Setting the Context
Supporting healthy ageing requires emphasizing wellness and prevention opportunities for all Canadians, especially when earlier life health activities can make a real difference to later-life health-related outcomes and costs. All Canadians, and not just older Canadians, can benefit from a greater understanding of how the things they do earlier in life can affect their overall health and wellness in their later years. Proper nutrition, regular physical exercise, proactively addressing hearing and vision issues, and avoiding certain activities such as smoking have been shown to reduce the likelihood of developing a variety of chronic diseases and extend overall life expectancy as well. In fact, through better management of vascular risk factors (e.g. diabetes, high blood pressure), an overall decline in the prevalence of certain forms of dementia has been seen in the population.[1],[2]
The greatest barrier to advancing healthy ageing is that the ‘health literacy’ skills, or the ability to access, understand, evaluate and communicate information as a way to promote, maintain and improve health in a variety of settings across the life-course[3], remain extremely low. In fact, it was recently shown that only 12% of older adults have adequate health literacy skills to support them in making basic health-related decisions.[4] Therefore, any broad efforts to support healthy ageing will need to place an equal emphasis on improving the health literacy skills of Canadians to ensure they can both appreciate and understand the things they can do to stay healthy and independent for as long as possible.
With respect to accessing information and resources that promote healthy ageing, although ‘online’ options can be very effective, only 61% of Canadians age 65 to 74 report that they use the internet daily and this drops to 35% for those over 75.[5] While the older adults are amongst the fastest growing demographic using the internet, improving health literacy and overall awareness of important issues will need to incorporate a variety of channels to ensure that all older adults can have access to information, including resources tailored to the full diversity of the population.
What Are the Issues?
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A Majority of Older Canadian Are Still Not Receiving All of Their Recommended Vaccinations
The vast majority of Canadian children and young adults are receiving their recommended vaccinations. However, the recommended vaccinations for older Canadians, such as influenza, pneumonia (pneumococcal), and shingles (varicella/herpes zoster) vaccinations have uptake rates below recommended levels, despite the proven benefits to older individuals. Additionally, the tetanus vaccination is recommended at regular intervals across the lifespan, but this is not emphasized adequately for older adults. Overall vaccination rates among adults in Canada remain stubbornly low, and for some diseases, such as influenza, appear to be declining in some parts of the country (See Table 1). Specifically, Canada remains below the Public Health Agency of Canada’s (PHAC) national immunization target of having 80% of the population vaccinated against influenza and pneumonia vaccinations.[6] With evidence showing the overall positive benefits of annual influenza vaccinations,[7] Canadian public health authorities have made progress in increasing the uptake of the influenza vaccine in older adults. Yet, the uptake of other vaccines such as pneumonia, shingles and tetanus are well below the recommended rates for older Canadians (See Table 6).
Table 6. Estimated Rates of Recommended Vaccination Coverage among Older Canadians
Risk Group |
Seasonal Influenza[8] |
Pneumococcal [9] |
Varicella/Herpes Zoster |
Tetanus and Pertussis [10] |
|
| 65+ years of age | 70.7% | 41.6% | 3.9%*[11] | 45.8% | 8.7% |
| General Population | 38.3% | – | – | 54% | 9.7% |
| Additional coverage needed to meet the PHAC 80% target for those 65+ | 9.3% | 38.4% | No target set | No target set | |
* – Canadian coverage rate not available. Figure reflects US Herpes Zoster vaccine uptake rates among older adults.
