Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_827_Библиотеки_им_академика_М_И_Перельмана
.pdf
144 S.K. Sinha and C. Christmas
https://t.me/med1917
expected to double in Asia and the Latin America/Caribbean
regions by 2030. Sub-Saharan Africa has the youngest of the
world’s regions, with only 2.9% of its population being older
than 65 years in 2000. It continues to remain the youngest
region as the proportion of its older population grows slowly
owing to the combined effects of high fertility rates coupled
with an overall population decline due to the impact of AIDS.
Nevertheless, population aging in many developing countries
means they eventually encounter the same debates around
intergenerational equity, social security, and increasing
health care costs that have already emerged in Europe, the
USA, and Canada [17].
Concepts in Individual Aging
Individual aging refers to the length of life for individuals,
measured most often in years. A summary measure of individual aging for a population is most often represented by
life expectancy [7]. Life expectancy is calculated from death
probabilities observed throughout the age range over a
selected time period, usually one calendar year, and may be
estimated for a given birth cohort or for a population reaching
any age or age range [7]. With individuals now living longer
on average than ever before, there is growing interest around
the degree to which life expectancies at birth and older ages
can increase. While the risk of death remains relatively high
at birth, it rapidly declines to its lowest point during sexual
maturity, followed by an exponential rise until around
85 years of age. Thereafter, it has been demonstrated that the
rate at which the risk of death increases actually begins to
decelerate [18–21].
Complicating any discussion about individual aging is the
idea that there may be some maximal lifespan that is biologically determined for every species, including humans. This
belief, interestingly, had its nonscientific origins in biblical
references to a human lifespan of 120 years (Genesis 6:6).
Indeed, if there is some age x beyond which no one could survive, arguably there must be some eventual limit to the rise in
life expectancy. The existence of such a maximal age is becoming increasingly questioned [22]. First, if it is possible to
survive to age x, surely it must also be possible to survive to
age x plus 1 day. Following this logic, there may be no finite
limit, even though survival to very old age is already, from a
statistical standpoint, highly unlikely. The oldest individuals
whose ages have been reliably documented are a Frenchwoman,
Jeanne Calment, who died in 1997 at the age of 122, and an
American, Sarah Knauss, who died in 1999 at the age of 119
[23, 24]. Because the chance of death is high at such ages, the
probability of observing significantly older individuals in the
near future is exceedingly small. Nevertheless, these records
are likely to be broken eventually.
Differential, Usual, and Successful Aging
Chronological age (age in number of years) and physiological
age (age in terms of functional capacity) do not always coin-
cide, and often the physical appearance and health status of
an individual belie their chronological age. Increasingly, it is
being observed that disparities in the timetable of aging may
occur among individuals or among selected populations, or
in other words, that some individuals “age” at much slower
or faster rates than others. Furthermore, changes with aging
are heterogeneous not only among individuals within a select
group, but also among various organs within each individual
person. The onset, rate, and magnitude of the changes vary
depending on the cell, tissue, organ, system, or laboratory
evaluation of several parameters [25–27] and the manifestations of aging are a complex interplay between genetic
variables, disease states, and environmental exposures.
Attempts to define in humans a physiological “norm”
inevitably disclose a range of functional decrements with
advancing age. In earlier studies, the comparison of several
functions from younger to older age focused on a gradation
of decrements with increasing age [25]. However, as the
prevalence of chronic diseases increase with age, the functional loss that was noted with age in these early studies, may
have been due to the effects of disease rather than the natural
concomitants of aging itself. More recent research has further
continued to challenge the inevitability of functional impairment with chronological aging. While significant changes in
laboratory evaluation of some physiological functions may
be erroneously attributed to aging, normal aging changes
may also be misinterpreted as evidence of disease. Laboratory
values are generally interpreted with reference to a normal
range. Many of the age-related levels do not change on
average, but the variance (i.e., the deviation from average)
tends to increase [26], making deviation from the norm
increasingly common with aging.
Regulation of certain functions may remain efficient until
advanced age, whereas in others it declines at an early age.
Examples of such differential aging may be inferred from
fasting blood glucose levels and acid–base balance, which
remain stable as late as 70–90
state. In contrast, the basal metabolic rate declines continuously throughout the life-span, while certain sensory modalities, such as vision and hearing, show functional decrements
beginning during early adulthood. Although fasting blood
glucose values are minimally affected by aging, when these
levels are determined after increased physiological demand,
the ability of the organism to maintain normal levels and the
rate at which the levels return to normal are markedly different
in mature and aged subjects. Similarly, cardiac index parameters, renal function, respiratory function, and conduction
velocity in nerves have been demonstrated to tolerate less
years of age in a nonstressed
14511 The Demography of Aging and Disability
https://t.me/med1917
stress in the elderly than in younger individuals but are seemingly unimpaired in nonstressed states. Such declining ability
of the aging organism to withstand or respond adequately to
stress reveals an age difference not otherwise obvious.
Aging is believed to be a slow, continuous process.
Therefore, some of its effects can be observed only when
they have progressed sufficiently to induce identifiable
alterations that can be validated by available testing methods.
An illustrative example is atherosclerosis, the consequences
of which manifest during middle and old age even though the
atherosclerotic lesion may start early in infancy. Whatever
organ or tissue is considered, timetables of aging represent
an approximation, as the onset of aging cannot be pinpointed
precisely by a specific physiological sign.
