The Chief Public Health Officer's Report on the State of Public Health in Canada 2014 – Changing demographics, aging and health

Changing Demographics, Aging and Health

The structure, composition and distribution of the population influences public health. Canada's population has—and continues to—change. This section explores Canada's population, looking specifically at the shift toward an older demographic and its influence on health. This section:

• includes a broad examination of demographic trends and how these will influence public health in the future; and
• discusses select health issues and other factors where public health attention or action can improve healthy aging.

A changing population

Canada's population continually undergoes changes in pattern and growth. From confederation until the turn of the 20^th century, Canada's population grew slowly, at an annual growth rate of 1.3%, and this growth was primarily due to natural increase—more births than deaths.^{Footnote 4-6} Between 1941 and 1971, the baby boom and increased immigration pushed Canada's annual population growth to about 2.1%.^{Footnote 4} Since then, the rate of annual population growth has stabilized at slightly above 1%.^{Footnote 4,Footnote 5,Footnote 7}

Since 2001, population increase has mostly been as a result of immigration.^{Footnote 4,Footnote 5} In 2011, Canada's overall foreign-born population represented 20.6% of Canada's total population (with varying length of residency in Canada).^{Footnote 8} The majority of newcomers (those who immigrated in the past 5 years) migrated during their working years (median age is 31.7 years).^{Footnote 8} While numbers of immigrants are increasing, their fertility rate (birth of second-generation immigrants) is similar to the overall Canadian rate.^{Footnote 4} The global aging population may also influence Canadian migration patterns in the future.

Canada's aging population

Public health and the aging population

The long-term impact of an aging population on society is largely unknown, but public health professionals must plan for future health issues associated with an aging population and the expected increase in demand for programs and practices. Public health has a role to play in:

• optimizing health and well-being for all ages by contributing to reducing the impact of disease and injury through prevention and health promotion activities across the lifecourse;
• addressing risk factors and the determinants of health by advocating change to address the root causes of disease as well as differences in health between populations;
• factoring complex health problems into planning by considering those living with multiple health conditions (comorbidities) and developing broad policies as well as individual and population interventions that tackle these conditions; and
• creating a society for all ages by taking into account the needs of all populations and intergenerational issues, as well as promoting healthy behaviours from birth to old age as well as encouraging age-friendly universally accessible environments.

Health issues and an aging population

An aging population indicates that society has met many of the requirements needed for people to live longer and healthier lives.^{Footnote 29,Footnote 30} Still, many health trends and issues that are of concern have their foundation in younger age groups, suggesting that more can be done to ensure healthy aging in younger age groups. As well, many of today's seniors live with one or more chronic diseases, have a mobility issue, or experience a mental health problem.^{Footnote 29-31} Key health issues are highlighted here because they represent:

• trends among younger age groups that can adversely affect health over the long term; and/or
• a significant burden of disease for seniors, with rates that are of concern and/or increasing and a related cost that will continue to impact individuals and societies.

Chronic conditions

The incidence and impact of chronic conditions in the later years can be influenced by experiences and health issues from earlier in the lifecourse.^{Footnote 32} These include being overweight or obese, healthy diet and physical activity, mental health problems or injuries.^{Footnote 29,Footnote 33-36} Yet, apart from an overall decrease in smoking rates, younger age groups have less healthy behaviours and less healthy weights and are living longer with chronic diseases and mental health concerns than previous generations.^{Footnote 37-44} While the causes of some diseases are unknown, healthy behaviours such as participating in physical activity can positively influence healthy aging.^{Footnote 29,Footnote 45}

A range or combination of health issues such as living with one or more chronic diseases, having an acute disease or condition and/or experiencing a loss of cognition or mobility can adversely influence quality of life. Comorbidities also increase demands on the healthcare system.^{Footnote 30,Footnote 46,Footnote 47} In 2012, 85% of seniors aged 65 to 79 years and 90% of seniors aged over 80 years reported having at least one chronic condition.^{Footnote 38,Footnote 48} About 24% of seniors have three or more chronic diseases and account for 40% of all healthcare use among seniors.^{Footnote 30} Currently, people aged 85 years or older with no chronic disease use half as many health services as people aged 65 to 74 years who have three or more chronic diseases.^{Footnote 30} Public health can help alleviate this by focusing on the earlier, pre-senior years and upstream efforts to protect younger Canadians from disease and injury and promote healthier practices.

