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 people either, even if it means a great deal to medical experts who take a biomechanical model to assess ageing well. In one study, fewer than a fifth of older people can be demonstrated to be ageing well if these criteria are used.14 Yet, if you ask them to assess themselves, around half of them say that they are, in fact, ageing very well, thank you.
Some have argued that it is easier to talk about disability-free life than about healthy life expectancy, and Sir John Grimley Evans was at pains to persuade the Lords select committee to take this different view, because ‘it is disability and its associated loss of autonomy that older people fear, and which in turn leads to dependency with its cost implications for the health and social services’.
The trouble is that there are so many ways of estimating healthy life expectancy. It can be based either on self-assessed general health or self-assessed limiting long-standing illness. When it is a question of mortality, there is no doubt: deaths are formally registered. But when it comes to illness or disability, you have to get the information using a subjective assessment by the individual. And when it comes to information about rates of ill-health in the population, this is derived from the British General Household Survey, a nationally representative interview survey of residents in private households, conducted over many years. Each year about 25,000 individuals are interviewed, of whom around 4,000 are aged 65 and over. But the General Household Survey only includes people living in private households. Yet residents in communal establishments, care homes, nursing homes and sheltered housing and the like represent a significant proportion of the elderly and of those in ill health. The healthy life expectancy figures, on the other hand, are adjusted to take into account the health of residents in health and care institutions.
They also ask very different sort of questions. For the survey, people are asked questions like ‘Do you have any long-standing illness, disability or infirmity?’ For the Census, people are asked questions like ‘Do you have any long-term illness, health problem or handicap which limits your daily activities or the work you can do (yes or no)’. For both the General Household Survey and the Census, people are asked: ‘Over the last 12 months would you say your health has on the whole been good, fairly good or not good?’
We do get a little closer to what individuals actually feel with these questions, rather than what the definitions say they are supposed to feel – but not very much. There are concerns about this kind of subjective test, and whether one person’s ‘fairly good’ is the same as someone else’s, but there is a big plus: research shows that ‘self-perceived health’ is actually a good predictor of health outcomes. That being the case, there is good reason, despite the scientists’ concern at the lack of objectivity, to trust the responses given by ordinary members of the public. They know how they feel and, apparently, their responses tie in neatly with their subsequent mortality, suggesting that the individuals concerned often had a clearer idea of what was going to kill them, and when, than the doctors did.
The difficulty comes in making comparisons with other countries, because they rely on different criteria. For example, the United States, Canada and Australia ask whether health is perceived as ‘excellent, very good, good, fair or poor’. In those countries, those who perceive their health to be ‘fair’ are in the fourth category rather than the third. It is generally accepted that the prevalence of disability in later life has fallen in the United States since the 1980s, but we don’t really know how this compares with this country. As far as the UK is concerned, ‘the informed view is that we simply do not know what is happening, but there is certainly no evidence that disability levels in later life are falling as in the USA,’ Sir John Grimley Evans told the Lords committee.
The benefits of using disability as a definition is that some international comparisons are possible. It is easier to define than ill health, but it is still far from being an absolute. Countries have different ways of defining what constitutes disability. Australia takes disability to be one or more of seventeen defined conditions. Japan takes disability to be confinement to bed. France includes as disabled all those in retirement homes. In the UK, disability is self-reported as a long-standing limitation on activities in any way.
So we still don’t know, despite all the different ways of defining it, whether a healthy lifespan is increasing faster or more slowly than the lifespan itself. Yet the fact remains that, on any measure, there are a number of years – about eight in the case of men and eleven in the case of women – during which older people regard themselves as not being in general good health, or as having a limiting long-standing illness or disability. Such evidence as there is suggests that this period of perceived ill health is not decreasing, and may well even be increasing.
Life
