Healthy Ageing PDF Past Paper

Healthy Ageing Lectures​ 2 Lecture 1​ 2 Summary​...

Healthy Ageing Lectures​ 2 Lecture 1​ 2 Summary​ 5 Lecture 2​ 5 Intermediary summary 1​ 6 1. Defining healthy ageing and wellbeing​ 6 Intermediary summary 2​ 8 2. Biological theories of healthy ageing: why do humans, and other species, age?​ 8 Intermediary summary 3​ 10 3. Social and Psychological Theories of (healthy) Ageing: how to maintain health and wellbeing at older ages.​ 10 Summary​ 11 Lecture 3​ 11 1. Increased longevity​ 13 Patterns of human mortality​ 14 Past changes in life expectancy​ 14 The future of life expectancy​ 14 Maximum lifespan​ 14 2. Population ageing​ 14 Population development over time​ 14 Changes in the age structure of populations​ 14 Summary​ 14 Lecture 4​ 14 Summary of last lecture​ 14 1. Theories: are additional years of life healthy ones​ 15 2. Operationalizations: how do we measure health, what is good health​ 16 3. Applications: health life expectancy and social inequalities​ 17 Summary​ 18 Lecture 5​ 18 1. Cognitive function: what does it include, how is it measured?​ 18 Intermediary summary 1:​ 19 2. Cognitive decline: cognitive abilities over age and the development of Alzheimer’s disease​ 19 Cognitive abilities over age​ 19 Mild cognitive impairment and the development of Alzheimer’s disease​ 19 Intermediary summary 2​ 20 3. Consequences of cognitive decline: what does it mean for individuals, families and society?​ 21 Intermediary summary 3​ 21  4. Risk factors of cognitive decline: lifetime determinants for cognitive function​ 21 Summary​ 22 Lecture 6​ 22 Lecture 7​ 23 Current trends in health care expenditures​ 24 What is driving the change​ 25 Demographic time dimensions​ 26 Conclusion​ 29 Lecture 8​ 30 Lecture 9​ 34 1. Life course and health​ 34 a. What is the life course perspective​ 34 Intermediate summary 1​ 35 b. Life course approaches to health​ 35 2. Life course determinants on health at older ages​ 36 a. Life course approach to physical capabilities​ 36 b. Life course perspectives on diet and ageing​ 37 c. Residential environment over the life course and healthy ageing​ 37 Summary​ 38 Lecture 10​ 38 Lecture 11​ 41 Part 1: Mobility change lab​ 42 Part 2: Insight into mobility experiences in later life​ 42 In conclusion​ 44 Lecture 12​ 44 Motivation: is population ageing a global population issue​ 45 Current, past and future population age structures​ 45 Intermediary summary 1​ 46 The role of MIPAA in shaping an ageing friendly environment​ 46 Intermediary summary 2​ 47 Focus: ageing in Sub-Saharan Africa​ 47 Intermediary Summary 3​ 1 Lectures Lecture 1 Aim of the course: ​ Understanding of healthy ageing from a socio-demographic perspective. ​ Knowledge of population ageing.  ​ Trends in health and cognitive functioning, measures of health and ageing from different perspectives. ​ Introduction to determinants of healthy ageing over the life course. At both the societal level; -​ Why is healthy ageing a topic of current debate in contemporary societies? What are the causes and consequences of population ageing? How can societies react to population ageing And at the individual level; -​ What influences individuals' chances to age healthy? What is health at older ages? How do elderly people live in their environment? Learning objectives: 1.​ Discuss the complexity of healthy ageing from a socio-demographic perspective and differentiate between concepts of healthy ageing. 2.​ Assess the causes and consequences of (healthy) ageing from an individual as well as from a societal perspective. 3.​ Formulate the societal challenges of ageing populations and the relevance of healthy ageing. 4.​ Investigate data sources on ageing-related indicators and compare these ageing indicators in different country settings. 5.​ Generate a research report based on ageing-related data and assess the ageing situation in different European countries. ​ What is MIPAA: ​ UN recognized population issue in ‘Madrid International Plan of Action on Ageing’ ​ Adopted at the Second World Assembly on Ageing. ​ Political response to ageing challenges. Not binding but commitment to create age-friendly societies with older adults as valued and productive members. ​ The MIPAA has 3 priorities: ○​ 1. Older persons and development ​ Active participation in society and development ​ Work and ageing labour force ​ Rural development, migration and urbanisation ​ Access to knowledge, education and training ​ Intergenerational solidarity ​ Eradication of poverty ​ Income, social protection and security, poverty prevention ○​ 2. Advancing health and well-being into old age ​ Health promotion and wellbeing throughout life ​ Universal and equal access to health-care services ​ Older persons and HIV/AIDS ​ Training of care providers and health professionals ​ Older persons and disability ○​ 3. Ensuring enabling and supportive environments.  ​ Housing and living environment ​ Care and support for caregivers ​ Neglect, abuse and violence ​ Images of ageing ​ Resource for policy making ​ Reviewed every 5 years Why healthy ageing? Healthy ageing and population ageing have become topics of great importance. It is often mentioned in the media and political discussion. As population ages, there are challenges that come to mind, such as: An ageing population is a growing concern and has its societal consequences. It is often seen as a problem considered to be related to worse health and high costs. But at the same time, there is an individual preference to ageing healthy. Ageing as a threat What is the population ageing? Content of lectures 3 and 4 Humans around the world are getting older and older. Life expectancies are rising in most parts of the world. As more people live to higher ages, populations are ageing. An ageing population is a threat to the health care system, retirement system, and economic system. Other concerns related to ageing are that rising life expectancy can lead to more medical conditions. There is also a relative imbalance between younger and older age groups, which can be a threat for sustainability of the health care system and public finances. It is also a threat to the long term care system. Cognitive decline and dementia are central reasons for concerns about population ageing. Research predicts that the global number of dementia cases will increase 3 times. Dementia is a high burden for individuals, families and societies as individuals require constant support. Motivations for healthy ageing: ​ Societal, population or macro level motivation to cope with population ageing → delaying disease and disability, longer productivity and work lives, lover societal costs → are ageing populations a time bomb? ​ Individual or micro level motivation to spend most years of life in good health, self-determined and socially integrated → how do we achieve that ​ What is healthy ageing? What does it comprise? From populations to individuals ​ Population ageing a macro level demographic phenomenon (macro level concerns a group of people, societies as a whole, populations) ​ Healthy ageing a micro level phenomenon (micro level concerns individuals, individual behaviour and outcomes) ​ Healthy ageing leads to further population ageing ​ Ageing society seeks to enhance healthy ageing 7 Assumptions on healthy ageing 1.​ Normal ageing doesn’t exist 2.​ Taking hormones, vitamins and minerals doesn’t prevent ageing 3.​ There is no limit to the human life span 4.​ The number of years without disability is increasing 5.​ The chance for older people to develop dementia will decrease 6.​ Older people rate their health with an 8 7.​ We are responsible for our later days Aspects of healthy ageing: life course Aspects of healthy ageing: old age Healthy, ageing and the life course -​ Healthy ageing determined by our behaviours over the life course → life course is the comprehensive view on the progression of life over age -​ Smoking, nutrition and physical exercise over the life course are core components of health at older ages. -​ Also, social and physical environment play a central role in healthy ageing → intergenerational support and mobility Healthy ageing, an interdisciplinary field -​ Healthy ageing research and practice contains aspects from a variety of scientific disciplines, such as: -​ Demography, population studies, public health -​ Psychology, sociology, medicine -​ Spatial planning, health geography -​ Economics, social policy Summary ​ Healthy ageing is a topic of great societal interest ○​ Societal focus → cope with demographic challenges ○​ Individual focus → more years in good health ​ Often negative connotation to population ageing (time bomb) ○​ Course will introduce to population ageing and healthy ageing and discuss perceived threads Lecture 2 Definitions of health and wellbeing Health: ​ Old Definition by WHO: Definitions of healthy ageing: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”  ○​ Critique: healthy state can hardly be reached. Do you feel healthy right now? Also according to this definition? ​ An ability of an individual to function effectively and participate within society ○​ Functional perspective ​ Activities of daily living (ADL) ​ Instrumental activities of daily living (IADL) ​ ADL and IADL are measures to evaluate need of care and support ○​ Critique: not all people with illnesses picked up by this definition, neglect of people’s perspective. ​ Presence or absence of disease as diagnosed by medical professional ○​ Medical perspective ○​ Critique: depending on medical diagnosis, a person may feel ill or healthy but may not be diagnosed as such. ​ Health is the ability to self-adapt and to self-manage ○​ Huber et al. 2011 Wellbeing: ​ Good or satisfactory condition of existence ○​ State of being comfortable, healthy or happy ○​ Being physically, socially and mentally fit ○​ More holistic way of looking