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Health in an ageing world—what do we know? and a few middle-income countries, the major progress in reducing deaths from avoidable causes in older adults in countries with scarce resources is a reason to be optimistic. With increased international commitment, sound policies, and strengthening of health systems, marked gains in life expectancy in older adults could be feasible in all countries. That there is scope for improving the health of older adults is underlined in the Series papers by Martin Prince5 and Somnath Chatterji6 and their respective colleagues. Interventions that are particularly targeted towards older people, including health promotion, disease prevention, and the entire range from primary to palliative care in an integrated manner, hold the promise of keeping older adults in good health for much longer as they age. Population ageing is the biggest driver of substantial rises in prevalence of chronic conditions, such as dementia, stroke, chronic obstructive pulmonary disease, and diabetes, that are strongly associated with age. Diseases in early childhood are also drivers of these rises in prevalence. Increased survival with cardiovascular disease and other conditions will also mean greater disability at older ages. As populations live longer, a key research question is whether subsequent cohorts will be healthier than those who have preceded them. Although compression of morbidity—meaning improvement in functional status in older people despite increases in the prevalence of chronic disease—might be taking place in high-income countries, this is far from clear in low-income and middle-income

www.thelancet.com Published online November 6, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61597-X

Published Online November 6, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61597-X See Online/Series http://dx.doi.org/10.1016/ S0140-6736(14)60569-9, http://dx.doi.org/10.1016/ S0140-6736(14)61347-7, http://dx.doi.org/10.1016/ S0140-6736(14)61462-8, http://dx.doi.org/10.1016/ S0140-6736(13)61489-0, and http://dx.doi.org/10.1016/ S0140-6736(14)61464-1 See Online/Viewpoint http://dx.doi.org/10.1016/ S0140-6736(14)61461-6

Bethany Clarke/Stringer

The ageing of populations is poised to become the next global public health challenge. During the next 5 years, for the first time in history, people aged 65 years and older in the world will outnumber children aged younger than 5 years.1 Advances in medicine and socioeconomic development have substantially reduced mortality and morbidity rates due to infectious conditions and, to some extent, non-communicable diseases. These demographic and epidemiological changes, coupled with rapid urbanisation, modernisation, globalisation, and accompanying changes in risk factors and lifestyles, have increased the prominence of chronic conditions. Health systems need to find effective strategies to extend health care and to respond to the needs of older adults (aged 60 years and older). As the international momentum towards universal health coverage increases, the specific needs of older adults, who often have many chronic health conditions, will have to be addressed by health systems.2 Health care for older adults that is effective, safe, efficient, and responsive, without imposing an unbearable financial burden on individuals, will be central to achievement of the goal of universal health coverage. Furthermore, in the post-2015 development agenda, the goal of ensuring healthy lives and promoting wellbeing for everyone at all ages cannot be achieved without attention to the health of older adults. With an increasingly large proportion of this population living in low-income and middle-income countries, this will have implications worldwide. This Lancet Series on Ageing aims to focus attention on this neglected agenda, considering not just the health sector but also those engaged in social and economic policy development. The six papers address issues related to mortality, morbidity and disability, wellbeing, determinants, and potential health-system and other responses. As Colin Mathers and colleagues3 show in their analysis, another striking change that has been happening in the past three decades offers hope for the health of older adults—a continuing fall in mortality at older ages. This fall has been sharpest in high-income countries, driven by highly cost-effective strategies to reduce tobacco use and hypertension, and improved coverage and effectiveness of health interventions.4 Although most data come from high-income countries

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countries. The trends in functioning in older people and the effect of interventions need to be tracked to deliver cost-effective solutions. This is an agenda for all countries, even high-income countries where the baby boomer and subsequent cohorts might have adopted lifestyles that could be increasing morbidity at older ages. As with mortality data, health information systems in low-income and middle-income countries are ill equipped to monitor morbidity trends and determinants. The call for better health data globally should include the populations that are driving future trends. To increase the healthspan (the length of time that an individual is able to maintain good health) of older adults by maintaining adequate levels of functioning, and not merely preventing deaths from disease, will be the cornerstone of health interventions. Increasingly, as Steptoe and colleagues7 point out, besides ensuring the good physical health of older adults, subjective wellbeing also needs to be ensured. Although in high-income countries subjective wellbeing has a typical U-shaped pattern with age, it progressively decreases in older adults in the former Soviet Union, eastern Europe, and Latin America. This pattern is corroborated by evidence from Finland, Poland, and Spain, to the effect that poor health status is significantly associated with negative emotional status and reduced life satisfaction.8 Since the two-way relation between health and subjective wellbeing is associated with longer survival,9 economic and social policies need to target this component in older adults, more so in view of the proposed post-2015 goal of promoting wellbeing at all ages.9 Because a substantial proportion of older adults will have poor health and be in need of long-term care, this will not only strain health systems but will also have economic implications. As Bloom and colleagues10 reiterate, however, this pessimistic scenario might be exaggerated because several responses are possible. These range from prevention of chronic disease by both population-level public health responses and individual-level lifestyle changes. Effective treatment of chronic diseases to reduce disability, an extension of basic packages of cost-effective interventions to match the needs of older adults with appropriate technologies, a reduction of reliance on institutional care, training of appropriate human resources, and modification of policies so as to encourage older adults to remain part of the workforce for longer are all necessary. The degree 2

