Aging America: Can we Handle the Demand



Speaker Notes to AccompanyPreparing for the Aging TsunamiSharon K. Ostwald, PhD, RN, FGSA, FAHAProfessor & Isla Carroll Turner Chair of Gerontological NursingThe University of Texas Health Science Center at HoustonHouston, Texas, USAWe ARE an aging society! The world’s older population grew by an average of 870,000 people each month during 2008. By 2020, the world population aged 60 and older is expected to reach ONE BILLION. Although industrialized countries are further along in the aging of their populations, developing countries are already experiencing a fast transition to lower fertility levels and longer life spans.? Latin American countries will soon have much older populations who will put a higher demand on resources, including health care resources. Geriatric professionals must now prepare for the aging tsunami that is sure to come so that they will not be engulfed by the demands it will bring.The purposes of my presentation today are 1) To identify trends that will challenge geriatric nurses now and in the future and 2) To suggest some important areas of focus for geriatric nurses.The world’s population is aging. The growth in the older population has generally been associated with developed countries, such as the United States of America and Europe as shown on the map. Europe still has the highest proportion of people over the age of 65. In Europe, 1 out of every 4 people will be over the age of 65 by 2040 and 1 out of every 7 people will be over the age of 75 years. For years Sweden, Germany and Italy have had the highest percents of older people in the world. Percent Population 65 and Over, 2008 (presentation slide #3)Of the 25 countries in the world with the highest proportion of older people, 24 are in Europe. Japan, however, now has the highest percent of older people of any country in the world – 21.6% of the Japanese are over the age of 65. The World’s 25 Oldest Countries, 2008 (presentation slide #5)In many parts of the world the growth of older people is steady and they are living long and healthy lives. However, the exploding older population will produce challenges for many parts of the world. Projections for the aging population suggest that every month for the next 10 years, 1.9 million people over the age of 65 will be added to the world’s population. As shown on the map by 2040 people over the age of 65 will comprise more than 11% of the population in most of the countries in the world. Percent Population 65 and Over, 2040 (presentation slide #6)Adults over 65 will outnumber children under age 5.Declining fertility rates and improved health and longevity have generated rising numbers and proportions of older people in most of the world. For the first time in the history of the world, people aged 65 and over will soon outnumber children under age 5 Young Children and Older People as a Percentage of Global Population1950 – 2050 (presentation slide #8)Fewer children means fewer workers employed to support older people who retire. There will also be fewer family caregivers available to care for the growing numbers of frail elderly. A commonly used indicator of societal support is a dependency ratio, the ratio between youth and/or older people and working-aged people. The older dependency ratio (ODR) is defined as the number of people aged 65 and over per 100 people aged 20 to 64. Older dependency ratios are shown here. Higher dependency ratios mean more people over 65 compared with those under 65. Latin America is relatively low, but the ratio is estimated to increase over the next 30 years.Older Dependency Ratio for World Regions: 2000, 2020, & 2040 (presentation slide #10)The health care system will be challenged to provide more care at less cost and more alternatives for care of older people who do not have families available to provide long term care. This situation presents immense challenges for geriatric nurses. We need to be sure that nurses are receiving special education about the physiology of aging, pharmacology and how medications affect older people in different ways than younger people, the atypical symptoms of disease often seen in older people, the complexities of caring for older people who often have several chronic illnesses simultaneously, and the socioeconomic and environmental factors that may challenge an older person’s ability to return home and to care for themselves. Family and friends need to be taught how to care for the special needs of frail elders.Older populations will increase more rapidly in developing countries than in developed countries.The process of population aging is primarily determined by two factors – birth rates and death rates. Originally most countries have a large number of children below the age of 15 and a small percent of people over the age of 65 so that the age structure looks like a pyramid. Most developing countries have experienced a lower birth rate in recent years, similar to what occurred earlier in Europe and North America. As fertility rates drop, the number of children decreases. At the same time