While a number of functions undoubtedly decline as we
age, the extreme heterogeneity of overall functional status
even in the oldest cohorts supports the view that aging must
be evaluated on an individual basis. In addition to genetic
makeup, the elderly individual’s health, social status, and
economic and environmental conditions all contribute to
how they age [28]. Aging processes have thus been categorized as usual aging, referring to the average physiological
changes associated with some decrements in function, and
successful aging, referring to advanced chronological age
with minimal physical decrements [29].
Accordingly, individuals who age successfully are those
who do not exhibit pathology and have minimal functional
decrements. The concept of successful aging was formulated
as “a reconceptualization of the aging process, one that provides
a significant and necessary counterbalance to previous
research that tended to emphasize age-related declines in
functioning and health” [30]. It distinguishes three modalities
of aging (1) disease/disabled, characterized by the presence
of pathology, disability, or both; (2) “usual” (normal) aging,
characterized by the absence of overt pathology but the
presence of functional declines; and (3) “successful” aging,
characterized by few or none of the physiological losses seen
in the usual aging group. The concept is based on (1) the substantial heterogeneity among aged individuals; (2) the observation that aging is not a uniform or inevitable process of
disease or disability; (3) the persistence of plasticity well into
advanced age, that is, a continuing capacity for adaptive and
compensatory rehabilitation; and (4) the identification of
predictors of various patterns of aging, especially factors that
contribute to more successful trajectories of aging.
Current studies of successful aging provide evidence for
continuing good functional competence and recuperative
plasticity into old age [31, 32]. The distinction among
successful groups supports the hypothesis that extrinsic
factors play an important role in age-associated functional
decline. In one study, factors promoting maintenance or
improvement of functioning included younger age, higher
income, being Caucasian, low body weight, good lung
function, the absence of diabetes or hypertension, higher
education, and high cognitive performance. Other correlates
of high functioning were the absence of hospitalization,
participation in moderate/strenuous exercise, and receiving
emotional support [30]. Taking all such factors into account,
the prospects for avoidance, or eventual reversal, of functional loss with age are vastly improved, and the risks of
adverse consequences are reduced [29].
Consequences of Successful Aging
By focusing on the various modalities of aging, the heterogeneity of the aging process is emphasized, and the validity of
this concept is extended to all biomedical branches.
Interventions may be beneficial at all ages provided they are
customized to the individual [33, 34]. The potential for
rehabilitation at advanced age is much greater than previously supposed [27, 35–37], and there is a significant probability of regaining function at all levels of disability. Physical
exercise, dietary, surgical, and pharmacological interventions have proved successful in enhancing health even at
older ages. Identification of “predictors” designed to maximize
health and physiological competence enhances the quality of
life of the elderly, reduces their burden of disease and
disability, and decreases the socioeconomic need for health
care resources. This previously underestimated the ability
to significantly recover, though sometimes incompletely,
portends even more benefit to surgical therapies into advanced
age for certain individuals than once anticipated.
Future Trends
Rather than converging toward some biological limit, it seems
that mortality trends are now pointing in the direction of further gains in human longevity. Mortality rates continue falling across the age ranges in most developed countries, where
the pace of decline has accelerated among the elderly in particular. There is no sign in most demographic data that humans
are approaching a mortality plateau imposed by some fixed
biological limit [38]. The rapid increases in life expectancy
witnessed during the first half of the twentieth century has
slowed because the earlier increase resulted from the nearelimination of deaths during infancy and childhood which
ultimately yields a much larger increment in average life
expectancy than reducing deaths in later life. As measured by
the chance of death at any given age, however, the reduction
in mortality has been remarkably stable over the past century
and shows no sign of decelerating [39].
146 S.K. Sinha and C. Christmas
https://t.me/med1917
Current projections based on trend extrapolation anticipate that life expectancy at birth in developed countries will
be around 85 years in 2050 [40, 41]. Given the long-term
stability of mortality trends and the multiplicity of factors
that have contributed to the historical change, it seems naive
to believe that the pace of change in the future will be
substantially different from that in the past. Thus, it seems
unlikely either that the increase in human longevity will end
abruptly in the near future or that medical innovations will
lead to a significant acceleration in the pace of change.
Rather, we should expect continued slow improvements in
life expectancy, which will be accompanied by the continued
aging of the population and therefore an associated increase
in the demand for health and social services.
Aging and Disability
The extent to which a longer life will be a healthier one,
rather than one that contains more years of chronic illness or
disability will have a significant impact on the future demand
for health and long-term care services. While controversy
exists among studies in this area, recent studies have generally concluded that most of the gains in life expectancy seem
to be occurring without growth in disability and potentially
less disability for a given age with time. Thus, the increase in
total life expectancy does not specifically correspond to
increased time living in severe disability [42–46]. This
reflects what Fries [47] described as a progressive compression of morbidity that seems to be characterizing aging
populations. Likewise, Manton et al. [48] have characterized
the declining rates of disability and associated health care
expenditures among the elderly population in the USA.
According to Manton [49], what is largely responsible for
this continuing trend is that rate of decline in disability
prevalence continues to be a faster one than the increase in
total expected years of life. For instance, while disability
prevalence among older people declined 0.26% per year
between 1982 and 1989, the rate of decline increased to
0.38% per year between 1989 and 1994, and further to 0.56%
per year between 1994 and 1999 [
been attributed to this progressive decline in the prevalence
of disability, and including improvements in medical treatments,
overall socioeconomic status, positive behavioral changes,
and the more widespread use of assistive technologies.
The overall result is illustrated in Fig. 11.2 which demonstrates how the prevalence of chronic disability among older
people fell from 26% in 1982 through 23% in 1994 to 20%
in 1999 [45]. This, it is argued, not only lessens the upward
pressure of demographic change on health expenditures, but
also has the potential to lower per capita demands on health
and social services as well [50].
