The Aging Tsunami and Aging Successfully Sharon Ostwald, PhD and Jennifer Larson, MSE Division of Geriatrics and Palliative Medicine The University of

The Aging Tsunami and Aging Successfully

Sharon Ostwald, PhD and Jennifer Larson, MSE Division of Geriatrics and Palliative MedicineThe University of Texas Health Science Center at Houston

Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.

Percent Population Aged 65 and Over: 2008


Percent Increase in Population Aged 65 and Over; 2008 to 2040

(selected countries)


The World’s 25 Oldest Countries: 2008(Percent of population aged 65 and over)


Percent Population Aged 65 and Over: 2040


Young Children & Older People as a Percentage of Global Population: 1950 to 2050


Population in Developed and Developing Countries by Age and Sex- 1960





Older Populations Will Increase More Rapidly in Developing than in Developed Countries

Population Aging is Determined by Two Factors: Birth rates Death rates

Population Aging

Singapore, 316%

India, 274%

China, 209%

United States, 107%

United Kingdom, 66%

Japan, 30%


Percent Increase in Population Aged 65 & Over: 2008 to 2040


The Speed of Population Aging in Selected Countries

Life expectancy is a probability estimate of how long individuals can expect to live, given the environmental and disease conditions currently in existence.

Life expectancy is dependent on the interaction of behaviors and exposures that occur over a lifetime with biology and psychology.

Life Expectancy is Increasing

77.477.2

76.576.1

75.873.0

72.572.5

70.470.0

78.1

Costa RicaChile

ArgentinaUruguay

MexicoJamaica

BrazilColombia

PeruGuatemala

United States

Developing CountriesDeveloped Countries


Life Expectancy at Birth for Selected Countries by Region:2008

WOMEN 20 years life expectancy 13.3 in good health 6.7 dependent on others

MEN 17.1 years life expectancy 11.4 in good health 5.6 dependent on others

Age Expectancy at Age 65 in US


Female Advantage in Life Expectancy at Birth for Selected Countries: 2008


Highest National Life Expectancy at Birth: 1840 to 2000


Global Distribution of People Aged 80 and Over(Percent of world total in each country/region- 2008)


Percent Change in the World’s Population: 2005-2040


Survival Curve for U.S. White Females: 1901 and 2003


Proportion of All Deaths Occurring at Age 65 or Overin 29 Countries/Areas: Circa 2001

AGING INDEX is an indicator of theage structure in a country. Higher numbers = more older people China = 31 Northern Africa = 16 Northern America = 65

Disparities Exist Between Urban and Rural People Aged 65 and Over


Major Causes of Death in the European Union by Age:2001


The Increasing Burden of Chronic Noncommunicable Diseases on Low and Middle Income Countries

33.037.0

26.022.5

Cities* Puerto Rice

Poor Health Conditions Good Health Conditions

*Cities include Bridgetown, Barbados; Buenos Aires, Argentina; Havana, Cuba; Mexico City, Mexico; Montevideo, Uruguay; Santiago, Chile; & Sao Paulo, BrazilSource: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.

Chronic Diseases Are Becoming An Increasing Burden

Probability of Being Disabled at Ages 60 and Over Conditional on Early Childhood Health Conditions Latin

American/Caribbean Cities* & in Puerto Rico: Circa 2001

WHO (2002) Active Aging: A Policy Framework. Geneva: World Health Organization.

Important Role of Geriatric Health Professionals is to Maintain Functional Independence

and Prevent Excess Disability


Chronic Disability Decline in the United States: 1982 to 2005


Older Dependency Ratio: 2008

Note: Older dependency ratio is the number of people aged 65 and over per 100 people aged 20 to 64.

Older Dependency Ratio for World Regions:2000, 2020, & 2040



Standard and Alternative Older Dependency Ratios for Five Countries: 2006


Labor Force Participation Rate for Males Aged 55 to 64 in Six Latin American Countries


Labor Force Participation Rate for Females Aged 55 to 64 in Six Latin American Countries


Social Security Coverage in 13 Latin American Countries: Circa 2002

(Percentage of employed population paying contributions)

Regular exercise Healthy diet Avoid tobacco Alcohol in moderation Correct use of medications Screen for disease and treat early Education about caring for chronic illnesses Strengthen social network

Health Promotion Needs to be a Major Focusfor Geriatric Health Professionals

Social, Physical & Economic Environments Affect Healthy Aging


Living Arrangements for People Aged 65 and Over in Japan

(in percent)

