Shaping our environment to sustain healthier ageing
There is no biological law that puts a limit on life and there is no mandate that says we can only live until we are 80. In fact, as healthcare has improved, so have our average lifespans (1). Living longer does not necessarily mean we are living healthier, as longevity is associated with a higher incidence of one or more chronic diseases (2). Healthcare systems around the world are structured to treat diseases in isolation, and as a consequence, we are only making modest gains in extending healthy life. It has been estimated that the resolution of Alzheimer’s disease, a disease that receives billions of dollars of research funding, would result in around 19 extra days of life (3).
The concept of disease is changing. It is now acknowledged that we are commonly treating patients with multimorbidity, which make them more challenging to treat (4). In addition, age itself is now recognised as a disease in the latest edition of the International Classification of Diseases for Mortality and Morbidity Statistics (ICD-11) released by the WHO (5). This classification is a prerequisite for developing and registering therapies and releasing funding to actually treat the ageing process.
In the past three decades, the molecular signatures of ageing have been greatly elucidated. Four well-studied pathways that are known to regulate ageing, and whose modulation has been shown to influence the rate of ageing include Insulin/IGF-1, mechanistic target of rapamycin (mTOR), AMP-activating protein kinase (AMPK), and Sirtuin pathways (6). When these pathways are activated, either by diet or exercise, organisms become healthier, more disease resistant, and live longer lives (6).
Several molecules have been identified that may modulate these pathways, such as metformin, resveratrol, and NAD boosters, which can mimic the benefits of diet and exercise and extend the lifespan of diverse organisms. Trials using these molecules are actively underway, in the hope of replicating the same benefits in humans as has been indicated by animal models. Studies such as the TAME (Targeting Aging with Metformin) Trial will examine whether metformin can prevent or delay ageing as well as maintain quality of life (7). The results will be used to challenge the FDA and drug companies to start thinking about medications within an anti-ageing framework (7).
Researchers have recently attempted to estimate our potential longevity by omitting the things that usually kill us, such as heart disease or cancer. They found that treating disease would not stop the fundamental biological process of ageing, and the potential maximum life span for humans was somewhere between 120 and 150 years (8). However, by delaying ageing, where life is extended without concurrent disease and disability, a substantial social return would be accumulated. An analysis from the US estimated the economic value of delayed ageing would be $7.1 Trillion over 50 years (9).
The recent Intergenerational Report by the Australian Government discloses the population will continue to age, largely as a result of improved life expectancies and low fertility. In 2060-61, the report predicts 23% of the population is projected to be over 65, a rise of around 7% from 2020-21. The report also reveals that the ratio of working-age people to those over 65 is projected to fall from 4.0 to 2.7 over the next 40 years, and ageing will also reduce labour force participation (10). If healthy ageing is not prioritised, the pressure of increased healthcare spending and a smaller workforce will potentially overwhelm the budget. A key strategy must be to treat ageing itself, to ensure longer and more productive lives.
The challenge for healthcare
We need to prepare for a paradigm shift in how we treat ageing. There are several elements to this challenge including fostering, registering, and subsidising new therapies, providing equitable care, funding healthcare, and treating multimorbidity as well as disability.
There are several promising therapies that will enhance healthy ageing such as senolytics, gene therapy, cellular reprogramming and personalised medicine either on the horizon or entering the market. To approve these therapies, we will first need to recognise ageing as a modifiable disease. The current TGA definition of a therapy includes influencing, inhibiting or modifying a physiological process in persons (11), which could theoretically encompass ageing. Beyond this, we need to rethink what constitutes a ‘reasonable innings’ and take into account the benefits of prolonged productive healthy ageing when evaluating therapies for funding.
