Viewpoint

Towards a comprehensive public health response to

population ageing
John R Beard, David E Bloom

Lancet 2015; 385: 658–61 Worldwide, populations are rapidly ageing. This people want some form of work beyond traditional
Published Online demographic shift presents both opportunities and retirement ages, with a preference for workplace
November 6, 2014 challenges. Most people aspire to live a long and healthy flexibility. However, there are widespread barriers to
http://dx.doi.org/10.1016/
life, and older people (often defined for research purposes employment at older ages, including negative attitudes
S0140-6736(14)61461-6
as older than 60 years or 65 years) can be valuable of some employers and restricted access to training in
See Comment page 587
economic, social, cultural, and familial resources new technologies. If these barriers are not addressed,
Department of Ageing and Life
Course, WHO, Geneva,
(appendix). However, ageing populations may also be increasing the pension eligibility age might remove a
Switzerland associated with a shrinking workforce and higher demand crucial financial safety net. Delayed access to a pension
(Hon Prof J R Beard PhD); and for health care, social care, and social pensions. might be particularly challenging for older individuals of
Harvard School of Public Many of the challenges associated with population low socioeconomic status who, in addition to being
Health, Harvard University,
Boston MA, USA
ageing can be addressed by changes in behaviour and more likely to have substantial health problems, often
(Prof D E Bloom PhD) policy,1 especially those that promote good health in older work in the most physically demanding jobs and have
Correspondence to: age. However, so far, the debate on how best to achieve the fewest alternative job opportunities. Ensuring both
Hon Prof John R Beard, these changes has been narrow in scope.2,3 A economic sustainability and health equity will be a
Department of Ageing and Life comprehensive public health approach to population formidable challenge in the development of a public
Course, WHO, Geneva 1211,
Switzerland
ageing that responds to the needs, capacities, and health response to population ageing.
beardj@who.int aspirations of older people and the changing contexts in These complex challenges are exacerbated by major
which they function is needed. knowledge gaps. For example, although life expectancy
See Online for appendix Several factors make development of a policy on in older age is increasing in almost all countries, this
ageing difficult. First, the changes that constitute and Series emphasises that the quality of these additional
affect ageing are complex.4 These alterations only loosely years remains unclear.10 Incredibly, we cannot yet tell
correspond to chronological age, which changes at a decision makers whether people are living longer and
steady rate, whereas the variations in functioning linked healthier lives or are simply experiencing extended
with ageing are neither smooth nor well defined.5 As a periods of morbidity.
consequence, great inter-individual functional variability Several major longitudinal studies now underway will
is a hallmark of older populations; thus, policies to meet help to fill these knowledge gaps. However, the methods
the needs of older people should consider many of obtaining and interpreting information about ageing
different subpopulations. For example, although some and health also need to be reconsidered if we are to make
older people might wish to continue to participate in meaningful progress.
social and occupational activities to a similar extent to For example, this Series reinforces that, regardless of a
younger people, less healthy individuals in the same age country’s income level, the major causes of death and
group might need substantial health and social care and disability in older age are non-communicable diseases.
have little capacity for social engagement. Encompassing Much of this burden can be prevented or delayed, and
such diversity in a simple policy framework is difficult. increasing emphasis is being given to early life strategies
Second, this diversity is not random. Roughly 25% of of enabling healthy behaviours and controlling metabolic
the heterogeneity in health and function in older age is risk factors. However, the risks associated with these
genetically determined,6 with the remainder strongly determinants continue into older ages, although these
affected by the cumulative effect of health behaviours relations might attenuate, and strategies to reduce their
and inequities across the life course.7 Thus, someone effects continue to be effective. Yet, despite clear evidence
born into a poor family with limited access to education, of the importance of continued risk factor modification
or in a marginalised cultural group, is likely to have poor into older age, surveillance of health behaviours in older
health in older age and earlier mortality. Recent findings people is imperfect, and data that are available suggest
suggest that there might even be an association between that behaviours that put older people at risk remain
the ability to build financial security in older age and widespread.11 A greater emphasis on the neglected areas
decision making that maintains healthy behaviours.8 of health promotion and disease prevention in older age
Policymakers need to ensure that their interventions may yield substantial benefits.
