Later life in the UK

By Sorcha Daly - author of Inequalities in Mental Health, Cognitive Impairment and Dementia among Older People 

Sixty thousand people die each year from symptoms directly attributable to dementia, and 25% of older people are diagnosed with depression, rising to 40% in residential care homes. These conditions, along with mild cognitive impairment (MCI) are often seen as an inevitable part of ageing.  

Depression, of course, can happen to anyone. Indeed, many people with full and successful lives experience depression at some point in their lives, and particularly in later life as the result of bereavement, retirement or other significant life events. Similarly, mild cognitive impairment (MCI) is also accepted as an unavoidable part of getting older, as is dementia, if genes, family history, or even luck, are not on your side. However, although factors such as genes, and significant life events, are important, and often unavoidable, they only make up part of a picture that predicts increased risk of experiencing poor mental health, MCI and dementia in later life.    

Our report Inequalities in Mental Health, Cognitive Impairment and Dementia among Older People examined the roles of life course drivers for poor mental health, MCI and dementia and found that the likelihood of having poor mental health, MCI or dementia in later life is not distributed evenly across the UK. Social determinants of health across the life course will not only result in shorter life expectancy, but can also result in more of that shorter life spent in ill health and disability, and this includes poor mental health, MCI and dementia. 

These inequalities can be exacerbated in later life by a range of factors. Our report focused on unequal access to social connectedness, mental stimulation and physical exercise, and the social, economic and environmental conditions that drive and widen inequalities in access to these important social determinants of health.

Life course drivers:

Education is important. ‘Cognitive reserve’, meaning the skills, abilities and knowledge that increase the resilience and adaptability of the brain and its functioning, is built throughout the life course and increases the efficiency and flexibility of the brain, helping to reduce the risk, delay the onset, and ameliorate the symptoms of mild cognitive impairment and dementia in later life. Higher levels of education increase ‘cognitive reserve’, and some of the latest evidence demonstrates that children who attain higher grades in school, and then go on to occupations with high levels of complexity, have a lower risk of experiencing dementia.

There are other significant life course drivers. Poor quality, sporadic employment or unemployment can lead to job strain, increase the risk of later life poor mental health, in addition to increasing the risk of musculoskeletal conditions and more sedentary lives, whilst simultaneously reducing the levels of lifetime income needed to build material resources for a good standard of living in later life. The built and green environment also has a significant role. Good quality, well maintained green space, safe, walkable neighbourhoods and appropriate housing are all important drivers for improved life time health. 

But these life course social determinants are not evenly distributed in the UK, and areas of deprivation are less likely to have these essential, health promoting environments, increasing the risks of developing cardio vascular and respiratory conditions that are linked to mild cognitive impairment and dementia.

Later life drivers:

These conditions also increase the risk of developing poor mental health in later life, can speed up the rates of cognitive decline, and increase the risk of earlier onset of dementia.  They also decrease the financial and social resources available to cope with depression, or the symptoms of mild cognitive impairment or dementia when they occur.  

Poverty in older age, poor housing conditions and poorly maintained neighbourhoods and green space, influence levels of later life physical activity, mental stimulation and social connectedness. This is important because evidence demonstrates that cognitive reserve is not fixed, and can be built in later life through access to mental stimulation, reducing the risk and speed of cognitive decline, and delaying onset of dementia symptoms. So, although mild cognitive impairment and dementia, for some of us, may be inevitable, the severity of its symptoms, the impact it has on our lives, and the resources we have to cope with the conditions are modifiable and depend on our environmental, economic and social resources. 

Equally, depression does not have to be an inevitable part of growing old. Many older people can, and do, stay socially connected and lead full and purposeful lives. But almost a third of people over 80 report high levels of loneliness and in 2014 1million older people reported not speaking to anyone in over a month. This not only causes poor mental health and depression but is also life threatening.  

There is also evidence demonstrating that depression can hasten the conversion of mild cognitive impairment to dementia. Again, the social, economic and environmental risk factors for depression and loneliness in later life are modifiable and these risk factors affect people in lower socio economic groups disproportionately. Within these groups women, Black and Minority Ethnic groups, people with disabilities, and carers are more at risk of both life time and later life conditions that increase the risks of poor mental health, mild cognitive impairment and dementia and decrease the resources needed to cope with the conditions.   

There are legal, economic and social justice reasons for taking action on the social determinants that increase the risks of poor mental health, cognitive impairment and dementia. Caring for people with dementia costs £26 billion per year in health and social care, and more in informal care from family members. Postponing the onset of dementia by just two years could save £52 billion.

Developing policy and interventions which create the physical and economic environments that enable all older people to be active, socially connected and contributors in their own communities will drive economic development and save costs to the public purse and could result in a net economic contribution reaching £8 billion by 2030. 

Local authorities also now have a legal obligation under the Health and Social Care Act 2012 to demonstrate they give ‘due regard to the reduction of inequalities’.

