This chapter explores the extent to which people live the additional life years gained over the past decades in good or poor health. While life expectancy has been improving over time, such gains have started to stagnate across OECD countries. Still, not all years in old age are spent in good health, and significant inequalities exist across socio‑economic groups. Younger generations are experiencing smaller health gains compared to older generations. Unhealthy lifestyles, comorbid conditions, shifting disease patterns, and poor environments increase the risk that current and future generations of older people will not age healthily. Population ageing and health inequalities highlight the need for health and long-term care systems to step up in promoting healthy longevity.
The Economic Benefit of Promoting Healthy Ageing and Community Care
Abstract
Gains in life expectancy are slowing down, with signs of widening socio‑economic disparities. Over the past decades, countries have realised impressive gains in life expectancy, but progress has slowed down since 2010. Life expectancy growth has plateaued on average across the OECD but with some differences across countries: life expectancy at age 60 was stable in 30 countries and increased in eight countries. Among the causes of mortality, dementia and infectious diseases contributed to this stalling of life expectancy. While life expectancy tends to be higher for women, their rate of growth has been slower than men’s. People with lower socio‑economic status have lower life expectancy, and in some countries, the gap has been widening between people with higher socio‑economic status.
Not every additional year lived is a year lived in full health. In 2021, the gap between life expectancy and health life expectancy at age 60 stood at 5.7 years, meaning that the last years of people’s lives are characterised by poor health and limitations. This gap has increased by 0.5 years over the past two decades, from 5.2 years in 2000.
While overall trends in activity limitations show improvements over time, this hides different trends by age and level of severity. The share of older people with any limitations in (instrumental) activities of daily living decreased from 25.5% to 22.3% across the OECD between 2011 and 2021. Trends show that the improvement in activity limitations is driven mostly by a decline in the share of older people having low levels of activity limitations. In addition, older birth cohorts exhibit a decline in activity limitations, whereas younger birth cohorts show stagnation.
Engaging more older people in preventive health measures and chronic condition management can support healthy ageing. Only five out of 29 countries in the European Region exceeded participation rates in all three recommended cancer screening programmes for women. In contrast, around half of the population aged 75 and above took at least five medications at the same time, which can negatively impact safety and increase health risks, such as falls.
The home and community environment also matter for healthy ageing. More than 30% of older people aged 65 or older were living alone across the OECD. Adapted housing and urban design remain important to enhance older people’s independence, promote their social engagement, reduce the risk of social isolation, and delay long-term care needs.
Life expectancy has risen steadily in most OECD countries by over ten years on average since 1970 (OECD, 2023[1]). At the same time, population ageing will have an impact on healthcare and long-term costs. Health spending from public sources across the OECD is projected to grow at an average annual rate of 2.6% for 2019‑2040 for the base scenario and projected to reach 8.6% of GDP, an increase of 1.8 percentage points (p.p.) from 2018 (OECD, 2024[2]). Long-term care expenditures are projected to nearly double by 2050 (OECD, 2024[3]). Healthy longevity could then attenuate future demand for health and long-term care expenditures, even with population ageing. However, a previous OECD report showed that the pace of mortality improvement has slowed in several EU countries and Australia and Canada since 2011 (Raleigh, 2019[4]).
This chapter reviews the most recent trends in life expectancy, healthy life expectancy and activity limitations among older people. It highlights stark inequalities in the process of healthy ageing with certain groups experiencing lower (healthy) life expectancy. It also explores potential barriers to the full potential of healthy ageing and identifies areas for policy interventions to promote healthy ageing which will be discussed in more detail in the subsequent chapters.
2.1.1. Improvements in life expectancy show limited progress across the OECD
Lifespan has increased across OECD countries over the last 60 years, but progress has been limited in recent decades. Although average life expectancy at birth in OECD countries has increased by 13.3 years from 67.8 in 1960 to 81.1 in 2023 (United Nations, 2024[5]), improvement in life expectancy has experienced a slowdown since the mid‑2010s (Figure 2.1). Life expectancy growth had already started to stagnate before the significant decline during the COVID‑19 pandemic and subsequent rebound. This stagnation occurred in 2015 for life expectancy at birth and in 2012 for life expectancy at age 60.
Average life expectancy at birth and at age 60 in OECD countries, 2000-2023
Source: United Nations, Department of Economic and Social Affairs, Population Division (2024[5]), World Population Prospects 2024, Online Edition, https://population.un.org/wpp/.
