Instructor: Independent Study
Module Revised by: Shelley Bhattacharya, DO, MPH
Reviewed by: Anne Walling, MB, ChB
Specific Learning Objectives
A. Introduction
Reviewing the demography of the growing older adult population is essential to providing quality medical care to older adults. Understanding the growing numbers locally and globally as well as the ethnically differing needs of this cohort is important when establishing an effective provider patient relationship. It is the author’s hope that this independent study module will introduce you to the changing demography of the older adult population and develop an appreciation for this unique cohort.
Before reviewing the learning objectives and content, please take the Pre-Test.
B. Attitudes
The student will be able to demonstrate recognition of the wide degree of heterogeneity among older adults, in terms of health status as well as economic and social circumstances. The student will also appreciate the value of geriatric care regardless of which medical specialty they choose to pursue.
C: Knowledge - The student should be able to describe:
D. Skills
The student should demonstrate the ability to adapt recommendations for preventive measures based on active life expectancy. The student will learn to analyze patient-specific risks and benefits of therapy, rather than making broad assumptions in geriatric medical care.
E. Readings
Required Readings
Recommended Reading
- Kansas Elder Count 2000 – Population http://www2.kumc.edu/coa/Education/AMED900/Population.pdf
- Kansas Elder Count 2000 – Health
http://www2.kumc.edu/coa/Education/AMED900/Health.pdfAll of the charts within this module come from General Interagency Forum on Aging-related Statistics. Older American Update 2006: Key Indicators of Well-Being. Federal Interagency Forum on Aging-Related Statistics. Washington, DC: US Government Printing Office. May 2006
http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/2006_Documents/Health_Status.pdf
All of the “tips” in the Ethics and Cultural Perspectives in Geriatrics are from Chapter 7 of this text. Ham, Richard, et al. Primary Care Geriatrics: A Case-Based Approach; Chapter 7. Mosby Elsevier, 2007.
G. Cases
Life Expectancy
Life expectancy is the average number of years of life remaining to a person at a given age if death rates were to remain constant. In the United States, improvements in health have resulted in increased life expectancy and contributed to the growth of the older population over the past century.
Americans are living longer than ever before. Life expectancies at both age 65 and age 85 have increased. Under current mortality conditions, men who survive to age 65 can expect to live an average of 16.8 years and for women, the life expectancy at 65 is currently 19.8 years. The life expectancy of people who survive to age 85 today is 6 years for men and 7.2 years for women. Note, the life expectancy is a "moving target" and never actually reaches zero. Also life expectancies have improved dramatically over the last decade in the USA.
Life expectancy at age 65 in the United States is lower than that of many other industrialized nations. The longest life expectancies are for Japanese women. Within the US, the longest life expectancies are in Hawaii.
Life expectancy varies by race, but the differences change with age. In the US, life expectancy at birth and at age 65 is higher for white people than for black people. At older ages, however, the life expectancy among black people is slightly higher than among white people. This has been attributed to a "healthy survivor" effect, more social support, and other factors.
Why might women live longer than men? See abstract, "Why Women Live Longer Than Men: Sex Difference in Longevity" available online at: http://www.ncbi.nlm.nih.gov/pubmed/16860268?ordinalpos=12&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel. Pubmed_DefaultReportPanel.Pubmed_RVDocSum
Active Life Expectancy
The concept of active life expectancy (Katz, et al., 1983) is useful in thinking about functional status and independence in older adulthood. In life expectancy, the end point is death. In active life expectancy we are also concerned with the loss of independence or the need to rely on others for assistance with daily activities. Simplistically put, the remaining years of life for a group of persons can be “active” or “dependent,” or some combination thereof. Active life expectancy answers the question: “Of the remaining years of life for this cohort of persons, what proportion is expected to be spent disability free?” The answer has implications for individuals, families and societies.
“Not surprisingly, differences in life conditions of older persons with inadequate income and those above the median income in the U.S. have led to the conclusion that there is a major discrepancy of 1 to 2.5 years in active life expectancy between the poor and the non-poor” (Hooyman & Kiyak, 1999, p.24. Social Gerontology: A Multidisciplinary Perspective.)
Current life expectancy is approximately 86 years for women and 78 for men. At age 65, women have a life expectancy of 22 additional years and men have an additional 17 years. The further one progresses beyond age 65, the longer one is expected to live. Keep in mind that these numbers are averages. Individual life expectancies will vary based on existing comorbidities and quality of life.
As Abraham Lincoln once said, "And in the end, it's not the years in your life that count. It's the life in your years."
