Ageing can be seen as a big process which involves different components. Some of these are biological, social, spiritual, environmental and psychological in nature. The study of these components and their interrelations is gerontology. The sub-discipline of gerontology which focuses on physical processes, is called bio- and health gerontology. Some biologists and biochemists study the process of ageing on a molecular level and they try to figure out how the ageing process affects organs and the entire body. The scientific field of that study is called biogerontology. Some of the questions answered by biogerontologists are why human cells die and how organs stay stable over time. These scientists see biological ageing of the body as the result of the appearance and disappearance of the cells of organs.

Organs have cells that die and that are replaced by new cells. De Grey is a biogerontologist from Great Britain and he studied the free radical theory and the role of mitochondria and concluded that ageing can be seen as a disease. De Grey states that we have more and more knowledge about medicine and that, because of this, we will be able to address ageing just like we address many diseases. However, some gerontologists think that he is being too optimistic. This is because biogerontologists use animals like rats and flies for their studies and it is not clear whether these results can be generalized to humans.

Doctors who do clinical research and epidemiologists (they study populations) are in the field of health gerontology. That field is linked to the environmental and social aspects of human ageing. This field tends to focus on changes in the body as it ages, the consequences of this change for daily living and the use of health care services. Some of the questions with which health gerontologists are concerned with are how one can help people to live longer and how one can increase the healthy life expectancy. Health gerontology looks at social inequalities when trying to answer the questions. This can be between different educational levels or income groups. In this field two levels of health-related intervention are underlined. These levels are the individual level and the population level. The individual level might focus on health promotion and prevention and the population level might focus on housing conditions and organization of social care systems.

Theories and concepts

Although Europeans live longer than ever before, it doesn’t mean that the extra years are healthy ones. Old age often goes together with disease. However, it’s difficult to find where health ends and disease starts. It is difficult, because health can be understood in different ways.

Looking at the traditional definition of health, health is the freedom from disease. When people age, their health deteriorates and people develop diseases. Old age and good health were therefore seen as mutually exclusive states. This opposition can be explained with senescence. Senescence describes biological ageing. Bodies react to changes more slowly with senescence and as a consequence, they recover from illnesses with more difficulty. Because of this, health declines in old age and disease become more common. Some scientists have pointed out that there are two different reasons why older people have more health problems. They say that the first reason is that ageing itself causes health to decline. The second reason is that diseases require a long time to develop and they will therefore only manifest in older ages. So this reason doesn’t see ageing as a cause of diseases. Luckily for us, nowadays we can cure many health problems. Acute health problems, like aftermaths of infections or accidents, can often be treated to recovery. But some problems, like diabetes, can’t be treated to recovery. The symptoms of chronic health problems can be managed and this helps the individual to lead a normal life. Because of senescence, older people are prone to suffer from chronic diseases. Sometimes even from more than one disease at a time. Because of this, old people may have a hard time carrying out everyday activities. What’s actually the most important, is how older people think about their health. The presence of a disease doesn’t mean that one sees himself or herself in poor health. Even when they were diagnosed with several diseases, older people described their health status as good. It seems that people need to pay attention to older people’s perceptions when they discuss health in old age.

A positive approach

The World Health Organization (WHO) sees health as more than a physical state and the organisation therefore suggested a broader term. In 1948, they proposed that health is not only a physical state, but also a social well-being state. They were the first to include the subjective aspect of social well-being in the terminology of health. But the question that arose because of this, is what social well-being actually is. Gerontologists say that social well-being is a good quality of life. They see health in old age as a question of quality of life. According to them, quality of life has two dimensions. The first dimension is health related, like pain and discomfort. The second dimension is not health-related. This second dimension refers to personal resources. Some of these might be the capability to find spiritual satisfaction or the capability to form friendships. Because of this dual nature, good health in old age can be maintained by preventing diseases and enhancing personal resources. Strategies for promoting healthy ageing need to look at both ways to be healthy.

