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6

The Health of Aging Populations

As the length of life and number and proportion of older persons increase in most industrialized and many developing nations, a central question is whether this population aging will be accompanied by sustained or improved health, an improving quality of life, and sufficient social and economic resources. The answer to this question lies partly in the ability of families and communities, as well as modern social, political, economic, and health service delivery systems, to provide optimal support to older persons. However, while all modern societies are committed to providing health and social services to their citizens, these systems are always in flux, guided by diverse and evolving national and regional policy formulations. Health, social, and economic policies for older persons vary substantially among industrialized nations. Analysis of these variations through appropriate cross-national research may assist greatly in the formulation of effective policies aimed at enhancing the health status, as well as the social and economic well-being, of elderly populations.

Among the most important policy concerns relevant to health and longevity are the future fiscal viability of pension, health, and social insurance systems, both public and private, and the implications of these systems for savings and investment rates (see Chapter 3). How long people continue working, paying taxes, and saving will feature prominently in the consequences of population aging. Many people already work less than half a lifetime because of extended periods of schooling and training in early life, earlier retirement, and enhanced longevity, pos



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Page 200 6 The Health of Aging Populations As the length of life and number and proportion of older persons increase in most industrialized and many developing nations, a central question is whether this population aging will be accompanied by sustained or improved health, an improving quality of life, and sufficient social and economic resources. The answer to this question lies partly in the ability of families and communities, as well as modern social, political, economic, and health service delivery systems, to provide optimal support to older persons. However, while all modern societies are committed to providing health and social services to their citizens, these systems are always in flux, guided by diverse and evolving national and regional policy formulations. Health, social, and economic policies for older persons vary substantially among industrialized nations. Analysis of these variations through appropriate cross-national research may assist greatly in the formulation of effective policies aimed at enhancing the health status, as well as the social and economic well-being, of elderly populations. Among the most important policy concerns relevant to health and longevity are the future fiscal viability of pension, health, and social insurance systems, both public and private, and the implications of these systems for savings and investment rates (see Chapter 3). How long people continue working, paying taxes, and saving will feature prominently in the consequences of population aging. Many people already work less than half a lifetime because of extended periods of schooling and training in early life, earlier retirement, and enhanced longevity, pos

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Page 201ing a challenge to the sustainability of systems designed to support older persons. If the trend toward increased longevity continues without a parallel extension in working life, the stress on these systems could be even greater. As discussed elsewhere in this volume, labor force participation, investment and saving behavior, and provision of health services are complex phenomena that are interrelated at both the individual and societal levels (Quinn and Burkhauser, 1994; Smith, 1999). For example, incentives provided by government and employers play important roles in determining labor force participation. Reducing the implicit tax on continuing work beyond the normal age of retirement and reducing the costs of hiring (and possibly retraining) older workers have the potential to encourage longer working lives (see Chapter 3). Yet in designing such incentives, policy makers need to know how long they can reasonably expect people to keep working. Just how physically and mentally capable are older people? What is the trajectory of health and function as people age? Can their productivity be maintained and enhanced at older ages, and at what cost? Does the type of productivity and engagement change with age? How can health care services be provided in such a manner as to maintain optimal health and function? Most basically, policy makers must make difficult decisions about the allocation of limited resources to preserving and improving health. How is good health achieved at a reasonable cost? Should more resources be directed toward behavioral change and other health promotion and disease prevention programs, including health enhancement in early life, or should more be dedicated to the treatment of patients with advanced diseases? How much should be invested in the development of new health care technologies, service delivery enhancements, and professional training? A focus on national-level health status and its temporal trajectory is critical for several reasons. Health status is one of the most important indicators of well-being, and it predicts a large proportion of societal expenditures on health and social services for the elderly. Health status is also reciprocally affected by social and political policies and programs. Further, health status is malleable through high-quality health promotion and disease prevention programs, as well as effective medical services. National programs and policies that may appear to be devoted to health and health services for older persons often have important implications for and complex interactions with other economic sectors. Table 6-1 provides examples. This chapter is devoted to the centrality of health status and change in informing health, social, and economic policy formulation. We first outline the key issues to be addressed by research on the health status of the elderly. We then present a conceptual model of the determinants of health

