459468 2012
SJP0010.1177/1403494812459468Elderly people’s healthC. Lennartsson and I. Heimerson
Scandinavian Journal of Public Health, 2012; 40(Suppl 9): 95–120
Elderly people’s health Health in Sweden: The National Public Health Report 2012. Chapter 5. Carin Lennartsson1 & Inger Heimerson2 1Aging
Research Center, Karolinska Institutet/Stockholm University, Stockholm, Sweden, and 2Swedish National Board of Health and Welfare, Stockholm, Sweden
Summary Over 18 per cent of Sweden’s population – approximately 1.8 million people – are 65 years of age or older. The proportion of elderly people in the population has been growing for more than a century and is expected to continue to rise given the gains in average life expectancy and the fact that large age cohorts are reaching retirement age. The average remaining life expectancy among those who had reached the age of 65 in 2011 was 21 years for women and 18 years for men. The most common causes of death among elderly people are cardiovascular diseases and cancer. The risk of suffering a stroke or heart attack has declined and morbidity has shifted to the upper age groups. On the other hand, the cancer incidence has increased, while cancer mortality has declined, owing to earlier detection and more effective treatment. The most common forms of cancer among elderly people are prostate cancer, breast cancer, colorectal cancer, and lung cancer. There has been a rise in the proportion of elderly people who perceive their general state of health as good. In the case of women, however, the increase is mainly noticeable among younger pensioners, while in men, it is spread across all age groups, according to the Statistics Sweden’s Survey of Living Conditions (ULF). The percentage of elderly people reporting long-term illness has risen, while the proportion with illnesses or complaints that interfere with daily life activities has declined. The percentage of people suffering from impaired mobility has fallen since the 1980s, while pain issues have remained at about the same level. Reports of nervousness, anxiety and sleeping problems are frequent among the elderly population
and, as in the case of younger age groups, more common among women than men. One in every three women and nearly one in every five men in the oldest age group (85 years or older) suffer from anxiousness, nervousness or anxiety. Women also consume considerably more psychopharmaceutical drugs than men, although more men than women commit suicide. A quarter of all suicides are committed by people over the age of 65. It is estimated that 142,000 people suffer from dementia in Sweden. More women suffer from dementia than men. This is partly attributable to women’s higher susceptibility, and partly to the fact that women are more heavily represented in the oldest age groups. Approximately one third of the population aged 60 or over and every other person over 80 has a falling accident every year. Younger pensioners are more prone to wrist fractures, while hip fractures occur more frequently among the oldest old. Today’s older adults exercise considerably more than previous generations. The percentage who garden, take regular walks or stroll in the forest has also risen. Smoking has long been in decline among elderly men, but not among elderly women. This is reflected in the incidence of lung cancer, which has risen among women but declined among men. People over retirement age drink less alcohol than people in younger age groups. More than half of all people beyond retirement age are overweight. Although excess weight is more common in older age groups, its prevalence has risen less steeply among the elderly than among younger people. Many of the oldest old are also underweight,
Correspondence: Carin Lennartsson, Aging Research Center, Karolinska Institutet/Stockholm University, Stockholm 113 30, Sweden E-mail:
[email protected] © 2012 the Nordic Societies of Public Health DOI: 10.1177/1403494812459468
96 C. Lennartsson and I. Heimerson and involuntary weight loss among older people may be a sign of undernourishment or illness. The ability of people to manage their personal care needs tends to decline rapidly after the age of 80. Among people aged 85 or older, nearly half of women and just over one-third of men need assistance. The ability to cope with daily activities is not only a function of a person’s physical capacity; it is also contingent on factors in her/his surroundings, such as type of housing, distance to shops and access to assistive devices. A growing number of elderly people continue to live in their own homes well into old age. This is not merely due to a declining need for care and attention but also to a significant contraction in the number of places in special housing for the older people, to the point where the service is unable to meet current demand. As a result, more older people have been turning to relatives for assistance. As women tend to outlive