The limited growth in life expectancy between 2000 and 2023 demonstrates varied trends across countries. Based on the 10‑year averages, the growth rates of life expectancy at birth exhibited no clear trend in 26 countries, while consistently declining in five countries (Australia, Austria, Belgium, Iceland, Korea). Seven countries (Colombia, Czechia, Hungary, Latvia, Mexico, Poland, the Slovak Republic) saw a significant rebound in life expectancy after COVID‑19, temporarily increasing their growth rates. Similarly, the growth rates of life expectancy at age 60 remained stagnant in 30 countries during 2000-2023, except for eight countries (Chile, Colombia, Czechia, Hungary, Latvia, Mexico, Poland, the Slovak Republic) that showed an increase after the pandemic. No country experienced a downward trend in life expectancy at age 60. Among the 38 member states, Colombia, Czechia, Hungary, Latvia, Mexico, Poland, and the Slovak Republic were the only countries to consistently improve life expectancy growth both at birth and at age 60. A slowdown in life expectancy growth in numerous OECD countries has been similarly reported by previous studies using various sources (INSEE, 2019[6]; Mehta, Abrams and Myrskylä, 2020[7]; Raleigh, 2019[4]).
Diseases in older ages are becoming a major barrier to extending the lifespan. In the past, declines in childhood mortality and avoidable mortality with improved healthy behaviours have contributed to increases in the number of years people can be expected to live over time (Mathers et al., 2015[8]; OECD, 2023[1]; Mehta, Abrams and Myrskylä, 2020[7]; Lopez and Adair, 2019[9]). However, improvements in cardiovascular mortality have slowed in many countries. Respiratory diseases, including influenza and pneumonia, have claimed excess lives in some winters, while deaths from mental disorders or nervous system diseases in old age are rising. Fall-related deaths and injuries have plateaued or increased in the past decade after decreasing until 2010, particularly among older adults (Harada, Koyama and Yamada, 2024[10]; Kim et al., 2025[11]). In some countries, notably the United States and the United Kingdom, mortality improvements have also slowed or even reversed, particularly due to the rising numbers dying from drug use and Alzheimer’s disease (Raleigh, 2019[4]; Ho, 2022[12]).
2.1.2. Healthy life expectancy has also failed to keep up
People in OECD countries live longer, but not necessarily healthier. Healthy ageing can be assessed in various ways, such as measuring healthy life expectancy and other ways to document whether people are ageing in good health (Box 2.1). Over the past two decades, the difference between life expectancy and healthy life expectancy at age 60 has continued to grow slightly in many OECD countries. In other words, the increased lifespan achieved did not entirely translate into a healthy life, increasing the share of years lived in less than full health due to disease or injury. This gap in life expectancy and healthy life expectancy increased from 5.2 years in 2000 to 5.7 years in 2021 on average for OECD countries (Figure 2.2).
The gap between life expectancy and healthy life expectancy varies across OECD countries. In 2021, the difference ranged from 4.6 years (Mexico) to 6.6 years (Australia). By region, Central and Eastern European countries report the lowest gap between life expectancy and healthy life expectancy, approximately 5 years, while non-European countries report the highest gap, over 6.3 years.
Difference in years between life expectancy and healthy life expectancy at age 60, 2000-2021
Source: WHO Global Health Observatory (2024[13]), “Healthy life expectancy (HALE) at 60 (years)”, https://www.who.int/data/gho/data/indicators/indicator-details/GHO/gho-ghe-hale-healthy-life-expectancy-at-age-60.
Healthy ageing is defined as “the process of developing and maintaining the functional ability that enables well-being in older age” by WHO (WHO, 2020[14]). Healthy ageing is a process characterised by great functional ability, either with or without chronic conditions that are well-managed, influenced by experiences and exposures throughout life. Key considerations for healthy ageing include diversity and equity. The OECD also defines healthy ageing as a multidimensional concept that goes beyond the absence of disease, such as “maintaining physical, mental, and social well-being in older age, enabling older people to remain active contributors to society (Oxley, 2009[15])” With a focus on policy approaches, healthy ageing is seen as the state of maintaining good health and overall well-being with independence, which enables active participation in society, achieved through prevention and integrated policies.
Healthy life expectancy is one of the crucial measures for population health that counts not only years lived but also the quality of life. However, the method of measuring healthy life expectancy has not been agreed upon. For example, the WHO defines health-adjusted life expectancy (HALE) as “the average number of years that a person can expect to live in “full health” by taking into account years lived in less than full health due to disease and/or injury (WHO, 2023[16]).” The Eurostat’s healthy life years (HLY) are calculated more straightforwardly, based on two questions from the EU-SILC survey: “Are you limited because of a health problem in activities people usually do?” and “Have you been limited for at least the past six months?”.
The variations in definitions, measurement, and estimation methodologies across institutions can lead to differences in healthy life expectancy and, therefore, the estimated trends and ranking across the countries. The 2000-2019 Global Burden of Disease indicates a comparable upward trend in the LE‑HALE gap among OECD countries, consistent with WHO data, but starting from a significantly higher baseline. Focusing on Europe, the LE‑HLY difference from the Eurostat data also gradually widened from 2004 to 2023, although it temporarily narrowed during the COVID‑19 pandemic. However, its country rankings and estimate sizes differ significantly from those based on WHO data (OECD/European Commission, 2024[17]). Such data discrepancy in health trends among European countries has also been indicated in other studies (e.g. (Rubio-Valverde, Mackenbach and Nusselder, 2021[18])).
