The Ministry of Health’s refreshed action plans for successful ageing announced earlier this year include expanded housing options that integrate care as well as a new “Live Well, Age Well” Programme aimed at better inclusion of senior citizens in mainstream planning. But what does ‘ageing well’ really entail?  MEDICUS spoke with Dr Mary Ann Tsao, Chairperson of the Tsao Foundation and a council member of the Tsao Family Office, about successful ageing, the lessons—and opportunities—thrown up by the pandemic and what knowledge blind-spots keep her awake at night. 

MEDICUS: Starting with a definition: in your opinion, what does successful ageing mean?

Mary Ann Tsao: Actually, I like to think about longevity rather than ageing because people tend to use the word ageing in a negative way. But we’re really talking about a success story that we get to live 20, sometimes 30 years longer. So, we should think about how we can take advantage of these extra years of life, and how we optimise the benefit of living a long life.

So, what defines successful longevity? It is the ability to optimise the opportunities to lead as full a life as possible and have the choices to lead the lives we want.

MEDICUS: Longevity, then, is highly individualised. How do we create policies, and services to account for that?

Mary Ann Tsao: That’s why it is optimising opportunities because everyone’s different. And that means the individual, family, community and society all have a role to support each individual with all their differences so that they can optimise their ability to lead the life that they want fully. Of course, good health is important in this, but health is more than the absence of disease. The best predictor of someone living a longer, better and healthier life, as identified by a seminal Harvard study that started in 1938, is having strong social networks when you’re in your 50s. So, optimising health isn’t just about the healthcare system.

As an individual, a person should have access to information and means, so that they can lead a healthy life, and be enabled by the social and physical environment to do that.

The second thing is the family. They need to support the individual to lead a healthy life. Older people, in particular, often become a little more dependent on their families to support them and their lifestyle.

Then there’s the community. Does the community support that kind of healthy lifestyle? And this extends to the built environment. The social environment and policies around access to education, healthcare, employment, income —all make an impact. The private sector, too, has a role to play by creating workplaces that enable people to take care of themselves and providing opportunities for them to remain gainfully and meaningfully employed, or engaged in income generating activities, be it the gig economy or opportunities to create their own enterprises in their later years.

Every sector of society has a role to play to create an optimal environment for people to thrive regardless of the circumstances they’re in.

MEDICUS: How does the Tsao Foundation tailor its programmes to individuals and their families?

Mary Ann Tsao: We created a series of service models that cater to different phases of life and needs. The services are built to meet a certain needs profile, but within that profile, we customise our care for them based on their individual circumstances. We assess an individual’s needs and create a care plan that can mobilise what’s available in terms of services as well as other resources already there, including the older person’s strengths, and their family’s ability to provide care and be resilient. Our efforts also focus very much on self-care, enabling them or the family to take care of the older person as well as the caregivers. [This includes] psychosocial health as it is an important part of a person’s overall health and wellbeing. If and when necessary, we also mobilise community resources, such as neighbours and other members of the community.

And because we operate in the community, we have to remember that people are leading a life, they are not thinking about healthcare. So we have to integrate our services into their lifestyle.

MEDICUS: What ageing-specific lessons have we learnt from COVID-19?

Mary Ann Tsao: So, COVID-19 in a way revealed issues that have been brewing under the surface for a long time, such as social isolation and mental health issues, as well as opened a new vista on the issues ahead of us and helped launch us into a more tech-assisted way of providing support and enablement for the seniors at home in the community.

We thought we’d been doing a pretty decent job promoting and enabling self-care until people were locked down, particularly the seniors with dementia who were very frail. But we couldn’t go in to provide care and the families found that they were not sufficiently independent. All we could do was provide support from a distance. Some managed, many didn’t do so well.

But even without COVID-19, older people and their families do encounter spells of social isolation. This means we have to find ways to deliver services and retool our service model to not only just provide care, but also to build resilience in older people and their caregivers, including their emotional resilience, the ability to navigate basic care for themselves at home, and the ability for self-care, particularly for those with dementia. Family members and caregivers need to know how to work with them at home when they can’t go to a day centre, for instance. They have to understand how to create a structure and avoid behavioural issues, such as ensuring that spaces are not so loud and irritating, for example.

