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Abstract
Ageing
is not a disease. It is a natural phenomenon that
all species go through. Although, it continues
to be not very well understood it is the process
that transforms a salubrious person to a frail
one, with decline in the efficiency of most of
the body organs. Ageing usually impacts human
health in a way that is more destructive to the
body than any other disease. During ageing there
is a continuous deterioration in the function
of cells as time passes, increased vulnerability
to challenges and high prevalence of occurrence
of age-associated diseases that ultimately lead
to decreased ability to survive and death.
The number of old people worldwide is on the rise
and according to WHO, "between 2000 and 2050,
the proportion of the world's population over
60 years will double from about 11% to 22%, reaching
an absolute number to over 3 billion in the same
period". However, such increase will be seen
more and faster in the developing than the developed
countries despite the fewer dollars and the cost
implications on the health and social services
to be provided is high. The main reason for such
rapid increase is the decrease in the mortality
rate along with the increase in the average living
age of people reflected directly on the total
population size of such countries.
In this paper the issue of the elderly people
is highlighted and discussed in particular to
their percentage of the total population and the
forecast. It will also discuss issues related
to health deterioration and disabilities
as people tend to age, and the health needs of
this sector of the population with its cost implications.
Key words:
Elderly, geriatric, pattern, disabilities, cost,
health and social welfare.
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Review
"We all form part of a life cycle, and every
moment in this session, both at its beginning or near
its end must be regarded as a treasure and be an occasion
to celebrate" (World Health Organization).
To highlight the vast changes
among the population trend in the world, the World Health
Organization (WHO) adopted a slogan stating "The
world is turning gray" that indicate the continuous
rise in the number of elderly people and forecasting
that the whole world is ageing without any marked heterogeneity
between countries.(1) Although WHO defined old age as
"the segment of the population, aged 60 and over",
with many aged people leading an active life, the organization
has later introduced three different categories of ages:
'young old' from 60 to 69 years old, 'middle age old'
from 70 to 79 and 'old old' who are 80 and over.
Forecast
Due to the rapid decline in both fertility and mortality
rates and more public health prosperity, there is an
immense demographic change in the world (2) leading
to improvement in the health of old people and ultimately
increase in the average life span. (3) In the United
Kingdom it is reported that the average life expectancy
at birth for a man a few years ago was 68, but it is
now 75 years with a rise at a rate of 2 months every
year. The increase in the oldest old is even more dramatic
reaching 100 years of age. (1)
According to WHO, "between 2000 and 2050, the proportion
of over 60 years old from the world's population will
double from 11% to 22%, while their absolute number
is expected to increase from 605 million to 3 billion
over the same period of time" (Graph 1).
Graph 1: Projection of the number of population over
60 world- wide
Source: SIXTY-FIVE PLUS IN THE UNITED STATES. May 1995.
Economics and Statistics Administration (4)
Gorman, in 2002, projected a
monthly increase in the number of people aged 65 years
till the year 2010 reaching to 1.1 million.(5) Although
the current percentages (18% to 20%) of old people among
the population in the developed world is higher than
in the developing countries, it maintained its stability,
while there is a steady and rapid increase in their
number within the developing world. (6) It is alerting
to know that 80% of such increment will be most prominent
in low and middle-income countries. Reports indicate
that in Africa alone during the coming few years the
increase will reach 450 million (from an existing 213
million). (7) If the kingdom of Bahrain is taken as
an example of the MENA (developing) countries, the percentage
of old people reported in 1992 was 2.4%, that reached
to 3.2% in 2000, then 5% in 2003 and is anticipated
to be 10% and 25% in years 2025 and 2050 (Graph 2) respectively.(8)
Graph 2: Forecast of population up to 2050 in Bahrain
Source: Central Statistics Organization, State of Bahrain
1995-1996.(8)
Moreover, China will take around 34 years and Singapore
around 20 years to double the proportion of its ageing
population.(1) Meanwhile, the changes in the developed
world have been gradual and homogeneous occurring over
hundreds of years, before reaching its current ratios.
