Executive summary: The Chief Public Health Officer's Report on The State of Public Health in Canada 2010

Executive Summary

This is the Chief Public Health Officer's third annual report on the state of public health in Canada. The report examines the state of health and well-being of Canada's seniors, including factors that positively or negatively influence healthy aging such as falls and related injuries, mental health, abuse and neglect, social connectedness, healthy living, and care and services. From this examination, priority areas for action are identified where Canada can further foster optimal conditions for healthy aging.

Canada's experience in setting the stage for healthy aging

Given that individuals and populations are growing older, all Canadians have a vested interest in creating and maintaining opportunities to age well. Healthy aging is an ongoing process of optimizing opportunities to maintain and enhance physical, mental and social health, as well as independence and quality of life over the lifecourse.

A healthy aging approach considers factors impacting seniors, including earlier events and experiences in life that can influence health and quality of life as individuals age. The approach envisions a society that supports and values the contributions of seniors, appreciates diversity, works to reduce health inequalities, and provides opportunities for Canadians to maintain independence and quality of life and to make healthy choices across the lifecourse.

From a public health perspective, consideration of the lifecourse approach can help to ensure healthy aging is considered in the context of the entire lifespan rather than merely as a late-life phenomenon. It can also facilitate the identification and interpretation of trends in the health of populations, as well as the links between time, exposure to a factor or combination of factors, experiences and later health outcomes. In doing so, it allows for the development of appropriate interventions, programs and policies across the lifecourse.

A brief historical overview of some of Canada's many successes and challenges in setting the stage for healthy aging shows that past efforts have positively influenced the health of seniors over time. It also points to some broad challenges that lie ahead – like the continued prevalence of unhealthy lifestyles and chronic diseases.

As Canada's aging population grows, the need to identify and integrate opportunities to address these challenges and to promote healthy aging will become increasingly apparent. However, answering this need effectively will require widespread understanding that healthy aging is not simply about seniors; it is an issue that affects all age groups and generations. In order to ensure Canadians are healthy for as long as possible, opportunities must exist at all stages of life to have, maintain and enhance good physical, mental and social health.

The health and well-being of Canadian seniors

Over the past 30 years, the proportion of the population made up of those aged 65 years and older has increased from 9% of the population in 1978 to 14% in 2008. By 2050, seniors are projected to comprise 27% of the Canadian population. The life expectancy of Canadian seniors has also been steadily increasing over time. In 2006, seniors who turned 65 years of age could expect to live an additional 20 years. However, the increase in life expectancy for Aboriginal peoples continues to lag behind that of other Canadians and, among the general population, women continue to outlive men. The three main causes of death for seniors in 2006 were circulatory diseases, cancers and respiratory diseases. Among the less frequent causes of death were those due to injuries, with 41% of all injury related deaths being due to falls.

In 2009, chronic conditions were widespread among seniors, with 89% living with at least one chronic condition and many experiencing multiple chronic conditions. One in four seniors aged 65 to 79 years and more than one in three of those aged 80 years and older reported having at least four chronic conditions, including arthritis or rheumatism, high blood pressure, diabetes, heart disease, cancer, stroke, Alzheimer's disease, cataracts, glaucoma, mood disorder and anxiety disorder.

Falls are the most common cause of injuries among seniors in Canada, with an estimated one in three of those over the age of 65 years likely to fall at least once each year. Risk factors for falls among seniors include chronic and acute illnesses, mobility or balance issues, medications and cognitive impairment. While most eventually heal from their injuries, many never fully recover and may experience chronic pain, reduced functional abilities, curtailment of activities, institutionalization and even death.

Unhealthy weight is a consideration in the health of seniors. As in all age groups, obesity can increase the risk of poor health outcomes in seniors. Of note, 29% of seniors were considered obese in 2008 and this number is rising. Being underweight can also place seniors at risk of poor health, with outcomes ranging from malnutrition and osteoporosis to mortality.

Individual behaviours play an important role in the health of seniors. For example, physical activity and proper nutrition can help prevent illness, contribute to maintaining independence and result in positive mental health outcomes. The fact that the majority of seniors in Canada are physically inactive and do not eat a balanced diet is therefore cause for concern. The rates of smoking and alcohol use by Canadian seniors are lower than for younger cohorts, yet 6% to 10% of seniors exhibit problem alcohol use.

Use of medications can have both positive and negative health outcomes for seniors. When surveyed, over three-quarters of Canadian seniors living in private households reported using at least one medication (prescription and/or over-the-counter) in the past two days and 13% had used five or more different medications. These numbers were even higher for seniors living in institutions (97% and 53% respectively). With such high rates of medication use, it is disconcerting that approximately half of prescriptions taken by seniors are not used properly. This may reduce the medication's effectiveness or endanger the senior's health.