* – Updated numbers from the Public Health Agency of Canada in 2019 report that 28% of Canadians age 50 or older are estimated to have been vaccinated against the herpes zoster virus.[12]
Low vaccination rates among older Canadians is of concern, especially in the context of COVID-19 and the ongoing concern for older people who are more susceptible to acquiring multiple infectious illnesses than is the general population. There are approximately 3 to 5 million severe cases and 290,000 to 650,000 deaths worldwide due to influenza each year.[13] In Canada, it is estimated that influenza is responsible for approximately 12,000 hospitalizations and 3,500 deaths annually.[14] Influenza also has a serious economic impact leading to an estimated 1.5 million lost work days each year in Canada.[15] Influenza, along with all cases of pneumonia, is the 8th leading cause of death in Canada.[16] Individuals over 65 years also account for one-third of all community acquired pneumonia cases,[17] many of which are preventable as they are caused by a strain of pneumonia that the pneumonia vaccine targets. Despite this, less than half of older Canadians have received the pneumonia vaccine. Finally, 90% of Canadians are at risk of developing shingles,[18] yet only 28% of Canadians age 50 or older are estimated to have been vaccinated against the herpes zoster virus[19], which causes a painful and sometimes permanently debilitating skin and nerve condition. Low vaccine uptake may help explain why 130,000 Canadians are still diagnosed with shingles each year, resulting in 252,000 physician consultations and 2,000 hospitalizations a year, along with significant treatment-related costs, many of which could have been prevented.[20] Older adults are at an increased risk for developing Shingles infection. In Canada, over two-thirds of cases occur in adults over 50 years of age.[21] The Shingles incidence also doubles for adults 80 years and above (8 to 13 cases per 1000 persons per year) compared to those 50 years and above (4 to 6 cases per 1000 persons per year).[22]
There is a great opportunity to further advance the promotion of vaccinations among older adults through focused awareness campaigns and leveraging health care providers and points of care to offer this vaccination. Indeed, pharmacists are now given training and support to deliver influenza vaccinations in 9 of Canada’s 10 provinces. In addition, all provinces and territories except for Quebec have universal funding in place to cover the cost of an influenza vaccine for adults aged 65 or older.[23] In Quebec, individuals aged 60 to 74 do not have access universal access to publicly funded influenza vaccinations.[24] Where vaccines recommended for older Canadians by the PHAC are generally provided at no cost to older Canadians, barriers to their uptake remain, and need to be addressed. Research shows that promoting life course vaccination schedules that include older adults would be beneficial as it would aid in streamlining messaging and practices for providers and the general public.[25]
Canada currently has a National Immunization Strategy (NIS) that outlines immunization as a shared responsibility among the federal, provincial and territorial governments.[26] The strategy was initially established in 2003 by federal, provincial and territorial deputy ministers of health to facilitate inter-jurisdictional collaboration to improve the relevance, effectiveness and efficiency of immunization programs across Canada.[27] In 2016, the federal budget outlined a commitment by the Government of Canada of $25 million over 5 years to increase immunization coverage rates. This would fund PHAC to update national immunization coverage goals and disease reduction targets to improve the ability to identify under- and un-immunized Canadians and develop programs to increase vaccine uptake.[28]
While there are some mechanisms to address immunization at a national level, there remains a patchwork of immunization strategies across the country with different policies and coverage among the provinces and territories. For example, across Canada, it is difficult to capture how pneumococcal vaccines are being administered through physician billing data due to differences in billing codes among provinces.[29]
2. Falls Amongst Older Canadian Are Common, Costly, and yet Largely Preventable
For older Canadians, falls were the leading cause (81%) of injuries that landed them in hospital and represented 60% of all reported emergency room visits and over half of all injury-related hospitalizations from 2017 to 2018.[30] Out of all causes, falls also had the largest increase (9%) for hospitalizations due to sustained injuries over the past 3 years.[31] Falls amongst older Canadians not only threaten their independence and overall well-being, they also account for an estimated $2.3 billion annually in related health care spending across Canada.[32] Furthermore, Canadians who are hospitalized for falls remain hospitalized for an average of 14.3 days, while the average length of hospital stay in general is 7.5 days.[33] In Canada, between 20% to 30% of older adults fall annually, [34] making it one of the most common preventable health care issues for older Canadians.Causes of falls among older adults are multifactorial. Some of the leading causes of falls include: the presence of chronic and acute health conditions that can negatively impact a person’s strength and balance, independent balance or gait deficits, decreased sensory abilities, inadequate nutrition, social isolation, and challenges with the existing environment.