Prevention of premature death Delay of the onset of chronic diseases Postponement of disability related to chronic diseases Higher quality of life Greater participation in the life of the family and community in

paid and unpaid roles Reduction in medical care costs, especially hospitalization and

nursing home costs

Reasons for Geriatric Professionals to Focus on Health Promotion and Disease Prevention

Rapid aging of the world’s population, especially in developing countries

Imbalance of people over 65 and under 15 Increasing life expectancy with a rapid increase in numbers

over 80 Geographical inequities between urban and rural dwelling

older people Increasing prevalence of chronic diseases with a burden of

disability Social, physical & economic environments that affect

healthy aging

Warning Signs of the Aging Tsunami

WHO (2002) Active Aging: A Policy Framework. Geneva: World Health Organization.

Global Population Pyramid in 2002 & 2025

What is the difference between a geriatrician and a gerontologist?

Geriatrics- the study of health and disease in later life. The comprehensive health care of older persons. Focuses on medical care and changes that occur with age as a result of disease.

Gerontology- Greek translation literally meaning the study of old men. It is a multidisciplinary field that focuses on the biological, behavioral and social processes individuals go through as they grow from middle age through late life.

Why study aging?

Individual responsibility - Is old age to be lived or endured?Value of healthy behavior - (i.e., smoking, will die anyway) The chance of growing old with disabilities due to poor health is much greater than dying quickly from them.Management of the aged - Your grandparents, parents, older siblings; you may have to be the primary caregiver.Professional careers – With the large number of aging adults, the number of careers working with the elderly will increase dramatically.Enlightened citizens - It is our duty to be knowledgeable. Health care provisions affect everyone. There are critical economic, political and moral issues.

How old is old? The study of health and aging Fact or Fiction? Myths regarding aging and the agedHow long do people live? The biological theories of agingWhat is “normal” aging? The physiology of agingWhat illnesses effect elders most? Common geriatric syndromesCan late life really be enjoyable? The role of behavioral factorsWhat will my quality of life be like? A glimpse at “Successful” Agers

“A prejudice or discrimination against the old because of ignorance,

misconceptions and half-truths. It is an assumption that personal

traits of older individuals and their situations are due to age alone,

not other factors.”

Ferrini &Ferrini, 2000

Ageism

Myth #1: At some point, all elderly people end up living in a nursing home

Myth #2: Dementia is a normal consequence of aging

Myth #3: Depression and suicide is rare in the elderly

Myth #4: Mammograms are no longer necessary after age 70

Myth or Fact?

Myth # 5: If it’s available over-the-counter, it must be safe

Myth # 6: The elderly are immune from domestic violence

Myth # 7: Physical restraints help prevent falls in the elderly

Myth # 8: Caring for the elderly is anything but challenging and rewarding

Myth or Fact?

Normal versus Pathological Aging

Heart & Lungs Brain Kidney & Bladder Body Fat & Bone Sensory Organs

Physiologic Changes Associated with Aging

Heart and Lungs

Heart muscle thickens with age. Maximal oxygen consumption during exercise declines in both

men & women. The body’s ability to extract oxygen from blood diminishes

with age. Arteries tend to stiffen with age. Maximum breathing (vital) capacity may decline by about 40

percent between the ages of 20 and 70.

What is Normal?

The Brain

Brain becomes smaller & lighter with age Reduction of blood to brain Number of neurons decline in parts of the brain Fewer synapses & receptors Grey matter volume shrinkage Pervasive white matter loss

What is Normal?

Kidney and Bladder

Kidneys gradually become less efficient at extracting wastes from the blood.

Bladder capacity declines. Urinary incontinence, which may occur after tissues atrophy, particularly in women, can often be managed through exercise and behavioral techniques.

What is Normal?

Body Fat and Bone Density

Older individuals tend to lose both muscle and body fat.

Fat is redistributed in the body. Bone loss begins to outstrip

replacement around age 35. This loss accelerates in women at

menopause.

What is Normal?

0

10

20

30

40

50

60

70

water fat lean bone

age 29

age 70

AGE

Body Composition Changes with Age

Sensory

Vision lens more transparent; pupils

shrink; optic nerve less efficient Hearing

more difficult to hear higher frequencies with age

Taste & Smell both senses become less

discriminating in old age

What is Normal?