45]. Multiple factors have
Thus, if in addition to living longer, the current generation
of older people is healthier and less disabled than their
predecessors, the important question then becomes – what
level of disability is present in those extra years? With
disability representing the inability to perform a specific task
because of health or age, resulting in impaired functional
performance, the concept of active life expectancy has been
developed to measure the number of years that people can
expect to live on average without disability. Manton and
Land [51] estimate that a woman of 65 with a life expectancy
of 22.2 years remains fit and active for 15.7 years and a
man of the same age, with a life expectancy of 15.7 years
for 13.7 years.
In the classification of functional dependency, the
Activities of Daily Living (ADLs) and Instrumental Activities
of Daily Living (IADLs) are two classes of measures, based
on an individual’s ability to perform specific tasks, that are
widely utilized in home-dwelling populations to determine
the capability for independent living or, vice versa, as indicators of disability. ADL tasks refer to those that are required
to carry out basic self-care activities, such as transferring out
of a bed or a chair, walking, toileting, bathing, and eating
[52–54]. IADL tasks refer to those that are required to
maintain an independent household, such as doing light
housework, preparing meals, using the telephone, shopping
for personal items, managing money, and getting around the
community [55]. Within older populations, ADL dependency
is less common than IADL dependency, and in the community dwelling population, 85 years of age and older, only
16% required help with one ADL, 10% with two or three
ADLs, and 9% with four or more ADLs [56]. More than half
of the community dwelling population, 80 years of age and
over can still perform IADL tasks independently [56] which
generally demand a combination of both cognitive and
physical abilities.
Kane et al. [56] note that because health care professionals tend to see the sick, they may form a distorted picture
of the health and functional status of older individuals.
Indeed, most older people are self-sufficient and able to
function on their own or with minimal assistance. Even
though they carry a greater burden of chronic conditions and
impairments, 72% of older people report being in good to
excellent health. Among all older adults, 95% are able to
move about within their homes independently, 80% are able
to leave their homes without assistance and had no difficulty
with any personal care task, 68% had no difficulty with any
domestic task, and 69% had no difficulty with any locomotor
task [57]. As well, of those ages 75 and over, about one-fifth
report taking no medication on a regular basis, two-fifths
report needing medication regularly to control medical
problems, while the remainder report having multiple
medical problems and using three or four medicines on a
regular basis [58].
(Age-standardized to 1999 population aged 65 and older)
Institutionalized and disabled
6.6
6.1
5.7
4.2
1982
6.8
2.9
3.0
3.4
3.7
3.0
1984
1989
1994
1999
3.5
3.7
3.1
3.0
3.4
6.0
6.7
7.0
6.9
6.1
3.2
4.8
6.2
5.7
4.4
19.7
24.4
26.2
26.2
22.5
Total disabled
IADL only
1
1 or 2 ADLs
2
3 or 4 ADLs
2
5 or 6 ADLs
2
1
Instrumental activities of daily living.
2
Activities of daily living.
Note: The reference population for these data is the Medicare enrollees aged 65 and older.
Fi g u r e 11.2 Percentage of people
https://t.me/med1917
aged 65 and over with chronic
disability: 1982–1999 [45].
14711 The Demography of Aging and Disability
Aging and Health Services Utilization
Notwithstanding the low degree of dependency among the
majority of older people, this 12.4% of the population are the
principal users of health care systems. In being the predominant user of more expensive institutional services, they
account for over one-third of health expenditures in the USA
[56]. The 1997 National Medical Expenditure Survey
demonstrated that the annual per capita costs of health care
for older persons in the USA was $5,947 as compared to
$3,226 for those aged 45–64 years and $1,666 for those aged
18–44 years. Increasingly, questions are being raised around
whether societies with aging populations are able to cope
with the concomitant ever-increasing costs that seem to be
associated in providing care for them. Clearly, new costconscious models of care delivery to meet the needs of the
aging populations are needed.
While expenditure projections have traditionally examined the effect of age on health care costs, it is being increasingly argued that well-founded estimates should account for
the influence of remaining life expectancy, declining disability rates and the concentration of costs that often occurs
toward the end of life. Lubitz and Riley [59] demonstrated
that just under a third of annual Medicare payments are made
on behalf of persons in their last year of life, with over half of
their costs being incurred in the last 60 days of life, reflecting
the fact that over half the deaths among elderly persons occur
in the hospital [60]. In considering remaining life expectancy
148 S.K. Sinha and C. Christmas
https://t.me/med1917
on future health care spending, Seshamani and Gray [61]
demonstrated that the despite the pressure of population
increases and aging demographic structures on overall hospital expenditures, these will be partially countered by the
postponement of death-related hospital costs later in life. The
heterogeneous pattern of health care expenditures was further demonstrated when Lubitz et al. [62] determined that the
average calculated Medicare expenditure for those who died
at age 70 was $35,511 compared to $65,633 for those who
survived to age 101 in the USA. Thus, the average Medicare
expense per year from age 65 on for those who died at age 70
was $7,100 per year compared to only $1,823 for centenarians. While overall Medicare expenditures continue to
increase, this should be properly attributed to the combined
forces of cost inflation, therapeutic advances, and a growing
number of beneficiaries with chronic illness requiring longterm maintenance therapy as opposed to aging itself.