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Page 202 TABLE 6-1 Relationship of Public-Sector Programs and Policies to Health Services for Older Persons Sector Relation to the Provision of Health Services for Older Persons Housing Provision of suitable-quality housing, both in the community and within institutions, to sustain health. Reconstruction of housing to accommodate disabled older persons. Public Health Creation of prevention and health promotion programs that affect older persons. Education Training of all levels of health professionals and ancillary workers in special skills related to the problems of older persons. Manufacturing Provision of increasingly complex mechanical and electronic devices for the treatment and rehabilitation of older persons. Urban Design Location of housing for older persons so as to optimize access to health, nutritional, recreational, and social services. Opportunities for generativity and engagement by older persons. Transportation Provision of public transportation and facilitation of personal transport to enhance mobility and its social outcomes. status to provide a framework for the ensuing discussion. Next we review the basic measures of health status, presenting selected examples of basic international patterns and trends. This is followed by a brief look at the characteristics of national health systems. Data sources for cross-national research on the health status of the elderly are then considered, as well as the pitfalls and strengths of such research. Finally, we offer recommendations for strengthening research in this domain. KEY ISSUES National health policy decisions with respect to older persons are becoming increasingly complex for several reasons. As noted in Chapter 2, the numbers of the elderly and oldest old have increased dramatically in most industrialized nations. Countries that already have a substantial elderly population face increasing proportions in the coming decades, with all the accompanying social and economic demands. In addition, nations must prepare for the growing numbers of disabled younger persons who are now surviving to older ages because of improved health care. Policy decisions related to the provision of health services for the elderly have become complex from technological, fiscal, and ethical perspectives. Also, as noted above, health services are intimately tied to the

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Page 203provision of social services and economic support, including housing, nutrition, institutional care, and related activities. Preventive and rehabilitative services have added not only to the costs of care, but also to the potential for improved function, mobility, and social engagement. Health care for older persons is thus different from that provided to other age groups in several respects: greater resource demands; the intertwining of professional health services with social services; the frequent occurrence of important ethical conundrums; a higher prevalence of physical and mental disabilities; and, perhaps not as obvious in policy formulation, less scientific evidence for use in determining effective preventive and medical interventions. In this context, the following issues merit special emphasis. 1. What is the importance of health status for retirement preferences and patterns? How are health status and retirement age related? Have recent trends in reduced age-specific rates of disability translated into increased and longer labor force participation? 2. What impact does health have on families? How has the changing health status of older persons altered the productivity and economic status of families and households? How do families make economic provisions to care for unhealthy parents, and what are the effects on labor force participation? How does the changing health status of older persons, in particular the onset of infirmity, affect the capacity to be a caregiver for an ill or disabled spouse or other family member? What economic provisions do families make for long-term care of older persons, whether in the community or within chronic care institutions? How do these provisions dovetail with public and voluntary assistance and care programs? 3. How important is health to wealth and economic status? What evidence is there that health status directly affects individual wealth, assets, and economic productivity? What is the role of the health care system in the prevention, treatment, and rehabilitation of illnesses, and how does this work to maintain personal economic status? How do health shocks affect future economic status and personal and family wealth in accordance with underlying socioeconomic status? 4. How do economic status and educational levels affect the health of individuals across the life course? By what mechanisms and to what degree does economic status lead to better health status? At what ages do the effects of economic status have the greatest impact on health status? How does the distribution of wealth, income, and economic productivity within a nation serve to preserve, enhance, or depress health status independently of individual and family socioeconomic characteristics? How does the provision of health services affect long-term health outcomes?

