In the first of our blogs for the new decade, we welcome this post from Hamish Robertson, University of Technology Sydney, emphasising the contribution that population geographers can make to wider discussions of multimorbidity in the context of population ageing.
Population Ageing and Multimorbidity
In the Population Research Group, we all know that populations are dynamic entities. Population ageing in particular is re-shaping, or perhaps complicating, a wide range of social policy, economic and everyday aspects of society. This dynamic demographic process is also highly variable across countries and regions, but one constant is that population-level ageing has direct effects on the epidemiology of older people and consequent flow-on effects for health and social care systems, both formal and informal, funded and unfunded. One of the key intersectional demography-epidemiology features of the coming decade will, I suggest, be multimorbidity.
Older people’s health, unlike those in mid-life, is characterised by decline across a variety of physiological systems and rising clinical complexity associated not only with their primary health problems but also current treatment approaches including both clinical care and systemic service arrangements. So, for example, an older person is likely to be receiving multiple medications to address both their diagnosed health condition(s) and also the side effects of some the treatments they are on (e.g. blood pressure medications can make the patient dizzy or cause gastrointestinal distress etc.).
In addition, as older people’s healthcare trajectories progress, especially with chronic disease states, they may accumulate additional health ‘deficit’s’ associated with their primary health problems. For example, a dementia (syndrome) diagnosis is likely to eventually reach a clinical threshold in which various aspects of their central nervous system start to show decline (cognition, movement, behaviours, perception etc.) and a specific diagnosis of Alzheimer’s disease, Dementia with Lewy Bodies, a Fronto-Temporal Dementia or, as is increasingly common, some form of mixed dementia becomes identifiable.
By this stage, what we are often seeing is a mix of progressive clinical factors, treatment modality side-effects, and physiological sub-system changes combining to increase the health ‘burden’ experienced by the individual and the stress and/or complexities associated with their care. In other words, multimorbidity has come into play and, as population ageing progresses globally, this scenario will become increasingly common. The question then is, how will we work with and address these rising complex scenarios to the benefit of patients and their families?
Clinical and Systemic Complexity
Currently, many healthcare systems are poorly coupled across the primary care, sub-acute and acute sectors. When we add social care to that mix, an essential element if people are to age well in their communities, then that complexity scales up markedly. Ambulance services often see the consequences of this systemic dissonance with multiple callouts for an older individual until catastrophic events ensue. Medical specialities are slow to change and tend to protect their profession at the expense of systemic change and adaptation (with or without the inevitable financial consequences). New sub-specialities eventually emerge but not necessarily in a timely manner. The consequences for an ageing population of these often reactive strategies is a scenario in which many older people fear entry into aged care and hope for home-based support up to and including the point of their, eventual, death.
One of the roles of population geographers is, for me, that capacity to unpack generalised demographic scenarios and the cultural tropes offered up (poor ‘lifestyle choices’ for example) as excuses for not undertaking systemic change. At the same time, we also tend to know where these people are, how they are changing socially and clinically, and what probable problems are coming down the line for which we need to be prepared. Population geographers, and related sub-fields such as health geography, have a contribution to make.
Without the skills and knowledge of geography, the health and social care systems that exist to support population ageing will tend to continue to treat individuals in isolation and continue to separate out the easier parts of age-related health problems into convenient little bundles of care. This approach won’t work for rising multimorbidity because space, place and scale all matter. In effect, I propose that population ageing and its inevitable consequences are a key focus for geographers in the coming decades.