their older husbands, they assume responsibility for assisting the latter in their final years. Thus in most cases single women living alone are the ones who require municipal social care inputs in their old age. Introduction In this chapter, people aged 65 or older are viewed, somewhat categorically, as being ‘of retirement age’. In reality, retirement age varies although retirement at the age of 65 is still the norm. Nor are biological and chronological ageing always equivalent; rather, different people age at different rates, depending on environmental factors and their genetic predisposition. Today’s retirees were born in the first four decades of the 20th century and have witnessed the emergence of modern society and the development of the Swedish welfare state. The oldest retirees have lived through two world wars and the Great Depression of the 1930s. The youngest were children during the Second World War and their adult lives largely coincided with the emergence of postwar welfare society. Today, most people who retire in Sweden can look forward to many relatively healthy years, a continued active life, take part in social activities and enjoy a comparatively high standard of living. This period in life is usually called ‘the third age’. Most people also experience a ‘fourth age’ – when illnesses and functional impairments restrict normal daily life activities. However, this phase of life has shifted higher up the age range. In the population as a whole, there has been no significant increase in the need for care interventions by others before the age of 80. In the final stage of life, however, most people are exposed to a growing number of health problems, thereby generating a very substantial demand for health and social care. Only a minority of the elderly die quickly
without developing any significant health problems [1, 2]. Over 18 per cent of Sweden’s population, or approximately 1.8 million people, are 65 or older. The percentage of elderly people in the population has been growing for more than a century and is expected to continue to rise as life expectancy has increased and large age cohorts reach retirement age. By 2030, it is estimated that just over one in every five Swedes will be over the age of 65. The need for efficient and effective health and medical care and social services is particularly pressing in a society with an ageing population. On average, the final two years of life are spent in care, and a considerable body of research indicates that local government care inputs are already insufficient to meet the needs of the oldest old [1]. Causes of death among the elderly people The most common causes of death among elderly people are cardiovascular diseases and cancer (Figure 1). Most cancer deaths among the elderly people occur at a somewhat earlier age than deaths from cardiovascular disease. Deaths from prostate cancer, the most common form of cancer among men, occur mainly after the age of 80. Dementia is a frequent cause of death among the oldest old, as is pneumonia. The latter affects frail, elderly people far more severely than younger people and is frequently fatal. The most common age of death is 87 and 82 years for women and men respectively. Figures 2a and 2b show mortality trends from 1952 to 2010. Mortality among women followed a fairly constant decline in the 65–74 and over-75 age groups. Among men, however, mortality has fallen continuously only among those in the oldest age group. In the 65–74 age group, mortality remained largely unchanged between 1952 and 1980. Cardiovascular mortality actually increased among 65–74-year-old men in the 1950s, 1960s, and 1970s. Mortality among men aged 65–74 did not begin to decline until the early 1980s, mainly due to a significant reduction in cardiovascular mortality. A corresponding decline to that for men aged 65–74 is also found among middle-aged men (see Chapter 4, Health in the Working-Age Population). Cardiovascular diseases were previously the leading cause of death among elderly women and men. However, the relative importance of cancer as a cause of death has grown in conjunction with the decline in the incidence of cardiovascular diseases. In 2010, death from cancer was more common than death from cardiovascular disease for women and men aged 65-74. In the over-75 age group, cardiovascular diseases remain the predominant cause of death.
Elderly people’s health 97 Women
Number
Men
Number
2 500 2,500
2 500 2,500
2,000
2,000
1 500 1,500
1 500 1,500
Other Cancer, other Lung cancer Prostate/breast cancer Strokes
1,000
Cardiovascular excl. stroke
1,000
Accidents 500
COPD
500
Pneumonia 0
Dementia
0 65
70
75
80
85
90
95
100
65
70
75
80
85
90
95
100
Age
Age
Figure 1. Age patterns for causes of death among the elderly. Number of deceased by cause of death and age. Averages for 2000–2006. Women and men aged 65 or older. Source: Cause of Death Register, Swedish National Board of Health and Welfare.
