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134 B.J. Orandi et al.
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Section II
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Social/Societal Issues
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Chapter 10
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Invited Commentary
Michael E. Zenilman
Introduction
In this new section of our textbook, topics which have been
in the background of surgery in elderly patients are now
spotlighted. In the 10 years since publication of our first
edition, it has been very gratifying for me to watch as more
interest in the ramifications of surgery in the older patients –
not just technical prowess – has developed; it brings us to the
basics of medicine – “Primum Non Nocere.”
The increased interest has two mutually-non-exclusive
sources. First, there has been more academic attention to the
older surgical patient. For example, in 1976, the nine surgical
journals I typically read published a total of 358 articles in which
patients aged greater than 65 or 85 years were operated, in 1989
there were 368, in 1999 the number was 513, and in 2009 there
were 893 articles. My impression is that the quality of the papers
has drastically improved. Early articles proved – using simple
and then more complex analyses – that we could do surgery
safely, and discussed how to deal with the older patients, sometimes via editorial comments. The message was that chronologic age was not equal to physiologic age – especially if we
controlled comorbid illnesses and emergency surgery. In fact,
these concepts were the main message of our first edition.
Now papers are more scientific, and highly complex
statistical analyses of large databases have allowed researchers
to focus on outcomes and quality measures. We are only now
on the cusp of defining that consequence of chronologic age
and the aging process on surgical outcomes, and there is a
real effect. The impact of frailty and disability, two nonreversible aging processes, on surgical outcomes is significant.
Because of them and not comorbidity, the ultimate outcomes
of major interventions may not be as good as we hope. While
not reversible, these two processes are to some extent
preventable; lifestyle changes can delay their onset.
M.E. Zenilman (*)
School of Public Health, SUNY Downstate, Brooklyn, NY
and
Department of Surgery, Johns Hopkins School of Medicine,
Baltimore, MD
e-mail: mzenilman@downstate.edu
Second, the sheer increase in number of patients in the
older group has affected the population of patients we care
for; the baby boomers have come of age. The predictions of
the past – that the percentage of patients older than 65 and 85
in our population will grow – are coming true. While some
papers wrongly predicted that Medicare would be financially
insolvent by now, it is getting there. The shape of the age
distribution in the USA has changed from a classic pyramid –
where the small number of older population rest on top with
increasing numbers of persons at the bottom – to a more
rectangular (or trapezoidal) shape, where similar proportions
of younger and older persons exist at multiple age levels. As
our population pyramid changes, the demands on health care
are changing too.
The societal burden for the expansion of the elderly
patient population is intuitive, impressive, and expensive. An
Institute of Medicine report in 2008 from the National
Academy of Sciences entitled “Retooling for an Aging
America: Building the Health Care Workforce” showed that
the bulk of acute and chronic disease – diabetes, cardiac,
hypertension, and cancer – rests in patients over 75
age. The older patient population uses more services. For
example, 12% of our population uses up to one-third of total
hospitalizations, and a similar percentage uses emergency
medical responses and prescriptions for medication. The
expanding use of nursing homes, short term rehabilitation
facilities, and home care also has a cost.
The report suggested three goals to enhance the care of
elderly patients: use education to improve the competence
of health care providers, increase the number of geriatric
specialists, and establish new models of care.
Achieving these goals will not be cheap. The IOM report
noted that not only are chronic disease management, multidisciplinary care, and transitional care important for the
elderly population, but also that to date, they have been
underfunded. Bluntly, reimbursements for geriatricians,
home care nurses, and even surgical care in this population is
not very high, and the combination of low funding in all three
areas is also problematic.
While surgical training programs have been asked to focus
on education in geriatrics, to date it is mostly theoretical, and
years of
R.A. Rosenthal et al. (eds.), Principles and Practice of Geriatric Surgery,
DOI 10.1007/978-1-4419-6999-6_10, © Springer Science+Business Media, LLC 2011
137
138 M.E. Zenilman
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very few hospitals or institutions have active geriatric
services which work closely with surgeons. The foundation
of surgical training is to care for patients, not to just perform
procedures. But there is very little in the surgical training for
the topics described below.
