Despite popular conceptions that view older age in a negative light, it is not an illness. It is ‘a life journey to be embraced and celebrated’ (Andrews 2002). Increased age and ill health are not synonymous. Although the biomedical model, which conflated old age with illness, has for some time been the dominant paradigm, the reality is that the majority of older people are healthy, active and participate in the community. Studies have confirmed that the current generation of people aged over 70 are healthier and more adaptable than people of the same age ten and twenty years previously (Hermanova 1998). Similarly, more than two-thirds of older Australians rate their health as good, very good or excellent; and people over 75 scored the highest in terms of their mental health (AIHW 1998). Even those older people with chronic illness generally maintain satisfaction with life by adjusting their expectations and daily routines. However, ageing in some people is associated with increasing ill health, and you will need to be aware of some of the factors that contribute to this.

A biomedical explanation of ageing is that it is the progressive, generalised impairment of function that results in a slowing of the adaptive responses to stressors, and an increased risk of age-related disease (Davies 1998). There is no one point at which a person becomes ‘old’; there are certain biological and physiological changes associated with ageing that mean mortality rates rise throughout life from puberty and that the rate is uniform. So theoretically, ageing actually begins around puberty and occurs across a lifetime.

Let’s examine some of the biomedical challenges and solutions that may be associated with the ageing process.

May has arthritis, which is the most common long-term condition reported by people aged 65 and over. Damage to the hip and knee joints from arthritis and from other musculoskeletal conditions has restricted May’s mobility and increased her social isolation, which can often lead to depression. The primary health burden of this condition is pain. However, improved technology, pharmacological agents and alternative remedies have resulted in many older people experiencing dramatic improvement in their pain and mobility. There has been a dramatic improvement in quality of life and health outcomes following hip or knee replacement operations for many older Australians.

Many women of May’s generation are, like her, also at risk of developing osteoporosis. This condition, roughly translated as ‘porous bones’, is characterized by deterioration of bone tissue. It is a progressively debilitating disease that results in bone fragility and an increased susceptibility to fracture (Lemone & Bourke 2004). In older people, most fractures occur from a fall and are linked to osteoporosis. Many of these fractures will heal and cause minimal problems; however, others will result in deformity, chronic pain, disability and the need for supportive care.

Vision and hearing impairment are almost as common as arthritis among older Australians (AIHW 1998). For many older people, such impairment is moderate and recent advances in technology now mean that impaired vision and hearing problems are much more amenable to treatment. Vision is more easily corrected with eyeglasses and cataract excission and intraocular lens replacement, and hearing aids are now much more advanced. However, the initial deterioration of sight and hearing can be socially isolating. The very isolating nature of these impairments may mean that the needs of some older people for such treatment can be overlooked. Because May lived alone, for example, her increasing short-sightedness was not noted by her family for some time. Additionally, having a print disability made access to information about government services difficult for her. So the impact of vision and hearing impairment may be underestimated, as it is not as immediately obvious as other impairments. It may not, for example, appear to restrict a person’s mobility, but it can have a detrimental effect on communication, social outings, safety and general feelings of self-esteem and self-confidence.

Because of her problems with arthritis and her vision, May can no longer use a vacuum cleaner or clean her house. She is now reliant on community services to drive her to the shops for groceries and to help with her housework. Because of her mobility problems and the pain they cause, May does not go out very much, and is in danger of becoming socially isolated— a situation which frequently leads to depression. It is important for nurses to remain sensitive to these functional impairments and provide assistance and support so older clients avoid injury and are not socially disadvantaged.

Other conditions, such as cardiovascular changes, cancer, diabetes, and adverse drug reactions, are increasingly common as we age. As discussed in Chapter 3, cardiovascular disease (including coronary heart disease and stroke) is the most common cause of death and disability in older people in Australia, the UK and USA, and its risk factors are now well known lifestyle issues (AIHW 2002). There have, however, been improvements in this area in recent years. In Australia, death rates from cardiovascular disease are declining (AIHW 1998).

Due to the cellular processes associated with normal ageing, the older we get, the more likely we are to develop cancer. More than one-third of cancer deaths in Australia occur in people aged 75 years or over (AIHW 1998). The incidence of breast cancer is higher in older women, yet screening mammography, which is believed to detect cancers amenable to treatment, is under-utilised among this group (Scinto et al 2001). For men, the most common cancer, apart from non-melanocytic skin cancer, is prostate cancer. Colorectal cancer is the second most common cancer in males and females.

Another common lifestyle related disease that is increasingly implicated in the death of the older person is diabetes. Although diabetes was ranked seventh in terms of major conditions causing death in people aged 65 years and over in the 1995 National Health Survey, there is an increasing incidence of this disease in the community. In addition, it is a major problem for the Indigenous population, which has one of the highest prevalence rates of type 2 diabetes in the world (AIHW 1998).

