Not Dead Yet: A Manifesto for Old Age

Most observers and agencies concerned with forecasting future life expectancy used to predict that it would soon reach a plateau, when the gains from preventing early death had been consolidated. Then – or so they told us – the ageing process would settle down and we would see what it really was, stripped of early preventable deaths. But this never happened. Most evidence suggests that life expectancy within the UK and in other developed countries is still going up at the rate of about two years for each decade that goes by.

What is more, there is some evidence that it is speeding up. Studies in Sweden, where statistics have been kept since 1860, show that the increase in the age of the oldest person, far from slowing down towards a plateau, has been accelerating over the last 20 to 30 years. The UK government Actuary’s Department predicted recently that there could be a million centenarians by 2074.3 (#ulink_a5ddeae4-0884-50bd-83c5-d3a449005876) We are, in short, getting older and older.

Of course, these figures are based on the most optimistic life expectancy trends. If there is a serious flu pandemic, a late blossoming epidemic of BSE or a health decline due to obesity, it will not be quite so dramatic. Even the government actuary said the likely figure was nearer 350,000, which is still huge compared with the 10,000 or so centenarians now living in the UK. But people in their thirties now have a one in eight chance of living to be 100, and thousands could make it to 110, or even older.

There is still an academic disagreement about exactly what is going to happen. Emily Grundy, professor of demographic gerontology, has warned that the government has seriously overestimated, arguing that improvements in mortality rates in Denmark and the Netherlands have now stopped.4 (#ulink_c381eb31-cf2f-5a3e-a7e6-b760c9392706) On the other side is the British Longevity Society’s Myrios Kyriazis, who argues that the government is underestimating the numbers of us likely to reach 100. Like some American scientists, he believes that ‘stem cell technology could completely transform how long future generations live by continually replacing our diseased organs, allowing us to surpass a thousand years.’5 (#ulink_2fa1f3bd-1381-5704-bea3-2e87fad7ffbf) There are more bizarre predictions, especially among the futurist and IT community in the USA, which suggest we will soon be living to 5,000 years.

Similar arguments are going on around the world. There are already 25,000 centenarians in Japan, where there is a special ‘Respect the Aged’ day (19 September), when the latest group of centenarians is presented with a silver cup and a letter from the prime minister. Sri Lanka has an average life expectancy of 74.4 years, and Asian countries generally are shooting up the age expectancy tables, while Africa is showing a decline in age expectancy. Zimbabwe has a terrifying life expectancy of just 37.3 years and Botswana’s is 35.5 years. These are results of a mixture of terrible governments, civil war, malaria and HIV/AIDS. But in most nations the trend is definitely upwards. The real question is going to be what this will mean.

If people live to 100 but still retire at 65, they will be retired – and presumably drawing a pension – for almost as long as they have been working. Some public sector occupations allow people to retire at 60 or even 55. I look more closely at the financial implications of getting older in a later chapter, and certainly pensions will affect how we live in retirement, but the real question is how we will judge success in our old age – and how policy-makers will define an old age well lived on our behalf.

There is a growing, though reluctant, consensus that we will have to work longer, which will postpone the age when old age officially begins. We will probably extend our working lives into our seventies or even eighties, though this may be done part time. But we will take those decisions partly based on the kind of older life we aspire to have – and the truth is that most of us seem likely to find ourselves there without having thought much about that. There is a paradox: as a society, we seem to be fearful of getting very old, yet at the same time want more and improved healthcare to keep us going longer. We fear retirement and worry about the financial resources, yet we resist working longer. We dare not, sometimes, even look too far into the future for fear of meeting ourselves there. It is a paradox that, in some ways, makes effective policy-making far more difficult.

‘Ageism is worse than racism or sexism because there is so little recognition that it is wrong,’ said Sohan Singh, 66:

There is no commission fighting for your rights … Ageing is a little bit like disability in that a lot of the problems are socially created. People may have more or slightly different needs as they get older, but the key thing is to keep people as human beings functioning as fully as possible. It is society that imposes on you a sense that you are old. I feel pretty young.6 (#ulink_7b3f0c16-0dda-589e-b494-0d520bf68f5d)

In 2006, the journalist Stephen Moss interviewed eight centenarians in the Guardian, finding out about them in the pages of local newspapers.7 (#ulink_522adb1e-663f-5e45-9a37-618944ab6b3b) He told their stories extraordinarily tenderly and respectfully. But there was a note of surprise in what he wrote, as if he never expected to find what he found. In his interviewing, he was left ‘with one abiding impression: that they had been sustained by love – of parents, partners, and children. Most of all, partners, some long dead.’

