S4: Introduction to Ageing and Disease

Question 1

Describe demographic ageing trends in last 50 years

Answer 1

• In today’s modern era there is more chance of living to old age than ever before and when we get to old age there is a now a higher chance one will live longer in old age (i.e. life expectancy in old age is increased).
• Infant mortality has fallen significantly from around 35 to 6 from 1948 to 1996.
• As well as this, in the last 50yrs the proportion of the population that dies before 65 has decreased again drastically from 40% to 7%.
• Life expectancy at birth in the last 100 years has gone from the late 40s to late 70’s/early 80s.
• These changes in length of life have understandably led to a change in the population structure.

Question 2

Describe changes in population size over last 50 years in England and Whales

Answer 2

• Overall population size has increased by 20%, 0-4 age group only by 9% but the 80+ group by 240%!
• By 2007 there were more people over the age of 65 than under 18 and the over 85’s are the fastest growing segment of the population and set to double by 2020.
• This is not worrying as the younger people coming into employment help with physical care and taxes to elderly.
• The population has reached 56.1 million, up by 3.7 million in a decade.
• The percentage of the population aged 65 and over was the highest seen in any census - at 16.4%.
• There were 430,000 residents aged 90 and over in 2011 compared with 340,000 in 2001 and 13,000 in 1911.

Question 3

What are Population Pyramids?

Answer 3

Population pyramids are a graphical representation of the age demographics of a society. Populations divided into different age groups and stacked on top of each other (youngest at bottom, oldest at top).

Question 4

Population pyramid of steady death across life

Answer 4

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Question 5

Population pyramid as death rates reduce

Answer 5

• Pyramid becomes more square.
• If there is then a fall in fertility rates then we start seeing the pyramid invert with a more barrel shaped.
• Here the age group that is the largest starts to be around the 50/60 mark.
• Now the smaller younger generations have to sustain and look after the larger more dependent generations as they age.

Question 6

What is a survival curve?

Answer 6

Graphical representation of population survival with age. We can plot survival and ageing onto curves.

Question 7

Describe the 3 main types of logarithmic survival curve

Answer 7

• The logarithmic curve below depicts a population of animals or humans who live in severe environment where none reach old age and there isn’t much ageing.
• As populations start developing and are able to look after their young, individuals start to live longer with some people surviving to old age but most dying prematurely.
• Finally with further improvements in living conditions and in prevention of adult onset disease and premature death. This compacts all death to old age and is called squaring of the rectangle. This is the ideal although it will never be reached, that everyone lives until they reach a certain old age and then die

Question 8

Describe squaring of the rectangle in the UK

Answer 8

In the UK this squaring of the rectangle has been occurring, where greater numbers of people survive into old age and then start to die, due to a number of contributing factors but mostly further improvements in living conditions. Major factors in increasing survival of old age (squaring):

• A decreasing infant mortality.
• Increasing standard of living.
• Improvements in public health.
• Improvements in sanitation.
• Improved diet (abolition of corn laws in 1842, could then import cheap food from USA).

Question 9

Describe how life expectancy at older age is also increasing

Answer 9

As well as life expectancy at birth increasing, life expectancy at older age also increases. In other words if you reached age 80 in 1980 you would be expected to have another 5.8yrs of life. If you reached age 80 in 2000 you would be expected to have another 7 years of life.
Thus more years of retirement and older age. Length of life spent in retirement has increased by 4-8 fold since 1870, this is almost completely due to increased life expectancy. Average length of retirement increased by 5 years between 1981 and 2001.

Question 10

What is the significance of life expectancy at older age increasing?

Answer 10

An important question to ask however is that are these extra years that we have added to old age are they actually significant and are they good or are they spent quite miserably.

Question 11

Describe the theoretical gloom in older age

Answer 11

The issue is that although older people may have more time to enjoy their retirement there is an exponential relationship between age and prevalence of disability. In other words the older one gets the more likely they are to have a disability of some kind. There is also a exponential relationship between age and chronic disabling diseases. Some chronic disabling diseases that increase in prevalence with age include:
- Stroke
- Alzheimers
- Parkinson’s
- Osteoarthritis
An example is that the highest prevalence of epilepsy is in old age, thus advancing age does come with a physiological problems. Epilepsy high in old people brought on by stroke.

Question 12

What makes disability more common in elderly?

Answer 12

As one ages a combination of physiological ageing, acute illness, chronic illness and isolation and poverty all contribute to disability and make it more common in older people.