Most seniors are satisfied with their lives in general (97%) and feel that they have at least very good mental health (70%). However, an estimated 20% of seniors living in the community and 80% to 90% of seniors living in institutions have some form of mental health issue or illness. Sometimes mistaken as a normal part of the aging process, these issues often begin in early life, where negative experiences and circumstances can contribute to reduced mental health over the lifecourse. However, later life transitions or conditions can also pose mental health challenges.

Among the most prevalent mental health issues affecting seniors are Alzheimer's disease and other dementias, depression and delirium. Dementia impacts approximately 400,000 Canadian seniors, with numbers expected to double within 30 years. Seniors who live within the community tend to have lower rates of diagnosed depression (1% to 5%) compared to seniors living in long-term care facilities (14% to 42%). A recent study of Canadian seniors living in residential care found that 44% had either been diagnosed with depression or showed symptoms of depression without diagnosis. For senior women the prevalence of Alzheimer's disease and related dementias and depression is higher than senior men, although the reasons for this are not known. Delirium (also known as acute confusion) is another mental health condition found most commonly among seniors. In many cases, delirium is not recognized or is misdiagnosed. While the number of seniors who experience episodes of delirium is unknown, it is thought that 32% to 67% of seniors with the condition go undiagnosed.

Low-income can impact negatively on health. Seniors living in low-income may be unable to access nutritious foods, have difficulties paying their mortgage, rent or utilities, be unable to complete necessary repairs on their homes, and may have limited access to transportation and non-insured health services. Over the last 30 years, the number of seniors living in low-income has declined substantially from 29% in 1978 to 6% in 2008. The Luxembourg Income Study has credited Canada's pension system as being a major factor in the shift from Canada ranking as a nation with one of the highest occurrences of low-income seniors in the late 1980s to one of the lowest in the mid-2000s. However, low-income among some seniors persists. Aboriginal seniors and immigrant seniors – especially those living alone – continue to experience unacceptably high numbers of their populations living in low-income.

The social well-being of seniors can also play a part in healthy aging and is influenced by a number of factors, including satisfaction with life, social connectedness with others, and whether or not seniors are productive and active within their communities. Those lacking social support networks can experience feelings of loneliness and isolation and lack a sense of belonging. In 2003, more than 60% of seniors who reported a strong sense of community belonging also reported good health.

Life circumstances such as living arrangements, retirement and geographic proximity to family can play a role in seniors' level of social connectedness. Those who remain connected through activities such as organizational involvement or volunteering can maintain a sense of purpose and belonging. In 2007, more than one-third of seniors volunteered in some capacity and, on average, contributed more hours annually than any other age group.

Retirement can be a significant change for many individuals and can influence a seniors' standard of living, daily activities and social networks. Those who reported good to excellent health entering retirement also indicated an increase in life satisfaction post-retirement. However, not all Canadians retire when they reach seniors status and some choose to return to the labour force after retirement. Over the last two decades, there has been an increase in the number of seniors participating in the paid workforce (11% in 2009 versus 7% in 1990), with men more than twice as likely to do so as women.

Canadians, regardless of age, occasionally depend on social networks of family, friends and neighbours to help with errands and daily tasks. In 2003, 29% of seniors aged 75 and older reported receiving help from someone outside their home for transportation or running errands. And while some seniors are recipients of assistance and care, many are also caregivers. In 2007, 16% of caregivers aged 65 to 74 years and 8% of caregivers aged 75 years and older provided some form of unpaid/informal care to another senior.

Having access to appropriate care and services is important for all Canadians in order to maintain and improve their health and well-being. For seniors, this can include a wide range of resources and support such as physician services, in-home care and social support. In 2003, 15% of seniors' households reported receiving either formal or informal care. Of those requiring intense, ongoing care that cannot be provided at home, most are likely to reside in long-term care facilities.

Factors affecting seniors' access to care and services include availability of resources and health information, awareness regarding community health services and inclination to inquire about these services. Transportation issues (including costs associated with travel) and physical mobility issues can also limit seniors' access to care and services, as can financial concerns stemming from the costs associated with items such as prescription medications and assistive devices. Seniors who are Aboriginal, part of an ethnic minority group or who are new to Canada may face additional barriers to accessing proper care and services, such as conflicting cultural values or language barriers.

Health literacy is also an issue. In order to manage chronic conditions or other health problems and to make healthy lifestyle choices, seniors need to be able to read and interpret nutrition labels, follow dosage directions for medications and understand health information and instructions. Of concern, only one in eight adults over age 65 has the adequate health literacy skills required for many basic health-related decisions.