In addition, a frequently used indicator for health-related quality of life is activity limitations, measured by limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL). ADL and IADL limitations help countries assess a person’s needs for additional support to manage their daily life and provide long-term care benefits based on their limitations. The indicators of activity limitations can be used individually or in aggregate (also combined with other relevant measures, as suggested by the Ageing Trajectories of Health: Longitudinal Opportunities and Synergies (ATHLOS) project). In this report, data on activity limitation are sourced from the Survey of Health, Ageing and Retirement in Europe (SHARE) for EU countries. For non-EU OECD countries, the data come from international sister studies of SHARE: Health and Retirement Study (United States), English Longitudinal Study of Ageing (United Kingdom), Korean Longitudinal Study of Aging (Korea), and Mexican Health and Aging Study (Mexico).
Note: Japanese data is sourced from the Japanese Aging and Health Dynamics, which is not part of the internationally comparative database.
Source: OECD/European Commission (2024[17]), Health at a Glance: Europe 2024, https://doi.org/10.1787/b3704e14-en.
2.1.3. Nonetheless, trends in the share of people having activity limitations show signs of improvement
Dependency and disablement is a process where chronic and acute conditions impact bodily impairments, activity limitations, and social functioning (Verbrugge and Jette, 1994[19]; Jette, 2009[20]). This process often begins subtly after a stroke or cognitive decline and progresses to impair basic activities of daily living (ADLs), such as bathing and dressing, and instrumental activities of daily living (IADLs), like cooking and managing finances. Declines in physical performance in older ages are also associated with poor oral health (e.g. edentulism) and chronic pain (Kimble et al., 2022[21]; Balicki et al., 2025[22]). Older individuals experiencing disablement require some form of assistance to carry out everyday tasks on top of ongoing medical treatment over an extended period.
Between 2011 and 2021, the share of older people with any limitations in (instrumental) activities of daily living decreased from 25.5% to 22.3% across the OECD (Figure 2.3). Declines in IADL limitations (‑4.6 p.p.) contributed more to the overall decrease than declines in ADL limitations (‑2.8 p.p.). Seventeen out of the twenty-seven countries showed a decline, while nine countries exhibited a stagnant trend, and only one country, Spain, displayed an increasing trend. Poland showed the largest drop in any activity limitations (‑10.4 p.p.), while Spain showed the biggest increase (3 p.p.). A similar finding emerged when looking at two or more activity limitations, with the share decreasing from 15.7% in 2011 to 13.6% in 2021. These findings are consistent with previous research reporting improved functioning and lower disability among older adults (Crimmins, 2004[23]; Verropoulou and Tsimbos, 2017[24]), although other sources indicated increased prevalence (Nguyen and Hong, 2023[25]; Roma and Miglio, 2025[26]).
Percentage of people aged 65+ with any limitations in (instrument) activities of daily living, 2011 vs. 2021 (or nearest)
Note: First data points for England, Korea and the United States are from 2010, for Mexico from 2012, for Israel and Luxembourg from 2013, for Greece from 2015, and for Finland, Latvia, Lithuania, and the Slovak Republic from 2019. Last data points for England and Mexico are from 2018, and for Korea and the United States, from 2020. Japan has a single observation in 2017 and is not presented. All numbers are weighted estimates.
Source: Survey of Health, Ageing and Retirement in Europe (European Union and Israel), Health and Retirement Study (United States), English Longitudinal Study of Ageing (England), Korean Longitudinal Study of Aging (Korea), Mexican Health and Aging Study (Mexico).
Reduced activity limitations are associated with long-term care needs.1 From 2011 to 2021, the OECD average of long-term care needs shows a less than two p.p. decline in all levels of severity – low, moderate, and severe -, showing only minimal variation. Some countries experienced more notable reductions: Austria experienced the most significant decrease in low-level needs (‑5.2 p.p.), Poland in moderate needs (‑5.2 p.p.), and Israel in severe needs (‑4.8 p.p.). While most countries followed a moderate downward trend, a few countries reported an increase in LTC needs, such as Denmark (low level, 2.3 p.p.), Spain (moderate level, 2.9 p.p.), and Slovenia (severe level, 1.7 p.p.). Notably, the severity of needs also varied by age groups. Across the OECD, the decline in the low level of needs was more marked for people aged 75‑84, whereas reductions in medium and severe needs were more significant among people aged 85 or over compared to younger groups.
2.1.4. Younger generation lags behind older generation in health gains
Recent evidence suggests that the decline in activity limitations among older people in the past decade may not apply to their younger counterparts. Unlike older birth cohorts, which consistently reported health improvements, the trend for younger birth cohorts is less clear (Crimmins et al., 2019[27]; Verropoulou and Tsimbos, 2017[24]). Studies on activity limitation among people under 65 have yielded mixed findings, with some showing an increasing trend (Beller and Epping, 2021[28]; Freedman et al., 2013[29]), others a stagnating trend (Jehn and Zajacova, 2019[30]; Choi et al., 2022[31]), and still others an inconsistent trend (Lafortune and Balestat, 2007[32]) up to the mid‑2010s across Europe, England, Canada and the United States. These results are further nuanced by the severity of impairment, gender, income, and education, while the age and birth year thresholds varied slightly across the studies.