Personality• Personality is extraordinarily stable throughout adulthood. • However, certain individuals facing life-altering circumstances

can and do show signs of personality change during the final years of life.

What is Normal?

• Less time in stage 3 and 4 sleep (deep sleep)

• Increased insomnia• Increased nighttime arousals

Changes in Sleep Associated with Aging

We want a long life, but fear old age.

We have an increased awareness of the blessings of life, yet we fear infirmity, dependence, and death.

The Dichotomy

Section VI: Realities of Longevity

Organ

System

Functions

Age

The Effect of Age on Variability Between Individuals

Arthritis Hypertension Hearing Impairment Heart Disease

Orthopedic Impairment Chronic Sinusitis Diabetes Cataracts Other Visual Impairment

Most Common Chronic Medical Conditions of Older Adults

99105

112120

134

148158

0

20

40

60

80

100

120

140

160

180

1995 2000 2005 2010 2020 2030 2040

Years

Millio

ns

Source: The Robert Wood Johnson Foundation (1996), Chronic Care in America: A 21st Century Challenge

Number of People with Chronic Conditions

610

23

34

43

56

0

10

20

30

40

50

60

70

Per

cent

<18 18-44 45-64 65-74 75-84 85+

Age Groups

Prevalence of chronic illness and likelihood of disability increase with age.

Source: Kaye, H.S., (1997). Disability Watch: The Status of People with Disabilities in the United States. ( Data from the 1994 National Health Interview Survey). Volcano, CA: Volcano Press, Inc.

Percent of Individuals Limited in Activities Because of Chronic Conditions, By Age Group

Multiple coexisting diseases and conditions to manage.

Multisystem geriatric syndromes: e.g., gait instability, dizziness, and weight loss.

How is Health Different for an Older Adult?

Healthy Quality Living: The Role of Exercise and Nutrition

Physiologic Function

Optimal Reserve

Increased margin of reserve with good health care and self care

Age

Usual Reserve

Demand

Physiologic Demand and Reserve

Two thirds of older adults do not exercise regularly.

35% of adults aged sixty-five to seventy-four are completely sedentary.

44% of adults aged seventy-five and older are completely sedentary.

Staying Healthy: Exercise

CDC (2003)

Muscle Wasting

Physical Activity

Morbidity

AGING

Modified from Nair, S. Am J Clin Nutr, 2005.

The Role of Exercise in the Compression of Morbidity

Modified from Nair, S. Am J Clin Nutr, 2005.

Energy Expenditure

Obesity

Insulin Resistance

CVD Type 2 DM Dyslipidemia

Morbidity

Aging

Muscle Wasting

Muscle Weakness

Endurance Capacity

Fatigability

Physical Activity

Two greatest nutritional problems: Malnutrition Obesity

Nutritional needs change in late life Special Considerations Energy Intake

“Tell me what you eat, and I will tell you what you are.”

Jean Anthelme Brillat-Savarin

Staying healthy: Nutrition

Difficulty chewing Upset stomach Shopping & transportation Disease Decreases in olfactory

senses

Difficulty cooking Loss of appetite Medications Finances

Special Considerations

Nutritional Needs: Energy

Food Energy Sources GREAT: fats, oils, avocado, peanut butter GOOD: proteins, meats, custards, Snickers FAIR: cookies, rich breads, fruits POOR: vegetables

Eat with color

Nutritional Needs: Protein

Protein Sources GREAT: Animal products, meats, fish, eggs GOOD: Milk, nuts FAIR: Breads POOR: Fruits, vegetables

Fiber sources: GREAT: Legumes, Beans, Bran GOOD: Fruits and Vegetables,

Whole Grain, Breads and Cereals

FAIR: Cereals (oats) POOR: Chocolate

Nutritional Needs: Fiber

Soluble fiber can be found in such foods as oat bran, barley, nuts, seeds, beans, lentils, fruits (citrus, apples) strawberries and many vegetables

Insoluble fiber is found in foods such as whole wheat and whole grain products, vegetables, and wheat bran

Soluble Fiber Sources

Insoluble Fiber Sources

FLUID Sources GREAT: Beverages, milk, coffee, water GOOD: Fruit juices, soups, ice cream FAIR: Soft drinks, watermelon POOR: Vegetables/fruits

Nutritional Needs: Fluid

Psychological Health

Cognitive function includes Intelligence Language Learning Memory Decision-making Planning