to which health spending actually leads to health gains needs to be better measured and accounted for.11 As Beard and Bloom12 make clear in their Viewpoint, ageing populations are typified by marked heterogeneity in functioning. This heterogeneity might have resulted from the cumulative effect of health inequities during an older person’s lifecourse. This situation presents challenges to decision makers, who must avoid reinforcing these inequities while developing policy that responds to an enormous diversity of needs. These challenges are compounded by evidence gaps in many fields, and persistent approaches to care and research that view older people as generic vessels of singleorgan diseases that are best managed independently. Unless health systems change the selective underuse of interventions that are known to be effective in older adults, the burden on health systems is set to reach unmanageable proportions. Primary care systems need to be age-friendly, with appropriately trained healthcare professionals. The encouragement of healthy lifestyles is essential. Only then can we ensure that, as we live longer, we will do so in good health. The scarcity of knowledge about leading health issues in older people has hampered an effective response, and the shortage of research about the effectiveness of interventions has prevented an appropriate evidenceinformed policy from health and other sectors. This situation is particularly prominent in low-income and middle-income countries, partly because the epidemiological and demographic transitions have been recent and more rapid than in high-income countries. However, a burgeoning body of multidisciplinary international research from a range of low-income and middle-income countries supported by the US National Institute on Aging, such as WHO’s Study on global AGEing and adult health (SAGE)13 has begun gradually to increase our understanding of the complex evolution of health and wellbeing, and their determinants in older adults.14 Collaboration between psychologists, behavioural economists, and health professionals suggests low-cost ways of encouraging people to change lifestyles. Although this evidence comes from high-income countries, these data will spur further research.15 This Series provides a much-needed synthesis of the evidence as it stands today, points to important gaps that need to be filled, and suggests possible strategies to address the health and wellbeing of older adults.

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Richard Suzman, John R Beard, Ties Boerma, *Somnath Chatterji Division of Behavioral and Social Research, National Institute on Aging, National Institutes of Health, Bethesda, MD, USA (RS); Department on Ageing and Life Course, WHO, Geneva, Switzerland (JRB); and Department of Health Statistics and Information Systems, WHO, Geneva CH 1211, Switzerland (TB, SC) [email protected]

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We declare no competing interests. © 2014. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.

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UN Department of Economic and Social Affairs, Population Division. World population prospects, medium variant 2012 revision. http://esa.un.org/ unpd/wpp/index.htm (accessed Aug 28, 2014). UN General Assembly. 67th session, December 2012. Resolution A/ RES/67/81. http://www.un.org/en/ga/search/view_doc.asp?symbol=A/ RES/67/81 (accessed Sept 1, 2014). Mathers CD, Stevens GA, Boerma T, White RA, Tobias MI. Causes of international increases in older age life expectancy. Lancet 2014; published online Nov 6. http://dx.doi.org/10.1016/S0140-6736(14)60569-9. World Economic Forum. From burden to best buys: reducing the economic impact of non-communicable diseases in low- and middle-income countries. Geneva: World Economic Forum, 2011. http://www.3.weforum.org/docs/ WEF_WHO_HE_ReducingNonCommunicableDiseases_2011.pdf (accessed Sept 9, 2014). Prince MJ, Wu F, Guo Y, et al. The burden of disease in older people and implications for health policy and practice. Lancet 2014; published online Nov 6. http://dx.doi.org/10.1016/S0140-6736(14)61347-7.

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Chatterji S, Byles J, Cutler D, Seeman T, Verdes E. Health, functioning, and disability in older adults—present status and future implications. Lancet 2014; published online Nov 6. http://dx.doi.org/10.1016/S01406736(14)61462-8. Steptoe A, Deaton A, Stone AA. Subjective wellbeing, health, and ageing. Lancet 2014; published online Nov 6. http://dx.doi.org/10.1016/S01406736(13)61489-0. Miret M, Caballero FF, Chatterji S, et al. Health and happiness: cross-sectional household surveys in Finland, Poland and Spain. Bull WHO (in press). National Research Council. Subjective well-being: measuring happiness, suffering, and other dimensions of experience. Washington, DC: The National Academies Press, 2013. Bloom DE, Chatterji S, Kowal P, et al. Macroeconomic implications of population ageing and selected policy responses. Lancet 2014; published online Nov 6. http://dx.doi.org/10.1016/S0140-6736(14)61464-1. National Research Council. Accounting for health and health care: approaches to measuring the sources and costs of their improvement. Washington, DC: The National Academies Press, 2010. Beard JR, Bloom DE. Towards a comprehensive public health response to population ageing. Lancet 2014; published online Nov 6. http://dx.doi. org/10.1016/S0140-6736(14)61461-6. WHO. WHO Study on global AGEing and adult health (SAGE). http://www. who.int/healthinfo/sage/en (accessed Sept 9, 2014). Gateway to Global Aging Data. http://www.g2aging.org/ (accessed Sept 9, 2014). National Institute on Aging. Psychological science and behavioral economics in the service of public policy. 2013. http://www.nia.nih.gov/ sites/default/files/psychological_science_and_behavioral_economics.pdf (accessed Sept 2, 2014).

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Health in an ageing world--what do we know?

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