It was, he said, ‘much better than the usually quoted epigraph for extreme age – Shakespeare’s “second childishness and mere oblivion, sans teeth, sans eyes, sans taste, sans everything”.’

He did not find much in the way of regrets – ‘the survivor’s story was, at heart, a happy one’ – though Moss felt that they did not always seem as happy as they said they had been. On the other hand, he wrote: ‘They exhibited a stoic calm, an unshakeable acceptance of the hand that life had dealt them.’

They also lived for today. Harry Walker was asked what targets he still had in life, and replied:

There aren’t any. You live day by day. I wake up in the morning and make sure that my legs are still working. I don’t think I’m much trouble to the staff. I regularly go for a walk around the grounds. It’s getting a bit harder, but I’m still living.8 (#ulink_5cbf5e90-6f15-5886-b8e6-1800d8882efc)

These centenarians, on the whole, despite some forgetfulness, some dementia, a stroke, various frailties and ailments, thought of themselves as relatively strong, healthy, and in good spirits – and one was still driving her car. Not a sad tale at all. It was a surprising story because society fears extreme old age, even fears the thought of so many very old people in our society.

We have two ways of looking at ourselves when old that are contradictory, said Mary Riddell in the Observer shortly after these interviews.9 (#ulink_f56f5726-1c84-5c0f-9719-ca9aff9be143) Are we ‘British pensioners with double cataracts and leaking roofs’, or are we the Greek goddesses to whom immortality is indispensable? Again, this contradiction seems to allow the treatment of older people in ways that we would never allow for someone younger. Mary Riddell cited the case of the British actors Francesca Annis and Ralph Fiennes. They had been together for eleven years; she was then 61, he a mere 43. The public was asked by the media to forgive Fiennes’s affair with a singer on the grounds that Annis is ‘so old’– and cheating on a long-term partner is clearly all right if she is old. Yet, if we are to live to 100 or more, 61 is barely middle age.

As for couples who are both elderly, they get treated with the greatest contempt. Like Richard and Beryl Driscoll, both 89 and married for 65 years, who were separated for seven months because Gloucestershire social services refused to pay for Mrs Driscoll to be in a care home alongside her frailer husband, even though she was blind.10 (#ulink_88e4dd06-ecdd-57b3-ba4a-90e70b15b3da)

The question that Mary Riddell asked – What is all this extra life for? – is really the question at the heart of this book. Instead of allowing a gradual state of impermanence to take over – short-term marriages and relationships, constant cosmetic surgery, new ideas and yet more change – older people could call a halt to some of this, and ask the public at large to think again. But all this requires a real debate about what old age is for. Until we think about that a little more deeply, we will carry on treating older people as second-class citizens, and none of this will make much sense. And behind that question lies the issue of how we judge when old age is fulfilled and worthwhile, that state of being and aspiration which policy-makers call ‘healthy life expectancy’.

Healthy life expectancy

But here there is a major problem. If life expectancy is rising, there is some evidence that healthy life expectancy – the years we spend well – is falling as a proportion. This is a vitally important discrepancy, if we believe it, because it would imply that more of our extra years will be spent sick and disabled in some way or other. That is the view of the Department of Health and the Office of National Statistics (ONS). But the ONS, at least, concedes that ‘concerns remain about the reliability of subjective assessments … They are known to vary systematically across population sub-groups … [reflecting] differences in ill-health, behaviour, expectations and cultural norms for health.’

When the government responded to the 2005 report on ageing by a House of Lords select committee, they didn’t mention these nuances. ‘Although healthy life expectancy is increasing, it is doing so more slowly than overall life expectancy,’ they wrote.

This irritated the select committee, which responded a year later by saying: ‘this statement is made without any suggestion that it is either a cause of concern or that any remedial action is needed. It flies in the face of the claim by Professor Ian Philp, the National Director for Older People’s Health, in a report published in November 2004, that “health in old age is improving and should continue to improve”.’

So which is right? The National Director for Older People’s Health? The Director of Research and Development for the Department of Health? The Office of National Statistics? How is the ordinary person supposed to make sense of this if three government departments face three different ways? Should we not be saying that we need to know, and that real research needs to be done, with longitudinal studies looking at people’s health from the point of view both of experts and of older people, so that we know a little better what we are letting ourselves in for with all this increased life expectancy? Perhaps then we might make better decisions about it.