at people’s functioning ​ Two main approaches: ○​ Objective wellbeing ​ Ascribed ○​ Subjective wellbeing ​ Individual’s appraisal of his or her situation overall ​ INdividual judgement standards ○​ Critique on wellbeing: current aspects of wellbeing may decrease health and wellbeing in the future. ​ Challenge of definitions: concepts are used as synonyms: ○​ Life satisfaction, wellbeing, quality of life, happiness, subjective Intermediary summary 1 ​ Need to define a destination for ageing → health, wellbeing, happiness? ​ Different approaches to define this state depending on perspective (individual, societal) ​ How would you define the ideal state with regard to age? 1. Defining healthy ageing and wellbeing ​ Recap: why study healthy ageing? ​ Policies to deal with population ageing? ​ What is healthy ageing? ​ Needs to be defined before policies can be formulated Healthy ageing Different concept labels Theoretical definitions of healthy ageing vary greatly, also depending on the discipline: ​ Biomedical perspective ○​ Most widely used perspective ○​ Emphasises absence of physical and cognitive disabilities ○​ “The reduction of the amount of unhealthy life years or, living disease-free as long as possible”. ○​ Broader biomedical definitions, like instead of healthy ageing, call it successful ageing. ​ Freedom from disease and disability ​ Maintenance of high cognitive abilities and functioning ​ Social and productive engagement ○​ Prioritise achievement of medically inspired criteria ○​ Pessimistic view of healthy ageing → focus on decline ○​ Critique: ​ Disease-free older age is unrealistic for most people ​ Doctors' opinions are crucial, the older people’s perspective is neglected ​ Rather negative, normative, excluding, discriminating perspective. ​ Psychosocial perspective ○​ Healthy ageing = active ageing ​ Extended participation of older workers in the labour market ​ Continued participation of seniors in social, economic, cultural, spiritual and civic affairs, not just their ability to remain physically active or participate in the workforce. ○​ Healthy ageing = successful ageing ​ “the resilience of people who succeed in achieving a positive balance between gains and losses during the life span ​ Resilience is the ability to bounce back, to change and to adapt to new situations. ​ Psychological resources are important for healthy ageing. ​ Positive outlook, optimism ​ Self esteem ​ Confidence ​ Autonomy: the ability of older individuals to continue to make their own decisions regarding their lifestyle and their care. ​ Independence: living on one’s own, care for oneself ​ Resilience ○​ Characteristics ​ Focus on the active contribution of older adults to society, instead of deficiencies. ​ Emphasises competences and knowledge, positive view on ageing. ○​ Critique ​ Over-idealisation of active ageing ​ Deterministic → passive lifestyle = bad  ​ Psychosocial and biomedical perspective ○​ Compare characteristics to biomedical definitions ​ Prioritising psychosocial criteria ​ Allows for non-normative, individual trajectories of healthy ageing ​ No role model for healthy ageing but individualization ​ Dynamic, continuous process ​ Optimistic definition of healthy ageing ​ Focus on the psychological resources of older adults ​ Lay-based perspective ○​ Healthy ageing is subjective ​ Not professionals/scientists determine what is health, but individuals themselves. Lay is non professional. ​ From the views and perceptions of older adults themselves. ​ Researchers and older adults themselves define healthy ageing differently. ​ Contextual circumstances are important. ○​ Additional priorities and aspects deemed important by individuals themselves: ​ Social relationships ​ Financial security ​ Environmental quality ​ Physical appearance ​ Spirituality Intermediary summary 2 The healthy ageing concept comprises a variety of aspects, like biomedical focus on absence of disease, the psychological focus on staying active and involved and individual preferences for not directly health related priorities. Defining healthy, successful and active ageing depends on chosen perspective or combination of perspectives. 2. Biological theories of healthy ageing: why do humans, and other species, age? Theories of Ageing ​ As for definitions, different explanations how health is maintained or deteriorating over age. ​ Depending on discipline theories, explain different aspects of healthy ageing, biological, psychological and social. ​ Theories may be complimentary as the ageing process is still not fully understood and theories from different fields focus on one specific aspect of the ageing process → healthy ageing determined by environmental and personal factors. Biological theories of ageing in the past ​ Galen, A.D. 129 - 199 ○​ Thought that ageing was due to changes in body “humours” that began in early life. These changes caused a slow increase in dryness and coldness of the body. ​ Roger Bacon, 1220-1292  ○​ One of the first to suggest a “wear and tear” body. ○​ Ageing is the result of abuses and insults to the body system. ○​ Good hygiene might slow the ageing process. ​ Charles Darwin, 1809-1892 ○​ Attributed ageing to the loss of irritability in the nervous and muscular tissue. Biological theories of ageing ​ Explain why health deteriorates with age ​ Difference between ageing and senescence (loss of a cell's power of division and growth.) ​ More than a dozen biological theories of ageing. ​ Can be grouped in three broad types of theories: ○​ Genetic theories ○​ Molecular/cellular theories ○​ System-level theories ​ Theories are not mutually exclusive but focus on different levels of ageing studies ​ Genetic theories ​ General idea: complex genetic interactions regulate ageing process and death ○​ Ageing and disease explained by a malfunctioning or deviation of certain genes ○​ Turned-off genes fail to produce necessary substances or resources ○​ Studies show that the number of cell replications declines over age, suggesting that our length of life depends on how often our cells can replicate. ○​ Different theories about the finite number of cell replications ○​ Genetic regulations are affected by environmental factors ○​ DNA can be repaired ​ Molecular theories ○​ Free radicals theory most prominent in explaining ageing and emergence of disease. ​ Malfunctioning molecules cause diseases. ○​ Related theories suggest that older cells lose the ability to get rid of oxidative waste matter. ​ Can lead to Alzheimer's over time. ○​ Like in genetic theories also in molecular theories assumption about existence of protective molecules that maintain health ​ System level theories ○​ Organisms need a certain stability of environment and intracellular conditions. ○​ After episodes of instability, organisms return to stability. ○​ Over age ability to stabilise, declines. ○​ Wear-and-tear theory postulates that using certain organs over a long time leads to deterioration and malfunctioning. ○​ Exposure to stress and ability to cope with stress are also seen as determinants for maintaining health and postpone emergence of disease. Intermediary summary 3 ​ Ageing is a chronological process not necessarily implying bad health. ​ Senescence as a biological process suggesting deterioration with age. ​ Different theories on genetic, molecular and system level why senescence occurs. ​ Decay is strongly influenced by individual and societal factors. 3. Social and Psychological Theories of (healthy) Ageing: how to maintain health and wellbeing at older ages. ​ Social and psychological theories ○​ Many different theories on healthy ageing. ○​ Different schools of thought attributing ageing and health processes to internal or external factors influencing an individual. ○​ Studies on the individual development of personality or cognitive abilities versus outside factors that affect this development. ○​ Modern theories of ageing: life course theory, goal-oriented models, and resilience and ageing approaches. ​ Life Course Theory ○​ Health and ageing outcomes determined by individual life course ○​ Life course means developmental transitions and periods from childhood over adulthood to old age. ○​ Individual development is affected by social context, own choices and preferences and previous episodes. ○​ Studies show that e.g. economic conditions at childhood affect health and cognitive outcomes in later life. ​ Socioeconomic resources, gender etc., may improve/deteriorate outcomes. ​ Goal-oriented models ○​ Describes the development into adulthood and old age as a balance of gains and losses. ○​ Early adulthood is relatively successful in acquiring positive resources/characteristics → later in life characterised by losing resources and attempting to conserve these resources. ○​ Successful ageing by selection, optimization and compensation of certain resources → ageing as adaptation process. ○​ Example of piano player Rubinstein: with age reduction of pieces that he played and optimization of those pieces. ​ Resilience and ageing ○​ Resilience as a capability to withstand adversity. ○​ WHO defined resilience as “the process of optimising opportunities for health, participation and security in order to enhance quality of life as people age.” ​ Specific resources to withstand stress or other harmful external influences. ​ Individual resources, like education, financial resources.  ​ Contextual resources, like social support or inclusion. ​ Sociocultural resources, like access to health care, societal attitudes towards ageing. ○​ Adds up to: experience in coping with adversity, experience in judging the severity of certain health conditions and dealing with it → link to self perceived health. Summary ​ Different interpretation of what healthy ageing means from a medical/biological and psychosocial background. ​ Theories from different disciplines seek to explain why health deteriorates with age. ​ Biological theories focussed on general wellbeing and societal aspects of health and ageing. ​ Multidisciplinary understanding of health and ageing necessary. Lecture 3 Introduction: Universal aspects of mortality -​ Look at the probability of dying based on age. -​ The first pattern, called ontogenescence, is that in every species, there are newborns born with conditions that make them unable to survive. Up until a certain age. -​ The second pattern is senescence. The increase of mortality with age. It follows an exponential pattern. This exponential pattern is called Gompertz law of ageing. The risk of mortality, mu, follows a baseline, a, times e^(beta*age). Beta equals 10 percent. Alpha has been going down over the last years. We have been reducing the overall level of mortality. The rate of ageing hasn’t moved. -​ The biggest decrease has been in infant mortality. How do we capture the whole age pattern? There are 3 measures of social tendency. The mean, moat and median. Life expectancy is a mean. The mean is more sensitive to extreme values. The median and the moat are less sensitive. So life expectancy is an average, so it doesn’t really represent the whole life expectancy well. So for 12000 years, the life expectancy was between 20 and 35. But now, since the late 20th century, it has risen from 35 to 73. But these are the means. There are two different peaks that heavily influence life expectancy. The infant mortality, around age zero, counts for about 50% of the mortality. The other 50% chance is for when you’re an adult. But if you make it past age 15, your life expectancy isn’t that bad. -​ So saying that life expectancy is 20 years old, you had 50% chance to die at birth or young age, and the other 50% around age 40/50. -​ So taking away the mortality at birth, looking at the mortality at death, most populations lived to about 70 years old. -​ The evolution of life expectancy over time -​ For each particular year, pick the country with the highest life expectancy in the world. To measure what was the highest possible life expectancy for the world in that year. Because if you look just by country, it could not work because of a war, instability or epidemic.  -​ New Zealand was the winner for a long time when migrants were coming. This is because migrants are often in good health, otherwise they wouldn’t be able to migrate. -​ All female life expectancy -​ Every year, the life expectancy increases by about 3 months. How do we frame that? Well, the most popular theory by Omran about the epidemiological transition. There are different stages in the increase of life expectancy. 1.​ The age of pestilence and famine 2.​ The age of receding pandemics 3.​ The age of degenerative and man-made disease a.​ Subdivided into: the age of declining cardiovascular disease mortality, ageing and emerging diseases b.​ The age of aspired quality of life with persistent inequalities Future: life expectancy keeps increasing, breaking all the models. But the speed of the increase of life expectancy is stalling, not growing as quickly as before. Like in the US, since 2010 it has not increased. We are slowing down, at about half the pace than before. Like 0,1-1,15 instead of 0,25. -​ In the US it is about the pandemics, but it is actually the cardiovascular diseases that decrease the life expectancy. Not the drug pandemics. Up until the 80s, the pessimistics believed in a fixed limit in life expectancy. Now the optimistics, since the 80s, believe there is no limit. But it is an ongoing debate. -​ Is there a limit to the highest attainable life expectancy? It is very hard to say anything. One single dot can change the whole story. 1. Increased longevity Life expectancy: the average number of years a person of a certain age can expect to live. Lifespan: length of time a human lives. Maximum human lifespan: highest attained age. There are two levels of analysis, flows and structures. 1.​ The flows influence the structure, how a population can change. Like mortality, fertility or migrations. 2.​ We are on the side of the structures when we talk about population ageing. Definitions: ​ Senescence = individual ​ Increasing life expectancy = flows ​ Population ageing = stock ​ Individual longevity not necessarily causing population ageing. ​ Population ageing also due to other dimensions. The population balance exists of natural change and net migration. There are different drivers of a population ageing.  -​ Like mortality, migration, fertility, but also about the history of your population. You can have a cohort effect, like the baby boom, that leads to problems later on with an ageing society. -​ Once the baby boom is dead, you have a more stable population. Measures of population ageing: Median age: the age at which 50% of the population is older and 50% younger. Dependency ratios: relative sizes of average groups → split about consumers and producers -​ Child dependency ratio​ (N0-14)/(N15-65) -​ Old age dependency ratio​ (N65+)/(N15-64) -​ Total dependency ratio​ ((N0-14)+(N65+))/(N15-64) Patterns of human mortality Past changes in life expectancy The future of life expectancy Maximum lifespan 2. Population ageing Population development over time Changes in the age structure of populations Summary ​ Ever increasing life expectancy around the world, with no clear sign of stopping. Maximum lifespan is still difficult to judge. ​ Population ageing is by far not only linked to longer lives. The role of fertility and migrations is essential too. ​ Measures of population ageing are sometimes misleading or debatable because they are often arbitrary and do not take into account changes in old people’s health and capabilities. ​ Population ageing will continue in the future, with implications for societies as a whole. Lecture 4 Summary of last lecture ​ Increase in life expectancy for ca. 200 years, with no signs of stopping, overcoming all predicted limits. Maximum lifespan is harder to study because of sample size. ​ Despite continuous overall increase, different contributions from age groups and causes of death. → epidemiological transition ​ Prolonged survival, fertility decline and migration all contribute to the population ageing.  → measures; median age, dependency ratios. 1. Theories: are additional years of life healthy ones -​ As long as the young people survived the first years of life, there was never a question if that was good or not, ethically speaking. But is it a good thing in terms of quality of life, saving a baby? If you save a baby there is a good chance it will have a good quality of life. But if you save an 80 year old person, are you saving this life in a good state or in a bad state? -​ This is a new question, because in the past we were not focussed on saving old people. Living longer and healthier: 3 theories ​ In the 1970s, it became clear that life expectancy is not stopping. ​ Older adults are not mostly contributing. ​ Three theories exist on the relationship between mortality and health: ○​ 1. Expansion of morbidity (ziektecijfer, the rate of disease in a population) ○​ 2. Compression of morbidity ○​ 3. Dynamic equilibrium ​ Linked to the debate on life expectancy, but not only. 1.​ Expansion of morbidity by Gruenberg 1977 ​ Failure of success ○​ When we save people, we might not be able to restore them to their initial state. ​ Longer lifespan, more years spent in poor health ​ Reduction in the fatality rate of (chronic) disease ○​ Same onset of disease, but longer period with disease ​ “The net effect of successful technical innovations used in disease control has been to raise the prevalence of certain diseases and disabilities by prolonging their average duration.”  -​ We can increase life expectancy, postpone the moment when people die, but we can’t do anything about the moment they are getting sick/start to die. 2.​ Compression of morbidity by Fries 1980 (pessimistic scholar) ​ Shift in onset of morbidity to higher ages. ​ Fixed life expectancy, with an original limit of 85 years assumed. → again refers to pessimistics ​ “For example, the average age at first heart attack (non-lethal) for men appears to have increased approximately four years in the past sixteen, whilst life expectancy from age 40 increased by two years over the past 20 years.” -​ We might be able to increase a little life expectancy, but not that much. But we can do something about it when people get sick. So the onset gets delayed. -​ More pessimistic view 3.​ Dynamic Equilibrium by Manton 1982 -​ Reality must be somewhere in the middle. ​ Increase of life expectancy, but also decrease in incidence of disability, so unclear increase of years with disability. ​ Shift from severe to moderate disability -​ The truth lies somewhere in the middle, life expectancy will increase at the same pace as getting sick. -​ Healthy life expectancy remains the same For a long time, 1990 there were no population level surveys on health. 