CIHR Institute of Aging Strategic Plan 2019-2021: Living Longer, Living Better

Table of Contents

• Message from the Scientific Director
• Executive Summary
• The CIHR Institute of Aging
• The Aging Landscape
• Setting the Priorities for an Aging Society
  • Vision and Values
• Strategic Directions 2019-2021
  • Strategic Direction 1: Health and Wellness Over the Trajectory of Aging
    • 1.1. Life trajectory as a determinant of healthy and satisfying aging
    • 1.2. Added life to the later years
  • Strategic Direction 2: Solutions for the Complex Health Challenges of Older Populations
    • 2.1. Understanding, preventing and addressing multiple chronic conditions
    • 2.2. Facing the challenge of dementia
    • 2.3. Recognizing new emerging aging populations
    • 2.4. Ensuring the adaptation of healthcare and services to an aging population
    • 2.5. Informing late-life care and decisions
  • Cross-cutting Strategic Directions
    • Integrating an Indigenous perspective – Getting inspired by Indigenous cultures and addressing the specific health and wellness challenges
    • Ensuring appropriate capacity and training
    • Fulfilling a convenor role with all stakeholders
• Monitoring and Reporting on Progress

Message from the Scientific Director

Canada and the world have changed dramatically since 2001 when the Canadian Institutes of Health Research (CIHR) was first established, including its Institute of Aging. Since then, not only has life expectancy at birth increased, but the overall proportion of older individuals has also grown with an explosion of the number of oldest old (individuals aged 85 and over). An older Canada means many potential opportunities to embrace. Inspired by Canada’s Indigenous Peoples’ attitude towards their elders, we are invited to imagine a Canada of tomorrow in which older adults will play an important role in an optimally healthy and satisfying society.

Many older Canadians already demonstrate resilience as they maintain important and satisfying roles with their families and participate in social activities, while others may contribute to Canada’s workforce and/ or the volunteer sector. But in order to be able to continue to do so, it is important to ensure health and wellness throughout the life trajectory, starting at birth. At the same time, it is important to address the complex health challenges that some older Canadians have to live with, and to ensure access to appropriate social and health systems. We also have to ensure health and wellness for those Canadians, both old and young, who are caregivers for those in need.

The CIHR Institute of Aging is at an important crossroad on its own trajectory; in fact, the Institute of Aging just reached the age of majority! Following the important contributions of Dr. Réjean Hébert and Professor Anne Martin-Matthews as the first two Scientific Directors the current Institute of Aging team has worked hard to place research on aging as a crucial component in the health and wellness agenda for Canadians. Supported by our Advisory Board, along with team members in Montreal and in Ottawa, in partnership with the other CIHR Institutes and with the support of and in partnership with our stakeholders, we are proud of what we have accomplished over our current mandate. But there is still much to do, many opportunities to explore, and many topics to address.

On the eve of our transition towards the next Institute of Aging Scientific Director and team, we re-affirm the strategic directions of the Institute of Aging, while adding some of the new challenges that will need to be considered in moving forward. This 2019-2021 Strategic Plan is one of transition, with directions that will allow continuity and that will provide the next Scientific Director with the time needed to establish a new Institute plan for the 2020s.

I would like to thank all those who have participated in the consultations, townhall meetings, and discussions that nourished this plan. I was fortunate to have benefited from the support of our Advisory Board, from colleagues from the other Institutes and from our team in Montreal and in Ottawa as well as from CIHR’s management. I consider myself extremely privileged to have been able to contribute to the teen years in the life course trajectory of the Institute of Aging, which itself aims to optimize health and wellness along the life trajectory of all Canadians.

Yves Joanette, PhD, FCAHS
Scientific Director, CIHR Institute of Aging Montreal, March 2019

Executive Summary

As part of the Canadian Institutes of Health Research (CIHR), the Institute of Aging identifies and addresses through research and other actions, the knowledge gaps and opportunities related to Canada’s aging population. The Institute focuses on health and wellness across the entire trajectory of life while specifically addressing the health challenges of older individuals. The Institute plays an important role in Canada as a key convener and catalyzer for the research community and facilitates the links with policy makers, health systems, clinicians and the private sector. In delivering on its mandate, the Institute of Aging typically engages with other CIHR Institutes on a number of actions, from capacity building of trainees to the introduction of large platforms and consortia that inform policy makers and empower the public.

Given that the scientific leadership of the CIHR Institute of Aging will change in 2019, this 2019-2021 Strategic Plan supports the Institute transition and allows for the preparation of the next Strategic Plan by the new leadership team. In preparing this 2019-2021 Strategic Plan the Institute was inspired by the results of the vast consultations (web-based survey and a pan-Canadian series of townhalls) conducted some years ago, to which more recent consultations with all stakeholders were added. The Institute of Aging Advisory Board was also very active in the preparation of this Plan.

Enhanced health and wellness later in life depends upon a large number of factors that are linked to lifestyle choices and environmental factors throughout the life trajectory. These choices and factors, along with the genetics of each individual, determine an important diversity in the state of health and wellness among older individuals. Added to these factors, and therefore the complexity, are the physical, psychological, and social environments that can either contribute to, or interfere with, health and wellness along the life trajectory. Finally, the occurrence of multiple chronic conditions, with dementia and frailty being the most debilitating and contributing to the health challenges and diversity faced in the later years.

In keeping with this vision, the 2019-2021 Strategic Plan is based on two main strategic directions (a) the determinants of health and wellness along the life-long trajectory of aging, and (b) the complex health challenges of the older individual and their caregivers. Additionally, some cross-cutting strategic directions focus on specific aspects that need to be considered throughout the planning and implementation of first two directions.

Strategic Direction 1: Health and Wellness over the Trajectory of Aging

Over the course of people’s lives, there are many determinants that interact and influence health and wellness over the trajectory of aging. At the same time, and regardless
of the health condition of the older individual, the physical, psychological and social environments can contribute to quality of life during the later years. In other words, these environments can contribute to living better while living longer.

This first Strategic Direction is expressed through two complementary sub-Directions:

• 1.1 Life trajectory as a determinant of healthy and satisfying aging
• 1.2 Added life to the later years

Strategic Direction 2: Facing the Complex Health Challenges of an Older Population

Despite the advances in prevention and treatment, a number of older individuals struggle with multiple chronic conditions, which can have a negative impact on their quality of life in their later years. The effects of these multiple chronic conditions need to be better understood, addressed and ultimately prevented.