Number per 100,000
Number per 100,000
Women
4,000
4,000
3,000
3,000
Men Other causes of death Injuries Cardiovscular diseases Cancer
2,000
2,000
1,000
1,000
Infectious diseases
0 0
1952 58 64 70 76 82 88 94 00 06 2010
1952 58
64
70
76
82
88
94
00
06 2010
Figure 2a. Causes of death among people aged 65–74. Number of deceased per 100,000 by cause of death. Women and men aged 65–74, 1952–2010. Note: Different y-axis scales used in figures 2a and 2b. Source: Cause of Death Register, Swedish National Board of Health and Welfare.
Women
Number per 100,000 16,000 12,000
12,000
8,000
8,000
4,000
4,000
0
0
1952 58
64
70
76
82
88
Men
Number per 100,000 16,000
94
00
06 2010
1952 58
Other causes of death Injuries Cardiovscular diseases Cancer Infectious diseases
64
70
76
82
88
94
Figure 2b. Causes of death among people aged 75 years or older. Number of deceased per 100,000 by cause of death. Women and men, 75 years or older, 1952–2010. Source: Cause of Death Register, Swedish National Board of Health and Welfare.
00
06 2010
98 C. Lennartsson and I. Heimerson Period life expenctancy, in years 22
Women at the age of 65
20 18 16
Men at the age of 65
14 12 10
Women at the age of 80
8 6
Men at the age of 80
4 2 0 1900 10 20 30 40 50 60 70 80 90 00 2011
Figure 3. Period life expectancy in 1900–2011. Period life expectancy (number of years) at 65 and 80 years of age. Women and men, 1900–2011. Source: Population projection, Statistics Sweden.
Per cent 25
20
Women 1980–83
15
Men 1980–83
10
Women 2002–05
5
Men 2002–05 0 16-19 25-29 35-39 45-49 55-59 65-69 75-79
85+
Age
Figure 4. Poor general health. Percentage of people who assess their general state of health as poor*, by age. Women and men over the age of 16, 1980–1983** and 2002–2005. Subjects interviewed directly and indirectly. * In 1996, the response options were changed from “Poor” to “Poor” and “Very poor.”. ** For the period 1980–1983, no one over the age of 84 was included in the study. Source: Survey of Living Conditions (ULF), Statistics Sweden.
Life expectancy among the elderly people In 2011, average life expectancy was 84 years for women and 80 years for men. This is expected to rise to 86 years for women and 84 years for men by 2050 [2]. Average period life expectancy for people who have reached the age of 65 is estimated at 21.2 years for women and 18.4 years for men, assuming that
the death risks in 2011 for any given age continue to apply. Since 1990 alone, period life expectancy after retirement age has risen by 2.2 and 3.1 years for women and men respectively. However, it is likely that death risks will continue to fall, and today’s 65-year-olds will probably live even longer. Period life expectancy has increased significantly even among those who have reached the age of 80; it is now 9,6 years for women and 8,1 years for men. The percentage of women in the population increases with age. The number of men and women aged 60 in the population is approximately equal. Over the age of 65, 55 per cent are women. At the age of 85 and over, there are twice as many women as men. The gender disparity in period life expectancy is three years at the age of 65. In the first half of the 20th century, the disparity was very small (Figure 3). Since 1950, however, period life expectancy among women aged 65 has risen more rapidly than among men. The gender disparity in life expectancy among the older people peaked in about 1980. In the 1960s and 1970s, the disparity in period life expectancy at age 65 increased but has declined since 1980. This trend is mainly due to the gender disparity in cardiovascular mortality referred to above. People’s health perceived as improving except among the oldest old Health can be perceived as good – or poor – whether or not the person actually has an illness. The subjective perception of health is influenced among other things by one’s expectations and one’s frame of reference. For example, elderly people tend to have lower demands in terms of what they regard as ‘good health’ than younger people [3]. The number of people who perceive their health as poor increases with age and the gradual onset of illnesses and functional impairments. People aged 65–69, however, are an exception to this trend. Members of this age group tend, on average, to perceive their general state of health as better than it was at the age of 60–64 (Figure 4). This improvement following on retirement at the usual age of 65 is more evident among men than women and more visible today than it was 20 years ago. Manual workers are also experiencing a greater improvement in their general state of health than white-collar workers (see Chapter 1, Public Health – An Overview). Figure 5 shows that, between 1980 and 2010, more people assessed their general health as good, with the exception of women over the age of 75. In fact the percentage of women over 75 who report