The American Geriatrics Society has been an advocate in
retooling the education practice of surgeons. Through their
Jahnigan Scholars program, over 20 surgical specialists, in
all disciplines, have been selected to do research, publish
scholarly work, and teach geriatrics. Some basic curricula
have been developed, and there is even one geriatric surgery
fellowship available in the USA.
The real future of geriatric surgery is embedded in the
chapters of this section; the foundation of education is evolving
to a level of complexity higher than that described in the first
edition of this textbook, and the need for multidisciplinary
management is clear. To provide the elderly patient with
quality care, we must be well versed in recognizing and
addressing frailty and disability, not just controlling the established comorbidities of cardiac, pulmonary, kidney, and
endocrine systems. Palliative care, do-not-resuscitate orders,
and use of rehabilitation facilities and hospice need to be
integrated early in a patient’s care. As you will read, the
American College of Surgeons, through the National Surgical
Quality Improvement Project and the Task Force on Geriatric
Surgery, is establishing quality indicators for the elderly patient,
which will likely lead the change. In the future, these indicators
will be just as important as the “core measures” we now follow.
Last, what about the elderly surgeon? While society has
not yet mandated removal of driving licenses from older
drivers, the elderly surgeon still has the same mandate as the
younger “above all, do no harm.”
Chapter 11
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The Demography of Aging and Disability
Samir K. Sinha and Colleen Christmas
Over the previous century, there has been an extraordinary
demographic shift which will no doubt persist well into this
one. The lengthening of life span by over 50% and consequent
increase in the proportion of the population that we refer to as
the “elderly” has created a new and different social, economic,
and medical imperative. We are now faced with the daunting
task of providing health and social care for a huge number of
persons living well into old age with more chronic illnesses,
and increased needs and expectations. Anticipating the kinds
of health care services, this population requires coordinated
and creative efforts by many sectors of society and considerable educational and research activities to determine the best
methods to deliver services. Indeed, this textbook has been
written to respond to some of these challenges by addressing
the specialized needs of older persons facing surgery.
The Demography of Aging
In the USA, as in other developed countries, the absolute
numbers and relative proportions of older populations have
continually increased to the point where there is now a higher
percentage of older people than at any time in history. Indeed,
while the overall US population had almost quadrupled in
size over the course of the twentieth century, the portion of
the population 65 years and older had increased 11-fold.
The older population has grown from 3.1 million (4.1% of the
overall population) in 1900 to 35 million (12.4%) in 2000 [1].
Among this latter figure, 18.4 million (53%) were aged 65–74,
12.4 million (35%) aged 75–84, and 4.2 million (12%) age 85
and older [2]. While it is predicted that these figures will
increase slowly over the next few years, what follows is a
period of marked accelerated growth in the second and third
decades of this century. This pattern of shifting demographics
largely reflects the impact of birth rates; the slower change in
the near future reflecting low fertility rates during World War
II and the preceding worldwide economic depression, while
the subsequent growth surge stems from the “baby boom”
that characterized the postwar years (1946–1964) in many
nations. The first members of this “baby boom generation”
will reach age 65 in 2011. As a result, by 2030 the older population is projected to be twice as large as in 2000, growing
from 35 million to 72 million, which will then represent
nearly 20% of the total US population. Predictions are that
this trend persists at least until the mid-century. In 2050, the
older population is projected to number 86.7 million [
The most rapid and profound change in numbers has been
seen among the oldest old individuals, defined here as those
aged 85 years and older. In 1900, there were only 122,000 of
these individuals, but by 2000, their number had increased
34-fold to 4.2 million. This trend is expected to continue
with this population doubling to 9.6 million by 2030 and
then more than doubling again to 20.9 million by 2050 [1].
The USA, despite the growth projections for its older
population, remains a relatively young population when
compared with other developed countries. While its proportion of older adults stood at 12.4% in 2000, at least a dozen
developed countries were reporting proportions ranging
between 15 and 18% (Table 11.1). Part of what explains this
difference is that the USA has experienced higher levels of
fertility and immigration in recent decades than those of
other developed countries [
expectancy at birth in the USA reached a high of 76.9 years,
the highest rates were being reported for Swedish males and
Japanese females at 77.6 and 84.1 years, respectively [1].
1]. In 2000, while average life
1].