[35] There has been a concerted effort on behalf of PHAC to raise awareness of falls prevention strategies nationally, along with many provincial and local falls prevention programs (see Box 4).[36] The federal government introduced a Home Accessibility Tax Credit[37] in Budget 2015, which provides up to $1,500 (15%) towards home renovations, once $10,000 has been spent.[38] Individuals aged 65 years or older, or those holding a valid disability tax certificate, as well as those supporting others who directly qualify, are entitled to claim this tax credit.[39] A more accessible home renovations support program for lower income older adults is the Seniors Safe @ Home Program introduce by the Prince Edward Island government in 2015 which allows up to $5,000 in grants to lower income older adults to support home renovations.[40] Occupational Therapist (OT) led home-safety assessments and related home renovation programs have been shown to be effective and are currently recommended by PHAC for the prevention of falls among community dwelling older adults. [41],[42],[43] Therefore, making these services available and accessible at little or no cost for all older Canadians should be considered an essential component of any national falls prevention strategy.
Nevertheless, in Ontario and other jurisdictions where falls prevention activities are being provided at no out-of-pocket cost to participants, identifying other barriers to participating (such as having suitable complementary transportation services to get people to the classes) is still required to address this significant issue. Falls awareness and prevention activities should also be provided to older adults in a way that is most accessible. Additionally, the federal government should make use of existing investments, such as PHAC’s Participaction Program, to focus on falls prevention for older adults.
Evidence-Informed Policy Options
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Broaden the Mandate of and Fund the National Immunization Strategy in Collaboration with PHAC, to Bring Together the Patchwork of Provincial Immunization Strategies. Include a Life Course Vaccination Approach.
With prevention being one of the most important tools in the health care system, immunization is a key public health policy that requires national leadership. Canada’s current patchwork approach to immunization is not as effective as it could be, and should be supported by national coordination. Through the National Immunization Strategy, there is already a method to bring federal, provincial and territorial governments together. The federal government should properly fund the National Immunization Strategy in collaboration with the PHAC to support building national frameworks with collective and consistent policies across the country including the promotion of life course vaccination schedules for older adults.
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Further Support Provinces to Better Address Falls Prevention
PHAC has recently begun to focus more of its attention on raising awareness of the significant impact falls have on the health and wellbeing of older Canadians and the health system as whole. While the federal government has made substantial investments in programs such as PHAC’s Participaction Program it is almost exclusively focused on promoting physical activity amongst younger Canadians. There is an opportunity to leverage the media reach of Participaction to include healthy ageing, falls prevention, and the benefits of physical activity at all ages. Furthermore, supporting the provinces and territories to advance the adoption of successful, low cost and evidence-informed falls prevention programs has the potential to generate significant savings related to current falls-related health care spending, while also addressing relayed issues like social isolation. As such, PHAC could play a strengthened role as the key knowledge translation mechanism to spread the adoption of falls prevention best practices across the country.
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Advance the Recommended Actions in the New National Dementia Strategy
More than 419,000 Canadians (6.9%) aged 65 years or older are living with diagnosed dementia.[44] The impacts of dementia on the patient, caregivers, and the health care system are significant. With the increasing number of older adults, the main demographic group with dementia, the total health care costs and out-of-pocket caregiver costs of dementia is expected to double between 2011 to 2031 from $8.3 to $16.6 billion in Canada.[45] As understanding of the causes of dementia improve, approaches to dementia care must increasingly emphasize preventative measures. In 2020, the life-course model published by the Lancet Commission found that 12 modifiable risk factors in early life (e.g. education), midlife (e.g. hypertension, obesity, hearing loss) and later life (e.g. depression, physical inactivity, social isolation) account for around 40% of dementia worldwide.[46] The modification of these risk factors necessitate action through both public health programmes and interventions at an individual level across the life course.