Living with chronic conditions can also weaken the immune system and increases the likelihood of complications due to interactions between medications. This vulnerability can increase susceptibility to infectious diseases such as seasonal influenza, food and water-borne infections as well as healthcare-associated infections.^{Footnote 49,Footnote 50}

About 76% of Canadian seniors in private households reported using at least one medication (prescription and/or over-the-counter) to manage chronic diseases, decrease pain and increase physiological function, and 13% had used five or more medications in the past two days.^{Footnote 51} The proportions are even higher among seniors living in institutions, where 97% used one medication and 53% used five or more.^{Footnote 51} Problems associated with multiple or frequent use of medications can result in reduced effectiveness, more side-effects or dependency and increased risk of falls.^{Footnote 51,Footnote 52} It is estimated that about 50% of prescriptions are not taken properly by seniors, and about 20% of hospitalizations of people who are 50 years and over are the result of problems with medications.^{Footnote 52}

Medication use (and associated drug-related spending) is projected to continue to increase based on an expected increased use among seniors and current medication practices among younger populations.^{Footnote 53} Some of these medications may be taken because of physician-patient miscommunication, inaccessibility to other therapies, lack of medication reviews and reliance on multiple pharmacies or physicians.^{Footnote 54} In particular, as the baby boom generation ages, a substantial increase in substance misuse is anticipated as this age group uses more medications than did previous generations.^{Footnote 55} To help address this issue, Health Canada, through the Drug Strategy Community Institute Fund (DSCIF), has called for proposals to improve prescriber education through the development of guidelines, training and tools.^{Footnote 56,Footnote 57}

Tuberculosis (TB) is a preventable and curable infectious disease, and yet it remains a significant global public health challenge.Footnote 1, Footnote 2 Each year, tuberculosis infects millions of people and is the second leading cause of death due to infectious diseases worldwide.Footnote 1 While the majority of TB cases and deaths occur in low- and middle-income countries, TB does exist in Canada.Footnote 1, Footnote 3, Footnote 4 During the first half of the twentieth century, TB was one of the leading causes of death and hospitalization; today, however, TB disease and death rates in Canada are low.Footnote 4-Footnote 6 Still, certain populations are disproportionately affected by TB, including the foreign-born and Canadian-born Aboriginal populations.Footnote 3, Footnote 4 As well, new treatment-resistant strains of TB are emerging.Footnote 7, Footnote 8 Efforts to reduce impact of this infection are ongoing.

Tuberculosis infection and disease

TB is an infectious bacterium that is spread from person to person primarily through the air.^{Footnote 8, Footnote 9, Footnote 13} TB bacteria of the lungs or airways enter the air when a person with active TB disease exhales by coughing, sneezing, and even just talking.^{Footnote 8, Footnote 13} Once in the air, the bacteria can stay there for hours.^{Footnote 8, Footnote 13} Once an individual inhales them, the human body can react in one of three ways:

• a healthy immune system can fight off the TB bacteria;
• the immune system is not able to fight the TB bacteria completely and inactive bacteria stay in the body (latent TB infection);
• the immune system does not respond sufficiently, allowing the TB infection to take hold and symptoms to start showing (active TB disease).^{Footnote 11, Footnote 14}

Many factors influence the development and spread of TB. Known risk factors for developing either latent TB infection or active TB disease include:

• having a weakened immune system or underlying illness such as human immunodeficiency virus (HIV) or diabetes;
• coming into close contact with individuals with known or suspected TB, for example, by sharing living space or living in communities with high rates of infection or disease;
• having a personal history of active TB;
• having received inappropriate or inadequate treatment for TB disease in the past;
• living in a low income household, in crowded and inadequately ventilated housing or experiencing homelessness;
• being malnourished or affected by other socio-economic conditions;
• having a history of smoking or substance abuse;
• being a resident in an institutional setting such as a long-term care or correctional facility; and
• working with people at risk of developing TB (e.g. healthcare professionals, correctional staff).^{Footnote 13, Footnote 15, Footnote 16}

