This article first appeared in Forum, The Edge Malaysia Weekly on July 31, 2023 - August 6, 2023

In a previous State of Health article ­(“Systematically screening an ageing Malaysia”, Issue 1470, May 1, 2023), we discussed the importance of targeted health screenings as Malaysians grow older, and how state governments such as Selangor and Penang are pioneering policies for health screenings. In this month’s State of Health, we propose that ageing Malaysians need more than just healthcare and screening; healthier seniors also need social, legal and economic care that integrates with healthcare.

We introduce the concept of “healthspan” or “healthy life expectancy”, or HALE. Lifespan or life expectancy is defined as the total duration of a person’s life, regardless of the quality of life. In contrast, healthspan or HALE is defined as the duration of life spent in good health and defines the quality of life, not just its duration. Healthspan is especially relevant for people who live longer than average, but who may suffer from physical, social or economic problems that reduce their quality of life. Therefore, to achieve higher healthspan, we need social, legal and economic instruments in addition to health instruments.

Take five major issues with ageing citizens: falls, dementia, loneliness, mental health issues and financial scams. Every year in Malaysia, one in six older adults experiences at least one fall, leading to fatal injuries and fractures which lead to high healthcare costs and suffering. The prevalence of dementia in Malaysia is already close to 18% among the elderly, with an estimated total economic burden of RM8 billion annually, representing 0.8% of gross domestic product just for one illness.

In addition to physical health needs, senior citizens have social and mental health needs. An estimated 50% of senior citizens in Malaysia are at risk of social isolation, defined as the lack of a social network and low frequency of meaningful and supportive interactions. One in four senior citizens in Malaysia has depression, which is strongly associated with poor social support. Related to this, the lack of social and family support may lead to poor financial management and increased vulnerability to abuse. Exacerbated by the Covid-19 pandemic, as many as 81% of Malaysians were estimated to have inadequate savings to live above the poverty line after retirement.

The lack of social care combines with cognitive decline, psychological vulnerability and the lack of knowledge to make senior citizens prone to physical, emotional or even financial abuse, which includes scams, thefts, coercion and deception. In many cases, due to severe dementia, they may even lose the capacity to make decisions, whether the decisions are financial, health-related or personal. These factors make senior citizens vulnerable to neglect and abuse. Therefore, a longer lifespan provided by advanced science is meaningless if science does not provide a longer healthspan.

Other countries have been forced to respond to the above-mentioned issues, and Malaysia can learn from them. Let’s start with clinical protocols. Australia, with 16% of its population aged above 65, has strong clinical guidelines to prevent and manage falls. There are recommendations for exercises, medication review, home safety and vision, as well as screening for falls at least annually. South Korea, with 14% of its population above 65 years old, declared a “War Against Dementia” in 2008. Its National Dementia Early Detection Programme manages a network of more than 250 community dementia reassurance centres (“Chime Ansim Centres”) to provide early dementia screening and diagnosis and support to senior citizens with dementia.

Some 20% of the population in the Netherlands are aged 65 and above. The country pioneered the construction of Hogeweyk, a village specially designed for senior citizens affected by dementia. Hogeweyk created a safe environment that maintains the autonomy of residents to live as normal a life as possible, including the relevant legal instruments to protect the senior citizens. Hogeweyk is a successful experiment in healthcare and political will to increase healthspan using social, legal and economic instruments.

The US, with 17% of its citizens above 65 years old, has one of the world’s most comprehensive sets of elder laws, which deal with financial protection, long-term healthcare and guardianship. For example, the Senior Safe Act 2018 protects senior citizens from financial abuse, and authorises banks to hold financial transactions temporarily for investigation when there are suspicions of exploitation. (This comprehensive set of laws is mainly due to the strong and well-organised senior lobby in the US, another lesson for coalition-building in Malaysia.)

The UK has the Mental Capacity Act 2005 that protects senior citizens who lack the mental capacity to make decisions, and encourages senior citizens to make advance decisions; Singapore followed suit as long ago as 2008. Advance decisions are legally binding and serve to uphold the individual’s autonomy to choose while the individual has the mental capacity, including refusal of life-sustaining treatments.

Returning to Australia, the Charter of Aged Care Rights states the rights for senior citizens to receive safe and appropriate care that meets their physical, mental and social needs. Aged care providers are legally obliged to perform the required standards of duty of care that comply with the Aged Care Quality Standards, failing which legal action may be taken. Finally, and more controversially, some countries such as Belgium, Canada and the Netherlands have legalised euthanasia, aligned with an increasingly equal priority for healthspan and lifespan.

Our first recommendation is to update Malaysia’s laws. The current legal framework includes statutes that are applicable but not specific to senior citizens and may be inadequate to address their needs. For example, the Domestic Violence Act 1994 and Care Centre Act 1993 have not caught up with advances in science, public policies and societal norms, and the Mental Health Act 2001, which has been used to assess decision-making capacity in senior citizens, was originally intended for people with psychiatric conditions, not dementia. Therefore, an omnibus national law to protect the rights of senior citizens may be needed, in consultation with senior citizens associations, lawyers and gerontologists.

This omnibus national law will require examining (and potentially merging) several existing laws and creating new ones. For example, the Mental Health Act 2001 may need to be supplemented by a Mental Capacity Act that addresses the needs of senior citizens (not people with psychiatric conditions). A Senior Safe Act may be needed to account for the vulnerability of senior citizens, which may not be covered in the Penal Code. The Private Aged Healthcare Facilities and Services Act may need to incorporate duty of care, and expand beyond aged care institutions to the homes of seniors who are living independently.

Our second recommendation is to integrate health and social services. Currently, medical social workers exist in the public system, but they can and must work more closely with clinicians in hospitals and clinics. Social Medicine or Social Prescribing is a new field of medicine, where patients are prescribed a social solution (such as welfare, economic aid, membership in a social club or other social services). Such a system of social prescribing should be trialled and then institutionalised across Malaysia. Currently, the Ministry of Health does not systematically provide social prescribing, or mainly outsources it to the Department of Social Welfare Malaysia.

Integrating health and social services also means closing the loop from screening services. A structured and comprehensive programme to screen for falls risk, dementia and senior risks should be strengthened in the primary healthcare system, and at-risk seniors must be channelled into relevant medical and social programmes. Preventive strategies for these three large problems will help improve health outcomes and save costs associated with treating their complications in the long run. To address social isolation, screening, support groups and regular check-ins should be incorporated as part of primary healthcare services. Finally, to help senior citizens navigate the complicated health system, a care coordination function should be central in the care of senior citizens, in all public, private and non-governmental organisation health facilities.

Lifespan is an easily measured metric of “X years of life”. Healthspan is much more difficult to measure, “X years of healthy life”. In several decades, we may need to consider “good-life-span” that measures “X years of a good life”, although “healthy” will be easier to measure than “good”.

One thing is clear: healthcare alone will not be adequate to deliver lifespan, healthspan or good-life-span. Therefore, we need an all-of-society approach to deliver the healthcare, social, economic and legal instruments for healthy ageing and longer healthspans for Malaysians. It will be a long journey measured in years or decades, making it imperative that we start now.

Dr Ginsky Chan is medical director of Angsana Health and is trained in public health. Dr Khor Swee Kheng is CEO of Angsana Health and specialises in health systems.

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