do not reinforce these inequities. For example, a Furthermore, regardless of how effectively non-
common policy response to increasing life expectancy communicable diseases can be prevented or delayed,
has been to raise the age at which pensions can be many older people will inevitably be affected. Improved
accessed. This response is consistent with findings from systems are needed to provide chronic management
a US survey9 suggesting that a substantial proportion of for, and adequately address the consequences of, these

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disorders. One barrier to building these systems is the not be directly applicable to them. Innovative approaches
lingering perception that this chronic disease burden is are needed to bridge this gap, identify the optimum
made up of individual diseases that are best managed treatments for individuals with several disorders, and
independently. In reality, older people are more likely to minimise adverse drug interactions. Until these methods
have multiple, coexistent, and inter-related problems, are developed and adopted, improvement in post-
and this multimorbidity is commonly manifested marketing research could provide some guidance.
through a loss of function and the broad geriatric Finally, population ageing is not taking place in isolation.
syndromes of frailty and impaired cognition, Other broad social changes are transforming society and
continence, gait, and balance.12 Functional assessments these are interacting with ageing to affect social and
of these syndromes are better predictors of survival intergenerational dynamics. Understanding the interplay
than the presence or number of specific diseases,13 so between these trends is crucial if policy makers are to
the fact that comprehensive assessment and make the best decisions to promote the health and
coordinated care provide the best outcomes in older wellbeing of older people.
adults should not be surprising.14 Yet, informed geriatric Foremost among these factors is the changing situation
assessment and coordinated care remain the exception of older people in society. However, in many parts of the
rather than the norm, and much research fails to world, policy often seems to assume a division of the life
consider these more holistic perspectives. course into a series of stages that is based on chronological
Additionally, the importance of non-communicable age and social roles—typically student, working age, and
diseases in older age should not obscure other health retirement—that have little physiological basis. This rigid
issues. Although our understanding of the burden of framework prevents the flexible types of participation
communicable disease in older age is poor, these older people are increasingly seeking9 and is exacerbated
disorders clearly remain an important cause of morbidity by ageist stereotypes of frailty and mental diminution.
and mortality in older populations, particularly in Effective health, social, and economic policy needs to
low-income and middle-income countries. However, acknowledge the changing aspirations of older people
outdated perceptions of behaviour in older age could rather than reinforce outdated stereotypes.
limit both surveillance and response. For example, older Additionally, typical household composition is changing,
people, particularly those who are unmarried, might not along with attitudes about the obligations and respon-
be regarded as sexually active, and are often excluded sibilities that might be expected of different generations.
from HIV screening programmes or advice on safe sex Increased spatial mobility and changes in family structure
practices. At the same time, individuals with HIV are mean that, in many countries, older people are
living longer, increasing the likelihood that a sexually increasingly living alone or as part of a couple, rather than
active older person will face exposure to HIV via a in the larger, multigenerational households of the past.
potential sexual partner. Older individuals with HIV For example, in some European countries nearly 50% of
infection also need specific clinical management.15 For women aged 65 years or older live alone.18 These patterns
services addressing the prevention and treatment of HIV present challenges, since older people living alone have
and other infectious diseases to have maximum effect, less opportunity to share the resources typically available
they will need to adapt to changing demography. in a larger household and might also be at increased risk
Although vaccination can reduce the burden of infectious of isolation, depression, and suicide.
disease across the life course, immune function, Provision of care and support by families to older
particularly T-cell activity, declines with age. These changes people with substantial functional decline is becoming
mean that the capacity to respond to new infections and more difficult because of changing household structures.
