Aug 2023 | Reading time: 15 min
A broader argument for why longevity/aging biology is important, and the need for policy changes to address aging population demographics.
[skip to essay or skip to references for reading material]
I’d like to start this off by saying all those “by 204x” predictions are a lot closer in the future than immediately obvious. We are closer to 2040 than to 2000, which should be kind of alarming, no?
It is very alarming to me and I try not to think too hard about it or else I effectively launch myself into an existential crisis.
To get my point across, some quick math:
2040 - 2023 = 17 years
2023 - 2000 = 23 years
… so at the time of writing this, we are 5 years closer to 2040 than to 2000.
One area of strong concern I think not enough people care about is the impending and massive demographics shift that the entire world will experience, just some countries to a greater extent than others. Birth rates are declining and people on average live longer; it doesn’t take a genius to understand what the implications are–an aging population with an increasingly higher number taken as the average age.
The focus of this essay is on Canada, but I think it wouldn’t be far fetched to say the overaching problems faced are universally applicable.
This essay came to be because I took a health policy course to attempt to start understanding what is broken about Canada’s healthcare system. And for all the praise the Canadian healthcare system receives, some of it highly merited, it still has many areas that are lacking in a way that is also not immediately apparent.
For the course, we could write about any health policy adjacent topic, so I picked this one to advocate for a stronger push for some sort of active aging policy. Notably, I am more so picking at problems here than proposing a good solution because I don’t have concrete ideas and answers for how one would go about creating and implementing policies in an effective manner that is also highly contextualized and specific to subpopulations within the broader population. There is no one-size-fits-all solution here (or at least I don’t think there is, nor should there be).
As Canada’s population continues to undergo significant demographic shifts, characterized by declining birth rates and longer life expectancies, the country will face unprecedented challenges. An active aging policy for increased funding and determinants-driven support systems, based on the World Health Organization’s (WHO) active aging framework (World Health Organization, 2002), is critical for the wellbeing of Canada’s aging population; to develop age-friendly environments, align health systems and long-term care with older populations’ needs, and accelerate research innovation.
This essay advocates for further development of WHO’s active aging framework, to ensure evidence-based funding allocation for determinants-driven support systems. For nuanced discussion, this essay integrates a case study on “Dementia Villages”, a radically different approach to dementia care currently being adopted in Langley, British Columbia (Wilson, 2023), inspired by its original implementation in Hogeway, Netherlands (Planos, 2014). Contrasting this deinstitutionalized and community living model with conventional models in the context of active aging provides unique insights into the benefits, drawbacks, and feasibility of the aging-in-place approach, which is widely recognized to be preferred by older adults (Employment and Social Development Canada, 2016).
–
Background on the projected burdens of Canada’s aging population
One of Canada’s most prominent healthcare systems, Medicare, finds itself ill-prepared to handle the demands of an aging society. It was designed to cater to the acute care needs of a young population in 1966 with a median age of 25.5 (Canadian Medical Association, 2018), Alarming projections indicate by 2042, one in every four Canadians will be aged 65 or older (Thomson, 2022). This demographic tsunami, coupled with the inevitable increase in healthcare costs, necessitates a comprehensive examination of Canada’s health and social systems to ensure the wellbeing and satisfaction of its aging population, and the country’s overall political and economic stability.
The aging population will drive up the costs of Canada’s publicly funded healthcare system with a projected cost of 12000 dollars annually for the average senior, compared to 2700 dollars for the rest of the population; this adds approximately 93 billion dollars to healthcare costs over the next ten years, significant future spending not yet accounted in funding allocation plans (Canadian Medical Association, 2018). Studies have also disconcertingly revealed that Canadian seniors express lower satisfaction levels with the quality of care received (Zafar, 2018). While Canada introduced a national dementia strategy in 2019, with progress in policy development of reported recently (Public Health Agency Of Canada, 2023), there are substantial concerns about whether its maintenance and scaling post its five-year funding commitment (Stall et al., 2019). Hence, there is a strong need for proactive management of the impending challenges.
–
Developing age-friendly environments through the sociological paradigm
Deriving from the sociological paradigm, developing age-friendly environments fosters older populations’ autonomy and promotes multi-sectoral collaboration, to enable sustained social and civic engagement.