2. Operationalizations: how do we measure health, what is good health What is health: a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. → WHO 1948 ​ However, health is often measured as absence of disease. Disease vs. Illness. vs. Sickness ​ Disease ○​ Medical conception of pathological abnormality which is indicated by a set of signs and symptoms → implies biomedical cause and often already known treatment. ​ ICD = international classification of disease ​ Illness ○​ Individual’s experience of ill-health, indicated by the person’s feelings of pain, discomfort and the like (Field 1976) → wide concept that may refer to temporary mild problems to long lasting severe problems. ​ Sickness ○​ Social consequences/role attached to the health problem by society at large (Hardon) → like sick leave. ​ Disability Free Life Expectancy → DFLE ​ Acute disease ○​ Relatively rapid onset  ○​ Rapid progression ○​ Short duration ○​ Relatively direct causation ​ Chronic disease ○​ Slow onset ○​ Slow progression ○​ Long-lasting or life-long ○​ Relatively complex etiology Self-reported health ​ Self-rated/assesses/perceived ○​ Is fake ​ On purpose vague, to let people define themselves what it means to be in good health. ○​ Subjective, but also comparable ○​ Valid and reliable, keeps giving the same value for the same state. Valid because it measures what it is supposed to measure. ​ Question like “in general etc”, answers in like “1, good, 2, very good” Health life expectancy ​ Health-adjusted life expectancy (HALE), health expectancy (HE), healthy life years (HLY), disability-free life expectancy (DFLE). ​ Average number of years in health a newborn can expect to live based on current rates of health and mortality. ​ Companion to life expectancy → age-standardised ​ Test of the 3 theories, but not 100% straightforward 3. Applications: health life expectancy and social inequalities Social inequalities are visible in the Swiss case. -​ Use of 3 levels of education: mandatory, secondary and tertiary. Because an 80 year old might say that they are retired, so you have no idea what their previous job was. But you can definitely relate their socioeconomic status to their education. -​ Start measuring at age 30, because after that it is likely to assume that education level doesn’t change anymore. -​ Within the same country, you can find different life expectancies, like based on education level. But that could also be because those people earn the most. And in Switzerland you pay out of pocket health care, so they can afford better health care and therefore have a longer life expectancy. Lower education levels might take longer to go to the doctor. Social inequalities: ​ Convergence in LE and divergence in HLE. ○​ Literature does not differentiate between health and mortality differentials by education. ○​ How can convergence and divergence coexist ​ Swiss health care system  ○​ Similar to dutch system, both mandatory and private ○​ High out of pocket payments ○​ Very dense network of hospitals and specialist doctors. Summary ​ Question whether gained years of life experience are spent in good or bad health. ​ Three theories: compression, expansion or equilibrium. ​ Measuring health is complex, difficult to compare and explained objectively. ​ General trends of both LE and HLE are increasing, but at different speeds across countries and social groups. Lecture 5 Last lecture: -​ Gained years of life in good or bad health? -​ 3 theories: compression of morbidity, expansion of morbidity and dynamic equilibrium -​ Operationalization of health -​ Application of theories and addition of relative vs. absolute compression, expansion and equilibrium -​ Social inequalities in Switzerland Today’s topics: 1. Cognitive function: what does it include, how is it measured? Cognitive function is the mental ability to process and interpret information of daily life. -​ In different areas of the brain. -​ Another part of the brain with an important role is emotions. ​ Cognitive function includes a variety of cognitive domains such as: ○​ Memory, attention, reasoning, planning of tasks, language and information processing speed. ​ Cognitive function assessment can happen via neuropsychological testing ○​ Mini mental state exam (MMSE) ○​ Rey-Osterrieth Complex Figure ​ How to: ​ First step: copying freehand to test recognition functioning ​ Second: drawing from memory to test recall functioning ​ Scored by time and the presence and right location of each line ​ It measures: ​ Visuospatial abilities ○​ Can you place specific items ​ Memory ​ Attention ​ Planning ​ Working memory  ○​ Trail Making Test ​ Measures: ​ Part A: primarily cognitive processing speed ○​ How fast can you do it, how fast can you connect the dots. ​ Part B: primarily executive functioning ○​ Can you manage the change between alphabetical order and numbers ​ Also visual attention and task switching/mental flexibility ○​ Verbal fluency ○​ Verbal memory test ​ Name as many animals as you know, can you after five minutes remember the animals you said. Intermediary summary 1: What are cognitive functions? -​ Different to emotions, different but related. Cognitive function is important in memory, planning, and sensory skills. Interaction. Why are they important? How can they be tested? -​ Sometimes it is a bit age discriminatory. Focus is on cognitive decline. 2. Cognitive decline: cognitive abilities over age and the development of Alzheimer’s disease Cognitive abilities over age ​ Decline in cognitive test scores over 10 years ​ All cognitive scores, except vocabulary, declines in all 5 age categories ​ P-value: whether there is a significant difference across age categories -​ All cognitive abilities decline overage. The percentage changed overage. -​ There is a natural decline of functions. Happens to everyone, except for maybe vocabulary. Mild cognitive impairment and the development of Alzheimer’s disease Diagnosis of a mild cognitive impairment (MCI) A.​ Modest cognitive decline from a previous level of performance → one or more cognitive domains such as; complex attention, executive function, learning and memory, language, perceptual-motor or social cognition based on: a.​ Concern of the individual, a knowledgeable informant, or the clinician that there has been a mild decline in cognitive functioning. b.​ A modest impairment in cognitive performance, preferably documented by a standardized neuropsychological testing or another quantified clinical assessment.  -​ When does it become problematic? When at least two of the factors named above are affected. When a boss or relative would be concerned about your memory, it is often a sign to get checked. Middle-aged persons can also have episodes of this behaviour. B.​ Cognitive deficits do not interfere with capacity for independence in everyday activities such as; paying bills or managing medications are preserved (greater effort, compensatory strategies may be required) a.​ Selection, optimization, compensation C.​ The cognitive deficits do not occur exclusively in the context of a delirium. D.​ The cognitive deficits are not better explained by another mental disorder, like depression or schizophrenia. Dementia diagnosis ​ Comparable to diagnosis of MCI ​ Differences: ○​ Impairments in cognitive performance are severe instead of modest ○​ Cognitive deficits do not interfere with independence in everyday activities. -​ Can not in the long run live independently anymore. ​ Dementia: ○​ Alzheimer’s disease (70%) ○​ Vascular dementia (15%) ○​ Frontotemporal dementia ○​ Lewy body dementia Three stages of Alzheimer’s disease 1.​ Forgetfulness, disorientation, change of personality, reduced reactivity. 2.​ Problems in activities of daily living, problems with short term memory but memories from the remote past are clear, reduced control over emotions, difficulty recognizing friends and family, possibly apathy. 3.​ Total dependence, need for 24h care. -​ Accumulation of blocks in the brain by different cells. It’s a continuous process. Based on the symptom stage one could also be MCI. Progression from MCI to AD ​ Most of the subjects with MCI will progress to AD at a rate of 10-15% per year. ​ For comparison, healthy control subjects progress at a rate of 1-2% per year. ​ Conversion to AD of up to 80% during approximately 6 years. Intermediary summary 2 What is MCI and what is the difference to dementia? -​ Mild form of cognitive decline, but it is normal to lose some cognitive function. MCI goes a bit beyond that. It does not yet fully affect your daily life. How do MCI and dementia affect our lives at older ages? -​ Global dementia mortality  -​ The problem of dementia is that it is a global issue, but mostly in countries with a high life expectancy. Not only based in the northern hemisphere, but there are different countries influenced by deaths of dementia. -​ For Russia it is low, there is a low life expectancy. -​ Lot of care needs, a lot of medical needs. Burden on society and families. -​ Different proportions among age groups and areas. -​ Women have a higher life expectancy so they also have a higher chance of getting alzheimer’s disease. 3. Consequences of cognitive decline: what does it mean for individuals, families and society? Cognitive decline with macro and micro level consequences. ​ Burden on ○​ Patient ○​ Family ○​ Informal caregiver ​ Not nurses, but family of the patient usually. ​ Also physically demanding, not just emotionally demanding. ​ It is often the female relative taking care of this person. ○​ Society as a whole ​ In the Netherlands 96% of the total costs of dementia can be attributed to costs for care in nursing homes and homes for the elderly. ​ Increased demand for prolonged independent living and informal caregiving. ​ Long term care expenditures can amount to 4.3% of GDP. Intermediary summary 3 What are burdens that are associated with dementia and cognitive decline? From a global perspective, what are the outlooks in terms of dementia burdens?​ Any reason to be optimistic? -​ Dementia is on the rise, it is a burden on society. Also on informal caregivers. Often the patients rely on their families. It paints a dark picture of the future, but is there a reason to be optimistic? 4. Risk factors of cognitive decline: lifetime determinants for cognitive function Pharmaceutical treatment of dementia can only modestly improve symptoms. The newly introduced drug Lequembi is promising in slowing the progression of Alzheimer’s. The mayor focus is however on prevention. -​ The treatments can help, but not cure Alzheimer's disease. The biggest focus is on prevention. There are 7 risk factors combined that are estimated to account for half of dementia cases worldwide. The risk factors are not independent of each other. 