Older Adults

THE LONGEVITY REVOLUTION

As of the early twenty-first century, the United States was on the threshold of a longevity revolution. Richard J. Hodes (1943–), the director of the National Institute on Aging, recognized this revolution when he observed in “Director's Page” (February 16, 2008, http://www.nia.nih.gov/AboutNIA/DirectorsPages/) that “life expectancy has nearly doubled over the last century, and today there are 35 million Americans age 65 and older.” What has fueled this new era of long life is a combination of better sanitation (safe drinking water, food, and disposal of waste), improved medical care, and reduced mortality rates for infants, children, and young adults.

In 1900 life expectancy in the United States was 47.3 years at birth; by 1970 it had increased to 70.8 years. (See Table 10.1.) By 2004 the National Center for Health Statistics projected that life expectancy for those born in that year was 77.8 years. Those who were sixty-five years old in 2004 could expect to live 18.7 more years, with women living an average of 20 more years and men 17.1 more years. In 2004 white men and women had longer life expectancies at age sixty-five than African-American men and women: 18.7 more years versus 17.1 more years.

AGING AMERICANS

According to the U.S. Census Bureau, 35.1 million (12.4%) of the U.S. population were aged sixty-five years and older in 2000. (See Table 10.2.) Those aged sixty-five years and older are projected to account for 20.7% of the population, or 86.8 million people, in 2050. Furthermore, 38.3 million (18.5%) men and 48.4 million (22.7%) women will be over sixty-five.

Who are the “older” Americans? Table 10.3 shows the characteristics of this group in 1990, 2000, 2005, and 2006. Nearly one-third (29.9%) of both men and women in this age group were widowed in 2006. Breaking down this statistic by gender reveals the longevity gap between men and women: 42.4% of women were widowed, whereas only 13.1% of men were.

Table 10.3 also shows that a greater percentage of people aged sixty-five and older continued to work past this typical retirement age in 2006 (15%) than did people in 1990 (11.5%), 2000 (12.4%), and 2005 (14.5%). One-fifth (19.8%) of the sixty-five-and-over men were still working, whereas only one-tenth (11.4%) of women in this age group were still employed in 2006. Over these years, many of those aged sixty-five and older have pulled themselves above the poverty level. In 1990, 11.4% of those sixty-five and older lived below the poverty level, whereas in 2006, 10.1% did so. Nonetheless, more older women (12.3%) than older men (7.3%) lived below the poverty level in 2006.

Baby Boomers

The first children born during the post—World War II baby boom (1946–1964) will be turning sixty-five in 2011. Baby boomers, the largest single generation in U.S. history, will help swell the sixty-five and older population to approximately 54.6 million in 2020. (See Table 10.2.)

The Oldest Demographic

Americans aged eighty-five and older account for the most rapidly growing age group in the population. Predictions vary as to how fast this “oldest old” segment of the population is increasing. The Census Bureau's prediction is that there will be approximately 20.9 million people aged eighty-five and older by 2050. (See Table 10.2.) However, if life spans continue to increase, the Census Bureau may have to revise its calculation for this portion of the general population.

LEADING CAUSES OF DEATH AMONG THE ELDERLY

Six out of ten (59.8%) people aged sixty-five and older who died in 2004 were the victims of diseases of the heart, cancer (malignant neoplasms), or stroke (cerebrovascular diseases). (See Table 10.4.)

Coronary Heart Disease

Coronary heart disease (CHD) is the leading cause of death in the United States and remains the leading cause of death among older Americans. Eight out of ten (81.8%; 533,302 out of 652,029) people who died of CHD in 2004 were aged sixty-five years and older. (See Table 10.4.) This figure is up from 1980, when a slightly lower percentage of those aged sixty-five and older died of CHD (78.3%; 595,406 out of 760,132). This shift is because more young people aged one to fourteen years and twenty-five to forty-four years died of CHD in 1980 than in 2004. In fact, fewer people in the sixty-five-years-and-older age group died from CHD in 2004 than in

1980, even though the numbers of deaths from all causes in this group rose from 1.3 million in 1980 to nearly 1.8 million in 2004. Nonetheless, CHD is still the leading cause of death among older Americans.

The risk of dying from heart disease increases as a person ages. The death rate from CHD in 2004 for those aged seventy-five to eighty-four was 1,506.3 deaths per 100,000 population, almost three times the rate for those aged sixty-five to seventy-four (541.6 per 100,000). (See Table 10.5.) For those aged eighty-five and older, the death rate rose sharply to 4,895.9 deaths per 100,000 population—nine times the rate for those aged sixty-five to seventy-four. In 2004 females had a lower incidence of death from heart disease than did males at all ages, except for ages one to fourteen. At those ages the risk for both sexes was approximately the same.

