Healthy Ageing

A Capability Approach to Inclusive Policy and Practice

Christine Stephens, Mary Breheny

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781317272991
• Edition: 1
• Topic: Psicología
• Subtopic: Historia y teoría en psicología

What does it mean to age well? This important new book redefines what 'successful' ageing means, challenging the idea that physical health is the only criteria to gauge the ageing process and that an ageing population is necessarily a burden upon society.

Using Sen's Capability Approach as a theoretical starting point Healthy Ageing: A Capability Approach to Inclusive Policy and Practice outlines a nuanced perspective that transcends the purely biomedical view, recognising ideas of resilience, as well as the experiences of older people themselves in determining what it means to age well. It builds to provide a comprehensive response to the overarching discourse that successful ageing is simply about eating well and exercising, acknowledging not only that older people are not always able to follow such advice, but also that well-being is mediated by factors beyond the physical.

In an era where ageing has become such an important topic for policy makers, this is a robust and timely response that examines what it means to live well as an older person. It will be hugely valuable not only for students of gerontology and social care, but also professionals working in the field.

1
Healthy Ageing

Healthy ageing is the ideal trajectory from birth to death. As we reach older age, physical changes are inevitable, but it is not simply the effect of these changes that makes ageing healthy or unhealthy. An older person may have many years of incapacity as they decline slowly towards death. Or they may be well and functioning happily until a very rapid shift into loss of life (the ideal of dying suddenly in one’s sleep while in the midst of life). It is the latter trajectory that many people desire and the aim of promoters of healthy ageing. However, the question raised by this recognition of the ideal trajectory is, what is health?

Concerns regarding population ageing have brought ageing and health under additional scrutiny. These concerns have coincided with new perspectives on healthy ageing, captured in descriptive phrases such as ‘successful ageing’, ‘active ageing’, ‘positive ageing’, or ‘ageing well’. In this chapter we discuss the context of healthy ageing in the 21st century, including an ageing population and current policy discourses of ‘successful ageing’. Critiques of these influences lead us to examine the effects of dominant discourses that view ageing as a problem to be solved and conflate ageing with poor health. Together, these discourses construct ageing as a social problem which will increase the need for health care and make unreasonable demands on the public purse. This chapter describes alternative ways of understanding health for older people and introduces the Capability Approach as a socially based and ethically oriented way to understand older people’s health.

Ageing population

The world’s populations are ageing. Population ageing means that there is both a rise in the average age of the population as well as a growing proportion of older people within populations. According to the WHO (World Health Organization, 2012), between 2000 and 2050 the proportion of the world’s population aged over 60 years will double from about 11% to 22%. Nearly a quarter of the population will be older than 60 and by 2025, for the first time, there will be more older people than children.

We might have expected that the growing numbers of older people would make a difference to their acceptance. However, recognition that the population is ageing has engendered additional fear and distaste. These shifts in the shape of the population are usually described in terms of the proportion of older versus younger people, and increased ‘dependency ratios’. Dependency ratios are calculated in terms of the proportion of older and younger people in the population. As such, understandings of these changes are shaped in terms of generational shifts and intergenerational burden. Such generational changes have focused attention on the likely increased costs of health care and pensions for increasing numbers of older people (Binstock, 2010). Older people are more often portrayed as some sort of universal ‘other’ in the media or in policy statements where images such as a ‘silver tsunami’ or ‘tidal wave’ of ageing people about to descend upon ‘us’ are used (e.g., Martin, Williams, & O’Neill, 2009). Ann Robertson (1997) has critically named this the “apocalyptic demography” scenario in which the growing older population, with its ailing, retired bodies and high health care costs, drains the larger society and brings economic and social catastrophe.

Government policies today are largely driven by these concerns about the arrival of greater proportions of ‘baby boomers’ and subsequent generations at retirement age. From the late 20th century, policies in many countries have shifted from the focus on decline, dependence, and care of older people to those which encourage participation, independence, and good health. The overt aim of these policies is not to change ageist attitudes, but to reduce the potential burden of older people on health and welfare systems and at the same time maximise their contribution to society (Stenner, McFarquhar, & Bowling, 2011). Such policies focus on older people as a ‘resource’ that can be used to address the difficulties associated with population ageing (Peng & Fei, 2013).

