Family Matters No. 94 - October 2014

Opinion - Re-thinking ageing research

Questions we need to know more about
Patricia Edgar

Abstract

This opinion piece calls for for more - and better - research on ageing in Australia. It considers the wide range of issues needing further attention, including the markers of ageing, dependency, economic and social contribution, retirement and productivity, healthy ageing, changing family relationships and living arangements, social isolation and life satisfaction, life expectancy, sexuality, and successful ageing. This article is an edited version of Dr Edgar's In Praise of Ageing presentation, given as part of the AIFS seminar series on 12 June 2014.

I want to talk about the need for more and better research on ageing in Australia.

My recent book In Praise of Ageing did not start out as a formal research project, but from my interest in the whole process of ageing - as I got older myself - and why some people seem to age better than others, living to a ripe old age in an engaged and meaningful way, despite having the same problems that everyone has as they age with failing health, loss of loved ones or economic decline. My inspiration was a woman called Lesley Falloon, aged now 94, who managed to stand up and chat throughout a long event at University College while I (with a then current hip problem) had to sit down and wonder at her energy. I was also pretty impressed with my friend Jim Brierley who, at 87, was still sky-diving, the oldest active parachutist in the world.

So my book contains several case studies of people aged over or close to 90 years old; not a random sample, but typical of the older people I know and others to whom I was introduced. As I did those interviews and had them write their life stories and attitudes to growing old, I studied the research literature on ageing - especially the research that seemed to be influencing government policy - and found it sadly wanting. There were several Australian Institute of Family Studies (AIFS) papers that were very useful that challenged prevailing stereotypes about ageing, but on the whole the underlying assumptions were of old age as frailty, dependence, a burden on families and society. Such assumptions need to be challenged and to do that we need more and better research on ageing as a modern-day social phenomenon. For ageing today is not what it used to be.

For a start, definitions of ageing are all over the place. Stereotypes of the aged dominate our thinking.

The old age pension was introduced more than 100 years ago at 65 for men and 60 for women. Since then our life expectancy has increased by 35 years and will continue to increase. The aged represent the fastest growing demographic and their stage of life is becoming the longest part of our life span. At 50 you are entering what I call "the second half of life"; you are not on the scrap heap.

When is someone old? South Australia's Ageing Plan has been based on interviews with Australians over 50. Is 50 the magic number when you turn into an old person? Is 70 the new 60 now that we are supposed to work until we are 70? Are we old when we qualify for a Seniors Card? When we retire from the workforce? When we qualify for the pension? When we get sick? When we have grandchildren? When we get grey hair? When we access our superannuation? The answers have very different policy implications, but so far we don't have a clear handle on the meaning of this stage of life. We can't develop sensible policies and programs for people when we don't know who we are talking about.

Do we become dependent when we become old? Treasury seems to think so. The department is obsessed with the gross domestic production (GDP), which they measure four times a year. Treasury, successive governments and the Productivity Commission carry on about the ageing population and the dependency ratio, insisting the old are going to squeeze the life out of younger workers. Treasury predicts the ratio of workers to retirees by 2056 will be 2.6 to 1 (see Colebatch, 2011). So they question, how can tomorrow's workers be expected to finance so many retirees?

But how useful is the measure of GDP in understanding this assertion? GDP ignores the productivity and value to society of older people through caring, voluntary and creative work. It is culturally linked to Western ideas of independence, personal responsibility, individual agency and economic productivity. It also ignores many other things. For example, Italy will estimate revenues from drug trafficking and the sex trade as part of their calculation of GDP from next year. It is a move expected to boost Italy's economic results. The calculation will also include revenues from contraband tobacco and alcohol, even though they will be very difficult to measure, being unreported illegal activities. The Bank of Italy in 2012 estimated the value of the criminal economy at 10.9% of GDP. Theoretically that could mean Italy's GDP result would come in far higher than the government's 1.3% growth estimate. The grey economy of businesses that do not pay taxes is already calculated in Italy's GDP and was estimated to be worth between 16.3% and 17.0% of the economy in 2008, which is the last year for which the calculation was made (Weekend Australian, 2014).