The second Strategic Direction for the Institute is best expressed through five complementary sub-Directions:

• 2.1 Understanding, preventing and addressing multiple chronic conditions
• 2.1 Facing the challenge of dementia
• 2.3 Recognizing new emerging aging populations
• 2.4 Ensuring the adaptation of healthcare and services to an aging population
• 2.5 Informing late-life care and decisions

Cross-Cutting Strategic Directions

Over and above the first two specific strategic Directions, the Institute of Aging also recognizes the need for cross-cutting strategic directions that must be taken into account in all strategic directions and sub-directions.

The first cross-cutting strategic direction relates to Canada’s rich Indigenous culture. The Institute will integrate an Indigenous perspective on aging when possible, in all its actions, whether research initiatives, implementation or convenor actions.

The second cross-cutting strategic direction relates to ensuring appropriate research capacity in aging as well as research on the optimal training of health professionals and workers for an aging population.

Finally, the third cross-cutting strategic direction relates to the different actions to ensure the convenor and catalyst roles of the Institute of Aging with all stakeholders.

The CIHR Institute of Aging is dedicated to realizing the achievement of a longer and more satisfying life for Canadians by supporting the capacity and the creation of knowledge, and ensuring its transformation for the health and wellness of Canadians, and better care and health systems for an aging population.

Moving towards a Canada where we can all live longer and live better…

The CIHR Institute of Aging

The Canadian Institutes of Health Research (CIHR) is Canada’s research funding agency for all types of health research, including basic biomedical approaches, clinical and translational research, research on health services and policies, research on prevention and public programs, and research on social determinants of health and wellness. Through its many programs, CIHR supports academic research in universities and research centres throughout Canada and around the world, while also constantly ensuring that the relevant new knowledge generated will have a direct impact on the health and wellness of Canadians and of populations throughout the rest of the world.

The Institute of Aging is one of the thirteen CIHR Institutes that have collectively, and within their own respective research mandates, the responsibility of identifying and addressing research gaps and opportunities. The Institute of Aging focuses on health and wellness along the entire trajectory of life while specifically addressing the health challenges of older individuals. The Institute of Aging plays an important role in Canada as a key convener and catalyzing agent for the research community and facilitates the links with policy makers, health systems, clinicians and the private sector. In delivering on its mandate, the Institute of Aging typically engages with the other CIHR Institutes on a number of actions, from the support of the capacity building of trainees all the way to the introduction of large platforms and consortia that inform policy makers and empower the public regarding healthy aging.

The WHO Concept of Healthy Aging

HealthyAgeing is about creating the environments and opportunities that enable people to be and do what they value throughout their lives. … Being free of disease or infirmity is not a requirement for HealthyAgeing as many older adults have one or more health conditions that, when well controlled, have little influence on their wellbeing.^{Footnote 1}

Mission of the CIHR Institute of Aging

To support research, to promote healthy aging and to address the causes, prevention, screening, diagnosis, treatment, support systems and palliation for the complex health challenges that can be present in older individuals.

Purpose of the 2019-2021 Strategic Directions

In 2019, the third Strategic Plan (2013-2018) of the Institute of Aging will have come to an end and the leadership of the Institute will transition.

The purpose of the Strategic Directions for 2019-2021 is to ensure a continuity of strategic actions during the transition of the Institute leadership, while also providing the necessary time and space to the new leadership team to be able to engage in the necessary consultations that will help to shape the next iteration of the Institute’s Strategic Plan.

The Aging Landscape

Since the beginning of the new millennium, Canada’s population has continued to age, along with that of the rest of the world. By 2050, there will be more than 50 super-aged countries in the world. A super-aged country is one in which 30% of the population is 60 years and over (Figure 1).

Figure 1: Evolution of the number of super-aged countries (30% or more of 60 years and older) between 2015 and 2015

Source: World Health Organization (WHO), 2015.^{Footnote 2}

It is forecasted that Canada will reach super-age status by 2035. As is the case for many countries, the aging of the Canadian population is characterized by:

• A decrease in the number of younger people, as a result of a lower birth rate (Figure 2).
• An increase in the number of people who are reaching old age due to the fact that more people engage in healthy lifestyles (Figure 2).
• A drastic increase in the number and proportion of the oldest old (i.e. individuals who are aged 85 and over), including an explosion of centenarians (Figure 3).
• An increase in the difference between the relative numbers of men and women, the latter representing the vast majority of the oldest old (Figure 3).

Figure 2: Evolution of absolute numbers of younger (0-14 years) and older (65 years and older) Canadians from 1998 with projections up until 2018. Data from 1998 to 2018 are population estimates. Data for 2019 to 2038 (shown in the graph as dotted lines) are population projections taken from Population Projections for Canada (2013 to 2063), Provinces and Territories (2013 to 2038)

Source: Statistics Canada.^{Footnote 3}

Figure 3: Evolution of number and sex of centenarians in the Canadian population since 2001 with projection up until 2061

Sources: Statistics Canada, censuses of population, 2001, 2006 and 2011, and Statistics Canada, 2010, Population Projections for Canada, Provinces and Territories, 2009 to 2036, Statistics Canada Catalogue no. 91-520 (medium growth scenario), projection scenarios for Canada are available up to 2061.^{Footnote 4}

The Aging World: Limitations and Cohort Effects

Given the biological constraints of the human species, the world population is not expected to age indefinitely. However, even for Japan, currently the oldest and only super-aged country in the world, the number and proportion of older individuals is expected to continue to increase until at least 2050. In some countries, such as Spain and the UK, the increase in life expectancy at birth has recently slowed, and in some cases decreased; however, this phenomenon is thought to be related to specific cohorts and the aging trend is expected to resume. Globally, it is also anticipated that the rise of some current indicators of poor health, such as child obesity, could induce a dip in life expectancy at birth. Nonetheless, this phenomenon should not affect the long-term tendency for the population to be characterized by an increased proportion of people aged 65 and over, and an even larger increase of those aged 85 and over.

Healthy Aging – Towards a Decade of Action on Healthy Ageing

In 2015, the World Health Organization (WHO) published the World Report on Ageing and Health^{Footnote 5}, which has become a cornerstone of the strategic actions undertaken by many countries through their public health and research strategies. The CIHR Institute of Aging actively contributed to the work done by the WHO to transform this report into an Action Plan^{Footnote 6}, which is currently being disseminated in the context of a global “Decade of Action on Healthy Ageing” that will span from 2020 to 2030.

