Global Ageing and Its Effects on Health Systems
The Demographic Challenge
The global population aged 65 and older is growing at an unprecedented rate and is expected to reach 1.6 billion by 2050, placing enormous pressure on health systems worldwide. 1 The most rapidly ageing populations are in low- and middle-income countries, creating a "double burden" where these nations must simultaneously manage both communicable and non-communicable diseases. 2
Key Demographic Facts
- In Europe, over 50 million people have at least one chronic disease 1
- In the United States, the number of people aged 50 years and older with at least one chronic disease will increase by 100%, from 71 million in 2020 to 142 million by 2050 1
- More than 50% of older adults have three or more chronic conditions (multimorbidity) 1
- The incidence of life-threatening falls among older adults (aged ≥70 years) continues to rise globally 1
Impact on Health Systems: The Multimorbidity Crisis
Disease Burden Characteristics
Most older individuals are affected by multiple chronic diseases, leading to complex drug treatments and increased risk of physical and cognitive disability. 1 The leading contributors to disease burden in older people are:
- Cardiovascular diseases (30.3% of total burden in people aged 60+) 3
- Malignant neoplasms (15.1%) 3
- Chronic respiratory diseases (9.5%) 3
- Musculoskeletal diseases (7.5%) 3
- Neurological and mental disorders (6.6%) 3
Specific Challenge: Dementia as a Model Disease
Dementia exemplifies the challenges of global ageing. The world population suffering from dementia is approximately 50 million and grows by 10 million per year, with 5-8% of the elderly population above 65 years affected. 1 By 2030, this will reach 82 million, and 152 million by 2050. 1
The financial burden is staggering: in 2019, expenses on dementia worldwide totaled 1.3 trillion dollars (0.76% of worldwide GDP), with informal care costs representing 49.6% of total costs. 1
Health System Inadequacies and Challenges
Fragmented Care Delivery
Healthcare systems and clinical practice guidelines are mainly oriented towards single-disease rather than multimorbidity, which can lead to contradictory recommendations that are impractical or even harmful. 1 Current health systems for older people often feel reactive, fragmented, and disjointed, harboring inequity and ageism. 2
Clinical Management Barriers
- Improving or preserving health and quality of life is challenging due to lack of well-established clinical guidelines for multimorbidity 1
- Physicians are forced to engage in cycles of "trial and error" centered on palliative treatment of symptoms rather than root causes 1
- Application of multiple disease-specific guidelines without integration may be misaligned with patients' preferences and values 1
- Older adults with multimorbidity are regularly excluded or underrepresented in clinical trials, translating to less focus in meta-analyses and guidelines 1
Polypharmacy and Drug Interactions
Over one-fifth of older people with multimorbidity receive medications that may adversely affect a coexisting condition. 1 Polypharmacy creates higher risk of:
- Inappropriate medication use (overuse, underuse, misuse) 1
- Adverse drug reactions 1
- Drug-drug and drug-disease interactions 1
Required Health System Transformations
Shift to Home-Based Care
To alleviate pressure on health systems, transition to home-based care (HBC) represents a sustainable solution, as the majority of older adults choose to remain in their own homes for as long as possible. 1 However, this requires:
- Technological innovations including Internet of Medical Things (IoMT) platforms for long-term health monitoring 1
- Capability to manage medical emergencies requiring rapid attention 1
- Modifications of homes and medical equipment 1
Continuous, Holistic, and Integrated Care
Care for people with multimorbidity needs to be "continuous, holistic and integrated" throughout the disease course. 1 This requires:
- Strengthening continuous integrated services across all disease stages 1
- Establishing cross-professional service teams to provide physical and life care 1
- Coordinating care across transitions between emergency departments, in-/outpatient units, and skilled nursing facilities 1
Community Services and Administrative Support
Health systems should focus on grass-roots units and strengthen community services following the "Aging in Place" concept, where elderly receive services at home in familiar environments. 1 This approach:
- Makes elderly feel relaxed, conducive to maintaining functions 1
- Saves social resources 1
- Requires early screening services for high-risk populations 1
Multidisciplinary Team Approach
A holistic patient care requires coordinated teamwork between cardiologists, medical specialists, nurses, pharmacists, social workers, family, and caregivers for successful comprehensive geriatric assessment. 1 This approach:
- Assists in decision-making and enables personalized treatment strategies 1
- Evaluates complexity, feasibility, and adherence to treatment 1
- Selects drugs and doses to optimize benefits while minimizing harm 1
- Improves quality of care for patients with chronic cardiovascular disease 1
Workforce and Resource Implications
Human Resource Challenges
The notable changes in global demographics, combined with prevalence of frailty among older adults, underscore the importance of expanding human resources in the public health sector, though economic and occupational constraints make this unfeasible. 1 Specific challenges include:
- Need for policy and financial support for nursing workers 1
- Caregiver burden: family caregivers provide up to 11 hours of daily care 1
- Most caregivers are spouses who are also elderly 1
Financial Burden
23% of the total global burden of disease is attributable to disorders in people aged 60 years and older, with disability-adjusted life years (DALYs) per head 40% higher in low-income and middle-income regions. 3 The societal cost is enormous, especially for age-dependent disorders like dementia, stroke, and chronic obstructive pulmonary disease, where long-term care costs outweigh health expenditure. 3
Common Pitfalls in Addressing Global Ageing
- Misplaced global health priorities: Persistent beliefs that chronic diseases afflict only the affluent and elderly, and that control is too expensive 4
- Ageism: Health systems harbor inequity and ageism that leave patients and providers dissatisfied 2
- Poor preparedness: Health systems are poorly prepared to deliver age-appropriate care for chronic diseases 3
- Lack of financial support: Retards capacity development for prevention, treatment, and research in developing countries 4
- Orientation toward acute care: Health systems remain oriented toward acute rather than chronic care 4
Strategic Priorities for Health Systems
The WHO has established main priorities including supporting country planning and action, collecting better global data, aligning health systems to needs of older people, laying foundations for long-term integrated care, combating ageism, and enhancing age-friendly cities and communities. 5 However, there is little evidence on application of active ageing frameworks in developing countries, and greater national capacities with closer monitoring through age-disaggregated data is needed. 5