TB is a classic example of the relationship between an infectious disease and the social determinants of health.Footnote 16 A landmark study illustrated TB's decline in the U.K. from 1838 to 1970, and attributed this decline primarily to improving social and economic conditions rather than clinical advances.Footnote 17 The research claims that, while effective medical interventions (e.g. antibiotics, chemotherapy) helped to reduce TB rates, those interventions were introduced only after TB rates were already in decline, and thus could not have been the main driving factor.Footnote 17 Rather, it was improvements to nutrition, hygiene, housing and working conditions in the post-industrial era that contributed most to the health progress achieved during this era.Footnote 17, Footnote 18

Mental health across the lifecourse

Mental health problems and mental illness can occur at any point in the lifecourse.^{Footnote 67,Footnote 68} The current mental health status of younger generations will be an important indicator for aging in the future. Those living with poor mental health or a mental illness are at greater risk of developing physical and mental health problems later in life. For example, depression raises the risk of heart disease and stroke and reduced longevity.^{Footnote 34,Footnote 69}

Certain risk factors for poor mental health tend to increase with age.Footnote 22,Footnote 67 These risk factors include recurrent or chronic mental illnesses that were ineffectively addressed earlier in life; late onset disease; chronic diseases with known mental health complications (e.g. cerebrovascular disease, chronic obstructive lung disease and Parkinson's disease); and cognitive, behavioural and psychological symptoms associated with dementia or other neurological condition.Footnote 67 As well, seniors who have experienced trauma or distress earlier in life, such as First Nations, Inuit and Métis seniors who had attended residential schools, have been shown to have poorer mental health outcomes later in life.Footnote 70

One in four Canadian seniors have a mental health problem or a mental illness.^{Footnote 71} The most common mental health issues were mood and anxiety disorders, cognitive and mental disorders due to a medical condition (including dementia and delirium), substance misuse (including prescription drugs and alcohol) and psychotic disorders.^{Footnote 67} Between 2008 and 2009, 44% of Canadian seniors living in long-term care facilities were diagnosed with or showed symptoms of depression.^{Footnote 72} Seniors had the highest rate of reported symptoms for anxiety disorders with about 5% to 10% of adults 65 years and over affected.^{Footnote 67,Footnote 73}

Older adults may face serious and undertreated mental health issues. Often the diagnoses of age-related health conditions focus on cognitive decline and do not acknowledge possible mental health problems.Footnote 67 Underlying health issues and/or their treatment can also mask symptoms of mental illness.Footnote 67 Changing Directions, Changing Lives: The Mental Strategy for Canada (2012) made a number of recommendations related to changing outcomes for seniors' mental health in the future.Footnote 74 These included countering the impact of age discrimination on mental health; helping older adults participate in meaningful activities, sustain relationships and maintain good physical health; and increasing the capacity of older adults and those who support them to identify mental illnesses, dementia, elder abuse and risk of suicide and the importance of intervening when signs first emerge.Footnote 74 Public health can focus efforts upstream by developing early identification and intervention programs.Footnote 67 Interventions such as the Seniors' Mental Health Policy Lens are intended to facilitate environments that promote and support the mental health of older adults.Footnote 75

Considering dementia and other neurological conditions

The number of Canadians who experience and live with neurological conditions is expected to increase as will the costs of these conditions for individuals, families, healthcare and society.^{Footnote 76} However, difficulties in diagnosis, data accuracy and capture (particularly in institutional settings) creates gaps in information which makes forecasting the future prevalence, duration and potential impacts of these diseases complex.^{Footnote 76} Still, these information challenges do not diminish the importance of these issues.