adults are living to be older. This causes a change in the shape of the population pyramid. By 2050 the population pyramid for developing countries will look very much like the those currently in the USA and Europe. As this process accelerates, age structures within countries will change. Eventually, older people become an ever-larger proportion of each nation’s total population. Population in Developed and Developing Countries by Age and Sex- 1960, 2000 & 2040(presentation slide #11-13) The percent of increase in the developed countries is not expected to change nearly as much as in the developing countries. -412751282222Percent Increase in Population Aged 65 and Older 2008 to 2040 (presentation slide #17)Many of the countries in Latin America are expected to see large increases in the population over 65 between 2008 and 2040. In Japan, for instance, the elderly population is expected to increase by only 30%, while in Chile it is projected to increase by 160%. Furthermore, developing countries will have less time to prepare for the aging changes in the population. While the US has had 69 years to prepare for the doubling of the aging population, Chile will only have 27 years to prepare.The Speed of Population Aging in Selected Countries (presentation slide #18)Life expectancy is increasing.Most countries show a steady increase in longevity over time. Life expectancy is a probability estimate of how long individuals can expect to live, given the environmental and disease conditions currently in existence. Life expectancy varies by country, but generally continues to rise with only a few exceptions (like Russia). It has surpassed 80 years in at least 7 countries. Japanese have the longest life expectancy from birth with an average of 82 years. While genetics may influence how long older people live, it is the behaviors and exposures that occur over a lifetime that interact with biology and psychology that determine whether people reach old age with good or poor health. In all European countries (as well as the USA and Canada) the life expectancy for both males and females age 75-84 is increasing. In all Latin American countries, life expectancy has now pasted 70 years of age.Life Expectancy at Birth for Selected Countries by Region: 2008 (presentation slide #21)Some personal characteristics have been found to be associated with life expectancy and health, regardless of culture. In most countries women have a longer life expectancy than men. The ratio of women to men in the age group over 85 is 2:1. Female Advantage in Life Expectancy at Birth for Selected Countries: 2008(presentation slide #23) A difference in sex-ratio to mortality throughout the world has been contributed to lifestyle and environment, rather than genetics. Men have traditionally practiced more risky behaviors (i.e., driving without seatbelts), been exposed to more occupational hazards (i.e., pesticides), and maintained a more unhealthy lifestyle (i.e., smoking and alcohol consumption). Highest Life Expectancy at Birth 1840 – 2000 (presentation slide #24) It is currently estimated that about one-third of the years lived after age 65 are lived in a state of dependency (WHO, 2002a). For instance at age 65 the average woman has approximately 20 years of life left. It is estimated that 13.3 of those years will be spent in good health and 6.7 years will be spent being dependent on others. The estimates for 65 year old men are similar, except that their life expectancy after age 65 is 17.1years with 5.6 years estimated to be spent needing assistance from others (Administration on Aging, 2007). The number of the oldest old is rising. The absolute number of elderly is increasing; the percent of elderly in global populations is increasing, and the average life expectancy at birth and at age 65 is increasing. In addition, the number of oldest old is also increasing. Demographers usually talk about the young-old (65-74), the old-old (75-84) and the oldest-old (> 85). Among the over 65 age group, the oldest individuals are the fastest growing group. As can be seen the people over the age of 80 in China made up over 17% of all of the people over age 80 in the world. The US contributes 11.7% and Latin American countries together contribute 7.3%Global Distribution of People Aged 80 and over (Percent of Worldwide Total) 2008(presentation slide #26)Since as people get older, they are likely to require more health care resources, there is particular interest in the increase in the oldest-old. The fastest growing group of adults over the age of 65 is among the oldest-oldest-old, those over the age of 100 who we call ‘centenarians’. The world population of centenarians is projected to increase 746% between 2005 and 2040. By 2040 the population over 100 is projected to reach 1.2 million. Percent Change in the World’s Population 2005 – 2040(presentation slide #27) Disparities exist between urban and rural people aged 65 and older.The health status of older people may not only be related to what country they live in, but also whether they live in rural or urban areas. In general