Monthly Archives: October 2013

How normal aging has changed

Here is the bad news.  As we age our bodies change: our skin becomes less elastic, our hair thins, we lose as much as two inches in height by the time we are 80, we lose muscle mass, and some of the mineral content in our bones. Our senses become less acute: most of us need glasses by the time we are in our 40s, and it becomes more difficult to hear the high-frequency sounds of human speech. We sleep less long and not as deeply. Our metabolism slows and we need less food. Our brains become smaller with less blood flowing through them; some memory loss is normal. Our organs also change: most of them become less efficient and more vulnerable to extremes of activity or diet.  Male sexual response times slow and women stop ovulating. The pace of aging varies not only because of differences in one’s genetic makeup but also because of income, social status, education and many other determinants of health. Heart problems, arthritis, lung disease, chronic digestive issues and their associated problems are much more common as we age. Dealing with such conditions is a significant part of the normal aging process.

There are many ways in which the health status of humans has changed over the centuries. For example, we know that for many centuries life expectancy at birth was between 30 and 35. There was a very high rate of infant and child mortality. Many deaths were due to infectious diseases – typhoid fever, cholera, small pox among others. In fact, if you lived to the age of 20 your chances of surviving to 60 were pretty good.

The critical point for me is that in previous eras almost everyone over the age of 40 had one or more chronic diseases.  For example, while doing some work on seventeenth century philosophy and science, I found that many of the famous philosophers and scientists of the time, such as John Locke, Robert Boyle and Thomas Hobbes, all suffered from chronic diseases from quite early on.  Many of these conditions were the consequence of infectious diseases that they had survived as children or teenagers. By the time they were 40, they and their peers were considered to have entered old age. Still death was not usually a result of chronic conditions – at all ages the greatest risk of dying was from the big killers, like cholera, tuberculosis, and other infectious diseases.

A great shift in mortality began in the industrialized world in the middle of the nineteenth century.  Longevity was increasing and many of the diseases of aging were starting later in life. Today, we hear that “60 is the new 40.” And it is. This rapid increase in life expectancy is continuing, as is the delay in the onset of age related morbidity. One can describe the changes of the last several centuries in terms of this delay of the onset of the diseases associated with aging.  If in the 1600s almost everyone over 40 had one or more chronic diseases, now almost everyone over 65 is affected.  If old age began at 40 in the 1600s, we can say that it now begins at 65.

Some of the main features of the mortality shift are the reduction of maternal and infant mortality, and the elimination of many communicable diseases. Infant mortality in the developed world has dropped by almost a hundredfold from more than 10% to almost 0.1% over the last 150 years.  Maternal mortality which was about 500 for every 100,000 births is now about 12. Deaths from diseases like small pox, cholera, typhoid fever tuberculosis and other communicable diseases have virtually disappeared in Canada and other developed countries. The recent WHO atlas of morbidity tells us that in Canada 89% of deaths are due to non-communicable chronic diseases. Competing explanations of the Mortality Shift have greatly impacted health policy, some of which I will review in the next blog.

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How should a healthcare system respond to an aging population?

We all agree that the population of Canada (and of other industrial countries) is getting older. People are living longer and the birth rate is dropping. As a result, the average age of the population is rising. We have long recognized that our society must make adjustments for this change and we have introduced some effective economic and social policies to avert the impoverishment of our older population; however, our healthcare system has responded less well to this demographic change: despite the fact that they have become the heaviest users of the system, the system has, if anything, become less friendly to them and their caregivers.

There is a great disparity between the different responses to an older population. The social and economic responses have been relatively strong and the healthcare response has been disappointing. What are some of the indications of this disparity, and why is the disparity so great?

It is economically easier for people to live after retirement because we have been encouraged to save for old age through both mandatory and voluntary pension contributions; we have increased the age of retirement and, in some cases, have eliminated mandatory retirement altogether for people who want to continue to work. We also have more developmental support, and educational and leisure services for older people. These economic and social adjustments have occurred over a long period of time with both positive and negative outcomes that affect not only older people but the rest of the population as well. For example, the disappearance of mandatory retirement and increased longevity has made it more difficult for young people to enter certain parts of the works force; the increased wealth of the elderly has created the first generation of relatively independent older people who do not have to depend on their offspring to support them economically in their old age. This is evident in some of the statistics on the economic status of older people:

1. The fastest growing segment of the population are the over 85s

2. People over 65 have the lowest debt load of any segment of the adult population

3. In recent years the largest increase in debt has also been of the over 65s as they are increasing their expenditures

It is at first somewhat puzzling how poorly the healthcare system has accommodated to an older population. We know that older people have very different health need, particularly less dramatic intervention and more support. However, many of the conditions associated with aging have been characterized as diseases, even though a large number of them are in fact a natural consequence of getting older, rather than the result of a particular pathology. As a result, healthcare services appear to remain quite narrowly focused on hospital and specialist care, and in some cases people must have an acute episode before any serious consideration is given to their care. Families faced with aging parents have great difficulty in finding services that suit their needs beyond the most basic medical and nursing care; suitable supports for aging in one’s home still require great effort and remain hard to come by.

A great proportion of Canada’s healthcare dollars are spent on a relatively small part of the population – elderly people who are kept in acute hospital for long periods of time because of inadequate long term care. Once discharged this group of patients are often at high risk of returning to hospital frequently in a kind of revolving door syndrome. In Canada it has been determined that 5% of the population uses something like 20% of the funding for healthcare, and this group of elderly people are a large part of that population. In the United States there is a similar problem of mostly older people who return to hospital within 30 days of discharge, which means a great deal of energy is being focused on this population. The objective is to improve their transitions of care to keep them out of hospital once they are treated, and so far there has been no great and clear success in these efforts.

At Patients Canada we think that this problem has deep roots and we are exploring it slowly. We think that much of the problem is related to the kind of healthcare system we have created, to its focus, the kinds of strengths it has and how resources are allocated to it. I’ll continue to review these issues in the coming weeks and I encourage anyone interested to add their feedback or comments.

The ‘high fliers’ who account for 21% of healthcare spending

Today a Kaiser Health News article took to illustrate a problem that is common to the US and Canada, and which I suspect has similar causes – the lack of community support for patients that hinders a system’s ability to avert acute episodes and hospitalization, or that returns a patient to a home that is not properly suited to his or her needs.

The article is especially interesting because it is very explicit about the lack of community based supports for patients that would allow them to stay home. Here we speak instead about “difficulties of transition.” In this story, the problems are not enough primary care physicians, lack of air conditioning in the home, and a lack of services to support people with multiple health conditions in their homes.

Many of these problems in the US were described forty years ago by Ted Kennedy, in “In Critical Condition: The crisis in America’s Health Care”. Kennedy includes similar anecdotes, such as respiratory patients who return to hospital because they cannot afford humidifiers. Additionally, the Kaiser Health article gives an overview of the American view of the “high fliers”, or the most frequent users of the healthcare system, or those using over 20% of the health care dollar. The similarity of the Canadian situation is worth noting.

Click here to read the ‘Costliest 1 Percent of Patients Account For 21 Percent Of U.S. Health Spending’

In conversation with Sholom Glouberman

Healthcare Quarterly — With credentials from McGill and Cornell universities and a diverse career as philosopher-in-residence at the Baycrest Centre for Geriatric Care in Toronto, fellow at the King’s Fund in London and many engagements as policy advisor and consultant on both sides of the Atlantic, Sholom Glouberman, PhD, has contributed to Canada’s finest healthcare organizations. Click here to read the article.