The WHO active ageing policy framework (World Health Organization, 2002) has influenced the construction of such policy approaches. The word ‘active’ refers to continuing participation in social, economic, and civic affairs, as well as the ability to be physically active or to participate in the labour force (Walker, 2002). The active ageing policy framework has been influential in shaping the shift in government policies that are discussed in terms such as ‘successful’, ‘active’, ‘healthy’, or ‘positive’ ageing strategies. Such strategies lead to a focus on independence and productivity (Walker, 2002).

Government policy is one very strong influence on the ways in which people are seen as a certain sort of person in society. Peter Townsend (1981), an English sociologist, showed how policy influences citizenship and constructions of ageism in society. He revealed how UK policy in the 20th century (responding to the changing workforce needs of a capitalist society) produced a deficit model of ageing based on disengagement and dependency. This led to the stigmatisation of older people as dependent and costly. Current recognition of growing numbers of older people has made this particular construction increasingly frightening, especially as ‘they’ are also living longer. Townsend’s (1986) influential work showed the key role of governmental social policy in constructing different versions of old age. Currently, the powerful policy notions of successful ageing, promulgated through the media (Rozanova, 2010), have contributed to a discourse of ‘successful ageing’ (which includes descriptors such as ‘active’, ‘positive’, ‘resourceful’, ‘well’, and ‘healthy’ ageing) as the dominant way to talk about old age in our societies. The general popularity of this new ‘successful ageing’ discourse may be understood as a response to widespread concerns regarding the ageing of world populations.

Successful ageing

An important influence on current research, intervention, and the development of recent public policy around ageing has been JohnRowe and Robert Kahn’s (1997) ‘successful ageing’ model. ‘Successful ageing’ stresses intervention aimed at supporting older people to avoid disease and disability, maintain high mental and physical functioning, and remain socially engaged. In their seminal 1987 paper in Science, Rowe (a geriatrician) and Kahn (a social psychologist) suggested a new approach to the dominant conceptualisation of ageing as a process of inevitable decline and morbidity. They noted that the effects of the ageing process had been exaggerated and pointed to the heterogeneity of older people’s lives and the importance of diet, exercise, personal habits, and psychosocial factors in explaining individual differences. This model crystallised earlier work on successful ageing (Katz & Calasanti, 2015) and shaped the current focus of health researchers on the delay of illness, disease, disability, and mortality (Ryff & Singer, 2009) and the behavioural determinants of healthy ageing (e.g., Peel, McClure & Bartlett, 2005). These theoretical approaches and associated empirical focus on measuring success have contributed to a discursive construction of successful ageing which influences “retirement lifestyles, policy agendas, and anti-aging ideals” (Katz & Calasanti, 2015, p. 209). A ‘successful ageing’ discourse positions older people as responsible for engaging in exercise, diet, and social engagement prescriptions to produce good health.

Shifting from previously dominant discourses that featured decline and dependence to a successful ageing discourse, alongside recognition of the need to provide environments that foster participation and active contribution, has been beneficial for many older people. Thus, many gerontologists and allied social scientists have supported the development of conceptual models of successful ageing. Rowe and Kahn (2015) have recently noted that the successful ageing model suggests the ‘what’ and it is for psychological models to focus on the ‘how’. However, the ongoing development of such models remains problematic while the meaning and location of successful ageing within broader society remain unexamined. By supporting the ‘successful ageing model’ uncritically, researchers and practitioners risk reinforcing a wider discourse which is potentially damaging to the well-being of older people in our society. The main critiques of the broader successful ageing discourse in this regard may be summarised within four general areas: support for biomedical constructions of health including healthism and denial of death, homogenising ageist discourses, oppressive ideals, and a dominant ideology of individual responsibility. Each of these will be described in turn.

Healthism and denial of death

Although ‘successful ageing’ has been seen as a positive shift in our views of older people, its ideals remain constrained by the dominant biomedical construction of health. Estes and Binney (1989) have described the ways in which healthy ageing was captured by a biomedical model which constructs ageing as a medical problem. They described the arenas of social life shaped by biomedicalisation as the scientific construction of ageing, the professions engaged in working with older people, the social policies around ageing, and the public perceptions of older people. These arenas are necessarily intertwined and together have important consequences for the ways in which we understand the roles and needs of older people and all who work with them. Although many aspects of social life and the environment may be taken into account as predictors of healthy ageing, the focus of medicalised research is on outcomes measured in terms of life expectancy, falls, multimorbidity, disability, hospitalisation, institutionalisation, and self-rated health. In The Fountain of Age, Betty Friedan (1994) described her personal experience of encountering this model in action during a seminar ostensibly on ‘Health, Productivity, and Aging’ attended by doctors and government officials:

Day after day, when the participants broke into discussion groups after each lecture, they only wanted to talk about Alzheimer’s, senility, and nursing homes… . Clearly they did not want to think about people over sixty-five except as helpless patients, clients of their compassionate care.