Moreover, the dependency ratio is based on current workforce productivity figures. An increase in productivity, through advanced technology or improved management systems, of a mere 0.5% would cover the costs of the aged-care and aged-health expansion.

In a report prepared for the Monash Centre for Population and Urban Research titled The Ageing of the Australian Population: Triumph or Disaster? Katharine Betts concluded that over the last 35 years the so-called dependency burden has actually fallen. Older Australians have increased their contribution to the labour force, and financial dependency on the wage-earning population has fallen. Her research seems more accurate than that of Treasury.

The fact is, more older people are staying in the paid labor force and they are still being economically productive: Australian Bureau of Statistics' figures on workforce participation show only 13% of workers plan to retire by 60 (ABS, 2009). Those who say they will never retire have gone from 384,000 to 575,000. Able-bodied people don't want to sit around for what is shaping up to be possibly the longest stage of their lives without contributing.

People want to work. Deloitte showed that a 5% increase in paid workforce participation by people over 55 would add $48 billion per year to national income (Ryan, 2014).

Yet, discrimination in the workforce is keeping them out of work. We need to have major research undertaken to help anchor this discussion in evidence (about job flexibility, work-family balance, age discrimination by employers and HR managers), against which to measure progress rather than have repeated claims that the aged Baby Boomers are the pampered generation. In fact, Baby Boomers do not form a unique bulge in the population pyramid. (Bernard Salt's scary premise is wrong.) The cohorts following the Baby Boomers are larger, so even existing age-specific rates of labour force participation will mean growing numbers in the paid labour force (Betts, 2014).

What, even, is productivity when the GDP fails to measure the significant dollar value of caring work, voluntary work, community work and creative work, without which our economy could not function, and none of which is a monopoly of the young? When Joe Hockey says people should work as long as they can, he discounts this significant contribution. Treasury should do some sums on the social capital that volunteer work produces and how that affects our economy.

AIFS did some valuable work back in 1999 when Christine Milward published Understanding Links Between Family Experience, Obligations and Expectations in Later Life. And her Family Relationships and Intergenerational Exchange in Later Life questioned the nature of dependency and showed that the flows of both financial assistance and moral support run from old to young more than from young to old. David De Vaus, Matthew Gray and David Stanton measured The Value of Unpaid Household Caring and Voluntary Work of Older Australians in 2003 and found that those over 55 contributed the staggering sum of $74.5 billion a year through caring for spouses and grandchildren and in other unpaid voluntary work. This figure would be much higher today. Women aged 65 to 74 contributed $16 billion in unpaid work inside and outside the home; men of that age, who are fewer in number, contributed another $10.3 billion. The press has reported that in 2011, 937,000 children received child care on a regular basis from a grandparent, a huge contribution to the economy.

This question about the meaning of dependency is a very important issue for government policy. How can commentators claim the dependency ratio will bring our economy to its knees when the value of volunteering is worth more to Australia than the mining industry?

Dr Lisel O'Dwyer, a Senior Research Associate in the Adelaide University's School of Social Sciences, has estimated the true value of Australia's 6.4 million volunteers as more than $200 billion a year, outstripping revenue sources from mining, agriculture and the retail sector. Her study also suggested that even a 1% increase in social capital (including volunteering) was likely to lead to falls in homicides, sexual assaults, burglaries and vehicle thefts.

And it's not just the direct economic contribution that helps: volunteering and caring actually help people live longer and better lives. More and more retirees are finding purpose in volunteering and caring, and their contribution is highly relevant to this debate about who is deserving of a pension. Volunteers get satisfaction from helping others, enhancing the quality of their life and their health. They are healthier, fitter, more mentally alert and more socially connected than other people as a result, and the payback to the economy and workplace is massive. The cost of a pension to such people is an investment in the social order.

In short, our assumptions about the burden of the aged, the dependency ratio and the future workforce are riven with inaccuracy. How to counter negative stereotyping would be a profitable research project to pursue.