1.​ Diabetes  2.​ Midlife hypertension 3.​ Midlife obesity 4.​ Physical inactivity 5.​ Depression 6.​ Smoking 7.​ Low educational attainment -​ In prevention it is easier to focus on less diabetes, less obesity, less smoking. Than just fixing early cognitive decline. Reason for optimism: ​ Cohort studies give a more optimistic outlook, group of individuals born the same year. ​ Older cohorts have higher prevalence than young ones. Why is that? -​ Look at risk factors. Later generations have better education for example. Risk factors of cognitive decline Remaining socially active may help build cognitive reserves. The cognitive reserve enables individuals to better compensate for changes in the brain that could result in symptoms of: ​ Increase in connections in the brain ​ Using alternative routes of communication in the brain ​ Social interactions: ○​ Cognitive stimulation (use it or lose it) ○​ Stress reduction ○​ Health behaviour enhancement Summary ​ Cognitive decline is a major threat to healthy ageing. ​ AD as a prime cause for future long term care demands → burden for individuals and society at large. ​ Prevention is key to maintain cognitive functioning to older ages → health behaviours and education over the life course are crucial. Lecture 6 Guest lecture: The potential of remote digital assessments of cognition for the early detection of Alzheimer’s disease What is dementia in general: umbrella term for loss of memory and other thinking abilities severe enough to interfere with daily life. The most common cause of primary dementia is Alzheimer’s. -​ Biomarkers are symptoms that something is going wrong in the brain. The accumulation of a protein in the brain causes issues. The second biomarker is another protein accumulation in the cells.  -​ There is hope: in disease-modifying therapies, DMTs. They target the proteins in the brain. The drug removes the protein in the brain and the people who got the medicine had increased cognitive thinking. -​ -​ The biomarker does not tell you a lot about the cognitive state of the patient. -​ How do we measure cognitive decline -​ short paper and pencil tests → least sensitive. These tools are not able to look at the early stages. -​ Neuropsychological test batteries -​ Remote testing of cognitive function is also possible, due to phones. It is tested under realistic conditions. -​ Example: proof of concept stage, explore app. -​ GPS region of the brain → hippocampus, geheugengebied -​ With the data, we looked into wayfinding profiles. How long did they take, what was their movement speed? How often did they look at the map on the app? Did they make orientation stops? -​ 3 types of walkers → high performing, intermediate performing (in the middle), low performing (longer distances, slower, looked at the map more often, insecure) -​ High performing are younger adults, low performing are scd patients. The scd patients were more often stopping. -​ Neotiv -​ Trial research -​ Note down early progress, because the new treatments coming to the market are most productive in early stages. Lecture 7 Introduction: Old age dependency ratio: remember that one. Relate that one to health care expenditures, in this lecture. Current trends in health care expenditures Health care expenditures: HCE -​ From the perspective of demographic changes. Looking at trends and what is driving this change. There we will include the demographic element. And how much of this is due to longevity. -​ Reading/lit about the ‘red herring’ term. -​ Sometimes we are lured into thinking that population ageing is the driver between HCE, when it’s not. The red herring is the false presumption that it is age, when it is not. Trends in HCE ​ Trends in HCE’s show that the expenditures are rising after covid. Before covid, there were more steady. ​ How do we cover HCE? We cover it mostly by the government, and a bit out of pocket. Some characteristics of the Dutch system: ​ Stagnating share of GDP → higher deductible, sectoral agreements, generics and home care. ​ Low out-of-pocket payments ​ Long-term care sector is particularly expensive. -​ In the 60s, we spent, in the OECD, fewer than 5% of our GDP on health care. -​ We see a global trajectory increase in the share of GDP. -​ How do we cover HCE? A very large portion of the health care in the US is private. So there is less control on how the money is spent. There are fewer deals made between pharmaceutical companies by the government and private institutions. -​ It is very inefficient. It costs a lot of money, a big portion of the GDP is spent on health care. But life expectancy does not reflect this at all. -​ The way we deal with health care expenditures is a very political problem. Are we doomed comparing HCE and age? -​ One argument is that there is a relationship between age and health care expenditures per person. -​ But, population ageing is not the biggest contributor to rising health care expenditures. -​ And is age the end of the story? Is ageing linked to all the variables? What is driving the change ​ Population composition ○​ Age ○​ Education ​ The distribution of levels of education in the population. It is known that there is a life expectancy gap between high and low education levels. ​ There is a dramatic increase in people with a high level of education. A big part of higher life expectancy is due to this. So something similar could have been going on in HCE. ​ You could also mention urban vs rural areas ​ Longevity ○​ (Healthy) life expectancy ​ Also mobility ​ Practices ○​ Demand ○​ Supply ○​ Knowledge, technology and policies France as an example -​ At each age group there is an increase in cost per capita. Which is about 10-20 percent. So they divided this effect by looking at the HCE. For a given age group, are they more or less healthy, The overall result is that there is an increase in ageing by 3.4%. But the practices/pharmacy cost more with a 12% increase. China as an example -​ Only about 1% of the growth in HCE is due to population ageing. The biggest increase came from the cost per case. How much it costs to treat a diagnosis. Of that 8% about 12% can be related to cardiovascular disease. Furthermore: Dormont et al. Does increased longevity push costs? Is age an absolute concept? ​ For any developed country, an increase in the proportion of the elderly entails an increase in per capita health care expenditure. This is undoubtedly true, given that individual health care expenditure is an increasing function of age. ​ Is life more like tennis or football? ○​ Tennis: ​ Match ends when score is reached ​ Time is relative to each match ​ Critical periods = end (of games, sets and match) ​ Outcome depends on coming events, with some conditionality  ○​ Football: ​ Match ends when it is time ​ Time is absolute ​ No clear critical period ​ Outcome depends gradually on past events Relative age ​ Idea: define old people not by their age, but by their remaining life expectancy ​ Advantage: takes improvements in health and life expectancy into account ​ Example: prospective old age dependency ratio ○​ (Number of persons with remaining life expectancy < 15 years) / (number of persons between age 20 and age with remaining life expectancy = 15) ​ Fixed starting age not necessary, could also be less than 15 years of life expectancy vs more than 15 years of life expectancy Is age an absolute concept? We use age as a comparison. So is age relative or absolute? We can base it on how much people still have to live. Age vs time to death -​ Age and time to death can be highly correlated. -​ The probability of being in the hospital increases in the last year of life. -​ There is a bit of an age effect, there is a 30% increase no matter how close to death in the ages 65 to 95. But the biggest increase in health care expenditures is in years close to death. Demographic time dimensions Age, period and cohort -​ Having a big cohort of old people is not an issue, as long as the majority of them has a healthy life expectancy and are not close to time of death. If that is stable, than it would not drive HCE up.  -​ On this diagram, we can see calendar time; which year we are in. We can see how old we are, and we can see when you are born. -​ Age -​ Period -​ Cohort Lexis surfaces Further time dimensions -​ If you know two of them, you know the third one. Alternative lexis diagrams Age vs. time to death ​ Back pain: depends on chronological age because caused by wear and tear ​ Mental health and SRH: depends on how long remains to live because, either people feel they approaching death (mental health) or their body generally shuts down (SRH) ​ Smoking: determines how old you’ll live, not remaining time to live, because people start smoking around the same age. ​ Blood pressure: if you are young with high blood pressure, it is a bad sign and you will die soon. If you are old with a high BP, it is not going to kill you soon. Conclusion ​ Morbidity varies across all demographic time dimensions, and chronological age is only one of them. ​ Because the other dimensions overlap with chronological age and are rarely measured, we tend to take for granted that old people are more unhealthy and generate more health care expenditures. ​ Because of methodological challenges, theses conclusions are still strongly debated ​ We tend to think of demographic time in absolute terms, football, but age is relative, tennis. Summary: ​ Population ageing brings challenges that can be used as scarecrows, such as healthcare expenditures. ​ HCE are more affected by increasing demand and supply of healthcare (practices) and costs per case, than population ageing (age structure of the population) ​ The link between age and healthcare expenditure (through morbidity) is not as obvious as it seems (still hotly debated) ​ Costs are only slightly affected by population ageing, and possibly not at all by increasing life expectancy. Lecture 8 Guest lecture about the city of Groningen becoming a more ageing friendly city Healthy city and healthy region Topics: ​ Why do we mingle with health and public space? ○​ Challenges in the field of health. The RIVM published a study showing how the situation is regarding the health of Dutch people. In this report, there are 5 major challenges until 2050. And there is a big regard towards ageing people. ​ We need new forms of housing to see people living longer on their own. ​ There are big health inequalities between high and low socio-economic status. People with a high socio-economic status live 14 years longer in good health. Health inequalities have not been getting smaller over time. ​ The lack of a healthy lifestyle for young people. 