When it was implemented, Medicare was designed to deal
primarily with the effects of acute illness, which was then
seen as the major threat to the health and financial security of
older individuals. Now, the implications of having increasing
numbers of older people living increasingly longer with
chronic illness is becoming readily apparent, when 68% of
current Medicare spending is accounted for by the 23% of
Medicare beneficiaries having five or more chronic conditions [63]. Furthermore, federal outlays for Medicaid and
Medicare are expected to grow substantially, from 21% of
current government spending to an estimated 31% in 2017
[64]. The increasing cost pressures associated with financing
public health insurance programs likely affect public spending around other priorities, and overall economic growth,
especially as the ratio of nonelderly taxpayers to elderly beneficiaries contracts. It is likely that unless the financing
mechanism for Medicare is changed, or its benefit structure
altered, the Medicare Trust Fund will be depleted in 2019
[65]. Increasing consideration is being given to determine to
what extent the government will be willing to shift the costs
of providing care to current recipients and to what extent it
will look at shifting resources to support the provision of
preventive care or health promotion services – not currently
covered by Medicare or Medicaid – that may help to lessen
the burdens associated with managing chronic disease.
Finally, the significant indirect costs associated with treating
chronic diseases in the elderly should also be noted when
relatives may shoulder an enormous personal and economic
burden when caring for an older spouse, parents, or other
relations unable to live independently.
The pattern of increasing Medicare expenditures, however,
remains in distinct contrast to the accumulated liability that
increased life expectancies have on Social Security expenditures, without any foreseeable countering mechanisms.
While the Social Security trust fund will have resources until
2041, the more critical dates are when Social Security and
Medicare begin paying out more in benefits than they are
receiving in taxes because that represents the time the government must start redeeming the bonds in the trust funds that
support these programs. To do that, the government will have
to increase its borrowing on financial markets, raise taxes or
divert money from other government programs. For Medicare,
the threshold when benefits exceed program income already
occurred a few years ago. For Social Security, it is estimated
that this threshold will be crossed in 2017.
Effective Interventions in the Elderly
With the growing expectation that future older cohorts will
live longer and be in better health at later ages, greater consideration is being given to how treatment interventions can be
extended to mitigate morbidity and mortality within older
populations. While more comprehensive evaluations of the
efficacy of treatment interventions at later ages will better
inform practitioners about how and for whom these interventions should be extended, overcoming agism around treating
illness at later ages will be just as important.
Agism is a term that describes the negative stereotyping of
older adults and discrimination because of older age. As Salzman
[66] notes, health concerns and symptoms in the elderly are
sometimes overlooked or dismissed as part of the normal aging
process. Consequently, several conditions in older adults continue to go significantly underdiagnosed and undertreated which
continues to provide further evidence of age discrimination still
occurs in the delivery of health care [67–69].
While health care professionals do not necessarily intend
to behave in a discriminatory fashion, it is clear that a lack of
skills and confidence in working with older people can lead
to behavior which may be perceived as discriminatory.
Nevertheless, the quality of the care older individuals receive
has also been demonstrated to be affected at times by negative
staff attitudes in a number of settings [70, 71].
Denying access to services on the basis of age alone is not
acceptable. Decisions about treatment and health care should
be made on the basis of a patient’s health needs, the overall
health status of the individual, their own wishes and aspirations and, where appropriate, those of their carers, and the
patient’s ability to benefit as even complex treatments, used
appropriately, can benefit older people.
The extension of surgical interventions to individuals at
increasingly later ages is an area of active research. Largely,
this body of literature demonstrates that the benefits of surgery
in advanced age may have been underestimated. Hosking et al.
[72] examined how intraoperative mortality rates in patients
over 90 years of age had significant declined from 29 to 8%
14911 The Demography of Aging and Disability
https://t.me/med1917
over a 20-year period. Furthermore, the 5-year survival rate of
this group at 21%, which had a mean age of 93.5 years, was
determined to better than that of the comparable general population cohort at 16%. Elayda et al. [73] demonstrated similar
results in demonstrating the efficacy and improved 5-year survival rates in patients 80 years of age and over undergoing
aortic valve replacement. Ko et al. [74] demonstrated the
increasing efficacy of elective coronary artery bypass surgery
versus conventional medical treatment in patients 80 years of
age and over with coronary artery disease.
Interventions with low mortality risks that have been
demonstrated to significantly improve function and thus
disability burden in older patients include cataract extractions and joint replacements. In regards to cataract extractions, Lundstrom et al. [75] demonstrated in one of few
studies that looked specifically at individuals 85 and over
that about 85% of patients achieved improved visual acuity
from the surgery. Therefore, despite the higher risk of
complications, cataract extraction remains a highly effective
procedure for the very elderly [76]. In a recent review of
36,711 hip and knee replacement performed among nonagenarians and centenarians, the low in-hospital mortality data
suggest that arthroplasties should not be denied to centenarians solely because of their relatively short remaining life
expectancy estimates, when they can significantly improve
functional status in these individuals [77].
The ability of pacemakers to improve survival and quality
of life outcomes in elderly patients has become well established [78, 79]. In reviewing patients 80 years and over receiv-
ing pacemakers, Schmidt et al. [80], determined that pacemaker
therapy is both a clinically and economically effective therapeutic option to control bradyarrhythmia-related symptoms,
considering the median survival time of their patients stood at
8 years. Interestingly, while practice guidelines recommend
dual rather than single-chamber pacing for patients with highgrade atrioventricular (AV) block, Toff et al. [81] noted that
not only were elderly patients less likely than younger patients
to receive more sophisticated dual-chamber pacemakers, but
also 51% of elderly patients with this diagnosis were receiving
them, despite their perceived association with improved quality of life and lower mortality risk. Nevertheless, their
UKPACE trial, the first to evaluate and compare the long-term
clinical impact and cost utility of dual versus single chamber
pacing in patients aged 70
block, suggested no mortality benefit of dual over singlechamber pacing in this population [82].