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Page 204 The formulation of health service delivery policies and systems for older persons requires a continuing flow of information, including quantitative data on the above and other issues related to population health status and directions, as well as the resources expended in the health care system. In particular, the ability to draw on international experiences in health and health care can greatly enhance the potential of such policies and systems. Moreover, cross-national research can enable the creation of evaluative mechanisms that would often not be feasible in any one country because of the homogeneity of medical practices and administrative cultures. Such research can also help address the above issues by providing a range of observations of change over time and, perhaps, early indications of emerging health trends. And comparative work can improve our understanding of how particular diseases and conditions are expressed as disability in a variety of work, social, policy, and living environments, thus providing insight into which adjustments in those environments may be most cost-effective. CONCEPTUAL MODEL OF THE DETERMINANTS OF HEALTH STATUS As noted above, the determinants of health are complex and comprise multiple policy domains. One basic but important conceptual model that can be used to illustrate the breadth of these determinants is shown in Figure 6-1. This construct represents the health of all demographic groups in a society, although the emphasis here is on the health of older persons. The determinants are presented in a set of concentric circles, with the community population at the center. Outermost, and often difficult to quantify, are the general social, economic, cultural, and environmental (physical-chemical) conditions that have important long-term health effects. The next circle contains society's basic social, health, and economic institutions, which sustain or impair a healthy existence. The next circle emphasizes the critical role of social and community interactions and exchanges, whereby individuals make their collective decisions. The circle next to the core highlights the importance of individual behavioral choices (e.g., cigarette smoking, risk-taking behaviors) in the determination of health status. One drawback of a two-dimensional representation is the absence of time. Other models highlight more fully such issues as the role of infancy and childhood and the environment on health outcomes in later life. Nevertheless, the model in Figure 6-1 is useful in many respects. For example, it highlights the intimate interaction between the economic and employment environments and health discussed above (see Annex 6-1 for a specific policy example). As a corollary, the model places the role of

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Page 205 ~ enlarge ~ FIGURE 6-1 A conceptual framework for determinants of health status. SOURCE: Dahlgren and Whitehead (1991). Reprinted with permission. professional health services in an important but not dominant role among the institutional forces that mediate health status. The model quite appropriately also emphasizes the role of basic public health determinants, such as the physiochemical environment and the provision of safe and adequate food and sanitary services. In addition, the model reflects an appreciation of individual responsibility for health status, both in the selection of behaviors and in the collective decisions made by individuals. Finally, the model shows that policy interventions in one institution or domain may or may not have the desired effect because of the multiple sectors involved. Thus, policy outcomes may be enhanced only through multiple intervention points; conversely, interventions in one sector may have unpredicted outcomes in others. MEASURING HEALTH STATUS During the 20th century there were great changes in patterns of population health status and survivorship in both the industrialized and developing worlds. Among industrialized nations, the early part of the century saw the greatest improvement in mortality among infants, children, and pregnant women. These improvements continue to the present time.

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Page 206Later in the century, however, substantial reductions in mortality among older adults occurred in nearly all developed countries as a result of declines in deaths primarily from heart disease, but also from other major causes. Moreover, there has been a shift among older persons to surviving, and even thriving, with prevalent chronic illnesses such as various heart conditions and arthritis. Population surveys have also indicated that the age-specific prevalence of physical disability has declined in some countries (Jacobzone et al., 1998). Developing countries have lagged behind their more industrialized counterparts in terms of mortality decline and the overall epidemiological transition from a preponderance of infectious and parasitic diseases to one of chronic and degenerative diseases. As noted in Chapter 2, however, the overall gap between more and less developed countries has narrowed considerably. The last third of the 20th century also saw a significant expansion in the ways population health status can be characterized, particularly by supplementing mortality data with emerging measures of personal clinical signs and symptoms, diseases and conditions, and functional disabilities. The potential availability of more specific types of health data has greatly increased the set of quantitative tools for health policy and planning, particularly as regards older persons, whose rates of disease and disability are higher than those of other demographic groups. Identifying the trajectories of important health measures is central to forecasting health care needs and generating policies for older persons. Yet, defining “health” and the health status of individuals is not an easy matter. Even under optimal circumstances and without resource constraints, it is challenging to fully assess the physiological state of individuals, to understand the nature and determinants of personal or social behavior, and to predict the range and intensity of the outcomes of environmental challenges (e.g., from the workplace or elsewhere in the community). Nor is it easy to predict what effects various medical services or interventions will have on individuals. With the newer and more precise measures of health status now available, however, much can be accomplished. Health status can be characterized from varying perspectives depending on the goals and uses of the information. For example, personal health can be assessed by subjective self-report, more objective physiological and biochemical measurement, or standardized indicators of diseases and disabilities present. In fact, all of these perspectives are important and complementary. Further, health status may be characterized according to major domains such as physical health (e.g., the function of the heart and lungs), mental health (e.g., the presence of depressed mood), and physical and social functional health (e.g., the ability to climb stairs or work at a particular occupation). Health may also be thought of in its

