Chapter 5: The Chief Public Health Officer's Report on The State of Public Health in Canada 2010 – Toward healthy aging

Chapter 5: Toward Healthy Aging

Over time, Canada has created many of the conditions necessary for healthy aging. As a result of societal changes and the progress made in areas such as public health, health care, living conditions, social norms and individual choices, Canada has a vibrant aging society and one of the highest life expectancies in the world.

Through planning and foresight, Canada has made substantial in-roads in preparing for an aging population. In fact, the Organisation for Economic Co-operation and Development has indicated that Canada is in a good position to adapt to its aging population given the reforms that have strengthened the financial stability of seniors.^{Footnote 305} Still, there are some persistent and emerging issues that can negatively influence the current and future health of Canada's seniors.

Ensuring that Canada's seniors can meet basic needs is fundamental to addressing the health issues facing this population. Without those needs being met, opportunities to maximize health or to develop safe and supportive communities that encourage healthy aging are not fully effective.

It is also important to note that what works for one community or individual may not work for another. However, we can do better to ensure there is a continuum of care across the lifecourse and that this care addresses the range of needs of Canadians. Information-sharing is critical to determine if there are ideas and solutions that could be more broadly implemented. Evidence from other countries and jurisdictions shows that negative outcomes related to seniors' health can be successfully reduced or mitigated. Canada can learn from and adapt these lessons as we continue to address the health of seniors.

Priority areas for action

The evidence profiled in this report indicates that there are areas in which Canada can move forward in creating, improving and maintaining the conditions for healthy aging. This chapter outlines priority areas for action where efforts to advance the conditions for aging well can make a difference to the health and well-being of Canadian seniors. These priority areas are:

• tackling issues of access to care and services;
• improving data and increasing knowledge on seniors' health;
• valuing the role of seniors and addressing ageism;
• targeting the unique needs of seniors for health promotion;
• building and sustaining healthy and supportive environments; and
• developing a broad falls prevention strategy.

Tackling issues of access to care and services

While Canada has had success with long-term, acute and emergency care, there are gaps in ensuring seniors have access to a continuum of care – from home to palliative care. As well, the level of care varies across Canada. Underserviced communities may not have the resources to meet the needs of seniors with chronic and/or declining health conditions. Assisted living arrangements, long-term care facilities palliative and end-of-life care need to consider how to provide culturally sensitive services that meet the needs of Aboriginal and immigrant seniors.^{Footnote 274} As well, seniors who have to navigate, manage, make decisions and pay for a range of care services often experience difficulties coordinating all of the various pieces to ensure they are receiving the appropriate care and services.

Difficulties also occur in the transition between care providers as seniors move from home-based care to assisted living and/or long-term care. Challenges to receiving care in Canada include the growing demand for health care services, the difficulty in accessing care services (including home care), the ability to age in the place of one's choice and a lack of support for caregivers. To strengthen care services requires that they be linked with broader social and community services to ensure a coordinated approach. It is also imperative, as a fair and compassionate society, that all seniors in Canada have access to quality, basic care and services regardless of income level.^{Footnote 274}

Informal care, given by family, friends and peers, offers seniors opportunities to age in the place of their choice and retain some independence and sense of community. As such, informal caregivers play a vital role in caring for seniors and reduce the burden on health care systems and professional caregivers. Canada has made progress in recognizing this contribution through the tax system, as well as by providing job protection and increasing work flexibility through labour codes and programs such as Canada's Employment Insurance Compassionate Care Benefit and local community supports and services. However, there are limited mechanisms beyond this to support informal caregivers in Canada. Issues continue to exist related to the provision of unpaid care and the need for mental and emotional support for caregivers. Evidence points to the need for broader societal recognition of the important role that caregivers play, which can translate to better access to supports/services (e.g. respite, financial, information) and flexible workplace environments. Measures such as these can allow caregivers to continue with their efforts to provide valuable and essential care to some of the most vulnerable members of our society.^{Footnote 601}

Many seniors may have received good dental care earlier in the lifecourse due to employer health insurance plans and greater access to services. However, management of oral health care can often decline with age due to issues with access and affordability.^{Footnote 270 Footnote 506 Footnote 507} Given the overall importance of dental health to overall health and wellbeing, it is important that as a society, we consider how to ensure that seniors have access to quality dental care across the lifecourse.