In the United States of America, for example, the proportion
of old people in 1990 was 4% and amounted to only 13.9%
in 2010 (9) (Graphs 3,4). Also it took over 100 years
for Belgium to double the proportion of its 60+ population
from 9% to 18%. (1) Such a long period of gradual increase
provided sufficient time for policy makers and scientists
to conduct studies and regulate policies enabling the
society to prepare and act in the best interests of
this segment of the population, a luxury that the developing
world would not have. (6)
Graph 3: USA population trend from 1900-2050
Source: U.S. Senate Subcommittee on Aging; American
Association of Retired Persons (10)
Graph 4: Trend of elderly population increase in
the USA
Source: Economics and Statistics
Administration, U.S. Department of Commerce (4)
The traditional population pyramid
that has a wide base and tapering end reflecting shape
of the population with more of the younger generation
than elderly has been changing over the years due to
the changes in the population structure. In certain
countries it can't be called a pyramid any more. (Graph
5 - example Germany). (11)
Graph 5 ; Population forecast I Germany
Source; United Nation Population
database (11)
Life span in relation
to gender:
Within all of the developed countries, and as is the
case in many of the developing countries, there are
improvements in the maternal and child health care services
that are reflecting directly on the life span of the
human being. In addition to that, other biological factors
that are not related to the different socio-cultural
issues have all lead women to live on average longer
than men. (Graph No 6)
Graph 6: Life Expectancy by Gender
Source: World Population Ageing 2013 Report (12)
Socio-economic
constraints
Politicians of the poorer countries are much more likely
to neglect considering their responsibilities to older
people, or worse, remain in a state of denial in which
it is assumed that traditional values will ensure that
'the family will cope with the care of old people'.
(13) Such ignorance will just add upon the problems
and their complications. It is recommended by most agencies
that the responsibilities of overlooking such problems
should be shared between the government, society and
the families where there is a social contract between
the three parties emphasizing on the social values from
which policies should grow.(14) It seems likely that
in all countries there will be a need for re-defining
the role of the state in 'welfarism' as suggested by
Lloyd-Sherlock, who also highlighted the importance
of changing the economic, social and cultural contexts
in which social policies for older people are enacted.(15)
It should be clear that institutions or homes for the
elderly are not always the solution for elderly problems.
Studies have indicated that elderly people living in
institutions are more prone to physical, health and
social deterioration, than those living within their
family at home. (16) It is also reported that at least
3% of the elderly among the age group 65-75 years are
affected with some cognitive impairment, while many
of those who are older than 85 years of age could get
dementia (4) that increases to 66% when they are residing
in social institutions. (17)
Whether it is a rich or poor country, the fact is that
the cost of health care for old people is increasing.
The rising costs for social welfare, has led consequently
to the increasing emphasis on identifying what are seen
as 'cost-effective' measures, such as enhancing the
caring capacity of families and communities, asserting
the responsibility of individuals to make provision
for their own old age and drawing on collective support
for older people from 'civil society' institutions,
including non-governmental organizations (NGO).(2) According
to a UK study a few years ago, the cost of health care
of a young person in England averaged to about £
140 per year, while for the elderly it shot up to reach
£500- £600 per year. Graph No.7, highlights
the pattern of increasing health care cost with increasing
age in the developed countries. However, despite such
high cost pertaining to the health care and social services
to elderly, the developed countries consider caring
for them as a moral and social obligation.
Graph 7: Per capita health cost by age
Source: Health Care Spending by Age and Country (18)
Ageing
process
Ageing occurs in all people, even to those who have
means of a good living. No matter how much effort is
put into maintaining health and living a healthy life,
we should accept the certainty of getting old, ageing
and eventually, death. (19) Although it commences from
early stages of life, even since the embryo stages,
ageing is still considered to be a mystery which continues
to be not very well understood.
Ageing is a process in which individuals undergo an
exponential decline in vitality that transforms a salubrious
person to a frail one. (19) Moreover ageing impacts
human's health in a way that is more destructive to
the body than any other disease. The efficiency of most
organ systems is decreased as well and there is a loss
of function at a rate of 1% a year starting from the
age of 30 years. (20) The progressive decline in the
efficiency of body cells lead to lack of cell ability
for auto repair while the disturbance of the immune
systems lead to functional decline in the ability to
respond to new pathogens.(1) In addition one of the
most important elements in ageing is the decreased ability
to respond to stress and as a result of gradual loss
of homeostatic mechanisms.(6) It is a prime major factor
that contributes to the likelihood of disease occurrence
leading to decline in all of man's physical and mental
abilities.