Nonetheless, data analysis suggests that in OECD countries, gains in old-age health over the last decade may not be equally distributed across generations (Figure 2.4). Particularly, midlife health has shown a sign of stagnation or even decline from 2011 to 2021, revealing an age divide before and after the age of 75. The prevalence of ADL limitations remained stable at around 8% under age 65 across three consecutive cohorts, whereas at age 65‑74, the reduction rates of ADL prevalence became smaller across cohorts. Similarly, the prevalence of IADL limitations declined less for later cohorts under age 75. At ages 45‑54, IADL limitations have in fact become more prevalent for people born in the 1970s (17%) compared to those born in the 1960s (13%). In contrast, an improvement in activity limitation among the later born becomes noticeable after they reach the age of 75. Despite healthcare advances and improved living conditions, young-old (ages 65‑74) and midlife functional health lag behind older age groups.
Percentage of people aged 45 or over with any limitations in (instrument) activities of daily living, 2011-2021
Note: Activity limitation includes activities of daily living and instrumental activities of daily living. The estimates are weighted estimates pooled across available datasets between 2011 and 2021.
Source: Survey of Health, Ageing and Retirement in Europe (European Union and Israel), Health and Retirement Study (United States), English Longitudinal Study of Ageing (England), Korean Longitudinal Study of Aging (Korea), Mexican Health and Aging Study (Mexico), Japanese Aging and Health Dynamics (Japan).
The limited improvement in life expectancy over recent decades highlights the need to examine the underlying social determinants of health – the non-medical factors that influence health outcomes. These factors are related to the conditions in which people are born, live and age, including social (like access to education and decent housing), economic (like income and social protection), and environmental (like living in safe neighbourhoods) aspects. A critical factor is the unequal distribution of health outcomes across different segments of the population. According to the WHO,2 social determinants may influence health more than healthcare quality or lifestyle choices, accounting for 30‑55% of health outcomes. In particular, health outcomes in older age vary by demographic characteristics, such as gender, and socio‑economic status, such as education and income, with disadvantaged groups facing worse results (Hiam et al., 2018[33]; Kabir and O’Brien, 2023[34]).
2.2.1. Women are consistently experiencing smaller gains than men
Life expectancy and healthy life expectancy are generally higher for women than men, although the gap is closing due to smaller gains for women. In 2023, life expectancy at birth was 83.7 years for women and 78.6 years for men across OECD countries, with women also having a higher healthy life expectancy at birth. Likewise, healthy life expectancy at age 60 is also higher for women across the OECD than for men. Over the past decades, growth rates in healthy life expectancy and life expectancy have been lower for women than men, leading to reductions in gender differences (Figure 2.5). Over the period from 2010 to 2021, life expectancy increased at an annual rate of 0.24% for men, while it rose by only 0.16% for women. Similarly, men’s healthy life expectancy has grown by 0.21% each year, whereas women’s has risen by half that rate (0.10%).
Annual growth rates in life expectancy at birth and healthy life expectancy at birth by male and female, 2000-2021
Note: Estimates for life expectancy at birth are based on the UN World Population Prospects, and those for healthy life expectancy at birth are based on the WHO Global Health Observatory.
Source: UN Department of Economic and Social Affairs, Population Division (2024[35]), https://population.un.org/wpp/; WHO Global Health Observatory (2024[13]), “Healthy life expectancy (HALE) at 60 (years)”, https://www.who.int/data/gho/data/indicators/indicator-details/GHO/gho-ghe-hale-healthy-life-expectancy-at-age-60.
Paradoxically, owing to their longer life expectancy, women spend more of their lives in debilitating health than men due to chronic diseases and activity limitations. Women generally experience higher prevalence and poorer outcomes in conditions like chronic kidney disease, rheumatic heart disease, depression, dementia, and multimorbidity, while men have higher premature death rates from cardiovascular diseases (Schmitz and Lazarevič, 2020[36]). Moderate conditions with a high prevalence contribute to a greater prevalence of old-age disability in women compared to men (Nusselder et al., 2019[37]; Portela et al., 2020[38]). Women’s more rapid cognitive decline compared to men is suspected to be a contributor to women’s deteriorating functional activities in old age (Levine et al., 2021[39]; Nader et al., 2023[40]; Gure et al., 2013[41]). The difference between men and women in activity limitation increases with age, partly due to the survival effect, whereby men who reach very old age tend to be the healthiest (Scheel-Hincke et al., 2020[42]).
