitator and commu nicator in promoting exchange of knowledge and experience on ageing. For this reason the MEPs with the opportunity to exchange views with other organisations to raise awareness of older people’s interests. Another group, Intergroup the on Health is coordinated by Health Alliance (EPHA). European Public the European Older People’s European Platform Older (AGE). People’s The group meets several times per providing year, • European employment strategy, • SHARE, the Survey of Health, Ageing and 170 • open method of coordination in social pro- Retirement in Europe encompasses 22,000 tection and inclusion, people older than 50 across Europe. This survey includes health data, psychological • working conditions, and economic variables and social support • anti-discrimination and diversity, and data, • gender equality. • FELICIE is an acronym for Future Elderly Living Conditions in Europe, a project run- In October 2006, European Commission pub- ning in nine European countries for people lished a Communication entitled “The demo- older than 75. It gathers data on health, graphic future of Europe – from challenge to family and socioeconomic conditions and opportunity” (15). It sets out the following five aims to estimate the future needs of old-age steps to prepare for the consequences of the populations, European demographic transformation: • AGIR, Ageing, Health and Retirement in • promotion of demographic renewal by giv- Europe, is a systematic collection of existing ing more support to families and potential national data and estimation for the future parents, development of health-care and pension • ‘active ageing’ and longer working lives. costs, and Disease prevention is mentioned as an im- • The MERI research project concerns the portant measure for increasing productivity circumstances of older women in Europe. at work and reducing health care costs, • higher productivity and adaptation to the A proposal for a new Research Framework changing needs of an ageing society, Programme (FP7) for 2007–2013 (11) has • welcoming and integrating migrants into the been adopted. The new programme will consist European labour market and civil society, of several operationally autonomous sub-pro- and grammes allowing for joint and cross-thematic • sustainable public finances. approaches to research subjects. The nine themes include health and socioeconomic sci- DG EMPL also stresses that the challenge of ences. One aim of the social sciences theme is to Europe’s ageing population needs to be inte- understand and assess the implications of key grated in all policies. trends in European society, such as changes in DG Research (DG RTD) reports to the Re- the related aspects of lifestyles, families, health search Framework Programme (FP6) (16) that and quality of life, and demographic change supports several projects associated with ageing including ageing, birth and migration. and health. Most focus on clinical research into Healthy ageing as a cross-cutting issue is also diseases affecting the very old and their effect related to other European Union policy areas, on health care systems. There are also studies each of which may include potentially relevant on demographic and health-related data: structures or processes. Some examples: healthy ageing | international policies 171 - - - - The Commission’s anti-discrimination unit, matters. NGOs are enabled to comment ongoing issues and the on Commission uses these occasions to announce new initiatives. Commission’s anti-discrimination unit The in DG Employment also organises ad hoc meetings. Age falls within their sphere. nation in an enlarged European Union (17) sets (17) Union European enlarged an in nation out the European Commission’s analysis progress of made in tackling discrimination, in of age. cluding discrimination on the grounds Reports More specifically,in July 2005 report a was published on Age Discrimination and Euro pean Law (18). Community Action Programme Under the Community to Action combat discrimination (19), Programme the European Commission funds four European NGO um brella networks representing and the rights defending of people exposed to discrimination – which include AGE (The European Platform). People’s Older jointly with the European Platform of Social NGOs, organises biannual meetings NGOs where are invited to discuss Community defines principles that offer everyone in the EU the in everyone offer that principles defines a common minimum level of legal protection against discrimination. A legal-expert network the analysing and monitoring for responsible is Member the in directive this of implementation States and includes a co-ordinator specifically for age. Consultation A Green Paper on Equality and Non-Discrimi

- - - and physical life- activity, and free movement of and regional development, and pensions, age discrimina and health action plan, and e-health, technology and and food policy, and food policy, and pharmaceutical markets, and pharmaceutical policies on age discrimination reform of structural funds where ageing and ageing where funds structural of reform health should have priority. enterprise environment culture/education long learning, and regional policy agriculture social policy directive, tion, employment information ageing, internal market professionals, patients and health U other criteria) in the form of the Employment Equality Directive, 2000/78/EC. This Direc tive establishes a general framework for equal treatment in employment and occupation and belief, disability or sexual orientation. Employment Directive EC law has since been enacted of in anti-discrimination the area against age (among Article 13 granted Amsterdam of Treaty the of 13 Article the Community new powers to combat dis crimination on the grounds ofas gender, racial age or ethnic as origin, well religion or issue in healthy-ageing strategies. policies specifically target Few age discrimination: EU measures to combat age discrimination more are general in the specific certain However, context policy. discrimination of wider anti- references can be found. E Age discrimination is a particularly relevant • • • • • • • • Conclusion References 172 Healthy-ageing policies and practice are be- 1. World Health Organization, ed. Declaration ing encouraged across EU policy domains, of Alma-Ata. Primary health care, Report of such as in life-long learning, working longer, international conference at Alma Ata; USSR. retiring more gradually and living actively after Geneva. UNICEF; September 6-12, 1978 retirement, and acting to sustain and improve (http://www.who.int/chronic_conditions/pri- health. Awareness is increasing that a healthy mary_health_care/en/almaata_declaration.pdf). and active society will be a key determinant of 2. World Health Organization, ed. Ottawa economic growth and sustainable productivity Charter for Health Promotion. Ottawa, in an ageing Europe. However, healthy ageing Ontario, Canada; November 17-21, 1986 has not yet achieved sufficient and comprehen- (http://www.who.int/hpr/NPH/docs/ottawa_ sive attention in European policies. Instead of charter_hp.pdf). being considered as long-term investment in 3. World Health Organization, ed. The Bangkok human capital, both ‘health’ and ‘older people’ Charter for Health Promotion in a Globalized are still being viewed as a cost. Concrete rec- World. Geneva; August 7–11, 2005. ommendations are needed to include the issue 4. World Health Organization. Health 21 – of healthy ageing in policies related to growth Health for All in the 21st Century. Copenhagen: and prosperity in the European Union. WHO Regional Office for Europe; 1998. 5. International Healthy Cities Foundation. 2006. Retrieved 2006-04-28 from www.healthycities. org/overview.html. 6. WHO/Europe – Healthy Cities and urban governance. 2006. Retrieved 2006-05-05 from http://www.euro.who.int/healthy-cities. 7. World Health Organization. Active ageing: a policy framework. Report No: WHO/NMH/ NPH/02.8 (http://whqlibdoc.who.int/hq/2002/ WHO_NMH_NPH_02.8.pdf). Geneva: World Health Organisation; 2002. 8. United Nations, ed. Report of the Second World Assembly on Ageing : Madrid, 8-12 April 2002. New York. United Nations; 2002. 9. Communication from the European Commis- sion – Working together, working better: A new framework for the open coordination of social protection and inclusion policies in the European Union. COM(2005) 706. Brussels: European Commission; 2005. healthy ageing | international policies 173 - - -

tion in an enlarged European Union”. COM tion in an enlarged European Union”. (2004) 379 Final. Brussels: European Commis sion; 2004. O’Cinneide C. Thematic Report on Age Brussels: Discrimination and European Law. Produced under the authority of The European in the Network of Independent Legal Experts by the Non-discrimination Field and published European Commission; 2005. Council decision no 2000/750/EC of 27 November 2000 establishing a Community Action Programme to combat discrimination the (2001-2006). Brussels: The Council of European Union; 2000. Parliament and of the Council of 27 June 2002 Parliament and of the Framework Programme concerning the 6th for Research, of the European Community and demonstration technological development to the creation of the activities contributing Areas and to innovation European Research The European Parlia (2002–2006). Brussels: of the European Union; ment and the Council 2002. Green Paper “Equality and non-discrimina Decision no 1513/2002/EC of the European Decision no 1513/2002/EC 18. 19. 17. 16.

- - - - - – from challenge to opportunity. COM(2006) – from challenge to opportunity. 571 final. Brussels: European Commission; 2006. sion – Community Programme for Employ ment and Social Solidarity – PROGRESS Brussels: (2007-2013). COM (2004) 488 Final. European Commission; 2004. Communication from the European Com mission – The demographic future of Europe physical activity: a European dimension for the physical activity: a European dimension chronic prevention of overweight, obesity and diseases”. COM (2005) 637 Final. Brussels: European Commission; 2005. Communication from the European Commis European Commission; 2006. of Green paper “Promoting mental health mental the population, towards a strategy on (2005) health for the European Union”. COM 2005. 484. Brussels: European Commission; and Green Paper “Promoting healthy diets Communication from the European Commission Commission European the from Communication for a decision of the – Amended proposal and of the Council con European Parliament of the cerning the 7th framework programme European Community for research, technologi cal development and demonstration activities Brussels: (2007-2013). COM (2006) 364 Final. 2002 adopting a programme of Community 2002 adopting a programme of public health (2003- Action in the field statements. Brussels: The 2008) – Commission and the Council of the European Parliament European Union; 2002. Parliament and of the Council of 23 September Parliament and of the Decision no 1786/2002/EC of the European Decision no 1786/2002/EC

15. 14. 12. 13. 11. 10. 174 C H A P T E R 1 6 Policies in European countries 176 healthy ageing | policies in european countries 177 - -

- y c

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for g e in ir a age y- h tionn lt es it must have a coherent policy framework policy coherent a have must it older people need also realistic objectives and specific actions to to have clear, realistic need They objectives. these reach and sustained resources and an evalua tion process to measure outcomes. The focus in the questionnaire was on pub together work sectors and partners where in an integrated approach, coordination, inter-sector have should it it should be based on scientific evidence, and good policies for health promotion for polices). This WHO document has inspired the the inspired has document WHO This polices). formulation of policies and strategies. Qu The Healthy Ageing project sent out a ques tionnaire to elicit what policies and strategies in European countries meet the challenge of ageing populations. lic health and promoting healthy ageing rather • • • • hea

------

rgani , senior senior , O f f older people are I Dr Louise Plouffe Louise Dr , in Geneva. in , fficer at the World Health Health World the at fficer O O

ne part of the Healthy Ageing project is to elucidate the policies and strategies a good policy for health promotion in later in promotion health for policy good a life needs to be comprehensive; it has to include health in other policies besides health,

She identified some features that are echnical echnical • The 2002 WHO document “Active Age motion for older people: not not identifiedthey tend to become invisible says neglected.”, or important for good policies for health pro “The benefit of having policy a identifiesolder people is as a group that to be in it cluded cluded in development. WH zation, T should be based on the rights, needs, prefer ences and capacities of older people, embrac the recognises that perspective life-course a ing important influence of life experience on how individuals age. (See Chapter 15, International in European countries that promote health in older age. ing” provides a framework for governments and clarifies how policies programmes and O Policies in European countries than on health care or care of older people. It Summary of policies 178 was answered by 23 countries with information on 22 policies (Scotland sent information For more information, on three policies, Finland and Spain on two see www.healthyageing.nu each). All but five of the countries have policies for healthy ageing, separately or included in general public-health policy or national the Czech Republic health policy. Projects for healthy ageing Ministries and governments are in general Main theme: Active involvement responsible for implementing the policies; The main aim of the funding programme programmes are usually funded by central is to support NGOs, cities, municipalities, government. organisations and agencies in their work for The time frames for the policies vary from ‘a ageing people and their families by financial couple of years’ to 2010 or 2030. The majority support (grants may be applied for once in a have been endorsed by the respective national year from 2003). The project covers all top- boards or departments of public health. Policy ics, for example increasing health, independ- aims vary too. One country has an evaluable ency and socialising ageing people. long-term goal: “increasing life expectancy, improving quality of life and reducing social Time frame: Calls for application have been inequality in health”. Others mention “physi- declared every year since 2003. cal activity” or “health promotion”. Other principles mentioned are “active involvement”, denmark “maintenance of autonomy”, “equality for all Healthy Throughout Life generations” and “social integration”. One pol- Main theme: Increasing life expectancy, icy has a broad and general aim: “give citizens improving quality of life and reducing social the opportunity to live as healthily as possible”. inequality in health. The primary target group for the policies is Healthy Throughout Life has a special focus decision-makers and politicians, non-govern- on the major preventable diseases and mental organisations, health staff and research- disorders. The quality of life of many ers. Older people are another target group. The people can be improved substantially by definition of older people varies from 50+ to more systematic efforts in counselling, sup- 65+ years, possibly depending on countries’ porting and rehabilitating patients. In addi- social structures, economy, pension age and tion, Healthy Throughout Life establishes ways of viewing older people. targets for several risk factors, target groups One question was whether the policy tar- and efforts in the major settings for health geted any special “setting” (urban/rural area, promotion. One target group is older people. workplace, transport, home). Many policies have no special setting, others mention old- Time frame: 2002–2010 age care, older people living at home, the local community, transport; or are as broad as “no special settings but all sectors of society...”. healthy ageing | policies in european countries 179