Elderly people’s health 99 Data sources The findings presented in the present chapter were mainly taken from, Statistics Sweden’s Living Conditions Survey (Survey of Living Conditions (ULF)) and the Swedish Panel Study of the Living Conditions of the Oldest Old (SWEOLD). The Survey of Living Conditions (ULF) compiles annual data on people up to the age of 84. However, only data from 1988–1989 and from 2002 onward are available for people older than 84 and thus no continuous trend for this age group can be shown. In the figures, age groups up to 84 are represented by continuous lines, whereas the over-85 age group is shown by dotted or short, discontinuous lines. The SWEOLD study, which has no upper age limit, was conducted in 1992, 2002, and 2004. One problem with sample health studies is that people in poorest health do not take part for various reasons. As a result, actual health states in the population are probably slightly worse than the statistics suggest. However, as the studies are repeated based on similar procedures – and constrained by same deficiencies – it is still possible to form a view on how the health of the population has evolved across different points in time. The Survey of Living Conditions (ULF) underwent a methodological change in 2006. A change was made from on-site interviews to telephone interviews, which could have an impact on comparisons over time. Among older adults, dementia or other illnesses can prevent people from responding to questions themselves. In such cases a relative may sometimes answer on behalf of the respondent, in a so-called indirect interview. In this section, indirect interviews have been included in most of the analyses. Exceptions would include, for example, questions relating to pain which another person would find difficult to answer. In the Survey of Living Conditions (ULF), only a small percentage of the interviews are indirect with the exception of people in the oldest, over-85 age group, where they account for approximately 20 per cent.
having good general health has not risen over the entire period except for the last years. Another population-based study, SWEOLD, also found a deterioration among men over 77, whose health worsened between two measurement points, in 1992 and 2002. Assistance needs rise rapidly after 80 People’s ability to cope with daily life activities is contingent not only on their ability to function physically and mentally but also on factors in their surroundings such as type of housing, distance to shops, and access to assistive devices. Women more frequently report having problems with housework and shopping for groceries than men, i.e. performing heavier tasks that require muscular strength (Table I). In the past, elderly men reported needing help with cooking meals significantly more often than women. This gender disparity is probably more related to lack of habit and skills than to physical functionality, and in more recent years has almost disappeared [4]. In the years leading up to the mid 1990s, elderly people became somewhat better at shopping, cooking and housework, but no further improvement has since been reported. Difficulty in managing one’s personal care needs (personal ADL) becomes common only at a very advanced age. The first problems usually involve
bathing and showering. Few people need help with their own care before the age of 80. After 80, however, the proportion who do need help increases rapidly with age (Table II). At the age of 85 and above, 44 per cent of women and 36 per cent of men need help with personal care. The percentage who need help with bathing or showering, undressing and dressing, or getting in or out of bed has not changed significantly in the past two decades.