Globally, the significant burden of dementia (an umbrella term for a variety of brain disorders including Alzheimer's disease) for families, societies, and health systems is expected to grow substantially.^{Footnote 22,Footnote 77,Footnote 78} The World Health Organization estimated that 35.6 million people lived with dementia worldwide in 2010, and predicts this number will double by 2030 and more than triple by 2050.^{Footnote 79} Although the risk of developing dementia increases with age, it is not a normal part of the aging process. In 2011, an estimated 340,200 (2%) of Canadians 40 years and over had Alzheimer's disease and other dementias and this number is expected to double in 20 years.^{Footnote 76} The rate at which new cases of Alzheimer's disease and other dementias are diagnosed is also expected to increase. In 2011, the incidence rate for Canadians 40 years and over was 3.6 cases per 1,000, and this is expected to rise to 5.3 cases per 1,000 by 2031.^{Footnote 76} Increasing numbers of other neurological conditions more prevalent among older age groups, such as Parkinson's disease, will also need to be considered by public health professionals in the context of Canada's aging population. Parkinson's disease affected 84,700 Canadians in 2011 and, like dementias, this number is expected to double by 2031.^{Footnote 76}

Increases in the number of those diagnosed or living with a neurological or related disability will impact direct (e.g. healthcare) and indirect costs (e.g. lost income) in Canada.^{Footnote 76} Most people with dementia will require some level of care—from assisted daily living to residential nursing care.^{Footnote 79} Canadian institutional long-term care demands in 30 years' time are projected to be 10 times the current demand solely based on increases in dementia need and decreasing supply of caregivers.^{Footnote 80} The estimated costs of these demands do not include the social and mental burden of illness on individuals and their families, which cannot be adequately measured based on calculations focusing solely on money or time.^{Footnote 31,Footnote 80} Informal dementia care is projected to rise from a current estimate of 19 million unpaid hours per week to 39 million unpaid hours per week over the next 20 years.^{Footnote 81}

Planning for an increase in demand for care will require more research and the identification of disease and best practices on meeting needs including interventions that support people with dementia and their caregivers.^{Footnote 22,Footnote 30,Footnote 80} A new research hub, the Canadian Consortium on Neurodegeneration in Aging, aims to bring together research on improving the quality of life and services for those living with the effects of neurodegenerative diseases and their caregivers.^{Footnote 82}

In 2010, the estimated global costs — including direct and indirect — of dementia were estimated to be approximately US $604 billion.^{Footnote 79} The 2013 G8 Summit Global Action against Dementia focused on research and the growing public health and economic impacts of dementia (see the textbox "Global Action against Dementia").^{Footnote 83} Canada endorsed the declaration released at the Summit and, as part of the 12 commitments it outlines, is co-leading one of the Legacy Events that aims to foster collaborative efforts between academia and industry.^{Footnote 83,Footnote 84}

One step in reducing the impact of dementia is to increase public understanding of the diseases and their risk factors.^{Footnote 77} Evidence suggests that engaging in healthy behaviours (particularly nutrition and physical activity) as well as reducing comorbidity can decrease the risk of dementia, delay onset and reduce the severity of its impacts.^{Footnote 77,Footnote 80,Footnote 86,Footnote 87} In addition, underlying chronic diseases and conditions such as type 2 diabetes, hypertension and obesity can influence the risk for Alzheimer's disease and other dementias, preventing and managing chronic diseases is important.^{Footnote 77,Footnote 80,Footnote 86,Footnote 88}

Preventing injuries and falls

Across all age groups, injuries are a major cause of disability and death and are one of the leading causes of hospitalization in Canada.^{Footnote 89,Footnote 90} Residual effects of injuries suffered earlier in life or new injuries during the senior years can significantly impact aging, mobility and independence.^{Footnote 89,Footnote 91} Of particular concern to seniors are injuries as a result of falls.^{Footnote 92} Such injuries will continue to be a public health issue in Canada in the future.^{Footnote 89}

Between 20% and 30% of Canadian seniors will experience a fall in any given year.^{Footnote 89} Almost half of these falls result in a minor injury, and 5% to 25% cause serious injury.^{Footnote 92} Considering the current rate of falls and projected population growth, estimates show Canada could expect between 2.1 and 3.1 million falls among seniors in 2036.^{Footnote 16,Footnote 89}

