description and analysis
By the year 2025 about one third of Europe’s population
will be aged 60 or more. Portugal is the Member State with the highest male and
female mortality rate over the age of 65, while France is the country with the
lowest mortality rate (European Commission, 2003). The ‘elderly index’
(obtained by dividing the population aged 65 or more by the population aged
0-14 years [per 100]) shows that Italy is the ‘oldest’ EU country, followed by
Germany and Greece. There are more women than men at the older ages, especially
aged 85 plus. This elderly population will continue to increase; while the
proportion of adults aged 15–64 is expected to decline and the proportion
under-15 to remain stable. This change in demography partially explains the
growing burden of chronic disease (European Commission, 2003). The most common
causes of death in women over 65, according to prevalence, are malignant
neoplasms, diseases of the circulatory and respiratory system (these being more
common in the very old) and external causes. In men over 65, the most common
causes of death, according to prevalence, are malignant neoplasms (again, most
common in the very old), other external causes, diseases of the circulatory
system and diseases of the respiratory system (Assoc. of European Cancer
Chronic diseases and disablement are predominant in older
people. In spite of the fact that, on average, people live longer and more
healthy years (see above), too many years are still lived with activity
limitations (i.e. about 15 years for men and 19 years for women, including 5 to
6 years with severe limitations). Longer lives do not necessarily translate
into healthier lives and patterns of health and illness in women and men show
marked differences. Women’s longevity makes them more likely to suffer from the
chronic diseases commonly associated with old age. For example, women are more
likely to suffer from osteoporosis, diabetes, hypertension, incontinence and
arthritis. Chronic illness and decreased mobility influences the quality of
life. Men are more likely to suffer from heart disease and stroke, but as women
age, these diseases become the major causes of death and disability for women
too. The common view that heart disease and stroke are exclusively men’s
problems has obscured the recognition of their significance for older women’s
health. Indeed, more research is necessary in this area.
In the age group above 65, accidents are very frequent,
with the majority of them related to falls (Figure 9.4.2). As much as about 30%
of those over 65 who live independently experience a fall; this figure further
increases for those in residential or acute care settings. Less than 10% of
falls result in fractures, but 20% require medical cares. Hip fractures are
increasing and represent an important cause of death and institutionalisation.
Injury to older people can be prevented with programmes promoting safety,
injury prevention and actions against violence and suicide. The individual
approach should include physical and nutritional aspects, careful prescription
of psychotropic drugs and safe housing (European Healthy Aging, 2007). Systems
of cooperative care - which hold great promise of reducing disability and
institutionalisation - have been developed between geriatric medicine and
orthopaedic surgery (Geriatric Medicine Society, 2002). Risk factors for falls
are listed in Table 4.1. These difficulties can also lead to motor vehicle and
pedestrian-related injuries. Although older drivers drive less than younger
ones, they succumb to fatal accidents more often. This may be because many
medicines can impair driving ability, but a history of falling has also been
identified as an important risk factor (WHO/HEN, 2004).
Figure 9.4.2. Fatal injuries by causes of death, 65+
Mental health problems ranging from depression to complex
neuro-psychiatric disorders represent four of the six major causes of years
lived with disability. The burden of ill health in older people can be improved
by addressing factors that impact on mental health and wellbeing such as social
relationships, poverty and discrimination. Raising awareness of mental issues
relevant to older people, such as depression and dementia and an increase in
the provision of psychotherapeutic and psychosocial interventions are also
effective (European Healthy Ageing, 2007).
Depression and Suicide: Only cardiovascular disease has a
greater toll on morbidity and mortality than depression; yet, depression
remains under-recognised and highly stigmatised across Europe. Depression
affects 10-15% of people over 65. Older people with depression are 2-3 times
more likely to have 2 or more chronic illnesses and 2-6 times more likely to
have at least one limitation in their daily life activities.
Depression is the major cause of suicide in elderly
Europeans. Rates of suicide and self harm are approximately 26% higher in
Europeans over 65 than amongst the 25-64 age groups (exceptions include men in
Ireland, and women in Ireland and Luxembourg) (European Commission, 2003). The
highest rates of suicide are found among males in Hungary, Lithuania and Slovenia.
In 90% of EU countries, the suicide rate is higher in those over 75. More
appropriate medical training, increased social awareness and better access to
treatment options are needed to prevent, diagnose and treat late-life
depression. The higher risk of depression in older women and in people of lower
socio-economic status deserves particular attention (International Longevity
This category includes ischemic heart diseases and other
heart diseases as well as stroke and other cerebro-vascular diseases.