vaccinations decreases in later life—a decline known as This challenge is exacerbated by the increasing proportion
immunosenescence. Furthermore, an age-related increase of older people compared with younger family members
in serum concentrations of inflammatory cytokines— and by internal and external migration of younger
known as inflammaging—has been linked to a broad generations. This change in balance is even evident in
range of outcomes including frailty, atherosclerosis, and sub-Saharan Africa, where the HIV epidemic has
sarcopenia. Fresh consideration of these trends might removed potential support for nearly 1 million older
provide innovative interventions for older age groups in people that would have been normally forthcoming from
the future.16 younger generations.19
A more comprehensive understanding of population These changes are stimulating increasing debate on the
ageing starts with research. However, many established roles of government and family in providing the social care
mechanisms for development and assessment of clinical many older people need. Changing gender norms add a
interventions have not been adapted to population ageing. further layer of complexity to this debate. In most cultures,
Despite being the most frequent users of many drugs, traditional carer roles are assigned to women. This role
older people are generally excluded from clinical trials.17 limits their capacity to engage in the formal workforce,
Yet, their altered physiological status means that the which places them at greater risk of poverty, abuse, and
evidence we extrapolate from younger populations may poor health in older age, while reducing their access to

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quality health care, social care services, and pensions. The much as possible, to age in place (eg, at home or in the
increasing participation of women in the workforce will community). Ideally, these services would be seamlessly
help overcome this inequitable burden and will have great linked with social and long-term care to provide a
benefits for socioeconomic development, but it will also continuum of care that extends from the community to,
challenge traditional familial roles and restrict families’ where indicated, institutionalised care. Core services
capacity to provide informal care at the same time that would include prevention and early detection of disease,
demand for it is growing. New, sustainable models of care acute and chronic care, rehabilitation, provision of assistive
that balance the role of family and government, and that devices, and palliative care. The importance of each of
overcome gender inequities, are urgently needed. these services would differ between settings, dependent on
Advances in information and communications demographics and level of socioeconomic development.
technology, assistive devices, medical diagnostics, and Although few low-income and middle-income
interventions offer much promise. For example, the countries have established such a continuum of care,
advent of wearable devices that can continuously monitor there is an opportunity for existing health services to be
physical activity may rapidly transform our understanding adapted to better meet the unique needs of older people.
of functional trajectories and their determinants. However, These adaptations might include basic geriatric training
if the benefits of technological advances are to be fully for all health staff, or practical steps such as reducing
realised, designers must also better understand the queuing time for frail older people. Diagonal
changing needs and opportunities of older age. A greater approaches—an integration of vertical models that focus
focus on how these innovations might meet the specific on a disease and horizontal models that focus on
needs of older people in low-income and middle-income health-care delivery systems—might also be considered
countries is also needed. to meet emerging needs (eg, control of hypertension) by
Thus, an effective public health response to population building on existing services (eg, chronic HIV care).
ageing must take into account the diversity in the In all settings, greater attention will need to be given
health, social, and economic circumstances of older to building and supporting an appropriately trained
people, the disparities in the resources that are available workforce, including both formal and informal carers.