Australia is an egalitarian society with a universal healthcare system. Australians are not used to paying for healthcare and a two-tier society where the rich get access to anti-ageing medications would not be acceptable. Therefore, programs such as the Pharmaceutical Benefits Scheme (PBS) would be called on to fund access to anti-ageing therapies, which would put significant stress on the budget, potentially resulting in rationing. Work needs to be undertaken now to future proof programs such as the PBS as well as the Medicare Benefits Scheme (MBS) to allow for sustainable growth and to also allow system offsets, such as productivity gains, to be incorporated into budget allocations. In addition, more research funding should be allocated to healthy ageing research to focus on technologies, therapies or programs which keep people healthier for longer.
As the population ages, the proportion of people with multimorbidity also steadily increases (12). Increases in multimorbid populations present challenges to the entire medical profession, from general practice and community care to acute and long-term hospital settings. Greater specialisation, particularly for hospital-based doctors, has improved our ability to treat single diseases, but unless we react to the increase in multimorbidity, it will disadvantage the increasing proportion of patients with multiple seemingly unrelated diseases. New treatment models are needed to meet the needs of older people, their families and carers, and to support healthy ageing.
Disability is also an incredibly important area when considering the complex challenge of healthy ageing. Disability can take many forms including physical, intellectual, sensory, or neurological (to name a few). In Australia, around one in 5 people live with a disability and the prevalence is highly correlated with age (13). People with a disability are typically poor and live in disadvantaged areas, compounding their needs (13). Despite the National Disability Insurance Scheme (NDIS) covering around half a million Australians, there are millions of Australians with disabilities who want to provide meaningful contributions but are unable. To promote healthy ageing, more effective and cost-effective care models are needed to ensure older Australians with disabilities can continue to contribute in a productive manner.
The challenge for business
Responding to an ageing population and trying to promote healthy ageing brings many challenges and opportunities for business. Although older adults can be a significant asset to businesses, ageism and social norms tend to push older adults out of the workforce. Considering the strong correlation between age and disability, modern office environments and work practices require rethinking to allow older people to remain engaged in meaningful work for longer. Research shows that diverse perspectives drive better business outcomes and that when people feel a sense of belonging at work, they are healthier and more engaged (14).
An increasing prevalence of healthy older adults can also be viewed as a significant opportunity for business, in terms of a potential market. Older adults are generally wealthier, with fewer financial commitments and therefore more disposable income. They are physically more active than previous generations and are more tech-savvy. A significant opportunity exists for businesses to address the healthy ageing market by providing products and services that enhance mobility and connectivity. This has the potential to create a significant societal impact if these products facilitate greater productivity through healthy ageing in the older population.
The challenge for Government
An ageing population presents many challenges for Governments. The WHO Strategy and Action Plan on Ageing and Health (15) includes five priority areas for action:
- Commitment to healthy ageing
- Aligning health systems with the needs of older populations
- Developing a system for providing long-term care
- Creating age-friendly environments
- Improving measurement, monitoring, and understanding.
This includes consideration of not only the health and care needs of an ageing population but also the requirement to create age-friendly cities and communities. The latter takes into account elements such as outdoor spaces, transportation, housing and social participation (16). In responding to this challenge the Queensland Government has developed a healthy ageing strategy to support healthy ageing and drive health service effectiveness through identifying priorities for service improvement and innovation in the delivery of health care for older people (17). The strategy highlights the multi-factorial nature of a healthy ageing framework by considering the determinants of health decline such as disability, chronic conditions, and frailty, as well as other important aspects such as diversity, living arrangements and aged care.
While this shows that Governments are responding to the challenge of healthy ageing, much work is needed, so that strategies become inclusive, collaborative and rolled out at a national level.
Conclusion
Considering the ageing population, the potential arrival of anti-ageing therapies and the economic and social benefits of achieving healthy ageing, we need to invest in a society-wide change in the way we conceptualise ageing. For too long we have viewed ageing as inevitable and we have ignored the underlying determinants of ageing. Our society, including our social structures and our physical infrastructure, are not built to facilitate healthy ageing. However, change has already started with the classification of ageing as a disease, and our health system, businesses and Government will need to respond.
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