------Health promotion Physical activity ageing people must be ensured opportuni ensured be must people ageing with an adequate income, residential and local services and trans port must be developed for ageing popu independent an safeguard to groups lation capabilities life even when ageing people’s and deteriorate, ties to function actively in to society, de their and skills and knowledge their velop ability to care for themselves, ageing people should have the possibility quality good of life independent an live to inland information sharing, coordination of activities activities of coordination sharing, information and training of instructors. Clients should give feedback to the municipality, the serv ice provider and the instructor in order to improve the supply, targeting and location of services. 2. Government resolution on the Health 2015 public-health programme Main theme: The concepts “settings of and “life course” everyday play key roles in the life” pro gramme. The strategy presents eight targets for public health, focusing requiring concerted action: on problems • 1. Quality recommendations for guided health-enhancing physical activity for older people Main theme: The quality recommendations are based on They practice. proved and research latest the guided of quality the for level target a define health-enhancing physical activity for older people. They are based on cooperation, • • f

Improve health and social 10-year programme rooting out age discrimination, person-centred care, intermediate care, general hospital care, stroke, falls, mental health in older people, promotion of health and active life in to tackle age discrimination and ensure older age. problems associated with older age and problems associated with older age to promote the health and well-being of older people through co-ordinated action by the National Health Service and local councils. to to assessing individuals’ needs and cumstances cir and for the commission and provision of services for them, to specifically address conditions which are particularly significantpeople – stroke, falls for and mental health older that older persons are treated with respect with treated are persons older that and dignity, supported are persons older that ensure to by integrated services approach cohesive and with coherent ordinated, a well co- England The eight national standards of the National the of standards national eight The Service Framework are as follows: 1. 2. 3. 4. 5. 6. 7. 8. framework for older people Main theme: care. The programme plans: • The National service Time frame: • • •

finland (cont.) Germany 180 • a programme for developing services Work Group 3 “Healthy Ageing” of the needed for daily life and long-term care German Forum on Disease Prevention for older people should be worked out. and Health Promotion (DFGP) It should involve municipalities, informal Main theme: To present concrete and ac- care-givers, voluntary organisations and cepted recommendations, to present creative commercial services. It should use modern contributions and solutions to the further technology. development of the social health system. Time frame: 2004–2015 Disease prevention and health promotion for ageing people are important tasks for a france society. Fulfilling these tasks in a federal sys- The Elderly tem such as the Federal Republic of Germany requires the involvement of all important Main theme: Maintain autonomy, preserve quality of life of the elderly. organisations and interest groups. The main task of the DFPG is this integration. Work “The Elderly” programme at the National Group 3 integrates organisations concerned Institute for Prevention and Health Educa- with “healthy ageing”. Focus points are: tion (INPES) is set forth in the national “Healthy Ageing” plan. The INPES is also • to agree on aims of disease prevention, in charge of the communication and health • to develop effective and comprehensive promotion aspects of the “Healthy Ageing” concepts for implementing these aims, programme. • to stimulate scientific projects – whenever necessary, The policy plan has four strategic direc- • to present strategies for integrating tions: activities at national, rural and urban • to favour the acquisition of individual levels, and capabilities for health, • to run national campaigns and confer- • to develop the prevention of incapacities, ences on special issues of prevention. • to develop the competence of health- and sociomedical professionals in health pro- Time frame: Since 2003 motion and health education, • to favour the implementation of family health education and health promotion in the elderly professional environment. Time frame: 2005–2007 healthy ageing | policies in european countries 181 - - -

1998–2000 at national level. Give citizens the opportunity Social integration From 2005 to promote better health for ageing peo nated action between health and social services. ple, and to provide high-quality health care and social services for the elderly by coordi To tackle the problem of an ageing To popu ithuania taly the burden of most frequent chronic diseases chronic frequent most of burden the (cardiovascular diseases, tumours, mental and locomotor diseases). Different forms of support for active ageing have to be made available to the public. Time frame: The regions have adapted their plans to the national framework. National strategy for the impact of ageing on the population Main theme: The strategy promotes healthy ageing and social equality. The aim of “Health and Social Services” is: activities for • National health plan – Health protection of vulnerable people Main theme: as possible. to live as healthily developed has Health of Ministry the lation, an inter-sectoral collaboration policy. This includes promotion of healthy lifestyles and environments, prevention and decrease of Time frame: •

l i - - - - Give Hungarian citizens the 2003–2010 prevention of and decrease in the most frequent chronic diseases, involvement in grammes, healthy-setting public in resources human of development pro of communication and monitoring health, the public-health programme, and prevention of diseases such as AIDS. promotion of healthy lifestyles and envi ronment, The Hungarian government is seeking to Hungary forms of support for active ageing, (Univer sports, sity voluntary for work, Elderly, etc) have to be made available to the public. Time frame: The goal of the sub-programme is to improve to is sub-programme the of goal The the quality of life for an ageing population This number. in growing continuously is that Different issues. mental and somatic involves age and Hungary. The basic methodology of methodology basic The Hungary. and age programme is prevention: the public-health • • Main theme: as healthily as possible. opportunity to live decrease the significantdifference between aver EU the between birth at expectancy life Improving the health of the elderly • • •

The Netherlands 182 Policy for older persons in the housing. Central government sees itself as a perspective of an ageing population supervisor rather than an initiator. Attention Main theme: Stimulate participation must be paid to the living environment: The programme objectives are: • the accessibility of public transport and • to remain fit and healthy for as long as the availability and proximity of facili- possible. ties, Long-term policy choices relate to the prob- • to ensure adequate and high-quality care lem of unhealthy lifestyles. Factors such as provision. obesity and lack of physical activity are well The demand for both curative care and on their way to displacing smoking as the nursing and treatment will continue to rise. major health problem. Prevention policy Inevitably we will find ourselves balancing was and remains the answer here since between individual and collective responsi- citizens neglect their personal responsibility. bility. Specific attention should be paid to The government favours sport and physical improving the quality of care of older peo- activity and is committed to combating lack ple. The scope of the care can be narrowed, of exercise, but its quality must improve, • to make an active contribution to society. • to ensure the right to die with dignity. Given the vastly improved state of health The right to die with dignity is the last target of older people, it is reasonable to ask them of the Netherlands government policy for to make a productive contribution to soci- older people. The government believes we ety for longer. The labour participation rate should act with care and sensitivity in all amongst older people must be increased, age matters relating to the end of life, consistent discrimination must be eliminated, possible with the views in society. obstacles to anyone wishing to work after Time frame: Until 2030 65 must be removed and there should be incentives for doing volunteer work, • to ensure sufficient financial resources. A social minimum will be guaranteed by income support. • to ensure adequate housing facilities and living environment. In the long term, the need for adequate housing can be met only by a combination of new developments and alterations to existing healthy ageing | policies in european countries 183

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Reduce social and regional Active ageing – promote active promote – ageing Active 2006–2015 2004–2010 to reduce differences in access to health The strategy involves partners such as the services, and to support healthy lifestyle choices, to create a example workplace, educational setting). healthy environment (for Portugal Poland are vulnerable and fragile. all departments, council city the media, mass the social partners, sectors of government, teachers at all levels (to promote in younger people a different view of older people). Time frame: and quality of life of the Polish population is population Polish the of life of quality and The three main directions the main strategy. are: • National plan for the health of the elderly theme: Main life and autonomy of the elderly. The plan aims at promoting active ageing, the autonomy and independence of people, older their empowerment and the crea tion of stimulating environments through an approach. inter-sectoral The policy gives special attention to those older people who National Health Programme Main theme: differences. The National Health Programme is a long- term health policy project in Poland (2006– 2015) addressing all the population special with attention to mother-and-child pro disabled and older and adults young tection, people. Improvement of the health status • • Time frame:

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o 2006–2009 Physical activity. www.shdir.n orway Website: local environment and leisure. The initiative requires co-operation between sectors and ministries eight and administration, of levels the and development the in collaborating are follow-up of this plan. Time frame: The plan aims at increasing and strength ening factors that promote physical activ ity and reducing factors leading to physical An inactivity. increased level of physical ac strategy total a through attained be will tivity that includes measures in work, transport, and a manifestation of positive self-affirma tive experience. Parliament White Paper no. healthier a for “Prescription (2002–2003) 16 Norway” emphasises the physical importance activity for health and of well-being. The action plan on physical activity 2005–2009 Main theme: diseases of number a prevents activity Physical and is a source of an joy, expression of life Working together for physical activity: n Scotland 184 1. Delivering for Health • to increase integration relating specifically Delivering for Health, launched by the to health improvement priorities, and Scottish Health Minister in 2005, outlines • to provide a strategic framework to sup- a fundamental shift in how the National port the processes required for faster Health Service (NHS) works in Scotland, health improvement in Scotland. with a strong commitment to tackling the Time frame: Ongoing (latest target date causes of ill-health and promoting the an- 2022) ticipatory mode in which the NHS should work to deliver health improvement. The Kerr Report sets out an action plan Slovak Republic which, amongst other key health service For older people to live healthier changes, emphasises “a wider effort on and more valuable lives improving health and well-being through Main theme: Improve quality of life. preventive medicine, through support for The plans are, for example self-care and through greater targeting of • to arrange health prevention and health resources on those at greatest risk.” education for older people to support the Time frame: From 2006 to 2009 social environment of the target group, (http://www.scotland.gov.uk/Publications/ • to develop concepts, and then edit and 2005/11/02102635/26356) disseminate leaflets and brochures to implement educational activities for target 2. Opportunity age: Meeting the group – pilot seminars in Bratislava, challenges of ageing in the 21st century • to develop and edit method manuals/ Main theme: Promote healthy ageing – guidelines to spread educational activities different themes. throughout the country (teaching by way of seminars for the regional public health A key theme is to prepare effectively for the authorities of the Slovak Republic), and age shift which will gather pace between • to implement educational activities for now and the middle of the century and to target group – seminars, regional discus- help meet everyone’s aspirations for better sions in the Slovak Republic to control the later lives for themselves and their families. quality of community information distrib- Time frame: Ongoing uted to elderly people – “Observation” to monitor target group health status and 3. Improving health in Scotland: health awareness and behaviour after two The challenge years. Main theme: Narrowing the health gap. Time frame: Since 2005 Key themes are: • to pull together many existing strategies and targets rather than starting new ones, healthy ageing | policies in european countries 185 - -

Active living – secure, inde From 1998 enlarged resources and better coopera control and quality assurance, more research, increased knowledge and competence, development and renewal, improved quality of life for relatives and older people, efforts against ill-health, health promotion for older people should be developed by preventive home visits by the home-help services and by general health promotion. tion, governance and organisation, tion, governance more reasonable fees, strengthened supervision, more effective Sweden National action plan on policy for the elderly Main themes: access to services. pendent, respect, Measures proposed: • • • • • • Time frame: • •