In the sixty-five-and-older age group the death rate for males from heart disease has been consistently higher than the death rate for females of the same age group regardless of the race. For example, the death rate from heart disease for African-American males aged sixty-five to seventy-four years was 1,096.6 per 100,000 population in 2004, whereas the death rate from heart disease for African-American females was 656.5. (See Table 10.5.) In another example, the death rate from heart disease for Hispanic males aged sixty-five to seventy-four years was 572.2 per 100,000 population in 2004, whereas the death rate from heart disease for Hispanic females was 305.5.

Since the 1950s deaths from heart disease have consistently declined. (See Table 10.5.) Several factors account for this decrease, including better control of hypertension (high blood pressure) and cholesterol levels in the blood. Changes in lifestyle, such as the inclusion of physical exercise and a healthy diet, help decrease the incidence of heart disease. The expanding use of trained mobile emergency personnel (paramedics) in most urban areas has also contributed to the decrease, and the widespread use of cardiopulmonary resuscitation and new drugs have increased the likelihood of surviving an initial heart attack.

Until the 1990s almost all research on heart disease focused on white, middle-aged males. Researchers, physicians, and public health officials agree that more research and prevention efforts should be directed toward

women, racial and ethnic minorities, and older adults. In Heart and Stroke Statistics—2008 Update (2008, http://www.americanheart.org/downloadable/heart/1200082005246HS_Stats%202008.final.pdf), the American Heart Association notes that at age forty and older, 23% of women who have heart attacks die within the first year after the incident, compared to 18% of men.

The symptoms of heart attack can be significantly different for women than for men. Heart disease in

women is often due to coronary microvascular dysfunction, in which the small blood vessels of the heart do not dilate (widen) properly to supply sufficient blood to the heart muscle. This dysfunction may occur alone, or besides, blockages that reduce blood flow in the large coronary arteries as is often the case in men. Because of the differences in the sizes of the involved blood vessels, symptoms of a heart attack may differ between women and men. When the large vessels are blocked, symptoms may include pain, pressure, burning, aching, and tightness in the chest, along with shortness of breath, sweating, weakness, anxiety, and nausea. When small vessels are blocked, symptoms may be more subtle and may include discomfort spread over a wide chest area, exhaustion, depression, and shortness of breath. Nausea, back or jaw pain, shortness of breath, and chest pain may accompany these symptoms.

Cancer

Cancer (malignant neoplasms) is the second-leading cause of death among older adults. In 2004, 385,847 people sixty-five and older died of cancer. (See Table 10.4.) The risk of developing many types of cancers increases with age and varies by race and ethnicity. (See and Table 10.6 and Table 10.7.)

Regarding ethnicity, African-American males had the highest incidence of cancer of all types between 2000 and 2004 (663.7 per 100,000 population) and Native American and Alaskan Native females had the lowest incidence (282.4 per 100,000), followed closely by Asian-American and Pacific Islander females (285.8 per 100,000). (See Table 10.7.) African-American males also had the highest mortality rate from cancer between 2000 and 2004 at 321.8 deaths per 100,000 population. Asian-American and Pacific Islander females had the

lowest cancer death rate during this period at 96.7 deaths per 100,000 population.

Regarding age, the older people become, the higher their probability of developing invasive cancers. For example, the older a man gets, the more likely he is to develop prostate cancer. The chance of dying from prostate cancer also rises with age. The American Cancer Society reports in Cancer Facts & Figures 2008 (2008, http://www.cancer.org/downloads/STT/2008CAFFfinalsecured.pdf) that about 64% of men newly diagnosed with prostate cancer are older than sixty-five. The probability of developing prostate cancer is 1 in 10,553 for men who are younger than forty; 1 in 39 for forty- to

fifty-nine-year-olds; and 1 in 15 for men aged sixty to sixty-nine. (See Table 10.6.) The odds rise to one in seven for men aged seventy and older.

Stroke

Stroke (cerebrovascular disease) is the third-leading cause of death and the principal cause of serious disability among older adults. In 2004, 130,538 people aged sixty-five and older died of a stroke. (See Table 10.4.) The death rate from stroke increases markedly with age. In 2004 the death rate from stroke for those aged sixty-five to seventy-four was 107.8 deaths per 100,000. (See Table 10.8.) This rate more than tripled for each successive decade of age after that, to 386.2 deaths from stroke

per 100,000 for those aged seventy-five to eighty-four, and 1,245.9 deaths per 100,000 population for those aged eighty-five and older.

Men aged sixty-five to seventy-four years and seventy-five to eighty-four years were more likely to have suffered a stroke in 2004 than females (121.1 versus 96.6 per 100,000 population, and 402.9 versus 374.9 per 100,000, respectively). (See Table 10.8.) However, in the eighty-five-years-and-older age group, women were more likely than men to have suffered a stroke (1,303.4 versus 1,118.1 per 100,000 population). This pattern was consistent from 1960 to 2004 for all ethnicities and generally for each ethnicity.