Older people often metabolise drugs at a different rate to younger people, and if their prescribing doctor overlooks this point, adverse reactions can occur. Because older people have more chronic illnesses, they are more likely to be taking multiple medications concurrently. This is also known as polypharmacy. Rochon & Gurwitz (1997) urge cautious use of drugs prescribed for older people and suggest that, in many cases such as osteoarthritis, measures such as gentle exercises and weight reduction may be effective alternatives. A risk of drug side-effects is ‘the prescribing cascade’. This can occur when an adverse drug reaction is misinterpreted as a new medical condition, and a new drug is prescribed for the ‘new’ condition, placing the patient at risk of further adverse effects from what is, in reality, unnecessary treatment. May, for example, has had osteoarthritis for past 20 years and it was steadily worsening. At one stage she was taking a ‘cocktail’ of drugs to deal with her problem, none of which seemed to work. The pain woke her during the night and she began to use sleeping tablets. May was initially resistant to the idea of trying options other than medication to relieve her pain, such as exercise, and stated firmly that ‘rest is the answer’.

In terms of intellectual function, crystallised intelligence, that is, such things as knowledge, wisdom and vocabulary, are generally maintained with increasing age. Neuro-psychological testing does show, however, a slowing of central processing time and acquisition of new information, as well as the decline of what is called fluid intelligence. For example, it can become more difficult as we age to sort new information into categories. Slight memory loss is common with ageing, but it is not usually sufficient to cause problems with daily functioning. Within the general community there are older people with some memory impairment, who nevertheless have normal physical and mental functioning. This condition is called mild cognitive impairment (MCI) (Hogan & McKeith 2001) and people with MCI do have an increased risk of developing dementia (see below).

There is evidence to suggest that, with increasing age, environmental factors, behavioural actions and preventive measures in earlier life become more important than genetic factors in determining good health (Hermanova 1998). For this reason, health promotion strategies for older people have focused on health conditions that are potentially preventable or able to be postponed; have a significant bearing on the independence and wellbeing of older people; and have important consequences for the health system and demands on its performance (Teshuva et al 1994). In the foreseeable future, nurses and allied health professionals are likely to occupy an even greater role in health promotion and disease prevention than has been the case in recent times, possibly in conjunction with general practitioners. It is vital that all health professionals working with older people are well prepared to respond to these challenges. There are a number of health promotion strategies that are proven to promote health and prevent disease in older people. These include improving the individual’s level of physical activity, their nutritional status, and reducing their smoking and alcohol consumption; all of which may be amenable to health promotion strategies, even among older people.

The benefits of physical activity are well documented. Exercise can help weight control, increase feelings of wellbeing, aid digestion, decrease stress and tension, increase immunity, prevent premature ageing, improve balance, circulation, flexibility of joints, and improve sleep. Physical activity among older people has also been shown to offer some protection against a number of diseases and conditions, including coronary artery disease, stroke, diabetes, and mental disorders (Munro et al 1997). In addition, exercise is a major component of health promotion activities that aim to prevent falls, because exercise improves muscle strength and balance (Lord et al 1997).

Balanced nutrition and access to healthy foods are key factors in the health and wellbeing of older people, as they are in all people regardless of age. Poor nutrition can lead to illness and disease, and the reverse is also true; that is, that ill health can result in poor nutrition. Frail older people are most at risk, but poor nutrition in otherwise well community-dwelling older people is also a serious problem. Although concerns about nutrition often focus on risks associated with being overweight, Williams et al (1998) found that one in three Australians over the age of 60 are at high risk, and one in two were at moderate risk of developing diseases related to under nutrition. Dental problems, including badly fitting dentures that affect chewing and digestion, can exacerbate nutritional problems for older people.

Chapter 3 demonstrated that cigarette smoking may cause ill health at any age; however, its effects often become most apparent in older age. Smoking plays a major role in many diseases, including myocardial and cerebral infarction, lung and other cancers, and chronic lung conditions such as chronic obstructive airways disease (AIHW 1998). In addition, the longterm effects of excessive alcohol consumption can be debilitating in older people because of damage to the liver, brain, pancreas, cardiovascular, haematological and gastrointestinal systems and memory. However, light to moderate intake of alcohol can reduce the risk of heart disease (AIHW 1998). While tobacco and excessive alcohol consumption can contribute to adverse long-term health outcomes, fortunately changing negative habits even in older age can produce health benefits.

Growing older inevitably leads to significant life changes with psychosocial as well as physical challenges. This next section considers the psychosocial aspects of some key issues confronting people as they age.