Researching the health needs of elderly people
BMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6945.1655 (Published 25 June 1994) Cite this as: BMJ 1994;308:1655
- C K Cassel
Life expectancy is increasing dramatically throughout the world, more visibly in developed countries, where unprecedented falls in mortality have led to increasing numbers and proportions of elderly people. Although the increase in life expectancy during the first half of the 20th century has been attributed to public health measures rather than to medical interventions (the McKeown hypothesis), many experts believe that the continuing increases in life expectancy in the second half of the century are due to advances in medical science and health care. Whatever the reasons, people live longer and many of them have more years of healthy, active, and independent life. For this group and their carers, maintaining vigour and independence is a therapeutic goal at least as important as further reductions in mortality.1
Britain's Medical Research Council recently reviewed the health of elderly people to identify opportunities and priorities for further research.2 Elderly' was defined as over 65; the report did not stratify people by age beyond this. Examining separately the young old (<=75), the old old, and the oldest old (>85)3 would have had important implications for policy because by the researchers' own analysis some dramatic demographic and epidemiological differences exist between them. For example, the report points out that while the total population of England and Wales is expected to increase by 8% between 1991 and 2031, the population aged 60 to 74 will increase by 43%, that aged 75 to 84 by 48%, and that aged >=85 by 138%. Causes of death changed as patients age: deaths from circulatory disease increase slightly after 65 while deaths from cancer fall slightly in both men and women. The incidence and prevalence of many cancers increase with age, but the lethality of cancers does not: people who succumb to fatal cancers generally die before they reach advanced old age.
Deaths from chronic degenerative neurological conditions (for example, Alzheimer's disease) increase, as do decisions about not treating otherwise treatable medical conditions, such as pneumonia and urinary tract infection, in these patients. A life span perspective suggests that many of these deaths are not premature, so attempting to prevent them is not necessarily desirable.
In developed countries more than 80% of people reach 65, mostly in reasonable health. According no Neugarten, people aged between 65 and 75 resemble more closely those who are a decade younger than they do those who are a decade older.4 They are generally independent and active, continue work if they enjoyed work, and have a few, manageable medical problems. People over 75, however, have many more chronic medical problems, increasingly need help with daily activities, and are less likely to be able to live alone. And more than half of the oldest old require some help with daily activities and depend increasingly on networks of social support.
Recognising that for most elderly people the quality of life after 75 or so is more important than the length of life leads to a somewhat different set of priorities for medical research and health care for these people than for the rest of the population. Cardiovascular and cerebrovascular diseases top the medical Research Council's list (as they would most similar lists in the United States). Yet cardiovascular deaths in advanced old age may not be avoidable, nor may research on this topic be the best use of public funds. Cerebrovascular disease, which can cause years of substantial disability, seems a much better candidate for more research. In general, the main priorities should not be diseases that kill but those that result in long term disability - osteoarthritis, osteoporosis, incontinence, dementia, depression, and visual and hearing disorders. Advances in preventing or delaying the onset of these disorders could greatly increase the independence and productivity of people in their older years.
The search of intergenerational solidarity
The Medical Research Council's report coincided with the European commission's year of older and solidarity between generations (1993). In the United States the question of intergenerational equity has also been raised - by children's advocates who believe that elderly people receive too many of society's resources and children not enough. This is a sign that the most important bond that keeps our society together - that of intergenerational connectedness with in families and communities - is under threat. A research agenda that aggressively pursued the causes of and treatments for the non-fatal, disabling diseases of old age would probably contribute more to intergenerational solidarity than any political effort because it would reduce dependency.
The United States is embroiled in another of its periodic struggles to extend health care insurance to all, and the existence of federally funded insurance programmes that are available only to elderly people (Medicare) and disabled people (Medicaid) has probably exacerbated the intergenerational arguments. But everywhere policymakers and providers face the problem of allocating limited resources. As medical care becomes ever more effective and its main beneficiaries (elderly people) increase in numbers this challenge will grow apace. The temptation to use chronological age as a bureaucratic mechanism to ration health care is understandable and, some would argue, just - as it applies equally to everyone who reaches that age.5 But, given what we know about the variability of health status in old age, basing medical decisions on chronological age alone becomes ever less defensible.
It would be far better to improve health care providers' and policymakers' knowledge of the needs of elderly people and to invest more research into outcomes and assessment of technology so that new technologies are applied where they are most likely to have the greatest effect, regardless of the patient's age. Here again, it might be argued that extensive treatments to delay death from cancer or heart disease for a short time may be less cost effective than hip or knee replacement operations if these maintain people's independence long term. Such decisions go far beyond the adoption of simple, age based criteria to ration health care; they reflect a more prudent and enlightened approach medical care as we move into the 21st century.