older people are usually concentrated in rural areas, but no clear world-wide pattern exists. Health care services are usually grouped in large metropolitan areas so older people living in larger cities may have more access to health and social care, and therefore live longer, healthier lives. Chronic diseases are becoming an increasing burden.Fewer numbers of children and better treatment of infectious diseases, results in aging populations. This causes a shift in deaths to chronic diseases. The survival curve for most countries looks like this one from the USSurvival Curve for U.S. White Females: 1901 and 2003(presentation slide #28)This trend is also seen in Latin American countries where the trend is toward more deaths in older populations groups. The proportion of deaths occurring over the age of 65 for American countries is shown here.Proportion of All Deaths Occurring at Age 65 or Over in 29 Countries/Areas: Circa 2001(presentation slide #29)Age makes older adults more prone to the development of chronic diseases like heart disease, cancer, strokes, and diabetes. It is well-accepted that health in older adults results from lifelong interactions between an individual’s genetic make-up and the social and physical environments in which they live. Over 75% of the deaths in the developed world are due to chronic diseases and most of these deaths occur after the age of 65. This graph demonstrates the increase in chronic diseases as a cause of death as people age.Major Causes of Death in the European Union by Age 2001(presentation slide #31)Within the next two decades, the World Health Organization expects a shift in the burden of disease to shift from infectious or communicable diseases to chronic or non-communicable diseases in all developing countries. They predict that by 2030 the burden of chronic or non-communicable diseases will exceed 50% in developing countries and the burden of communicable disease will drop to 32%.The Increasing Burden of Chronic Non-communicable Diseases on Low and Middle Income Countries (presentation slide #32) Research during the last 20 years has suggested that poor health in adults is related to early childhood risks, especially malnutrition during pregnancy and early childhood. In Latin America, early malnutrition has been correlated with diabetes in adulthood. In addition, childhood infections may have long term effects on adult mortality. In addition, failure to thrive in children may be related to poorer physical, cognitive, and emotional functioning in later years. In Puerto Rico, the probability of being disabled among people growing up in poor conditions was 60% higher than among people with better childhood socioeconomic levels. In cities the probability was 22% higher. Probability of Being Disabled at Ages 60 and Over Conditional on Early Childhood Health Conditions Latin American/Caribbean Cities* & in Puerto Rico: Circa 2001(presentation slide #33)-74083171027*Cities include Bridgetown, Barbados; Buenos Aires, Argentina; Havana, Cuba; Mexico City, Mexico; Montevideo, Uruguay; Santiago, Chile; & Sao Paulo, Brazil Geriatric nurses have an important role in promoting health and preventing disease among older adults. While some believe that older adults may be too old to change their lifestyles, regular exercise, a healthy diet, avoiding tobacco, using alcohol in moderation, and correctly using medications can increase an older person’s health and improve their quality of life. An individual’s risk for disease can be altered, even in old age. A major focus of geriatric nurses is to develop interventions that help older people to promote their health, prevent disease, and manage chronic illnesses to prevent excess disability. Attention to health promotion and disease prevention programs can lead to a delay in the age that people develop a chronic disease. This postponement in the onset of disease will result in fewer premature deaths, less time with disability and a smaller proportion of total life spent with disease and disability. Personal health practices and the strength of the social network significantly impact the development of disability. The prevalence of disability increases with age.Studies in different countries have consistently shown that dependence in activities of daily living (ADL) and instrumental activities of daily living (IADL) increases with age, beginning at about age 75 and is higher in women and people with low incomes. An important focus for geriatric nurses is to maintain independence in ADL and IADL and prevent disability in older adults. If chronic diseases can be controlled early, excess disability can be reduced and quality of life improved Maintaining Functional Capacity Over the Life Course (presentation slide #34)Fortunately, the prevalence of disability has been declining among older people in countries like the USA. If this trend continues, as can be seen here, and holds for other countries, as well, the number of older adults living with disability will decrease significantly over time. This is particularly important in controlling costs related