Circulatory diseases are responsible of about 42% of all deaths among older
people (65-84 years of age) and over 50% of deaths of persons aged 85 and over.
The highest death rates occur in Estonia (2,305 men and 1,318 women per 100
000) and Lithuania (2,219 men and 1,335 women), while the lowest rates are
observed in France (402 men and 169 women) and Portugal (460 men, 275 women)
(Eurostat, 2006). Age specific death rates demonstrate that the risk for men
increases with age and that there are considerable variations between
countries. In the over 75 years of age bracket there is a 400% difference in
age specific death rates between Denmark and Portugal. Note: In the 45-54 age
group there is a ten fold difference between that of Finland and Portugal
(European Health Men’s Forum, 2003). Morbidity for Coronary Heart Disease appears to be increasing
in those over 75 years old. This may be related to the introduction of more
effective forms of treatment for CHD, leading to more people surviving, but
suffering from the disease (British Heart Foundation, 2001).
Cerebro-vascular disease. If the median age specific death
rates for men are compared with those for women it is seen that up to the age
of 74, men have the highest rate of death from cerebro-vascular disease, whilst
women have the highest rate above this age (European Health Men’s Forum, 2003).
Stroke. Recurrent strokes typically account for about 20
to 30% of all stroke events; this can be as high as 50 to 70% in patients over
75 years of age. A recent European study showed that the prevalence of stroke
increased from 5% in people aged 65 to 84, to 7% in those aged over 75. It was
thought that older people with stroke had a short survival time; however,
recent evidence suggests that survival may be much longer. Prevalence, therefore, is
probably higher than previously believed (Kwan, 2001). Age can affect after stroke
outcomes. It is likely that elderly sufferers require greater care after a
stroke than younger counterparts. A recent study of stroke care for older
patients in thirteen hospitals in ten European countries found that stroke care
varies considerably. Older people are more likely to gain access to organised
stroke care in many centres, but less likely to receive diagnostic
investigations, therapy input and outpatient review (Bhalla et al, 2004).
For both men and women, the proportion of people with
diabetes increases with age; in the 60-69 years of age group diabetes affects
between 10-20% of people, whilst in the 70-79 years of age group it affects as
many as 25-30%. Over 85, the main causes of death are the diseases of pulmonary
circulation and other cardiac pathologies.
Global figures show that the WHO European Region, with 48
million affected, along with the Western Pacific Region currently has the
highest number of people with diabetes (International Diabetes Federation,
2003). Long-term complications affect older people making it difficult for them
to work until a later age. This is cause for concern in Europe that has become
an ageing continent: where the dependency ratio (number of people aged 65 and
above relative to those aged 15 to 64) is set to double and reach 51% by 2050.
Diabetes affects less than 10% of under sixties and between 10 and 20% of the
60-79 age group. The prevalence of isolated postload hyperglycaemia,
particularly impaired glucose tolerance, is notably higher in older women than
in older men (i.e. individuals >70 years of age) (DECODE Study Group, 2003).
In 70 to 79 year olds, the prevalence of diabetes stands at about one quarter
of the population in that age group. Impaired glucose regulation (IGR)
prevalence also increases with age, affecting 25% of men and 30% of women above
70 years of age. There is a wide variation in the total diabetes prevalence in
the older population in Western European countries, however, without a clear
geographical pattern (Rathmann et al 2005).
Cancer causes a large part of all deaths after the age of
65. Prostate cancer is the most common cause of cancer death in men, whereas
breast cancer is the most common cause of cancer death for women.
Breast Cancer. About 25% of all breast cancer
patients are aged 75 or older. Data from cancer registries show that contrary
to popular opinion, the prognosis for older people is poor. Possible causes are
that treatment is not as good as that given to younger people. Older people may
not tolerate intensive treatment, or doctors do not focus on finding suitable
treatments for this group or clarify what kind of care these patients are
seeking/requiring. There are not enough specific trials conducted on older
patients. Specific clinical trials are needed for elderly women with breast
cancer. (Note: some women aged 70 and over are included in trials, but tend to
be selected because they are particularly healthy). Trials conducted
specifically for older women have produced surprising results. An International
Breast Cancer Study Group trial, carried out in women aged 66 to 80 in the late 1970s, was still showing benefit in outcomes more than 20 years later (Jassem and
Prostate Cancer. Deprivation incidence gradients
reported in both England & Wales and Scotland, show higher rates in the
least deprived populations, but it is not known to what extent the incidence
differences reflect true variation in risk by socio-economic group, or
differences in access to screening (Qinn et al, 2001).