What about health? Is this where the aged will be a burden? Not so, if you look at the research in more detail. And not if the medical profession would only move away from medication and technological intervention towards a more preventive approach. Health care costs are rising, but demographic ageing is not the sole cause or even the main cause. Improvements in care are the main cause of the increase, and where demography does enter the equation, population growth has more than twice the effect of ageing. In 2004, Michael Coory used data from the year 2000 from 26 OECD countries and showed there was no connection between expenditure on health as a percentage of GDP and the proportion of population aged 65+. Better health means serious illness and morbidity is compressed into the last year or two of life.

When I turned 70 I was advised by three different members of the medical profession I would no longer be notified to have a pap smear, and not to return for another colonoscopy or a mammogram. It seems a new cancer would take some years to develop, bringing me close to my statistical life expectancy, so expensive health preventive measures were not seen as cost effective. Yet only 8% of old people are in aged care accommodation, most preferring to live independently for as long as possible.

There are many significant ways in which current health costs can be reduced:

  • Medical guidelines for the dying must be improved. We are still not very good at talking about death. "I'm not afraid of dying", Woody Allen joked, "but I don't want to be around when it happens". In the absence of talk, millions of dollars are wasted on "futile" aggressive medical interventions for patients unable to speak for themselves and whose death is inevitable. It has been calculated that advanced care planning would save $250 million annually (Powell, 2012). Further, millions of Australians believe that the final curtain is our business and that voluntary euthanasia should be considered a human right.
  • The Grattan Institute (Duckett, 2013) has argued that the government could save $1.3 billion each year by reforming the Pharmaceutical Benefits Scheme (PBS).
  • The new science of pharmaco-genomics - of prescribing drugs based on an individual's biomarkers - would save the health system $12 billion over five years by avoiding adverse drug reactions and unnecessary pharmaceutical spending (Batt, 2011).
  • Improved anaesthetics and improved cataract surgery have already helped reduce the duration of hospital stays. New surgical techniques should be subjected to the same level of scrutiny as new drugs.
  • Widening the boundaries for diseases like high blood pressure, osteoporosis, attention deficit disorder, asthma and high cholesterol adds significantly to costs in the medical system.
  • This applies particularly to definitions of mental disease. The APA's diagnostic manual lists 374 disorders for depression, with criteria so vague as to potentially include all of us. Australia has a population of 23 million, and recently Patrick McGorry claimed that 4 million of us (17%) have a mental disorder (McGorry, Purcell, Hickie, 2007). Dare I say I don't believe it?

This is where more research on family relationships and inter-generational contact might be useful. One factor that stands out in the research on healthy ageing is the issue of social isolation; more than pain or any chronic medical ailment, lack of social contacts and support can be their undoing.

The AIFS journal Family Matters (1991, No. 30) highlighted the topic with "Ageing: Everybody's Future". Ilene Wolcott's paper in that issue, "The Influence of Family Relationships on Later Life", concluded that for the majority of men and women aged 50 to 70 years, family contact across the generations was important and frequent, despite the fact that young families often lived a distance away from their ageing parents. Parents provided and expected to continue to provide emotional, practical and financial support to their adult children, and in many cases for grandchildren. For those with older parents, being available to provide care was more dominant than providing financial support. Life appeared to be satisfactory for the majority of those aged 50 to 70. However, for those with health problems, income insecurity and who were alone without close family, many aspects of their lives were less than satisfactory, and they were less positive about the future, and were concerned about their own health and the health of family members and their own and their children's future financial security. A repeat survey now might find similar or even stronger concerns.

Changed patterns of marriage, separation, divorce and remarriage experienced by people on the verge of entering later life are likely to have different consequences for family relationships and support between generations. Where is the research on support for the aged when divorce has disrupted contact between grandparents and grandchildren? Or where a new partner does not get on with their in-laws? Or where perhaps the existence of multiple parents and grandparents transforms the nuclear couple family into an extended "lattice family" with multiple support networks?