Physical, psychological and financial abuse or neglect can greatly impact the well-being of seniors. For example, those who have experienced abuse have been found to have higher rates of depression and anxiety than those who have not been subjected to abuse. While it is difficult to know the extent to which this problem exists in Canada, available research indicates that between 4% and 10% of seniors experience one or more forms of abuse or neglect from someone they rely on or trust. Certain sub-groups of seniors, including women, the frail, and those who have a cognitive impairment or physical disability, are more likely to experience abuse or neglect. Physical illnesses and disability coupled with dependency and the need for greater care also place seniors at higher risk.

Setting conditions for healthy aging

Opportunities to prevent illness and promote health can be introduced through initiatives and interventions at all stages of the lifecourse. Making progress on the key areas of concern for seniors covered in this report – falls and related injuries, mental health, abuse and neglect, social connectedness, healthy living, and care and services – necessitates consideration of best practices, strategies and approaches that demonstrate what can be accomplished in these areas and highlight where more work needs to be done. An examination of underlying conditions, such as meeting basic needs and having supportive age-friendly communities and environments, is also necessary when considering actions that support healthy aging.

Having adequate income is fundamental to healthy aging and Canada has been effective in reducing seniors' poverty mostly due to government income programs and public pensions that offer widespread eligibility. However, more can be done to support subpopulations of seniors living with incomes below the after-tax low-income cut-offs. It is also important to consider that all seniors can be disproportionately vulnerable to an interruption in having their basic needs met, especially during or after emergencies. During emergencies seniors can also play an important role as volunteers and caregivers and by contributing specific skills and knowledge in order to help others meet their basic needs. In Canada, multi-sectoral and partnership work is underway to address the role of seniors and their vulnerability during these critical events.

Being able to age in a place of choice is another significant component of healthy aging. While most Canadian seniors report preferring to live in their own homes, evolving circumstances may encourage or force seniors to move. Programs that offer home assistance or that pay for home adaptations can help extend the amount of time low-income seniors can live independently and in their own homes. The age-friendly cities approach creates healthy aging environments that are of benefit to all age groups and levels of ability by incorporating factors such as: universal design; accessible spaces; available/accessible transportation and housing; social and economic opportunities; and community support and access to appropriate health services. Canada has played a leading role in creating age-friendly environments, and has also created a guide for rural and remote communities.

Among the key areas covered in this report is falls and injury prevention. There are five approaches detailed that can contribute to reducing falls and preventing injuries, or can mitigate the impact of these events on the health of seniors, including: developing falls prevention guidelines; increasing broad education and awareness programs; supporting healthy behaviours and choices; preventing falls by creating safer environments; and addressing driving-related injuries. While guidelines do not directly prevent falls, setting practices, standards, and management and assessment applications can contribute to overall falls prevention. So too can appropriate educational programs and awareness campaigns targeted at practitioners, community members, families and seniors to increase the understanding of the risks and consequences of falling and the benefits of prevention strategies. Initiatives that focus on addressing risk factors such as exercise programs to improve balance and strength, appropriate use of assistive devices, and drug management practices have had some success. For injury prevention due to motor vehicle crashes, efforts to address seniors' road safety involve raising awareness of safe driving practices, as well as conducting research to identify, analyze and examine the issues around safe motor vehicle operation by seniors.

Positive mental health is an important aspect of healthy aging that should be supported throughout the lifecourse. Efforts to improve mental health and well-being that target behaviours and other socio-economic determinants of health can make a difference, as can initiatives that create and support more inclusive communities and environments. Stigma related to mental health must be addressed given the adverse impact it can have on health and social outcomes – especially for seniors who may experience stigma associated with both old age and having a mental health issue. Increasing awareness of mental health disorders and the importance of good mental health can help in this regard. While some anti- stigma programs undertaken in Canada show promise – including the relatively recent launch of the Mental Health Commission of Canada's anti-stigma/anti-discrimination campaign – more can be done to specifically address this issue for seniors. The establishment of knowledge networks has had some success in sharing practices, guidelines and research in areas of seniors' mental health that can lead to more effective, targeted interventions. A Canadian initiative to support research and share information on this issue would complement these efforts, as would the development of broad mental health strategies for all Canadians.

The abuse and neglect of seniors is often a hidden, underreported issue with limited data and information. Interventions such as laws and policies are necessary for the protection and health of all Canadian seniors. Although criminal, family violence, adult protection and adult guardianship laws do protect seniors from abuse and neglect, their success can be hindered by a lack of awareness and a reluctance to pursue action under these laws. Prevention involves: increasing the capacity of social and health professionals to identify abuse and find appropriate supports; raising awareness among seniors, their families and others about the issue of abuse and neglect and about existing supports; and informing seniors of their rights and actions. The goal of education and awareness programs is to reduce stereotyping and age-based assumptions, as well as to target a range of audiences. Supporting these efforts includes creating knowledge and information networks to identify current and emerging issues, develop strategies and frameworks, and share information and best practices. And it requires coordinated community-based efforts that map resources, develop common understanding of this issue and build communication and service networks.