(p. xxvi)

In the broader social context, Johnson (1995) describes how this approach to ‘healthy ageing’ has generally promoted ageist attitudes in Western society through which older people are seen as ‘other’ to be segregated, cared for, and controlled.

This powerful and pervasive construction of ageing and its effects on the treatment of older people persists today. Franco et al. (2009) described a common definition of ageing as “the progressive loss of function accompanied by increasing morbidity and decreasing fertility,” and healthy ageing defined in terms of the ‘Healthy Ageing Phenotype’, which is “having highly preserved functioning metabolic, hormonal and neuro-endocrine control systems at the organ, tissue and molecular levels” (p. 15). Thus, a biomedical model frames ‘normal ageing’ in terms of biological processes with a focus on the diseases of ageing, and old age as a process of biological and psychological decline and disability to be fought against. This approach reduces people to their deficiencies and individualises their treatment by divorcing health from social and material life. Antonovsky (1993) described this process this way:

When we focus on risk factors, on a disease, and on its pathologic development, we are pressured to identify the person with the disease. Bob Scott, now at the Palo Alto Behavioral Sciences Center, many years ago wrote an unfortunately not well known book called The Making of Blind Men. He analyzed how we come to transform a person who is a woman, a shop owner, a mother, a devout believer, etc., etc., and who also has the very important characteristic of having extreme difficulty in seeing physical objects in her proximity – how we transform her (and how she internalizes the transformation) into a blind person, period.

(p. 6)

While focusing on achievements in conquering diseases and extending individual lives, the dominance of this model has prevented attention to the wider lifetime and social aspects of health and ageing.

The promotion of physical health is an important aspect of successful ageing models which supports the ideology of ‘healthism’. First characterised by Crawford (1980), healthism describes an individualised version of the meaning of health which encourages individuals to take responsibility for that health. Crawford (2006), Rose (2001), Petersen (1996), and Lupton (1995) have drawn upon Foucauldian theory to describe the pursuit of health by the active, responsible citizen who engages, by choice, in a regime of constant self-evaluation and mastery of conduct, diet, and lifestyle. The successful ageing discourse has been identified as closely bound to the moral imperative of ‘healthism’ (Clarke, Griffin, & Team, 2008). In successful ageing models, good health is seen as the product of certain practices, rather than other possible definitions such as being generally well. Walker (2013) referred to these practices as “self-correction variables”: diet, exercise, and social interaction. This biomedically based perspective on ageing emphasises individual lifestyle practices to prevent decline and disability. Paying attention to diet, exercise, cognitive activities, and appropriate social interaction is encouraged as part of a focus on preventing ill health and delaying death. For example, a Canadian policy workshop on healthy ageing (Health Canada, 2002) began with an introductory suggestion that healthy ageing involves three factors: low risk of disease and disease-related disability, high mental and physical function, and active engagement with life. The members of the workshop went on to focus on injury prevention behaviour, healthy eating, smoking cessation, and physical activity as key determinants of health in terms of personal health practices (pp. 5–6). Such messages have been successfully promulgated throughout many societies. Interviews with 60 people aged 55 to 70 (Pond, Stephens, & Alpass, 2010) showed that older people recognised that there were many effects on their health such as luck, genes, ageing, social and family relationships, and sometimes work stress. Nevertheless, the participants drew most strongly and consistently on particular health practice themes of diet, exercise, mental stimulation, and social engagement.