At present, and historically, Government policy places greater emphasis on diagnosis and access to treatment rather than addressing the main drivers for the inequalities found in poor mental health, MCI and dementia.  But the inequalities in prevalence of poor mental health, MCI and dementia, which are unjust and avoidable, are driven by social, economic and environmental factors. Without urgent action to address these factors the burden of ill health will continue to fall, disproportionately – and unnecessarily – on the less advantaged. 

Blogging from the University of California, Berkeley

By Felicity Porritt (Head of Communications)

7/11/15

Day five of Michael’s book tour across the US was at University of California, Berkeley. It was an occasion I wanted to witness, in person. Forty years ago Michael’s journey into public health started at Berkeley where he earned his MPH, then his PhD on acculturation and coronary heart disease in Japanese Americans. Forty years ago the University of Sydney, where he studied medicine, suggested Michael asked too many questions about why patients kept coming back for treatment. Forty years since Michael first noticed it was his patients social circumstances that were making them sick.

As Michael waited in the lobby of the David Brower Centre at Berkeley, old faces kept appearing. Like long lost friends there were greetings after greetings. They’d travelled from far and wide from around the San Francisco bay area, and beyond, just to say ‘hello’. The atmosphere was one of a homecoming.

Michael’s former supervisor, the great Professor Len Syme, introduced Michael. The whooping started. The audience could barely contain their excitement. The event was vastly oversubscribed. The lucky 120 clapped and cheered as Len welcomed Michael up to the lectern. Despite jetlag, Michael’s face was the picture of rude health – a huge smile from ear to ear. He clearly felt he’d come home.

Over the last eight years as head of communications at the UCL Institute of Health Equity I've listened with rapt attention to my boss speak, numerous times. But this was different. Michael may have been awake from 3am (he arrived in the US from Taiwan on Monday to two speaking engagements in Seattle, hot footed it east to Chicago for two more talks, then back West for two more) but you’d never have guessed. The passion and energy behind his messaging, as he marched stage right to stage left and back again, was stronger than ever.

The organisers told him ‘five more minutes’, then ‘one more minute’. ‘Oh come on’, exclaimed the orator. Clearly the audience too wanted more. As Michael rapped up his 45-minute lecture, the room erupted. It was a huge privilege to have witnessed this homecoming. But then it continues to be a privilege to work for such a great man who, bit by bit, is changing the world.

As Len Syme whispered to me just before Michael began to speak ‘they say Michael is the most influential person in public health, across the world, you know’. ‘I know’, I whispered back. ‘Then let’s communicate better’ exclaimed the 83 year old, whose guiding supervisory role is clearly as sharp as ever. That was me told!

Health information that’s difficult to find, understand and use can lead to worse health for all ages and widen health inequalities.

By Jill Roberts, author of 'Improving Health Literacy to Reduce Health Inequalities'.


Following years of assessing evidence, there’s general agreement that the biggest contributor to health is the wider determinants of health - so, where and how we live, and the social and economic conditions around us, starting from the womb. Inequalities in these social determinants give rise to unfair differences in health, so to have the greatest impact on health inequalities we need to address these social determinants.

How we find, understand and use information about all aspects of health – healthcare, health behaviours, genetics, and crucially, the social determinants of health - underpins our ability to both prevent and treat ill health. This is often referred to as ‘health literacy’. Health literacy is therefore one of the pathways to good health, but it is influenced by the social determinants of health.

This week IHE have published a paper, commissioned by PHE, which sets out why we all need to have the appropriate skills, knowledge, understanding and confidence to be able to find, understand and use health information – be that making GP appointments online, to understanding dosage instructions on medicines, leading a healthy lifestyle or even lobbying for safer, greener environments.

But ‘health literate individuals’ alone are not enough: we also need ‘health literate organisations’. This means that employers and all services with the potential to influence people’s health – such as GP services, hospitals, children’s centres and local councils, to housing and adult education services - need to provide clear, accessible information for all, and make a particular effort to reach, engage and serve those people and population groups with the worst health. They also need to advocate for healthy social, economic and environmental conditions.

A well-educated person can have limited health literacy when required to understand and use unfamiliar language and concepts in unfamiliar healthcare settings, and when navigating health information online, especially when illness makes them more vulnerable. Research has found that in England, 42% of working-age adults are unable to understand and make use of health information, rising to 61% when numeracy skills are also required for comprehension. Basic literacy and numeracy skills are therefore essential necessities for adequate health literacy, but they are not sufficient.

It is, however, the people and population groups with limited financial and social resources – those people with no work or unstable work, no or low income, poor quality housing, limited social support networks, for instance - who are more likely to have limited health literacy, and, at the same time, who are less likely to be adequately served by those services that influence health. These vulnerable groups, including more disadvantaged socio-economic groups, migrants and people from some ethnic minorities, older people, people with long-term health conditions and disabled people, are, in turn, more likely to have a poor diet, to smoke and not exercise, and to have an increased risk of morbidity and premature death.