to them, concurrent social trends, changing aspirations, Relying on international health worker migration is
and knowledge gaps. How can such a response be problematic since it can simply shift shortages from
achieved? First, health needs to be viewed in a way that more to less developed countries. Strategies to retain
is relevant to all older people. In view of the likelihood older health workers, and perhaps to recruit and train
of comorbidity and the centrality of geriatric syndromes older people as new health workers, will therefore be
in older age, a conceptual framework that focuses on important. For those entering the workforce, a greater
functioning rather than disease would probably be most emphasis on geriatrics in core medical training
relevant. Public health policy for ageing could then be curricula, along with a rethinking of the culture of
designed to maximise levels and trajectories of many clinical services that treat older people as generic
functioning in older age and the ability of older people vessels of single-organ disease, is essential.20
to do the things that are important to them regardless of Finally, since functioning is inextricably linked to
their functional capacity. context, a comprehensive public health strategy would
This approach has several strengths. Fostering functional need to take into consideration the physical and social
capacity can take place at all stages of older age, and before, environment. In recent years, several interventions have
and is a worthwhile goal even for the frailest or most been developed to create environments that foster active
cognitively impaired people. This process would also lead and healthy ageing. These include the WHO Global
to a thorough consideration of the contextual factors— Network of Age-Friendly Cities and Communities,
including issues of equity—that are so fundamental to which now has over 200 members responsible for almost
wellbeing in older age, and will probably encourage the 100 million people.21 Not all the resulting strategies will
development of the more coordinated systems of health need complex policy measures. For example, older
and social care that best address the needs of older people. people repeatedly identify simple aspects of the urban
Such coherence is absent from most policy environment, such as access to public toilets and seating
approaches, which insufficiently address key aspects in public spaces, as crucial to their social engagement.22
of heterogeneity among older populations.3 Instead, For development of this comprehensive public health
policies often emphasise either the need to minimise response, a rigorous evidence base that can serve to
the economic costs of population ageing—with a recent counter entrenched stereotypes and identify the most
focus on maximising the labour participation and net cost-effective strategies for the future is needed, followed
contribution of older people—or the goal of meeting the by mechanisms to ensure this evidence is translated into
needs of the most vulnerable. policy and practice. Some obvious knowledge gaps that
To optimise trajectories of functioning, health systems urgently need to be filled include our understanding of
could be redesigned to better provide coordinated and the actual and potential contributions and costs of older
informed geriatric services that enable older people, as populations; changing patterns of morbidity in

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This Series is a useful step towards filling many of research/landmark_RetirementReSet.php (accessed Aug 1, 2014).
these gaps. Recent work started by WHO will advance 10 Crimmins EM, Beltrín-Sínchez H. Mortality and morbidity trends:
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prioritise work on ageing and to develop a World Report 11 Lloyd-Sherlock P, Beard JR, Minicuci N, Ebrahim S, Chatterji S.
on Ageing and Health, followed by a Global Strategy and Hypertension among older adults in low and middle income
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Ghana and China, to help establish evidence-based policy and geriatric syndromes: the health and retirement study.
J Am Geriatr Soc 2009; 57: 511–16.
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13 Lordos EF, Herrmann FR, Robine JM, et al. Comparative value of
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Contributors
14 Ellis G, Whitehead MA, Robinson D, O’Neill D, Langhorne P.
JRB and DEB contributed to the design, content, and writing of this Comprehensive geriatric assessment for older adults admitted to
Viewpoint. hospital: meta-analysis of randomised controlled trials. BMJ 2011;
Declaration of interests 343: d6553.
We declare no competing interests. 15 Cordery DV, Cooper DA. Optimal antiretroviral therapy for aging.
Sex Health 2011; 8: 534–40.
Acknowledgments 16 McElhaney JE, Zhou X, Talbot HK, et al. The unmet need in the
We thank many colleagues who reviewed the paper in part or in whole for elderly: how immunosenescence, CMV infection, co-morbidities
their advice, particularly Jeffrey Adams, Des O’Neill, Jean-Pierre Michel, and frailty are a challenge for the development of more effective
Larry Rosenberg, Aki Kuroda, and Laura Wallace. The views expressed in influenza vaccines. Vaccine 2012; 30: 2060–67.
this manuscript are those of the authors and do not necessarily represent 17 Gurwitz JH, Goldberg RJ. Age-based exclusions from cardiovascular
the views or policies of WHO or any other organisation with which the clinical trials: implications for elderly individuals (and for all of us):
authors are affiliated or from which they derive financial support. comment on “the persistent exclusion of older patients from
DEB’s work on this Series was supported by grant P30AG024409 from the ongoing clinical trials regarding heart failure”. Arch Intern Med
National Institute on Aging to the Harvard School of Public Health. 2011; 171: 557–58.
18 Tomassini C, Glaser K, Wolf DA, Broese van Groenou MI,
© 2014. World Health Organization. Published by Elsevier Ltd/Inc/BV. Grundy E. Living arrangements among older people: an overview of
All rights reserved. trends in Europe and the USA. http://www.ons.gov.uk/ons/rel/
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