Because of the increasing healthy life-expectancy, old age has been given a positive image. There are now new concepts of old age, like the concept of successful ageing and active ageing. Active ageing is optimizing opportunities for health, participation of security and with this, enhancing quality of life. Successful ageing looks a bit like active ageing, but it has been received a more critical reception. According to Rowe and Kahn, successful ageing is a combination of three elements: absence of diseases and of risk for disease, engagement in productive activities and maintenance of cognitive and physical abilities. Both active ageing and successful ageing underline the activities of older people. Successful ageing does not draw attention to quality of life, while active ageing does. The term ‘ successful ageing’ can be seen as troublesome, because if successful ageing exists, than unsuccessful ageing must also exist. What is that? According to Baltes, the concept of succesfull ageing might be an oxymoron, because the concept implies that people age successfully if they do not age at all. Because of this problem, discussions on healthy ageing do not really focus on successful ageing, but on active ageing and quality of life.

Facilitating healthy ageing

In the previous section, a couple of possibilities for the achievement of healthy ageing were discussed. The three most important approached for reaching healthy ageing are learning from health promotion strategies, slowing down the ageing process and utilizing the potentials of preventive medicine. Health promotions focus on reducing the risks leading to four diseases in particular: lung diseases, diabetes, cancer and cardiovascular diseases (also strokes). The promotions suggest that moderate intake of alcohol, not smoking, a healthy diet and enough physical activity reduce the risk of getting these diseases. Also, a stable social and psychological situation seems important because this situation helps people to cope with the challenges of old age (losing a spouse). Another strategy is slowing down the ageing process. Ageing can be seen as a life-long process. The foundations of healthy ageing are laid during ones childhood and youth. If you have a healthy life-style at a young age, the chances of you ageing healthy will be higher. Adopting a healthy lifestyle at a young age is a strategy to slow down the ageing process. Anti-ageing medicines are also seen as a potential means for slowing down ageing. These medicines can vary greatly, because they can be vitamin pills, hormones or herbal components. However, there is not really conclusive evidence that taking anti-ageing medicine slows down the ageing process. It’s therefore better to focus on maintain a healthy life-style. Another approach in promoting healthy ageing is to utilize the potentials of preventive medicine. Preventive medicine is for people who did not yet fall ill. This strategy tries to avoid that the healthy individuals develop diseases. Preventive medicine makes use of the other two approaches just described. It also finds an early diagnosis of diseases important, because this allows for higher chances of recovery and more effective treatments. Early diagnosis can help us to ensure good health in old age.

The current state of Europe

With health-related information, an insight in the current state of Europe can be found. We have information about the living situations of older Europeans and how governments react to population ageing. There is a big difference in the health status of older people across Europe. Europeans who reached the age of 65 years in 2009 could expect to live for 15-21 more years, depending on the country in which they were born. The countries with the highest remaining life expectancies at age 65 lie in Northern, Southern and Continental Europe. In Eastern Europe, the countries with the lowest life-expectancies at birth lie. You can see the life-expectancy of different countries in Figure 2.1 on page 20 of the book ‘Old age in Europe.’ Slovakia has the lowest remaining healthy life expectancy, which is 3 years and the highest one is 14 years in Sweden. Continental and Northern Europe have the highest healthy life expectancies and the lower healthy life expectancies are concentrated in Southern and Eastern Europe.

The capabilities of older people also vary across the countries in Europe. Some older people confirmed that they were severely limited in their everyday activities. The number of people with limitations in their activities increases with increasing age. This is common in all countries. What does vary with countries, is how many people are limited and how quickly the limitations progress with age. In the Netherlands and Switzerland few older people are limited in their everyday activities. In Greece and Germany, many older people are limited in their everyday activities and with increasing age come increasing numbers of people with limitations. But there is no clear geographical pattern when it comes to capabilities.

The differences between countries in life expectancies and capabilities of older people are caused by diseases and health problems. The state of frailty is the state in which older people are especially vulnerable to have accidents or fall ill. Frailty can be considered a disease if three or more of the following criteria are present:

• Self-reported exhaustion

• Unintentional weight loss (4.5 kilograms in one year)

• Low physical ability

• Slow walking speed

In 2004, 3% of male and 7% of female Western Europeans aged 50 years and over were frail. There are two life-style factors that are often held responsible for diseases, premature death and frailty: lack of physical activity and smoking. A lack of physical activity is especially common among European women with a low educational level and smoking is especially common among European men with low income. Also, researchers have found that the further north older Europeans live, the more physically active they are.