To address these issues, the care of seniors needs to be part of mainstream health care, with comprehensive and integrated systems involving a broad range of services to address the varying needs of seniors. Access to quality care that meet basic needs must also be achieved without differences in accessibility, eligibility and cost. It is clear that an integrated strategy within a Canadian context may be difficult to achieve given the federal/provincial/ territorial environment within which it would be required to operate. Nevertheless, it is an area that requires additional thought and effort.

Improving data and increasing knowledge on seniors' health

Data on seniors' health and the effectiveness of existing programs are lacking. More and better data and information are needed in order to identify long-term trends, future concerns and the effective initiatives, interventions and strategies that could be expanded or adapted in future.

As noted in Chapter 4, a better understanding of the health of Canada's seniors would be beneficial to creating conditions for aging well – especially in certain areas such as abuse and neglect where little is known about the extent of the issue. This may be due to a lack of understanding about what constitutes abuse and neglect and the associated laws that criminalize abusive behaviour.^{Footnote 431} Preventing abuse and neglect involves raising awareness and changing attitudes but efforts could be better targeted and more effective if more data on the issue were available. To begin to address this issue, Human Resources and Skills Developing Canada is funding a two-year project entitled Defining and Measuring Elder Abuse and Neglect: Preparatory Work Required to Measure Prevalence of Abuse and Neglect of Older Canadians in Canada starting in 2010. This project, being led by the National Initiative for the Care of the Elderly, will further develop the knowledge base of definitional, methodological and ethical issues concerning the measurement of elder abuse in Canada. This work will help inform the future development of Canadian surveys or smaller studies on the prevalence of abuse and neglect of older adults in community and institutional settings, as well as further identify risk and protective factors.

Other areas where information and data are lacking are mental health issues facing seniors and seniors' dietary habits. Similarly, more research would be useful to better understand why some seniors are resistant to physical activity in order to create efforts to overcome these barriers.

To address the need for better data collection and information on seniors' health, the Canadian Institute of Health Research's Institute of Aging is developing the Canadian Longitudinal Study of Aging. This is a national long-term study that will follow approximately 50,000 Canadian men and women between the ages of 45 and 85 for a period of at least 20 years.^{Footnote 602} This comprehensive research effort will collect information on the changing biological, medical, psychological, social and economic aspects of people's lives as they age. It will also consider lifecourse factors in order to understand their impacts on health and the development of disease and disability. One of the aims of the research is to understand successful aging by capturing associated transitions, trajectories and profiles. Another longer-term goal is to build capacity for sustained research on aging in Canada.^{Footnote 602 Footnote 603}

Also of note is the Canadian Community Health Survey's Healthy Aging (2009) module that collected survey data about the factors, influences and processes that contribute to healthy aging. Efforts focused on the health of Canadians aged 45 years and older, and the various health, social and economic factors that determine healthy aging (including general health and well-being, physical activity, use of health care services, social participation, and work and retirement). Ultimately, the goal is to provide valuable information to researchers and decision-makers that can better support policy making to ensure that Canadians have the most appropriate policies and programs in place.^{Footnote 604}

Having knowledge on and identifying best practices to promote healthy behaviours is important in addressing seniors' health in Canada. To do this effectively, information needs to be shared among individuals, researchers and practitioners as well as across communities, jurisdictions and sectors. Sharing information and best practices can showcase successful interventions and the lessons learned, which can inspire and motivate others. Knowledge networks can facilitate information-sharing among interested stakeholders and across sectors and jurisdictions by creating opportunities for coordination and cooperation.

Progress on this front in Canada includes efforts by the Canadian Network for the Prevention of Elder Abuse which allows members to share information to identify current and emerging issues, develop strategies and frameworks and share information and best practices across and within local, provincial, territorial, national and international communities. The National Initiative for the Care of the Elderly (NICE) also promotes informationsharing though its national network of researchers and practitioners involved in the care of seniors through medicine, nursing, social work and other allied health professionals. NICE works to help close the gap between evidence-based research and actual practice.^{Footnote 392 Footnote 447}

Future efforts to share information and knowledge are also being planned as part of the Mental Health Commission of Canada's National Mental Health Strategy currently under development. The proposed strategy includes the creation of knowledge networks and broad education/awareness and anti-stigma campaigns. By further developing and strengthening a mental health knowledge network, practitioners in Canada, as well as seniors and their families, can share information and best practices and provide information to individuals on practices, guidelines and support strategies.^{Footnote 376 Footnote 377}

In addition, the eventual adoption of electronic health records will help in bettering our understanding of seniors' health needs, identifying potential cases of misuse of medications or health hazards associated with drug interactions, and likely improving continuity of care and the management of chronic conditions.^{Footnote 274} The benefits of electronic health records to senior's health should be further investigated.

