Primary Prevention of Ill Health in Older People 2014


Executive Summary

1. Introduction – context and scope

Cambridgeshire has an ageing population, and there are opportunities to maximise the potential for residents to enjoy good health and wellbeing throughout their lives, and ensure that local communities benefit from the vast assets of the older people population.  This JSNA focusses on modifiable lifestyle behaviours, for which there are clear associations with poor health outcomes and opportunities to take a preventative approach: active ageing and physical activity, maintaining a healthy diet (including preventing malnutrition), and stopping smoking.

2.  Primary Prevention for Older People

The underlying principle to primary prevention is that modification of risk factors in later life is still beneficial for health: chronic degenerative disease and ill health are not inevitable concomitants of ageing.  A lifecourse approach recognises the impact of earlier exposures to risk factors for health, on-going behavioural choices, and the opportunities for change and support through life-stages.  There is significant variety in the way individuals experience and respond to their senior years, and a range of cultural differences, preferences and perspectives on what healthy ageing means for each person which could inform effective preventative work locally.

Evidence suggests that interventions which focus on encouraging healthy behaviours in 55-75 year olds may be more effective as they may be more ready, interested and intend to change than individuals in older age groups.  Older adults with negative health behaviours are less worried about the effect of the things they do on their health, and have less intention to change than those with positive health behaviours; this may reflect some of the complexities linked to health inequalities.  Much of the societal emphasis on retirement is about winding down, and carers may, with good intention, also express care and concern in ways that discourage independence.  Supporting primary prevention in older people may therefore require much broader discussions around ageing and society, as well as recognising the significant crossover between physical health, mental health and emotional wellbeing, as important influencers of health behaviours.

3.  Wider Determinants of Health

The underlying social, economic and environmental conditions that influence the health and wellbeing of individuals and populations are recognised to be ‘wider determinants of health’. These determine the context of daily life for older adults.  One in five pensioners lives in a household receiving Housing Benefit or Council Tax Benefit.  The distribution of the benefit population follows similar patterns to the distribution of poor educational attainment and poor health status. In measurements for the Income Deprivation Affecting Older People Index, deprivation is more widely spread across Cambridgeshire. There are some pensioners who are not receiving benefits, but who may be experiencing income poverty, particularly in areas with a high proportion of owner-occupied households.

The adequacy of housing for older people in Cambridgeshire is crucial; changes in both the population of older people resident in the county, their needs, and their preferences about the sort of housing they wish to occupy, require ongoing consideration.  The sufficiency of housing for older people in Cambridgeshire has been recently assessed in Chapter 9 of the Prevention of Ill Health in Older People JSNA, and in the Housing and Health JSNA, both published in 2013.

Cambridgeshire is by and large a rural county and the availability and access to means of transport is an important factor which influences healthy behaviours.  An approach to facilitate active ageing requires consideration of how to ensure the mobility of older people so that they are able to participate in society and the community around them, maintain social networks, access services, and benefit from leisure, social and volunteering opportunities.  Access to local shops and food sources is also important in maintaining a healthy diet.  A Transport and Health JSNA is being prepared for 2015 which will consider the local situation, evidence base, and implications for health and wellbeing in detail, and inform local policy and decision making.

Social and emotional wellbeing is impacted by participation and engagement with family, friends, civic organisations, and services in the neighbourhood and further afield. Societal change including geographic dispersion and fragmentation of extended family networks may mean other local social networks are increasingly important. Primary prevention work offers an opportunity to support the role of communities in meeting the needs of older people and set health behaviours in the context of the social norms of the communities which older people relate to. Loneliness has detrimental impacts on physical and mental health, and increases the likelihood of multiple unhealthy behaviours. Effective interventions to tackle isolation and loneliness may be those with a theoretical basis, where older people are active participants, and which address the vicious cycle of loneliness. Isolation may also be addressed through provision of services in rural areas, and through embedding social elements within other public health interventions.

4.  Physical Activity

Physical inactivity is the fourth leading risk factor for death worldwide; the positive impacts of physical activity and the negative impacts of physical inactivity on the health of older adults are well known.

‘How active?’ guidelines for older adults have been produced by Chief Medical Officer (CMO) which describe ideal levels of activity that are beneficial to health and wellbeing. In terms of how many older adults meet these guidelines, there is data for England available and an indication of participation for Cambridgeshire.  Older adults are not a homogenous group; an interpretation of the CMO guidelines for three groups of older adults (‘actives’, in ‘transition’ and ‘frail’) is available.

There is some evidence of what works; volume of activity is more important that engaging in specific types of activity. There is evidence of the cost effectiveness of interventions and indication of the cost of physical inactivity.

Cambridgeshire is not a blank page; assets in the community exist.  These may not be available to all, and sustained funding is not assured.  The local assets include older adults who are trained volunteers.

5.  Diet

Dietary factors contribute significantly to the global burden of disease.  Dietary improvements made in older age significantly reduce the risk of chronic diseases.

There is very limited information about the healthiness of the food consumed in Cambridgeshire; new Public Health Outcomes Framework indicators on fruit and vegetable consumption will provide a snapshot in future.  Nationally, older adults consume low levels of fruit and vegetables, fibre, oily fish, and high levels of salt relative to recommendations.

