(Published in ENRICH magazine, 2022)
A MOMENTOUS DEBATE raging in the global medical community will profoundly alter the way we perceive and treat the many diseases and infirmities that inevitably come with growing old.
At issue is the vexed question: "Is ageing a disease"?
It is a conundrum the informed Filipino layman will likely answer with, "Of course, not". In his world view, ageing is not a disease because he knows of no disease or medical condition called ageing. But he does realize chronic diseases like cancer, diabetes, stroke, arthritis, heart disease and Alzheimer's are prevalent among his old parents and even older grandparents.
The World Health Organization (WHO), however, no longer holds with certainty the view that ageing is not a disease. In January 2022, WHO effectively paved the way for defining ageing, specifically biological ageing or senescence, as a disease in the 11th revision of the International Classification of Diseases (ICD-11).
Its reasoning: old age gives rise to biological changes that make people more vulnerable to diseases that worsen with age like cancer and arthritis. Some experts contend ageing is the biggest risk factor for heart disease, cancer and dementia.
WHO, therefore, has apparently redefined ageing as a treatable condition that can be delayed and cured like a disease. It likely sees "ageing itself" as the principal cause of the myriad of illnesses linked to old age.
This redefinition of ageing as a disease should also lead doctors and scientists to address not only the effects of ageing but the underlying causes of the symptoms linked to ageing.
It's known that the processes underlying age-related diseases probably overlap. Therefore, if scientists can determine what biological processes make people more susceptible to age-related diseases such as heart disease and Alzheimer’s, a treatment might be found that can potentially treat multiple diseases at once instead of one at a time.
Age-related diseases are deadly. Of the 150,000 people that die every day across our planet, about two-thirds (close to 100,000) die from age-related causes. Even wars can't kill as many people. Some 27,000 people died daily in World War 2, the deadliest war in human history.
What exactly is ageing?
This festering dispute among the learned leads us to the question as to what ageing -- or the process of becoming older -- really is.
A medical definition describes chronological ageing as a time-dependent functional decline marked by a progressive loss of physiological integrity. This attenuation leads to the impairment of bodily functions and increases one's vulnerability to death. In other words, the older you get, the weaker and sicker you become. But is this due to the cumulative effects of individual age-related diseases, or to ageing as a disease? That is the question.
At the biological level, ageing is caused by the gradual accumulation of molecular and cellular damage over a person’s lifetime. These molecular level changes trigger a decline in mental and physical function and increase the risk of disease and death.
Then, there's the role cellular senescence plays in ageing. Ageing is also defined as the accumulation of senescent cells. Senescent cells cause many of the degenerative changes we perceive as ageing, as well as age-related diseases.
Cellular senescence is the process in which cells age and stop dividing permanently -- but don't die. Over time, massive numbers of old, or senescent, cells accumulate in our body tissues.
These "living-dead" cells or zombies release a range of inflammatory factors and enzymes that destroy the tissues in which they reside. As a result, our immune cells attack and kill senescent cells, thereby changing our tissues for better or worse.
In one fell swoop
ICD, the tool that ignited the ageing firestorm, is a globally used diagnostic tool published by WHO to help doctors and healthcare professionals identify diseases. It is a healthcare classification system providing diagnostic codes for classifying diseases.
The specific changes to ICD-11 about ageing involve general symptoms (code “MG2A”) and in the causality section of “XT9T”. ICD-11 classifies "old age" as a specific disease in contrast to ICD-10 where old age is classified as a “general symptom”. Another contentious change was replacing the code for “senile debility” with the code MG2A, which originally stood for “old age”.
WHO also implemented an extension code (or a new category of codes) for "ageing related", or XT9T diseases. These are diseases “caused by pathological processes which persistently lead to the loss of organism’s adaptation and progress in older ages”. Extension codes provide additional information on a disease, injury or disorder.
The new code XT9T can be immediately applied to relevant conditions listed in ICD-11, as well as to future relevant medical conditions.
On the other hand, the implementation of the extension code XT9T in ICD-11 "is not tantamount to formal recognition of ageing as a disease," asserts an editorial in the peer-reviewed scientific journal, The Lancet. The advent of XT9T does, however, "signal acknowledgment by WHO of ageing as a major disease risk factor and of the considerable public health problem posed by ageing-related diseases".
The new proposals in ICD-11 intend to ensure ICD has a complete list of pathologies and disorders related to ageing. It also seeks to guarantee and account for the full spectrum of degenerative changes.
Accomplishing this means all ageing-related pathologies will have to be included in disease or disorder classifications, which wasn't the case previously. This omission meant an ageing diseases classified and assessed for the level of severity in one organ can be unclassified in another. It is a confusing situation at best.
More seriously, the absence of classifications and staging can result in less than ideal treatments since pathological ageing changes are not included in ICD.
The ageing-related changes to ICD-11 came from a joint proposal submitted to WHO’s ICD-11 Task Force by the Biogerontology Research Foundation, the International Longevity Alliance, and the Council for Public Health and the Problems of Demography.
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Raging storm
The release of ICD-11 quickly ignited a storm of controversy, splitting medical professionals involved in gerontology, longevity science and other disciplines having to do with ageing into pro-disease and anti-disease factions.
Advocates for classifying ageing as a disease have long argued ageing is the biggest risk factor for chronic diseases, which are today treated individually as a matter of course. They contend ageing is not a deviation from the normal state as can be expected from a disease.