These health disparities between men and women in old age have persisted across OECD countries over the past decade. Data from 27 OECD countries suggest a decline in ADL or IADL limitations for both men and women between 2011 and 2021, yet limitations remained more common among women (Figure 2.6). Although the overall gaps in limitations narrowed from 6.6% to 5.0%, 11 countries reported increased limitation gaps, without a significant age difference between men and women. Notably, in Hungary (‑19.7 p.p.), Denmark (‑18.2 p.p.), and Slovenia (‑10.1 p.p.), the relative prevalence of activity limitations among men dropped even further in 2021 compared to 2011, exacerbating the gap considerably. The differences in activity limitations were reduced in nine countries and remained unchanged in three countries (<5%). Simultaneously, Germany, Sweden, Korea and Finland exhibit reversed gaps due to a greater prevalence of limitations among men than women.
Proportion of men 65+ with any limitations in (instrumental) activities of daily living relative to women, 2011-2021
Note: First data points for England (United Kingdom), Korea and the United States are from 2010, for Mexico from 2012, for Israel and Luxembourg from 2013, for Greece from 2015, and for Finland, Latvia, Lithuania and the Slovak Republic from 2019. Last data points for England and Mexico are from 2018, and for Korea and the United States, from 2020. Japan has a single observation in 2017 and is not presented. All numbers are weighted estimates.
Source: Survey of Health, Ageing and Retirement in Europe (European Union and Israel), Health and Retirement Study (United States), English Longitudinal Study of Ageing (England, United Kingdom), Korean Longitudinal Study of Aging (Korea), Mexican Health and Aging Study (Mexico).
2.2.2. Health gaps tied to socio‑economic status are widening
Health in older age is shaped by social determinants of health throughout their lifetime, influencing people’s ability to live long and healthily. People from higher socio‑economic backgrounds tend to have a longer life expectancy and enjoy more years of better health than those from lower backgrounds. The burden of disease is greater among people with less education, low income, and from deprived areas due to more chronic diseases, more activity limitations, and poorer working and living conditions (OECD, 2021[43]; OECD, 2023[44]; OECD, 2017[45]). In 2017, the gap in life expectancy at birth based on socio‑economic status in the EU ranged from approximately 2 years in Greece to nearly 11 years in the Slovak Republic (Figure 2.7). In the OECD, longevity advantages for the educationally and financially better-off are well-documented. The high-low educational differentials in life expectancy at age 65 were 3.5 years for men and 2.5 years for women across OECD countries around 2011 (Murtin et al., 2017[46]). Such educational disparities in longevity account for around 10% of the overall differences in ages of death, on average.
Life expectancy at birth across different SES levels, 2017 (or nearest year)
Note: For the United Kingdom (England and Wales), low socio‑economic status refers to occupations classified as class 1‑3 according to the National Statistics Socio-Economic Classification, high socio‑economic status corresponds to occupations classified as class 5‑7 according to the National Statistics Socio-Economic Classification. For Australia, low SES level refers to the 1st decile of the Socio-Economic Indexes for Areas (SEIFA), medium refers to the 5th decile and high refers to the 10th decile. For all other countries, a low socio‑economic status corresponds to people with level 0‑2 of education according to the International Standard Classification of Education (ISCED 2011), while a high socio‑economic status corresponds to level 5‑8 of education according to the International Standard Classification of Education (ISCED 2011).
Source: Eurostat (2023[47]), “Eurostat data on LE by age, sex, education attainment level”, ONS (2022[48]), “Trend in life expectancy by National Statistics Socioeconomic Classification, England and Wales: 1982 to 1986 to 2012 to 2016” for the United Kingdom (England and Wales), Australian Government Centre for Population (2021[49]), “Life tables by relative socio economic advantage and disadvantage”, https://population.gov.au/sites/population.gov.au/files/2021-12/sgm-paper3.pdf, for Australia.
Socio‑economic disparities in life expectancy have widened over time, mainly due to health advantages for the better-off. Over the past decades, socio‑economically advantaged groups have seen steady gains in life expectancy, whereas disadvantaged groups have faced stagnation or decline. In the United States, mortality rates among bachelor’s degree holders continued to decline, while those of people without the degree rose from 1992 to 2021, expanding the gap in life expectancy by 8.5 years in 2021 (Case and Deaton, 2023[50]). Similarly, men in the top income percentiles live, on average, 14.6 years longer than those in the bottom percentile from 2001 to 2014; for women, the difference was 10.1 years (Chetty et al., 2016[51]; Deaton, 2016[52]). These patterns are also echoed in other OECD countries, including the EU (Rubio-Valverde, Mackenbach and Nusselder, 2021[18]),3 Norway (Kinge et al., 2019[53]), Sweden (Hederos et al., 2018[54]) and Finland (Tarkiainen et al., 2012[55]).
People from lower socio‑economic backgrounds experience earlier onset of chronic diseases and activity limitations, leading to shorter healthy life expectancy and greater time spent in poorer health. From 2000 to 2014, people with less education experienced a higher proportion and a higher rate of increase in all measures of functional limitations, compared to those with more education, in the United States (Tsai, 2016[56]). Consequently, declining health among disadvantaged groups has contributed to the slowdown in the improvements in life expectancy and healthy life expectancy. However, the magnitude and speed at which socio‑economic disparities affect life expectancy may differ by country. In the United States, the high-low income gaps in life expectancy increased from 6.2 years to 8.4 years for men, and from 2.5 years to 6.2 years for women between 2005 and 2015 (Chetty et al., 2016[51]). In Sweden, the gap increased by approximately one year for men and two years for women between 1986 and 2007 (Hederos et al., 2018[54]).