Question 13

Describe dependency profile of elderly people by age and 4 possible quality of life scenarios as a result

Answer 13

Graph demonstrates the dependency (need for someone else to help you) with various tasks at different ages and we can see that as we age we become more dependent on others as disability becomes more prominent. So with the extra years that we have managed to add to older life through changes in public health, the four possible scenarios with regards to the quality of this extra life:

1. With every year of life gained it is going to be spent in a dependent state (1 year of additional woe),
2. With every year of life gained, some of it will be spent in dependent state (less than 1 year of additional woe).
3. With every year of life gained there is no change in dependency (no additional woe.
4. With every year of life gained, there is actually less period of dependency (less woe). This is known as Fries Compression of morbidity.

Question 14

What is the actual quality of life scenario due to older population in UK 1981-2001?

Answer 14

It appears that as well as life expectancy at 65 increasing over the past 20 years e.g. 13.0 to 16.1 in women. The healthy life expectancy (life that is free from long standing illness) is also increasing, for women 7.6 to 8.9. The global health survey which analysed trends over last 20 yrs found no change in the proportion of elderly people reporting their health as good, fairly good and not good. No change means that despite people living longer and potentially living longer with illness, this doesn’t appear to be occurring rather people are living longer and not experiencing an additional period of ill health as a result.

Question 15

Does days spent in hospital before death change with older population?

Answer 15

Generally whether you die very old or relatively young, it is very likely that the last 3yrs of your life you would have spent a significant amount of time in hospital.
The median number of days spent in hospital 3yrs prior to death is 23 and this did not rise with age above 45.
- So it is not the age you die , but the last three years before death where most medical services used regardless of age.

Question 16

Describe projected numbers of people over 65 in UK unable to perform activities of daily living

Answer 16

Ageing to the rescue process means with time, the no. of people unable to perform daily activates decreases with increasing ageing over. Normal function can happen in extreme old age as long as their is no pathology. If you get sick in old age, reserves are low and you get sick dramatically and it is much harder to recover.

Question 17

When does our eyesight have maximum function?

Answer 17

Our eye has maximum function at age 14 and then signs of ageing occur.

Question 18

Describe and define ageing

Answer 18

• The progressive and generalised impairment of function (i.e. doesn’t happen suddenly and it is not specific to one structure or organ).
• Ageing results in a loss of the body’s adaptive response to stress (ageing itself doesn’t make people dependent, but when exposed to pathology the bodies ability to adapt and compensate is severely reduced, leading to dependency).
• Ageing comes with a growing risk of age related diseases (such as the ones mentioned earlier e.g. stroke).
• Ageing is non-focal (i.e. not one structure, all body systems are affected) and symptom free (i.e. no pain, nausea etc.).

Question 19

Describe Fraility

Answer 19

• Frailty is a new concept, it is a physiological syndrome characterised by decreased reserve and diminished resistance to stressors, resulting from cumulative decline across multiple physiological systems and causing vulnerability to adverse outcomes.
• We diagnose physical frailty in clinic by using signs like grip strength, weight loss, fatigue and slow gait etc.
• Frailty is distinct from ageing, the majority of elderly people are NOT frail, but it is the age group where frailty is most common. So you can be young and frail.

Question 20

Describe Strechler’s concepts for true afeing provess

Answer 20

Strehler identified things that constitute a true ageing process and thus may help in differentiating disease and ageing. These concepts therefore mean that in order to be true ageing, the following must be met:
- Universal (changes present in every species).
- Intrinsic (changes are not due to exogenous source).
Progressive (changes continue progressively over time).
-Deleterious (should eventually be harmful to organism).

Question 21

Describe how ageing is universal

Answer 21

The change must be present in all members of a species even though it may affect individuals to a different extent. Examples include collagen cross links in skin and loss of calcium from the bones.

Question 22

Describe how ageing is intrinsic

Answer 22

Must not require an exogenous source to make process happen, e.g. changes in skin of axilla these are changes of endogenous origin, changes in the face would be due to light so this is photo-ageing not true ageing.

Question 23

Describe how ageing is progressive

Answer 23

May occur at different rates but occurs over time, e.g. loss of muscle power, greying of hair.

Question 24

Describe how ageing is deleterious

Answer 24

Most controversial of the concepts, reduced visual acuity is bad, but is greying hair bad?