Firstly, age-friendly environments entail the provision of safety and inclusivity for older adults, paramount for independent mobility (Council of Canadian Academies, 2017). Older adults may face obstacles during the transportation journey: planning the trip, travelling to or home from the station, boarding the transport vehicle, and travelling between vehicles (Council of Canadian Academies, 2017). Older adults also take part in a broad spectrum of transportation activities ranging from day-to-day trips (ie, medical appointments) to longer trips (ie, family visits), which each present unique challenges concerning the “user experience” (Council of Canadian Academies, 2017). Notably, many older adults who struggle with driving or lack personal vehicle access rely on public transportation services to access essential health and social services; so, access to transport systems is a social determinant of healthy aging (Abud et al., 2022). And most critically, the integration of technology alone is insufficient, as its design is often exclusionary or focused on younger audiences with digital literacy. For example, with challenges in wayfinding, the physical abilities and preferences related to fatigue, mobility support, or even lack of internet connectivity, vary drastically. These concerns were also identified as areas requiring more scrutiny by the CLSA (Canadian Longitudinal Study on Aging, 2018). Beyond technology, user experience (ie, customer service) improvements are key for developing infrastructure that supports the needs and preferences of older adults.
Additionally, fostering these age-friendly environments necessitates multi-sectoral collaboration. In addition to physical health, the mental wellbeing of older adults is equally important, especially in acknowledging the diverse social determinants of mental health in active aging (Jeste et al., 2022). Apart from transportation systems, there are equivalently human-driven elements in other systems that provide the social infrastructure for creating individualized experiences to provide net positive health outcomes. For example, the provision of appropriate and relevant mental health services requires a comprehensive support network that engages healthcare providers (in emergency and health monitoring services), community organizations, and local government agencies. Here, a lack of communication across stakeholders results in a fragmented network and experience for older adults, which may result in a net negative health outcome. For example, social support programs that help combat depression from social isolation require consistent engagement from each stakeholder the older adult population interacts with (Jeste et al., 2022). Any negative experience can discourage the adult from further engagement, creating a “leaky” pipeline that may fail to serve the vulnerable groups that truly need support. As such, avoiding the medicalization of mental health is critical. Instead, forming mental health services and social support programs framed around the social determinants of health provides a more holistic approach that acknowledges the structural challenges faced by these populations, beyond what is immediately obvious (Jeste et al., 2022).
–
Case study: evaluation of “Dementia Villages” through the sociological paradigm
From a sociological health paradigm, the “Dementia Village” aligns with the principles of person-centred care. It recognizes the importance of tailoring care to the unique needs and preferences of individuals, by creating an environment that implements care systems integrating the social determinants of health in a non-demeaning manner. A roam-free environment fosters a sense of agency, contrasting traditional long-term care models that may restrict individuals to designated areas. And in safety concerns, certain “at-risk” older adults may even be detained in locked facilities, severely exasperating feelings of confirmed and loss of independence. Moreover, the small-scale community living model of the “Dementia Village” is socially integrative, with its infrastructure acting as a small-scale replica of everything one might find in a town.
The community-driven environment allows individuals with dementia to interact with their peers organically and engage in social activities that are meaningful to them. Notably, staff are dressed in non-uniform, to closely mimic the feeling of being at home without compromising individual safety if the adults struggle with navigation (Planos, 2014). While there are concerns about cost-effectiveness, the inherently low-stress environment that ensures overall wellbeing reduces long-term health costs, with emergency care costs associated with fall risks and acute events such as heart attacks (Planos, 2014). This aging-in-place allows for continuity in quality of life that may not otherwise be possible in highly institutionalized settings.
–
Equitable health and social systems through the human rights paradigm
Applying the human rights paradigm, orienting health and social systems around intrinsic capacity (Chhetri et al., 2022) to design people-centric care and build an appropriately trained workforce is crucial to developing equitable systems.