Causes and Consequences
of Population Aging
C. Christmas (*)
Program Director, Johns Hopkins Bayview Medical Center,
4940 Eastern Avenue, B1-114E, Baltimore, MD 21224, USA
e-mail: cchristm@jhmi.edu
R.A. Rosenthal et al. (eds.), Principles and Practice of Geriatric Surgery,
DOI 10.1007/978-1-4419-6999-6_11, © Springer Science+Business Media, LLC 2011
The term population aging refers to the process through
which the proportions of older individuals within an overall
population age structure increase. Changes in the age structures of populations principally result from changes over
139
Ta b l e 11.1 Countries with significant elderly (65 years and over) populations as a percentage at 2000, 2030, and 2050
2000 2030 2050 2000 2030 2050
Africa Europe
Ghana 3.4 6.6 11.8 Albania 7.1 17.3 22.1
Mauritius 6.1 16 21.6 Austria 15.5 26 30.1
Reunion 5.6 11.4 17.1 Belgium 16.8 25 27.7
South Africa 4.7 11.6 13.6 Bosnia and Herzegovina 8.6 20.6 26
Algeria 4.3 10.3 21.3 Bulgaria 16.6 24.6 33.8
Egypt 4 8.8 14.8 Croatia 15.1 24.4 29.6
Libya 3.9 7.6 15.7 Czech Republic 13.8 24.3 33.1
Morocco 4.6 9.1 16.2 Denmark 14.8 22.7 24.6
Tunisia 6.1 12.9 23.8 Finland 14.9 26 27.3
Near East
France 16 23.7 26.8
Iraq 3.1 5 10.9 Germany 16.4 27.5 30
Israel 9.9 14.9 20.1 Greece 17.4 24.9 32.1
Jordan 3.2 7.7 16.4 Hungary 14.6 21.9 29.4
Lebanon 6.7 10.2 23.2 Ireland 11.3 18.4 25.1
Qatar 2.3 16.3 19.6 Italy 18 27.2 33.5
Syria 3.2 6.1 13 Macedonia 9.8 18.2 25.1
Turkey 6 12.9 22.4 Netherlands 13.6 23.5 26
United Arab Emirates 2.2 16.8 16.2 Norway 15.2 22.4 25
Asia
Poland 12.3 22.2 29.6
Bangladesh 3.3 6 11 Portugal 16 23.2 30.6
Burma 4.7 9.8 18.3 Romania 13.3 19.6 30
China 6.9 16.4 24.5 Slovakia 11.4 21.3 30
East Timor 2.6 6.9 10.7 Slovenia 14 26.3 34
Hong Kong SAR 11.5 29.3 39.3 Spain 17 25.3 34.5
India 4.6 9 14.6 Sweden 17.2 24.4 25.7
Indonesia 4.5 10.9 18 Switzerland 15.1 24.7 29
Iran 4.6 9.3 21.3 UK 15.6 22.5 25.7
Japan 17.1 28.8 34.3 Yugoslavia 14.1 20.8 27.2
Korea, North 6.3 14.6 21.4
Latin America and the Caribbean
Korea, South 7 20.6 29.2 Argentina 10.2 14.8 21.2
Malaysia 4.1 9.4 13.4 Bolivia 4.5 8 13.8
Mongolia 3.7 8.1 16.2 Brazil 5.3 13.1 21.9
Pakistan 4 6 10.8 Chile 7.2 16.4 22.1
Phillipines 3.7 7.7 12.9 Colombia 4.7 11.5 16.6
Singapore 7 24.4 37.1 Costa Rica 5.2 12.8 19.7
Sri Lanka 6.5 15.2 23.1 Cuba 9.5 20.3 28.1
Thailand 6.4 16.2 23.7 Dominican Republic 4.8 10.2 14
Taiwan 8.7 21 29.3 Ecuador 4.6 9.7 16.3
Vietnam 5.5 11 19.2 El Salvador 5 7.7 12.7
Central Asia
Honduras 3.5 6.2 10.3
Estonia 15 24.5 32.2 Jamaica 6.8 12.5 22.3
Latvia 14.7 23.1 31.2 Mexico 5 11.5 19
Lithuania 13.7 23.7 32 Nicaragua 2.8 6.6 13.8
Armenia 8.9 16.1 25.2 Panama 5.8 12.1 18.5
Azerbaijan 6.9 11.4 16.2 Paraguay 4.7 7.9 10.8
Belarus 13.7 19.5 26.6 Peru 4.7 10.4 17.2
Georgia 13.5 23.4 28.8 Puerto Rico 11.2 22.8 30.3
Kazakhstan 6.5 14 20.4 Trinidad and Tobago 7.3 24.2 33.9
Kyrgyzstan 5.8 8.5 12.4 Uruguay 12.9 17 23.2
Moldova 9.8 14.9 20 Venezuela 4.6 11.6 18.5
Russia 12.5 21.5 28.3
Oceania
Turkmenistan 4 6.6 10.4 Australia 12.4 21.1 24.6
Ukraine 13.9 19.7 26 Fiji 3.4 9.5 14.1