In the field of organ transplantation, common practice has
been to exclude older recipients because of the chronically
limited supply of organs and lower expected survival of older
patients after transplantation. While consensus guidelines for
the selection of transplant recipients often recommend an
upper age limit of 65 years, the number of people 65 years
years and over with high-grade AV
and older in the USA who have received organ transplants
nearly tripled between 1996 and 2005, going from 1,145 to
3,154 [83]. Currently, elderly patients including those into
their early 80s have come to represent 12% of the annual
transplant recipients. Furthermore, Mahidhara et al. [84] have
suggested that the idea that younger patients do better than
older patients may not actually be valid after demonstrating
that 73.6% of their elderly lung recipients were alive 3 years
after surgery, compared with 74.2% of younger patients.
There is increasing evidence to support the greater use of
nonsurgical interventions in the management of conditions
common to the elderly patient as well. While the benefits of
treating of hypertension in the very elderly were unclear as to
whether they could be countered by an increased risk of
death, the HYVET Trial demonstrated that treating hypertension in patients 80 years and older to a target of 150/80
was associated with a 64% reduction in the rate of heart failure, a 23% reduction in the rate of death from cardiovascular
causes, a 30% reduction in the rate of fatal or nonfatal stroke,
a 39% reduction in the rate of death from stroke, and a 21%
reduction in the rate of death from any cause [85].
The increased recognition of osteoporosis as a preventable
and treatable disease common in older individuals would aid
in the dissemination of proven medical therapies that could
significantly impact on the excess morbidity and mortality
associated with this disease. Nevertheless, Kamel et al. [86]
demonstrated that the failure of surgical and medical specialists to diagnose and initiate the treatment of osteoporosis in
elderly patients hospitalized with hip fracture remains problematic when those treating the consequences of osteoporosis
may often be ignoring the underlying condition [87].
Even though near complete vaccination coverage rates
have been achieved in children, significantly fewer adults
are being vaccinated against serious and even deadly diseases, such as influenza, pneumonia, and shingles. The CDC
has established a goal to vaccinate at least 90% of individuals 65 years of age and over against influenza and pneumococcal disease, however, coverage estimates in this age
group were just 69 and 66%, respectively in 2007. Despite
being available for 1 year and having been integrated into
the US Preventive Services Task Force guidelines as a
recommendation for all elderly, only about 2% of eligible
older adults appeared to have been vaccinated against shingles by 2007. While their effectiveness with aging is debated,
estimates are that many of the 63,000 deaths in the USA in
2005 due to influenza and pneumonia could have been
prevented by immunization against influenza and pneumococcal infections [88].
Because the aging population carries the greatest burden
of illness and disability, it not only poses the most complex
diagnostic and therapeutic problems, but also reaps the most
benefit from medical and nursing care. The health problems
150 S.K. Sinha and C. Christmas
https://t.me/med1917
of older people are also inseparable from their social
relationships and circumstances. As a result, their problems
challenge various health and social care professionals to
understand their patients through the organic, social, and
psychological dimensions of their lives. Furthermore, evaluating the potential benefits of therapeutic interventions for
elderly individuals with specific health profiles, and understanding in general what service increases are needed to meet
the needs of the growing numbers of older patients is not
only necessary, but as Manton et al. [48] assert, require consideration of the long-term demographic and health changes
that are constantly evolving integrated with an understanding
of both personal and cultural values. For older patients, especially those at late ages, it is clear that the cost-benefit ratios
of therapeutic medical and surgical interventions have been
commonly underestimated – because life expectancies, mortality benefits, the amount of functional capacity that can be
regained is usually underestimated. In the management of
elderly patients, understanding the heterogeneous nature of
this population and that the use of physiological age, rather
than chronological age is becoming increasingly more relevant in the prognostication of an individual’s disability and
mortality profile is important.
References
1. Wan H, Sengupta M, Velkoff V, DeBarros K (2005) 65+ in the
United States: 2005. U.S. Census Bureau, Washington, DC
2. Hetzel L, Smith A (2001) The 65 years and over population: 2000.
U.S. Census Bureau, Washington, DC
3. Myers GC (1990) Demography of aging. In: Binstock RH, George
LK (eds) Handbook of aging and the social sciences. Academic,
New York, pp 19–44
4. Thomlinson R (1976) Population dynamics. Causes and consequences of world demographic change. Random House, New York
5. Moore TJ (1993) Lifespan. Simon and Schuster, New York
6. National Center for Health Statistics (2003) Special excerpt: trend
tables on 65 and older population. Department of Health and Human
Services, Washington, DC
7. Olshansky SJ (2003) The demography of aging. In: Cassel CK,
Leipzig RM, Cohen HJ, Larson EB, Meier DE (eds) Geriatric medicine: an evidence-based approach. Springer, New York
8. Austad SN (2006) Why women live longer than men: sex differences in longevity. Gend Med 3(2):79–92
9. Nathonson CA (1984) Sex differences in mortality. Annu Rev
Sociol 10:191–213
10. Verbrugge LM (1985) Gender and health: an update on hypotheses
and evidence. J Health Soc Behav 26(3):156–182
11. Verbrugge LM (1989) The twain meet: empirical explanations of
sex differences in health and mortality. J Health Soc Behav
30(3):282–304
12. Krieger N (2003) Gender, sexes, and health: what are the connections and why does it matter? Int J Epidemiol 32:652–657
13. Anderson RN (1999) Method for constructing complete annual
U.S. life tables. Vital Health Stat 2(129):1–28
14. Arias E (2002) United States life tables, 2000. Natl Vital Stat Rep
51(3):1–38
15. Federal Interagency Forum on Aging-Related Statistics (2004)
Older Americans 2004: key indicators of well-being. U.S.