Falls among seniors can result in acute injury, traumatic brain injury, chronic pain, reduced quality of life, precipitation of long-term care and even death.^{Footnote 89,Footnote 91-93} Although preventable, most falls are a result of a combination of compounding factors (including biological, behavioural, environmental and/or socioeconomic factors).^{Footnote 89} These factors can interact to influence a person's ability to keep or regain balance.^{Footnote 89} Having underlying health conditions or disabilities can increase the likelihood of sustaining injuries with falls.^{Footnote 89,Footnote 93} Falls can result in painful fractures that often require surgery and can have long-term health consequences including increased vulnerability to other health conditions.^{Footnote 89,Footnote 94} Recovery from a fall involves not just physical healing but also psychological adjustment.^{Footnote 91-93} Periods of immobility can lead to further frailty and increased loss of autonomy. Post-fall syndrome can lead to fear and anxiety of additional falls, loss of independence and immobility.^{Footnote 89,Footnote 91} While older people's falls are of concern, the increase in chronic conditions among younger people, as well as less healthy behaviours, can affect their future mobility and increase their risk for falls during their senior years.^{Footnote 93-95}

Research on fall prevention has increased over the last decade, and there are a number of ways known to reduce the risk of falls.^{Footnote 89} Broad population-based practices such as falls prevention guidelines, education and awareness programs have been shown to reduce falls.^{Footnote 89,Footnote 96} As well, individual risk assessment practices have been effective.^{Footnote 89} Creating accessible and encouraging environments can also make a difference.^{Footnote 26,Footnote 97,Footnote 98} Many seniors live in environments that fail to meet their physical and mental health, transport and social needs.^{Footnote 29,Footnote 31,Footnote 99} In response, an international age-friendly movement has evolved to identify community-based factors, such as land use planning and urban design, that can improve the health outcomes for seniors.^{Footnote 97,Footnote 98} The goal of adopting the age-friendly approach is to ensure that seniors are involved in community-level decision making that allow programs and policies to facilitate seniors aging in a place of their choice and independent living.^{Footnote 97,Footnote 98} Ensuring that infrastructure, housing, services and technologies are universally accessible can create a safer environment for all ages.^{Footnote 26,Footnote 100} By applying principles of universal design (creation of environments and products are inclusive to the largest number of people without requiring modifications) there are opportunities to support all populations.^{Footnote 29,Footnote 99-101}

Changing demographics, aging and society

As the population changes, how societies organize themselves and relate also changes. With an aging population there are expected issues with supply and demand of select services such as health services.^{Footnote 29,Footnote 30} There are also changes in relationships including families and society.

Shifting views on aging

With a changing population the structure of elements of society such as family, work and other social networks also evolve. These elements are important determinants of health, and how they change and interact for individuals and within populations will also shape future health outcomes. Planning for changing demographics involves challenging attitudes and perceptions about aging and the roles of seniors, family and societal organizations (see the textbox "Myths associated with an aging population").^{Footnote 102,Footnote 103}

Valuing aging starts with challenging these myths and changing attitudes.^{Footnote 29,Footnote 31,Footnote 104} With aging, as with most life transitions, there are changes but not all are negative. Also, disease is not driven by age alone. Healthcare is an important component for all populations, and while seniors can be larger users, other issues such as staying active and living independently are more often a focus.^{Footnote 102} In addition, evidence suggests that investments into healthy aging can reduce healthcare and related costs.^{Footnote 29,Footnote 105}

Tackling ageism is a global priority and efforts have been made to establish positive ways to view aging.^{Footnote 31,Footnote 106} One component of these efforts is to empower seniors to fully and effectively participate in the economic, political and social lives of their communities through income-generating and voluntary contributions.^{Footnote 26,Footnote 29,Footnote 104} In 2009, the Canadian Federal/Provincial/Territorial Ministers Responsible for Seniors created The Seniors' Policy Handbook: A guide for developing and evaluating policies and programs for seniors to help policy planners consider seniors perspectives, diversity, and current and future issues.^{Footnote 107} Work still can be done to develop national programs to address ageism and promote societies for all ages.