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To improve To the conditions of 2003–2007 Four years equality of opportunity, equality of opportunity, cooperation, training, information and investigation. The aim is to improve the life conditions Spain 2. Health plan of the Canary Islands, Programme for older people Main theme: Social integration. Target groups are the primary health care 65. of age the above people older and sector Time frame: of older people by providing them with a wide range of resources. The plan has four action areas, each with its own objectives with strategies, organizations and timetable: measures, collaborating • • • • Time frame: city councils, NGOs, the Scientific Society of Gerontology and Geriatrics, universities, trade unions, employer organisations and experts. Ministries of Health, Economy Science and and Leisure Culture, Education, Technology, Suggestions Finance. and Interior the Sports, have also been given by the National Adult Spanish the services, social regional Council, Municipalities and Provinces Federation, action plan takes as indicators demographic data, economy, housing, ways of coexist ence, level of education, main activities of old people and social services for old peo ple. The Ministry is collaborating with the 2003–2007 Main theme: life for older people, putting a wide net of disposal. resources at their The Ministry of Work and Social Affairs Action plan for older persons

Wales Health data 186 The healthy ageing action Most of the policies contain no reference to plan for Wales health data. Main theme: To contribute to the relevant Some countries state that their policy is based strategic objectives and to the achievement on statistics on health development in reports, of the health targets set up in the strategy for mortality and morbidity data from the Central older people in Wales. To maintain existing Statistics Office or on the latest research; as well programmes and develop new initiatives. as on policies put into practice and evaluated. The purpose of the action plan is to: Norway recommends a programme of physical • to bring together in one document ex- activity as “only six per cent of older people isting and proposed health promotion (65 + years) are physically active on the level initiatives for older people in respect of that is recommended by national authorities”. physical activity, healthy eating, smoking, Portugal reflects on indicators for the evalua- alcohol, sexual health, emotional health tion of gains in health but “in this area we are and well-being and health protection and less developed than other European countries”. safety promotion, The Welsh policy includes the latest data from • to provide guidance for use at local level the Welsh health survey regarding the health on key evidence-based health-promotion and health behaviour of older people, and also interventions with older people, thus pro- the current targets for older peoples’ health”. viding the major implementation tool for the “Promoting Health and Well-being Respondents’ comments Standard” of the National Service Frame- work for Older People in Wales, Most of the respondents to the Healthy Ageing • to outline responsibilities of the Welsh project questionnaire commented on policies/ Assembly Government and its partners, strategies/action plans for promoting healthy and ageing. Many mentioned the need for the in- • to introduce new Assembly-led initiatives volvement of older people in planning, and the as part of the Welsh Assembly’s response need to promote positive images of older peo- to Health Challenge Wales. ple and not focus on chronological age: Time frame: Initially 2004–2007 • “...Need a response from older people, employers and voluntary bodies to change attitudes to ageing”, • “...The ageing component of the national public-health strategy is much more about rhetoric and lip-service than real implementation”, healthy ageing | policies in european countries 187

------In some of the countries surveyed, health The German policy proposes co-operation A policy is valuable only as long as it is being is it as long as only valuable is policy A which in the longer term should lead to a wide range of benefits. This is good as it may give ministries and organisations an incentive work to together. The Netherlands has an am bitious system for monitoring It includes their a follow-up of policy. how older persons remain fit andhealthy, physical activity,jury in prevention, social, labour and voluntary policy once endorsed is not communicated to the target groups, the chance to make it work re sometimes questionnaire The missed. is able flected wishful thinking about the benefits of a “reduces that such as policy the not is It policy. local but elderly” the among differences health application of the policy. promotion for older people is included as part commonly most This policy. health national of focuses on health care and treatment than rather on health promotion and illness preven tion. For example: the National Framework for Scotland “sets out a plan to develop health care in Scotland that is about delivering best the available care as close to the patient possible”. But Scotland as also has the Opportu action: for issues of list long a with Project nity ex equality, age workers, older of employment people, older for opportunities learning tending house building, transport etc. home security, to older people and their health. also differences There in the ways people understand are terms such as health promotion, health educa to relate they how and information health tion, or treatment. illness prevention used – for lobbying, motivation, encourage ment to act. It is a working tool for ministries, organisations and institutions with older peo ple as their target group. Unfortunately, if a

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lt a

hea es “... For some regions healthy ageing is not a One cannot assess the quality of the poli ation of them across the EU is most useful”. ation of them across the EU is most ...“Do not focus on chronological age (which (which age chronological on focus not ...“Do “...Have in mind prevention (it is NEVER too late) and rehabilitation”, “...The life-time perspective!” “...Include elderly people in the preparation of policies etc.” “...Haveand long-term goals”, both short- “...Promoteimages of the elderly”, positive “...Sharing plans and any subsequent evalu neity of this group should not be seen as a problem, but as a challenge!” status”, health on more but figures!), only is the regions is needed”, action into translated be to have Policies “... so that people in this age group may reap the benefits and be able to enjoy a healthier, more fulfilling life”, ...“Include all elderly people, the heteroge priority. In priority. my opinion a network between o used in the questions. The respondents’ vary ing knowledge of English and problems with short formulations added to the communica tion problem. Some related those only not activities, different respondents many presented of policies and whether the policy has led to action in the form of projects. cies from reading the questionnaire answers: it depends on how people define the terms D The last questions in the questionnaire investi health to relate may policy/strategy a how gate promotion, benefits and possible side effects • • • • • • • • • • to participation, financial resources, housing Conclusion 188 facilities, transport, insurance and the right to die with dignity. Most European countries have policies for Lithuania’s action plan has been adopted for healthy ageing which are either separate from implementation. Indicators include life expect- or included in general public health policy or ancy, number of older people receiving social national health policy. A negative side-effect services at home, guaranteed incomes for older of policies embracing the whole population is people etc. the lack of a central theme for policy regard- The Slovak Republic states that the policy ing older people. Most policies do not refer to will increase health behaviour and knowledge public-health data. This is an interesting and among older people. perhaps surprising finding of this compilation Sweden answers that the policy has led to of health policies. “increased awareness of the need for health The respondents to the Healthy Ageing promotion and intervention for older people”; project questionnaire state the need for the in- that research on older people has increased and volvement of older people in the planning and that special resources have been allocated for the need to promote positive images of ageing health promotion and prevention. and not focus on chronological age. Positive side-effects of the policies include Often no special allocation of money for “promoting participation in issues concerning health promotion is included in the policies. older people”, “guidelines reducing prejudices This may obstruct their realisation at local and attitudes to age discrimination” and/or level. “encouraging people to work after 65”. One Policies are valuable only when they are respondent mentions that “elderly people will used – for lobbying, motivation, encourage- gain an increased interest in their own lives”. ment – action. A policy should be a working A negative side-effect mentioned is that there tool for ministries, organisations, institutions is no central theme for older people if the policy etc. which have older people as a target group embraces the whole population. Financing ac- for their activities. They need to be applied tivities outlined in a policy is also an important locally and thus should be published in a form issue, but often there is no special allocation of that can be read and understood by the target money. group themselves. These readers may then act as a pressure group. healthy ageing | reflections on work done 189

C H A P T E R 1 7 eflections R on work done 190 healthy ageing | reflections on work done 191

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English has been the working language of the of language working the been has English healthy is The aim to of promote the project Knowledge of ageing, e.g. biological ageing, each. Older people are defined differently with different age categories, sample sizes etc. This the when Further, difficult. comparisons makes data originates from know- different the projects countries research EU-related and different ledge becomes quite diverse and scattered. An additional problem to be resolved is that some of the data is not free for use. project. With publications, statistics, etc., more etc., statistics, publications, With project. accessible in English there is a bias English in the towards basic data. For the same reason there is also a “western bias” in the context of the project. ageing in as have later life. therefore We far as data basic our from treatment excluded possible policy. and practice good papers, statistics, on is extensive but with many limited tives, and there perspec is a great need to increase the knowledge base. It is important however experi and knowledge the use and disseminate to ence we have gathered to date. Statistics One problem of statistical older data people is concerning that it is difficult to compare countries, data being applied differently in

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eflections

geing and health promotion are Ageing Healthy a The issue. challenging and huge The eastern and central European context The over-fifties are a heterogeneous group We We have worked at a general level with a differs from that in western older people in the new EU Member States are Europe. Many living in poverty and face different problems from those in the old Member States. different socioeconomic cultural and groups, ethnic groups living in different different project The areas. geographical and conditions sought to take the heterogeneity into account, but we lacked basic data relating to older peo ple, specially regarding heterogeneity. team team of researchers, we conducted review- for literature papers relevant identify to searches experts. consulted we and evidence level and may be divided into different age groups, holistic approach and on the basis of the experi the of basis the on and approach holistic gen often most participants, project the of ence whole a with start not did we Although eralists. ageing and health promotion. This project will project This promotion. health and ageing hopefully be followed by further projects. project relates to all groups of people in Europe Europe in people of groups all to relates project include covered Areas older. and years 50 aged statistics, literature, good practice and policy. The project has a holistic approach, intending to give an overview and an understanding of A R on work done Drop-out frequency in questionnaires varies Note that other papers might indicate conflicting 192 substantially amongst older people, which also results or suggest additional evidence: our litera- makes statistical comparisons between Euro- ture searches may not have reflected all possible pean countries difficult. written material relating to the effectiveness of At present, few countries have information interventions targeting older people. about health determinants for the population Since literature searches do not necessarily aged 85 years and older. Experience from identify all possible relevant papers, therefore, Sweden and elsewhere shows that it is possible we also sought expert opinion, as mentioned to collect statistics about this age group. earlier, to find additional important papers and also the ‘grey’ literature relating to the topics. Literature The databases used were organised and in- We compared the results of our literature dexed for the entire population and not just searches and selection of papers (see matrices) for the over-fifties. The papers often covered with the list of references produced by Euro- another, wider, age span. In some papers it was link Age in the report “Proven Strategies to also difficult to understand which age group Improve Older People’s Health” (1). However, was being described; in such cases we contacted there was no duplication. The explanation of the authors of the papers for clarification. this is that the present report has focused on The papers included in the literature review reviews and meta-analyses, whereas the Euro- were predominantly in English, although other link reference list includes mainly reports on languages were also represented. Since most single studies. Before 1999, very few reviews were systematic reviews or meta-analyses, the and meta-analyses were available in this area. usual biases apply when interpreting the find- As the project has increased the knowledge ings: publication bias, bias towards English base by focusing on reviews and meta-analyses literature, bias towards randomised and quasi- in the literature searches, it was feared there experimental designs, which might exclude might be a lack of new and innovative find- studies following a more complex settings ings that had yet to be included in reviews and approach. meta-analyses. In the major topics “Retirement Many of the studies were conducted in the and pre-retirement” and “Use of medication US rather than in EU countries, raising the and associated problems”, there was a lack of question of transferability of the interventions. papers on review-level evidence of the effec- Further, as health care systems vary in different tiveness of interventions. For this reason, these countries, comparisons of “usual care” in an chapters consist only of one part. intervention being investigated caused prob- The Project has not graded the evidence in lems when reviewed studies had been carried the different papers, but has summarised and out in many countries. This is a problem when presented findings and assessments made by assessing the effectiveness of home visits for the authors of the reviews and meta-analyses. older people. healthy ageing | reflections on work done 193