Recognizing the intrinsic capacity for functional ability is crucial for promoting equitable health and social systems. This approach emphasizes health promotion across various levels, including primary, secondary, and tertiary prevention (Lind Infeld & Whitelaw, 2002). Promoting the maintenance of functional abilities throughout the three levels of care, through addressing social determinants of healthy aging such as nutrition (Shlisky et al., 2017), improves the self-efficacy of the older population. Specifically, primary prevents the occurrence of the disease, secondary prevents an early condition from developing into a more significant problem, and tertiary prevention focuses on reducing disability and frailty amongst those already with a disease (Lind Infeld & Whitelaw, 2002). Providing health and social support systems, such as regular access to nutrition health specialists, transforms interventive care into preventative care, and further transitions tertiary into primary prevention. Within this scope of health promotion, a human rights perspective is essential as systemic access barriers cannot be discounted in the design of health and social systems. Otherwise, the developed infrastructure may only benefit the minority with preexisting access (Noren Hooten et al., 2022). Addressing racial determinants of healthy aging is difficult, but vital, to ensure marginalized and vulnerable communities do not become the sole targets of the accelerated aging phenotype (Noren Hooten et al., 2022). Preventative care is only as preventative as it is inclusive, recognizing that its effectiveness hinges on generating positive health outcomes for all individuals. Otherwise, there may be disproportionate gaps in health outcomes for minority groups, relative to what seem to be positive population health outcomes when an average is taken.
Additionally, improving care coordination through a trained workforce is key to addressing ageism. Ageist attitudes and practices can hinder older adults’ access to quality services and are especially damaging when self-reinforced. For example, individuals who lose interest in healthy preventative behaviours and engagement with health and social support systems often are those who gain belief in these negative age stereotypes (Todd D, 2016). As a result, recovery from illness is impaired, stress sensitivity is increased, and overall longevity is decreased (Todd D, 2016). Promoting inclusivity alone is also insufficient, as sustainable upholding of human rights values in health and social systems necessities requires a bottom-up approach. Community-level collaboration with stakeholders including politicians, educators, physicians, healthcare workers, and even families is required so everyone involved in the system, directly or indirectly, understands the value of affording older adults dignity in their care (Todd D, 2016). Although they may face many challenges with impaired abilities, maintaining agency within the scope of individual ability is core to maintaining intrinsic capacity. Older adults should not be subjected to paternalistic systems; instead, this population should similarly uphold the right to make informed decisions about their care based on the human rights principles of dignity, autonomy, inalienability, and inherent self-worth.
–
Case study: evaluation of “Dementia Villages” through the human rights paradigm
The “Dementia Village” aging-in-place model is highly aligned with human rights values through its deinstitutionalization of care. Its roam-free infrastructure emphasizes autonomy and the preservation of self-informed decision-making by older adults, to the degree to which they have functional ability. This is based on the concept of intrinsic capacity, in which individuals are treated as autonomous with their unique abilities, preferences, and rights, irrespective of their age or cognitive decline.
These aging-in-place communities foster a strong sense of belonging by refraining from defining individuals solely based on their age. Staff are trained to minimize the influence of negative, implicit biases in their method and tone of interaction with older populations. However, to enable diverse implementations of aging-in-place (ie, within individual homes), as not all individuals may have access to or be able to afford care in such settings, investment in such training standards is necessary across the workforce. The “Dementia Village” serves as an excellent example for developing human-rights-aligned infrastructure to inform policy development, though unlikely as a standard solution because it is unrealistic to provide a filtered lived experience for all older adults, like those in “Dementia Villages”.
–
Accelerating integrated research innovation for sustainable health promotion
Finally, accelerating integrated research innovation that accounts for the political-economic implications of aging incentivizes the translation of sociological and human rights approaches into sustainable health promotion. Canada has a strong need for increased funding allocation for research innovation and strengthened health promotion initiatives for transforming the public aging narrative.
