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Sexagenarians in the City: Take home messages for urban design from the Royal Society of Medicine Global Ageing Conference
Jacob King and Jianan Bao, London School of Hygiene and Tropical Medicine reflect on the Global Ageing: Challenges and opportunities conference hosted by The Royal Society of Medicine in London UK on 24th and 25th April 2017 on how future demographic and geographical changes will affect the health of increasingly older populations.
If it was not already abundantly clear that we are hurtling directly towards the Age of the City, this conference made the point inescapable. City living permeates health through and through. Not only the root of psychosocial, cultural, economic, biological risk factors and protective health factors alike, The City fundamentally shapes the way we interact with health care too. Concurrent with universal mass migration into cities, global aging and super-aging offers substantial new challenges to health.
The global population is ageing exponentially
Opening the conference with a detailed review of the future demographic and geographic changes affecting our shared home was WHO director of the Department of Ageing and Lifecourse, Dr John Beard. Published in 2007 the WHOs “Global age-friendly cities: a guide” framework will be familiar to many readers. From this starting point Dr Beard highlighted the substantial demographic changes in age across developing areas of the world. He explained that while developed countries like the UK saw national life expectancy slowly grow from 40 to 60 years between 1800 and 1920, India saw the same age jump in just 35 years (1960 - 1995), and China in just 15 years (1950 - 1965).(1) Populations largely naive to supporting large numbers of elderly citizens are similarly those most faced by the challenges of rapid urbanisation. World Urbanisation Prospects, from the UN highlights that while currently around 54% of the world’s population live in cities, by 2050 it will have increased to 66%, with 90% of this change coming from Africa and Asia.(2)
Major new housing construction project in Zheijiang, China. Photograph by Jianan Bao
The rise of dementia
Importantly, old age represents a rather different profile of mental health conditions compared to other age groups. Old-age psychiatry stands as a separate area of subspecialty within psychiatry for exactly this reason. While mental health problems affect people of all ages (for example, older people have similar rates of depression to other age groups (3), dementia stands almost uniquely as a mental health condition that predominantly affects the elderly. Dementia is set to increase rapidly around the world, especially amongst people who live in low and middle income countries as a consequence of longer life expectancies and changing risk factors for disease. Given a standardised age profile, dementia affects 5-7% of the population, a rate that is constant across all countries. Dementia causes more disability than any other condition in elderly people and with that comes the need for care, a need which puts a great strain on countries without the infrastructure for domiciliary care. Unfortunately this often results in huge economic losses for households that may need to provide sometimes quite intensive care for relatives with dementia. Carers of people with dementia may find it difficult to travel long distances for care, resulting lower rates of healthcare utilisation in this group of people for whom social and health care needs are high, and more often than not unmet.
A group of Hangzhou residents doing their morning exercises, 2008. Photograph by Jianan Bao
Assessing the cognitive footprint in urban design
Dementia is only the tip of the iceberg; cognition and cognitive impairment lies underneath the surface, and to tackle that could reduce the rates of dementia. Many factors similarly contribute to cognitive impairment: exercise, pollution, loneliness, poverty. Professor Martin Prince pointed out that a reduction of risk factors by 10% could reduce the prevalence of dementia by 8%. There is a clear opportunity therefore to address some of the risk factors of city living which are also implicated in cognitive decline through thoughtful urban design. Professor Rossor suggests that concept of a ‘cognitive footprint’ should be considered when assessing the impact of policies: how will this affect cognition and brain health?
There is good evidence that some factors associated with city living are good for mental health: higher employment, better healthcare access, varied recreational opportunities. However, many negatives co-occur: fewer spontaneous opportunities for exercise, less societal integration, fewer green spaces, safety fears, and noise and light pollution. (4) Physical limitations, cognitive decline, a different profile of mental and physical conditions and perhaps relative lack of social support among older people make the mental health implications of cities different to other groups. Yet, overall, only patchy evidence applies the bio-psycho-social variations in the elderly experience of city living to mental health outcomes. Despite the increase in funding for dementia, as a field of research it suffers from a lack of researchers. At the conference, Professor Rossor called for more interdisciplinary research in this field involving biomedical researchers, sociologists and of course urban planners.