to the aging tsunami. Chronic Disability Decline in the United States 1982 to 2005 (presentation slide #35)Higher educational levels have long been associated with good health, healthy lifestyles, and functional independence. Countries with high levels of educational attainment have higher life expectancies and a higher quality of life in old age. Reactions to risk factors may partially be a function of educational level. People with higher educational backgrounds are more likely to adopt healthy lifestyle behaviors (WHO, 1999). Social, physical and economic environments affect healthy aging.Overall health can be influenced by multiple factors that are outside of the individual’s control – the social, physical, and economic environments within which they live. Poverty is a powerful determinant of health which controls where older adults live, what they eat, and where they shop. Poverty increases older adults’ risks for chronic and infectious diseases, decreases their access to medical care, and ultimately decreases their physical and mental health, their independence, and their life-expectancy. Lack of income can contribute to poor nutrition and homelessness, which in turn can contribute to greater poverty and ill health. Countries throughout the world are trying to determine how to pay the pensions and health care costs of a rapidly increasing older population. In many countries, there is a trend for older adults to remain employed until older ages. This trend can be seen in the labor force participation for men and women in many Latin American countries.Labor Force Participation Rate for Males Aged 55 to 64 in Six Latin American Countries(presentation slide #39)Labor Force Participation Rate for Females Aged 55 to 64 in Six Latin American Countries(presentation slide #40)Lack of social support, poor social conditions, housing, isolation, poverty, and poor education increase the likelihood of poor health by increasing the risk for disability, dependence on others, and death (WHO, 1999). Older adults who are most vulnerable to poor health are those with less education, lower incomes, and poor social support. The availability of social security income after retirement is important in helping to maintain higher function in older ages. Social security coverage for 13 Latin American countries can be seen here.Social Security Coverage in 13 Latin American Countries: Circa 2002 (presentation slide #41)(Percentage of employed population paying contributions)In addition to income, social support is important in helping the elderly to maintain good health and function. Availability of social support appears to be decreasing in many countries of the world. As can be seen in this graph of living arrangement of older adults in Japan, cultural changes are changing the family support available to older adults.Living Arrangements for People Aged 65 and Older in Japan (presentation slide #45)In developing countries, the aging of the population places a “double burden of disease” on health care systems that are also trying to manage epidemics of infectious diseases and malnutrition among their populations, while caring for people with chronic diseases (WHO, 2008). To be effective, health care professionals must develop systems of care that provide comprehensive, coordinated primary care that is easily accessible to older adults. Geriatric professionals have a crucial role in the care of older adults. Health promotion and disease prevention activities are important to prolong active aging and to increase the quality of life of older adults. The international perspective of active aging implies maintaining autonomy, independence, and intergenerational solidarity, as a part of health promotion and disease prevention (WHO, 2002). Throughout the world, regardless of gender, ethnicity or socioeconomic status, the major causes of death and disability in populations above the age of 60 are chronic diseases. While some have questioned the importance of expending resources on promoting health and preventing disease in older people, many reasons exist to support health promotion and disease prevention activities among older adults. These include: 1) prevention of premature death, 2) delay of the onset of chronic diseases, 3) postponement of disability related to chronic diseases, 4) higher quality of life, 5) greater participation in the life of the family and community in paid and unpaid roles, and 6) reduction in medical care costs, especially hospitalization and nursing home costs. Because the risks of disease and disability are higher in older people, even small increases in health can make big differences in active life expectancy and the cost of medical care. Geriatric professionals need to be prepared by education and experience to take a leadership role in meeting the challenges of an aging population.What are the implications for geriatric professionals?Geriatric professionals can have a very crucial role in helping the rapidly increasing number of people aged 65 and older to age with health and dignity. They need to be prepared to:Screen