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Page 207temporal, longitudinal dimensions. For example, how is health status changing, or did an individual live or die? Changes in health status may be reflected as well in the intensity of health care resource utilization, such as pharmaceutical, institutional, or rehabilitative care. This temporal perspective is critical and leads to an emphasis on longitudinal, cohort data sources. While there are no wholly standardized approaches to characterizing health status, there are several meaningful ways in which individual health is assessed and described. These data may not be available from many areas in a computerized or otherwise readily retrievable format, but can usually be obtained by abstracting clinical records or surveying patients, health professionals, administrators, and/or populations within a geographic area. Annex 6-2 describes in detail the health status measures most commonly used for survey and administrative data collection in the categories of clinical signs, symptoms, and syndromes; morbidity (i.e., discretely defined medical conditions); self-rated health; functional status and disability; physiological and pathological measures; mortality data and derived measures; and aging and mental illness. CHARACTERIZING HEALTH CARE SYSTEMS As noted in the model of health determinants discussed above, both personal behaviors and many public health measures bear on health status. Health promotional activities aimed at older persons may or may not involve direct contact with the formal health care system; examples of the latter activities include education programs and provision of good preventive nutrition, safe transportation to enhance mobility, and assurance of adequate housing. Thus the efficacy and net impact of many basic public health programs, with their incumbent costs, can be assessed only by using population survey information in addition to the data derived from clinical sources. Moreover, decreased use of toxic substances and increased exercise and structured leisure activities, and even paid and unpaid work, are associated with enhanced function, decreased occurrence of physical and emotional illness, and higher quality of life among older adults. Effective national and regional policies for health promotion among older persons therefore require that important deficits in these areas be identified. Population surveys may be the only means of acquiring accurate information on such issues as cigarette and alcohol consumption, perceived elder abuse, the availability and use of exercise and other leisure and recreational programs, and levels of mobility and social interaction. Also central to national health policy for older persons is the ability to provide community-based preventive services, generally delivered in the

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Page 208context of primary care. The presence of such services has been used in the United States and elsewhere as a benchmark of the general quality of care (Bloom et al., 2000). Included are such activities as provision of appropriate immunizations and screening for early and treatable conditions, such as colon and breast cancer, high blood cholesterol, high blood pressure, and depression. Explicit geriatric screening and management programs are recommended for falls, early cognitive impairment, physical disability, and inappropriate use of medication. Provision of these services leads to a higher quality of life and helps maintain or enhance function in the elderly. Even in the presence of overt illness, a systematic approach to the complex functional and medical problems of older persons, often referred to as geriatric assessment, can help maintain useful function. Some preventive activities may be recommended by health professionals but executed by others. An important example is environmental screening of residences to prevent falls and enhance mobility, such as by providing ramps rather than stairs and handrails at appropriate locations. Coordination of public and clinical policies relevant to health promotion and disease prevention among the various sectors involved is essential if these policies are to have the desired positive effects on the health status of older persons. International comparisons of preventive service delivery programs may help identify those with the most desired outcomes and indicate which individual programs may be applied usefully in many nations. For example, standardized specific blood cholesterol levels predict very different heart disease rates in different countries (Kromhout, 1999), possibly leading to different priorities for prevention programs. Again, the most effective means of obtaining the information necessary for such cross-national research is representative household surveys of older persons. All national health systems are extremely complex in structure, function, and administration. This complexity and diversity makes their classification difficult, a difficulty that is exacerbated by the fact that all health systems are constantly evolving in accordance with ongoing political and economic forces. This complexity also makes policy initiation and assessment, regardless of how broadly construed, extremely challenging. At the same time, however, most modern health care systems, particularly within developed countries, face common forces and challenges: rapid and costly technological innovation; the increasing infusion of business practices to contain the costs of delivering care; growing consumer demands for care that is uniformly distributed geographically and socioeconomically; the provision of effective quality assurance programs; the need to identify funding for the breadth of health services demanded by communities, to balance the needs of primary and specialty care programs,