Who will do the research on how the trend for young people to live at home into their 30s, delay marriage and bring sexual partners into the parental home, plus the rising cost of housing and extended "earn or learn" policies for unemployed youth combine to alter the patterns of inter-generational relationships and, in particular, the way family support systems cope with an ageing population? Such changed patterns will generate new challenges for future public policy decisions. Perhaps we are moving gradually to a more inter-dependent concept of family life because so-called "independence", "autonomy" and "privacy" are less possible in a threatened economy and environmental decline? All questions to be examined carefully.

We need much more work here.

I have recently become an ambassador for the National Ageing Research Institute (NARI). NARI is trying to move into research on the social and psychological factors affecting ageing. One recent study on chronic obstructive pulmonary disease (COPD, which affects up to one in five people over 40 years old in Australia and is currently the fourth most common cause of death in men and sixth most common in women) shows it can increase the risk of mental illness, anxiety and depression. Perhaps not surprisingly, the study found telephone contact helps. NARI provided a telephone support service for older adults with COPD and depression. Half of those enrolled took part in a course of cognitive behaviour therapy delivered over the phone by a trained psychologist. The remaining 150 received regular telephone support from trained volunteers who avoided talking about health problems. This research showed "talk to a friend" telephone support was just as effective as cognitive therapy in helping people with COPD to reduce their anxiety and depression. NARI believes that linking trained volunteers to offer telephone support has the potential to assist people with other chronic diseases who are also suffering anxiety and depression.

In this technological age, we should be developing social networking sites that link the old and the young. I was taken with research in Holland, by an inventive group of medical professionals at an institute in Amsterdam called the Waag Society (Wildevuur et al., 2013). They used the Internet to pair elderly shut-ins in a nursing home with young partners. Some of the young people volunteered and others who were jobless were paid to participate. The senior citizens, some of whom were seen as virtually senile with too much time on their hands, had to learn how to use the computer. Expectations were low, but the elders jumped at the chance to be learning something useful; to be doing something that actually connected them to young people. And they felt happier. There were no scientific tests, there were simple self-reports of feeling better, not just from the elders but from the kids too. Both groups began feeling a sense of optimism. Soon the nurses noted that seniors weren't requesting as much medication for pain, anxiety, depression, memory loss or even their physical ailments. Cognitively they were doing things that a few months before seemed beyond their mental grasp. They weren't dying as fast as they used to, so more beds were required.

It makes very good sense to support such activities. In Australia, 66% of those over 75 say the Internet helps them connect with their families and makes them feel more secure in their homes. The Baby Boomers are the fastest growing users of information technology, and appropriate training provided in a supportive environment can greatly assist older workers to learn new technology systems effectively. But cost is a deterrent for some. So Australia's telcos could show community leadership and offer subsidised rates for seniors to get online.

And what about a social network that links the old and the young? I Googled "old and young" online to see if anyone had done such a thing and what did I find? The words "old and young" link to porn sites. So we need a new name, but it is a good, potentially commercial idea.

There is insufficient research that shows how people age differently according to ethnicity, religion and gender.

As far back as Simone de Beauvoir's lament about her unattractive ageing body (she was only 50 and her womanising partner Jean Paul Sartre was not helping), there has been a clear gender difference because women were traditionally more "dependent". But was that ever true with women who were peasant farmers, or factory workers, or servants who worked until they died? And now that women are better educated, more likely to stay in the labour force and more aware of their human rights, how has this affected the way they age? Better education is clearly related to better health, higher incomes and life expectancy. Yet we know little about how that is linked to their experience of marriage, having children and the fact that smaller family size increases the burden of caring for an ageing parent on the surviving children, usually the females.

Where is the research on how ageing affects different ethnic and religious groups? On migrants and refugees without extended families? Or on the way older migrant groups experience language difficulties when confronting a medical and aged care system based on English and on cultural assumptions they do not share?