Uzbekistan 4.6 7.5 12.1 New Zealand 11.5 17.8 24.1
North America
Papua New Guinea 3.6 6.1 10.8
Canada 12.7 22.9 24.9 Solomon Islands 3 5.4 11.4
USA 12.4 19.6 20.6
Source: Data from [1], Current Population Reports, P23–209 (Table A–1)
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14111 The Demography of Aging and Disability
Age and year
All races White Black
a
Both sexes Male Female Male Female Male Female
At Age 0
1900
b,c
47.3 46.3 48.3 46.6 48.7 32.5 33.5
1950
c
68.2 65.6 71.1 66.5 72.2 59.1 62.9
1960
c
69.7 66.6 73.1 67.4 74.1 61.1 66.3
1970 70.8 67.1 74.7 68.0 75.6 60.0 68.3
1980 73.7 70.0 77.4 70.7 78.1 63.8 72.5
1990 75.4 71.8 78.8 72.7 79.4 64.5 73.6
2000 76.9 74.1 79.5 74.8 80.0 68.2 74.9
At Age 65
1900–1902
b,c
11.9 11.5 12.2 11.5 12.2 10.4 11.4
1950
c
13.9 12.8 15.0 12.8 15.1 12.9 14.9
1960
c
14.3 12.8 15.8 12.9 15.9 12.7 15.1
1970 15.2 13.1 17.0 13.1 17.1 12.5 15.7
1980 16.4 14.1 18.3 14.2 18.4 13.0 16.8
1990 17.2 15.1 18.9 15.2 19.1 13.2 17.2
2000 17.9 16.3 19.2 16.3 19.2 14.5 17.4
At Age 75
1980 10.4 8.8 11.5 8.8 11.5 8.3 10.7
1990 10.9 9.4 12.0 9.4 12.0 8.6 11.2
2000 11.3 10.1 12.1 10.1 12.1 9.4 11.2
At Age 85
2000 6.3 5.6 6.7 5.5 6.6 5.7 6.5
a
Data shown for 1900–1960 are for the non-White population
b
Death registration area only. The death registration area increased from ten states and the District of Columbia in 1900 to the contiguous USA in 1933
c
Includes deaths of nonresidents of the USA
Source: Data from [1], Current Population Reports, P23–209 (Table 3-1); National Center for Health Statistics 2003 (Tables 11 and 28). For full
citations, see references at the end of the chapter
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time in fertility, mortality, and migration patterns [3].
Measures of population aging that can also be used to compare populations and assess changes over time include the
median age, aged-dependency ratios or, most commonly, the
proportion of a given population that is aged 65 and older. It
has been the combined effects of declines in both mortality
and fertility rates during more recent times that have largely
been responsible for the demographic transition that led to
the aging of human populations.
The earliest and most important causes of the decline of
human mortality during the past few centuries were the
general improvements in living conditions resulting from
social and economic developments. Innovations in industrial
and agricultural production and distribution methods led to
significant improvements in nutrition [4]. Industrialization
also brought about enhanced standards of living by improving
the quality and quantity of available housing, running water,
and electricity, which enabled individuals to be protected
from the hazards of nature. Thereafter, a complex interplay
of advancements in public health efforts, particularly sanitation, and later in medical and preventative health care,
coupled with new modes of familial, social, economic, and
political organization helped to promote and sustain further
gains in human longevity [5].
