1. Living longer in a rapidly changing environment lessons from Singapore
Angelique Chan
Centre for Ageing Research and Education, Duke-NUS Medical School
Programme in Health Services and Systems Research, Duke-NUS Medical School
Department of Sociology, NUS

2. The Singapore context is changing……..
Ultra-low fertility
Increasing non-marriage/divorce (Loneliness)
Increased migration
Increased prevalence of non-communicable diseases (Healthy Life Expectancy)
Productive ageing (Employment and Intergenerational Transfers)

3. Source: Population Division of the Department of Economic and Social Affairs of the United Nation Secretariat, World Population Prospects: The 2010 Revision,

4. Source: Population Division of the Department of Economic and Social Affairs of the United Nation Secretariat, World Population Prospects: The 2010 Revision,

5. Social Isolation and Loneliness

6. Loneliness and Mortality: Results from a
Longitudinal Survey of Social Isolation, Health, and Lifestyles
Angelique Chan, Prassana Rahman, Stefan Ma, and Rahul Malhotra
Duke-NUS Graduate Medical School, Singapore

7. Trends in living arrangements in Singapore, South Korea, and Japan
This is especially important for policy as demographic and social trends are making this less sustainable;
It may also not be sufficient to address the needs of an older population; other factors may be more important drivers of health and well being.
Source: UN Demographic Yearbook

8. (House, Landis, and Umberson; Science, 1988)
Why is loneliness important?
Social relationships, or the relative lack thereof, constitute a major risk factor for health - rivaling the effect of well-established health risk factors such as cigarette smoking, blood pressure, blood lipids, obesity, and physical activity.
(House, Landis, and Umberson; Science, 1988)
Longer life expectancies and changing family and social structures have created an epidemic of loneliness in older adults (Holt-Lunstad et al.; Basu, 2012)
10% of British adults over the age of 65 are chronically lonely (Khaleeli, 2013).
1 in 5 elderly adults (<75) in Singapore are lonely (Basu, 2012).
Despite improvements in physical health in the elderly and high co-residence rates in Singapore, progress on mental health issues is negligible (Basu, 2012).
Lonely adults experience a greater risk of cardiovascular disease, high
blood pressure, cognitive impairment, decreased immunity , and mortality.
(Steptoe et al., 2013; Luo et al., ).

9. How does loneliness affect mortality?
Pathways
Main effects model: Social relationships directly encourage protective health behavior, and loneliness can alter human physiology (increased vascular resistance, higher systolic blood pressure)
Mortality
Loneliness
Empirical studies
Studies from the U.S., Europe, and China have shown that participants
who expressed feelings of loneliness were more likely to die (Shiovitz &
Ayalon, 2010; Mazella et al., 2010; Wen et al., 2005; Cacioppo, 2014)
B. Many studies also found that once health indicators were added to the model, the effects of loneliness on mortality disappeared (Patterson &
Veenstra, 2010; Sugisawa et al., 1994)
C. In studies using multiple loneliness variables, authors reported that
social relationships were not associated with mortality, but loneliness was (Holt-Lunstad et al., 2010).
Buffering model. Social relationships help dampen responses to stressors.

10. Methods
PHASE -1 , 2009
Nationally representative survey conducted by MCYS of community- dwelling adults aged 60 years and above (N=4,990)
PHASE –
Follow-on to SIHLS
Sample restricted to only those who answered the social isolation questions in 2009 (N=3,802)
Variables: Socio-demographics, chronic diseases, social isolation and loneliness, cognitive impairment, depression, disability, functional status, vision, sleep, lifestyle, dental health, mental health

11. Measuring social isolation
UCLA 3-item Loneliness Scale
How often do you feel that you lack companionship?
How often do you feel left out?
How often do you feel isolated from others?
Responses: Always, fairly often, occasionally, rarely, never
Score range: 0-12
Reverse coded to ensure that a higher score indicates higher loneliness level

12. Independent variables
Modified Lubben Social Network Scale (12 questions)
How many relatives/friends/neighbors …
do you see or hear from at least every month?
are close enough to ask for help or discuss private matters?
How often do relatives/friends/neighbors…
consult you before making an important decision?
available to talk when you have an important decision to make?
Responses: 0, 1, 2, 3-4, 5-8, more than 9
Score range: 0-60
Higher score indicates better social network