Certain diseases play an important role in older age. These diseases are related to the heath and blood vessels (cardiovascular diseases), diabetes and cancer. Cardiovascular diseases are the leading cause of death in developed countries. They were responsible for almost every second death in Europe in 2008! The most common cardiovascular diseases among Europeans aged 65 years and older are ischaemic heart diseases (heart attack) and cerebrovascular diseases (stroke). The second most important cause of death in Europe is cancer. The most common forms of cancer that affect Europeans aged 65 years and older are cancer of the breasts, lungs, colon and prostate glands. Diabetes is also a common disease in Europe. Diabetes is a chronic disease and the prevalence will also increase as populations age. Older people do not only suffer from physical health problems, but also from mental health problems. Among older Europeans, late life-depression is common. There are more depressed older Europeans in Southern Europe than in Northern Europe. Possible causes for this late-life depression is financial problems, social isolation, the death of loved ones and health problems. Another common mental health problem in late life is the decline in cognitive function, because of dementia. People with dementia lose a couple of their cognitive capabilities, like their language, memory and problem solving ability. Researchers think that more and more people in Europe will suffer from dementia, as the population ages.

Taking care of frail Europeans

The health profile of Europe changes as the European population ages. Because of this, care arrangements also need to change. There are two care arrangements older people benefit from: formal arrangements and informal arrangements. Informal arrangements are arrangements in which people provide unpaid care to relatives or friends. Usually, women provide this care to their parents, children or partners. The number of older family members will increase, as population ages. This can result in women having to provide care to more parents and in-laws. This increasing need for care can be hard to put together with paid work and taking care of children. However, population ageing also goes together with a decrease of children in families. This will result in a lower need of childcare and this may ease the situation of informal care-providers. People stay healthy until a later age and this means that older family members might also provide informal care. This might ease the situation of middle-aged women in informal care arrangements.

Table 2.1 on page 23 of the book ‘Old age in Europe’ shows how many Europeans receive informal help or care and how many older Europeans provide informal help or care. 15% of older Europeans in Spain received informal care, while in Germany this percentage was 28%. 15% of older people in Spain provided informal care, while in Denmark this percentage was 48. More help is provided and given in Northern Europe than in Southern Europe. Also, the table shows that in many countries, older people help out more than they receive help. This fact shows that old age is today a time of good health and activity for many people. European policies are aware that informal caregiving is important and quit common and they try to support the informal caregivers. They introduced financial support in a couple of countries in Europe. But older Europeans can also receive formal care arrangements. These are arrangements in which paid professionals provide care in the homes of frail person or in institutions, like nursing homes. These professionals can belong to the social care sector, the health care sector and in a couple of countries like the Netherlands and Germany, to a separate long-term care sector. That sector is specialized in the provision of care over a longer period of time. The older users have to cope with several health problems and their care needs change over time. Because of this, they might need services from different health and social care providers. Countries spend different amounts on formal care arrangements. Countries with high public health care expenses are located in Continental and Northern Europe. The countries with the lower public health care expenses are located in Eastern Europe. There are also more long-term care facilities in Northern Europe than in Southern Europe. Northern Europe has also more long-term care workers than Southern Europe and Eastern Europe.

Policy-makers know that Europeans live longer and that their life-expectancy will continue to increase. They are happy with this development, but is it desirable to live longer? One can’t only look at the number of life years gained in order to decide whether longer lives are desirable. You must also look at the quality of the additional life years. You must see whether the additional years are healthy and free of disease. There is a discussion between researchers about the relation between health problems (called morbidity) and longer lives. There are two hypotheses about this: the first one describes a compression and the other one an expansion of morbidity. The first hypothesis states that the most severe health problems are concentrated in the last years of life. This means that living longer goes together with more years in good health and health problems will arise in a higher chronological age. The expansion of morbidity hypothesis states that the number of life years increases when the life-span increases. This means that living longer will result in spending more years battling health problems. Evidence has shown that both hypotheses might be in part accurate. It seems that the most severe health problems are concentrated in the last years of life and the years before that are characterized by chronic diseases which do not lead to disability. A person who can cope with chronic diseases can have a pleasant old age. Health care professionals should look at attitudes and social factors when they try to prolong lives. Longer lives can be something to look forward to when there is a good medical care, a right attitude and a well-developed social network.