The ONS also gave an explanation, of sorts, for the apparent widening of the gap between life expectancy and healthy life expectancy. They say that people are getting more sensitive about their health, or have adopted higher expectations about their health, so that conditions that wouldn’t have seemed like problems a few years ago are now considered to affect daily living. It may be that economic incentives are persuading people to think of themselves as ill more readily. There are theories, too, that improvements in survey methods have led to the discovery of a growing proportion of health problems.

Diseases are also being detected earlier, especially chronic diseases. People with ill-health are living longer. Illnesses and injuries that used to be resolved by dying are now more often managed instead. Short deadly illnesses, such as infectious diseases, have been replaced by diseases which are chronic and take a long time to resolve, if they ever do. Any of these could give the impression that healthy life expectancy was going down.

There is no doubt that feeling they are suffering from ill-health – even if they might be objectively no sicker than previous generations – would be quite enough to undermine people’s quality of life and their sense of well-being. The question is what we can do about it. In their evidence to the House of Lords Committee, the Royal College of Physicians in Edinburgh warned that ‘disability may be postponed but it cannot be eliminated’. That is obviously true. Nor can the adverse effects of disability be eliminated. But the question is whether it is possible to increase disability-free years in the UK, as they have in the United States, and how to reduce the adverse effects of disability on older people’s lives?

At the moment it is hard to imagine how we can take on Professor Sir John Grimley Evans’s advice to the House of Lords Committee on ageing. He said: ‘Live longer, die faster’. That may be a wise piece of advice. But how do we put it into action, short of killing ourselves, something most of us don’t want to do? And that’s the stuff of another story, in another chapter.

If there is really an increase in ill health, nobody has ever explained it or measured it. The questionnaires that ask people to assess themselves on ‘vague’ concepts like health, while they may enable comparisons to be made with replies to the same questions from different groups or different areas, are not reliable enough to give us objective measures of health in old age. Perhaps the real question is whether the researchers are using sensible categories – and who, anyway, is deciding how people feel? Who is defining healthy old age?

Different definitions

This business of who decides if we are having a successful old age is important – and it is no small problem. One of the issues that has come up over and over again when I was researching this book has been the difference of approach between the ‘experts’ and the lay people, particularly those who are in fact old themselves, and have some experience to add to the picture. Behind that is the context in which these figures are generated.

We seem to have become caught in a technocratic idea in which the optimization of life expectancy together with the minimization of physical and mental deterioration is the only thing that healthy old age is all about. So the literature tends to focus on the absence of chronic conditions, on risk factors for disease, on levels of physical functioning – judged by others, rather than by older people themselves – and the extent to which their cognitive functioning is impaired. Alternatively, they may be quite healthy by objective standards and still beset by what Diana Athill describes as something more fundamental:

Our main trouble is that what he calls his ‘weakness’ – the dreadful draining away of energy from which he suffers – goes so deep that he has lost interest in almost everything.11 (#ulink_441e8ebf-768e-57c8-bc7b-37ab79d35a8b)

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 (#ulink_5cde15c4-ba37-5394-81c7-c8df24635837) 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 (#ulink_3bc0945f-1711-54b8-8739-e74cbfb886b8) 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 (#ulink_59024819-4fed-5cd7-bdf3-e406785a6f88) 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 satisfaction and well-being

But it is even more complicated than that. Two other American gerontologists, Christopher Callahan and Colleen McHorney, took part in an academic retreat in Indianapolis to discuss successful ageing, and found an even wider difference in how ‘experts’ define success.15 (#ulink_8a2d1adc-83fa-5565-988e-76064a2f166d) What emerged was that, for some scientists, health was the main – if not the only – definition of successful ageing. But for others it was something quite different and quite complex.

‘To a humanist, health may be less relevant than realizing one’s ambitions or helping a fellow human being to achieve his or her ambitions – neither necessarily requires health or longevity,’ they wrote. ‘If someone fulfilled the dreams of a nation, yet died of lung disease at aged 50 years, is that successful ageing?’

The narrow definitions of successful ageing may be inadequate, they said, but ‘we may not have the tools to embrace the broader, more complex perspective’. The problem is that scientists, with their biomechanical, biomedical models, are not very good at complexity, and any discussion with older people – humanist or not – suggests that the scientific model is simply inadequate.