The recent slowdown and disparities in healthy ageing, despite the increased healthcare spending, underscore the importance of various social determinants shaping life expectancy throughout the life course (Venkataramani, O’Brien and Tsai, 2021[57]). Unhealthy lifestyles, insufficient physical activity, chronic diseases, dementia, and multimorbidity increase the risk of reporting poorer health and developing ADL and IADL limitations in old age (UK OHID, 2023[58]; Nguyen and Hong, 2023[25]). At the same time, while shifting disease patterns and causes of death contribute to the stall in life expectancy gains (Ramsay et al., 2020[59]), health and long-term care systems, as well as the community environment, have not yet been fully adapted to these changing needs in old-age health. To remove the barriers to living longer and healthier in old age, health systems would need to adapt to these new patterns, which demand more prevention, integrated services, and long-term care management.
2.3.1. Many people are not engaging in preventive health measures
Across the OECD, a significant portion of the population makes unhealthy lifestyle choices, with a higher likelihood among older people than their younger counterparts. As illustrated in Chapter 1, only one in four people aged 65 and above meets the physical activity recommendations of at least 150 minutes of moderate‑intensity physical activity per week. Unhealthy diets and sedentary lifestyles can significantly increase the risk of chronic diseases, including cardiovascular disease, diabetes, obesity, dementia, and cancer, as well as metabolic anomalies and increased mortality (Malhotra, Noakes and Phinney, 2015[60]; Livingston et al., 2020[61]). Poor oral health literacy among older people also leads to their reduced use of dental care services, resulting in an increased risk to nutritional intake and overall health (Gil-Montoya et al., 2015[62]; Lowenstein, Singh and Papas, 2025[63]). These factors not only lead to 2‑6% of a country’s overall healthcare spending worldwide (WHO, 2018[64]), but also result in a loss of 6.3 healthy years in life expectancy and 2.9 years of chronic disease‑free years after age 50 (Leskinen et al., 2018[65]).
Encouraging healthy lifestyle choices can help people live longer in good health. For example, engaging in physical activity lowers the prevalence and severity of chronic diseases, improves mental health and bone density, and reduces muscle loss and osteoporosis, thereby helping to decrease falls and related injuries and activity limitations (Bull et al., 2020[66]; OECD/WHO, 2023[67]). Choosing healthy eating also reduces the mortality risks related to cardiovascular disease, one of the most significant contributors to the life expectancy stall, by helping to avoid putting on weight and taking in essential nutrients (Ramsay et al., 2020[59]; Steel et al., 2025[68]; Mehta, Abrams and Myrskylä, 2020[7]). Improving oral health literacy among older adults can help encourage preventive dental visits and enable them to make informed choices (Lowenstein, Singh and Papas, 2025[63]). Proactive measures to help make healthy lifestyle choices can support healthy ageing and improved quality of life in old age. Investments in prevention measures, such as routine health checkups, immunisations, and screenings, can help mitigate risks before they escalate (see Chapter 3).
At the same time, the share of older people having received routine vaccinations is heterogeneous across OECD Member countries and often ranks below international recommendations. In 2021, only the United Kingdom, Korea, Ireland and Denmark met the WHO and the 2009 EU Council Recommendation to have at least 75% of their population aged 65 and above vaccinated against influenza (European Council, 2009[69]). The share varied widely across OECD countries, ranging from 80.9% in the United Kingdom to 7.7% in Latvia, with the average of 34 OECD countries amounting to 55% (Figure 2.8). Particularly, people of a lower socio‑economic status, lower levels of education, and lower levels of income display lower vaccination rates than those of a higher socio‑economic status, the more educated and more affluent (Okoli et al., 2020[70]; Gatwood et al., 2020[71]). These gaps in vaccination make older people more vulnerable to communicable diseases which are vaccine‑preventable, leading to higher death risks as shown in England (Raleigh, 2024[72]).
Percentage of population aged 65 and over vaccinated for influenza, 2019 and 2021
Note:1. Data refer to the calendar year 2020 or the flu season 2020/21; otherwise, refer to the calendar year 2021 or the flu season 2021/22.
Source: OECD Health Statistics (2023[73]), “Immunisations”(Indicator), http://data-explorer.oecd.org/s/2g5.
Participation is also largely insufficient in public screening programmes, such as cancer screening. The European Council recommends breast cancer screening for women aged 50‑69, colorectal cancer screening for individuals aged 50‑74, and cervical cancer screening for women aged 30‑65. In 2021 (or the latest year available), only five out of 29 countries in the European Region exceeded participation rates in all three cancer screening programmes, them being Austria, Denmark, Finland, the Netherlands and Slovenia (OECD, 2024[74]). This limits the potential of early diagnoses and early intervention, which are essential to reducing the impact of cancer on individuals.