The decline in human mortality has been the main driver
of increased life expectancy throughout the world. The rapid
mortality decline particularly among infants, children, and
women of childbearing age increased average life expectancy from 47.3
years in 1900 to 68.2 years in 1950 [6]. The
need to replace children lost to early mortality waned as the
risk of death at younger ages declined rapidly [7]; this eventually led to declines in total fertility rates. Death rates from
chronic diseases were stable in the USA from 1954 to 1968;
thereafter, research programs around chronic diseases intensified and reductions in mortality from chronic diseases followed. In recent years, continued advances in the management
and treatment of chronic diseases are now largely driving
reductions in mortality at older ages.
Sex and Racial Differences
Interestingly, reduced mortality rates have not benefited men
and women equally, with women having gained several more
years of life expectancy than men (Table 11.2). For example,
in the USA over the past century, life expectancy had
increased by 31.2 years for women (from 48.3 to 79.5 years)
Ta b l e 11.2 Life expectancy at birth, at age 65, 75, and 85 by race and sex: selected years, 1900–2000
142 S.K. Sinha and C. Christmas
Causes of death
Rank in 1900 Rank in 2005
All ages All ages 65+ 65–75 75–85 85+
Heart disease 4 1 1 2 1 1
Cancer 8 2 2 1 2 2
Stroke 5 3 3 4 4 3
Chronic lung
diseases
9 4 4 3 3 5
Alzheimer’s
dementia
10 7 5 10 5 4
Diabetes – 6 7 5 6 7
Influenza/
pneumonia
1 8 6 8 7 6
Nephritis 6 9 8 7 8 8
Accidents 7 5 9 6 9 9
Septicemia 2 10 10 9 10 10
Diarrhea and
enteritis
3 – – – – –
Source: Data for 2005 from National Vital Statistics Report, Vol. 56,
No. 10, April 24, 2008
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but by only 27.8 years for men (from 46.3 to 74.1 years).
It appears that women may have a natural advantage over
men that should imply a difference of about 2 years in terms
of life expectancy at birth. Several hypotheses have been
proposed to explain sex differences in longevity, including
more active female immune functioning, the protective effect
of estrogen, compensatory effects of the second X chromosome, and the influence of oxidative stress on aging and
disease. At present, none of these hypotheses are strongly
supported, although weak support is available for the oxidative stress hypothesis [8]. Nevertheless, other factors are
thought to contribute to the much larger gap now being
commonly observed between the sexes. Differences in life
expectancy are attributed to differences in behaviors, social
roles, attitudes, and biological risks between men and
women, with the near-elimination of maternal mortality in
developed countries explaining only a small fraction of this
trend [9–12]. While these differential gains have been typical
of developed countries, the gap has started to decline in
recent years. Between 1900 and 1970, overall life expectancy
in the USA increased by 26.4 years for women and 20.8 years
for men, thereby increasing the gender gap in life expectancy
from 2.0 to 7.6 years. This increase has been largely attributed to higher male mortality due to ischemic heart disease
and lung cancer, both of which are related to the widespread
and early practice of cigarette smoking among men [13, 14].
However, between 1970 and 2000, overall life expectancy
rose by 4.8 years for women and 7.0 years for men, thereby
narrowing the gender gap from 7.6 to 5.4 years. This subsequent decrease has been related to the proportionately larger
increases in lung cancer mortality among women than men
and a proportionately greater decline in heart disease mortality
among men than women [13, 14].
In addition to the expected growth of the older population, demographic studies predict that the racial and ethnic
diversity of this population in the USA also increases over
the coming decades. Comparisons between racial groups in
2003 to what is predicted for 2050 suggest that while nonHispanic whites decrease from representing 83–61% of the
older population, the proportion of Blacks grows from 8 to
12%, Hispanics from 6 to 18%, and Asians from 3 to 8%
[15]. While this growing diversity largely reflects the aging
of a more diverse younger population, there is evidence that
it also represents, to a small degree, the enhanced immigration of older individuals [16]. These demographic changes
continue to have important implications, especially since
mortality rates among the elderly have also been shown to be
unevenly distributed across racial and ethnic groups. These
differences appear to reflect different disease profiles for
underlying populations, unequal access to health care, and
likely other socio-demographic factors, such as income
and education that have yet to be completely understood.