Normal Mental Function in Older Adults

Short-term memory Recall Speed of mental processing Learning involving physical coordination and strength Distractibility

What Changes

Capacity to learn Ability to draw on experience Vocabulary

What Does Not Change

Mental disorders are not a part of normal aging

18-54 yrs 55+ yrsAny anxiety disorder 16.4% 11.4%Any mood disorder 7.1% 4.4%Severe cognitive impairment 1.2% 6.6%Any mental disorder 21.0% 19.8%

http://www.surgeongeneral.gov/library/mentalhealth/home.html

Mental Disorders

Not a normal part of aging Often goes undiagnosed or misdiagnosed Bereavement is not depression

Depression

Signs and symptoms of depression

Tired all the time Sad most of the time Guilty Worthless Unable to think clearly or make decisions No enjoyment in what used to be fun Trouble sleeping Weight gain or loss – hungry or loss of appetite

Depression

Signs and Symptoms —

Symptoms usually occur suddenly or appear with in a short period of time

Close family members or care givers may notice “something just isn’t right” as first symptom

Symptoms vary throughout the day/night

Delirium

Sudden or short time onset

Variation in status throughout the day

Usually has an organic root Treatable

Gradual onset over time Mental status usually

constant No organic causality No curative procedures

Delirium Dementia

Dementia comes from the Latin root for mind, “mens” and the prefix de or out. It means of be literally beside oneself or out of one’s mind.

It results from the death of, or permanent damage of brain cells.

Dementia Is not a Normal Part of Aging

Everyone experiences forgetting Many people exaggerate the importance of forgetting Many also ignore the signs of memory loss and fail to

recognize developing illness

Forgetting vs. Dementia

Education Physical activity and lung function Strong social support High self-efficacy

MacArthur Foundation Study, Rowe & Kahn 1999

We can grow and change throughout life

Old dogs can and do learn new tricks!

Predictors of Strong Mental Function

—Oh, let her drink, she has no other pleasures left in life.

—None of my older clients drink. Seniors just don't drink.

—It's none of my business what my neighbor, Ned, drinks. He isn't hurting anyone.

Substance Abuse and Elders

Memory trouble after having a drink or taking medicine

Loss of coordination (walking unsteadily, frequent falls)

Changes in sleeping habits Unexplained bruises

Difficulty staying in touch with family or friends

Wanting to stay alone a lot of the time

A decline in Grooming Housekeeping & routine chores Eating habits

Signals that may indicate a substance abuse problem:

Trembling hands Smoke burns on clothing and

furniture Increased accidents

Declining health Slurred speech Smell of alcohol on breath

Signals that may indicate a substance abuse problem:

A 70 year oldwho drinks…

Is Equivalent to….

Because Metabolism Slows in the Aging Body:

…a 21 year old who drinks…

A Sobering Fact

NyQuil contains an active ingredient of 25% alcohol, the same as 50 proof booze.

Alcohol comes in many forms

+ = Potential Danger

Mixing Alcohol with Drugs

Why are older adults at risk to abuse substances and/or medications?

Functional Limitations Loneliness Death of Partner or Spouse Retirement Depression Feeling like a Burden to Others Low Self Esteem Physical Pain Changes in Living Situation

Risk Factors

History of Substance Abuse Co-occurring Psychiatric Disorders Decreased Social Support Care Giving Role Custody of Grandchildren Male Living in a Health Care Setting

Blow, 2004

Other Risk Factors

“Age is not a particularly interesting subject. Anyone can get old.

All you have to do is live long enough.”

—Groucho Marx (1890-1977)

Successful Aging

Madame Jeanne Calment-- She is the believed to have lived longer than any other person in recorded history.She was 14 when the Eiffel tower was completed.She sold painting supplies to Vincent Van GoughShe outlived her husband, daughter and only grandson

Centenarians

They were born in 1912 or earlier.

Resiliency Independently functioning In good health at least to

the age of ninety. Few centenarians are obese Substantial smoking history

is rare

Source: Perls T., Silver M., Lauerman J, 1998

Centenarian Characteristics

(30%) had no significant changes in their thinking abilities

Women who have a history of bearing children after the age of 35 years and even 40 years

50% of centenarians have first-degree relatives and/or grandparents who also achieve very old age, and many have exceptionally old siblings

Exceptional longevity runs strongly in families

Photo Credit: Melanie Stetson Freeman

Source: Perls T., Silver M., Lauerman J, 1998

Beating the Odds

This is a splendid trend in the United States Aging is Complex Exercise, Exercise, Exercise You are what you eat Achievements of centenarians demonstrate that it is

possible to not only enjoy life but it relish it.