- - - - - Time Time appears to be crucial. Third parties Of the sixteen projects, few have been trans been have few projects, sixteen the Of In most countries, many examples that were that examples many countries, most In questions of structure and dissemination, such as ‘who should start a debate on engaging the staff, the experts and volunteers?’ – e.g. politicians and decision-makers – often demand rapidly successful outcomes and cost considered good practice were available. Here limited a only as necessary was selection further Ageing Healthy the in included be could number met in project. Not all the criteria were always the examples of “good practice”. Thus there was often no evaluation of the interventions, sometimes due to the difficulty of measuring However project. real-life of kind this in effects it has to be stressed that the examples in this Report are illustrations and do not represent countries. the status of practice in the different formed into permanent programmes. This is probably quite a common problem and under lines the importance of establishing measures for the sustainability and further development of projects. Collaboration between NGOs and experts is beneficial both because ages NGOs it encour in their voluntary work and gives the experts access to new angles of approach to health problems occurring in later life. Ex change of experience and knowledge raises If applicable, four additional criteria were im be to ought project The selection. the in portant sensitive to and/or address gender inequalities in health, be innovative of in healthy the ageing promotion in include a later method life for stages assurance. quality and The management/ last results desired the achieved project the optional whether criterion was use of resources. with the most cost-efficient

- - - - - In general, the aim of the studies was not to In the papers identified in the literature tainability, viability and continuity, and should and continuity, and viability tainability, be able to serve as a model for generating new projects and initiatives elsewhere. later life stages, should be relevant to the major the to relevant be should stages, life later topics in the project, should have been evalu ated by process evaluation or outcome evalua tion, should clearly describe the objectives and sus for plan a have should outcomes, expected ing, which means focusing on good practice related to public health and not primarily to health care or care of older people. Partners selected the examples of the good basis of six practice criteria. The on example should address the promotion of healthy ageing in the projects are still running. Project partners were asked to select two or of ongoing three interventions in examples their country that could serve as examples for other age healthy promoting on be countries. should focus The Good practice ident were countries nine from projects Sixteen ified as examples of good practice. Several of is also a lack of studies on the cost-effectiveness cost-effectiveness the on studies of lack a also is of interventions targeting older people. Differences in cultural and religious beliefs will beliefs religious and cultural in Differences need to be taken into account in prevention and health-improvement approaches. reduce inequalities among older people. There Report, we found few studies tions specifically on targeting vulnerable interven groups, women and low-income groups. Older people particularly be can groups minority ethnic from likely more example for are they disadvantaged: to suffer discrimination in accessing services. searches and subsequently included in this effectiveness. Health promotion for older peo- There is a bias towards comprehensive na- 194 ple is, however, a time-consuming business and tional policies. This affects local ones. In many the problems relating to an ageing population European countries, local and/or regional poli- cannot be resolved overnight. cymakers have major public health responsi- Motivating the least motivated is another cru- bilities, including the ageing population. cial issue in promoting health. Among the least Finally, looking back to the results in the motivated are those who are disadvantaged for Euro-link Age report “Proven Strategies to some reason, those with the least access to pub- Improve Older People’s Health” (1) from 1999, lic services and last but not least the very old. on four specific strategies for healthy ageing, The examples of good practice illustrate that it becomes obvious that European countries a common database of good practice exam- are now developing strategies and policies for ples selected on the basis of specific criteria is health promotion among older people. workable and could aid further development of healthy-ageing interventions. Such work could Turning evidence into practice build on ongoing national, regional and local Turning evidence into practice by translat- projects, as well as on European-level projects ing evidence into advice and guidelines for that have considered means of measuring the public-health policy-makers and practitioners quality and transferability of interventions. has recently drawn attention. Many national initiatives, such as NICE (England), the Nor- Policies wegian Knowledge Centre for Health Services, To review current policies and strategies for the NIGZ Centre for Review in the Nether- healthy ageing across Europe, a draft question- lands are trying to build the evidence base for naire was disseminated to the project partners public health and to ensure its implementation with the intention of conducting a pilot study. in their countries. Seven countries responded to this question- There are also several European-wide initia- naire. An improved questionnaire was sent out tives, in particular the WHO Health Evidence to all EU member states, accession states and Network and the GEP ‘Getting Evidence into members of the European Economic Area in Practice’ consortium and Special Interest Group March 2006. The pilot study countries received (consisting of national health agencies, IUHPE only the supplementary questions. Altogether, and EuroHealthNet). They have developed 23 countries completed the questionnaire – a tools and methods such as review protocols, good response. However, achieving this high re- quality guidelines and evidence briefings to sponse rate required reminders such as e-mails help transform knowledge of health promotion and extensive phone calls to non-responding into practical steps. countries. Of relevance here is the suggestion by Kelly The focus of the majority of the policies was et al. (2) that evidence-into-practice is based health and promoting the health of older peo- on the integration of evidence, learning, local ple. Some answers described policies embrac- practitioners’ knowledge and local health- ing the whole population and not just older improvement needs. people. healthy ageing | reflections on work done 195 - - - ces n e r e prove older people’s health. London: Eurolink prove older people’s Age; 1999. Meyrick J. Getting evi Speller V, Kelly MP, dence into practice in public health. London: Health Development Agency; 2004. Drury E, Walters R. Proven strategies to im Drury E, Walters f 2. 1. this Report, is therefore a first important step forward. Re like healthy ageing, which pertains to lifestyle determinants and also wider socioeconomic determinants, is an enormous task. and timely Correct information to policy-makers and practitioners on effective interventions to pro in described those as such ageing, healthy mote However, However, transferring the evidence base into practice on a wide and comprehensive issue 196 healthy ageing | recommendations 197

C H A P T E R 1 8 ecommendations R 198 healthy ageing | recommendations 199

socioeconomic determinants, inequalities in health, gender, minorities. retirement and pre-retirement, social capital, mental health, environment, nutrition, physical activity, injury prevention, substance use/misuse, use of medication and associated problems, preventive health services. Plan of Action on Ageing The WHO Active Ageing Policy Framework Policy Ageing Active WHO The The United Nations Madrid International The Healthy Ageing project, the European co-funded Commission, aims by to promote years and healthy ageing in later life stages (50 older). The project has reviewed the literature, statistics, good practice and policies extending throughout Europe. The focus has cross-cutting themes: been on • • • • and ten major topics: • • • • • • • • • • • •

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ecommendations

he increasing challenge great a pose ageing-population 2050 to up projected trends The EU “Lisbon process” of strategic priori strategic of process” “Lisbon EU The EU Treaty Article 152 on health protection EU policies, inter alia on age discrimination and demographic change Health 21 – health for all in the 21st cen tury and the Strategy to prevent and control non-communicable diseases in the European region WHO ties to 2010 for all citizens The Healthy Ageing project makes its recom its makes project Ageing Healthy The Responsibility for legislation and govern through stimulating innovative action and the exchange of experience and good practice. Member and institutions EU the to mendations States in the context of EU, UN policies related to healthy ageing, including: and WHO • ance on health and ageing In States. Member the to in mainly belongs Union the European health promotion/public health, an extended mandate of the European Union based on the Amsterdam Treaty supports the policies to and opportunity for Europe’s economic and to and opportunity for Europe’s social development. Health promotion for the ageing population is an urgent and essential have countries many and this, tackling for task already started work in this field. T

• • • R PRIORITY ACTION TOPICS

The Healthy Ageing project definition To achieve the aims of this project and to take 200 of healthy ageing the work on healthy ageing forward, recom- Healthy ageing is the process of optimising mendations have been developed, for suggestion opportunities for physical, social and to the Commission and to Member States. The mental health to enable older people to process has culminated in consensus. Significant RESEARCH PRACTICE POLICY take an active part in society without in the process was the discussion, at a European discrimination and to enjoy an independent Seminar in Helsinki in 2006, with high-level and good quality of life. officials from ministries throughout Europe. The core principles developed in this project are essential to healthy ageing and influence all CORE PRINCIPLES the recommendations.

PRIORITY ACTION TOPICS

RESEARCH POLICY

PRACTICE

CORE PRINCIPLES

Figur 28. Recommendations of the Healthy Ageing project. The recommendations on policy, research and practice interrelate and are connected to the priority topics for action. They are all based on the core principles. Illustration: TYPOFORM healthy ageing | recommendations 201

- - - - y c develop sustainable policies, health pro mes, with the participation of older people, at all levels and specifically at local levels. strengthen health promotion in basic and continuing education in gerontology geriatrics and for groups. all relevant professional grammes and financial frameworks,cific spe and/or integrated inprogrammes other and frameworks, policies, for promotion healthand prevention of ill-health for European,national,regionalat people older and local levels. health and health of significance the integrate promotion for older people in areas such all as economy, policy housing, transport and the environment. develop indicators for healthy ageing, and incorporate these in relevant statistical sys tems at European and national levels. health- implementin for plans action develop program disease-prevention and promotion tion, and variations in health, disability and socioeconomic status. The generation gaps among older people must also be taken into account. There are several generations be 50 and those aged 100+. tween people aged • The The Healthy Ageing project suggests that the States: Member the and Commission European • The Healthy Ageing project suggests that the Member States: • Recommendations Recommendations for policy, research below. practice are presented and Poli • •

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in es l age p i y c h lt rin p e hea Older people are of intrinsic value to society to value intrinsic of are people Older Heterogeneity Heterogeneity among older people must be in differences includes It account. into taken orienta sexual ethnicity, and culture gender, Autonomy and personal control essential are control personal and Autonomy for human dignity and integrity throughout life. All individuals must have the opportu nity for self-development and should take part in making decisions that concern them. Equity in health health Tackling inequalities in later life and determinants for older people should be at the core of any healthy-ageing strategy and health-promotion activity. Equity in health for older people explicitly discrimination of older people. includes non- health promotion interventions exclude older older exclude interventions promotion health people. improving the underlying socioeconomic It is never too late to promote health Evidence indicates that health interventions can promotion extend longevity and im prove quality of life. Health and promotion very of groups in even possible are prevention and programmes preventive Many ages. high bers and friends, and carry work in organisations and associations. Age out informal discrimination is prohibited in certain EU legislation, but implementation and educa tion are needed. Many older people live a most meaningful con They society. for resource a are and life tribute to work society, in a paid or unpaid mem family for care volunteers, as capacity • Cor •

• • • of Research • rely on scientific data and evidence-based 202 health promotion when designing and The Healthy Ageing project suggests that the implementing projects and programmes. European Commission and the Member States: • develop research to assess the effectiveness • inform a wide range of audiences about and the cost-effectiveness of health-promot- health promotion and effective health in- ing interventions and interventions for the terventions targeting older people, using a prevention of disease or ill-health throughout variety of information and dissemination the life course and especially in later life. methods and channels. • strengthen research to find ways of motivat- • create the conditions and opportunities ing and changing the lifestyles of older peo- for older people to have regular physical ple, especially the “hard-to-reach” groups, activity, healthy eating habits, social rela- paying special attention to environmental tions and meaningful occupations. and cultural aspects. • strengthen research to develop indicators of Priority topics for action healthy ageing, and to include data on the Policymakers, NGOs and practitioners should very old in health-monitoring statistics and consider the following priorities for action research. when working with older people: • disseminate research findings and promote their practical applications among all stake- Retirement and pre-retirement holders. Increase the participation of older workers and the quality of their working lives using new management concepts. Keep a balance between Practice personal resources and work demands and do The Healthy Ageing project suggests that the not tolerate age discrimination. Prevent illness European Commission and the Member States: in the workplace, promote healthy lifestyles • stimulate exchange of knowledge and expe- and a supportive and stress-free transition from rience of healthy-ageing interventions. work to retirement.