50% is now overweight, 70% of people in their 20s will be overweight. In the 90s 17% of people in their 20s were overweight. ​ Continuity of good care is also an issue. There is an increasing demand and shortage in the health care sector. ​ Healthy design in living environments is the 5th challenge. ​ The national government directs more and has an agreement with the local government regarding the regulation and prevention of bad ageing. ​ Kind of disastrous with this government. Luckily the local governments have a lot of power regarding the policies in their own areas. ​ Legislation on health issues also helps. Like not smoking in public spaces. ​ Mental health is also causing a large health-burden on the city of Groningen. There has to be some action taken there. ​ Healthy city policies of the municipality of Groningen ○​ Health in all policies-strategy. The WHO developed this strategy in 2012. ○​ The model regarding the determinants of health  ​ ​ Many principles influence health. Our environment is important for our health, like health care, education, if you’re lonely or not, water and sanitation etc. ​ All these aspects influencing your health are related to local government policies. ​ To improve the health of citizens, a broad approach is needed. Because health is related to all the policies of the municipalities, together with the GGD shows an advice: develop a healthy city in your own government policies. ​ 36% of health is personal behaviour. But individual behaviour is always related to social and physical surroundings. 24% social conditions, 7% social and physical surroundings, 22% genes, 11% medical care. So what can governments do to make the environment healthier? The most important health benefits of the 20th century were gained by measures outside of the medical domain. Like city hygiene, public housing, social legislation, education and emancipation. This was a breakthrough for the future. Livelihood/resilience, mental toughness of the population and living environment, topic of today. ○​ There is often a connection between the living environment and the socio-economic state of the neighbourhood. ○​ What is a healthy living environment? ​ Living conditions, so the social and physical living environment have a direct impact on the public health, and on the access to health care and  participation. Local and national governments can influence these living environments to some extent. ​ Healthy city is a city with a healthy environment, spacious, hygienic, respects cultural heritage, friendly for bicycles and pedestrians, traffic and personal safety, healthy outdoor spaces, green city, no heat stress/noise/pollution. ​ Blue zones are areas around the world where people are getting very old. Scientists went to these areas to try and find the reasons why people were getting so old. Similarities lied in strong social conditions, they moved physically everyday, were optimistic, and ate their own foods. These are interesting findings because we can integrate these insights in our own policies. ​ Food/social conditions/daily movement are very important factors here, according to the scientists. ​ You find all different types of rankings when googling healthy cities. Like Copenhagen pops up quite often. It is a bicycle city with a high level of happiness, with a good balance between work and life balance. Vancouver is another example. It is a very green city, with space at the water. There is a big ambition to make it a healthy city. ○​ Lifestyle is not a personal choice. It is heavily influenced by their surroundings. Now our healthcare system is stuck, because there are not many healthy lifestyles at play anymore. ○​ Last year there was a EU report on the quality of life in European cities. Looking into safe and cohesive cities, finding a house, public transport, culture, health care etc. Groningen had high scores and was in the top 10 sometimes. Lower scores were on housing, jobs and walkability. Bikes take up a lot of space and that makes it difficult to walk around on foot. ○​ History of city planning: Hausmann was a French official responsible for a massive renewal in Paris. He had a lot of critique. The reason to tear Paris down was because it was filthy, dangerous and unhealthy. New design made it easier to crush riots. Health was the main reason. The new design improved traffic, sewage, water and green spaces etc. City design had a huge impact on epidemics. Good city design led to lesser outbreaks of diseases as cholera or tyfus. ​ The direct relation between city planning and health disappeared with the rise of the medical sector developments. Now when you got sick you could get medicine, and did not worry anymore so much about the living environment. ​ Now there are new problems, like quality of air, welfare diseases which relate to city planning. We need a new approach. ​ Characteristics of healthy cities, in specifics Groningen ○​ Groningen is divided into 7 districts. In the Northern part red is not good in regards to health. Health inequalities in Groningen there are differences between  the North → Paddepoel, Vinkhuizen, Selwerd, and the average health situation in the city. The municipality invests in renewal in the northern part of the city. ​ So the northern neighbourhoods are lacking behind. The districts are different, but they do have some similarities. In the Northern neighbourhoods there is a high health care consumption, there is a high percentage of minimum households, poverty, lack of social cohesion and low literacy. Many vulnerable groups live there. Selwerd is in the worst state. ​ Resident input is necessary to improve the neighbourhoods. Selwerd defined four goals in their neighbourhood plan. ​ Happiness ​ Health, most important goal ​ Affordable and sustainable housing ​ Green and safe neighbourhood ​ Active part in development of the neighbourhood ​ The issues regarding mental health in Selwerd are related to loneliness, poverty and the physical environment like unsafe streets. ​ Connect spatial development with social issues ○​ Like overweight people in the city you also see the eastern and western part of the city. But for smoking it is also big in the city centre, likely regarding students. Difficulty making the ends meet is more in the Northern part of the city. Mental health problems are in the northern region with a high risk of developing anxiety or depression. ○​ The goal of the city of Groningen is to improve more healthy years and reduce socio-economic health inequalities. How? By a broad integrated approach. It is a shared ambition focused on a small scale and prevention. ​ Healthy policy strategy ○​ 4 goals, healthy base, improve security, equal opportunities, healthy environments, healthy mind ○​ Healthy environments: ​ City, inner city and areas like the new ring roads. ​ Areas like Meerstad are healthy, newly build and have high socio-economic status ○​ Mobility is no longer the main factor in designing. There are now 10 new dimensions for accessible types of streets: accessible for everyone, safe, ecosystem, stimulating experience, healthy, creating value, having an identity. ​ Streets as a public space for people, not just for connections. ○​ Stadsbouwmeester: from prosperity to wellbeing. Focus opportunity by mixing functions. There are four types of city architects. City, landscape, district renewal, social architect → social and physical combined. The social architect is new, realising the combination of social domains with spaces. Spatial translation of social issues, focussing on community wellbeing. ​ Soft cities → david sim ○​ 50 years ago there were cars all over the inner city.  ​ 7 core values of a healthy city, focussed on prevention ○​ Active citizenship: looking into social networks, caring for each other, engaging citizens, participating, taking them seriously, letting them develop their neighbourhood or street. ○​ Accessible green spaces: designed so they are attractive, that you can meet there, can do something, has quality, is climate adaptive. ○​ Active leisure: develop the city in such a way that the public space can be defined as a sport facility, stimulated to sport, play, meeting opportunities. ○​ Healthy transport: better to go by bike than car. ○​ Housing; diverse housing, variety of housing for different demands. ○​ Consumption: healthy diet, more easy attainable, short food change. ○​ Safety; social and physical safety. Unsafe environments cause stress and unhealthy behaviour. Because children then might not be able to go to school by bike. If the slowest group can go around the city, 35% of the inhabitants, you will have a healthy city. Large main roads function as barriers in the city, so that cannot make a pedestrian city. Lecture 9 Recap: ​ What makes a healthy city ​ G7 for Groningen → active citizenship, green spaces, active leisure, resilience, health transport, healthy buildings, healthy diet ​ Different on the ground approaches focused on prevention and meeting G7 1. Life course and health a.