Valuing the role of seniors and addressing ageism

Seniors play a critical role in society and make a significant contribution to Canada's economy as employees, volunteers, caregivers and taxpayers. With the growth in population of those aged 65 years and older, this important contribution can be expected to increase. If Canadians are to age well, they must have the opportunity for physical, social and mental well-being across the lifecourse as well as the ability/capacity to participate in society and to have needs met when required.

One factor often impeding participation and contribution by seniors is ageism – a negative view of aging that devalues seniors based on the mistaken belief that they have little to offer.^{Footnote 274 Footnote 475} Changing these views is critical to creating conditions for healthy aging.

Efforts to address ageism should give consideration to issues of caregiving, as discrimination can be associated with those who live in institutional settings. Supporting caregiving options and placing positive value on aging and care for seniors is important to ensuring Canadians understand and appreciate the significant role seniors play in our society and that the appropriate mechanisms are in place to address physical and mental health issues associated with aging.

As we have seen earlier in this report, Aboriginal Elders are the cornerstone of their communities. Elders have the responsibility of passing on and carrying forward their wisdom, historical and cultural knowledge and language, and in playing an integral role in the health and wellbeing of their families, communities and nations. As a society we can learn from the Aboriginal view of Elders and the respect they are shown within their culture.

Canada would do well to consider how we can better recognize the value of seniors in our society. As well, all sectors have a role to play in creating further opportunities for individuals to participate in paid and unpaid activities, encouraging participation in civic duties by addressing barriers to social interaction, and supporting practices for early interventions, prevention and care.^{Footnote 12 Footnote 605}

Targeting the unique needs of seniors for health promotion

Seniors are a diverse population and not enough has been done to specifically target health promotion to them. As a result, the effectiveness of such programs among seniors has been limited. More applied research is necessary to develop and test interventions specifically targeted to seniors. As well, vigorous evaluations must be conducted to ensure that we are achieving the desired results. Although Canada has developed A Guide to Physical Activity for Older Adults, more is required to reach those who remain unaware of the benefits of physical activity as a part of healthy aging and to motivate and support seniors who may experience barriers associated with engaging in physical activity.

In addition to physical activity, healthy eating habits and nutrition can also help prevent illness and may reduce the necessity for medications and health care services over time.^{Footnote 180} The unique nutritional needs of seniors must be considered in all programs and policies. Oral health is also an issue as people age. As noted, poor oral health can lead to illness, disease and poor nutritional intake.^{Footnote 268 Footnote 505 Footnote 506} Awareness campaigns on the benefits of good oral health across the lifecourse that are specifically targeted to seniors would be of benefit, as would efforts to ensure dental health providers promote good dental health practices to patients of all ages. Steps can also be taken to better integrate oral health into public health frameworks.

Another important area requiring a targeted approach is mental health. As noted in Chapter 3, mental health issues among seniors can be misunderstood as a natural part of aging. While there are many policies, programs and initiatives in place in Canada around mental health, work to date has primarily been focused on younger adults. As we move forward, it will be important to ensure that mental health strategies have a seniors' component. Decision-makers need to: support research into effective seniors' mental health initiatives and anti-stigma campaigns; increase public education and professional training; and plan for an aging population with current and possible future prevalence of mental health issues that will require prioritization and investment of increased resources in seniors mental health. This is especially true of seniors in long-term care, where the majority of residents have been found to have a cognitive and/or mental health disorder.Footnote 206 Footnote 207 Footnote 388 With more seniors requiring long-term care in the future more effort is warranted, and the needs of subpopulation groups such as Aboriginal and immigrant seniors must be considered.

As well, given that the majority of seniors suffer from some type of chronic condition or other health problems, their need for adequate health literacy is vital in order to deal with daily issues related to those problems. All levels of governments have a responsibility to address healthliteracy challenges. Governments can apply plain-language principles to all health information and related services. There is also a responsibility to monitor effectiveness of these actions to ensure needs are being met. Gathering information on health literacy trends and issues is necessary to continue providing effective support for those in need.