Improving health literacy can have a range of benefits, including building resilience, encouraging positive lifestyle changes and empowering people to effectively manage long-term health conditions; all of which can help to reduce the burden on over-stretched health and social care services, improve everyone’s general health and wellbeing, and reduce unfair differences in health.

We’ve therefore set out simple, effective and cost-effective examples of health literacy strategies that are known to improve health outcomes. These include: the ‘teach-back’ method, which involves professionals asking service-users to repeat the information they have just received to check for understanding; local areas adopting an early-intervention approach to health literacy promotion, and; community-based, peer-support approaches to help distribute health literacy among social networks.
Even small changes to the way we communicate health information can make a big difference. 

Whether you’re a professional who works to improve the conditions in which people are born, grow, live, work and age (across all tiers of an organisation), or a community-member, we all have a role to play in making sure that the information people need for a healthy life touches, and is understood and used by everyone, but especially those who have the most to gain.

Dr Angela Donkin Responds to Alarming New Data from Joseph Rowntree Foundation

Today JRF published alarming data that illustrate again an increase in the numbers of households not able to afford an acceptable standard of living. Of all the households studied, there has been an increase in those unable to afford an acceptable standard of living, from 21% in 2008/9, to 24.8 % in 20011/12, and now to 27.3% for this year.

For families with children it is more worrying.  In 2008/9 30.6% were unable to afford a minimum standard of living, now the figure is at 39%.

In the Marmot Review we made it very clear that having a sufficient income to lead a healthy life was a key social determinant of health. Therefore increasing numbers living below acceptable standards will be bad for health outcomes, and inequalities in health.

Not having enough money makes it difficult to afford a healthy diet, decent housing, fuel for heating and cooking, appropriate clothing, and to pay for any exercise that carries a cost.  Items such as travel and birthday cards that are important for social integration, are often out of reach. Alongside the associated health impacts of inadequate nutrition, and cold and damp housing, not having enough money, and particularly being in debt, is associated with increased stress and depression.  Increased stress and depression have been linked to a range of negative health outcomes, and can have a negative impact on children’s development.

It is deeply embarrassing to live in a country where nearly 4 out of 10 households with children cannot afford a decent standard of living.  We support JRF’s call for improvements in income and efforts to moderate the costs of essential goods.   

Dying of Cold

This blog is written by Jessica Allen, Deputy Director of the Institute of Health Equity, and is based on an article published by Public Health Today in September 2011.

Every year we have a public health emergency in England – it's called winter.  In 2008/9 there were 35,000 excess winter deaths associated with the cold.  Every year, the increase in deaths during winter months is measured, assessed, published and analysed, and every year the figures are shocking – and this winter they are likely to be even worse.  Just imagine the huge national outcry, level of resources and political attention if flu or BSE or other public health threats killed and harmed as many people.

In London, an average of 3,710 Londoners die every year as a result of living in a cold home, and there are over 23,000 additional emergency hospital admissions and almost 93,000 additional outpatient attendances. An awful lot of avoidable suffering and expense.

Many of these deaths and illnesses are preventable. The effects of cold homes are not confined to excess mortality, as our report 'Health Impacts of Cold Homes and Fuel Poverty' shows. They include reduced weight gain in infants, asthma in young children, impeded ability to learn in older children, various and often multiple mental health problems in adolescents, increased incidence of colds and flu, exacerbation of rheumatism and arthritis, depression and dementia, and chronic lung diseases, heart attacks and strokes in older people.

The numbers of people in fuel poverty, and suffering the health and financial impacts, will rise this winter as fuel prices increase.  More people will die and be made ill and suffer mental health problems.  There are many good local interventions to reduce the impacts, but they are of insufficient scale and often lack resources – many are being cut altogether.

Recent changes in policy may worsen the impact of cold weather.  We need urgent, national action in 3 areas:

1.   Fuel prices: Fuel prices continue to rise and without tighter controls and demands on fuel companies to keep prices affordable it will be very difficult to stop increasing fuel poverty. It is not right that publicly funded payment schemes to householders act as subsidies to fuel companies, and increase greenhouse gas emissions.
2.  Household income: In times of increased unemployment and cuts to welfare spending it is very important that household incomes are sufficient to enable householders to keep their homes warm. 
3. Domestic energy efficiency: To address both fuel poverty and climate change it is necessary that the energy efficiency of homes is dramatically improved, an activity that is difficult but not impossible. The more insulated homes there are, the lower the winter mortality from cardiovascular disease – the UK, Ireland and Portugal all have warmer winters than other countries  in Europe, such as Finland and Sweden, which have much lower death rates and ill health from the cold.  That is because their homes are insulated.

We know the scale of our annual public health emergency, and we know what to do to prevent it. 

Jessica Allen