Question 25

Ageing vs Disease

Answer 25

Disease needs to be identified in elderly as it may respond to treatment of be preventable. Ageing is not reversible but may be compensatable. All changes old people have should not be put down to age, most are not rather they tend to be pathologies that may not have yet been identified.

• Ageing is universal, whereas disease is individual.
• Ageing is always intrinsic changes, whereas disease can be intrinsic or extrinsic.
• Ageing is progressive and cannot be reversed, whereas disease is progressive but can be halted or reversed.
• Ageing is deleterious, disease is deleterious also but may be arrested or cured.

Question 26

Why do we want to postphone disability in old age?

Answer 26

• As the health of the population improves and by aiming to delay the onset of disabling disease until when a person is old enough that when hit by the disabling disease they die, it means that duration of disability before death will be shorter.
  Therefore they would have spent longer free of suffering and dependency.
• Thus this is what we want to do, if a person has a stroke at 60 it is unlikely to kill them but they will be left with a severe disability to live with for many, many years. If we delay the stroke until the person is 90, it will likely kill them or they will die shortly after due to having aged so much thus the period of time they spend in a disabled state will be very short. This would result in the prevention of suffering.

Question 27

How can we postphone disability in old age?

Answer 27

• Health promotion.
• Illness prevention.
• Appropriate use of existing technologies.
• Utilising new technologies.

Question 28

What is primary and secondary prevention of disease?

Answer 28

Primary prevention is trying to reduce the incidence of healthy people getting disease. Secondary prevention aims to prevent the progression of a disease early on by providing treatment at the early stage to delay/halt its progression.

Question 29

Describe secondary prevention and rule of halves

Answer 29

• An example of secondary prevention in UK is 78,000 patients with CHD, only 48% have had their cholesterol measured, of those only half received statins and of those only half had hit the target level of below 5mmol/L of cholesterol.
• This is called the rule of halves and we see it with many diseases, another example being hypertension. It is essentially with regards to these diseases, that of the population the qualifies for lipid lowering treatment only half are actually treated with lipid lowering therapy. Of that that half, only half achieve the treatment goals.

Question 30

What is so dangerous about the drug treatment of older people?

Answer 30

Even more unfortunate than rule of halves is the fact that if we look at the drug treatment of older people, we’ll find that 10% are actually on drugs they are contraindicated on, drugs they shouldn’t be on! In fact 6% of acute admissions of the elderly to hospital are due to them being prescribed inappropriate medication.

Question 31

What are the economics debates surrounding an ageing population?

Answer 31

We have shown that we can indeed increase the length of life in old age and actually increase the amount of healthy life in old age which is the most important thing.

• But is this affordable?
• What are the economics of providing all this healthcare to this population.
• How do we combat ageism, where people may start thinking older people are a massive burden on them (how do we convince them old people are a resource)?

Question 32

Describe economics of ageing population

Answer 32

• The treasury often comes out saying that we can’t keep old people healthy as it is too expensive but if we look at the data we see that prevention of disease in the elderly is cheaper than the cure. Understandably, postponement of onset of illness and thus a longer period of life living independently is cheaper than paying for institutional care for people who develop chronic disability.
• Increases in healthcare expenses in old age can be due to availability of new treatments and appropriate expectation that older people would benefit from them.
• However, age specific need for health care is falling and expenditure on health care always maximal in the last year, irrespective of age of death.
• Interestingly health expenditure on the elderly is actually falling and there are smaller increase in per capita costs for older ages compared with younger age groups.
• But in terms of the non-health benefits of keeping old people healthy there are many. It is important to bear in mind that old age is a social construct as much as it is a biological phenomenon. This means that older people as well as being consumers can also be producers for example volunteering, childcare.

Question 33

How does retirement age change?

Answer 33

There is some desire to pin the median age of compulsory retirement to the median age of death in the population. In other words if the median age of death in the population is 70 and then rises over time to 75 the age of retirement should move up with it.

Question 34

Describe healthy old age

Answer 34

• Not unaffordable.
• Involves postponement of onset of disease.
• Then once disease is present trying to abate it, in order to postpone disability and dependence.
  A healthy old age is not unpleasant, a human rather than an animal death and memorable last words.

Question 35

Life expectancy results that did not follow trend in UK

Answer 35

• Life expectancy at some older ages fell between 2011 and 2012.
• People living in Scotland spend the highest proportion of life in ‘good’ health despite having the lowest life expectancy.