At the same time, we also need to get them onto digital and other tech platforms, so we can beam in exercise programmes to keep people physically active, beam in activities that keep their mind and emotions engaged and help them stay socially connected. These telehealth or online capabilities are something we’re trying to build up. We are also exploring other tech solutions to enable the professional staff to monitor and provide other services more effectively and easily, as well as enable the family in care giving work and the older person in self-care.

MEDICUS: With the greater incorporation of technology into care service models, can digital platforms make up for the loss of an ‘eyeball’?

Mary Ann Tsao: The eyeball factor has very much been enhanced by the incidental discovery and rapid adoption of video conferencing that was brought about by COVID-19. The COVID-19 era has made it normal to use video conferencing. We were able to connect with many people, starting with WhatsApp, which was very useful because it is so easy to use. And for those that made it on to Zoom or other video conferencing platforms, with them, we could do all sorts of things. So, we can augment our eyeball time with technology so that we can step up our monitoring between in-person interactions. We can interact with them more often for shorter durations which is easier to slot into their other routines and is a lot cheaper. It also helps us in the not-for-profit sector to manage resources more efficiently.

MEDICUS: Has COVID-19 setback our efforts to create an inclusive society?

Mary Ann Tsao: The Singapore government has really put a lot of attention into making sure older people were not excluded in terms of resources. The effort that has gone into reaching seniors is something quite remarkable. I think there’s been some unintended exclusion because they made older people and their families afraid of their vulnerability. And not all older people are vulnerable. They put so much fear into the hearts of people that they became unnecessarily isolated. Both because of older people’s anxieties and their family members’. So they lost function—cognitive  as well as some physical function—because they were not engaged the same way as before.

But the one thing that COVID-19 blew the lid off on is mental health. Suicide rates—which were already high among older people around the world—spiked during COVID-19. Almost one-third of people over 60 are isolated, even though they may be living with family, and social isolation increases with age, so I think that understanding the psychology of people and their mental health is very important.

MEDICUS: How does the work of centres like CARE at Duke-NUS dovetail with what you do through the Tsao Foundation and what areas are most important for further research to make an impact?

Mary Ann Tsao: At the Foundation, we’re big proponents of supporting research and we want to catalyse more research.

Our big aspiration is to enable older people to live well and die well in the community and for their families to joyfully “care-give” to the end—joyfully “care-give”. But there is a limit to what family members can do for well-known reasons like lack of time, financial resources and smaller family sizes.

Therefore, we want to understand what the family system looks like, what are the strengths and capabilities we can tap and what areas we need to support, so that those family members can care for their parents till the end. And it is not just in financial terms and time but also in psychological aspects. It is really about intergenerational solidarity. A lot of times, families love each other but there is tension from past emotional “baggage” and this unresolved tension means that there is a lot of suffering there. So how can we strengthen the psycho-emotive relations within the family? How can we prevent social isolation?

If the relationship between generations becomes weaker and the relationship within even a loving family is fractured, and the default long-term care means a nursing home for most older people, I don’t know what that means actually. It’s not the actual financial cost, but I think it’s probably a lot more terrible than we can imagine, so that is a concern for us. We want to understand the factors that glue families together and ones that tear them apart, and what kind of intervention might be doable on the individual and family levels.

With regards to understanding the mental health needs of older people, we need to focus on resilience research, a relatively new area in the field of longevity studies. How we can build mental and emotional resilience for older people, so that’s another area.

And that needs to be complemented by training of all our health-related professionals to think about mental health. Right now, we don’t train our doctors and nurses to pay sufficient attention to mental health. The mental health of older people, in general, has gone under the radar. And it’s not just about detection and treatment, but creating an environment where older people can thrive, so they don’t even have to be at risk of mental health issues, depression and social isolation.

So really understanding social isolation, how to build resilience, what the mental health needs of older people are as well as how to keep intergenerational ties strong, that’s what we will be focusing on.

MEDICUS: Thank you for your time, Dr Tsao, and your generous sharing.