The aging landscape in Canada, and around the world, is increasingly characterized by diversity in individual trajectories, including a higher number of people working later in life, either by choice or by financial obligation. Genetic makeup, epigenetic exposures, and, mostly, lifestyle choices, such as nutrition, physical exercise and cognitive stimulation, are known to be drivers of vitality in late life. Despite the diversity in the trajectories of aging and in particular between women and men, the late years do allow for multiple opportunities, whether in relation to work, family time, further education, travel, entrepreneurship and community engagement. As the result of lifelong adaptation and resilience, older individuals represent a source of invaluable wisdom that should be better integrated in all aspects of society. Older adults contribute massively to families and their communities through caregiving as well as volunteer activities. Health and wellness throughout the life trajectory and in the late years represents a central contribution to the Canadian values of happiness and fulfillment, as stated in the Preamble of the CIHR Act (https://laws-lois. justice.gc.ca/PDF/C-18.1.pdf )

At the same time, multiple chronic conditions still characterize the health of older individuals and more than half (57%) of individuals aged 80 and over live with three or more chronic conditions^{Footnote 7}, many of which are controlled by medication and/ or lifestyle. Moreover, frailty is a prevalent condition that affects up to 35% of older Canadians placing them at higher risk of disability, institutionalization and even mortality. Frailty is particularly onerous in those aged 85 and older, reaching a prevalence of close to 50%. Frailty is associated with an increased risk of injuries due to falls, mobility disability, depression, and cognitive impairment. Cognitive impairment resulting in dementia is one of the most prominent and debilitating conditions for all older people and their caregivers, particularly among those in the oldest old age group (more than 40% of individuals aged 85 and over are living with some form of dementia). Despite these challenges, the vast majority of people aged 65 and over still live in private dwellings (92% for those aged 65 and over, and 68% for those aged 85 and over), while only a fraction (8% for those aged 65 and over, and 32% for those aged 85 and over) live in protected and /or long- term care facilities.^{Footnote 8Footnote 9}

Nevertheless, the environment in which older Canadians live is not always supportive of health and wellness. There is a clear need for more age-friendly housing, and communities in both urban and rural environments, as well as for more knowledge to address the issues of stigma and elder abuse, regardless of the form they may take (i.e. physical, emotional/ psychological, or financial). Loneliness also represents a major challenge for many older individuals, especially within the oldest old age group.

Older people with health challenges represent an important proportion of health system users and associated costs. Unfortunately, the system is not equipped to deal with older individuals who have multiple chronic conditions, in particular as it relates to ensuring a coherent transition between the different components of the health system, especially in the last years of life.

Canada’s demographic landscape and aging trajectory is characterized by an ongoing increase in the numbers of older people, and even more of the oldest old. This new landscape will require knowledge and measures in order to optimize health and wellness in aging, as well as adapted health and social interventions and health services that will support older individuals in their needs and diversity.

The Institute of Aging: Two Decades of Investments and Impacts

The Institute of Aging constitutes the centrepiece and a unifying force for research in the field of health and wellness in aging in Canada. The Institute’s vision, values and priorities are fully aligned with CIHR’s overall strategic directions. The Institute’s Strategic Plan and its priorities reflect a living application of CIHR’s directions and priorities in the field of aging. In line with the Institute’s many significant achievements since being founded in 2001, the Strategic Directions for 2019-2021 will continue to have a genuine impact on research and on the quality of life for older Canadians, as well as for their caregivers who themselves are aging and experiencing substantial health, social and economic impacts. Some of the milestones to date of the Institute of Aging include:

Setting the Priorities for an Aging Society

The priorities for the strategic actions of the Institute of Aging were inspired by the gaps and opportunities identified by the Canadian population, including the knowledge producers (i.e. researchers and trainees) as well as the knowledge users (i.e. clinicians, policy-makers, community associations, and the general public). In 2012, the Institute conducted a comprehensive, pan-Canadian consultation that included a widely disseminated web consultation, a series of townhall meetings across Canada (the Speaking of Aging Tour), and targeted interviews. The prioritization exercise also took into consideration and fed into the CIHR Strategic Plan.

The Consultation and Speaking of Aging Tour in Numbers

• Over 1,000 Canadians participated in the web consultation
• 600+ individuals participated in 17 townhall meetings that were held in 15 cities across Canada
• A special townhall meeting was held with representatives of Indigenous communities
• More than a dozen international experts participated in focused interviews

Demographics of Participants

• Ages of participants ranged from 25 to 85, the median of which was 45 to 55
• 63% of participants were women and 37% were men
• 60% of participants were knowledge producers and 40% were knowledge users

The results of this extensive consultation allowed for enhanced insights into and understanding of some of the most important areas recognized as gaps and/or opportunities by all stakeholders. The most frequently mentioned topics included:

• Addressing the challenges of cognitive impairment and dementia in older adults;
• Providing appropriate home care to enable aging at home;
• Addressing the challenge of adequate access to care and the impact of the aging society on the cost of healthcare;
• Encouraging preventative lifestyle measures (e.g., nutrition, fitness) in order to optimize health and wellness in the aging trajectory;
• Reducing mobility challenges, including more age-friendly environments;
• Facing social isolation/loneliness;
• Providing support to caregivers, including with fiscal measures; and
• Enhancing understanding of the biology of aging mechanisms.

The richness of the results provided by this consultation exercise is still relevant today, and the success and breadth of it is such that many governmental stakeholders have requested access to the data and information collected. Moreover, the consultation process demonstrated the willingness of CIHR and its Institute of Aging to listen to the needs
of the Canadian population in planning its strategic investments.

In preparation of the refreshed 2019-21 Strategic Directions, the Institute of Aging began its renewed consultations with the community in 2017. The vision of these consultations were to start from the 2013-2018 Strategic Plan in order (a) to validate the on-going relevancy of the 2013-2018 priorities, and (b) to identify new emerging topics not previously addressed and that were brought forward by numerous stakeholder groups.