In my book there are case studies of women who have reinvented themselves and survived well after divorce or the death of their male partners. We know that male life expectancy is lower than that for women, but today's workplace is likely changing that. It may be safer but it is more sedentary. Men still delay medical treatment more than women, but women are now subject to many of the same stresses and diseases that have affected men. Divorce and job discrimination may still impoverish women more than men, but how does this affect ageing, when women maintain family and friendship relationships more effectively than men?

Little is known about ageing and sexuality either. Because there are fewer men than women, older men are more likely to have a sexual partner and to be sexually active. Overseas research has found, however, that older adult participation in and satisfaction with sexual activity has increased over time, as have positive attitudes towards sexuality. Sue Malta's (2013) PhD study found that older women aged 60 plus were just as likely to initiate new relationships on Internet dating websites as men of the same age. She discovered that relationships became sexual quickly, and for many women they were more enjoyable than their previous (mostly) long-term married experiences. Some participants had a series of short-term relationships and others had multiple partners. Aged care homes are rife with newfound love affairs. The stereotypes are again wrong, with older adult needs and priorities regularly left out of vital national health, research and policy agendas.

According to Paulene Mackell, Australian men aged 80 and above have the highest suicide rate of any age or gender group (Cattell, 2000). According to the 2007 National Survey of Mental Health and Wellbeing, 30% of women with a mental health problem visited a general practitioner, compared with 18% of men. Older men lose both meaningful workplace activity and their ongoing partnership, resulting in a loss of identity. They seek medical (especially mental health) assistance less than women and that disconnect needs to be addressed.

Finally, let me say a few words about the notion of "successful ageing". I have been accused of promoting an unrealistic image of the all-singing, all-dancing, prancing, happy oldie, which is just as unproductive as the stereotype of all old people being frail, dependent and demented.

The title of my book, In Praise of Ageing, was not meant to suggest that everyone can age happily, wisely or healthily. My own experience of growing older tells me I have been lucky compared to many people. And I have had breast cancer and a hip operation; my husband Don has had cancer too and has survived. We are educated, financially secure and have a very positive relationship with our grown children and grandchildren, but others are not so lucky.

Some recent British research directly challenged the concept of "successful ageing", suggesting that although we do want to stay healthy and active as long as possible, the idea has run away with itself and is now almost a new form of ageism. To age "successfully" almost means not to age at all, and is based on the notion that everyone starts from a place of health and "high functioning". They ask what "successful ageing" might mean to people who have had a long-term physical or intellectual disability or a chronic mental illness, or come from a culture that is less individualistic and preoccupied with the importance of independence than we are (such as Hindus and Buddhists who accept the transience of life and place the values of family life and acceptance of death above being "active" until your very last breath; see Lamb, 2014). Such meanings are likely to feed into attitudes and thus all the other aspects of health and wellbeing we know about. How, they ask, can we involve more marginalised groups, people who have compromised health, in our thinking about ageing? There are many areas of research that flow from such questions.

I wrote my book in order to show the need to shift policy thinking away from negatives that produce even further negatives, to indicate how our increasing longevity can be a positive for society as a whole as well as for the individual experience of ageing. Indeed, the research now coming out suggests there is a lot more we could do to make ageing a more positive process, despite the inevitable onset of physical deterioration and death.

Itt has to be noted that, while about 30% of one's likelihood of living to 100 is determined by genes, and longevity does run in families, several longitudinal studies have shown that personality and attitude are important in determining whether we will live a long life well.

A Harvard study by George Vaillant (1998) found that (controlling for variables such as income, ill-health and divorce) those with a positive attitude to life, those who saw ageing as an opportunity to re-invent themselves and get on with the business of living, made the most significant contribution to longer life expectancy.

Christina Bryant et al. (2012) of the University of Melbourne also found in their studythat positive attitudes to ageing were associated with higher levels of satisfaction with life, better self-reported physical and mental health, and lower levels of anxiety and depression, after controlling for confounding variables. Better financial status and being employed were both associated with more positive attitudes to ageing and better self-reported physical health. Relationship status was also significantly associated with mental health and satisfaction with life, but not with physical health.