Preventive health services such as immunisation must be
made accessible to older people, giving special attention to frail people.
Under certain conditions, preventive home visits should be considered (European
Healthy Ageing, 2007).
Many of the old and oldest individuals, who have chronic
diseases affecting respiratory functions and immunocompetence, could represent
an under-diagnosed reserve of infection, as surveillance and epidemiological
studies on aged persons is sporadic. Comparisons of the notification rate in
45-64 year olds, and those over 64 years of age, show evidence of a higher
prevalence of TB in older individuals. This is true in most countries, with the
exception of Romania and Estonia, where adults are more often affected than
aged individuals. Gender differences have been highlighted, with general higher
prevalence in males. In a small sample of patients resident in Lombardy, the
highest incidence appeared to be during the 4th decade in females and in the
6th decade in males (Cattaneo, 2007).
Sexually Transmitted Infections. The rates of gonorrhoea
and syphilis have increased by 55 per cent in the UK since 1995. In the 65-plus age group the rise has been more than 300 per cent. A six-year, retrospective
study of 239 new patients, 60 years of age and older, receiving genito-urinary
medical care at a hospital in the United Kingdom showed that older people who
are sexually active may be at risk for HIV and other sexually transmitted
diseases. Many infections were newly acquired. Over half (121) of the 239
patients were single, divorced, separated or widow/widowers. Their single
status often resulted in sex with casual partners and prostitutes. On the other
hand, protective sex was performed by only a minority of this group, probably
because they link protection with contraception only (Jaleel et al, 1999).
There has been a notable increase in sexually transmitted infections among
post-menopausal women. As pregnancy is not an issue for post-menopausal women,
many do not use condoms. Wrongly considered to be at low risk, post-menopausal
women are not included in safe sex messages. They are assumed to be either in
monogamous relationships or relatively sexually inactive. Among ageing and
menopausal women aged 45 to 64 in the UK, rates of chlamydia rose by 177%, from
150 to 416 cases, between 1995 and 2003, whilst cases of gonorrhoea rose 249%,
from 39 to 136. In 2003, women over 40 made up 7% of patients diagnosed with
HIV, up 2% from 2001. Ageing women are especially at risk as oestrogen
deficiency means vaginal and cervical tissue becomes more fragile, resulting in
tears or abrasions which lead to increased susceptibility to STIs (Mahar,
Delirium: Delirium, or acute confusion, is a frequent
consequence of illness in later life. A reduction of in-hospital delirium from
15% to 9%, with concomitant savings in personal suffering and resource
utilisation has been seen with the application of specialised programmes
(Geriatric Medicine Society, 2002).
Dementia: Assessment and care packages have been
instrumental in reducing the yearly incidence of dementia by more than half,
through systolic hypertension control (Geriatric Medicine Society, 2002).
Dementia does not solely affect older people, although
rates increase with age, doubling every four years over 65. After the age of
85, rates of Alzheimer’s Disease (AD) increased in women but not in men. The
EURODEM studies also noted that the rates of AD were higher among women of
lower education, but that education was not a significant risk factor in men
(see chapter on dementia for further details and reference).
Urinary incontinence: Urinary incontinence affects 10%
of older Europeans. It is possible to counter unnecessary suffering and
inconvenience with assessment and management of urinary incontinence (Geriatric
Medicine Society, 2002).
Disability: While most elderly people are not
disabled, most disabled people are elderly. The WHO has recognised that
preventable non-communicable diseases, including cardiovascular diseases and
cancers, can be a major cause of disability (Geriatric Medicine Society, 2002).
Various measures have been developed to forecast the care needs of an ageing
population. One of the most commonly used projections is to estimate
disability-free life expectancy. The most recent findings for developed
countries show that severe disability is declining in older people at a rate of
1.5% per year. For those who are disabled, improvements in rehabilitation and
adaptations of the physical environment can help reduce the progression of
disability (WHO, 1999). Data on life expectancy without disability are limited,
but suggest that life expectancy without disability is either stagnating
(United Kingdom) or increasing (Germany and France). The data also suggests
that increased life expectancy is not accompanied by an increase in the time
spent with severe handicap or severe disability. Even worse, there may be a
pandemic of light or moderate handicaps or disabilities.
Eyesight/blindness: It is estimated that over one
million people are visually impaired, with 70% of these being over 75
(estimates for 1996).
Table 9.4.2. Most
common causes of blindness and partial sight in people aged 65 and over