Stroke and Alzheimer's disease are two primary causes of dementia. Death rates from stroke have declined dramatically since the 1950s. (See Table 10.8.) Regardless, stroke leaves approximately one-third of the survivors with severe disabilities, and they require continued care.

DEMENTIA

Older people with cognitive (mental) problems were once labeled “senile,” which had a derogatory connotation and meant an elderly person who was cognitively impaired. Researchers have found that physical disorders can cause progressive deterioration of cognitive and neurological functions. In the twenty-first century these disorders produce symptoms that are collectively known as dementia. Symptoms of dementia include loss of language functions, inability to think abstractly, inability to

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care for oneself, personality change, emotional instability, and loss of a sense of time or place.

Dementia has become a serious health problem in developed countries, including the United States, because older adults are living longer than ever before. One indicator of diminished cognitive functioning in older adults is memory loss. Table 10.9 shows the percentage of people aged sixty-five and older with moderate to severe memory impairment. For each age shown, a higher percentage of men than of women show memory impairment. Nevertheless, in 2002 about one-third of men and women aged eighty-five and older exhibited memory impairment.

Alzheimer's Disease

Alzheimer's disease (AD) is the single most common cause of dementia. It is a progressive, degenerative disease that attacks the brain and results in severely impaired memory, thinking, and behavior. First described in 1906 by the German neuropathologist Alois Alzheimer (1864–1915), the disorder may strike people in their forties and fifties, but most victims are over age sixty-five.

Alzheimer's autopsy of a severely demented fifty-five-year-old woman revealed deposits of neuritic plaques and neurofibrillary tangles. The latter characteristic, the presence of twisted and tangled fibers in the brain cells, is the anatomical hallmark of the disease.

SYMPTOMS. The onset of dementia in AD is gradual, and the decline of cognitive function progresses over time. Mild or early AD is not easily distinguishable from the characteristics of normal aging—mild episodes of forgetfulness and disorientation. Gradually, the AD patient may experience confusion; language problems, such as trouble finding words; impaired judgment; disorientation in place and time; and changes in mood, behavior, and personality. The speed with which these changes occur varies, but eventually the disease leaves patients unable to care for themselves.

In the terminal stages of AD, patients require care twenty-four hours a day. They no longer recognize family members and need help with simple daily activities, such as eating, dressing, bathing, and using the toilet. Eventually, they may become incontinent, blind, and unable to communicate. The course of the disease varies widely—some patients die within a few years of diagnosis, whereas others live as long as twenty-five years.

PREVALENCE. In 2004, 65,313 deaths from AD were reported for those aged sixty-five and older. (See Table 10.4.) In that year AD was the fifth-leading cause of death in the sixty-five-and-older age group, whereas in 1980, AD was not even in the top-ten leading causes of death for this group. Figure 10.1 shows that the number of deaths from AD had increased 44.7% between 2000 and 2005, whereas the percentage change in numbers of deaths from heart disease, breast cancer, prostate cancer, and stroke had all decreased.

In “Prevalence of Dementia in the United States: The Aging, Demographics, and Memory Study” (Neuroepidemiology, vol. 29, nos. 1–2, 2007), Brenda L. Plassman et al. use data from the University of Michigan's Health

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and Retirement Study to determine the prevalence of AD and other dementias in the United States. Table 10.10 shows some of the results from this study. Nearly 5% of all individuals aged seventy-one to seventy-nine suffered from a dementia of some type in 2002. Of these 5%, 2.3% suffered from AD and 0.9% suffered from vascular dementia, which is the second-most common form of dementia after AD. It is caused by problems with the

supply of blood to the brain, such as when a person suffers a stroke, has chronic high blood pressure, or has diabetes.

Plassman et al. note that the prevalence of dementias increased dramatically in those aged eighty to eighty-nine from those aged seventy-one to seventy-nine. The prevalence of any dementia increased fivefold to nearly 24.2%. Dementias more than tripled in males (from 5.3% to 17.7%), but increased nearly sixfold in females (from 4.8% to 27.9%). Likewise, the prevalence of AD increased dramatically from those in their seventies to those in their eighties. In men, the prevalence increased from 2.3% to 12.3%, and in women from 2.3% to 21.3%.

The prevalence of AD in those ninety years and older declined to 9.7%–7.1% in men and 11.5% in women. This decline is due to deaths of those with AD.

Table 10.11 shows national estimates of the number of individuals with AD or any dementia (including AD). In 2002 approximately 2.4 million people seventy-one years and older were living with AD. About 3.4 million had dementias of some type.

DEPRESSION

According to Dan G. Blazer, in “Depression in Late Life: Review and Commentary” (Journals of