​ What is the life course perspective “Old age is like everything else. To make a success of it, you’ve got to start young.” Timing perspectives: ​ Life course perspective ○​ “emphasizes a temporal and social perspective, looking back across an individual’s or a cohort’s life experiences or across generations for clues to current patterns of health and disease, whilst recognizing that both past and present experiences are shaped by the wider social, economic and cultural context” ​ What is the life course? ○​ Birth, infancy and childhood, adolescence, young adulthood, etc. ​ Life course in perspective, in health research ○​ Study of long term effects on later health or disease risk based on physical or social exposures during gestation, childhood, adolescence, young adulthood and later adult life.  ○​ Multidisciplinary approach to healthy ageing: followed by demographers, psychologists, anthropologists, sociologists, biologists and economists. ​ Phases of the life course Intermediate summary 1 ​ Old age health is influenced by earlier life events for cohorts and individuals ​ Life course as a theoretical approach that accounts for timing perspective ​ Exposure to health risks/health prevention over phases of life course effects (in-utero, childhood, adolescents, adulthood, working life and old life) b.​ Life course approaches to health ​ The Fetal Origins Hypothesis ○​ On approach to show how later life health outcomes are already determined in-utero. ○​ “The developmental (or fetal) origins hypothesis proposes that coronary heart disease, type 2 diabetes, stroke and hypertension originate through developmental plasticity, in response to undernutrition during fetal life and infancy” (Barker 1995; Barker et al. 2002) ​ Foetal origins and life course approach ○​ Postulates negative early childhood effects prevail independent of later life health behaviours or environmental influences. ○​ Criticism: neglects that health at older ages is determined by various biological and social factors. ​ Over life course these factors independently, cumulatively and interactively influence health and disease in adult life. ​ Less focus on early life but on all stages of the life course. ​ Question: are there conceptual similarities between the life course approach and the biological and psychosocial theories of healthy ageing? ○​ Biological theories to affect behaviours. External stressors how they influence the life course approach. Life course approach puts the idea of health factors into situations that your body can’t fix anymore, when you are of old age. ​ Life course effects on health ○​ Focus on prevention. ​ Pathways to unhealthy ageing ○​ Accumulation of risks: negative effects gradually accumulate through episodes of illness and injury, adverse environmental conditions, and health damaging behaviours. ○​ Cumulative damage to biological systems as number, duration or severity of exposures increase → body systems age and become less able to repair damage. ○​ Chains of risk model ​ Sequence of linked exposures that raise disease risk  ​ One bad experience or exposure tends to lead to another and then another ​ Different types of chans can lead to increased or decreased risk ○​ Social, biological and psychological chains of risk are possible and involve “mediating factors” and often “moderating factors” ​ Mediating factors: positive or negative factors that explain the link between cause and consequence like low socioeconomic status, family characteristics and later life health. ​ Moderating factors: beneficial effects that lowers negative risk outcomes, like resilience. ○​ Links are probabilistic, not necessarily deterministic → negative transitions are likely to occur but not available ○​ Life course approach models 2. Life course determinants on health at older ages a.​ Life course approach to physical capabilities ​ Physical capabilities at older age ○​ Physical capability is the capacity to undertake the physical tasks of daily living, is a key component of healthy biological ageing and highly valued by older people. ○​ Link to activities of daily living ADL and instrumental activities of daily living IADL ○​ Physical capabilities important for risk of death. ○​ Immobility, risk of falls etc, central concern for adults ○​ Differences in physical capabilities at older ages result from changes across life course → social, behavioral and biological processes from early life onwards. ○​ Studies usually assess physical capabilities by different measurements, like grip strength, chair rise time, standing balance performance or walking speed ○​ Measurements of physical capabilities are related to normal functioning of the body system, especially the musculoskeletal, cardiovascular, respiratory and nervous system. ​ Declining physical capabilities over age ○​ Overall decline of physical capabilities over age results from several factors related to ‘normal’ ageing processes. ​ Reductions in muscle mass and quality other deteriorations in the musculoskeletal system ​ Neurological, hormonal and cardiovascular functioning decline ​ Detrimental (unfavourable) changes in weight and health behaviours, and the increasing risk of developing chronic conditions. ○​ Inter-individual variations in physical capabilities at older ages result of different effects over life courses: ​ Genetic factors: heritability of better physical functioning explains only the 30-65% variation.  ​ Lifestyle factors: physical activity over the life course → continuous exercise and training related to better physical functioning at old age, also sudden increase of exercise at older ages nog necessarily beneficial ○​ Lifestyle factors (continued) ○​ Smoking behaviour ​ Cumulative effect of smoking on respiratory and cardiovascular systems decreases physical capabilities already at age 53. ○​ Body size ​ High BMI related to worse physical capabilities at older ages → longer phases of obesity over life course decrease with physical capabilities ​ Also lower birth weight or undernutrition at young ages related to lower grip strength at older ages b.​ Life course perspectives on diet and ageing ​ Nutrition over the life course ○​ Diet refers to foods that provide energy, macronutrients (protein, fat and carbohydrate) and micronutrients essential to maintain health (vitamins, magnesium, iodine etc). ○​ Individual diet may be a modifiable, changeable, factor with strong effects on health ageing. ○​ Different nutrition patterns over life course affect later life cognitive and physical health outcomes. ○​ Under- and over-nutrition. ○​ Importance of nutrition for health reflected by public health guidelines, policy recommendations etc → different nutrition pyramids, “eatwell” plates or exemplary diets (mediterranean) that suggest certain combinations of foods. ○​ Diet over the life course result of several factors: ​ Socioeconomic conditions affect availability and affordability of food ​ Cultural or social norms affect food preferences or dietary rules ​ Social norms and preferences change over the time → take out food, fast food ○​ Period of life when exposed to nutrition patterns or in need for certain nutrients are central ​ Nutrition of mothers can influence fetal growth ​ Breastfeeding was found to have a positive effect on cognitive and health outcomes in childhood and in later life. ○​ Childhood overweight adverse long term health outcome → cardiovascular diseases, diabetes, musculoskeletal disorders, breast and colon cancers ○​ Major life events can influence nutrition patterns ​ Depressions can change food preferences or overall food intake ​ Ageing related factors like dental loss affect food preferences ○​ Life course nutrition and cancer risks c.​ Residential environment over the life course and healthy ageing ​ Residential environment  ○​ Characteristics of the places people live in childhood and adult life can influence health at older age ○​ Higher vulnerability of individual during certain life stages ○​ Area deprivation has a negative impact on later life health outcomes → access to certain services, recreational areas, socioeconomic status of neighbourhood, exposure to pollutants etc. ​ Area deprivation and physical functioning ○​ Area deprivation = percentage of employed persons in the area working in partly skilled or unskilled occupations. Summary ​ Later life health outcomes determined over the life course ​ Vulnerable phases (in-utero, childhood) have long range implications ​ Different pathways how life course events affect late life health (cumulative, clustering) ​ Wide range of determinants with interactions (socioeconomic status, health behaviours) ​ Examples for physical capabilities, nutrition, place of living Lecture 10 Guest lecture Jodi Sturge University of Twente Ageing Right Care(fully): a snapshot of the housing and healthcare continuum for older adults. Research context The housing continuum. So this is an ideal world. ​ Ageing in place, so ageing in independent living and care provision in home, one big critique is loneliness. The ideal is that kids take care of them, but that is not always the case. It can be very isolating living alone at home. In this ideal, old people cannot always sustain themselves. ○​ An example of ageing in place ​ Based on the desire of most people to age and have healthcare services at home.  ​ The goal is to live at home for as long as possible without moving to a long-term care facility. ​ A lonely experience for some older adults and impacts health. ​ The focus is on the housing environment and falsely assumes a supportive environment ​ A need to design environments that support outdoor mobility, social health and well-being. So how do we create an environment that supports mobility, social health and wellbeing? ​ Sometimes the architecture prevents you from social interactions. So there has to be a look into how we can design the future for people to stay in one place. How to design for social sustainability: ​ Better policy, zoning and design guidelines ​ Technology developments to link older adults with younger populations and healthcare providers. ○​ Like phone booths, ipads in the house. ​ Modular housing design and new layouts with open plans ○​ Wheelchair users and have better oversight ​ Universal design and human-centered design approaches ​ Collaboration care and housing organisations for hybrid building complexes ​ Both semi-public / common spaces for spontaneous encounters Older adults in the Netherlands ​ Greying, ageing population ​ Municipalities are ageing ​ A high number of people have dementia ○​ Most people that have dementia live at home, and 30% of them live alone at home. Long term care crisis in the Netherlands ​ 20.000 people are waitlisted for residential care home ​ Not enough personnel to provide care or organise activities ​ Many organisations could face bankruptcy in near future ​ Inflation, energy costs and cutbacks are causing additional strain Challenges moving along the housing continuum ​ Not wanting to move is the main reason ​ But aside from that, it is not really ideal. In the Netherlands there is some innovation, the Hogeweyk dementia village concept ​ A pioneering health care model ​ “A place for normal life for people living with severe dementia” ​ Weesp ​ 152 residents living in small-scale home-like environments ​ Amenities such as a grocery store, hair salon, cafe ​ Attracts global interest as an alternate care model for people with dementia. ​ Canada did a translation of this. But many things went wrong. It tried to be as safe as possible, and that can put constraints on zelfredzaamheid. There are big roads, and things are named differently. They are treated differently, like children. The intention is good, but people with cognitive decline are treated differently. Housing innovations: emerging models ​ More research is needed how these care models work ​ A need for translation guidelines to inform planning and architecture decisions ​ Explore ways people with dementia can remain in society ​ A need for new innovative models for housing and care for older adults Most recent project These systems are going to be very expensive. The cycle from the home to the hospital is going to be more common. But for older adults, this is going to be more difficult. How do we help people age better by looking at these environments? ​ Social environment ​ Built environment ​ Technological environment How can technology support ageing in place in healthy older adults? A systematic review Aim: to identify technologies that support the ageing in place of healthy older adults plus how such technologies engage healthy older adults. Findings: technologies can be categorized in three groups; accessible communication, emergency assistance and physical and mental well-being. Conclusion: patient-centered approach for developing, implementing and evaluating technology benefits ageing in place. Exercise, first video robot one: is this positive or negative? We are not listening to the user's needs. The robot is not a good communication tool, it is not a human. Second video: also really crazy. A lot could go wrong. It is more like machine learning. If AI makes our decisions for us, what could go wrong? A lot. Lecture 11 Mobility in later life Outline: Part 1: Mobility change lab ​ Experience the mobility challenges that come with life itself Part 2: Insight into mobility experiences in later life ​ Mobility and caregiving ​ Mobility and low income ​ Urban and rural mobility Part 1: Mobility change lab ​ Introduction ○​ Common impairments that impact mobility in later life ​ Loss of hearing ​ Loss of eyesight ​ Arthritis ​ Difficulties walking ○​ Aim: experience what it feels like to move around when you’re ‘old’ ○​ You can be creative in solving the issue faced with mobility stages. ​ Discussion ○​ You’d have to change your clothes for example, if you can’t close a zipper. ○​ Important to recognize these issues and act on them. Part 2: Insight into mobility experiences in later life ​ Mobility defined ○​ The ‘mobility turn’ ​ From: movement from A to B ​ To: mobility as “the systematic movements of people for work and family life, for leisure and pleasure, and for politics and protest” – Sheller and Urry ○​ The mobility turn happened because of globalisation and the internet as well. ​ The mobility turn ○​ Lessons learnt: ​ Movement of humans, things and ideas ​ Mobility happens at different spatial scales ​ Mobility as a resource ​ Not everyone has access to resources, like cars or airplanes. ​ Conceptualising mobility ○​ Dimensions of mobility → Cresswell ​ Physical movement ​ Movement from A to B ​ Representations ​ What it does to you or us if you see for example mobility in real life. ​ Practices ​ Experiences of mobility, what is it like to go from A to B. How does it make you feel? ​ Mobility later in life ○​ Often: impairments that impact mobility ○​ Mobility = “the overcoming of any type of distance between a here and a there, which can be situated in physical, electronic, social or other kinds of space” ○​ Mobility of the self = will to be connected with the world and be mobile ​ If people stay more engaged, their well being tends to stay higher. ​ Dementia caregiver mobility in the UK ○​ Background: ​ Dementia prevalence ​ UK = 885000 people with dementia ​ 50% of dementia care is provided by informal caregivers ​ Condition with a large burden ○​ Caregiver mobility: ​ Capability to be mobile ​ Real opportunities ​ Impact of being a caregiver ​ Can drawing be a valid scientific method of data collection ​ Graphic elicitation (lowe et al, 2023b) ○​ Changed mobilities ○​ Linked mobilities ○​ To sum up: mobility is impacted by that of other people ○​ Example: caring for someone with dementia ​ Mobility restrictions ​ Mobility becomes local and oriented on care ​ Past can be idealised ​ Active older adults with low income in Vancouver ○​ Background ​ Subjective and temporal dimensions of mobility experiences ​ Emerging themes include: ​ Maintaining a sense of self ​ Being resourceful ​ Engaging in superficial contact ​ Leaving the immediate neighborhood ○​ Mobility gives meaning ○​ To sum up: overcoming physical and social disparities ​ Maintaining a sense of self is vital ​ Mobility choices ​ Chronic illness does not mean no activity ​ Resourcefulness is key ​ Mobility on the urban-rural continuum of the Northern Netherlands “I choose the quiet roads” ○​ Background ​ Later life comes with impairments, physical and cognitive impairment. The mobility challenges faced can be different in urban and rural areas. ○​ Rural-urban continuum ​ Rural and suburban areas ​ Often very car dependent ​ Issue of losing drivers license later in life ​ Expensive mode of transportation ​ Urban areas  ​ Walking ​ Cycling ○​ In rural areas between towns ​ Cycling and driving ​ Big use of e bikes ○​ Villages and urban-rural fringe ​ Variation in getting around ​ Car-dependence ​ (E-)biking ○​ In cities ​ Walking and cycling ​ Recreational and utilitarian ○​ Impairments also decide on what mode of transport to use. ○​ To sum up ​ Environmental characteristics ​ Age-related impairments ​ Transfer of skills outside living environment ​ Creativity and agency ​ Barely any use of public transport in this example In conclusion ​ Mobility is more than moving from A to B ​ Mobility = “The systematic movements of people for work and family life, for leisure and pleasure, and for politics and protest” ​ Mobility impairments can be tough ​ Three research examples have shown that opportunities and barriers in everyday mobility depend on: ○​ Other people, especially who you care for ○​ Your physical and social health ○​ Where you live ​ Creativity and resourcefulness Lecture 12 Population ageing in global perspective ​ Last lecture ○​ Mobility as a central component of healthy ageing but heavily influenced by cognitive and physical decline over age ○​ Modern definitions of mobility going beyond movement from a to b (“mobility turn”) ○​ Mobility extends to other dimensions of human interactions such as digital or social mobility and contains different motives (forced, voluntary) ○​ Examples of caregivers’ mobility and mobility in urban and rural areas ​ Today’s lecture  ○​ Motivation: is population ageing a global population issue ○​ Current, past and future population age structures ○​ The role of MIPAA in shaping an ageing friendly environment ○​ Focus: ageing in Sub-Saharan Africa Motivation: is population ageing a global population issue Question: is population ageing an international population issue? ​ Dependency ratio ​ Recap: how to measure the age of a population Current, past and future population age structures ​ Median ages across world regions ○​ ○​ All over the world we see an increasing median age. ○​ Ages went down in the 80s/90s in Africa, because of high fertility. There are also epidemics, so older people die. Overall, median age goes down. ​ Median ages according to economic development ○​  ○​ Median age can also be dependent on economic development. In high income countries, it is more likely to have a higher median age. ​ Global population ageing ○​ Share of 60+ year old increases from 12-22% between 2015 and 2050 ○​ Already today, more 60+ year olds than children below 5 ○​ In 2050, 80% of older persons will live in low and middle income countries ○​ Despite overall ageing, different pace across and within regions ​ Two examples: ○​ 1. Europe ​ Changing world leaders in ageing ​ Number of elderly in the world ​ The graph is on median age. So keep that in mind when drawing conclusions. ○​ 2. Worldwide population change ​ Global ageing patterns ​ Changes from EU to also EU and Asia over 70 years ​ Also interesting for change in labour and consumptions patterns Intermedi