The evidence on primary prevention of cancer, cardiovascular disease, and diabetes draws from the all adult population; research for older adults focusses on bone health and preventing cognitive decline.  Population approaches to improving nutritional status include taking opportunities at all ages to prevent the development of chronic disease, and supporting behaviour change for healthier diet and healthy ageing.  Weight management interventions (12 weeks with >1kg lost and maintained for life) can be more cost effective for older adults because older people gain health benefits sooner.

Daily vitamin D supplementation is recommended by the Department of Health for all adults aged 65 years and over.  It is not known how far this is practiced locally; NICE guidance on the implementation of vitamin D recommendations is due November 2014.

Local assets include lifestyle support services accessed by older adults, and practical advice and support through social care and voluntary sector organisations.  There may be opportunities to look at enhancing messaging about a healthy balanced diet for older adults through local services, stakeholders, health and social care professionals, and to consider the healthiness of the food offered in residential and social settings.

6.  Malnutrition

Malnutrition is measured as a Body Mass Index (BMI) lower than 18.5kg/m2 or unintentional 10% weight loss.  NICE identified malnutrition as the sixth largest source for potential NHS savings.   The annual health care costs associated with malnutrition are primarily due to more frequent and expensive hospital in-patient spells, more primary care consultations and the greater long-term care needs of malnourished individuals.

About two thirds of cases of malnutrition are not recognised; the impacts are increased burden of disease and treatment costs.  It is estimated 10,000 to 14,000 older residents in Cambridgeshire are malnourished, many more are at risk.  Social networks have a preventive role, as interest groups and shopping clubs support motivation and the means for good nutrition.

Regular screening for malnutrition is recommended by NICE; early intervention screening and appropriate treatment is cost-effective.  Those at risk should have a ‘food first’ approach, including dietary advice to optimise their intake, and support with practicalities.  NICE estimates that the overall resource impact of increased screening, early intervention and appropriate treatment could lead to a saving of £71,800 per 100,000 people.

Awareness of malnutrition needs to be improved by both healthcare workers and the wider public.  Efforts to prevent malnutrition should be integrated with other care to prevent ill-health, and between healthcare workers, carers, social workers, and the voluntary sector. There is much good practice in place at Addenbrooke’s Hospital, and developing plans for Hinchingbrooke Hospital.  A clear pathway for post-discharge support for those at risk, particularly for older adults who live independently could help to prevent or reduce malnutrition.  Community dietitians provide training for care home staff to screen residents for malnutrition; care homes should use a validated screening tool and should audit to ensure CQC compliance.

The majority of individuals at risk of malnutrition live in the community; preventative resources include home help schemes, community navigators, lunch clubs, day care centres, shopping services and the support offered by voluntary organisations.  Coverage is not even across the county e.g. there are fewer lunch clubs in rural areas, where social isolation may be a greater problem.  Lack of awareness of the problem and services or support available can hinder engagement and access to support.  This might be improved by raising awareness amongst older adults, their families and GPs about the services available in the community.

7. Smoking

Smoking is the primary cause of preventable and premature death in the UK, responsible for approximately 100,000 deaths/year.  Nearly a fifth of the population of England smokes (19.5%); prevalence is lowest among the 60 and over age group (12%) and is probably the result of many factors including death before age 60 from both smoking and other causes of death, and higher cessation rates amongst older people.  A recent systematic review of the evidence on smoking cessation in the 60+ age category concludes that smoking cessation significantly improves health and reduces mortality for all ages.

In Cambridgeshire, there are estimated to be 112,210 smokers and 17,461 of these are over the age of 60 years (16%).  Prevalence is significantly higher in Fenland when compared to the national average.

There are no specific recommendations for reaching or delivering services specifically to older populations; smoking cessation interventions known to be effective in the general population have been found to be effective with older smokers across a variety of treatment methods.

9% of CAMQUIT (the local stop smoking service) clients are aged 65 and older.  In Cambridgeshire the quit rate for all service users is 47%, and is 5% higher among those aged 65 and older (52%).  Also, fewer older smokers are lost to follow-up than other age groups. Older adults are more likely to access the CAMQUIT service via their GP, and less likely to access support via core or pharmacy services.  They appear to be less sensitive to some national smoking cessation campaigns; local tailored advertising is used.  Increasing access to stop smoking services should be encouraged for older smokers.  Local feedback suggests it might be important to emphasise the continued health benefits of quitting at older ages and that it is ‘never too late to quit’.  There are significant opportunities to encourage referral or signpost older adults to stop smoking services from a broad range of settings including primary care, social care, community and acute health care, housing, and community interest groups.

8.  Conclusions

There are health and wellbeing benefits to be experienced by older adults in Cambridgeshire through modifying their health behaviours and lifestyle risk. This can be supported by interventions and enabling societal and environmental structures.  There is a key message to disseminate that it is never too late to make changes, and this could be personalised to individuals to emphasise the specific benefits for their own quality of life. There are opportunities for local health and social care professionals to make every contact count towards this.  A positive view of healthy ageing and an increased awareness of the available local assets will enable tailored support for older adults to access appropriate services, with potential advantages in overcoming social isolation and in strengthening local communities.