Government Printing Office, Washington, DC
16. Rogers A, Raymer J (2001) Immigration and the regional demographics of the elderly population in the United States. J Gerontol A
Biol Sci Med Sci 56B:S44–S55
17. Kinsella K, Velkoff V (2001) An aging world: 2001. US Census
Bureau, Washington, DC
18. Kannisto V (1996) The advancing frontier of survival. Odense monographs on population aging, 2. Odense University Press, Odense
19. Manton K, Stallard E (1996) Longevity in the United States: age
and sex-specific evidence on life span limits from mortality patterns
1960–1990. J Gerontol 51A:B362–B375
20. Vaupel JW (1998) Demographic analysis of ageing and longevity.
Am Econ Rev 88:242–247
21. Thatcher AR (1999) The long-term pattern of adult mortality and
the highest attained age. J R Stat Soc 162(1):5–43
22. Gavrilov LA, Gavrilov NS (1991) The biology of life span: a quantitative approach. Harwood Academic, Chur
23. Wilmoth JR (1996) Mortality projections for Japan: a comparison
of four methods. In: Caselli G, Lopez A (eds) Health and mortality
among elderly populations. Oxford University Press, Oxford, pp
266–287
24. Robine J, Vaupel JW (2002) Emergence of supercentenarians in
low-mortality countries. North Am Actuar J 6(3):54–63
25. Shock NW (1960) Age changes in physiological functions in the
total animal: the role of tissue loss. In: Strehler BL, Ebert JD, Shock
NW (eds) The biology of aging: a symposium. American Institute
of Biological Science, Washington, DC, pp 258–264
26. Cavalieri TA, Chopra A, Bryman PN (1992) When outside the norm
is normal: interpreting lab data in the aged. Geriatrics 47:66–70
27. Timiras PS (1996) Physilogy of aging: standards for age-related
functional competence. In: Gregor R, Windhorst U (eds) Human
physiology from cellular mechanisms to integration. Springer,
Berlin, pp 2391–2405
28. Suzman RM, Willis DP, Manton KG (1992) The oldest old. Oxford
University Press, Oxford
29. Rowe JW, Kahn RL (1987) Human aging: usual and successful.
Science 237:143–149
30. Seeman TE (1994) Successful aging: reconceptualizing the aging
process from a more positive perspective. In: Vellas BJ, Albarede
JL, Garry PJ (eds) Epidemiology and aging: facts and research in
gerontology. Springer, New York, pp 61–73
31. Berkman LF, Seeman TE, Albert M (1993) High, usual and impaired
functioning in community-dwelling older men and women: findings from the MacArthur Foundation Research Network on
Successful Aging. J Clin Epidemiol 46:1129–1140
32. Seeman TE, Charpentier PA, Berkman LF, Tinetti ME, Guralnik
JM, Albert M, Blazer D, Rowe JW (1994) Predicting changes in
physical performance in a high-functioning elderly cohort:
MacArthur studies of successful aging. J Gerontol 49:M97–M108
33. Martin GM (1996) Genetic modulation of the senescent phenotype
of Homo sapiens. Exp Gerontol 31:49–59
34. Fedoroff N, David B (1992) The dynamic genome: Barbara
McClintock’s ideas in the century of genetics. Cold Spring Harbor
Laboratory Press, Plainview, NY
35. Strawbridge WJ, Kaplan GA, Camacho T (1992) The dynamics of
functional change and disability in an elderly cohort: results from
the Alameda County Study. J Am Geriatr Soc 40:799–806
36. Strawbridge WJ, Camacho T, Cohen RD (1993) Gender differences
in factors associated with change in physical functioning in old age:
a 6-year longitudinal study. Gerontologist 5:603–609
15111 The Demography of Aging and Disability
https://t.me/med1917
37. Kaplan GA, Wilson TW, Cohen RD (1994) Social functioning and
overall mortality: prospective evidence from the Kuopio Ischemic
Heart Disease Risk Factor Study. Epidemiology 5:495–500
38. Kannisto V, Lauritsen J (1994) Reduction in mortality at advanced
ages. Popul Dev Rev 20:793–810
39. Wilmoth JR (1997) In search of limits. In: Wachter KW, Finch CE
(eds) Between zeus and the salmon: the biodemography of longevity. National Academy Press, Washington, DC, pp 38–64
