Increased life expectancy and a growing ageing population have made the pursuit of healthy ageing a crucial policy to minimise health and social care costs, as well as maximise quality of life in later years (Chief Medical Office (CMO), 2023). The number of people aged ≥90 years has increased consistently; by 2019, almost one in every 100 people in the UK were aged ≥90 years, with improved male life expectancy, narrowing the gap between males and females reaching 90 years of age (Office for National Statistics (ONS), 2024). In 2022, the estimated population aged ≥90 years living in England and Wales grew a further 2.1% compared with 2021, and is now over half a million (550 835 people). Similarly, the population of centenarians (n=15 120) living in England and Wales has more than doubled since 2002 (ONS, 2024).
Present day ‘older people’ differ markedly from the older people of yesteryear; this is, in part, because medical advances have enabled people to live with conditions which were hitherto untreatable. Indeed, many people aged ≥65 years are very active and healthy, and do not view themselves as old, debunking the notion that chronological age is a useful measure of ageing. A distinction is now made between ‘old age’ and ‘very old age’ with the British Geriatrics Society using 85 years as a threshold, while some other European countries use 90 years. Regrettably, not everyone reaches an older age without significant health issues reflecting their previous lifestyles, which includes a wide range of behaviours such as physical activity, nutrition, cognitive engagement, social interaction and emotional wellbeing, which all contribute to shaping the trajectory of healthy ageing (Bosnes et al, 2019; eBioMedicine, 2023). Achieving healthy ageing in later life requires sufficient physical activity, a good diet, mental engagement and emotional wellbeing incorporated into daily life; this task is easier for some people, as is evidenced in the inequality of life expectancy and healthy life expectancy in England and Wales (CMO, 2023).
The CMO (2023) Annual Report for England focused on improving quality of life in later life through reducing ill health and disability, and environmental adaptations to enable independent living. The Report is critical of the relentless negativity about growing old and contested the portrayals that most people have dementias, or major debilitating conditions before they die. Instead, it asserted that many people have sufficient health to have independence and a good quality of life, while undertaking important roles, including volunteering and childcare of grandchildren (Glaser and Hank, 2018). This optimistic report (CMO, 2023) contests the view that a longer life inevitably means a longer period of ill health; rather, it proposed that a compression of morbidity is a realistic possibility so that people spend less time living with ill health at the end of their lives. Where older people have ill health, it is often multiple conditions which run counter to the current trends in medical specialisation, with its focus upon single diseases rather than a holistic treatment approach to multimorbidity. An additional challenge is the geography of older age, with it skewing away from large urban areas where the infrastructure to support older people is better developed in terms of healthcare, transport and housing, and where personal social networks were present, but are broken with relocation to coastal and rural areas in retirement. The Report highlights the imperative for policy makers and government (central and local government) to redress the infrastructure and environmental adaptation needs of older people outside large urban areas, if relocated older people are to live independent and enjoyable lives.
‘Achieving healthy ageing in later life requires sufficient physical activity, a good diet, mental engagement and emotional wellbeing incorporated into daily life. This is easier for some people, as is evidenced in the inequality of life expectancy and healthy life expectancy in England and Wales.’
The English Longitudinal Study of Ageing (Almeida-Meza et al, 2021) 15-year follow-up data (n= 12 280 [59–99 years] of whom n=602 developed dementia) found that higher levels of cognitive reserve were associated with lower risk of dementia. Cognitive reserve was assessed using the level of education through to higher education, the complexity of occupations and the level of leisure activities. The findings suggested that those with higher levels of cognitive reserve were able to mask the symptoms of cognitive decline and to manage unexpected life events better. Humans are social beings but unfortunately, since the COVID-19 pandemic, over half a million more people are experiencing chronic loneliness, with younger (16–29 years old) and older (>70 years old) people most likely to feel lonely (Campaign to End Loneliness, 2021). Being lonely is detrimental to health and is associated with depression, dementia and cardiovascular disease (Taylor et al, 2023), with a UK Biobank prospective cohort (n=458 146) analysis finding all social connection measures were independently associated with overall mortality risk and cardiovascular death risk (Foster et al, 2023). Additionally, drawing upon observational study evidence, Sommerlad et al (2023) have also asserted that greater social participation in midlife and late life is associated with 30–50% lower subsequent dementia risk. Key to social participation is adequate hearing; Lin et al (2023) were able to demonstrate through a multi-centre randomised control trial that a hearing intervention may reduce cognitive decline in those at risk of cognitive decline, indicating the importance of hearing tests and hearing aids, where needed.
The challenge of how to create solutions for an ageing population is not unique to the UK. Chen et al (2023) have described an area in Taipei, Taiwan, where 18% of the population are aged ≥65 years. This area has developed the Gan-Dau Healthy Longevity Plan following the principles of healthy ageing (World Health Organization, 2021). The plan comprises integrated care services addressing prevention, diagnosis and treatment, rehabilitation and end-of-life care. Digital technologies will ensure good data access for healthcare providers regarding people's health needs to promote precision healthy ageing at community and population levels so that as far as possible, disability, dementia, and social isolation are prevented through community-based interventions.
Japan has the longest life expectancy globally; therefore, restructuring for a superaged society is an imperative. Led by the University of Tokyo, the KASHIWA project in Chiba has a population approach with a community-based activity programme to prevent frailty, together with a comprehensive integrated care system to allow people to live in familiar surroundings until the end of life (Chen et al, 2023). Digital technology is used to increase connectivity between people of all generations and also includes a senior employment platform to enable job-sharing and job-matching after retirement. The emphasis is on quality of life, rather than years of life; in other words, maximum health and well-being/happiness, rather than extra years of life.
Alongside environmental adaptations and adequate infrastructure, an attitudinal change is essential to address ageism and the associated negative narratives which permeate society (CMO, 2023; International Longevity Centre, 2023). The Centre for Ageing Better (2023) presents a worrying account of ageism in the UK, including examples of institutional ageism alongside interpersonal ageism in healthcare. Kydd and Fleming's (2015) narrative review reported that older healthcare users have perceived negative attitudes with the evidence generally being found in acute care services, where there is an emphasis upon swift discharges and where slower recoveries may be perceived as troublesome by some healthcare professionals. Liu et al's (2013) systematic review of 25 studies on the attitudes of registered nurses and student nurses found that staff show inconsistent attitudes towards older people, with a preference to work with older people and knowledge of ageing being associated with positive attitudes. There is no available evidence regarding the attitudes of nurses working in the community.
The challenge is for community nurses alongside primary care colleagues to nurture older people as they age, with timely support being provided when needed, while enabling a high quality of life and independent living for as long as possible. To this end, the National Institute for Health and Care Excellence (2015) published a guideline setting out effective interventions/activities to promote independence and mental well-being, with an emphasis upon targeting efforts towards those at risk of a decline in their independence and well-being. The extent to which healthcare commissioners have responded to these recommendations is unclear.