older adults for common problems like high blood pressure, high cholesterol and diabetes – before they become seriously ill.Develop hospital and community health promotion programs to reduce risk factors for chronic disease with a focus on diet, tobacco, exercise, alcohol, and accident prevention.Treat chronic disease early to prevent excess disability - chronic pulmonary disease, cardiovascular diseaseEducate older people to manage their own chronic diseases – diabetesAssist older people to maintain their dignity and be involved in decisions that affect their lives.Encourage intergenerational interaction between younger and older peopleEducate family and friends to provide care to frail older peopleStart outreach programs that address poverty and income inequities, low literacy levels, and social isolation that increase illness and interfere with treatment.Advocate for elimination of environmental hazards – unsafe housing, poor air and water quality, lack of transportation crime and abuse.Provide public education to decrease discrimination against older adults with mental or physical disabilities We have described a number of global aging trends that warn us of an aging tsunami that is to come within the next two decades. Rapid aging of the world’s population, especially in developing countriesImbalance of people over 65 and under 15 Increasing life expectancy with a rapid increase in numbers over 80Geographical inequities between urban and rural dwelling older peopleIncreasing prevalence of chronic diseases with a burden of disabilitySocial, physical, and economic environments affect healthy aging.The changing global population pyramid illustrates these aging trends.Global Population Pyramid in 2002 & 2025 (presentation slide #52) The world is undergoing a rapid change – a tsunami wave is coming. The rapid population shift has created a “double burden of disease” in many countries who are simultaneously dealing with epidemics of infectious and chronic illnesses. Two directions hold promise for improving the lives of older adults in the 21st century – 1) health promotion, disease prevention, and chronic disease management for every person throughout their lifespan, and 2) institution of public policies that guarantee a safe and healthy environment in which to age. As the population of the world lives longer, the quest is also to live better. Geriatric professionals can and WILL make a difference in the lives of older adults. ReferencesCenters for Disease Control and Prevention (CDC) & The Merck Company Foundation. (2007). The State of Aging and Health in America 2007. Whitehouse Station, NJ: The Merck Company Foundation. Retrieved December 27, 2008 from , K., Wan, H, U.S. Census Bureau, International Population Reports P95/09-1. An Aging World: 2008. U.S. Government Printing Office, Washington, DC, 2009. Retrieved on July 15, 2009 at States Department of Health and Human Services (USDHHS). (2000). Healthy People 2010: Understanding and Improving Health. Retrieved December 27, 2008 from Health Organization (WHO). Toward a Policy for Health and Aging: Fact Sheet. Retrieved August 28, 2009 from Health Organization. (1998). Growing Older and Staying Well: Ageing and Physical Activity in Everyday Life. Geneva, Switzerland: World Health Organization Press. Retrieved August 25, 2009 from Health Organization. (1999). Ageing: Exploring the Myths. Geneva, Switzerland: World Health Organization Press. Retrieved December 26, 2008 from Health Organization. (2002). Active aging: A policy framework. Presented at the Second United Nations World Assembly on Aging, Madrid, Spain. ?Geneva, Switzerland: World Health Organization Press. Retrieved June 10, 2009 from Health Organization. (2004). Towards Age Friendly Primary Health Care. Geneva, Switzerland: World Health Organization Press. Retrieved December 28, 2008 from Health Organization. (2008). The Global Burden of Disease: 2004 Update. Geneva, Switzerland: World Health Organization Press. Retrieved December 28, 2008 from Photographs used for the cover slide are allowed by the MorgueFile free photo agreement and the Royalty Free usage agreement at Stock.xchng. They appear on the cover slide in this order:Wallyir at archive/display/221205 Mokra at sxc.hu/photo/572286Clarita at archive/display/33743The Training Excellence in Aging Studies (TEXAS) program promotes geriatric training from medical school through the practicing physician level. This project is funded by the Donald W. Reynolds Foundation to the division of Geriatrics and Palliative Medicine within the department of Internal Medicine at The University of Texas Health Science Center at Houston (UTHealth).TEXAS would also like to recognize the following for contributions:Houston Geriatric Education CenterHarris County Hospital DistrictMemorial Hermann FoundationThe TEXAS Advisory BoardOthello "Bud" and Newlyn HareUTHealth Medical School Office of the Dean UTHealth Medical School Office of Educational ProgramsUTHealth School of NursingUTHealth Consortium on Aging ................
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