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Page 209and to respond to complementary and alternative medical practices; and, in many cases, the decentralization of authority in previously monolithic systems. A variety of classification systems have been proposed and applied in the comparative study of health systems, but no generally accepted taxonomy has emerged. A broad range of health system typologies is reviewed by Mechanic and Rochefort (1996); these typologies variously emphasize such dimensions as political organization and control, economics and fiscal management, population demands and utilization, the role of market forces, universality of coverage, cultural influences on professional practice, the degree of professional dominance, and adherence to various social movements and principles. Because of the higher rates of morbidity and disability that occur with increasing age, older people make substantial use of formal health services. Such services consume an enormous amount of resources, and a central policy issue for all countries is how to expend available resources in a way that will yield the best health outcomes feasible by the most efficient means. Again, cross-national comparative research is one important avenue for addressing this issue by examining international variations in organization, financing, delivery, and evaluation of elder health services. To illustrate, Figure 6-2 highlights the international variation in per capita nursing home utilization across 20 countries, and Figure 6-3 shows variation in spending for health services across the G7 nations. One of the most important macroanalytical policy questions is the relationship of health system organization, administration, and financing to health status and outcomes. Little work has been done in this area, but cross-national analyses offer the best approach to understanding how major components, such as the level of investment in new technology, affect health outcomes. There are many units of analysis for characterizing health systems, depending on the issues being addressed. Table 6-2 lists examples of analytic variables commonly used to describe health systems at either the national or regional level. These variables involve a substantial amount of conceptual complexity, and several issues should be considered when using them. As noted earlier, health status is determined only in part by the units of health service delivered. Health systems offer numerous preventive care and public health services in ways that are difficult to quantify. In all age groups, but particularly among older persons, there is a substantial amount of self-care, as well as varying levels of alternative and complementary health care practices, including self-medication with herbs and the use of alternative practitioners, that may have an impact on health outcomes. Further, both preventive and clinical care may impact health outcomes and quality of life only in future decades, and this latency

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Page 210 ~ enlarge ~ FIGURE 6-2 Percent of elderly population in residential care: Circa 1991. SOURCE: Organization for Economic Co-Operation and Development (1996). ~ enlarge ~ FIGURE 6-3 Medical spending in the G7 countries: 1990. SOURCE: Cutler (1999).

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Page 239 ANNEX TABLE 6-1 Options for Comparing Mortality Rates Type of Data Approaches Data Needs Measures and Methods Collective Cross-sectional Deaths by age, gender, and calendar year; population at risk Deaths by cause and year, population at risk, and competing events Rates by age, age-standardized cancer ratio, proportional mortality ratio, standardized mortality rates, probability, life table, life table by cause Longitudinal (by cohort) Deaths by age and year of birth, population at risk Rates by age and cohort, probability and life tables by cohort Individual Longitudinal biographies Death records, data on individual survival, linkage data Survival analyses, Kaplan-Meier models, Cox models, etc. Follow-up data Analysis of life histories, biographies (hazard models) through age 99 and as a single group for those aged 100 and over, although most countries have recently made efforts to publish data for individual ages for the latter segment of the population as well. Kannisto (1994) has constructed a database that comprises a mortality series for persons aged 80 and over for a set of industrialized countries that publish such data annually. The data have been subjected to a number of tests of their plausibility and internal consistency. On the basis of these tests, countries have been classified into four quality categories: those with good-quality data (Czechoslovakia, Denmark, England and Wales, Finland, France, Germany, Hungary, Iceland, Italy, Japan, Luxembourg, the Netherlands, Norway, Scotland, Sweden, and Switzerland); those with acceptable-quality data (Australia, New Zealand-non Maori, and Portugal); those with acceptable data under certain conditions (Estonia, Ireland, Latvia, Poland, and Spain); and those whose data should be used with caution (Canada, New Zealand-Maori, and the United States).