Part of the reason for the low participation of older people might be related to health literacy. Older people are displaying lower levels of health literacy than younger ones. Across EU countries, the shares of people needing help to read medical instructions are larger for older age groups. At ages 65‑74, 16% of people need help to read medical instructions and this share nearly doubles to 29% among people aged over 75 (OECD/European Commission, 2024[17]). Promoting health literacy in communities, as discussed in Chapter 3, might help older people make informed choices that benefit health across their lifespan, while also increasing access to services for uptake.
2.3.2. Complex health needs in old age require people‑centred and integrated approaches
Older people are vulnerable to age‑related health conditions, such as falls, frailty, and cognitive decline. Falls are common among older adults, often caused by multiple risk factors at biological, individual, environmental, and social levels, necessitating multifactorial interventions for prevention. In the United States, each year, about 1 in 3 people aged 65 and older and 1 in 2 people aged 80 and older experience at least one fall (CDC, 2023[75]). Falls can lead to bone‑related injuries, accelerated frailty, and even deaths in older adults, resulting in emergency department visits and increased health expenditures (WHO, 2021[76]; Florence et al., 2018[77]; Dykes et al., 2023[78]). Cognitive impairment and decline are also prevalent conditions in old age, affecting 20 to 50% of the population aged 65 or older (Manly et al., 2022[79]; Yao et al., 2020[80]). Cognitive decline is a well-known precursor to dementia, which is the second leading cause of disability among people aged 70 and older, costing over USD 1 trillion annually worldwide (OECD, 2018[81]).
The risk of chronic conditions and disability also increases as people age (OECD, 2023[44]). Across OECD countries, nearly two in three people aged 65 and over live with more than one chronic condition (OECD, 2019[82]). Mental health issues are also significant in old age, with more than 35% of people aged 75 or over having multiple depressive symptoms in the EU in 2021‑2022 (OECD/European Commission, 2024[17]). Depression and anxiety are the most common mental health conditions for older people and increase their risk of developing certain chronic diseases, including heart disease, diabetes, stroke, pain, and Alzheimer’s disease (National Institute of Mental Health, 2024[83]). Chronic conditions and mental health significantly impact instrumental activities of daily living limitations in older adults. Multiple chronic conditions are associated with increased ADL and IADL limitations, with the effect varying by age and specific tasks (Mueller-Schotte et al., 2020[84]; Nguyen and Hong, 2023[25]). Likewise, mental health conditions account for 10.6% of the total disability in old age (WHO, 2023[85]). The synergistic effect of concurrent mental and physical chronic conditions predicts persistent and future incidence of IADL limitations and self-reported poor health, dragging down the improvement in healthy life expectancy (Gontijo Guerra, Berbiche and Vasiliadis, 2021[86]; UK OHID, 2023[58]).
The presence of multiple chronic conditions among older people often results in polypharmacy, where they are prescribed an increased number of medications to manage their complex health needs (OECD, 2025[87]). Across 15 OECD countries with available data, around half of the population aged 75 and above took at least five medications at the same time, ranging between 21% (Denmark) and 89% (Luxembourg) (Figure 2.9). Polypharmacy increases the risk of inappropriate medication usage, inappropriate prescription, insufficient monitoring, poor adherence, adverse drug interactions, and dosage errors (Gurwitz et al., 2003[88]). It could also lead to a higher risk of falls, disability, memory problems, and death (Hung, Kim and Pavon, 2024[89]; OECD, 2023[1]), increasing emergency hospital admissions, healthcare costs and resource inefficiency (Budnitz et al., 2021[90]; Clark et al., 2020[91]; Schiavo et al., 2022[92]; Chang et al., 2020[93]).
Share of population aged 75+ taking more than five medications concurrently, 2014 and 2024
1. Latest data from 2022-2023.
Source: OECD Health Statistics 2023, https://www.oecd.org/en/data/datasets/oecd-health-statistics.html.
Health systems can enhance their awareness and responsiveness to the health conditions of older adults. The specific vulnerabilities and needs of older adults may be overlooked in community and primary care settings due to a lack of awareness and ageism among older individuals, their families, and healthcare professionals. New workforce models, with care pathways for older people and co‑ordination across different professionals, can help detect and manage age‑related health issues such as polypharmacy, chronic diseases, falls, and cognitive decline (see Chapter 4).
