What is it to Grow Old?

“It is to spend long days/ And not once feel that we were ever young./ It is to add, immured/ In the hot prison of the present, month/ To month with weary pain.”

These words, written by the British poet Matthew Arnold in his 1867 poem Growing Old, portrays a rather morose image of ageing as debilitation and the losing of self. How do Arnold’s words relate to older citizens in modern society, particularly in a world with an unprecedented rapidly growing ageing population?

A new reportOld Americans 2012: Key Indicators of Well-Being—released by the US Federal Interagency Forum on Aging Related Statistics, provides an updated picture of the wellbeing of Americans aged 65 years or older. This report not only tracks the trends in an ageing population domestically, but also compares the ageing demographic and US life expectancy with other countries. Among developed countries, the USA is relatively young—about 13% of the US population was aged 65 years or older in 2010, compared with 23% in Japan and more than 15% in most European countries. However, the percentage of US population aged 65 years or older is predicted to climb to nearly 20% in 2030. Population ageing is the result of increasing longevity and declining fertility. The life expectancy of Americans who survive to age 65 years was 20·3 years for women and 17·6 years for men in 2009, which lags behind that of many other developed countries such as the UK and Australia.

In terms of health status, 76% of Americans aged 65 years or older reported their health as good, very good, or excellent during 2008—10. Additionally, many of the health risks and behaviours, such as air quality and physical activities, have shown long-term improvements. As for end-of-life support, hospice care use in the last month of life escalated substantially from 19% of decedents in 1999 to 43% in 2009, and the percentage of decedents aged 65 years or older who died at home increased from 15% in 1989 to 24% in 2009.

The increasing life expectancy can be regarded as a successful story for medical sciences and socioeconomic development, but it also challenges health and social systems to adapt to the dynamic changes in an ageing world. Indeed, the ageing population already has a different outlook on the world, different behaviours, and different health risks to any that have lived before. As highlighted in the report, death rates for chronic lower respiratory disease increased by 57% between 1981 and 2009 in the USA. The prevalence of obesity has risen in American men aged 65 years or older during the past 12 years. Furthermore, older Americans in the poor or near poor income category continue to spend a high proportion of their household income on health-care services through 2009.

Worryingly, several emerging problems for ageing populations, in particular sexually transmitted diseases (STDs), are entirely ignored in the report and often disregarded in elderly health care as well. As estimated by the US Centers for Disease Control and Prevention, around 11% of new HIV infections in the USA occur in people aged 50 years or older, and 33% of all people living with HIV infection are in this age group. HIV may be just the tip of the iceberg. Several risk factors, such as an ageing immune system and a lack of screening, might put older people at greater risk of being infected with STDs than their younger counterparts.

More disturbingly, older people are not only overlooked in sexual health studies, but also seriously under-represented in many other clinical research areas, especially clinical trials. A study published in the Journal of General Internal Medicine in February, 2011, pointed out that of 109 clinical trials published in high profile journals (including The Lancet) in 2007, about 20% excluded patients older than a specific age, while nearly 46% of the remaining trials employed eligibility criteria that could disproportionately exclude older adults. Normally, older adults account for the major share of health-care utilisation and expenditures. But without robust evidence, how can the physician ensure proper and effective health care for their older patients?

Aside from the challenges in providing and funding health care for older people, an even tougher task might be reinventing the way health workers and the wider public think of ageing itself. Ageing should not be the inevitable progression of sickness and seclusion, but, as defined by WHO, “the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age”.

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