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Page 240The database was constructed from data on deaths arranged into cohort survival histories. Once mortality measures by age are available, life tables can be constructed and analyses of elderly survival performed. Amalgamation of data on life expectancy, diseases, and disabilities will make it possible to derive measures that incorporate healthy and disabled life expectancy. Quality of Vital Records It is well known that mortality estimates at old ages may be hampered by various problems (Coale and Kisker, 1986, 1990; Kannisto, 1994, 1996; Thatcher et al., 1998). For example, age misreporting is usually found both in death registration and in censuses and other surveys. The most common manifestations of the data quality problem are implausible age-specific mortality fluctuations and abnormally low mortality estimates at older ages (Preston et al., 1997). Two common problems are the tendency to report age in round numbers (the nearest 5 or 0) and age exaggeration among the oldest old. Other problems in the quality of data on occupation, education, and surviving kin have been described. Causes of Death While causes of death have been registered throughout the industrialized world dating back to the beginning of the 20th century, it is only recently that certain quality changes have been introduced in standardized registration procedures. Death certificates are the responsibility of medical doctors, according to WHO guidelines. The certificate is divided into two sections. The first lists the diseases leading to death, and the second details other conditions, so-called associated causes, which may have contributed to the death event. In the first section, the doctor must list the direct cause of death, known as the immediate cause; followed by the pathology immediately preceding this, or the intermediate cause; and lastly the originating or initial or main cause. A death certificate may contain indications regarding more than one cause, thus making it possible to trace back the whole process leading to death, at least in theory. Death is taken to be the end result of a chain of diseases, whose advent and development may be linked to other preexisting diseases. Published mortality analyses tend to emphasize the main cause, which, particularly when dealing with the elderly, is often difficult to identify. To shape policies targeted at the prevention and treatment of selected diseases, it would be highly useful to have available all the information contained in the death certificate. Having these data is crucial to identifying certain diseases, such as diabetes, that may not appear among the principal causes

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Page 241on the certificate but play a leading role in mortality levels. Indicators of mortality by multiple causes (Nam, 1990) may also be defined if the necessary data are available. It should be noted that there are several sources of error in certification of the causes of death. Physician certifiers may make errors in diagnosis, or there may be inadequate clinical information available. Sometimes, ill-defined descriptors of older persons, such as “senility” or “heart attack,” are entered when no specific clinical information is available. There may also be errors in coding of reported death events by vital registrars. However, quality control in this area is increasing, and this source of error is diminishing. Individual Data and Mortality Differentials The study of mortality differentials has provided a number of explanatory hypotheses and offered the possibility of moving from description of the differences observed to identification of their root causes. Many studies have involved analyzing mortality differences according to socioeconomic status, usually encompassing cross-sectional analyses of older populations (e.g., Mare, 1990; Martelin, 1995). However, the impact of social status may be cumulative throughout the life course. Mortality at old age can depend on living conditions during childhood, adolescence, and adulthood, and thus a longitudinal approach may be valuable. Such an approach involves a more complete overview of the entire process as it occurred during the individual's lifetime (Sahli et al., 1995). Death is considered the final event in a life history composed of a succession of various passages spanning a variety of situations and experiences, gradually culminating in an illness (or accident) and then death (Caselli et al., 1987). Data from health, census, and other sources are linked to derive a lifetime picture of social, economic, medical, and other influences. Cross-National Mortality Contrasts Cross-national comparisons of the mortality of older persons can be instructive. Annex Figure 6-4 shows the probabilities of death for men and women aged 80-99 (the oldest old) in five countries—Sweden, Japan, France, Italy, and Australia—during the last half of the 20th century. In addition to the clear decline over the study interval and the almost universal finding of higher mortality probabilities in men than in women, three observations stand out. One is that gains in survivorship are happening even among the oldest segments of the world's elders. Another is that the relative survivorship gains among women have been greater than those among men. Finally, the dispersion of the gains is greater among

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Page 242 ~ enlarge ~ ANNEX FIGURE 6-4 Probability of death at ages 80-99 in five countries: 1952 to 1994. SOURCE: Prepared by the panel based on data from the Max Planck Institute for Demographic Research, Rostock, Germany.