In June 2019, the National Dementia Strategy was released by the Canadian government to identify common principles and national objectives to support people living with dementia and their caregivers, with $70 million in federal investments over five years.[47] One of the three key national objectives was to prevent dementia through advancing research and expanding awareness on modifiable risk and protective factors, establishing an evidence base on effective interventions, and improving access to built and social environments to support healthy living. The federal government plays a key leadership role in ensuring that the recommended actions will be implemented cohesively at regional levels, including for those facing barriers to equitable care, such as older Canadians who are racialized Black, Indigenous, and people of colour (BIPOC), who are lesbian, gay, bisexual, transgender, queer, intersex, and/or Two-spirit (LGBTQI2S ), and who navigate barriers to accessibility, such as individuals who are isolated, living with disabilities, and those who have limited financial means.
References
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[2] Kivipelto, M. (2001). Midlife vascular risk factors and Alzheimer’s disease in later life: longitudinal, population based study. BMJ, 322(June 2001), pp. 1447-51.
[3] Public Health Agency of Canada. (2010). The Chief Public Health Officer’s report on the state of public health in Canada 2010. Available at: http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2010/fr-rc/cphorsphc-respcacsp-06-eng.php.
[4] Public Health Agency of Canada. (2010). The Chief Public Health Officer’s report on the state of public health in Canada 2010. Available at: http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2010/fr-rc/cphorsphc-respcacsp-06-eng.php.
[5] Statistics Canada. (2017, November 14). The Internet and Digital Technology. Retrieved January 20, 2019, from https://www150.statcan.gc.ca/n1/pub/11-627-m/11-627-m2017032-eng.htm
[6] Public Health Agency of Canada. (2018). Vaccine Uptake in Canadian Adults: Results from the 2016 adult National Immunization Coverage (aNIC) survey. Available at: http://publications.gc.ca/collections/collection_2018/aspc-phac/HP40-222-2018-eng.pdf
[7] Public Health Agency of Canada. (2014). Statement on seasonal influenza vaccine for 2014-2015. http://www.phac-aspc.gc.ca/naci-ccni/flu-grippe-eng.php#tab5.
[8] Public Health Agency of Canada. (2019).Seasonal Influenza Vaccine Coverage in Canada, 2017-2018. Retrieved, from http://publications.gc.ca/collections/collection_2019/aspc-phac/HP40-198-2018-eng.pdf
[9] Public Health Agency of Canada. (2018). Vaccine Uptake in Adults: Results from the 2016 Adult National Immunization Coverage Survey (aNICS). Retrieved from http://publications.gc.ca/collections/collection_2018/aspc-phac/HP40-222-2018-eng.pdf
[10] Public Health Agency of Canada. (2018). Vaccine Uptake in Adults: Results from the 2016 Adult National Immunization Coverage Survey (aNICS). Retrieved from http://publications.gc.ca/collections/collection_2018/aspc-phac/HP40-222-2018-eng.pdf
[11] Langan, S., Smeeth, L., Margolis, D., Thomas, S. (2013). Herpes Zoster vaccine effectiveness against incident Herpes Zoster and post-herpetic neuralgia in and older US population cohort study. PLOS: Medicine. DOI: 10.1371/journal.pmed.1001420
[12] Public Health Agency of Canada. (2019b). Provincial and territorial routine vaccination programs for healthy, previously immunized adults. Retrieved from https://www.canada.ca/en/public-health/services/publications/healthy-living/2018-2019-influenza-flu-vaccine-coverage-survey-results.html#_About
[13] World Health Organization. Flu (influenza). Available at: https://www.who.int/news-room/fact-sheets/detail/influenza-(seasonal)
[14] Government of Canada. Flu (influenza): for health professionals. Available at https://www.canada.ca/en/public-health/services/diseases/flu-influenza/health-professionals.html
[15] Skowronski, D.M. (2000). Influenza: the elusive plague – part 1 (guest editorial). BC Medical Journal, 42(1), 16-17. Retrieved from: http://www.bcmj.org/editorials/influenza-elusive-plague%E2%80%94part-1-guest-editorial
[16] Statistics Canada. (2017). The 10 leading causes of death, 2013. Retrieved from: http://www.statcan.gc.ca/pub/82-625-x/2017001/article/14776-eng.htm