The Elderly in Kansas
Kansas ranks eleventh among states in percentage of persons aged 65 and older-13.8 percent" compared to 12.5 percent for the U.S. as a whole. Kansas ranks fifth among states in the percentage of persons aged 85 and older. By the year 2010, the Census Bureau projects that 15.3 percent of Kansans will be aged 65 or older, and that the state will be among the 10 most "aged" in the U.S.
As in other states, elders living in rural areas are of particular concern. In some Kansas counties, the proportion of elderly in the population is over 20%. While the actual number of elderly people is smaller than in the urban areas, the relatively small number of potential caregivers, lack of infrastructure, and problems of distance and communication make the rural elderly more vulnerable.
For detailed information on the Elderly in Kansas, please reference Kansas Elder Count, 2002:
Understanding the changing demography of the older adult population is essential when entering the practice of medicine. The aging of the baby boomers, persons born between 1946 and 1965, will significantly increase the aged population in the early part of the 21st century. By the year 2030 the American population is expected to grow by 84 million persons, from nearly 263 million in 1995 to nearly 347 million, a growth of 32%. During the period from 1995 through 2030, growth is expected to be lowest for persons age 0 to 19 (23%) and those 20 to 64 (20%). The elderly population, however, will more than double, from 34 million in 1995 to more than 69 million in 2030. Between the year 2010, when the first baby boomers reach 65 years of age, and 2030, the population aged 65 and over is expected to increase from 13% to 20% of the U.S. population.
Mortality
Overall, death rates in the U.S. population have declined during the past century. But for some diseases, death rates among older Americans have increased in recent years.
In 2001, the leading cause of death among people age 65 and over was diseases of heart (1,632 deaths per 100,000 people), followed by malignant neoplasms (cancer) (1,100 per 100,000), cerebrovascular diseases (stroke) (404 per 100,000), chronic lower respiratory diseases (301 per 100,000), influenza and pneumonia (155 per 100,000), and diabetes mellitus (151 per 100,000).
Specific causes of death may be more common in specific groups e.g. diabetes is more commonly reported as a cause of death in Black or Hispanic populations. (See Ethnic and Cultural Perspectives in Geriatrics)
Reported causes of death may be influenced by several factors including:
- changes in the prevalence of a health condition (e.g. heart disease)
- increased virulence (higher case fatality) of a disease (e.g. influenza, resistant pneumococcal disease)
- variations in diagnosis or reporting (e.g. Alzheimer's Disease)
Diseases of heart and malignant neoplasms are the top two leading causes of death among all people age 65 and over, irrespective of sex, race, or Hispanic origin.
Source: Older Americans Update 2006: Key Indicators of Well-being
Rectangularization of the Mortality Curve
This concept refers to the change in the proportion of a cohort to survive to a given age without experiencing morbidity, disability or mortality.
In the figure, the horizontal axis represents age and the vertical axis describes the probability (expressed as a percentage) of a group of people surviving to a given age without suffering a health event. The spatial relation of the curves can be used to interpret changes in health burden on society of age-related morbidity and disability. Specifically, the areas in the figure are defined by a product of age (time) and the average probability of having a given health status. Consequently, the areas describe the number of person-years the life table cohort occupies in specific health states.
(Manton, K & Soldo, B.J., (1992). Disability and mortality among the oldest-old: Implications for current and future health and long-term service needs. In (eds) Suzman, R., Willis, D.P., & Manton, K.G., The Oldest Old. New York: Oxford Press, p.201)
Morbidity
Compression of Morbidity Theory
Similarly some experts predict that future cohorts of older adults will have fewer debilitating illnesses and will experience "the compression of morbidity" in which people experience only a few years of major illness and disability in very old age, rather than living many years in a -debilitative state. In other words, the number of years that a group of older adults can expect to live with the debilitating effects of illness or disability may be reduced in the future. This positive outlook implies that even if "baby boomers" life longer than previous generations, their burden of illness and disability may actually be less.
Other experts are less optimistic, especially in view of the already-significant prevalences of chronic conditions such as diabetes, obesity and hypertension in middle-aged and young-elderly Americans. Whether morbidity will be compressed or expanded has serious implications at the individual, family and societal levels, particularly as the baby boomers move into "geriatric" age groups
Chronic health conditions are long-term, usually pervasive conditions that can be managed but are rarely cured. Conditions such as heart disease, stroke, cancer, and diabetes are among the most common and costly health conditions of older adults. The impact of other chronic conditions such as arthritis and mental health problems is frequently under-reported and underestimated. Chronic health conditions negatively affect quality of life, contributing to declines in functioning and the inability to remain in the community. Lifestyle and behavioral interventions often play a major role in managing these conditions. Five of the six leading causes of death among older Americans are chronic diseases.