What partly explains our lack of understanding is that
“minority” older adults have largely been excluded from
studies or categorized together as “non-White,” ignoring the
significant heterogeneity that also characterize these groups,
their differences in physiological aging, access to health
care, educational levels, health habits, disease prevalence
and progression, response to treatments, and social contributors to health. Indeed, the increasing heterogeneity of the
older population in the coming decades will certainly have
important implications for the delivery of health and social
care services and associated research studies.
Shifting Mortality Patterns
With individuals now being better able to survive acute
illnesses, increasing longevity has contributed to the rising
incidence of chronic illness and greater likelihood that individuals die as a result of complications associated with
chronic conditions. While the proportion of elderly fatalities
caused by heart disease, strokes, and cancer fell over the last
25 years, this decrease was partially offset by a concurrent
increase in the number of deaths attributable to other chronic
diseases, such as diabetes, chronic lung disease, renal disease, and dementia. Today, the pattern of death at older ages
generally reflects that of the population as a whole. However,
while the leading causes of death are essentially the same,
differences in the rankings become apparent when mortality
rates across age groups are considered (Table 11.3). While
heart disease and cancer remain the leading two causes of
death across all older age groups, over the past 25 years the
Ta b l e 11.3 Changes in most common causes of death in the USA at
all ages and those 65 years and older cohorts
14311 The Demography of Aging and Disability
2030
2000
20.0
16.3
5.9
12.0
14.0
21.6
5.6
11.9
4.4
8.4
12.4
3.7
10.1
2.9
Asia
Latin America/Caribbean
Near East/North Africa
Northern America
Sub-Saharan Africa
Europe
Oceania
https://t.me/med1917
largest decrease in heart disease mortality (−55.5%) was
experienced by individuals between the ages of 65 and
74 years, followed by those between the ages of 75 and
84 years (−49.7%), and those 85 years and over (−37.0%).
While cancer mortality has increased slightly for individuals
75 years and over (+3.8%), it decreased somewhat for the
65–74 age group (−7.7%). The more significant drop in heart
disease as opposed to cancer mortality within the 65–74 age
group has meant that cancer mortality is now the most common cause of death among individuals in this subgroup.
Further shifts in mortality rates has meant that chronic lung
disease and diabetes-related mortality now have their greatest impact among the youngest older age groups, while
stroke, dementia, influenza, and pneumonia-related mortality have their greatest impact among the oldest age groups.
Fertility
Historically, the decline in human mortality has been followed, in most regions of the world, with a decline in fertility.
This has caused some concern as extremely low levels of fertility, sustained over a period of time, are causing some populations to decline. The implications of population decline in
conjunction with population aging can be significant.
Governments, for example, may encounter the challenge of
financing social security programs and health care costs
while facing possible labor shortages. Further, these labor
shortages may disproportionately impact low-wage work,
such as those providing personal care to the elderly. These
concerns have led some countries to develop progressive
immigration policies in recent decades to help counter declining fertility rates and fuel overall population growth.
Developing Countries
Fertility and mortality rates have fallen in most developing
countries, but usually not to the same degree as with their
developed counterparts. These falls are partly due to economic
growth but are mostly due to the adoption of modern
medical and public health practices. While the populations
of virtually every nation are aging, the level and pace with
which they are doing so varies within regions (Fig. 11.1).
Surprisingly, the most rapid proportionate increases among
older populations are and will continue to be in the developing world. In 2000, 249 million people 65 and older living
in developing countries represented 59% of the world’s older
population; their proportion of the global elderly is projected
to rise to nearly 80% or 1.2 billion elderly people living in
developing nations by 2050. In contrast, 171 million people
were aged 65 and older in developed countries in 2000, and
they are projected to grow to 327 million by 2050. Although
developing regions had lower overall proportions of older
people than developed regions in 2000, these proportions are
Fi g u r e 11.1 Percentage of the
population aged 65 and over for
regions of the world: 2000 and
2030 (from US Census Bureau
2004, International Programs
Center, International Data Base,
at http://www.census.gov/ipc/
www/idbnew.html.).
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