Fostering interdisciplinary research collaborations is essential for exploring the multifaceted interactions between social, political, economic, and biomedical factors in aging populations. Aging is a complex phenomenon that is influenced by a range of interconnected factors and neglecting one in favour of another results in a fragmented solution. Promoting collaboration between researchers from diverse disciplines, such as sociology, economics, political science, and biomedical sciences, provides a more holistic understanding of the challenges and opportunities associated with an aging population. This interdisciplinary approach allows for a comprehensive analysis of the social determinants of health, the impact of political and economic policies on aging populations, and the development of innovative interventions that address the diverse needs of older adults. Here, Canada critically lags behind the United States in terms of government-funded aging research innovation, with the National Institute of Health funding approximately 2.9 billion dollars in 2020 (Alzheimer’s Association, 2021), versus 49 million dollars from the Canadian Institute of Health (Public Health Agency Of Canada, 2023). There are strong national-level incentives for increased funding, as the downstream impacts of an aging population extend well beyond health and social challenges. Poor health outcomes result in declined labour force participation, heavily influenced by pension income availability and tax transfer systems (Bos & von Weizsacker, 1989), which will severely affect growth in per-capita income (Fraser Institute, 2017). Also, the majority voting power will shift, with yet-to-be-scrutinized implications.
Furthermore, transforming the public narrative on aging is crucial for promoting sustainable health promotion. Aging is often viewed as an inevitable process, but perhaps reframing accelerated aging as a product of social determinants of health or as a “treatable” illness, similar to cancer, can foster a proactive attitude towards health promotion, across the entire population. Integrating the sociological and human rights paradigms in health promotion initiatives allows for a comprehensive integration of the complex factors that accelerate or deaccelerate aging. The inclusion of these paradigms overcomes some shortcomings of a purely political-economic lens. Political and economic considerations overlook the nuances of individualized lived experiences and needs. Incorporating sociological perspectives can capture the social contexts and cultural factors that influence health outcomes, and the human rights lens ensures that innovation does not neglect the dignity of older adults in favour of economic efficiency or political agendas.
–
Conclusion: a path forward for healthy and active aging in Canada
In conclusion, there is an urgent need for more funding allocation and infrastructure development to design and execute a healthy aging policy in light of declining birth rates and longer life expectancies. As Canada’s population ages, it is essential to prioritize the development of age-friendly environments, the alignment of health systems and long-term care with the needs of older populations, and the acceleration of research innovation. Age-friendly environments play a critical role in promoting the wellbeing and autonomy of older adults. Further aligning health and social systems with needs and preferences enables prolonged and meaningful engagement of older adults within society. Here, addressing ageism in the context of medicalization and racialization is a must, to prevent further stratification of the accelerated aging phenotype. Finally, accelerating research innovation across a broad spectrum of disciplines and enabling collaboration ensures long-term political-economic stability.
With the aging-in-place model identified as preferred by older adults, lessons learned on sociological and human-rights aligned infrastructure in “Dementia Villages” can be applied, to drive further in-context development of the WHO’s active aging framework into relevant policy reforms at regional, provincial and national levels. By embracing these principles, Canada can begin to prepare itself for the imminent demographic “tsunami”, to create a more compassionate society for all.
–
Note: I wrote “a path forward”, but I didn’t really identify a path forward, I just wrote about some of the problems that need to be addressed. But this was an essay for a class, so I hit a word limit. Maybe I’ll expand in the future after more research.
Especially on the note of the “aging-in-place” model being advocated for here, having thought a little more about it, I’ve realized how unscalable the approach is. The unit economics of existing implementations simply don’t work out and it would remain inaccessible to the general population. Contributing to the already uneven distribution of positive and negative outcomes only exasperates existing issues. And then it feels like we’re just back at square one, so what was the point, really.