The prevalence of chronic conditions differs by sex. Women report higher levels of hypertension, asthma, chronic bronchitis, and arthritic symptoms than men. Men report higher levels of heart disease, cancer, diabetes, and emphysema.
Differences also occur by race and ethnicity. Among people age 65 and over, Blacks report higher levels of hypertension and diabetes than non-Hispanic whites. Hispanics report higher levels of diabetes than non-Hispanic whites but similar levels of hypertension. (See Ethnic and Cultural Perspectives in Geriatrics)
The prevalence of some conditions, especially hypertension and diabetes, is increasing over time. Obesity, lifestyle choices, increased screening and diagnostic advances all contribute to changing prevalences of chronic conditions. Some of these effects show significant time lags e.g. changes in smoking-related disease incidence 20+ years after declines in the prevalence of smoking in the population.
NOTE: Despite the heavy burden of illness and disability in the older population, most report their overall health to be good or excellent, even in the over 85 age group.
In older adults, understanding the ability to function is as important as knowing the diagnoses and medical status of an individual. Functioning in later years may be diminished if illness, chronic disease, or injury limits physical and/ or mental abilities. Functional ability is strongly influenced by social factors and cultural expectations. (For more on functional ability see the module on Functional Assessment)
Classical measures of disability include Basic Activities of Daily Living (commonly referred to as simply ADLs) and Instrumental Activities of Daily Living (lADLs) that may be influenced by social and cultural expectations and changes in technology. The proportion of older adults reporting difficulty in ADLs or lADLs is slowly decreasing. Nevertheless, the growing size of the older population means that more people are living with disability.
Aspects of physical functioning such as the ability to lift heavy objects, walk 2 to 3 blocks, or reach up over one's head are more closely linked to physiological capabilities than are ADLs and IADLs,
Mental health problems such as depression or cognitive problems also impact functional abilities. Significant memory problems are reported by 15% of men and 11% or women over 65 years of age but for 34% and 31 % respectively of those older than 85 years.
Depression is reported by 11 % of men and 18% of women over 65 years of age but 15% and 22% of those older than 85 years
In all older age groups women are more likely to report functional problems than men. Rates of disability and functional impairment increase dramatically with age. Overall, 23% of the elderly age group reported some limitation in activities of daily living (ADLs) or the more complex tasks known as instrumental activities of daily living (IADLs), while 53% of those 85 and over reported some functional limitation.
Those experts who believe in the "rectangularization" of morbidity and disability hold that disability will become uncommon till advanced age but this is controversial.
Remember, despite high rate of medial conditions and disability, most elders rate their health as good.
The latest estimates of the over 65 year old population are approximately 36 million people (12% of the population). By 2050, this is expected to increase to 90 million. Particularly rapid growth is anticipated in the over 85 age group. The elderly population is also expected to become more ethnically diverse.
Currently about 10% of elders overall live in poverty with the remainder equally divided between 'high", "middle" and "low" incomes. Rates of poverty vary considerably by education level, race and sex. About half of all elderly black women who live alone are poor. The projected financial status of "baby boomers" in old age is highly controversial and likely to show a wide range of financial status.
For more detailed information by state and gender from the Census Bureau, click on this link. http://www.census.gov/prod/2001pubs/c2kbr01-10.pdf
Over 65% of those aged 65-74 live with their spouse. Single and widowed individuals also overwhelmingly live in the community. Families and other provide a tremendous amount of support to the elderly. Only 1.5% of all individuals aged 65-74 years live in long-term care but this rises to nearly 25% for those older than 85.The numbers living in long term care facilities are declining slowly but the level of disability of residents is rising. (See Ethnic and Cultural Perspectives in Geriatrics)
Squaring of the population pyramid
“A population pyramid (or age/sex pyramid) is a graphic representation of the distribution of a population by age and sex. It is called a pyramid because the ‘classic’ picture is of a high-fertility, high-mortality society (which characterized most of the world until only several decades ago) with a broad base built of numerous births, rapidly tapering to the top (the older ages) because of high death rates. Developed countries, such as the U.S. and France, have age/sex distributions that are more rectangular, or barrel-shaped , but we still call the graph a population pyramid.”
(Weeks, J. 1994. Population: An Introduction to Concepts and Issues. Belmont, CA: Wadsworth Press, p. 229).