Her conclusion? Having positive attitudes to ageing may contribute to healthier mental and physical outcomes in older adults. Overcoming negative stereotypes of ageing through change at the societal and individual level may help to promote more successful ageing.

The importance of the psychosocial domain highlights the need for social policies that promote social inclusion. Hitherto, little attention has been paid to ways in which people might be prepared for, and educated about, old age, beyond financial planning. It may be productive to place more emphasis on developing policies that challenge ageing stereotypes in order to promote more positive attitudes to ageing, alongside encouraging involvement in well established and modifiable predictors of successful ageing, such as social participation and physical exercise.

Even the research on dementia and the disease we fear more than death - Alzheimer's (which is not a consequence of normal ageing) - is beginning to recognise the importance of more positive, preventive approaches. Enormous effort has gone into finding pharmaceutical solutions with little success. But there may be simpler ways to lessen this so-called burden. Social isolation is believed to exacerbate all forms of dementia. Dementia is affecting more and more Australians every year and is projected to affect almost 3% of the total Australian population by 2050. NARI's research shows that improving physical and cognitive activity can reduce or slow down the onset of dementia and has promising effects for Alzheimer's too.

Researchers now believe the single most important thing anyone can do is to exercise the brain. Dr Yaakov Stern's research is based on autopsies performed on 137 people who were diagnosed with Alzheimer's disease in the 1990s, comparing brain pathology on death with symptoms the patient manifested while alive. The team found some severely disabled patients had brains that turned out to be less diseased than expected, and patients with few Alzheimer's disease symptoms had brains that were badly ravaged. What could account for the difference?

Stern's theory is that complex brain operations were taken over by the undiseased parts of the patients' brains - by what he calls cognitive reserves. So how do we get these cognitive reserves and minimise, slow down, or even reverse cognitive decline? The answer lies in brain exercise, not just doing the daily crossword but in continuing meaningful education, enjoyable work, pleasurable leisure activities, physical exercise, social interaction, learning new skills like a new language, or computer skills, playing video games and interacting on social networks.

A recent Scottish study showed that being bilingual has a positive effect on cognition among older people, including 195 who acquired a second language in adulthood. The original cohort from 1936 were given an intelligence test in 1947 at the age of 11 and were retested in their early 70s. The findings (Bak et al., 2014) indicated that those who spoke two or more languages had significantly better cognitive abilities compared with what would be expected. The stronger effects were seen in general intelligence and reading, both of which were present in those who acquired their ability to speak a second language at a young age as well as later in life.

The brain needs to be active and stimulated with rich and new experiences. Nonsense is talked about the dangers to youth of multi-tasking. There is no such thing as mono-tasking. The brain is inquisitive by design. What confounds the brain enlivens the brain. And to relegate the old to passive "retirement" or "having a well-deserved rest" or sitting drugged in an aged-care home, condemns many to unnecessary decline.

My argument assumes we must accept the responsibility for looking after ourselves to the best of our ability, both physically and mentally; that we make an effort to reinvent ourselves, our work and purpose as circumstances change over a long life. But it is not just a matter of self-responsibility.

Our attitude will make a difference, but we have a right to be respected as individuals, and given access, if we want it, to work opportunities (both paid and unpaid) and good medical support. The language used to talk about us, our cultural attitudes and media reporting should not be allowed to continue to create and amplify social problems for those living the second half of their lives that can be solved and bring benefit to all of us. Portrayals of the aged as a burden just do not help. It's time to praise and celebrate ageing, not bemoan what is a natural stage of our lives.

References

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Dr Patricia Edgar AM is a sociologist, educator, film and television producer, writer, researcher, policy analyst and an ambassador for the National Ageing Research Institute. This article is an edited version of Dr Edgar's In Praise of Ageing presentation, given as part of the AIFS seminar series on 12 June 2014.

I acknowledge the invaluable contribution of Don Edgar in the preparation of this article through his critical comments and advice.

Suggested citation:

Edgar, P. (2014). Opinion - Re-thinking ageing research: Questions we need to know more about. Family Matters, 94, 45-52.