Securing a future

With the portion of the population aged 65 and older increasing, concern for health issues associated with not meeting basic needs may arise.^{Footnote 29,Footnote 108} Without meeting seniors' basic needs—adequate food, shelter, security and healthcare—seniors' health could be compromised.^{Footnote 96} Over the last two decades, Canada has been effective at reducing overall poverty among people 65 years and over.^{Footnote 109} Still, 5.2% of seniors live in low-income after-tax households (see Appendix A).^{Footnote 109} As well, with an increasing proportion of seniors in the population there is some question about the state of pensions and economic security in the future. Although the debate continues across jurisdictions, efforts are being made to ensure that Canada's retirement income system is sustainable, reflects demographic change and continues to meet the seniors' needs.^{Footnote 110} For example, age of eligibility for the Old Age Security (OAS) program has been increased from 65 to 67 years (effective 2023) and Canadians can now defer OAS pension for up to five years to receive a higher pension.^{Footnote 110} Changes were also made to the Canada Pension Plan (CPP) to increase flexibility and sustainability in the future. As well, the Guaranteed Income Supplement was increased to assist low-income seniors.^{Footnote 110-114} Additional annual targeted tax relief has been created by increasing the Age Credit and Pension Income Credit, raising the age limit for maturing savings in Registered Retirement Savings Plans and introducing pension income splitting.^{Footnote 115}

The ability to meet future economic needs in years to come will be influenced by the composition of the senior population. The senior population will continue to be diverse and vulnerable segments—the very old, unattached, Aboriginal seniors, and those with disabilities—will require further consideration. In light of the current demographic composition and projected change, a significant proportion of future seniors will clearly be foreign-born.^{Footnote 4,Footnote 8} Although variation exists, the low-income rate among senior immigrants has declined and was halved between 1980 and 2005.^{Footnote 116} The longer immigrant seniors live in Canada, the more their economic situation converges with the trends of the overall population.^{Footnote 117-119} Also, issues may go under-detected given that recent immigrant seniors tend to live with extended family, act as parent/grandparent caregivers or rely on support networks.^{Footnote 117}

Access to economic supports and the benefits typically eligible for seniors often require having been previously employed and having made long-term contributions to earnings and pension programs. This is often not the case or exists at a reduced level for recent immigrant seniors.Footnote 117,Footnote 119 Canada has developed over 50 social security arrangements with other countries to facilitate benefits for immigrant seniors; however, other barriers can be experienced.Footnote 117,Footnote 120 Further investigation into the well-being of this population will help guide policies for public health and other sectors and identify future health needs.Footnote 117

Families and partnerships and society

Demographic changes have created complex, multi-generational and diverse families and communities.^{Footnote 121} Changes in partnerships, number of children and increased social activity among seniors have altered the roles of older people in Canadian families and partnerships.^{Footnote 104,Footnote 121}

In 2011, most Canadian seniors (92%) lived in private households and some lived in collective dwellings (8%), however of those collective dwellings almost half were 85 years and over.^{Footnote 122} The number of seniors who live with a spouse or a partner increased between 1981 and 2011.^{Footnote 122,Footnote 123} As the life expectancy of men and women has begun to converge, the number of years in a partnership and living in private households has increased. Still, a significant number of seniors — 35% of women and 17% of men — live alone.^{Footnote 123} Living alone does not necessarily mean living in isolation, however, level of social engagement or marginalization can depend on an individual's access to community facilities, transportation and affordable activities as well as having meaningful roles in the community.^{Footnote 29,Footnote 96,Footnote 98,Footnote 124}

Intergenerational relations have also shifted as a result of demographic change.^{Footnote 31,Footnote 121} On the one hand, familial relations and obligations have changed and distance between family members changed and widened.^{Footnote 121} On the other, there have been societal shifts in attitudes about the important role of external factors such as primary and institutional care and assistance with daily living.^{Footnote 104,Footnote 121} Despite these changes, middle generations, commonly referred to as the "sandwich generation," who support both younger and older family members in some capacity are reporting growing stress.^{Footnote 125,Footnote 126}

Intergenerational tensions are often seen as a risk of demographic change. Within society, sharing resources between generations raises debate as to who pays when and how much.^{Footnote 22,Footnote 105} With a larger proportion of the population in one age group questions remain as to whether public investments should focus on the needs of one population at the expense of others. Policy makers will need to achieve intergenerational equity to not polarize generations and/or populations.^{Footnote 22} A focus on healthy aging should investigate younger populations, those who are foreign-born as well as those living in remote communities.