The Healthy Ageing project suggests that local Social capital authorities, practitioners, officials and NGOs: Encourage the participation of older people in • design, implement and review projects and the community. Increase educational and social programmes involving older people, paying activity group interventions targeting older special attention to “hard-to-reach” groups. people to prevent loneliness and isolation. Pro- • encourage a partnership approach in health vide opportunities for voluntary work by older promotion strategies by involving older volunteers. people, policy-makers, academics and practi tioners. healthy ageing | recommendations 203

- - - of therapies and the inclusion of older people in clinical trials will also help. Preventive health services Make preventive health services such as vac cinations accessible to older Consider people. older frail people, to attention special paying preventive home visits under certain tions. Take health condi literacy into account when working with older people. Substance use/misuse Promote smoking cessation and the reduction of harmful alcohol consumption among older people. Medication and associated problems Problems associated with the use of medica tions can be avoided by of the quality systematic indicators for use drug use and better co-ordination among care providers. Surveys

- - - and nutritional aspects, careful prescription of psychotropic drugs, and safe housing. Injury prevention Initiate safety promotion and injury preven tion, including programmes against violence and suicide, at all relevant policy levels. The individual approach should include physical Increase the level of physical activity international among the reach to order in people older at of, more or minutes of 30 recommendations least, moderate-intensity physical activity on most, preferably all, days of the week. older people, with an emphasis on low intake of saturated fats and high and fruits. fibre-rich foods, green vegetables consumption of Physical activity Access to technology should be considered as well as the impact of climate change, excessive heat/cold and storms. Nutrition among habits eating and food healthy Promote tions for older people. tions for older people. Environment Improve access to safe and stimulating indoor and outdoor environments for older people. relationships, poverty, discrimination, have an that impact on mental health being in and later life. well- Raise awareness of mental issues relevant to older people, such as depres sion and dementia. Increase the provision of psychotherapeutic and psychosocial interven Mental health Address the wider determinants, such as social 204 healthy ageing | contributions 205 Contributions Contributions 206 The Report has been completed in close cooperation between the Project Group and the Steering Group.

Participants in the project AGE, European Older People’s Platform Isabel Borges Catherine Daurèle Anne-Sophie Parent Anna Thille Barbro Westerholm

EuroHealthNet Caroline Costongs Clive Needle

WHO, World Health Organization, Irene Hoskins Ageing and Life Course Alexandre Kalache Louise Plouffe

Austrian Health Promotion Foundation Rainer Christ Austria Petra Plunger

National Institute of Public Health Hana Janatova Czech Republic

The Health Development Agency(until July 14th 2005) Seta Waller England Middlesex University (from October 19th 2005)

Folkhälsan – an NGO for public Viveca Hagmark Finland health and health promotion Taina Johansson Per Lindroos

Università Degli Studi Di Perguia Zahara Ismail Italy

NIGZ, Netherlands Institute Gerard H. van der Zanden Netherlands for Health Promotion and Disease

The Norwegian Directorate for Health and Social Nina Waaler Loland Norway Affairs(until July 21st 2005) Norwegian Knowledge Centre for the Health Services (from October 1st 2005)

Ministério da Saúde Direcção Geral da Saúde Maria João Quintela Portugal Pedro Ribeiro da Silva

NHS Health Scotland Fiona Borrowman Scotland Nuala Healy

The Swedish National Institute Ylva Arnhof Sweden of Public Health (SNIPH) Karin Berensson Hans ten Berg Nina Bergman Göran Berleen Marianne Granath Martina Junström Anita Linell Elisabet Olofsson Bosse Pettersson Gunilla Ripvall Maj Sölvesdotter Gudrun Winfridsson healthy ageing | contributions 207

England, commissioned by by commissioned England, Borrowman Fiona Michele Lee (commissioned by Fiona Borrowman), and Caroline Costongs Daurèle and Ida Knutsson, SNIPH “Effectiveness of interventions” – Isabel Borges and Catherine Daurèle and Susanna Strandback, Folkhälsan Finland, and Anna Thille acknowledged. Chapter 8. Physical activity Loland Nina Waaler Chapter 9. Injury prevention Hana Janatova “Introduction” – Seta Waller and Petra Plunger Petra and Waller Seta – “Introduction” Waller “Effectiveness of interventions” – Seta Chapter 5. Mental health Concern Age Lee, Michele – “Introduction” Waller, “Effectiveness of interventions” – Seta Chapter 6. Environment “Introduction” – Isabel Borges, Catherine Chapter 7. Nutrition Johansson, Carola Ray Taina Chapter 2. Statistics Maj Sölvesdotter Chapter drafted – – Hans ten Berg Chapter finalised of Göran Berleen is also The contribution Chapter 3. Retirement and pre-retirement Zanden Gerard H. van der Chapter 4. Social capital - - - - Fiona Borrowman, members: group promotion” – Eino Heikkinen, University of Jyväskylä, Finland The steering group has commented and con and commented has group steering The Various Various texts in the report have been com The report has also been discussed and de “Inequalities in health” – Caroline Costongs ”Gender and ageing” – Maj Sölvesdotter Executive Summary Marianne Enge Swartz Chapter 1. Introduction “Aspects of becoming older” and “Health Forsell at the Karolinska Persson and Institute, Magnus Stenbeck at the National Gudrun Sweden. Board of Health and Welfare, tributed to the whole report. project evaluator. Support and comments are Sven Bjurvald Mats Andreasson, Sven by made Bremberg, Gudrun Eriksson, Karin Eriksson, Margareta Haglund, Paul Nordgren, Pettersson, Sarah Wamala Bosse at SNIPH, Yvonne services” have been reviewed independently by independently reviewed been have services” Dr Betsy Thom, Head of the Social Policy and Eng Research Centre at Middlesex University, land. The whole Report has been reviewed by Mårten Lagergren, Assistant Professor at the Stockholm Gerontology Research Centre and ministries responsible for public health in the European countries. “Retirement 3 Chapters experts. by on mented and pre-retirement” to 12 “Preventive health Loland and Gerard H. van der Zanden. Loland and Gerard veloped at European seminars. Public Health Institutes throughout Europe have contributed to the texts. The Recommendations have been discussed and developed by high officials at Caroline Costongs, Seta Nina Waller, Waaler Steering Chapter 10. Substance use/misuse Chapter 14. Health promotion for older 208 “Tobacco” – Hans ten Berg people is cost-effective and Pedro Ribeiro da Silva Lars Lindholm and Klas-Göran Sahlén, Umeå “Substance use/misuse, Alcohol” University, Sweden – Zahara Ismail Chapter 15. International policies Chapter 11. Use of medication “WHO and UN policies” – Louise Plouffe, and associated problems WHO Barbro Westerholm “EU strategies and processes in relation to healthy ageing” – Caroline Costongs Chapter 12. Preventive health services and Nina Bergman, SNIPH Caroline Costongs, Seta Waller “EU policies on age discrimination” and Michele Lee – Isabel Borges and Rachel Buchanan

Chapters 3–12: Chapter 16. Policies in European countries Database searches were conducted by Chapter based on analysis by Claes Sjöstedt Gunilla Ripvall, librarian at SNIPH. of a questionnaire to the European coun- Initial reviews and selection of papers, identi- tries. Text by Marianne Enge Swartz. Both fied in the literature searches were con- are engaged by the WHO and the lead city ducted mainly by Marten Lagergren. of the healthy ageing theme in the Healthy Summaries of “Community interventions” Cities project. Seta Waller. Sections on “Effectiveness of interventions” Editors of the Report All edited by Seta Waller Karin Berensson, Project Manager, Healthy Ageing project Chapter 13. Good practice Gudrun Winfridsson and Martina Junström, The chapter “Examples of good practice” is Information Officers, Healthy Ageing based on a questionnaire to the project project. participants in summer 2005. Kerstin Tode analysed the answers and Marianne Enge Swartz wrote the text. Both are engaged by the WHO and the lead city of the healthy ageing theme in the Healthy Cities project. Mental Health and Well-being in Later Life Programme Scotland – Fiona Borrowman, Nuala Healy and Gudrun Winfridsson. Appendices Appendix 1. 210 Life expectancy in EU/EFTA/EEA countries Healthy Ageing EU-funded project 2004–2007 Data selected and processed by Göran Berleen, Healthy Ageing project (Dec. 2005). All data below are from Eurostat and refer to 2003 or earlier.

Country Percentage of population Average life expectancy (years) (In order of GDP per inhabitant) 50–64 65–79 80+ 50 65 80 Males Fem Males Fem Males Fem Luxembourg 16.5 11.0 3.1 27.7 33.1 15.3 19.9 7.1 9.0 Norway 17.6 10.2 4.6 28.8 32.9 16.2 19.7 6.8 8.6 Ireland 15.2 8.5 2.6 27.7 31.9 15.3 18.6 6.3 7.9 Denmark 19.6 10.9 4.0 27.4 31.1 15.4 18.3 6.7 8.6 Iceland (2000) 15.0 8.8 3.0 ca 30.8 32.6 18.1 19.6 8.4 8.8 Sweden 19.5 11.9 5.3 29.6 33.4 16.9 20.0 7.2 8.8 Netherlands 18.4 10.4 3.4 28.1 32.4 15.6 19.3 6.5 8.4 Austria 18.1 11.4 4.1 28.4 33.1 16.3 19.7 7.1 8.5 United Kingdom 17.7 11.7 4.3 27.9 31.9 15.7 18.9 6.9 8.6 (2000) Finland 20.4 11.8 3.7 27.7 33.0 15.8 19.6 6.8 8.2 Belgium 17.5 13.0 4.1 27.9 32.8 15.8 19.7 6.8 8.4 Germany (2001) 18.7 13.8 4.2 28.0 32.8 16.0 19.6 7.2 8.6 France (2001) 17.4 12.0 4.4 28.7 34.7 16.9 21.3 7.7 9.7 Italy (2000) 18.4 14.4 4.8 29.0 33.9 16.5 20.4 7.3 9.0 Spain (2000) 16.2 12.7 4.2 28.6 34.1 16.5 20.4 7.3 8.8 Cyprus 16.2 9.3 2.6 ------Portugal 17.4 13.1 3.7 27.6 32.4 15.6 19.0 6.6 7.9 Slovenia 18.4 12.2 2.9 25.8 32.0 14.6 18.9 6.5 8.1 Malta 19.2 10.3 2.7 ca 27.8 32.4 14.9 19.0 5.9 8.6 Czech Republic 20.4 11.1 2.9 25.1 30.3 14.0 17.4 6.1 7.2 Hungary 19.1 12.3 3.2 22.7 29.2 13.1 17.0 6.2 7.3 Estonia 17.7 13.2 3.0 21.7 29.6 12.7 17.3 6.2 7.3 healthy ageing | appendices 211 em 9.3 6.2 6.6 7.7 7.2 7.7 7.6 7.2 – F ca 8 7.6 6.4 5.7 6.3 6.6 6.1 7.0 6.2 – Males ca 8–9 em – 21.0 15.7 15.8 16.9 17.7 17.9 17.0 16.6 F ca 20 – 17.4 14.0 13.0 13.1 12.5 13.3 13.3 12.9 80 Males ca 18 em – 34.5 28.3 28.1 29.0 30.7 29.8 30.1 29.7 65 F ca 35 – 24.4 21.4 24.1 30.1 23.0 23.3 23.6 22.5 50 Males ca 30 Average life expectancy (years) Average life expectancy 4.3 2.4 2.9 2.7 2.2 2.9 0.7 2.8 2.3 2.5 80+ 8.1 5.0 9.3 11.4 14.2 12.2 10.6 13.3 12.2 13.8 65–79 9.7 18.4 19.7 18.7 16.8 17.7 16.1 17.0 18.1 16.8 50–64 Percentage of population

No GDP is stated. country. Switzerland is not an EU/EFTA/EEA urkey Liechtenstein Switzerland Bulgaria T Romania Latvia Poland Lithuania Croatia (2000) Slovakia per inhabitant) Country (In order of GDP 29. 30. Appendix 2. Relation of Gross Domestic Product (GDP) to average life expectancy in EU/EFTA/EEA countries Healthy Ageing EU-funded project 2004–2007 212 Data selected and processed by Göran Berleen, Healthy Ageing project (Dec. 2005). All the data presented below are from 2004 (GDP) or earlier and published by Eurostat and OECD.