Treatments that focus on the underlying ageing process will “in one fell swoop, intervene in several or many chronic diseases of ageing,” claims Dr. Alexander Fleming, the founder of Kinexum (a company that develops drugs and biotech products).
Dr. David Sinclair, professor of genetics at Harvard Medical School and one of the better known longevity scientists, agrees that ageing is the main cause of all major diseases in society today.
"I'd argue that just because ageing happens to more than half of us, is no reason to not include it as a disease," he noted. "In fact, I would say it's even more important that we work on trying to combat it, because ageing is the main cause of all major diseases in society now.”
This line of thinking mirrors that made by Dr. Leonard Hayflick, professor of anatomy at the University of California San Francisco School of Medicine, back in 1962.
At the time, Dr. Hayflick argued that if old age is a risk factor for nearly all of the diseases likely to kill us, "why then are we not devoting significantly greater resources to understanding what … increase(s) vulnerability to all age-associated pathology?"
He said the lack of distinction between ageing and age-related diseases “is the most serious impediment to our understanding of the ageing process.”
Dr. Hayflick gained fame by discovering a limit to how many times human cells divide before they become senescent. His name is inextricably linked to the discovery of the key role telomeres play in the ageing process.
The declaration by WHO seems a belated acknowledgement of a landmark study about ageing published in February 1954 by Dr. Robert Perlman in which he described ageing as a “disease complex" while emphasizing the etiologic significance of both internal and external environmental stress.
Perlman's study, “The Ageing Syndrome”, published in the Journal of American Geriatrics Society has slowly gained adherents over the past half century.
In 2015, a team of international researchers published a study in the online biomedical and life sciences journal PubMed Central with the provocative title, “It is time to classify biological ageing as a disease.” It sees "the ageing process as the underlying cause for the chronic diseases affecting the elderly".
Alarm bells
The ageing-related revisions in ICD-11 were met with alarm by medical professionals holding the contrary but majority view. Current thinking contends ageing is a natural process and not a disease, and "should not be considered a disease in and of itself."
A paper published in The Lancet in October 2021 took WHO to task for supporting moves to classify ageing as a disease.
"We argue that simply equating old age as a disease in the ICD-11 is potentially detrimental and deleterious from clinical, research, and humanitarian points of view, and propose alternate productive solutions," wrote the study authors.
They argue chronological age has limited use in diagnosis, prognostication, and treatment guidance. In addition, “age by itself is of limited use for the assessment of population health, for the evaluation of initiatives designed to promote healthy ageing, and for health or social care planning. “
Instead on harping on ageing, the authors "propose that frailty should be included as a clinical disorder instead of old age." They ask WHO "develop the reporting of frailty in the ICD classification system" and argue that frailty "is a much more homogeneous and better-defined clinical entity" compared to old age.
They claim ICD-11 branding ageing as a disease will potentially magnify the socioenvironmental disadvantages in terms of equality in healthcare provision endured by the elderly. Ageing as a disease will also reinforce commonly held ageistic beliefs in society and the medical community. Validation of ageistic beliefs will also stand to worsen the societal marginalization and discrimination against the elderly.
The International Association of Gerontology and Geriatrics based in Belgium and comprising 84 national societies from 72 countries has also assailed the inclusion of old age as a pathological criterion in ICD-11. Others are urging WHO to revise the ICD-11 classification of old age.
What's at stake
Behind the fire and fury engulfing those for and against the proposition is a deep concern for the plight of the elderly. The implications of the WHO declaration that ageing is a disease -- which many medical professionals dispute or dismiss -- will massively affect the healthcare provided the elderly and the development of drugs needed to combat diseases of ageing.
The protagonists don't dispute ageing is a one-way street culminating in six feet of subterranean real estate. What they can't agree on is how to make this final journey more tolerable, which means an emphasis on healthy ageing or our healthspan.
Those that contend ageing should be classified as a disease want to goad governments and pharmaceutical firms into emphasizing the development of therapeutic interventions targeting ageing and ageing-related diseases.
They argue that new therapeutic interventions for ageing will lead to the acceptance of ageing as a disease. This acknowledgement will help ensure treatments are covered by health insurance providers, especially those in the West. It is also critical to boost funding from grant-awarding organizations for ageing research.
The poorest of Filipinos
The implications of this debate on ageing in the Philippines will be huge.
The country has an elderly population age 60 up of more than 12 million persons. This total comprises 11% of the total population of 110.8 million persons, estimated the Commission on Population and Development (PopCom).
In 2015, PopCom said the country’s population will begin to age by 2025 to 2030. It was because of this former PopCom executive director Juan Antonio Perez III said he was gravely concerned that “social protection systems have yet to catch up with social conditions”.
“People are living longer but in poorer health and socio-economic conditions," said Perez. "They are only partially reaping the benefits of better health and social conditions."
He warned the government has only 10 years to craft programs for the elderly that address healthcare, rehabilitation, depression and daily activities, among others.
He emphasized senior citizens will need the government’s help as they will be “the poorest members of the population because usually their pensions are not enough for them”. Not much has occurred since 2015 to negate this warning.
In 2017, the Philippines was ranked 60th out of 191 countries in WHO’s Ranking of the World's Health System. The country with the world’s best healthcare was France; Singapore had Asia’s best healthcare system.
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