Not Dead Yet: A Manifesto for Old Age. Julia Neuberger
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Healthy life expectancy
But here there is a major problem. If life expectancy is rising, there is some evidence that healthy life expectancy – the years we spend well – is falling as a proportion. This is a vitally important discrepancy, if we believe it, because it would imply that more of our extra years will be spent sick and disabled in some way or other. That is the view of the Department of Health and the Office of National Statistics (ONS). But the ONS, at least, concedes that ‘concerns remain about the reliability of subjective assessments … They are known to vary systematically across population sub-groups … [reflecting] differences in ill-health, behaviour, expectations and cultural norms for health.’
When the government responded to the 2005 report on ageing by a House of Lords select committee, they didn’t mention these nuances. ‘Although healthy life expectancy is increasing, it is doing so more slowly than overall life expectancy,’ they wrote.
This irritated the select committee, which responded a year later by saying: ‘this statement is made without any suggestion that it is either a cause of concern or that any remedial action is needed. It flies in the face of the claim by Professor Ian Philp, the National Director for Older People’s Health, in a report published in November 2004, that “health in old age is improving and should continue to improve”.’
So which is right? The National Director for Older People’s Health? The Director of Research and Development for the Department of Health? The Office of National Statistics? How is the ordinary person supposed to make sense of this if three government departments face three different ways? Should we not be saying that we need to know, and that real research needs to be done, with longitudinal studies looking at people’s health from the point of view both of experts and of older people, so that we know a little better what we are letting ourselves in for with all this increased life expectancy? Perhaps then we might make better decisions about it.
The ONS also gave an explanation, of sorts, for the apparent widening of the gap between life expectancy and healthy life expectancy. They say that people are getting more sensitive about their health, or have adopted higher expectations about their health, so that conditions that wouldn’t have seemed like problems a few years ago are now considered to affect daily living. It may be that economic incentives are persuading people to think of themselves as ill more readily. There are theories, too, that improvements in survey methods have led to the discovery of a growing proportion of health problems.
Diseases are also being detected earlier, especially chronic diseases. People with ill-health are living longer. Illnesses and injuries that used to be resolved by dying are now more often managed instead. Short deadly illnesses, such as infectious diseases, have been replaced by diseases which are chronic and take a long time to resolve, if they ever do. Any of these could give the impression that healthy life expectancy was going down.
There is no doubt that feeling they are suffering from ill-health – even if they might be objectively no sicker than previous generations – would be quite enough to undermine people’s quality of life and their sense of well-being. The question is what we can do about it. In their evidence to the House of Lords Committee, the Royal College of Physicians in Edinburgh warned that ‘disability may be postponed but it cannot be eliminated’. That is obviously true. Nor can the adverse effects of disability be eliminated. But the question is whether it is possible to increase disability-free years in the UK, as they have in the United States, and how to reduce the adverse effects of disability on older people’s lives?
At the moment it is hard to imagine how we can take on Professor Sir John Grimley Evans’s advice to the House of Lords Committee on ageing. He said: ‘Live longer, die faster’. That may be a wise piece of advice. But how do we put it into action, short of killing ourselves, something most of us don’t want to do? And that’s the stuff of another story, in another chapter.
If there is really an increase in ill health, nobody has ever explained it or measured it. The questionnaires that ask people to assess themselves on ‘vague’ concepts like health, while they may enable comparisons to be made with replies to the same questions from different groups or different areas, are not reliable enough to give us objective measures of health in old age. Perhaps the real question is whether the researchers are using sensible categories – and who, anyway, is deciding how people feel? Who is defining healthy old age?
Different definitions
This business of who decides if we are having a successful old age is important – and it is no small problem. One of the issues that has come up over and over again when I was researching this book has been the difference of approach between the ‘experts’ and the lay people, particularly those who are in fact old themselves, and have some experience to add to the picture. Behind that is the context in which these figures are generated.
We seem to have become caught in a technocratic idea in which the optimization of life expectancy together with the minimization of physical and mental deterioration is the only thing that healthy old age is all about. So the literature tends to focus on the absence of chronic conditions, on risk factors for disease, on levels of physical functioning – judged by others, rather than by older people themselves – and the extent to which their cognitive functioning is impaired. Alternatively, they may be quite healthy by objective standards and still beset by what Diana Athill describes as something more fundamental:
Our main trouble is that what he calls his ‘weakness’ – the dreadful draining away of energy from which he suffers – goes so deep that he has lost interest in almost everything.11
Two British researchers, Ann Bowling and Paul Dieppe, reviewed all the literature for the British Medical Journal, and criticized this simple division between ‘diseased’ and ‘normal’, which they said was unrealistic.12 There is a huge variety of conditions, of expectations of physical well-being, within all these groups. People see things differently and experience things differently.
To try to deal with this, two American researchers worked out a way of telling the difference between what they saw as usual ageing, with its normal decline in a variety of functions associated with age, and ‘successful ageing’ where people hang on to functions as much as they can.13 They argued that there are three components of successful ageing:
an absence or avoidance of disease and risk factors for disease
keeping physical and cognitive functioning
active engagement with life, including maintenance of autonomy and social support.
But that’s not good enough either. There is a real problem with that definition as well. Most older people will not be disease-free. Many people begin their career of chronic, though not severe, disease in middle age. Trouble with hips and knees and sporting injuries leading to later arthritis are commonplace for people in their fifties and sixties, and earlier amongst keen sportspeople. Though they do not perceive this as the start of chronic disease, it often turns out to be just that – damaged joints lead to arthritis and other painful joint conditions. In just the same way, post-menopausal women often embark on a career of taking thyroxin for the rest of their lives, and other conditions of the skin or eyes, which tend to deteriorate quickly in late middle age, also begin to make their presence felt. So by the time people can reasonably be classified as older, in their late sixties or seventies – and with new projections of ageing perhaps even their eighties – there will be a great many so-called ‘chronic conditions’ at play. Add that the scares many women will have had with cancer – and some will actually have had and survived the disease – and you have a picture of older people who are certainly not ‘disease-free’.
This description of being ‘disease-free’ is not a picture that means much to older