2.3.3. Shifting disease patterns require a new approach to long-term care
The changes in the dominant causes of illness and death over the past decades have significantly contributed to the stagnation in life expectancy gains, having chronic diseases and complex comorbidities in older populations – particularly Alzheimer’s disease and other dementias, as key contributors (Raleigh, 2019[4]; Darlington-Pollock and Norman, 2019[94]). Alzheimer’s and other dementias have become a leading cause of death across the OECD, particularly in the United States and the United Kingdom, where there has been a surge in deaths attributable to dementia by over 70% between 2000 and 2013, although this could be partly attributed to a change in the classification due to better diagnosis and awareness of dementia (Murphy and Grundy, 2022[95]; OECD, 2023[96]; OECD/European Commission, 2024[17]). From 2010 to 2020, there have been marked slowdowns in mortality due to cancer and cardiovascular diseases, contrary to the growths in selected infectious diseases (including COVID‑19) and Alzheimer’s and other dementias (Figure 2.10). Alzheimer’s and other dementias contributed to a 0.04‑year increase in the life expectancy gap compared to the previous decade.
Number of years each cause of death contributed to the life expectancy gap, 2000-2009 and 2010-2020
Note: The life expectancy differentials are decomposed into age and cause‑specific components using the analysis based on Arriaga decomposition (2014[97]).
Source: OECD analysis based on the WHO Mortality Database.
Moreover, Alzheimer’s and other dementias are closely linked to an increased risk of activity limitations and disability. Neurovascular dysfunction that causes dementia leads to both cognitive decline and functional impairment, while increasing frailty and the risk of falls, leading to higher morbidity and mortality over time (Nguyen and Hong, 2023[25]; Xia, Ntim and Wang, 2025[98]). These effects are further compounded when dementia co‑occurs with other chronic conditions, such as depression, cardiovascular diseases, and musculoskeletal disorders, resulting in a higher prevalence of ADL and IADL limitations (Marengoni, Angleman and Fratiglioni, 2011[99]). The downstream effects of dementia on health, frailty, and survival are particularly significant in people aged 90 or over (Ramsay et al., 2020[59]). However, having available support with everyday life, as well as good relationships with family members and relatives, can help reduce the likelihood of having functional limitations (Ćwirlej-Sozańska et al., 2019[100]).
Long-term care systems can delay the disablement process by providing targeted interventions and support that address the care needs of older people and their families. Providing accessible, affordable, and quality care services enables countries to ensure that older people with health conditions receive the care they need at the right time. Offering a range of care options in various settings can enhance personal choices and support older people in living in less restrictive environments (Chapters 5 and 6). Furthermore, these services can reduce the emotional and financial burdens on informal carers, as well as the negative impacts of caregiving on their own health and well-being.
2.3.4. Community environment does not always support independence and quality of life for older people
Community environments influence older people’s ability to remain active and engaged within their communities. Health and well-being at older ages are determined by multiple interacting factors, including individual physical and mental conditions, social connections, and the environment where people live and interact (Abdi et al., 2019[101]; Ćwirlej-Sozańska et al., 2019[100]). Older people’s basic needs, such as housing, food security, and basic mobility, significantly affect their care needs at home and in the community and health-related quality of life (Dobarrio‐Sanz et al., 2023[102]; Baptista et al., 2018[103]). Among others, a home is where older people spend most of their time (Hatcher et al., 2019[104]), and therefore, housing quality is vital for their ability to age healthily in place. Good quality housing can reduce respiratory, cardiovascular, and infectious diseases in older people (Howden-Chapman et al., 2023[105]), while promoting independence, reducing the risk of injury, and improving their quality of life (Oswald et al., 2007[106]). However, many older people still have unmet housing needs that support their age‑related lifestyle changes (see Chapter 5).
Community programmes that encourage older people to participate in social engagement opportunities and urban planning can positively impact their mental and physical health. Interpersonal factors, such as social engagement and cultural attitudes, also influence healthy ageing. Sufficient social support is linked to reduced disease and mortality, with psychological mechanisms involving stress buffering and brain networks affecting health and longevity (Vila, 2021[107]). In the past decade, the number of older people living alone has risen. In 2022, more than 30% of older people aged 65 or older were living alone across the OECD (OECD, 2024[108]). Changes in health and social connections, such as the loss of hearing, can heighten the risk of social isolation and loneliness (Reed et al., 2025[109]). Social isolation and loneliness can pose higher risks for physical and mental health and increase the likelihood of developing dementia in older people, even with increased use of long-term care services and support (Pomeroy et al., 2023[110]; Livingston et al., 2020[61]).
The spatial design of public spaces, including walkable streets, street furniture, and green spaces, promotes later-life health outcomes and life satisfaction and reduces difficulties in physical activities for those already experiencing functional decline (Finlay et al., 2025[111]; Laborde, Ankri and Cambois, 2022[112]). Increased access to diverse food options and services, facilitated by public transportation, promotes older people’s independence and mobility and reduces their need for assistance (Levasseur et al., 2015[113]).
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← 1. LTC needs are defined as low, moderate, and severe levels based on corresponding hours of care per week. See Box 1.1 in OECD (2024[3]) for more details.
← 3. This study uses the global activity limitation indicator (GALI), an instrument measuring longstanding activity limitation in performing usual activities due to health problems, with a survey item from the EU-SILC: “For at least the past six months, have you been hampered because of a health problem in activities people usually do? Yes, strongly limited / yes, limited / no, not limited” (OECD/European Commission, 2024[17]).