Prevalent diseases and functional impairments We are living longer. But are the added years, healthy years, or are they fraught with serious health problems? There are three main hypotheses on the connection between longer life expectancy and illness. The first states that morbidity is occurring later in people’s lives and for a shorter period. Thus the healthy years are replacing the years of illness, while the period preceding death, accompanied by illnesses and functional impairments, is shortened. The second hypothesis proposes that morbidity affects us for an equally long period at the end of life, but that this period is being shifted upwards to increasingly older age groups. The third hypothesis suggests that
100 C. Lennartsson and I. Heimerson Per cent
Per cent
Women
80
80
60
60
40
40
20
20
0
0
1980
1985
1990
1995
2000
2005
2010
1980
Men
1985
1990
1995
Good: 65–74 years
Poor: 65–74 years
Good: 75–84 years
Poor: 75–84 years
Good: 85+ years
Poor: 85+ years
2000
2005
2010
Figure 5. General state of health. Percentage who assess their general state of health as good or poor*. Women and men aged 65–74 and 75–84 in 1980–2010**, and women and men over 85 in 1988–1989*** and 2002–2005**. Subjects interviewed directly and indirectly. * In 1996, the response options were changed from “Good” to “Good” and “Very good” and from “Poor” to “Poor” and “Very poor.”. **Three-year moving averages. The Survey on Living Conditions (ULF) changed from on-site to telephone interviews in 2006, which could have an impact on comparisons over time. ***Averages for 1988–1989. Source: Survey of Living Conditions (ULF), Statistics Sweden. Table I. Need for assistance with grocery shopping, cooking and housework. Percentage of people who need help with grocery shopping, cooking and housework. Women and men aged 75–84 and 85+, averages for 2002–2005. Subjects interviewed directly and indirectly. Type of assistance
Age group
Women
Men
Years
Per cent
Per cent
Shopping Cooking Housework
75–84 85+ 75–84 85+ 75–84 85+
27 60 13 40 30 66
15 47 16 40 20 51
Source: Survey of Living Conditions (ULF), Statistics Sweden.
ADL, activities in daily life, refers to the ability to cope with daily activities. Personal ADL refers to the ability to manage one’s personal care, e.g. to get in and out of bed, dress oneself, eat unaided, and manage daily hygiene and visits to the toilet. Instrumental ADL (IADL) applies to daily tasks such as shopping, cooking, housework, and transportation.
increased life expectancy also entails longer periods of illness and health issues. At present, there is no definitive answer as to which of these hypotheses is correct. Several of the most prevalent disabling diseases have, however, shifted to the upper age groups, while a smaller percentage in any given age group report being hampered by illnesses and health problems.
According to the Survey of Living Conditions (ULF) carried out in recent decades, there has been a rise in the percentage of elderly people who report Table II. Need help with personal care (personal ADL). Percentage who need help with one or more of the following tasks: getting in/out of bed, dressing, eating unaided, managing daily hygiene, and visits to the toilet. Women and men aged 69 or older, by age, in 2004. Subjects interviewed directly and indirectly. Age group
Women
Men
years of age
Per cent
Per cent
69–74 75–79 80–84 85+
4 8 21 44
4 9 14 36
Source: SWEOLD/Aging Research Center (ARC)/Centre for Health Equity Studies (CHESS).
Elderly people’s health 101 Protracted illness Per cent 100
Women
80
80
60
60
40
40
20
20
0 1980
Men
Per cent 100
0 1985
1990
1995
2000
2005
1980
1985
1990
1995
2000
2005
2000
2005
Disabling protracted illness Women
Per cent 100 80
80
60
60
40
40
20
20
0 1980
Men
Per cent 100
0 1985
1990
1995
2000
2005
65–74 years
1980
1985
1990
75–84 years
1995
85+ years
Figure 6. Protracted illnesses and complaints. Percentage of people with a protracted illness or other complaint following an accident, and percentage who are hindered from carrying out various activities due to an illness or complaint. Women and men aged 65–74 and 75–84 in 1980–2005*, and 85+ in 1988–1989** and 2002–2005*. Subjects interviewed directly and indirectly. * Three-year moving averages. ** Averages for 1988–1989. Source: Survey of Living Conditions (ULF), Statistics Sweden.
having a protracted illness, a health problem following an accident, a handicap, or some other weakness. On the other hand, the percentage of people with illnesses or complaints that interfere with their daily life has declined. Thus it appears that while the number of illnesses has risen, the number of diseases associated with handicaps and functional impairments has declined (Figure 6) [5]. The total amount of purchased prescription medicines has also increased according to data from the Swedish National Board of Health and Welfare’s Register of Medicinal Products. Taken together, these data would indicate that more diagnoses are being made than previously.