Bergamini et al, 2007 described ageing as "a post-maturational
deterioration of cells and organisms with the passage
of time, an increased vulnerability to challenges and
prevalence of age-associated diseases with decreased
ability to survive". (21) While Atwood et al, 2011
in defining ageing theory stated "The Reproductive-Cell
Cycle Theory posits that the hormones that regulate
reproduction act in an antagonistic manner to control
aging via cell cycle signaling; promoting growth and
development early in life in order to achieve reproduction,
but later in life, in a futile attempt to maintain reproduction,
become dys-regulated and drive senescence. Since reproduction
is the most important function of an organism from the
perspective of the survival of the species, if reproductive-cell
cycle signaling factors determine the rate of growth,
determine the rate of development, determine the rate
of reproduction, and determine the rate of senescence,
then by definition they determine the rate of aging
and thus lifespan". (22)
It is due to the cellular changes that happen specifically
in the chemical structure of the body that makes the
waste bio-products build up in tissues due to oxidation
of some unsaturated fats causing the deposition and
accumulation of certain fatty brown pigments called
lipofuscin. Such deposition that is observed mainly
in the nerve, liver, kidney and thyroid cells leads
to decrement in the cell size, damage beyond repair,
loss of chromatin and ultimately loss of cell function
and in some cases the occurrence of fibrosis despite
retention of cell activities for a period of time till
it ceases completely. (23) The most vital tissues in
the body that are affected by ageing are the fibroblasts,
connective tissues, collagen and elastic fibers. When
these tissues age, they lose their properties. For example,
when the elastic property of certain cells is lost,
its smooth contraction and relaxation function is affected,
leading to stiffness that makes organs, blood vessels,
and airways more rigid. (24) In addition lack of elasticity
of the lung cells' affects respiration while altered
vessel wall elasticity causes stiffness leading to increased
pressure. Also, during ageing the collagen in certain
body components is distorted or decreased leading to
multiple complications. For instance, the transmutation
of joints' cartilage causes rigidity mainly due to the
disturbances in its collagen. The skin weakness is prone
to facile laceration due to changes in the fibroblasts
while (25) every change in any organ might be a result
of many direct or indirect causes that are related to
genetics, environmental or ageing related factors. All
of these changes will ultimately lead to death which
increases as ageing progress. It is estimated that the
risk of death after the age of thirty doubles every
eight years.
Challenges
faced by old people
As man grows, his appearance, moving abilities, mental
and psychological wellbeing, as well as the efficiency
of his internal organs diminish. Moreover, ageing has
been associated with numerous pathologies at the cellular,
tissue, and organ level reflected on most of the vital
system in the body. Hence, the size of different organs
is decreased, such as the brain, heart, kidneys and
lungs. (25,26,27) In addition there is decline in cardiovascular
function, bone strength, muscle mass and deterioration
or loss of brain functions, that include learning and
memory. (28) Such changes lead to various challenges
faced by old people, among which the most important
are; Immobility, Instability, Incontinence, Intellectual
impairment, susceptibility to Infection, Impairment
of vision and hearing, malnutrition, Insomnia, Immune
deficiency and Impotence. (20) All will play part in
their psychological wellbeing increasing the probabilities
of isolation and ultimately depression.
Is it possible to prevent ageing?
Scientists have not been able today to avert the process
of ageing. However, its deteriorating signs can be delayed
through screening and early detection of the factors
that play a role in speeding up its process. Moreover,
the illnesses' complications could be prevented or diminished
by early diagnosis of damaging factors. Resorting to
a salubrious healthy life style (in diet and exercise)
from as early as childhood will no doubt delay such
complications and result in an active senescent person.
Cell death usually occurs due to the accumulation of
bio products resulting from metabolism, (2) therefore,
antioxidants could protect the body from the harmful
effects of those free radicals that are normally produced
during metabolic processes. Recent studies indicated
that any reduction in the amount of calories of the
circadian food intake without affecting the daily needed
elements, (e.g. minerals, vitamins and fluids) would
definitely delay the ageing process and extend lifespan.
(21,25) Although, the downstream cellular targets regulated
by dietary restriction are largely unknown, (29) in
many organisms, dietary restriction appears to, at least
in part, act by down-regulating the nutrient-sensor
TOR (Target of Rapamycin). TOR inhibition elicits autophagy,
the large-scale recycling of cytoplasmic macromolecules
and organelles.(30)
Conclusion
The number of old people is on the rise worldwide, although
it is more prominent in the developing world where the
highest problems due to its consequences, occur. Due
to many factors of which the most important are lack
of resources and policies, the developing countries
will face a predicament, unless they start amending
such policies for the provision of better social and
health care services for the old people. Although ageing
is inevitable, healthy living with proper sanitation,
nutrition, exercise, health screening and health education
will no doubt reduce its undesirable effects and help
in active ageing.
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