Adapted from Scarlett McNally’s article in the BMJ 21 Oct 17
The NHS and social care are inextricably intertwined. The rising number of older people is frequently blamed. The rising social care costs in this age group can be modified however. NICE in 2015 said, “disability, dementia and frailty can be prevented or delayed”.
The need for relatives or paid carers arises when someone can no longer perform the activities of daily living such as washing, dressing and feeding themselves. For some people the ability to get to the toilet in time is the critical thing between having carers come to their own home twice a day and being admitted to a full time care facility.
The cost of care rises five times for those admitted to residential facilities. An average residential placement costs £32,600 a year and may be needed for months, years or decades.
A cultural change is needed so that people of all ages aspire to physical fitness as a way of maintaining independence into old age. There just doesn’t seem to be the local or national infrastructure to support this however.
Ageing is a normal, if unwelcome, biological process that leads to a decline in vision, hearing, skin elasticity, immune function and resilience, which is the ability to bounce back.
The decline in fitness with age starts around the age of 30 and accelerates after the age of 45. Things move downhill even faster if someone has a sedentary job that involves car driving and computer work. Diabetes, dementia, heart disease and some cancers become more common.
Some may think that fitness in old age is down to genes and luck but social strata differences exist with good nutrition and exercise as major factors in enhancing health and fitness into old age.
Apart from getting older, environment and lifestyle affect disease onset. At the age of 40, some forty percent of people have at least one long term condition and the rate goes up by ten percent each decade. As environmental and behavioural factors stack up over time, more people develop an increasing number of diagnoses. Yet, small habits such as cycling to work, can mitigate the effects of a sedentary job.
As time goes on, a person’s independence can be compromised by well -meaning carers and relatives doing more for their charges rather than letting them do things for themselves.
Genetics are thought to play only 20% of the part in the development of modern diseases. Lack of fitness has more of a part to play than disease and multiple morbidity.
Pain can lead people to limit their activity because they think it could make their illness worse, but strength, stamina, suppleness and balance training are usually needed more rather than less as you get older and accumulate illnesses.
These factors improve cognitive ability in midlife through to a person’s 80s. They can reduce the onset of dementia. Increasing independence results.
The Academy of Medical Royal Colleges go as far as describing exercise as “the miracle cure”. Improving the time to stand from sitting down, walking, and resistance training exercise all produce a dose response effect with the most frail benefitting the most. Any exercise or activity such as gardening that gets you slightly breathless and is done in ten minute bursts or longer counts as the 150 minutes minimum as recommended in the UK.
Stopping smoking and limiting alcohol are also worthwhile interventions. Gyms, walking groups, gardening, cooking clubs and volunteering have all been shown to improve the health and well- being of people of all ages with long term conditions.
When people are admitted to hospital they often experience a rapid decline in function. Patients are not allowed to move about or go to the toilet themselves in case they fall. The numbers of these are considered adverse incidents and are strongly discouraged. Thus the ambulant end up chair or bedbound. Most inpatients spend 80% of the time in bed and more than 60% come out with reduced mobility.
All patients should be encouraged to start an activity programme and gradually increase the frequency, intensity, and time that they do it.
The outdoor environment can be improved by even pavements, open spaces, tables and seating in public areas, safe cycle lanes and restriction in car use.
Money may need to be shifted from passive care and polypharmacy to activity and rehabilitation services.
People need to concentrate on being active every day. A quarter of women and a fifth of men do no activity whatsoever in a week never mind the minimum recommended 150 hours a week.
In the UK the total social care bill is over £ 100 billion which is virtually the same as spent in the NHS.
The cost of care doubles between the ages of 65 and 75 and triples between 65 and 85. If everyone was just a bit fitter, the savings would add up.
Individuals need to see it as their responsibility to stay fit or improve their fitness. There needs to be more national coordination regarding the environment, transport and our working schedules so that we can all stay that bit functionally younger into old age. We could be making the difference between staying at home or depending on social and residential care.