Social connectedness directly influences health and well-being, and initiatives that address social isolation and promote a sense of community and belonging are of importance across the lifecourse. For seniors, social engagement and minimizing marginalization can depend on access to community facilities, transportation and affordable activities, as well as on having a meaningful role in society. Part of valuing seniors is recognizing the important contributions they make to society. Among those contributions is volunteering, which can have positive health outcomes for seniors in two ways: as recipients of volunteer efforts associated with informal care networks and other activities that include and involve seniors; and as active participants in volunteering, working and interacting with others and providing many valuable volunteer hours. Establishing a greater understanding of what motivates seniors to become involved in volunteering will help with future efforts to promote this activity among seniors, maintain their involvement and recognize their valuable contributions in this area. Enhancing opportunities for social connectedness also involves challenging negative views of aging (ageism). Intergenerational initiatives between seniors and youth, such as those in some First Nations, Inuit and Métis communities, can promote the value of aging by recognizing the knowledge and expertise found among seniors and initiating and strengthening respect for the contributions they make to society. These initiatives are often rewarding for all participants and can help to bring balance to the broader community.

Engaging in healthy living practices can improve, maintain and enhance health and well-being. Across the lifecourse, creating conditions for individuals to chose and behave in ways that support healthy lifestyles (such as staying physically active and eating well) and discourage choices and behaviours that are detrimental to health (such as smoking and excessive drinking) contributes to healthy aging. Education and awareness about the benefits of active living specifically targeted to seniors can help to challenge assumptions about age and capacity. Social programs that encourage seniors to cook for themselves or dine with others can promote better eating practices and contribute to social connectedness. Efforts to promote healthy behaviours, such as physical activity guidelines and smoking cessation initiatives, are of benefit to all age groups but would be most beneficial to seniors if they acknowledged and addressed the unique needs and circumstances of this population. Further, encouraging healthy behaviours such as physical activity can only translate into action if seniors encounter environments that are safe, barrier-free, accommodating and affordable. Health literacy is an important issue among seniors, as those who lack health literacy may not have the skills necessary to make basic health decisions and to access and accurately assess relevant health information. Addressing health literacy challenges involves a multi-stakeholder approach to ensure at-risk seniors receive and understand the information they need to make healthy choices and to access appropriate programs and services. Initiatives to promote and offer opportunities for lifelong learning can also contribute to these efforts.

Quality care and accessible services are another important component in achieving healthy aging. In Canada, much caregiving is provided through informal channels. Some progress has been made to support to informal caregivers which include various tax deductions and credits, and the introduction of programs such as the Employment Insurance Compassionate Care Benefits Program that provides financial support to caregivers who require time away from their jobs to take care of gravely ill family members or friends and has also made inroads in supporting caregivers though work flexibility arrangements. While these efforts contribute to the support of informal care and caregivers, more can be done such as recognizing and acting on the need for further information about who is giving care, what the impacts are on the givers and recipients of care, the supports/information caregivers require to continue in their vital caring role, and the effectiveness of the care being delivered when many remain untrained.

Also important is the need to address challenges in the continuum of care along a range of care needs – from home care to palliative care. This includes ensuring seniors' access to affordable supportive housing with appropriate levels of care, tackling issues of unmet needs for care and services, working through transitions between levels of care. When devising efforts to address these issues it is important to recognize that an integrated strategy within a Canadian context may be difficult to coordinate given the federal/provincial/territorial environment within which it would be required to operate.

Toward healthy aging

Healthy aging benefits all Canadians. Canada has made progress in creating the conditions necessary for healthy aging, resulting in a vibrant aging society and one of the highest life expectancies in the world. However, as Canada faces a larger older population, efforts made toward healthy aging need to be managed in more effective and meaningful ways. Further, the efforts need to focus on what can be done for seniors now and for all Canadians earlier in the lifecourse in order to impact the health and well-being of seniors in the future.

Moving forward requires building on existing initiatives and measuring their impact so positive changes can be better realized. Understanding what makes some programs and initiatives successful and building frameworks for effective strategies will also be necessary to continue to make progress on the health of seniors in Canada.

Six areas for action where Canada can create conditions for healthy aging include:

• 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.

Progress in these areas will take strong federal/provincial/ territorial collaboration and will require participation from all sectors of Canadian society. Failing to take action will have an impact on all Canadians as they age. As a society, we can build on our existing momentum and be a leader in seniors' health and healthy aging to ensure that all Canadians are able to maintain their well-being and quality of life throughout their senior years.