40. Lee RD, Carter LR (1992) Modeling and forecasting U.S. mortality.
J Am Stat Assoc 87:659–675
41. Wilmoth JR, Skytthe S, Friou D (1996) The oldest man ever? A
case study of exceptional longevity. Gerontology 36:783–788
42. Crimmins EM, Saito Y, Ingegnari D (1997) Trends in disability-free
life expectancy in the United States, 1970–90. Popul Dev Rev
23(3):555–572
43. Manton KG, Corder L, Stallard E (1997) Chronic disability trends
in elderly United States populations: 1982–1994. Proc Natl Acad
Sci USA 94:2593–2598
44. Freedman VA (1998) Understanding trends in functional limitations
among older Americans. Am J Public Health 10:1457–1462
45. Manton KG, Gu X (2001) Changes in the prevalence of chronic
disability in the United States black and non-black population
above
age 65, from 1982 to 1999. Proc Natl Acad Sci USA 98:
6354–6359
46. Freedman VA, Martin LG, Schoeni RF (2002) Recent trends in disability and functioning among older adults in the United States. J
Am Med Assoc 288(24):3137–3146
47. Fries JF (1980) Aging, natural death, and the compression of morbidity. N Engl J Med 303(3):130–135
48. Manton KG, Stallard E, Corder LS (1998) The dynamics of dimensions of age-related disability 1982 to 1994 in the U.S. elderly
population. J Gerontol A Biol Sci Med Sci 53(1):B59–B70
49. Manton K, XiLiang G (2005) Disability declines and trends in
Medicare expenditures. Ageing Horiz 2:25–34
50. Singer BH, Manton KG (1998) The effects of health changes on
projections of health service needs for the elderly population of the
United States. Proc Natl Acad Sci USA 95(26):15618–15622
51. Manton KG, Land KC (2000) Active life expectancy estimates for
the U.S. elderly population: a multi-dimensional continuous-mixture model of functional change applied to completed cohorts,
1982–1996. Demography 37(3):253–265
52. Katz SJ, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW (1963)
Studies of illness in the aged. The index of ADL: a standardized
measure of biological and psychosocial function. J Am Med Assoc
185:914–919
53. Katz SJ (1983) Assessing self-maintenance: activities of daily
living, mobility and instrumental activities of daily living. J Am
Geriatr Soc 31(12):721–726
54. Katz SJ, Stroud M (1989) Functional assessment in geriatrics: a
review of progress and directions. J Am Geriatr Soc 37:267–271
55. Lawton MP, Brody EM (1969) Assessment of older people: selfmaintaining and instrumental activities of daily living. Gerontologist
9:179–186
56. Kane RL, Ouslander JC, Abrass IB (2003) Essentials of clinical
geriatrics, 5th edn. McGraw Hill, New York
57. Jarvis C (1996) Getting around after 60: a profile of Britain’s older
population. Age Concern Institute of Gerontology, Gerontology
Data Service, HMSO, London
58. Martin J, Elliot D, Meltzer H (1988) The prevalence of disability among
adults. Government Social Survey Department, HMSO, London
59. Lubitz JD, Riley GF (1993) Trends in Medicare payments in the last
year of life. N Engl J Med 328(15):1092–1096
60. McMillan A, Mentnech RM, Lubitz JD, McBean AM, Russell D
(1990) Trends and patterns in place of death for Medicare enrollees.
Health Care Financ Rev 12:1–7
61. Seshamani M, Gray A (2004) Time to death and health expenditure:
an improved model for the impact of demographic change on health
care costs. Age Ageing 33(6):556–561
62. Lubitz JD, Beebe J, Baker C (1995) Longevity and Medicare expenditures. N Engl J Med 332(15):999–1003
63. Anderson GF (2005) Medicare and chronic conditions. N Engl J
Med 353(3):305–309
64. US Congressional Budget Office (2007) The budget and economic
outlook: fiscal years 2008 to 2017. US Congressional Budget
Office, Washington, DC
65. Federal Hospital Insurance and Federal Supplementary Medical
Insurance Trust Funds (2007) Annual report of the board of trustees
of the Federal Hospital Insurance and Federal Supplementary
Medical Insurance Trust Funds. Federal Hospital Insurance
and
Federal Supplementary Medical Insurance Trust Funds,
Washington, DC
66. Salzman B (2006) Myths and realities of aging. Care Manag J
7(3):141–150
67. Alexander KP, Newby LK, Armstrong PW et al (2007) Acute coronary care in the elderly, Part II: ST-segment-elevation myocardial
infarction: a scientific statement for healthcare professionals from
the American Heart Association Council on Clinical Cardiology in
collaboration with the Society of Geriatric Cardiology. Circulation
115(19):2570–2589
68. Bouchardy C, Rapiti E, Blagojevic S, Vlastos AT, Vlastos G (2007)
Older female cancer patients: importance, causes, and consequences
of undertreatment. J Clin Oncol 25(14):1858–1869
69. Grant PT, Henry JM, McNaughton GW (2000) The management of
elderly blunt trauma victims in Scotland: evidence of ageism?
Injury 31(7):519–528
70. Health Advisory Service 2000 (1998) “Not because they are old”:
an independent inquiry into the care of older people on acute wards
in general hospitals. Health Advisory Service 2000, London
71. Lookinland S, Anson K (1995) Perpetuation of ageist attitudes
among present and future health care personnel: implications for
elder care. J Adv Nurs 21(1):47–56
72. Hosking MP, Warner MA, Lodbell CM (1989) Outcomes of surgery
in patients 90 years of age and older. J Am Med Assoc 261:
1909–1915
73. Elayda MAA, Hall RJ, Reul RM (1993) Aortic valve replacement
in patients 80 years and older: operative risks and long-term results.
Circulation 88:11–16
74. Ko W, Gold JP, Lazzaro R (1992) Survival analysis of octogenarian
patients with coronary artery disease managed by elective coronary
artery bypass surgery versus conventional medical treatment.
Circulation 86(Suppl II):191–197
75. Lundstrom M, Stenevi U, Thorburn W (2000) Cataract surgery in
the very elderly. J Cataract Refract Surg 26:408–414
76. Wong TY (2001) Effect of increasing age on cataract surgery
outcomes in very elderly patients. Br Med J 322:1104–1106
77. Krishnan E, Fries JF, Kwoh CK (2007) Primary knee and hip arthroplasty among nonagenarians and centenarians in the United States.