One of several explanations for this trend could be that although the number of diseases has risen, technical advances and improvements in housing and the local environment have meant that sick people suffer from handicaps and functional impairments to a lesser extent than in the past. Improved methods of treatment within the health care system could also mean that people who have contracted an illness are not troubled or incapacitated by it to the same extent as in the past. Another possible explanation is that the number of sick people has not in fact risen, but rather that more illnesses are being detected and diagnosed
102 C. Lennartsson and I. Heimerson Table III. Impaired mobility and severely restricted mobility. Percentage of people with impaired mobility* and severely restricted mobility**. Women and men aged 65–74, 75–84 and 85+. Averages for 2002–2005. Subjects interviewed directly and indirectly. Age group
Impaired mobility
Severely restricted mobility
Women
Men
Women
Men
Per cent
Per cent
Per cent
Per cent
65–74 75–84 85+
42 71 90
30 52 83
15 37 64
11 26 51
*The subject was unable to run a short distance, board a bus without difficulty, or take a short walk. **The subject required assistive devices to move about outdoors or indoors. People with severely restricted mobility are included in the group with impaired mobility. Source: Survey of Living Conditions (ULF), Statistics Sweden.
earlier. For example, the incidence of prostate cancer in the population has increased significantly with the introduction of new diagnostic methods. Similarly, the fact more elderly people are now treated for osteoporosis in order to prevent fractures could mean that osteoporosis is more widely perceived as a disease than previously. Thus an increase in the number of sick people may be due to wider public awareness of a particular disease, or because nursing staff more frequently investigate and treat risk factors or diseases at an early stage. In other words, the detection of more illnesses among the elderly people does not necessarily mean that they have become sicker. Physical Mobility and musculoskeletal pain Good physical mobility is critically important to the ability to cope on one’s own, and bodily functions such as muscle strength, balance, coordination, and condition are essential in this regard. However, mobility can also be reduced because of pain, which is common among elderly people. The percentage of people who have difficulty moving about increases with age (Table III), and women tend to have poorer mobility than men. The Survey of Living Conditions (ULF) found that mobility among 64 per cent of women and 51 per cent of men in the over-85 age group was impaired to such a degree that assistive devices of some kind were needed. According to the Survey of Living Conditions (ULF), the mobility of elderly people has improved significantly and the percentage of women and men with impaired mobility has declined since the 1980s among younger and older retirees (Figure 7). The percentage of people with severely restricted mobility, i.e. those requiring assistive devices in order to move about, has also declined. This may be explained in part by the decline in stroke morbidity, fewer hip
fractures in the under-84 age groups, and the considerable number of hip and knee surgeries performed in recent years [6]. Although few population studies have tested people’s functional ability and mobility, SWEOLD subjects were asked to undergo several simple functional tests. The tests and interview questions showed that the proportion of people with a functional impairment rose between 1992 and 2002 (Table IV). On both occasions, outcomes in terms of functional ability and self-reported mobility were poorer for women than for men [7]. Musculoskeletal pain is common in the population and increases with age. The Survey of Living Conditions (ULF) found that approximately one in every three women and nearly one in every four men of retirement age reported problems with severe pain (Figure 8). As expected given their poorer mobility, women report more pain than men. The gender disparities are wider among the oldest old than in the age groups immediately following retirement. The percentage of people with severe pain increased in the 1990s, only to decline again in the 2000s. Hearing and vision Hearing and vision impairment is discussed in detail in Chapter 17, Hearing and Vision. However, impaired hearing and vision is common in the elderly population; contact with other people and active participation in the community becomes more difficult for those affected. Table V shows the incidence of hearing and vision impairment in the Survey of Living Conditions (ULF) in 2002–2003. Impaired hearing is today one of the few physical functional impairments that affect men more frequently than women. However, as women live longer than men, elderly women with hearing problems still outnumber men. The most common cause of hearing
Elderly people’s health 103 Women
Per cent 100 80
80
60
60
40
40
20
20 0
0 1980
Men
Per cent 100
1985
1990
1995
2000
2005
1980
1985
1990
75–84 years
65–74 years
1995
2000
2005
85+ years
Figure 7. Impaired mobility. Percentage of people with impaired mobility *. Women and men aged 65–74 and 75–84 for the period 1980–2005**, as well as 85+*** for the periods 1988–1989**** and 2002–2005**. Interviewed directly and indirectly. * Impaired mobility means that the person is unable to run a short distance and is also unable to board a bus unhindered or to take a short walk. **Three years’ moving averages. ***In 1980–1981, only people up to the age of 74 were included in the study. In 1982–1987 and 1990–2001, people up to the age of 84 were included in the study. In 1988–1989 and 2002–2005, there was no upper age limit. ****Refers to averages for 1988–1989. Source: Survey of Living Conditions, Statistics Sweden.