Country GDP per Total % 65 % 80 Average life expectancy inhabitant population years years (€) (million) and older and older Total Males Females Luxembourg 56 500 0.5 14.1 3.1 78.2 (2002) Ca 74.9 Ca 81.5 Norway 43 900 4.6 14.8 4.6 79.5 77.0 81.9 Ireland 36 600 4.0 11.1 2.6 77.8 (2002) 75.2 80.3 Denmark 36 300 5.4 15.0 4.0 77.2 74.9 79.5 Iceland 33 700 0.3 11.8 3.0 Ca 80.6 Ca 78.7 Ca 82.5 Sweden 31 000 9.0 17.3 5.3 80.2 77.9 82.4 Netherlands 30 000 16.3 13.8 3.4 78.4 (2002) 76.0 80.7 Austria 29 000 8.1 15.5 4.1 78.8 (2002) 75.8 81.7 United Kingdom 28 700 59.7 16.0 4.3 78.2 (2002) 75.9 80.5 Finland 28 600 5.2 15.5 3.7 78.2 (2002) 74.9 81.5 Belgium 27 200 10.4 17.1 4.1 78.1 (2002) 75.1 81.1 Germany 26 900 82.5 18.0 4.2 78.3 (2002) 75.4 81.2 France 26 500 59.9 16.4 4.4 79.4 75.8 82.9 Italy 23 300 57.9 19.2 4.8 79.6 (2000) 76.6 82.5 Spain 19 600 41.0 17.0 4.2 79.6 76.1 83.0 Cyprus 16 800 0.7 11.9 2.6 77.9 (1999) Ca 75.3 Ca 80.4 Portugal 13 600 10.5 16.8 3.7 77.2 (2002) 73.8 80.5 Slovenia 13 100 2.0 15.1 2.9 76.6 (2002) 72.7 80.5 Malta 10 700 0.4 13.0 2.7 Ca 78.7 (2002) Ca 75.9 Ca 81.0 Czech Republic 8 500 10.2 14.0 2.9 75.3 72.0 78.5 Hungary 8 000 10.1 15.5 3.2 72.6 (2002) 68.4 76.7 Estonia 6 700 1.4 16.2 3.0 71.2 (2002) 65.3 77.1 Croatia 6 200 4.4 16.3 2.5 74.8 (2002) 71.2 78.3 Slovakia 6 200 5.4 11.6 2.3 73.9 (2002) 69.9 77.8 Lithuania 5 200 3.5 15.0 2.8 71.9 (2002) 66.3 77.5 Poland 5 100 38.2 13.0 2.4 74.7 70.5 78.9 Latvia 4 800 2.3 16.2 2.9 70.3 (2002) 64.8 76.0 Turkey 3 400 71.3 5.7 0.7 68.7 66.4 71.0 Romania 2 700 21.7 14.4 2.2 71.2 (2002) 67.5 74.8 Bulgaria 2 500 7.8 17.1 2.9 72.3 (2002) 68.9 75.6 Liechtenstein31 0.03 10.8 2.7 Ca 80.5 (2002) Ca 79 Ca 82 Switzerland32 38 900 7.4 15.7 4.3 80.4 (2002) 77.8 83.0

31. No GDP is stated. 32. Switzerland is not an EU/EFTA/EEA country. healthy ageing | appendices 213

es 13.8–14.6 14.2–15.0 14.8–15.3 – 20.1–20.7 19.3–19.9 18.1–18.7 19.0–19.6 17.7–18.4 18.5–19.1 18.9–19.4 18.8–19.3 20.1–20.7 19.1–19.8 19.6–20.2 14.1–16.0 17.4–17.9 17.8–18.3 17.7–18.7 16.5–17.1 15.8–16.2 16.3–16.9 15.5–16.2 15.9–16.4 15.9–16.5 15.8–16.3 15.5–16.1 interval 18.9–19.6 18.5–19.1 17.2–17.8 16.9–17.4 18.2–18.9 Uncertainty ountri c emales A/EEA 14.2 14.6 15.0 – 20.4 19.6 18.4 19.3 18.1 18.9 19.1 19.0 20.4 19.4 19.9 15.0 17.7 18.1 18.2 16.8 16.0 16.5 16.1 16.1 16.2 16.1 15.7 F 19.2 18.9 17.5 17.2 18.7 FT /E U

33 E) in E L 11.4–12.2 12.4–12.9 12.1–12.5 11.8–12.3 12.6–13.0 10.9–11.7 12.5–13.0 12.1–12.6 12.2–12.7 – 16.7–17.5 15.4–15.9 15.6–16.2 16.3–16.9 16.0–16.7 16.1–16.8 13.8–14.6 14.7–15.2 14.0–14.5 15.0–15.9 13.3–13.7 12.0–12.3 15.7–16.3 15.7–16.6 14.4–15.2 15.0–15.4 17.1–17.9 16.8–17.4 15.2–15.8 16.0–16.5 15.4–16.1 15.4–15.9 interval Uncertainty y (HA c n a t pec 11.9 12.5 12.3 12.0 12.8 11.3 12.8 12.3 12.5 – 17.1 15.7 15.9 16.6 16.4 16.4 14.2 14.9 14.3 15.4 13.5 12.1 16.0 16.2 14.8 15.2 17.5 17.1 15.5 16.2 15.7 15.7 Males x e

34 35 y lif

h ndix 3. lt The table above shows healthy life expectancy (HALE) at 60 years with 95 per cent uncertainty intervals (within a The table above shows healthy life expectancy (HALE) at 60 years certainty of 95 per cent, true value within this interval). Small intervals indicate large survey samples. certainty of 95 per cent, true value within this interval). Small intervals indicate large survey Data missing. country. Switzerland is not an EU/EFTA/EEA ea ppe urkey Bulgaria Liechtenstein Switzerland Lithuania Poland Latvia T Romania Malta Czech Republic Hungary Estonia Croatia Slovakia Italy Spain Cyprus Portugal Slovenia United Kingdom Finland Belgium Germany France Ireland Denmark Iceland Sweden Netherlands Austria Luxembourg Norway Countries per inhabitant) (In order of GDP 33. A project 2004–2007 EU-funded Healthy Ageing (Dec. 2005). project Healthy Ageing by Göran Berleen, and processed Data selected Data computed by the WHO and females. males (HALE) in years at the age of 60 for Healthy life expectancy below). between countries (see comments to assure compatibility H 34. 35. Comments on the HALE method 214 HALE is based on life expectancy but includes adjustment for time spent in poor health. It is most easily understood as the equivalent number of years in full health that a person who has reached 60 years can expect to live based on current rates of ill-health and mortality. The WHO published these data for 2002 in the 2004 World Health Report. Only HALEs at birth and at 60 years were published. The methods used by the WHO to calculate HALE were developed to maximise comparability across populations. The WHO analysed over 50 national health surveys for the calcu- lation of healthy life expectancy. It identified severe limitations in the comparability of self- reported health status data from different populations, even when identical survey instruments and methods were used. These comparability problems are a result of unmeasured differences in expectations and norms for health, so that the meaning that different populations attach to the labels used for response categories in self-reported questions (e.g. mild, moderate or severe) can vary greatly. An extensive description of the method is given in the WHO report mentioned above.

healthy ageing | appendices 215 emales F – – 62.9 57.5 – – – 62.8 59.9 58.2 61.9 60.0 58.7 61.4 59.6 61.0 61.3 – 60.6 – – 59.0 62.1 – – 55.9 – 56.4 – 62.8 62.8 (2002) 62.0 Males – – 62.6 – 63.5 61.0 59.4 64.2 60.7 58.6 61.9 59.7 60.9 61.6 – 63.7 – – 61.2 60.9 – – 60.0 – 59.8 Average exit age in years Average exit age in years 2003 – 62.8 62.0 (2002) 62.3 60.1 – – es – – em. 83 (u) 86 87 93 32 61 65 19 63 52 83 53 53 70 82 82 85 76 88 90 91 91 83 93 86 81 58 55 57 69 F

ountri 36 – c – 89 91 (u) 94 94 94 94 90 91 95 88 78 93 88 88 89 95 98 93 92 92 96 93 98 91 89 89 93 92 100 (u) Males Working full time 2004 A/EEA FT /E U em. F 61.8 41.3 58.6 33.1 35.7 51.9 32.9 54.0 – 41.9 37.8 – 61.6 32.6 45.5 49.1 30.8 32.7 42.9 51.6 34.8 17.2 47.3 33.6 67.4 43.1 61.4 82.2 72.2 45.9 36.6 56.5 in E e t a 51.5 66.7 53.4 58.6 66.2 47.2 61.2 – 56.2 52.0 61.6 53.6 60.3 57.6 57.4 68.0 78.0 68.1 56.4 65.2 68.2 Males 59.3 76.3 71.7 72.9 92.7 75.3 67.9 54.6 72.5 Employment 2004 81.8 –

nt r e

37 38 ndix 4. loym p u=unreliable data. Data is missing. country. Switzerland is not an EU/EFTA/EEA ppe urkey Luxembourg Romania Bulgaria Liechtenstein Switzerland Slovakia Lithuania Poland Latvia T Slovenia Malta Czech Republic Hungary Estonia Croatia France Italy Spain Cyprus Portugal Netherlands Austria United Kingdom Finland Belgium Germany Norway Ireland Denmark Iceland Sweden Country (In order of GDP per inhabitant) 36. 37. 38. A project 2004–2007 EU-funded Healthy Ageing 2005). project (Dec. by Göran Berleen, Healthy Ageing Data selected and processed average exit age from the age group and 50–64 of those working full-time (%) in the Employment rate (%) from Eurostat and the European Commission. labour market. Data Em Appendix 5. 216 Literature Review on Healthy Ageing Healthy Ageing EU-funded project 2004–2007 Mårten Lagergren, Gunilla Ripvall and Seta Waller

The chapters on the major topics have two mainly on systematic reviews, meta-analyses parts: introduction and effectiveness of inter- and literature reviews on health promotion. ventions. These are based on literature searches The searches were conducted on major top- and summaries of the findings by the authors of ics relevant to older people. Details of the search the chapters. The descriptive papers identified strategy can be found at www.healthyageing.nu. are summarised in each introduction, which The following databases were searched. The presents an overall view of the topic. The number of references/abstracts identified is authors have added papers not identified in the given below: literature searches, based on their own, col- leagues’ or other experts’ opinions. The parts Database Number of references/ on the effectiveness of interventions include abstracts papers selected for the evidence they provide. Cochrane database 66 The papers are reviewed and the chapters PubMed database 1,242 written mainly by the Healthy Ageing project (Medline) members. PsychInfo 85 The evidence is presented by nature of in- CRD (HTA, NHS, EED) 383 tervention, methods used, conclusions and Total 1,776 evidence statements. We have used the term ‘older people’ Selecting references throughout this report except when reporting From the gross list of 1,776 references, 189 from a paper which uses another term such as papers were selected for further examination. ‘elderly people’. Each was rated from 0–3 regarding the degree We aimed to: of relevance to interventions on health pro- • adopt a systematic approach, motion for older people. In the next step, 78 papers were chosen according to this rating. • describe the methods used to identify evi- In addition a second list of 14 papers describ- dence-based papers in the literature, and ing intervention projects was drawn up, based • summarise the findings from the database on an expert’s opinion, so as to shift the total searches in chapters on the major topics. balance in favour of papers on intervention. These 14 papers have a lower relevance rat- Search strategy ing, but the addition was made because of the A wide range of databases were searched to project’s focus on intervention. A few papers identify the relevant literature on interventions were added by the project steering group, as targeting people aged ≥50. The searches focused being relevant, based on their expert opinion. healthy ageing | appendices 217