Abud, T., Kounidas, G., Martin, K. R., Werth, M., Cooper, K., & Myint, P. K. (2022). Determinants of healthy ageing: A systematic review of contemporary literature. Aging Clinical and Experimental Research, 34(6), 1215–1223. https://doi.org/10.1007/s40520-021-02049-w
Alzheimer’s Association. (2021). Realizing the National Plan to Address Alzheimer’s Disease: Leadership Toward Treatment and Prevention. https://aaic.alz.org/downloads2021/2021_Milestones_Brochure.pdf
Bos, D., & von Weizsacker, R. K. (1989). Economic consequences of an aging population. European Economic Review, 33(2–3), 345–354. https://doi.org/10.1016/0014-2921(89)90112-8
Canada’s aging population and implications for government finances. (2017, October 31). The Fraser Institute. https://www.fraserinstitute.org/studies/canadas-aging-population-and-implications-for-government-finances
Canadian Longitudinal Study on Aging. (2018). The Canadian Longitudinal Study on Aging (CLSA) Report on Health and Aging in Canada Findings from Baseline Data Collection 2010-2015. Available from: https://ifa.ngo/wp-content/uploads/2018/12/clsa_report_en_final_web.pdf
Canadian Medical Association. (2018, July). Meeting the care needs of Canada’s aging population. Canadian Medical Association. https://www.cma.ca/meeting-care-needs-canadas-aging-population
Chhetri, Harwood, Ma, Michel, & Chan. (2022). Intrinsic capacity and healthy ageing. Age and Ageing, 51(11). https://doi.org/10.1093/ageing/afac239
Council of Canadian Academies. (2017). The Expert Panel on the Transportation Needs of an Aging Population. Available from: https://cca-reports.ca/wp-content/uploads/2018/08/transportaging_fullreport_en.pdf
Employment and Social Development Canada. (2016, October). Thinking about aging in place. https://www.canada.ca/en/employment-social-development/corporate/seniors/forum/aging.html
Jeste, D. V., Koh, S., & Pender, V. B. (2022). Perspective: Social determinants of mental health for the new decade of healthy aging. The American Journal of Geriatric Psychiatry, 30(6), 733–736. https://doi.org/10.1016/j.jagp.2022.01.006
Lind Infeld, D., & Whitelaw, N. (2002). Policy initiatives to promote healthy aging. Clinics in Geriatric Medicine, 18(3), 627–642. https://doi.org/10.1016/s0749-0690(02)00024-1
Noren Hooten, N., Pacheco, N. L., Smith, J. T., & Evans, M. K. (2022). The accelerated aging phenotype: The role of race and social determinants of health on aging. Ageing Research Reviews, 73, 101536. https://doi.org/10.1016/j.arr.2021.101536
Planos, J. (2014, November 14). The Dutch village where everyone has dementia. The Atlantic. https://www.theatlantic.com/health/archive/2014/11/the-dutch-village-where-everyone-has-dementia/382195/
Public Health Agency Of Canada. (2023, January). A Dementia Strategy for Canada: Together We Achieve - 2022 Annual Report. Government of Canada. https://www.canada.ca/en/public-health/services/publications/diseases-conditions/dementia-strategy-annual-report-parliament-2022.html
Shlisky, J., Bloom, D. E., Beaudreault, A. R., Tucker, K. L., Keller, H. H., Freund-Levi, Y., Fielding, R. A., Cheng, F. W., Jensen, G. L., Wu, D., & Meydani, S. N. (2017). Nutritional considerations for healthy aging and reduction in age-related chronic disease. Advances in Nutrition, 8(1). https://doi.org/10.3945/an.116.013474
Stall, N. M., Tardif, P., & Sinha, S. K. (2019). Ensuring Canada’s first dementia strategy is not shelved and forgotten. CMAJ : Canadian Medical Association Journal, 191(31). https://doi.org/10.1503/cmaj.190929
Thomson, S. (2022, December 5). By 2042, one in every four Canadians will be a senior. Our health-care system isn’t ready. The Hub. https://thehub.ca/2022-12-05/by-2042-one-in-every-four-canadians-will-be-a-senior-our-health-care-system-isnt-ready/
Todd D, N. (2016). Promoting healthy aging by confronting ageism. American Psychologist. https://doi.org/10.1037/a0040221
Wilson, A. (2023, May 6). A care revolution: Inside Canada’s first dementia village. Global News. https://globalnews.ca/news/9663849/dementia-village-canada/
World Health Organization. (2002, April). World Health Organization to the United Nations World Assembly on Ageing. Active Ageing A Policy Framework. https://extranet.who.int/agefriendlyworld/wp-content/uploads/2014/06/WHO-Active-Ageing-Framework.pdf
Zafar, A. (2018, February 8). Canadian seniors less satisfied with quality of health care in international survey. CBC. https://www.cbc.ca/news/health/seniors-satisfaction-cihi-1.4525303