The Institute met with numerous stakeholder groups from the scientifi  and clinical communities throughout 2017 and early 2018. Interactive and wide reaching consultations sessions were held at all major Canadian aging research conferences, including the Canadian Association on Gerontology as well as the Canadian Geriatrics Society. Furthermore, a special working session was held with the Directors of all the Canadian research centres on aging who were invited to share a draft version of the plan with their community. Moreover, the conversations were extended beyond the research and the clinical communities through meetings with groups representing older Canadians, such as the CARP, ORCA (Ontario Retirement Communities Associations) as well as the Quality End of Life Care Coalition of Canada.

Opportunity was also taken to exchange with different branches of the federal government that are part of the Interdepartmental Committee on Seniors. These exchanges included inspiring conversations with the Public Health Agency of Canada, Health Canada, Justice Canada, Correctional Services Canada, Canada Mortgage and Housing Corporation, Transport Canada, Status of Women, and Indigenous and Northern Affairs Canada. In addition, the Institute opened dialogue with groups of interests which were not previously involved in research in aging, such as the Canadian Foundation for AIDS Research.

In 2018, the Institute and its newly reconstituted Institute Advisory Board worked to further streamline and finalize the items to be included on the basis of the support from the community and the users (public and policy makers) to pursue the strategic directions of the 2013-2018 plan, and adding a limited number of new sub-directions that have emerged as critical since 2013. The extended Ottawa-based Institute team also contributed to provide feedback on this plan. Thus, this 2019-21 Strategic Directions document encompasses the feedback of the community and has the full support of the Institute Advisory Board members as well as the Institute team members.

In summary, the refreshed transitional 2019-2021 plan retains the two strategic directions of the 2013-2018 plan to which a few highly supported sub-strategic directions have been added. In addition, one of the Priorities (Priority 5 – Ensuring the Conditions for a positive impact on Older Peoples Health and Wellness) in the 2013-2018 plan was clarified and was transformed into the third Cross-cutting strategic direction.

Implementing the Health Research Roadmap II for Canada’s Aging Population

The Health Research Roadmap II is the current Canadian Institutes of Health Research (CIHR) Strategic Plan. A process is under way to provide CIHR with a new strategic plan that is tentatively expected for mid-2020. In the meantime, this table captures, in general terms, the contribution of the Institute of Aging’s strategic directions to the CIHR Health Research Roadmap II. At the same time, the availability of the Institute of Aging 2019-2021 Strategic Plan will feed into the engaged CIHR planning process.

Health Research Roadmap II Priorities

1. Enhanced patient experiences and outcomes through health innovation
2. Health and wellness for Indigenous people
3. A healthier future through preventive action
4. Improvedquality of life for persons living with chronic conditions

Examples of the Institute of Aging’s Strategic Topics

• Quality and continuity of health interventions and services for older individuals, including the oldest old
• Innovative interventions for the age-related chronic conditions
• Innovative technology to support quality of life during the later years of life
• Health and wellness challenges of the Indigenous population along the life trajectory
• Dissemination of the values of the Indigenous cultures regarding aging, and the role and influence provided by the elders
• Identification and dissemination of lifelong lifestyle choices and approaches to optimize health and wellness throughout the trajectory of aging
• Identification of the root cause of multiple chronic conditions in aging, with a special focus on dementia
• Better support for those living with multiple chronic conditions and their caregivers
• Suitability of the health system and its interventions with the reality of older individuals living with multiple chronic conditions
• Training of health professionals and health workers that is adapted to the needs of the aging population

Our Vision for Canada

A Canadian society that will be inclusive and respectful of its older citizens, including the oldest old, and which makes available
and disseminates the knowledge required to:

• Optimize the health and wellness of older Canadians in their later years;
• Provide support in order to add not only years to life, but life to years, respecting an individual’s place of living;
• Provide research-based interventions and health eco-systems, along with appropriately trained health professionals and workers; and
• Address health challenges, including dementia, in the context of multiple chronic conditions.

Our Values

• Consult all Canadians – from younger adults in the earlier stages of the life course to older individuals – as well as all stakeholders
• Foster collaboration at all levels, both nationally and globally, between researchers, policy makers, and all other stakeholders
• Assume a leadership role in relevant priority- driven initiatives as well as for the research communities and policy-makers
• Include an international perspective, when possible, in order to benefit from the experience of other countries and to contribute to the positioning of Canada as a global leader
• Engage with other CIHR Institutes on the current and future directions
• Ensure an impact on the health and wellness of Canada’s aging population and on the quality of the interventions, care and services provided as well as supporting all caregivers

Strategic Directions 2019-2021

The 2019-2021 Strategic Directions of the Institute of Aging are threefold. The first direction is focused on the factors that enable people to maintain an active and satisfying life while aging. The second direction deals with the health challenges and encompass the possible solutions that can be applied to older people’s complex health problems. The third cross cutting strategic direction concerns the condition that applies to all initiatives of the Institute and that helps put in place the conditions needed for research results to have a real impact on the health and wellness of the aging population.

Strategic Direction 1: Health and Wellness over the Trajectory of Aging

Over the course of people’s lives, there are many determinants that interact and influence health and wellness over the trajectory of aging, some of which can be modified and others that cannot. At the same time, and regardless of the health condition of the older individual, the physical, psychological and social environments can contribute to quality of life during the later years. In other words, these environments can contribute to living better while living longer.

The Institute of Aging’s first Strategic Direction is best expressed through two complementary sub-Directions:

• 1.1 Life trajectory as a determinant of healthy and satisfying aging
• 1.2 Added life to the later years

1.1. Life trajectory as a determinant of healthy and satisfying aging

Goal

To support the creation and translation of the required knowledge, from a lifelong trajectory perspective, in order to favor optimal health and wellness for older individuals living in an aging society, taking into account sex and gender differences as well as diversity and inequalities.

Objectives

In partnership with the Institute of Population and Public Health and policy makers in the area of public health:

• Support the identification of the multi-dimensional determinants of health and wellness in aging
• Ensure that the knowledge identified will be transformed into
  • useful and useable information for policy makers and health professionals
  • efficient empowerment strategies for people of all ages in the life trajectory
• Ensure a special focus on the health and wellness of the oldest old as a new and rapidly growing segment of the population

Potential Strategic Implementation Actions

Support the process towards Phase 3 of the Canadian Longitudinal Study on Aging (CLSA) platform, with the appropriate resources to offer access to this unique population-based data set to all interested researchers

• Promote the use of CLSA data by Canadian researchers through priority-driven initiatives as well as through any other relevant initiatives and the investigator-driven programs
• Pursue and enhance the partnership with the Public Health Agency of Canada (PHAC) and the Provincial/Territorial authorities in order to accelerate the transformation of the CLSA-based research outputs into lifelong preventative strategies for health and wellness in the trajectory of aging
• Complement the current CLSA efforts regarding the oldest old by developing appropriate initiatives in order to better understand the determinants of health and wellness for those in the rapidly growing oldest segment of the population

Expected Outcome(s)

Creation and dissemination of knowledge to inspire public health measures and to empower Canadians to optimize their health and wellness in aging trajectory.