A population pyramid takes on the shape of a rectangle when mortality rates at older ages decrease and a higher percentage of people survive to older adulthood. In general, this phenomenon occurs as fertility rates drop, and fewer people (proportionately) are added to the bottom of the pyramid through birth. The global migration rate can also affect the shape of the population distribution.
Culture, the shared values, beliefs and behaviors of members of a group, influences the presentation of symptoms by patients, the decisions of clinicians, and the patient’s compliance to a recommended treatment plan. Although socioeconomic factors are the most powerful determinant of health care and health status in the US, membership in a minority racial or ethnic group in an independent risk factor for lower quality, less intensive medical care. Excess deaths, morbidity and disability are prevalent among racial and ethnic minority older adults. African-Americans tend to favor more aggressive therapy than whites. The 2001 Health Care Quality Survey revealed that 32% of Asians and 26% of Hispanics felt their personal beliefs prevented them from following their physician's advice. African-American women suffer the greatest disparate mortality from cardiovascular disease. Tthe Surgeon General made eliminating racial and ethnic disparities one of its two goals in Healthy People 2010.
The doctor-patient relationship merges three cultures:
- Culture of medicine from beliefs learned from education, medical school training
- Culture unique to each physician’s background
- Culture unique to each patient, possibly unknown to the clinician
Who participates in health care decisions and responsibilities for care of the ill older adult varies enormously from culture to culture. Ultimately, clinicians must ask patients and families about preferences.
Tips in Cross Cultural Communication
Miscommunications between members of different speech communities originate from differences in style as well as differences in grammar and word use. See Tips in Cross Cultural Communication.
According to the 2001 Health Care Quality Survey, 32% of Asians and 26% of Hispanics reported that their personal beliefs prevented them from following their physician’s advice. For whites and African Americans, the numbers were 19% and 13% respectively.
Health Issues of Hispanic Older Adults
When patients perceive that they are being treated disrespectfully in the health care setting, they are less likely to pursue preventive care, follow their physician’s advice and received needed care, all of which have a greater impact on elderly minorities with one or more chronic diseases. Health Issues of Hispanic Older Adults demonstrates important cross-cultural care tips relevant to information gathering and effective communication.
As of the 2000 US Census, Hispanics of all races accounted for 12.5% of the US population, translating to 35 million people. Mexicans are the largest subgroup, accounting for 7.3% of the total population and 50% of the elderly Hispanics.
Health Issues of African American Older Adults
The rate of health insurance among Hispanics is the lowest in the US, a factor that undoubtedly contributes significantly to disparate health status. Click here to see a summary of key health issues among Hispanic older adults.
African American older adults generally suffer the same disorders as the non-minority population: cardiovascular disease, cancer and stroke. African American women suffer the greatest disparate mortality from cardiovascular disease. This is not due to the type of illness but to the stage of presentation. Illnesses such as breast and prostate cancer are diagnosed at a later stage, resulting in poorer survival. Click here and here for more information regarding diseases prevalent in African Americans.
These disparities demonstrate the need for more effective efforts to screen African Americans for disorders such as diabetes, hypertension, glaucoma, colon cancer, breast cancer wherein early diagnosis and treatments results in significant improvements in morbidity, mortality and disability.
Fitzpatrick found higher incidence rates of dementia in African Americans, especially African American women, compared with whites. In his analysis of a national sample of Medicare-eligible subjects, incidence of dementia was 34.7 per 1000 person-years for white women, 35.3 for white men, 58.8 for black women and 53.0 for black men. 2 However, African Americans with dementia are less likely to also suffer from depression (12%) than whites (33%) or Hispanics (39%) with dementia. 3
Although neglect has led to distrust of the healthcare system, African Americans may desire aggressive medical interventions. For example, at the 2007 American Geriatrics Society conference, an analysis of the National Kidney Foundation data found that African Americans were more likely to continue hemodialysis at a later age than Caucasians.
Health Issues of Asian American Older Adults
According to the 2000 US Census, Asian Americans represented 4.2% of the total US population, totaling 11.9 million individuals. The term “Asian” includes people from the Far East, Southeast Asia or the Indian Subcontinent (Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, Philippines, Thailand and Vietnam). US Census predicts that by the year 2050, Asian Americans will account for 9.3% of the total US population or 37.6 million. Click here for information that shows major health issues among Asian American older adults.
- Johnson J, Slusar M. Ethnic and Cultural Aspects of Geriatrics. 100-109
- Fitzpatrick Al, Kuller LH, Ives DG, et al. Incidence and prevalence of dementia in the Cardiovascular Health Study. J Am Ger Soc 2004;52: 195-204.