Building and sustaining healthy and supportive environments

The need for healthy and supportive environments is at the core of healthy aging. All Canadians have a role to play in establishing and maintaining these environments so that their benefits can be felt across the lifecourse. Community planners and leaders, for example, can ensure opportunities exist for recreation, physical activity, civic participation, and safe and healthy transportation. Canada has had some success in developing communities that promote healthy aging by establishing the Age-Friendly Communities Initiative and the Age-Friendly Rural/Remote Communities Initiative. Still, many Canadian seniors do not have the support to age in the place of their choice due to a variety of factors such as finances, health status and lack of support and services. Support is especially needed for those living underserviced areas of the country. More research is required to measure the effectiveness of age-friendly initiatives and the extent to which they address the needs of different multicultural groups.

When seniors are living in unsuitable or unsafe environments, we must take action. This includes meeting language and cultural needs of seniors, as well as ensuring there are appropriate home care and longterm care options so that seniors can choose where they grow old. Our country has made progress on providing supportive environments for vulnerable seniors. In particular, legislation has been developed to protect the rights of all Canadians and to identify and address risks for abuse and neglect. On every level and at every stage of life, a healthy and supportive environment is imperative to health and well-being. We can and must do more to ensure Canada's seniors have the opportunity to thrive in healthy, safe and nurturing surroundings.

The inclusion of issues related to seniors in broad mental health plans and health promotion strategies is an important component of creating greater understanding and more supportive environments for seniors.

Developing a broad falls prevention strategy

There is a lot of information that exists on falls prevention for seniors in Canada and many initiatives that show promise and could be applied more broadly, but more evaluation is required. Addressing falls prevention is an area where more effort would clearly have an impact given that the majority of injuries to seniors are the result of falls.^{Footnote 148} Collaboration and intersectoral action is key to these efforts. Much has been done by various levels of government and on the part of professional organizations, however recognition of best practices and coordination of efforts is required. As well, new approaches to falls prevention need to be developed and robustly evaluated to ensure they are effective and reach those who are most at risk.

In addition, although a number of falls prevention guidelines have been developed, no broad national guidelines currently exist. Establishing such guidelines is important because they can set standards and highlight the need for early assessments, management of environments, removal of barriers and change behaviours. To be effective, national guidelines would need to include the clinical management of chronic and acute illness, involve knowledge of drug interactions and consider safe environments to address home safety issues. Complementary to these efforts would be broad education and awareness campaigns around risks for falls and falls prevention.

A way forward

As a society, Canada needs to incorporate healthy aging into public policy, continue to invest in and support programs that contribute to healthy aging and identify worrying trends among younger populations so that opportunities to make a difference to the future of healthy aging can be achieved across the lifecourse. It is clear that aging well benefits all Canadians by ensuring everyone has the opportunity to be active, engaged and healthy for as long as possible. The individual, family, community and societal roles highlighted in this report demonstrate that much can be done at every stage of the lifecourse to reap improvements in health and well-being. As our country faces an increase in the number of seniors, we need to determine how best to manage our efforts so that they are effective and meaningful. Solutions lie in what we can do for seniors now and earlier in the lifecourse to impact the health and well-being of seniors in the future.

Our efforts must be focused on addressing the persistent and emerging issues highlighted in this report that are affecting the health of Canada's seniors. At the very least, we must ensure that we are meeting the basic needs of seniors. We must also continue to monitor falls, injuries, and abuse and neglect to ensure that risks are being minimized. The mental health of seniors needs to be better understood and evidenced-based interventions that promote mental health and/or address mental health problems need to be shared and supported. As well, situations of abuse or neglect must be prevented to ensure that all seniors are protected from harm and live in safe and respectful environments. Actions must be balanced between targeted and universal programs and must be coordinated and multi-pronged to effectively address Canada's extensive geography, diversity and vulnerable populations. They must also be sustained over time and not limited to short-term results. Canada needs to build on existing initiatives and measure their impacts so we are better able to effect change. Understanding what makes some programs and initiatives work and then building strategies to move forward is the challenge we face if we want to continue to make progress on the health of seniors in Canada. Failing to take action will have an impact on all Canadians as they move through the lifecourse. As a society, we can build on our existing momentum and be a leader in senior's health and healthy aging to ensure that all Canadians are able to maintain their well-being and quality of life throughout their senior years.

– From Words to Action –

I wrote this report in order to build awareness of the state of Canada's aging population and to highlight the importance of taking action now to make a difference for this population – now and for the future. I wanted this Report to emphasize that aging should not be viewed as a negative phenomenon where a decline in physical and mental health is inevitable. Instead, aging should be valued and the quest for a long life in good health should be taken up early in the lifecourse. I also saw this Report as an opportunity to pay special attention to areas in which Canada is making progress.