1.2. Added life to the later years

Goal

To ensure that the later years of life, with or without health challenges, are fully supported by physical, psychological and social environments that help to make these years satisfying, and in the individual’s preferred place of residence

Objectives

Identify the characteristics and features of optimal built environments that will support quality of life for older individuals living with various health conditions that may interfere with mobility or social participation

• Identify characteristics of optimal working environments for the aging work force as well as for the younger workforce who are engaged in either a single (parent) or double (parent/child) caregiving role, a situation disproportionately affecting women
• Contribute to combatting ageism and negative attitudes towards aging, including the associated stigma of being older, with a particular focus on the oldest old
• Harness and integrate the most recent technologies to support aging at home, despite health conditions, and ensure integration of the most efficient technologies into the health and social systems
• Ensure that Canadian researchers are included in international collaborative efforts in order to benefit from the experience of other countries at the forefront of demographic change
• Pursue the involvement of the Institute of Aging in global initiatives in this area that are led by the WHO and other relevant global organizations, such as OECD

Potential Strategic Implementation Actions

Participate in the CIHR initiative on Healthy Cities in order to learn how healthy cities can support mobility and social participation, while also extending and adapting solutions for small and rural communities

• Pursue the investment, in partnership with SSHRC, in the CIHR initiative on HealthyandProductiveWorkand ensure the dissemination of the results of the currently supported teams to policy makers
• Continue the leadership and convenor roles of the Institute, in both national and international contexts, in order to bring ageism and the stigma associated with aging to the attention of all relevant stakeholders
• Pursue and enlarge the Institute’s role as the co-lead of the CIHR initiative on eHealthInnovationsand ensure the dissemination of the results of the currently supported teams to policy makers and to industry
• Maintain the role that the Institute is playing on behalf of CIHR and Canada in the relevant Joint Programming initiatives in order to continue to foster the participation of Canadian researchers in jointly funded programs on the impact of demographic change (JPI-MYBL, in partnership with SSHRC) and on technology and aging (AAL Programme, in partnership with the AGE-WELL NCE and the Canadian Frailty Network NCE)

Expected Outcome(s)

Creation and dissemination of knowledge on the optimal physical, psychological and social environments to favour wellness and quality of life of older Canadians

Strategic Direction 2: Facing the Complex Health Challenges of an Older Population

Despite all of the current efforts to ensure health and wellness in the older population, many older individuals continue to struggle with multiple chronic conditions, which can have a negative impact on their quality of life in their later years. The effects of these multiple chronic conditions need to be better understood, addressed and ultimately prevented.

Neurodegenerative diseases causing dementia are the health conditions that have the most deleterious impact on the quality of life of the individual, as well as that of their caregivers. Similarly, frailty is a driver of severe physical disability that increases the rate of institutionalization affecting quality of life. At the same time, new emerging aging populations, such as people living with HIV/ AIDS, cancer survivors, or those with an intellectual or neurodevelopmental disability, spinal cord injury, stroke or traumatic brain injury, require particular attention due to the multiple health challenges that these people face later in life.

Given that the current healthcare system was not initially designed to be suitable for individuals who have multiple chronic conditions, frailty and/or cognitive impairments, it needs to be re-engineered in order to be more age-friendly and age- appropriate and, in particular, it needs to address the challenge of an integrated continuity in the context of aging. The health and wellness of caregivers, in the context of an aging population, also need to be considered. In addition, late-life care and decisions need to benefit from thoughtful reflections in order to be able to reconcile all of their diverse dimensions. Some of the key challenges include the frequent unpredictability of end-of-life in the context of multiple chronic conditions, as well as the complex new legal framework in Canada of medical assistance in dying.

The Institute of Aging’s second Strategic Direction is best expressed through five complementary sub-Directions:

• 2.1. Understanding, preventing and addressing multiple chronic conditions
• 2.2. Facing the challenge of dementia
• 2.3. Recognizing new emerging aging populations
• 2.4. Ensuring the adaptation of healthcare and services to an aging population
• 2.5. Informing late-life care and decisions

2.1. Understanding, preventing and addressing multiple chronic conditions

Goal

To understand the underlying mechanisms and causes of the multiple chronic conditions and frailty that are frequent among older individuals, with the aim of better prevention and treatment, while addressing the challenge of inappropriate medication

Objectives

Promote and accelerate the understanding of the complex interactions between the mechanisms of the biology of aging and the mechanisms that result in the chronic conditions frequently associated with aging (e.g., arthritis, Type 2 diabetes, and neurodegenerative diseases), and their relationship with the clinical concept of frailty

• Ensure the transformation of this new knowledge into multi-disease clinical pharmacological and non-pharmacological interventions that prevent and treat the multiple chronic conditions that are associated with aging

Potential Strategic Implementation Actions

In partnership with the relevant CIHR Institutes, including the Canadian Frailty Network, the Institute of Cancer Research, the Institute of Circulatory and Respiratory Health, the Institute of Gender and Health, the Institute of Indigenous Peoples’ Health, the Institute of Musculoskeletal Health and Arthritis, the Institute of Neurosciences, Mental Health and Addiction, the Institute of Nutrition, Metabolism and Diabetes, and the Institute of Infection and Immunity:

• Bring attention to, support, and promote the geroscience research approach that is aimed at the identification of the interactions between the mechanisms of the biology of aging and those of the various biological systems
• Promote and support the translation of geroscience research into pharmacological and/or non-pharmacological clinical trials that are aimed at preventing and/or treating multiple chronic health conditions

Expected Outcome(s)

Increased number of geroscience projects in the investigator-initiated programs

Geroscience – A Promising Approach to Multiple Chronic Conditions

The geroscience approach seeks to understand the molecular and cellular mechanisms responsible for aging that are considered as major risk factors and drivers of the development of common chronic conditions and diseases in the trajectory of life. While aging itself is not a disease, the aging process represents a major risk factor for the development of a number of chronic diseases and conditions, including cardiovascular disease, diabetes, many cancers, arthritis, and frailty, among others.