Arthritis Rheum 57(6):1038–1042
78. Bush DE, Finucane TE (1994) Permanent cardiac pacemakers in
the elderly. J Am Geriatr Soc 42:326–334
79. Shen WK, Hayes DL, Hammill SC (1996) Survival and functional
independence after implantation of a permanent pacemaker in octogenarians and nonagenarians: a population-based study. Ann Intern
Med 125:476–480
80. Schmidt B, Brunner M, Olschewski M, Hummel C, Faber T (2003)
Pacemaker therapy in very elderly patients: long-term survival and
prognostic parameters. Am Heart J 146:908–913
81. Toff WD, Skehan JD, De Bono DP, Camm AJ (1997) The United
Kingdom pacing and cardiovascular events (UKPACE) trial. Heart
78:221–223
152 S.K. Sinha and C. Christmas
https://t.me/med1917
82. Toff WD, Camm AJ, Skehan JD (2005) Single-chamber versus
dual-chamber pacing for high-grade atrioventricular block. N Engl
J Med 353:145–155
83. Health Resources and Services Administration (2007) Annual report
of the U.S. Organ Procurement and Transplantation Network and the
Scientific Registry of Transplant Recipients: transplant data 1997–
2006. Division of Transplantation, Health Resources and Services
Administration, Healthcare Systems Bureau, Rockville, MD
84. Mahidhara R, Bastani S, Ross D, Saggar R, Lynch J (2008) Lung transplantation in older patients? J Thorac Cardiovasc Surg 135(2):412–420
85. Beckett NS, Peters R, Fletcher A, Staessen JA (2008) Treatment of
hypertension in patients 80 years of age or older. N Engl J Med
358(18):1887–1898
86. Kamel HK, Hussain MS, Tariq S (2000) Failure to diagnose and
treat osteoporosis in elderly patients hospitalized with hip fracture.
Am J Med 109:326–328
87. Bauer DC (2000) Osteoporotic fractures: ignorance is bliss? Am J
Med 109:338–339
88. Kung HC, Hoyert DL, Xu J, Murphy SL (2008) Deaths: final data
for 2005. Natl Vital Stat Rep 56(10):1–120
Chapter 12
https://t.me/med1917
Providing Surgical Care to an Aging Population:
Implications for the Surgical Workforce
David A. Etzioni and Clifford Y. Ko
Introduction
The demographic trends underlying the “aging population”
have already been discussed in Chap. 12. As a result of
increasing life expectancy and the aging of the baby boomers, the United States (US) population will see a dramatic
increase in the number of older individuals. Between 2010
and 2030, those aged 65 years and older are projected to rise
by 78%, an absolute increase of over 30 million individuals.
These unprecedented changes in the demographics of the US
population will lead to significant growth in the demand for
surgical treatment.
This chapter comes with an acknowledgement. In the
interest of simplicity, we examine these trends within the
context of the US population only. Furthermore, we focus
more on general surgery and its subspecialties than on other
areas of surgical specialization. This is in the interest of
developing a succinct, circumscribed report. The analyses
described here are easily applicable within other fields of
medicine, as well as to other countries.
Another acknowledgement is also important. This chapter
could easily be its own textbook. In selecting which points
should be made, we focus on a survey of existing opinions
and concepts that are driving policy. We will also offer some
original analysis regarding how the aging population will
affect the delivery of surgical treatment. Our hope is at the
end of this chapter, the reader will be familiar with the
methods used to forecast the impact of the aging population
on the healthcare delivery system, and be able to differentiate
the relative importance of the various factors that will drive
health care expenditure in the immediate and more distant
future.
D.A. Etzioni (*)
Department of Surgery, Mayo Clinic Arizona, Mayo Clinic College
of Medicine, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA
e-mail: etzioni.david@mayo.edu
Older Individuals in the US Population:
Disproportionately High Use of Resources
In general, older individuals use medical and surgical services
at higher rates than do younger individuals. To illustrate and
characterize this fact, we will rely on analyses of the National
Hospital Discharge Survey (NHDS), a data source which
deserves at least a brief explanation. Since 1965, the National
Center for Health Statistics has conducted an annual survey
(sampling) of domestic discharges. Each year, over 350,000
discharges from approximately 500 hospitals within the US
are sampled, and the sampling strategy is designed to yield a
dataset that is representative of the universe of domestic discharges [1]. The NHDS reports specific information about
each discharge, including age, gender, race/ethnicity, diagnoses, procedures, diagnosis-related grouping (DRG) admission source (emergency room, home, etc.), and admission
type (emergency, elective, etc.). At several points in this
chapter, we will rely on analyses of the NHDS to give a
quantitative analysis of historical and projected trends in the
patterns of hospital-based health care delivery in the US.
Hospital-Based Care
According to data from the US census, in 2006, individuals
over the age of 65 comprised 12.5% of the US population
[2]. However, according to data from the NHDS, individuals
over the age of 65 were responsible for:
32% of cholecystectomies•
38% of hospitalizations•
43% of hospital days of care•
54% of colon resections•
55% of total hip replacements•
60% of total knee replacements•
This disproportionate use of services can be considered in
terms of an incidence rate curve, demonstrating the likelihood of an individual in the population requiring a specific
R.A. Rosenthal et al. (eds.), Principles and Practice of Geriatric Surgery,
DOI 10.1007/978-1-4419-6999-6_12, © Springer Science+Business Media, LLC 2011
153
Соседние файлы в папке Библиотека им академика М.И. Перельмана