Canada has helped secure significant health gains for our aging population through reducing and managing the prevalence of infectious diseases, understanding the factors that influence health, and investing in social infrastructure. Still, there are many worrying and persistent issues that can reduce the effect of these successes. Further, aging is a global challenge that presents unique opportunities for us now. As a society, Canada can build momentum and be a leader on the world stage in the area of healthy aging if every sector of society does their part.

American writer Frank A. Clark once said "We've put more effort into helping folks reach old age than into helping them to enjoy it." Our goal to ensure all Canadians have the opportunity to age well can only be fully achieved if we undertake a shift in our perception of aging to recognize it as a time in life deserving of individual celebration and society-wide appreciation.

In my capacity as Chief Public Health Officer, I will:

• Work with my federal colleagues and other sectors to promote and develop policies that support healthy aging;
• Monitor the health of Canada's aging population and improve data and knowledge-sharing in this area;
• Work with all counterparts to ensure the health care system is flexible enough to respond to the diverse needs of seniors and an aging population;
• Ensure work continues to change attitudes about aging and acknowledge the extensive contributions made by Canadian seniors through supportive environments;
• Continue to invest in and support public health initiatives in seniors' health and efforts to address their basic needs; and
• Ensure seniors are included in all efforts made to achieve healthy aging in Canada so that their experience and wisdom can benefit all Canadians in the years to come.

— Dr. David Butler-Jones

 

Textbox 5.1 Frank and Marie's story

In the coming years, Canada will experience a demographic shift that will result in a large population over the age of 65. How Canada, as a society, addresses this change will have a significant impact on the quality of life for many of our seniors.

Let us consider a fictional couple, Frank and Marie. They live in a newer neighbourhood in a mid-sized Canadian city. At 79 and 74 years of age respectively, Frank and Marie are lucky that they still live at home in the house they purchased 12 years ago. Their children and grandchildren live nearby and provide a lot of support, but they have busy lives and Frank and Marie do not like to call on them too often. The couple also receives support from several of their doctors. On the advice of their family physician, Frank has just purchased a brand new walker so that he is able to get some exercise, fresh air and participate in the dayto- day activities of shopping, family celebrations and outings through the seniors' group in his community.

Frank and Marie live in a two-storey townhouse, which makes mobility an issue for Frank. The couple cannot afford to move into more appropriate accommodations nor can they afford to add a lift for their stairs to safely move between levels. The walker must be used at all times as Frank's balance is not good due to a series of minor strokes. On this particular day, Frank and Marie decide to run some errands and, after much struggle, both Frank and the new walker are on the main floor heading out the door. Once out into the neighbourhood, there are only streetlights at the intersections and no sidewalks until they reach a main road. Even then, the sidewalks are cracked and uneven making it difficult to see clearly and move the walker forward. If the couple are to walk side by side, Marie must walk on the road.

After several rests they make it to the small shopping centre near their home, but it has taken much longer than anticipated. The couple shop for necessities, pick up prescriptions and take a moment to sit for a cup of tea before it is time to begin the trek back. Once home, they are both exhausted and from start to finish the outing has taken the better part of four hours. Frank and Marie wish walking in the community and running errands were a whole lot easier and dread the thought of repeating this exercise in inclement weather.

What if…

The city had better information and data that they could have accessed for planning purposes? Imagine if city planners had known that almost 57% of the residents in the new development were going to be over 50 years of age. Perhaps this would have had an impact on the types of lighting, sidewalks and housing styles developed in the neighbourhood. Accessible public transportation may have been more readily available so that Frank and Marie would not have to walk under dangerous conditions. And the local community centre could have considered establishing age-appropriate exercise programs for local residents to help with balance and strength issues.

What if…

Frank and Marie had a single point of contact to help answer questions and navigate "the system." Imagine if Frank had been assigned a caseworker who had been able to help the couple apply for a grant to have a lift added to the stairs in their home, or made them aware of door-to-door transportation for the disabled and helped them fill out the appropriate paperwork needed to access this service. Or if their home had been designed so that at least one bedroom and a bathroom were available on the ground floor.

What if…

There were supports in place to ensure that Marie, who provides care to Frank, does not put her own physical and mental health at risk by caring for her husband. Imagine if Marie had access to a support network and respite care to allow her to have balance in her own life. These changes would give Frank and Marie a better quality of life and the ability to more easily participate in their community.

Communities that are more aware of population needs can better accommodate age-specific requirements and priorities. This would result in more efficient use of resources and, ideally, more effective collaborative initiatives to address the needs of residents.