- - - - include papers from the international litera ture published from January 1990 to June 2005, focus on systematic reviews, meta-analyses and other good reviews with clear odology on meth health-promoting interventions and falls as such prevention ill-health on and heart disease. Primary and secondary pre vention was considered, for example in the case of dementia and depression. Secondary prevention refers to prevention of relapse or prevention of a readmission to institutional care. Collaboration, the National Institute of Health of InstituteNational Collaboration, the and Clinical Excellence (NICE), and the York Centre for Reviews and Dissemination review evidence-based medicine. Each stratifieslevel the using different descriptivehighest level of tools. evidence is based The on reviews of randomised controlled trials (RCTs) or in their studies. Inclusion criteria • Note that papers identified through the litera ture searches and included in this Report are predominantly written in English. Levels of evidence Cochranethe OrganisationsasBritain, suchin The review process The ”Effectiveness of interventions” sections include papers selected for the evidence, literature searches, from which and summarised are in the report reviewed by the Healthy Ageing project members. The chapter authors also included papers not literature searches, as identified mentioned above. Two in contacted also were papers reviewed the of authors participants of age-range the of clarification for •

- - - - did not pertain to the older population reported results from meta-analysis or re The selected papers were included in two cific organ or system in the body. focused on treatment or management of sometimes the line between secondary tertiary or prevention and treatment can hard to draw), be area, geographical specific a to only referred or referred only to a specific drug or to a spe (50+), disease rather than prevention (although showed clear, generally valid effects or re pertained to questions of significance and quality of life of older people, and involvedprioritised groups such aswomen, immigrants andpeople. older of groups differentvulnerable and groups socioeconomic the older population, sults, importance with regard to the health and views of issues regarding successful interven successful regarding issues of views tions and important health determinants for

searches in many databases were needed to find to needed were databases many in searches a sufficient number of relevant papers. matrices (see www.healthyageing.nu). Concerning four major topics health – services, Preventive Environment, Mental additional – health pre-retirement and Retirement and Papers were generally excluded that • promotion and disease prevention among older among prevention disease and promotion persons. Hence in the first place papers were chosen that: • The guiding principle health evidence-based for to relevance both was selection steps of the • • • • • • single RCTs. The Health Development Agency References 218 has published evidence briefings, reviews- 1. Hillsdon M, Foster C, Naidoo B, Crombie H. of-reviews on public health topics, and has The effectiveness of public health interventions presented the evidence predominantly focusing for increasing physical activity among adults: on systematic reviews, meta-analyses and good- a review of reviews. London: Health Develop- ment Agency, NHS; 2004. quality literature reviews of the effectiveness of public health interventions. Effectiveness is described, mostly quantitatively, in terms of outcomes; however, outcome measures vary and depend on the focus of the study (1). The ”Effectiveness of interventions” sections present review-level evidence on interventions targeting older people. The aim was to include a high level of evidence by reporting systematic reviews of randomised controlled trials (RCTs) and meta-analyses. In a few topic areas with few systematic reviews, we included good literature reviews and quasi-experimental, case- controlled, cohort or observational studies.

Evidence categories Evidence statements based on the findings of the papers reviewed are given at the end of every chapter, in the following two categories: Evidence of effectiveness: evidence derived from systematic reviews, meta-analyses and good-quality reviews of interventions with clear methodology including reviews-of-reviews. Inconclusive evidence of effectiveness: inconsistency of methods and observed effects in studies included in systematic reviews, meta- analyses, and good quality reviews of interventions with clear methodology including reviews of reviews. healthy ageing | appendices 219 ------h lt hea nd a

e l p o pe r e The Organisation for Economic Co-opera OECD Health Data 2005 is an interactive mainly demographic, economic and social data social and economic demographic, mainly the in systems health-care the of aspects key on 30 OECD member countries. The key indica tors in this database cover health status (life causes expectancy, of mortality etc., perceived health status and social expenditure on for ex resources, health survivors), and age old ample utilisation and expenditure, pharmaceuticals healthy lifestyles, reducing health risks increasing the quality and of life. One framework element of the WHO Healthy Cities project is a project to create a model for profiling older people in cities (2). tion and Development (OECD) provides com parable statistics on health, health health indicators, a systems, system of health accounts OECD an as well as etc., society ageing (SHA), OLIS OECD OLIS. OECD the warehouse, data will progressively become the single source of all OECD statistical datasets under one com warehouse data the in theme One system. mon is health and economic and demographic sta tistics. Based on the OECD health database, the OECD indicators can be used for example to provide evidence of large variations across countries in indicators such as health and health risks. status database of comparable statistics comprising harmonise European health interview surveys and move towards the use multi-country of surveys international (1). WHO Europe also highlighting is issues of active ageing, instance for fostering policy advocacy, promoting

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a t s l a i ndix 6. c As a coordinator of the EUROHIS project, The WHO Programme on Health Statistics ffi ppe nternational level Study on Global Ageing and (SAGE). Adult Health WHO Europe is involved in developing Euro- pean Health Surveys. EUROHIS aims to gramme and a World Health Survey to compile to Survey Health World a and gramme comprehensive baseline information on health of populations and the on the outcomes of stud addition, In systems. health in investment ies of special populations, such as the population, are older being continued in the WHO indicators (demographic and socioeconomic indicators, some lifestyle in databases of and (Register etc.) indicators related environment- the WHO Regional Office for Europe, 2003). The WHO has also implemented a survey pro is an integrated WHO initiative to strengthen country, regional and global health statistics imple programme and policymaking better for Health-for-All European WHO The mentation. contains about 600 health database (HFA-DB) The World Health Organization (WHO) and WHO/Europe provide statistics via the WHO Statistical Information System (WHOSIS) in different areas such as health-related informa tion, health indicators and burden-of-disease statistics. older people living in EU countries. this work,During a number of important sources of statistics were identified. I Healthy Ageing EU-funded project 2004–2007 Healthy Ageing EU-funded Maj Sölvesdotter gatherstatisticsHealthy theAgeingproject To has charted statistical data on health and A O consumption and non-medical determinants iour (lifestyles and other health determinants), 220 of health. They also cover demographic and disease and health systems (indicators of economic references, e.g. population age struc- access to care, quality of care, human resources ture. Statistics on lifestyle and behaviour, etc., and financial viability of health-care systems). do not include data by age group. According to the European Commission the The OECD Health Project measures and development of health information will be analyses the performance of health-care systems based on European health indicators with in member countries: factors affecting perform- agreed definitions, method of collection and ance, long-term care of older people etc. Ageing use. The work on indicators and data collec- society is one important issue for the OECD, tion is co-ordinated among working parties largely because the ageing of OECD popula- that are creating a prototype for the future tions over the coming decades will require health-monitoring system (3). comprehensive reforms in the labour market, The Health Monitoring Programme (HMP) pension systems, social benefits and systems aims at providing the European Commission of health and long-term care, etc. The OECD with relevant and timely information about the analyses the challenges that ageing implies for health situation in each Member State. This member countries in these policy domains (see health information system will be a mix of ex- e.g. the OECD publications Long-term care for isting and new data collected through health Older People, Ageing and Employment Policies surveys in various Member States. Problems – “Live Longer, Work Longer”, Ageing and here are the substantial variations between Employment Policies – Sweden, Ageing, Hous- Member States in content and methods of con- ing and Urban Development). ducting a survey, with inconsistency in health The International Compendium of Health information as a result. These inconsistencies Indicators (ICHI) is a Web-based application are a major problem when dealing with statistics containing a selection of the most relevant in any form, and preclude comparability (4). health indicators used by WHO Europe, OECD The Health and Consumer Protection Di- and Eurostat in their international databases. rectorate-General (DG SANCO) is developing These are the Health-For-All database of the instruments for collecting necessary health WHO, European region, the Health Data of information data in cooperation with Euro- the OECD, and the New Cronos database of stat, DG Research, OECD (System of Health Eurostat. The ICHI also includes the complete Accounts), the WHO (European Community list of health indicators developed by the ECHI Environment and Health Information System) (European Community Health Indicators) and with its own DG SANCO resources and project, see below. partners. A smaller set of health indicators at regional/sub-national level valid for 300 regions European level of the EU is also being developed through the The European Health information System support of the Health Indicators in the Regions One objective of the 2003–2008 Public Health of Europe, phases 1, 2 and 3 (ISARE) projects. Programme is to develop comparable informa- DG SANCO’s future objective is to develop tion on health covering: health-related behav- a European System of Information on Health healthy ageing | appendices 221 ------

Eurostat is the Statistical Office of the Euro the of Office Statistical the is Eurostat The ESS functions as a network in which statistics in close cooperation with the national the with cooperation close in statistics statistical authorities. ESS concentrates mainly on EU policy areas. with However, the exten sion of EU policies, harmonisation has been extended to nearly all statistical fields. There is also coordination between ESS and national organisations inter such as the OECD, the UN, the IMF and the World Bank. The Sta areas, for instance public health, carried out by the European Statistical System (ESS). ESS seeks to provide comparable statistics at EU level. This was prompted by growing requests well as level Community at statistics health for statistics for as requirements for high-standard monitoring policies in different areas. Statisti cal data on e.g. health and its determinants is also needed for a variety of sets of indicators. Examples are in the ECHI programme and in the Open Method of Coordination (OMC) on integration social and disability and care health the and Eurostat comprises ESS The indicators. statistical offices, ministries, agencies and cen mainly statistics official compile that banks tral in the EU Member States. pean Communities. It provides the European information statistical high-quality with Union services. Eurostat is to lead the way in harmonising REVES 2, the aim is to select a concise set of of set comprehensive a which from instruments EU the for produced be can expectancies health (health expectancies combine life expectancy with a health indicator). The European Statistical System (ESS) and Eurostat Work is in progress at EU level on establish ing the framework for all statistics in different

- - - - - A similar initiative is European Community Another important step in developing health developing in step important Another The European Community Health Indicators Health Community European The an EU-funded project, aiming at improving in formation and knowledge for the development of public health. ECHIM is developing co-ordinating work and on Health Indicators and Monitoring (HIM). In another project, Euro- System (EUPHIX). EUPHIX aims to develop a prototype for a sustainable, health Web-based information system for the EU. Health Indicators Monitoring (ECHIM), also health interventions, i.e. health services (health services health i.e. interventions, health systems and their subdivisions) (3). information in the EU has been taken in the framework of the European Public Health In formation, Knowledge & Data Management reasonably comparable. Where this is consid ered useful or appropriate, the indicators are stratified by gender and age.They are divided into demographic and socioeconomic factors, health status, and determinants of health and indicators list to serve as a basis for the Euro- pean health information and knowledge sys tem. ECHI 1 and ECHI a 2 comprehensive have list developed of items/indicators. approximately ECHI 2 400 has begun selecting are that items 40 of list” “short a for indicators ate structures for health monitoring, with the aim of proposing a coherent set of European Community health indicators. objective, The ECHI 2, is to continue the work on current specific indicators so as to complete the health is the EU Health Portal, which provides easy access by citizens and professionals needing thematic information resources on public health. EU-level (ECHI) project is further developing appropri and Knowledge fully accessible to all European all to accessible fully Knowledge and output main Its public. general the and experts tistical Programme Committee (SPC) has an population surveys of drug use. General-popu- 222 important role in ESS work. SPC is chaired by lation drug use and related factors are presented Eurostat and brings together the directors of in the EMCDDA representative sample surveys the Member States’ national statistical offices. of the whole population. SPC discusses the most important joint action Health interview surveys (HIS), health ex- and programmes for meeting EU information amination surveys (HES) and combinations of requirements. HIS/HES and other population surveys were Eurostat statistics on older people and health used in EU Member States to collect informa- are presented first under the themes health, tion about the self-assessed health of the popu- public health. The statistics on ageing are pro- lation, on health-related behaviour and the vided by age group concerning, for example, use of medical services. This information was self-perceived health, diseases, disabilities, collected and stored in the HIS/HES database morbidity, causes of death, health care, health by Eurostat. Under the ongoing 18 HIS-item status, healthy-life-years expectancy (=dis- project, internationally comparable data has ability-free life expectancy), health indicators been significantly improved (5). The 2002 data from national health interview surveys (HIS) compilation indicated several topics for which etc. Data on the ageing society theme concern existing national surveys could deliver suffi- old-age dependency ratios, pensions adequacy ciently comparable data: self-perceived health, (relative median income ratio), the risk-of- chronic conditions, smoking, body-mass poverty rate for persons aged 65 years and index, doctor/dentist consultations and use over, demographic changes (life expectancy at of medicines. For some other items, national age 65 by gender etc.) and public finance sta- approaches still differ significantly although bility (pensions expenditure, average exit age harmonisation seems possible. from the labour market by gender, expenditure The European Community Household Panel on care for the elderly, total employment rate (ECHP) is a longitudinal, multi-subject survey by age group, etc). covering many aspects of daily life, particularly employment and income, but also demographic The European Health Survey System (EHSS) aspects, environment, education and health. The European Health Survey System (EHSS) The health section of the ECHP contains ques- consists of the European Health Interview tions on perceived health, chronic conditions Survey (EU-HIS) or the 18 HIS-item Eurostat hampering daily activities, temporary reduc- Project, the European Community Household tion of activity because of health problems and Panel Survey (ECHP), the Survey of Income and hospitalisation, medical consultations, smok- Living Conditions (EU-SILC), the DG Health ing and Body Mass Index. The detailed inter- and Consumer Protection’s health Eurobarom- view results are stored at Eurostat and many eters, DAFNE – the European food availability statistics derived from the ECHP are available databank based on household budget surveys in Eurostat’s database, New Cronos. (food, socioeconomic and demographic data The European Community Household Panel collected in household budget surveys (HBS) (ECHP) project was replaced in 2005 by a new and the European Monitoring Centre for Drugs instrument, EU-SILC (Statistics on Income and and Drug Addictions (EMCDDA) – general Living Conditions). EU-SILC is a continuous healthy ageing | appendices 223