13. Independent variables
Living arrangements (categorical)
Living…
alone
only with spouse
only with child(ren),
with spouse AND child(ren)
only with others

14. Independent variables
Socio-demographic: Age, gender, ethnicity, marital status, housing type, and education
Health: Number of comorbidities, ADL limitations, IADL limitations, smoking status, depression, cognition

15. Distribution of responses on UCLA Loneliness Scale
Category
(n=4536)
Never Lonely
49%
Sometimes Lonely
32%
Mostly Lonely
19%

16. Distribution of responses on UCLA Loneliness Scale, by living arrangements

17. Results Covariates / Model Model 1 Model 2 Model 3 Model 4 Loneliness
(95% CI)
1.10 *
( )
( )
1.07 *
( )
Lubben Scale -
0.99 *
( )
0.99
Living arrangements (95% CI)
Alone
Living with spouse
Living with child
Spouse and child
Others only
0.44 * ( )
0.88 ( )
0.63 * ( )
Ref.
0.93 ( )
0.63 ( )
0.86 ( )
0.94 ( )
1.32 ( )
* for p<0.05

18. Insight
Perceived loneliness is associated with a greater risk of death in Singapore
It is more predictive of mortality than living arrangements and social networks
Possible underestimating of hazard ratio because there is no information
on the quality of social relationships

19. How can we apply what we learned to policy?
Multi-generational housing may be valuable, but it is not sufficient
Policy should address perceived loneliness
Psychosocial services
Promote awareness by community and health care providers

20. Healthy Life Expectancy
Healthy  Productivity
How do we increase healthy life years among the older population?

21. Healthy Life Expectancy
The proportion of years a person can expect to live without disability.
Differs from total life expectancy, 80 years for males and for females in Singapore.

22. Determinants of HLE Gender Education Ethnicity is
At age 60 women spend 70% of their life healthy versus 88% for men
Education
TLE and HLE ~ both are higher among those with high education
Ethnicity is
HLE ~ Higher among the Chinese

23. Women live longer but in poorer health
Gender is associated with
TLE, IALE ~ both are higher among Women
ALE ~ it is higher among men
Education is associated with
TLE and ALE ~ both are higher among those with high education
Higher educated have higher TLE due to higher ALE.
Ethnicity is associated with ALE ~ Higher among the Chinese

24. After the age of 60: women spend 70% of their life healthy Vs 88% for men

25. Healthy Ageing Policies
Need to be gender specific
Target minorities
Screening is necessary but not sufficient
More programmes to promote self management of chronic conditions – practical solutions, e.g., SCOPE

26. Productive Ageing

27. Policies to encourage employment among older persons = Positive outcomes

28. What happens after older workers retire?
Longitudinal analyses of the effects of retirement on well being.
N = 365
Findings were adjusted with age, gender, ethnicity, education level, and housing type (proxy of household income).

29. Benefits of work (vs. retirement)
Overall, employees reported better subjective health than retirees over time. Those individuals who kept working perceived improved health whereas those who had retired perceived deteriorated health.
Analyses were conducted based on 365 PHASE respondents who were working in year 2009 (Time 1) and participated in our survey again in year 2016 (Time 2).
At Time 2, 213 and 152 respondents were still working and did not work anymore (retired), respectively.

30. Benefits of work (vs. retirement)
Retirees felt lonelier than employees at Time 2. In fact, retirees, but not employees reported increased loneliness over time.

31. Policies to encourage intergenerational relationships - Necessary

32. Productivity within families
Older adults provide informal support to other family members
Intergenerational transfers of money, material support, and time were collected and analyzed in a longitudinal study
Significant gender differences – older women provide more time and money to other family members

33. Intergenerational Financial Support Flows
Source: PHASE 2011, elderly 62+

34. Intergenerational Material Support Flows
Source: PHASE 2011, elderly 62+
Notes: Material support includes food, clothes, and other material goods

35. Intergenerational Time Support Flows
Source: PHASE 2011, elderly 62+
Notes: Time support includes providing help for childcare and housework; receiving help for housework, ADL-related care, IADL related care

36. Intergenerational Emotional Support Flows
Source: PHASE 2011, elderly 62+

37. Discussion questions
Social isolation is an increasingly common issue, how can we prevent it?
Adding life to years, not just years to life – How?
Should there be a mandatory retirement age?
Can monetary transfers replace time and emotional support within families?

38. Thank you