- Gurland BJ, Wilder DE, Lantigua R, et al. Rates of dementia in three ethnoracial groups. Int J Geri Psych 1999:14:481-493.
You Are There
You are recruited to a rural community in Kansas to join a small group practice. The practice has been asked by the community to help with long term care planning since it is clear that there is a very high proportion of older adults in the area. You are asked to represent the group practice on the community planning board. You are advised that the community wishes to assure that there are adequate nursing home beds for those who require long-term chronic care and personal care for basic activities like feeding and dressing as well as community based care for those who require help with things like meal preparation, shopping and transportation. There are currently 100 nursing home beds in the county and capacity for 250 in the community care system. You are planning for the year 2010, when current baby boomers will start entering the 65+ cohort. You base your estimates on recent census projections for your county. Your county is expected to have a total population of 20,000 in 2010. Twenty one percent of the total will be age 65 or higher, including 6% of the total population who will be 85 or older. Current estimates are that in the age group 65-84, 5% will require nursing home care and another 10% will require community services. In the age group 85 and older, 20% will require nursing home care and another 40% will require community based services.
Questions:
- Estimate the number of persons age 65-84 in the county in 2010. How about the number age 85+?
- Will you have enough nursing home beds to accommodate the amount needed in 2010?
- Be prepared to discuss factors which could influence the future direction and changes in nursing home care. Think broadly
Answer:
Deciding About Preventive Measures
You are responsible for implementing preventive measures for your patients. Among those you care for are :
- A 70 year old woman with no active medical problems who is independent in all activities and is a master athlete
- A 65 year old man with COPD and an FEV1 of 0.7 liter
- An 85 year old man with no active medical problems who is independent in all activities.
- A 76 year old woman with mild dementia who lives alone and remains independent in all activities
- A 67 year old woman with advanced dementia who lives in a nursing home and requires total care
- A 72 year old man with lung cancer metastatic to bone and brain
Questions:
- What factors are you weighing when you contemplate implementing the following prevention measures for each patient:
- treatment for hypertension
- influenza vaccine ("flu shot")
- mammogram
- PSA
- stool guaiac
- treatment for hyperlipidemia
- pneumonia vaccine (Pneumovax®)
- To what extent is age a determinant of who should receive which preventive measurers?
- Under what conditions will Medicare pay for those preventive measures?
- What is the patient's role in requesting/accepting these measures
Answers:
- Life expectancy, comorbidities, quality of life and, most importantly, the patient’s goals of treatment need to be considered when deciding when to order screening tests or when providing preventive measures. Risks and benefits of any therapy must be weighed for any patient before providing that treatment. Patient 1 likely has a life expectancy of approximately 15 years. She would benefit from all the measures listed above, except PSA. Patient 2 is remarkably different with an FEV1 of 0.7 L indicating severe COPD (Normal FEV1 ~ 3.4, Mild COPD 3.0, Severe 0.9, CRPD 2.6). He likely has a life expectancy of approximately 1 year. He would benefit from a flu shot and pneumonia vaccine. Given his severe COPD, a discussion with him would be warranted discussing the degree of hypertension and lipid control.
Patient 3 is a healthy 85 year old man with a life expectancy of approximately 5 years. Colonoscopies are generally not given to patients with less than a 10 year life expectancy. He would therefore benefit from a flu shot, pneumonia vaccine, as well as hypertension and lipid treatment. PSA testing has been controversial as it is not very specific to prostate cancer and begins the pathway to aggressive interventions. Being that death from prostate cancer alone is rare, it is unclear whether detection and treatment of prostate cancer with consequent incontinence and impotence benefits patients. In fact, the USPSTF rates PSA testing as I (insufficient evidence to recommend for or against routine PSA testing). Prior to PSA testing, discussion with the patient discussing the risks and benefits is highly recommended.
Patient 4 has mild dementia and is independent in all her IADLs and BADLs. Alzheimer’s Dementia generally has a 10 year life expectancy, therefore Patient 4 likely has an 8-10 year life expectancy as opposed to about 1 year for Patient 5. Patient 6 is a hospice candidate. For him, hypertension treatment, stool guaiac, PSA, hyperlipidemia treatment would likely not be warranted.
- Generally, Medicare will pay for preventive measures if they are not Hospice patients.
- The patient plays a huge role in requesting or accepting these measures. The patient and the provider are a unit deciding on health care decisions together. This will maximize compliance, trust and quality medical care.
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