There are two main concerns about the effects of this focus on health as a product of individual behaviours. First, a moral imperative pervades: those who are healthy and diligently follow dominant health messages are seen to be living virtuously, whilst those who are unhealthy or indifferent to the prescriptions for health-related behaviour are seem as irresponsible and even blameworthy for any illnesses that develop (Crawford, 2006; Galvin, 2002; Lupton, 1995). Accordingly, older people’s talk about their health can be seen to include a moral dimension in which people position themselves and others as virtuous or irresponsible depending on their body’s condition and how well they engage in the recommended health-related practices (feeling guilty for not exercising or eating takeaways, or feeling proud of being active at 90; Pond et al., 2010). Health promotion discourse leads to individual responsibility and blaming, and people feel ashamed of their ill health. It is particularly difficult for older people to be subjected to this imperative because they are more likely to suffer a disability or general loss of physical abilities as they age.

Second, perhaps the even more misleading effects of healthist messages are the suggestions that focusing on maintaining physical well-being will allow us to live forever. The focus on the maintenance of health and avoidance of decline creates problems for older people because the effects of time itself on bodies are not acknowledged, and there is no space at all to consider the inevitability of death. Successful ageing discourse only includes good health outcomes and the possibility of avoiding decline; it does not include the realities of embodied ageing (Katz & Marshall, 2003; Powell & Biggs, 2004). Thus, successful ageing constructs a version of ageing in which people may never grow old. Daniel Klein (2012), writing in his 70s, provides an amusing account of his recognition of the denial of ageing among his middle-class American peers:

All around me, I saw many of my contemporaries remaining in their prime-of-life vocations, often working harder than ever. Others were setting off on expeditions to exotic destinations, copies of 1,000 Places to See Before You Die tucked in their backpacks. Some were enrolling in classes in conversational French, taking up jogging, and even signing up for cosmetic surgery and youth-enhancing hormone treatments. A friend of mine in her late sixties had not only undergone a face-lift but also elected to have breast implants. And one man my age told me that between his testosterone patch and seventy-two-hour Cialis, he felt like a young buck again. “Forever Young” was my generation’s theme song, and unreflectively I had been singing along with them.

(Kindle Locations 132–137)

Researchers are also affected. The ways in which the successful ageing construction presently shuts down any recognition of the effects of physical ageing within research is illustrated by the interpretation of research findings in a news media article (BBC Business News, 2013):

Retirement has a detrimental impact on mental and physical health, a new study has found. The study, published by the Institute of Economic Affairs (IEA), a think tank, found that retirement results in a “drastic decline in health” in the medium and long term. The IEA said the study suggests people should work for longer for health, as well as economic reasons. The government already plans to raise the state pension age.

The article further stated that “there is a small boost to health immediately after retirement, before a significant decline in the longer term.” And “the effect is the same for men and women, while the chances of becoming ill appear to increase with the length of time spent in retirement.” The assumption behind the article as it is quoted above is that if people stay working forever, this decline will not occur at all. Are these long-term effects the result of retirement or ageing? We found that the contradiction between these ideals and the actual experience of physical change was beginning to be noticed by our participants (Pond et al., 2010). One very active man who was working physically all day expressed concern about increasing tiredness and aching muscles; he was worried that the only solution (as suggested by health promotion advice) would be to increase his physical activity. Others expressed surprise when adherence to ideal health protective behaviour failed; they felt betrayed by the healthy ageing discourse. These were people who had followed all health promotion advice and still became unwell. They felt bewildered by the mismatch between their virtuous behaviour and their present poor health.

Death itself is largely ignored in these approaches, because of the biomedical focus on delaying death, which is seen as a poor outcome of a failed organism. Despite the growth of hospice movements and considerations of dying well (Kastenbaum, 2015), we struggle to include death within understandings of healthy ageing. Atul Gawande (2014) has written from a medical perspective about this neglect. He suggests that the medical profession and society should move from the indiscriminate focus on prolonging life towards consideration of what makes life meaningful. A reviewer of Gawande’s book was moved to tell her own story thus:

When my father-in-law was in hospital, we asked his doctor if he was dying. She blustered, looked embarrassed and, eventually, said no. He was, though, and afterwards we wished we’d known. It would have been a different, richer, kinder three months.

(Bedell, 2014)

This account highlights Gawande’s points about the damaging effects of not including death as an important aspect of ageing. He argues that this failure to confront death underlies our inability to deal sensibly with ageing. Ironically, the absence of death from the story of healthy ageing may make it more difficult for older people to age well. As people age, awareness of the proximity to death focuses attention on what they themselves value (Breheny & Stephens, 2017; Carstensen, 2006). A conceptualisation of health which does not acknowledge physi...