Focusing on care

As the demand for support services from informal and formal networks is expected to double over the next 30 years, the question for public health is how to best meet the needs of Canada's seniors and their caregivers now and in the future.^{Footnote 125,Footnote 128} Age-related care can be complex and involve both formal (healthcare, home and long-term care) and informal (non-paid, often family care) practices.^{Footnote 129} While many types of care require attention, this section only discusses informal care.

At some point, almost half of Canadians will have provided care to someone with a long-term health, disability or age-related need.^{Footnote 125} Spouses/partners provide the most care hours per week (14 hours), followed by children caring for a parent (10 hours).^{Footnote 125} In 2012, almost half of all caregivers over the previous year were providing some care for a parent or parent-in-law.^{Footnote 125} When asked, caregivers identify age and specific diseases (such as cancer, cardiovascular disease, mental illness and Alzheimer's disease and dementia) as the most common reasons for needed care.^{Footnote 125,Footnote 127}

As the population ages and population distributions change, the availability of adult-child caregivers may decrease.^{Footnote 128,Footnote 130} Meeting future demands will require consideration of the next generations' needs and the supply of caregivers.^{Footnote 131} Factors that influence the caregiving supply are living spouses and an increase in senior volunteers since the large majority of caregivers are seniors.^{Footnote 128,Footnote 132,Footnote 133} As well, the decline in births and survivor children (especially among the elderly seniors) means that there will be fewer children to provide parental care.^{Footnote 132} In many communities, especially those in remote and rural areas, over-dependence on a few local caregivers (primarily women) and an out-migration of younger family members and volunteers, can contribute to resource deficits in areas where formal care services may also be less available and/or adequate.^{Footnote 134} Given these changes, in the future Canada may need to rely more on a formal care system paid for by individuals and/or society.^{Footnote 128,Footnote 131}

Despite the demands of caregiving, many (73% of employed caregivers) report that they are satisfied with the current balance between their work and home life.^{Footnote 125} Still, caregivers also report feeling tired, stressed, worried or anxious.^{Footnote 125} The numbers of adverse feelings increases with number of hours committed to caregiving per week.^{Footnote 125,Footnote 135} Beyond the effects on individuals, there are broad impacts of caregiving on the labour market, governments and the economy.^{Footnote 136} Employee turnover and missed paid work due to informal caregivers' obligations was estimated to cost Canadian employers $1.28 billion in lost productivity in 2007.^{Footnote 137} In the same year, the cost of replacement for unpaid caregivers was estimated to be $24 billion.^{Footnote 138} To address this issue, the Government of Canada announced the intent to develop and launch a Canadian Employers for Caregivers Plan to engage with employers on cost-effective workplace solutions that will help maximize caregivers' labour market participation. The Plan will include the creation of an employer panel that would identify promising workplace practices that support caregivers.^{Footnote 115}

In the short term, a range of policies could support family and friend caregivers caring for older Canadians—flexible labour practices, income security, home/continuing care as well as health promotion and caregiver education and training.^{Footnote 128} Creating flexible workplaces may enable caregivers to continue working while also reducing the negative consequences of job interruption, reduced income and lower retirement pensions. In the longer term, reduced availability of caregivers may increase reliance on the formal system.^{Footnote 128,Footnote 131} As a result, broad-based home care, greater community involvement and private enterprise (for individual paid care) may need to be utilized more. Such practices involve increased expenditures for individuals as well as use of privately offered care.^{Footnote 128} However, privately offered care is not accessible and affordable to all who may require it.^{Footnote 131} Broad and comprehensive social approaches to deliver care may be necessary to improving wages and benefits, training standards, availability in remote areas, and improving recruitment and retention of these essential workers.^{Footnote 131}