To Summarize…

Baltes, P.B., Smith, J. Staudinger, U.R.., (1992). U.M. Wisdom and successful Aging. Ferrini, A. F., & Ferrini, R. L. (2000). Health in the later years (3rd ed.). Boston: McGraw Hill. Hetel, L. and Smith , A. U.S. (Oct, 2001). Department of Commerce Economics and Statistics

Administration U.S. CENSUS BUREAU The 65 Years and Over Population: 2000Census 2000 Brief Hobbs, Frank and Nicole Stoops, U.S. Census Bureau, Census 2000 Special Reports, Series

CENSR-4, Demographic Trends in the 20th Century, U.S. Government Printing Office, Washington, DC, 2002.

National Center for Health Statistics Health, United States, 2005 With Chartbook on Trends in the Health of Americans Hyattsville, Maryland: 2005

Perls TT. The Oldest Old. The Scientific American, 1995;272:70-75. Perls T. Centenarians prove the compression of morbidity hypothesis, but what about the rest

of us who are genetically less fortunate? Medical Hypothesis 1997;49:405-407 Perls T, Alpert L, Wager CG, Vijg J, Kruglyak L. Siblings of centenarians live longer. Lancet

1998;351:1560 Perls TT, Bochen K, Freeman M, Alpert L, Silver MH. The New England Centenarian Study:

validity of reported age and prevalence of centenarians in an eight town sample. Age and Ageing (in press).

Perls T., Silver M., Lauerman J. Living to 100: Lessons in Living to Your Maximum Potential at Any Age, March, 1998

References

Baltes, P.B., Smith, J. Staudinger, U.R.., (1992). U.M. Wisdom and successful Aging. Bengtson, V.L. & Scaie, K.W. (1999). Handbook of Theories of Aging. New York: Springer. Centers for Disease Control and Prevention (2001). Healthy Aging: Preventing Disease and

Improving Quality of Life Among Older Americans At A Glance. Centers for Disease Control and Prevention. (2003). Promoting active lifestyles among

older adults. Atlanta: CDC, National Center for Chronic Disease Prevention and Health Promotion. Nutrition and Physical Activity

Ferrini, A. F., & Ferrini, R. L. (2000). Health in the later years (3rd ed.). Boston: McGraw Hill. Gavrilova, N.A. and Gavrilova, L.A. (2002). Evolution Of Aging. In Encyclopedia of Aging.

Editor in chief: Ekerdt, D.J. (1st ed.). New York: Macmillan References USA. P458-467. Geriatric Review Syllabus, American Geriatric Society. 5th edition. 2002-2004 Living to 100: Lessons in Living To Your Maximum Potential at Any Age. TT. Perls,

MH. Silver, 1st edition, Basic Books, New York, NY, 1999

References

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment www.samhsa.gov

Hitt R, Young-Xu Y, Perls T. Centenarians: The older you get, the healthier you’ve been. Lancet, 1999;354 (9179):652

Silver, M.H., Jilinskaia, E., Perls, T.T. Cognitive functional status of age-confirmed centenarians in a population-based study. Journal of Gerontology, Psychol Sci 2001;56B:P134-P140.

Silver MH, Newell K, Brady C, Hedley-Whyte ET, Perls TT. Distinguishing between neurodegenerative disease and disease-free aging: correlating neuropsychological evaluations and neuropathological studies in centenarians. Psychosomatic Medicine 2002;64:493-501.

Perls T, Alpert L, Fretts R. Middle aged mothers live longer. Nature 1997;389:133. Perls T, Kunkel L, Puca A. The Genetics of Exceptional Human Longevity. J Am Geriatr Soc 2002;50:359-

368. Terry DF, Wilcox M, McCormick MA, Lawler E, Perls TT. Cardiovascular Advantages Among the Offspring

of Centenarians. J Gerontol Med Sci 2004;59:M385-389

References

http://www.samhsa.gov/

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Documents

The Aging Tsunami and Aging Successfully Sharon Ostwald, PhD and Jennifer Larson, MSE Division of Geriatrics and Palliative Medicine The University of