Healthy cities in a global context
Over many years numerous associations between the urban environment and mental health have been established. Elderly residents are more likely to spend time in the area surrounding their homes than younger adults who commute away for work. Prof Anthea Tinker in her workshop “Age-friendly cities in a global context” outlined the effects of neighbourhood qualities on numerous health measures. The so-called “walkability” of a neighbourhood is directly related to the amount of exercise elderly populations take. Furthermore this relationship may have benefit to mental health too. Evidence suggests that environments which are distinctive, recognisable, familiar are often reported by people with dementia as more comforting. Changes in urban design which therefore make a space more accessible: safe, walkable, but remain familiar are therefore likely to promote its use and quite possibly more than just mental health benefit.
A particularly important opportunity for urban design is green space. Professor Caroline Ward Thompson, Professor of Landscape Architecture at University of Edinburgh discussed how green space exposure impacts the mood of older people. It is clear from observational studies over many years that exposure to green spaces is good for mental health. But does it exert more or less impact for elderly people? How does physical decline affect this population’s ability to access green spaces? In her work Prof Ward-Thompson employed neuroimaging techniques, notably EEG (electroencephalography) to assess the experience of stress in green environments. In short, there seems to be evidence for the relaxing effect of walking in green space. To these writers’ relief, there was a strong feeling in the room that any practical applications of this knowledge should be reified through protecting and increasing the availability of green spaces and making them more accessible to the elderly. There is a danger that because of the difficulties of elderly populations accessing parks and especially so fields or forests, that artificially creating mock up green environments in elderly people's homes is an easy alternative. The “active ingredients” of green space exposure on mental health and mood are still largely unknown. Further studies to assess what exactly delivers the benefit - the exercise, the quiet or light, the greenery itself for example - are needed.
Photograph: Håkan Dahlström - Green picnic, CC BY 2.0, through Wikimedia Commons.
An emerging design challenge: facilitating older people's participation in the workforce
Recent work by speakers Dr Mauricio Avendano and Professor Karen Glaser examined the complex associations between mental health and retirement. They noted that some retirees giving up work receive a boost to their mental health, particularly when the retirement is planned but many others do not, particularly those who are forced to take retirement due to physical and/or mental health problems. (5) Given the health benefits of employment, alongside the economic unfeasibility of ever-longer periods of retirement, they proposed that retirement age should rise in line with aging populations. In this light we may have to find ways to facilitate longer working lives, and better incorporate different physical and cognitive abilities in the workplace. For urban designers, this sociological shift could mean examining the concepts of elderly commuting, and creating different sorts of work environments.
Elderly tourists near West Lake, Hangzhou. Sign reads: no vehicles allowed. Photograph by Jianan Bao
War, displacement and the elderly
Anthropologist Dr Hannah Kienzler and clinical academic Prof Richard Sullivan discussed the implications of war upon elderly populations. We frequently hear on the news about conflict zones around the world, but little time is spent considering the burden on older adults. The elderly population tend to stay within regions of conflict, in part due to the high risk associated with fleeing with potential sensory disabilities and health conditions (and indeed refugee camps often have challenges providing long term care). Dr Kienzler identified the role of older people as carriers of knowledge with a key role to be harnessed in post-conflict community rebuilding and humanitarian planning.
A number of posters were presented on the day, including one by UD/MH associate Jacob King titled: “Urban environments and depression in older adults: Designing mental health promotion into our cities” Concerning similar themes to Prof Tinker’s workshop, in the poster he suggested that mental health promotion can be built into cities. We have already seen that there may be benefit in making use of green space more accessible, making a neighbourhood more walkable, and community facilities more accessible, and so on. In short by following public health concepts originally developed in the fight against HIV, an intervention, an urban design feature, should be available, accessible, and acceptable. (6) For example, walking around a neighbourhood may be acceptable if it is safe, perhaps with fewer cars or less busy pavements. A green space could be accessible if there were well maintained flat walks ways and situated within a reasonable distance to residences, or indeed incorporated into one’s routine environment. And most simply, health care services are only effective if they are available in an area.
Only a limited number of factors which constitute the vast number of associations of city living, older adults and mental health could possibly have been explored at The Global Aging Conference. Several key facets, access to local amenities and health care, and social care and loneliness were notably missing. But while nothing especially new or ground breaking in the field of urban design and mental health was established at the conference, we reasonably believe that such emphasis, as was placed by 3 workshops and a selection of poster presentations, marks a notable step for a high profile medical conference. Employment, green space, neighbourhood quality are indeed three highly important areas in the urban space mental health connection. While rigorous evidence for the association of these factors is still in its early stages, each offers an interesting reference point to begin thinking about how the specific needs the elderly population require of their urban environment for good mental health.
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