Participating in community and work

Demographic change has raised concern for a possible inequitable burden of labour and community participation across population groups.^{Footnote 22} From the early 1920s to the mid-1960s, about 60% of Canadians were working age, but then, the baby boom population increased this proportion to nearly 70%.^{Footnote 14} In the future, this proportion is expected to decline rapidly and the number of working-age Canadians will fall from about 5 for every senior in 2012 to about 2.7 for every senior by 2030.^{Footnote 14} Views on retirement are evolving as people now tend to reach the age of retirement healthier and more active than in previous generations.^{Footnote 29} Some older people may want to be employed for the sake of a second or subsequent career, whereas for others, employment may also be a necessity to make ends meet.^{Footnote 22,Footnote 139} As more seniors work longer for financial reasons, social engagement and activity, the average age for retirement is increasing.^{Footnote 139,Footnote 140} Canada no longer has a mandatory age of retirement.^{Footnote 113}

Seniors' participation in the labour force has more than doubled since 2000, from 6.0% in 2000 to 13.0% in 2013.^{Footnote 141} In particular, for those aged 65 to 69 years, the participation rate more than doubled between 2000 and 2012 from 11.4% to 25.5%.^{Footnote 141} Seniors' participation in the labour force attenuates some of the impacts of a decreasing labour pool, leverages investments made in seniors' knowledge and skills, and provides opportunities for older Canadians to remain engaged and socially connected.^{Footnote 22,Footnote 31,Footnote 142}

Not all seniors are working into old age. Older workers report health problems as the most common reasons for premature exclusion from the workforce.^{Footnote 143} Of the 35% of workers who left work before their expected age of retirement, about 24% reported having three chronic conditions.^{Footnote 143} Older workers suggest that having opportunities to change work patterns (work part-time or have flexible hours), change careers or work in more accessible and age-friendly environments would extend their participation in the workforce.^{Footnote 142,Footnote 144} An UN report noted that employers who effectively supported older workers did so by offering flexible hours and promoting personal-development programs to keep workers active by participating in physical and mental activities.^{Footnote 145} They also provided flexible work schedules to accommodate the needs of workers who are also caregivers to older individuals and increased part-time work opportunities among seniors.^{Footnote 144} Making such changes to the workplace benefits all of society and can be enabled by collaborations across workplaces and jurisdictions.^{Footnote 142,Footnote 144}

Extended periods of retirement are often spent in good health and provide opportunities to be involved with family and/or community. While seniors provide the highest average number of volunteer hours, volunteering and community involvement tends to decline with age.^{Footnote 146} Seniors programs depend on volunteers and much informal care is given by seniors.^{Footnote 104} All sectors can contribute to increasing Canada's volunteer sector by encouraging future volunteers. People who volunteer when they are young are more likely to continue these contributions later in life.^{Footnote 104,Footnote 146,Footnote 147} In the future, public health may depend on the work of volunteers and can promote evidence that points to protective factors for health associated with volunteering and being involved in community.^{Footnote 147,Footnote 148}

Continuing research and understanding population change

Looking ahead to how Canada will adapt to a changing demographic involves projecting and forecasting based on current and known realities. The health issues impacting today's seniors are known but it is less clear what role these health issues will play in the future or how factors that influence the health of today's younger Canadians are interconnected and will evolve over time and as individuals age.^{Footnote 22,Footnote 29,Footnote 30} Canada has identified the need for research on aging and evidence to support the enhancement of programs, services, policies and care. The Canadian Longitudinal Study on Aging (CLSA) was established to contribute to meeting these needs (see the textbox "The Canadian Longitudinal Study on Aging").^{Footnote 149}

In addition to looking at aging populations more research is needed to consider how to address health issues of all populations and age groups over time to ensure the health of the population across the lifecourse.

Continuing efforts

While Canada has made great strides in implementing public health initiatives to maintain and improve the health of Canadians as they age, considerable challenges remain. The continued prevalence of unhealthy lifestyles and of chronic diseases challenges healthy aging now and is likely to continue to do so. Public health can invest in research, prevention and promotion programs and policies for seniors as well as younger Canadians to help reduce the burden of disease and increase the capacity for healthy aging over the next generation and beyond.