2.2. Facing the challenge of dementia

Goal

To provide optimal support the highest levels of quality of life for people who are living with dementia and their caregivers, while also ensuring the availability of treatment, risk reduction, and prevention interventions for neurodegenerative diseases causing dementia

• To address the over-representation of women among both caregivers and those living with dementia, as well as the over- representation of dementia among the Indigenous population

Objectives

Build upon Canada’s excellence in research in all disciplines related to the biological, psychological, and social aspects of brain diseases causing dementia, and harness the already established international collaborations

• Continue the support to the evolving pan-Canadian collaborative network of the best researchers in order to (a) engage in a balanced approach that includes prevention, treatment, and care and recognizes the sex and gender differences; (b) identify and implement optimal care for people living with dementia and their caregivers; (c) provide efficient treatment and risk reduction strategies for both people living with dementia and everyone else who wishes to avoid it; and (d) address the stigma associated with dementia and the challenges of social inclusion
• Maintain and enhance the participation of Canada in international collaborative efforts in the area of dementia
• Sustain and enlarge the convenor role of the Institute of Aging in the area of dementia, in Canada and around the world

Potential Strategic Implementation Actions

In collaboration with the Public Health Agency of Canada, the Alzheimer Society of Canada, relevant stakeholders, and patient and caregiver representatives:

• Maintain and aspire to increase the resources for the Canadian Consortium on Neurodegeneration in Aging in order to support its balanced and sex-sensitive collaborative approach to the various challenges of dementia, as well as its shared platforms, knowledge dissemination, ethical, legal and social activities, and inclusion of persons with lived experience
• Contribute to the preparation and implementation of the Government of Canada’s National Dementia Strategy, expected to be launched in 2019
• Pursue and increase the opportunities for Canadian researchers to work collaboratively with international colleagues through the programs of the EU Joint Programme – Neurodegenerative Disease Research (JPND) and the Centres of Excellence in Neurodegeneration (CoEN), while also promoting the globalization of the programs
• Continue support for the participation of Canadian researchers in the Alzheimer Disease Neuroimaging Initiative (ADNI), the NIH’s shared data initiative
• Maintain a role in the World Dementia Council, as a means to be inspired by and to influence the global response to the worldwide challenge of dementia

Expected Outcome(s)

Enhanced number of collaborative research projects on the different  brain diseases causing dementia

• Availability and use of pan-Canadian research platforms on dementia
• Creation and dissemination of new knowledge on risk reduction, as well as quality of life of people living with dementia and their caregivers

2.3. Recognizing new emerging aging populations

Goal

To recognize and understand the specific biological, psychological, and social dimensions of health and wellness of the increasingly growing number of aging individuals living with conditions that previously had very short-term life expectancies (e.g., people with HIV/AIDS, Down Syndrome, intellectual and neurodevelopmental disabilities) or who have survived health threatening episodes (e.g., cancer survivors, those living with spinal cord injuries, stroke survivors and traumatic brain injury)

Objectives

In partnership with the relevant CIHR Institutes, in particular the Institute of Infection and Immunity, the Institute of Human Development, Child and Youth Health, the Institute of Musculoskeletal Health and Arthritis, the Institute of Neurosciences Mental Health and Addictions, and the Institute of Cancer Research, and in the context of a life-course perspective:

• Promote and expand the research efforts to understand the elevated incidence of age-related chronic conditions, including dementia, in the aging trajectory of those living with HIV/AIDS, Down Syndrome and intellectual and neurodevelopmental disabilities, as well as those who underwent therapy for cancer and the survivors of major health challenges who are at risk for developing multiple chronic conditions and/ or dementia
• Ensure that the new aging populations are included in the initiatives that are focused on the care of (i.e. quality of life for those living with the condition and their caregivers) and on the social aspects relevant to (i.e. social inclusion and stigma) individuals living with dementia and other multiple chronic conditions
• Ensure that the health challenges of the new aging populations are connected to and included in the geroscience efforts (see 2.1.)

Potential Strategic Implementation Actions

Promote and ensure the inclusion of participants living with HIV/AIDS, Down Syndrome and intellectual and neurodevelopmental disabilities, as well as cancer survivors, and other survivors of health threatening episodes, and their caregivers in the research efforts on addressing multiple chronic conditions in aging (see 2.1.) and on facing the challenge of dementia (see 2.2.)

• Engage, as a convenor, with policy makers and patient regarding the multiple health conditions experienced by the new emerging aging populations, and contribute to the public dissemination of information

Expected Outcome(s)

Increase in number of research projects and identification of mechanisms responsible for increased chronic-diseases in new emerging populations

2.4. Ensuring the adaptation of healthcare and services to an aging population

Goal

To ensure that provincial, territorial and federal health systems are adapted to the multiple chronic conditions that are commonly present in older patients, and in particular the oldest old, with an emphasis on community- and/or home-based care and considering eHealth innovative solutions

• To ensure a distinct focus on the important role of primary care and the need for adapted and coordinated transitions between various healthcare components, including end-of-life care
• To better ensure the health and wellness of caregivers in the context of an aging population with multiple chronic conditions that can result in frailty

Objectives

Support research to provide evidence on and to transform this evidence into policies and practices related to the need for:

• Efficient health services that are both age-friendly and adapted to the realities associated with multiple chronic conditions, and that rely on a community-based primary care approach that embraces acute, rehabilitative, long-term and end-of-life care, incorporating eHealth solutions where appropriate and efficient
• An efficient  and humane transition within the components of the health system in order to adequately address the needs of older patients and manage their end-of-life trajectory, including home care, rehabilitation, short- term geriatric evaluation and, when necessary, long-term and palliative care

Potential Strategic Implementation Actions

In collaboration with the Institute of Circulatory and Respiratory Health, the Institute of Human Development, Child and Youth Health, the Institute of Health Services and Policy Research, the Institute of Indigenous Peoples’ Health, the Institute of Cancer Research, the Institute of Gender and Health, the Institute of Musculoskeletal Health and Arthritis, and the SPOR Strategy, as well as relevant provincial, territorial and federal policy makers and health service providers:

• Continue the support to the SPOR units and networks
• Maintain the support for research on how to plan and implement cost-effective, age- friendly, integrated health systems that are adapted to multiple chronic conditions and that emphasize the importance of community-based primary care and home care and incorporating efficient eHealth solutions where appropriate.
• Pursue the participation in the CIHR initiative on Transitions in Care, in particular the impact of inactivity on the health of older patients, and ensure the inclusion of aging considerations in all components of the initiative
• Include the health and wellness of caregivers in future initiatives related to the challenges of an aging population

Expected Outcome(s)

Identification of optimal and efficient  care and services for older Canadians including (a) adapted to the older person with multiple chronic disease, (b) taking into account the choice environment (home), (c) ensuring continuity of care, and (d) including integrated eHealth solutions

2.5. Informing late-life care and decisions

Goal

To make available appropriate research-based evidence on late-life issues, including the end-of-life care and decisions required for older individuals living with multiple chronic conditions, frailty with or without cognitive impairments

Objectives

Make available evidenced-informed care practices for late-life decisions, taking into consideration the unpredictability of the trajectory associated with the evolution of multiple chronic conditions

• Support research on optimal palliative care for older, and very old, individuals, including support for their caregivers and families
• Address the ethical and legal challenges of the care management of patients with cognitive impairments that interfere with their ability to make choices and express consent regarding desired levels of care, including access to palliative care and medical assistance in dying

Potential Strategic Implementation Actions

In partnership with the Institute of CancerResearch initially leading the palliative care initiatives, policy makers, and other relevant stakeholders, including community-based seniors associations:

• Support research towards the identification and implementation of appropriate late-life care, including palliative care and medical assistance in dying, that takes into consideration the increasing difficulty to reasonably predict the end of life in most multiple chronic conditions
• Support a series of trans-sectorial research initiatives, which include ethical and legal dimensions and are focused on the challenges to reconcile the legal context of medical assistance in dying with the characteristics of older individuals with health challenges

Expected Outcome(s)

Increased number of research projects on appropriate care and approaches regarding late-life care decisions, including palliative care as well as medical assistance in dying

Cross-Cutting Strategic Directions

Above and beyond the strategic Directions that focus on specific opportunities and challenges, the Institute of Aging also recognizes the need for cross-cutting strategic directions that should be taken into account in all previously mentioned strategic directions.

The first cross-cutting strategic direction relates to Canada’s rich Indigenous culture and the specific  health and wellness challenges faced by the Indigenous populations. Western cultures have progressively forgotten the privileged and important role that older people played in traditional cultures. The Indigenous cultures in Canada remind us of the importance of the role of elders and of knowledge keepers – a role that should inspire all Canadians.

At the same time, Indigenous older adults face specific health and wellness challenges in their aging trajectory, including diabetes and oral health problems, as well as a prevalence of dementia which is twice as high as for other populations. Environmental factors and changing lifestyles also contribute to lifelong changes that add to the potential health challenges associated with aging. In addition, research is needed on health services that respect the Indigenous cultures and address the geographic challenges.

For all these reasons, the Institute of Aging incorporates an Indigenous perspective in the way that health and wellness in aging is approached. The Institute also recognizes the fact that Indigenous health and wellness research must be driven by members of Indigenous communities, a fact that stresses the importance of capacity building efforts in order to ensure the appropriate availability of Indigenous researchers.

The second cross-cutting strategic direction relates to the recognized fact that there is a challenge regarding the training of all health professionals and health workers in Canada who are providing care and/or physical or emotional support for older individuals. There is growing recognition that most of the training programs for health professionals and health workers are either insufficient or inappropriate for the context of the aging population.

It is known that older individuals represent the most important cost driver for our health systems and, as such, represent an important proportion of the duties of health professionals and health workers. There is a need to engage with the certification bodies for both health professionals and health workers on educational research in order to ensure that the training programs are appropriate for the increasingly aging population and, in particular, for the oldest old.

At the same time, it is important that CIHR itself has the capacity to be able to deliver peer review that recognizes the specific and different ways of conducting research on aging. This requires the availability of trained peer reviewers with such a knowledge.

The third cross-cutting strategic direction relates to the convenor and catalyst role of the Institute of Aging. Across all of the Institute’s strategic direction topics, the Institute will maintain and enhance its convenor and catalyst role with the scientific  community, policy makers, all relevant governmental branches and agencies, clinicians, health service providers, industry (including pharmaceutical, information technology, and care), international funding agencies and, of course, the public.

With respect to engagement with the public, the Institute of Aging strongly believes in and will continue to promote the inclusion of end users and their contribution in the Institute’s various initiatives. The Institute holds an open definition of the concept of end users, such that it includes older individuals with health challenges and their caregivers as well as individuals of all ages who are actively seeking to optimize their health and wellness and to diminish the risks of developing multiple chronic conditions, including dementia.

The Cross-Cutting Strategic Directions of the Institute of Aging include the following three sub-Directions:

1. Integrating an Indigenous perspective on aging
2. Ensuring appropriate capacity and training
3. Fulfilling a convenor and catalyst role with all stakeholders

1. Integrating an Indigenous perspective on aging

Goal

To add an Indigenous perspective on aging, when possible, to the research, implementation and convenor actions supported by the Institute of Aging, taking into consideration their distinct recognition of the age at which aging is recognized, as well as their diversity, health inequities and specific environment

Objectives

Be inspired by the many positive Indigenous cultural values related to the role of the elders in the community to address stigma associated with aging and the diminished social role that is experienced by older individuals in non- indigenous communities.