- - - - - The EQUAL project (Successful practices in The European Quality of Life Survey age management) is an initiative for new ideas for European employment strategy and social inclusion the process. It is funded through the European Social Fund to promote inclusive more working life by fighting discrimina tion and exclusion for reasons of sex, racial or ethnic origin, religion age or beliefs, disability, or sexual orientation. EQUAL also has a data has focused on documenting and better derstanding the situation in un the new European Union. This firstled quality-of-life to Europe’s survey. (EQLS) was carried out by the Foundation in 28 countries in 2003. It examined issues such as education, household and family structures, housing, health care 2004 the Foundation and published an analysis of employment. In quality-of-life issues using data from the Euro pean Commission’s Eurobarometer surveys in the EU other and among from is, the acceding survey and the candidate of data The countries. components, based on different age groups, which allows presentation of data on ageing. Eurofound’s work on from living data includes also Europe in conditions life of quality and an interactive database of statistical quality- of-life indicators, EurLIFE. data EurLIFE from the Foundation’s offers own surveys and from other published sources. and economic variables, and the rotating mod rotating the and variables, economic and ules contain questions formulated by selected research groups for specific research purposes. The system of rotating modules flexibility and country-specific contextual data allows for on e.g. employment rates, tax expenditure etc. There levels, is currently no rotating social module on ageing. Extensive research by the European Foundation for the Improvement of Living and Working Conditions (Eurofound)

- - - - - DG SANCO also has a Health Euroba The European Social Survey (ESS) covers 20 nations and is jointly funded by the European Foundation Science European the Commission, participat each in bodies funding academic and change monitors module core The country. ing and continuity in numerous cultural, social launched publicly- an a inventory produce to of as so 30 health years on of barometers Euro- consultation. and analysis for tool available Other European Surveys and Databases on in-depth thematic studies carried out for departments of the European Commission or integrated then are These institutions. EU other into the are health on EBs special standard SANCO’s DG waves. Eurobarometer polling a consequence of this. In 2005, DG SANCO designed to gauge European public on opinion aspects of European integration and activities of the European institutions. These EBs are surveys of social Secondly, there are special or EB modules based living conditions. containing several instruments in specific do mains (health status, health determinants, use of medical services), collected at national level and co-ordinated by Eurostat (5). rometer. Standard Eurobarometers (EBs) are project is that, for the first time, comparable data on income distribution and EU. the on for produced poverty/ been have exclusion social modules different of way under is Development (EHIS) Survey Interview Health European a for hold in European countries. The reason for the for reason The countries. European in hold change was mainly to adapt the instrument to new political needs, above all priorities for the understand better a and poverty of eradication ing of social exclusion, based on commonly agreed indicators. The main output of the survey that covers statistics on living income conditions for different and types of house base, the EQUAL Common Database (ECDB), understand ageing and how it affects individu- 224 which contains information on all the projects als in the diverse cultural settings of Europe, financed within the European Union. The data that is, to study how differences in cultures, liv- is intended for those involved with EQUAL, for ing conditions and policy approaches shape the networking and for trans-national activities, lives of Europeans just before and after retire- for specific observers (political, researchers, ment. Areas studied include data on physical etc.) and for the public interested in employ- and mental health, health care services, well- ment issues, social integration, combating being, labour force participation, family and discrimination and inequality, innovation, etc. social networks, income and wealth (7). The MERI project – mapping existing The European Commission’s research and identifying knowledge gaps con- research programmes cerning the situation of older women in Europe The Key Action 6 on the Ageing Population – is another research programme under Key and their Disabilities is part of the Fifth Frame- Action 6. MERI aims at identifying the specific work Programme for Research and Techno- situation of older women and corresponding logical Development in the Quality-of-Life research and publication gaps. Research areas Programme. Key Action 6 was established to include health, education and qualifications, meet the challenges that society is facing in an ethnicity, labour market/paid and unpaid ageing Europe. The research seeks to promote work, income, social inclusion, social benefits, the global objective of healthy ageing with a violence, political participation/elections and Community-wide, cross-sectoral multidisci- interest representation (8). plinary approach. Key Action 6 is organised The European Research Area in Ageing into five action lines and different sub-areas: (ERA-AGE) under the Sixth Framework Re- age-related illnesses and health problems, basic search Programme, aims at facilitating the co- processes of physiological ageing, demographic ordination of European research programmes and social policy aspects of population ageing and knowledge exploitation, promoting joint (for example HALE, SHARE and FELICIE disciplinary research activities between coun- projects), coping with functional limitations in tries and sharing good practice in the coordi- old age, and health and social care services to nation and management of national ageing- older people (including health inequalities). research programmes. Another objective is The aim of the Healthy Ageing: a Longi- to help break down barriers between ageing- tudinal Study in Europe (HALE) project is to research programme policy and practice so study changes in and determinants of normal that the societal benefits of such research are and healthy ageing in 13 European countries realised as rapidly as possible. It is also impor- in terms of mortality and morbidity outcomes tant for the project to support the production and of physical, psychological, cognitive and of European priorities for ageing-research social functioning (6). programmes and ensure that these are fed The Survey of Health, Ageing and Retire- systematically into national/regional funding ment in Europe (SHARE) project is seeking to mechanisms. healthy ageing | appendices 225 - - Resources Key Action 6: The ageing popula Resources Key Action In: MERI-Mapping exist tion and disabilities. knowledge gaps ing research and identifying of older women in concerning the situation QLK6-CT-2002-30372. Europe. Contract No. ISIS - Institut für Soziale Frankfurt am Main: Commission; Infrastruktur and European 2004. p. 76. Quality of Life and Management of Living Quality of Life and

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ces n e r e Ageing and Retirement in Europe. European Journal of Ageing 2005;2(4):245-53. Ageing: a Longitudinal study in Europe. Report 260853003. Bilthoven, Netherlands: RIVM; 2005. Börsch-Supan A, Hank K, Jürges H. A New on Comprehensive and International View Ageing: Introducing the Survey of Health, Luxembourg: Office for Official Publications Luxembourg: Office for Official Publications of the European Communities; 2002. M, van Gelder B, Kromhout Bogers R, Tijhuis D. Final report of the HALE Project, Healthy 11-03 from http://ec.europa.eu/health/ph_ information/indicators/docs/shortlist_en.pdf. A. Response Conver Buuren S, Tennant Van sion for the Health Monitoring Program. Preventie TNO-report 2004.145. Leiden: TNO en Gezondheid; 2004. health. Eurostat. Health statistics: key data on surveys. Amsterdam: IOS Press; 2003. WHO/Europe – Healthy Cities and urban from governance. 2006. Retrieved 2006-05-05 http://www.euro.who.int/healthy-cities. 30, 2005. ECHI shortlist, final version of April 2006- European Commission; 2005. Retrieved tion. Regional Office for Europe. EUROHIS: tion. Regional Office for Europe. EUROHIS: developing common instruments for health Nosikov A, Gudex C, World Health Organiza Nosikov A, Gudex C, World f 7. 6. 4. 5. 2. 3. Re 1. work Programme for Research for the period 2007–2013. This research programme sists con of many elements themes of have been identified, continuity.including health, Nine socioeconomic sciences and the humanities. The European Commissionadopted a proposal for a new Seventh Frame has recently Appendix 7. Abbreviations 226 ACE Angiotensin-converting enzyme HFA-DB European Health for all database ADL Activities of Daily Living (Developed by WHO) ADR Adverse reactions HES Health examination surveys AGE European Older People’s Platform HIS Health interview surveys AGIR Ageing, Health and Retirement HMP The Health Monitoring Programme in Europe IADL Instrumental Activities of Daily Living AMD Age-related macular degeneration ICHI International Compendium of Health BMI Body Mass Index Indicators CC3 Candidate Countries INPEA International Network for the CEA Cost-effectiveness analysis Prevention of Elder Abuse (WHO) CHD Coronary heart disease INR International Normalised Ratio COPD Chronic obstructive pulmonary ISARE System of Regional Indicators disease in Health DG Directorate-General LGBT Lesbian, Gay, Bisexual and Transgender persons DG SANCO Health and Consumer Protection Directorate-General MEPs Members of the European Parliament ECHI European Community Health MERI Mapping Existing Research and Indicators (project) Identifying knowledge gaps concerning the situation of older ECHIM European Community Health women in Europe Indicators Monitoring MIPAA Madrid International Plan ECHP European Community Household of Action on Ageing Panel Survey NAOs Europe and National Action Plans ECOEHIS European Community Environment and Health Information System EES NIGZ Nationaal Instituut voor Gezond- European Employment Strategy heidsbevordering en Ziektepreventie in the Netherlands EHIS European Health Interview Survey NGO Non Governmental Organisations EHSS European Health Survey System NMS-10 New Member States EMCDDA European Monitoring Centre for Drugs and Drug Addictions NSAIDs Non-steroidal anti-inflammatory drugs EPHA European Public Health Alliance OECD Organisation for Economic EQLS European Quality-of-Life Survey Co-operation and Development ERA-AGE European Research Area in Ageing OMC Open Method of Coordination ESS European Statistical System PAD Peripheral arterial disease EU-HIS European Health Interview Survey QALy quality-adjusted life years EUPHIX European Public Health Information, RCTs Randomised Controlled Trials Knowledge & Data Management System SAGE WHO Study on Global Ageing and Adult Health EU-SILC Statistics on Income and Living Conditions SHARE Survey of Health, Ageing and Retirement in Europe Eurostat Statistical Office of the European Communities SNIPH The Swedish National Institute of Public Health FELICIE Future Elderly Living Conditions in Europe SPC Social Protection Committee GDP Gross Domestic Product SPC Statistical Programme Committee GP General practitioner WHO World Health Organization HALE Healthy life expectancy WHO HC WHO Healthy Cities HALE Healthy Ageing: a Longitudinal WHOSIS WHO Statistical Information System study in Europe (project)

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