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Page 243 women than among men. The latter two findings should prompt cross-national research into national differences in changing survivorship. Aging and Mental Illness Psychiatric disorders are significant contributors to physical, social, and emotional dysfunction and disability among the elderly, but it is only recently that such problems have drawn significant attention (Wells et al., 1989). All of the important mental conditions of young adulthood and middle age, including depression, mania, schizophrenia, personality disorders, addictions (including alcoholism), phobias, anxiety, and panic disorders, occur in older persons. Moreover, with increased survivorship and longevity among older persons, dementia and Alzheimer's disease have become quite common. The dementing illnesses themselves are often accompanied by additional psychiatric symptoms that require medical treatment. These symptoms are among the most important reasons for institutionalization or community-based long-term care. Various approaches to institutionalization of elders with mental and physical disability were discussed earlier in Box 6-1. A particularly important and common condition of older persons is depression, a disorder that illustrates the difficulties of determining the population burden and health service needs associated with psychiatric illness. Early epidemiological studies of mental illness indicated lower rates of depression among the elderly than among younger population subgroups, but there is much reason to doubt the validity of such estimates. Older people are more reluctant to admit to depressive symptoms than younger persons and are more likely to express their symptoms in somatic terms. Most of the instruments measuring depression in community settings, however, depend substantially on psychological items that elderly persons are less likely to endorse. Prevalence estimates of depression among the elderly can vary as much as 15-fold depending on the definitions used, populations studied, and research approaches (Gurland et al., 1996). An important difficulty in assessing and treating depression among older persons involves their different life circumstances as compared with younger persons. Elders have more physical illness and take more medications, making it more difficult to differentiate depression from other health states. In addition, older persons who suffer decrements in function and who lose spouses and friends experience depressive symptoms that they and health professionals commonly view as part of the aging process itself. Researchers often have difficulty differentiating reactions to the losses of normal aging from depression per se. Depression among the elderly is common in primary care practice, and doctors caring for this population tend to be skeptical of the psychologically

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Page 244oriented epidemiological instruments. New efforts are being made to derive valid measures of depression in elderly populations and to provide more appropriate treatment (Unutzer et al., 1999). Depression exemplifies the problems of determining the care burden of mental illness among older persons. Among elders, mental conditions are often associated with important medical illnesses, but receive lower priority in clinical diagnosis and treatment. In addition, as noted, many mental problems are mistakenly considered to be part of normal aging and not given appropriate attention, particularly in the primary care setting. Also, administrative and clinical records related to treating mental illness, while sometimes in the mainstream of medical systems, are often kept in separate locations with separate access restrictions. Thus, population rates of mental illness may not be attainable from clinical or administrative records, and the use of population surveys for this purpose should be considered. It is ironic that surveying for mental illness requires a substantial participant burden, as the instruments are often long and detailed. This constraint has limited the number of community- and population-based assessments available for planning and evaluation. Thus it is not surprising that even among industrialized countries, clinical services for the prevention and treatment of mental illness are often lacking because of their costs and competing clinical priorities. There are also substantial differences among cultures in the behavioral manifestations and lay and professional interpretations of mental symptoms and conditions. This variation makes international comparisons particularly hazardous, and necessitates extreme care and documentation of clinical events when conducting such research studies. REFERENCES Acheson, D. 1998 Independent Inquiry into Inequalities in Health Report . London : The Stationery Office . Agree, E.M., and G.C. Myers 1998 Aging Research in Europe: Demographic, Social and Behavioral Aspects . Geneva : United Nations Economic Commission for Europe . Andrews, G. 1999 A Research Agenda on Ageing for the Twenty-first Century. Draft report of an Expert Consultative Meeting, 1-3 February, Vienna . Bartley, M., and M. Marmot 2000 Social class and power relations at the workplace. In The Workplace and Cardiovascular Disease, Occupational Medicine: State of the Art Reviews 15(1), P.L. Schnall, K. Belkic, P. Landsbergis, and D. Baker, eds. Philadelphia : Hanley and Belfus . Bartley, M., A. Sacker, D. Firth, and R. Fitzpatrick 1999 Understanding social variation in cardiovascular risk factors in women and men: The advantage of theoretically based measures. Social Science and Medicine 49: 831-845 .

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