• Be inspired by the way Indigenous researchers include their community
• Incorporate an Indigenous research component, along with an indigenous leadership, in the largest number possible of the strategic initiatives led by the Institute of Aging, in order to address the specific health and wellness challenges related to aging that are prevalent among Indigenous populations

Potential Strategic Implementation Actions

In partnership with the Institute of Indigenous Peoples’ Health, the other CIHR Institutes, and the relevant policy makers:

• Promote to stakeholders and the public the Indigenous ways of recognizing and showcasing the important role of elders in their communities
• Strive to include an Indigenous component in the major initiatives led by the Institute of Aging, in particular the CLSA and the CCNA
• Contribute to the Network Environments for Indigenous Health Research (NEIHR), a multi-institute, long-term capacity building initiative, in order to ensure the capacity of Indigenous researchers to conduct Indigenous health research
• Pursue the contribution to other multi-institute initiatives, such as the Indigenous Healthy Life Trajectories Initiative (I-HeLTI) and the Pathways to Health Equity for Aboriginal Peoples (Pathways) initiative, both of which are important for the health and wellness of Indigenous Peoples

Expected Outcome(s)

Promotion of Indigenous cultures inspired attitudes towards aging and older Canadians

• Inclusion of appropriately-led indigenous perspective/components in IA-led initiatives

2. Ensuring appropriate capacity and training

Goal

To ensure the research capacity necessary in order to engage in and increase research on aging, while also ensuring that health professionals, health workers and policy makers are appropriately trained to serve and support older individuals with health challenges

Objectives

Contribute to the enhancement of the training in interdisciplinary and collaborative research

• Contribute to programs that would address the specific challenges of early- and mid- career investigators
• Promote access to longitudinal data and other relevant sources of data and the capacity to engage in longitudinal research
• Support educational research in order to ensure appropriate training for all health professionals and health workers who are providing care and/or physical or emotional support for older individuals, including the oldest old
• Ensure that interdisciplinary applications in the area of aging that are submitted to the investigator-initiated programs will be reviewed adequately and fairly

Potential Strategic Implementation Actions

Continue the coordination, in partnership with the host institutions, of the Summer Program on Aging (SPA), an annual interdisciplinary training program that is focused on the Institute of Aging’s current strategic actions and offers the opportunity for all of the participants, both Canadian and international, to establish long-term networking connections

• Contribute to the CIHR efforts aimed at ensuring a proper research support throughout the research career life cycle, and especially addressing the early- and mid-career challenges
• Support data analysis grants aimed at catalyzing and supporting the research efforts of Canadian researchers, particularly trainees and young investigators, to make use of available longitudinal data from the CLSA, with the aim to contribute to the creation of a longitudinal research community in Canada
• Ensure, in partnership with the certification bodies, that the training programs of all health professionals and health workers include the required inter-disciplinary and inter-professional aspects related to the specific care needs of older individuals, in particular the oldest old, who are living with health challenges
• Maintain and enhance the role and contribution of review committees, such as those on the Biological and Clinical Aspects of Aging and on the Social Dimensions in Aging, and ensure the availability of appropriately trained reviewers to evaluate the interdisciplinary applications submitted to the investigator-initiated programs.

Expected Outcome(s)

Pursuing training opportunities to enhance inter-disciplinary research capacity in aging

• Exploring the introduction of educational research projects to develop the best training approach for professionals and workers to face demographic changes

3. Fulfilling a convenor and catalyst role with all stakeholders

Goal

To optimize the catalyst role of the Institute and to position the Institute of Aging as the primary national convenor in all areas that are linked with the creation of knowledge and its translation into optimized health and wellness strategies for older individuals, including the oldest old.

Objectives

Fulfil this convenor and catalyst role with:

• The research community on aging and its leaders
• All federal government branches and departments as well as the relevant provincial and territorial authorities
• Federal, Provincial and non-governmental funders of research in the area of aging
• International funders of research in the area of aging
• Charities, patient associations, and community-based organizations
• Industry partners, in the area of solutions and services for the older population, and their leaders
• The public and the community associations

Potential Strategic Implementation Actions

Continue and expand upon the Institute’s convenor and catalyst role at all major national and international conferences and events, including the Canadian networking events as well as the Canadian Pavilions in the conference exhibit halls

• Maintain the coordination of the bi-annual meetings of the Directors of the Canadian Research Centres on Aging
• Actively participate in and contribute to the various governmental committees and activities that are related to aging and dementia, such as the meetings of the Health Portfolio, the Interdepartmental Committee on Seniors, the Interdepartmental Committee on Dementia, the Ministerial Advisory Board on Dementia, as well as the Best Brain Exchange events
• Enhance the active participation with various international organizations related to aging, such as the relevant WHO departments on Ageing, on Chronic Diseases, and on Health Development, the Milken Institute’s Center for the Future of Aging, the OECD, and those of other countries (e.g., Korea, Chile, etc.)
• Sustain the partnership with the National Research Council (NRC) – Industrial Research Assistance Program (IRAP), an innovation assistance program for small and medium-sized enterprises, and the support provided to the development and commercialization of technologies in the area of aging; and maintain the relationship with the pharmaceutical and information technology industries and their associations
• Pursue the convenor role with the general public, in the form of Public Events that are organized on topics of interest
• Enhance engagement with the media

Expected Outcome(s)

Maintain and enhance the role of the Institute of Aging as the primary convenor and catalyst in the area of knowledge creation and translation to support the aging society in Canada and around the world

Monitoring and Reporting on Progress

In line with the CIHR’s Performance and Outcome Measurement Framework, and in collaboration with the CIHR Results and Impact Unit, the Institute will develop a yearly operational plan that will include key performance indicators that will be tracked to measure success for each of the Strategic Implementation Actions. In the specific cases where the Strategic Implementation Actions are already included in an on-going major initiative with an evaluation framework, monitoring and measure will be coordinated with the yearly operational plan.

Living Longer, Living Better

As is the case worldwide, the Canadian population is aging while, at the same time, the life expectancy is still increasing along with the number of the oldest old and, in particular, the centenarians. The current situation affords some amazing new life opportunities but can also bring with it some major health and wellness challenges for older individuals and their caregivers.

Enhanced health and wellness in the later stages of life depends upon a large number of factors that are linked to lifestyle choices and environmental factors throughout the life trajectory. These choices and factors, along with the genetics of each individual, determine an important diversity in the state of health and wellness among older individuals. Added to these factors, and therefore the complexity, are the physical, psychological, and social environments that can either contribute to or interfere with health and wellness in older individuals. Finally, the occurrence of multiple chronic conditions, with dementia being one of the most debilitating, also contributes to this diversity in the later years.

As a result, research on health and wellness in aging must embrace this complexity and engage in interdisciplinary, cross-sectorial efforts to favour health and wellness in the later years. These research efforts will include the relevant population and individual approaches, whether lifelong-based or focused on specific health and wellness conditions in older individuals.

The CIHR Institute of Aging is dedicated to realizing the achievement of a longer and more satisfying life for Canadians.

… Moving towards a Canada where we can all live longer and live better …

Date modified:

2019-05-08