[17] My Health Alberta. (2015). How common is Pneumonia? Available at: https://myhealth.alberta.ca/health/Pages/conditions.aspx?hwid=hw62605&#hw62605-Bib
[18] Immunize Canada. (2014). Herpes Zoster (Shingles). Available at: http://immunize.ca/en/diseases-vaccines/herpeszoster.aspx
[19] Public Health Agency of Canada. (2019b). Provincial and territorial routine vaccination programs for healthy, previously immunized adults. Retrieved from https://www.canada.ca/en/public-health/services/publications/healthy-living/2018-2019-influenza-flu-vaccine-coverage-survey-results.html#About
[20] Public Health Agency of Canada. (2014). Canadian immunization guide: Part 4 active vaccines. Available at: http://www.phacaspc.gc.ca/publicat/cig-gci/p04-herp-zona-eng.php.
[21] Public Health Agency of Canada. (2020). Herpes zoster (shingles) vaccine: Canadian Immunization Guide. Retrieved from https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-8-herpes-zoster-(shingles)-vaccine.html
[22] Public Health Agency of Canada. (2018). An Advisory Committee Statement (ACS) National Advisory Committee on Immunization (NACI): Updated recommendations on the use of herpes zoster vaccines. Retrieved from https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/healthy-living/updated-recommendations-use-herpes-zoster-vaccines-eng.pdf
[23] Government of Canada. (2018). Public Funding for Influenza Vaccination by Province/Territory (as of September 2018). Retrieved from: https://www.canada.ca/en/public-health/services/provincial-territorial-immunizationinformation/public-funding-influenza-vaccination-province-territory.html
[24] Government of Canada. (2018). Public Funding for Influenza Vaccination by Province/Territory (as of September 2018). Retrieved from: https://www.canada.ca/en/public-health/services/provincial-territorial-immunizationinformation/public-funding-influenza-vaccination-province-territory.html
[25] National Institute on Ageing. (2018). The underappreciated burden of influenza amongst Canada’s older population. And what we need to do about it. Toronto, ON: National Institute on Ageing White Paper
[26] Government of Canada. (2017). National Immunization Strategy: Objectives 2016 – 2021. Retrieved February 18, 2019, from https://www.canada.ca/en/public-health/services/publications/healthy-living/national-immunization-strategy-objectives-2016-2021.html
[27] Government of Canada. (2017). National Immunization Strategy: Objectives 2016 – 2021. Retrieved February 18, 2019, from https://www.canada.ca/en/public-health/services/publications/healthy-living/national-immunization-strategy-objectives-2016-2021.html
[28] Government of Canada. (2016). Budget 2016: Growing the Middle Class. Retrieved February 18, 2019, from https://www.budget.gc.ca/2016/docs/plan/budget2016-en.pdf
[29] Government of Ontario. (2016 March). Schedule of Benefits – Physician Services Under the Health Insurance Act. Retrieved from: http://www.health.gov.on.ca/en/pro/programs/ohip/sob/physserv/sob_master20160401.pdf
[30] Canadian Institute for Health Information. (2019). Falls and vehicle collisions top causes of injury hospitalizations for seniors. Available at: https://www.cihi.ca/en/falls-and-vehicle-collisions-top-causes-of-injury-hospitalizations-for-seniors
[31] Canadian Institute for Health Information. (2019). Falls and vehicle collisions top causes of injury hospitalizations for seniors. Available at: https://www.cihi.ca/en/falls-and-vehicle-collisions-top-causes-of-injury-hospitalizations-for-seniors
[32] Canadian Institute for Health Information. (2018, July 5). Watch your step! Falls are sending more Canadians to the hospital than ever before. Retrieved January 20, 2019, from https://www.cihi.ca/en/watch-your-step-falls-are-sending-more-canadians-to-the-hospital-than-ever-before
[33] Canadian Institute for Health Information. (2018, July 5). Watch your step! Falls are sending more Canadians to the hospital than ever before. Retrieved January 20, 2019, from https://www.cihi.ca/en/watch-your-step-falls-are-sending-more-canadians-to-the-hospital-than-ever-before
[34] Public Health Agency of Canada. (2014). Seniors’ falls in Canada: Second report. Available at: http://www.phac-aspc.gc.ca/seniors-aines/publications/public/injury-blessure/seniors_fallschutes_aines/assets/pdf/seniors_falls-chutes_aines-eng.pdf.
[35] Public Health Agency of Canada. (2014). Seniors’ falls in Canada: Second report. Available at: http://www.phac-aspc.gc.ca/seniors-aines/publications/public/injury-blessure/seniors_fallschutes_aines/assets/pdf/seniors_falls-chutes_aines-eng.pdf.
[36] Government of Ontario. (2015). Exercise and falls prevention programs: How seniors (aged 65 and older can join free classes to help maintain balance and strength or prevent falls. Available at: https://www.ontario.ca/health-and-wellness/exercise-and-falls-prevention-programs.
[37] Government of Canada. (2015). Economic Action Plan 2015: Strong leadership a balanced-budget, low-tax plan for jobs, growth and security. Available at: http://actionplan.gc.ca/sites/eap/files/budget2015-eng.pdf.
[38] Government of Ontario. (2015). Healthy homes renovation tax credit. Available at: http://www.ontario.ca/seniors/healthy-homes-renovation-tax-credit.
[39] Government of Canada. (2015). Home Accessibility Tax Credit (HATC). Available at: https://www.canada.ca/en/revenue-agency/programs/about-canada-revenue-agency-cra/federal-government-budgets/budget-2015-strong-leadership/home-accessibility-tax-credit-hatc.html
[40] Government of Prince Edward Island. (2015). Seniors safe @ home. Available at: http://www.gov.pe.ca/photos/original/CSS_SSH_BROa.pdf
[41] Al-Aama, T. (2011) Falls in the elderly: Spectrum and prevention. Canadian Family Physician, 57, pp. 771-6.
[42] Seniors’ Falls in Canada: Second Report (2014). PHAC. Available at: http://www.phac-aspc.gc.ca/seniors-aines/publications/public/injury-blessure/seniors_falls-chutes_aines/index-eng.php
[43] Steultjens, E. (2004). Occupational therapy for community dwelling elderly people: a systematic review. Age and Aging, 33(5), pp. 453-60.
[44] Public Health Infobase. Canadian chronic disease surveillance system data on dementia, excluding Saskatchewan and Yukon. Government of Canada. 2018; https://www.canada.ca/en/public-health/services/publications/diseases- conditions/dementia-highlights-canadian-chronic-disease-surveillance.html
[45] Public Health Agency of Canada. Mapping Connections: An understanding of neurological conditions in Canada. Government of Canada. 2014; www.canada.ca/en/public-health/services/reports-publications/mapping-connections-understanding- neurological-conditions/mapping-connections-understanding-neurological-conditions-canada-11.html#fig1-9
[46] Livingston, G., Huntley, J., Sommerlad, A., Ames, D., Ballard, C., Banerjee, S., … & Costafreda, S. G. (2020). Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. The Lancet, 396(10248), 413-446.
[47] Government of Canada. (2019).A Dementia Strategy for Canada: Together We Aspire. Available at: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/dementia-strategy.html