Table IV. Impaired mobility, confirmed by test and self-reported. Percentage of people with impaired mobility, confirmed by test and self-reported. Women and men aged 77–79, 80–84, and 85+, in 1992 and 2002. Direct interviews only. Sex
Confirmed impaired functional ability (1) (2)
Self reported mobility impairments (3)
Age group (years)
1992
2002
1992
2002
48 50 70 56
38 65* 73 63
44 51 69 56
53 67** 75 68**
26 37 57 39
44 47 58 50*
26 32 69 41
35 49 * 64 51*
Women 77–79 80–84 85+ Total Men 77–79 80–84 85+ Total
Significance levels: * 5%, ** 1%. (1) The subject was unable to perform at least one of the following tasks: get up from a kitchen chair without using her/his hands, pick up a pen on the floor from a standing position, touch the toes on her/his left foot with the right hand or the right foot with the left hand from a sitting position, touch her/his right ear lobe with the left hand and vice versa, raise one kilo to shoulder height, place her/his hands under her/his thighs with the palms of the hands turned downward, or twist her/his hands with arms extended. (2) The subject responded that she/he was unable to perform at least one of the following tasks: stand unsupported, get up from a chair without help, walk 100 metes without difficulty, or climb stairs. Source: SWEOLD/Aging Research Center (ARC).
impairments is age-dependent changes in the inner ear. The percentage of retirement pensioners with selfreported hearing problems rose appreciably until the mid-1990s, since when it has remained unchanged [4]. Impaired vision on the other hand is more prevalent among women than men. However, Swedish studies show that vision among older people has generally improved since the beginning of the 1980s. Cataracts
are the most frequent cause of impaired vision among older people, and the most likely explanation for the improvement is the large number of cataract operations currently being performed. Some elderly people suffer from both impaired hearing and vision. In the Survey of Living Conditions (ULF), they report having difficulty hearing what is said in a conversation among several
104 C. Lennartsson and I. Heimerson Women
Per cent 45 40
40
35
35
30
30
25
25
20
20
15
15
10
10
5
5
0
0
1988
93
98
Men
Per cent 45
03
08 2010
1988
93
75–84 years
65–74 years
98
03
08 2010
85 + years
Figure 8. Severe pain – trends over time. Percentage of people who reported severe pain in the neck, shoulders, back, or joints. Women and men aged 65–74 and 75–84 in 1988– 1989* and 1994–2010**, and aged 85+ in 1988–1989* and 2002–2010**. Direct interviews only. *Averages for 1988–1989. **Three-year moving averages. The Survey on Living Conditions (ULF) changed from on-site to telephone interviews in 2006, which could have an impact on comparisons over time. Source: Survey of Living Conditions (ULF), Statistics Sweden.
Table V. Impaired hearing and vision. Percentage of people who have difficulty hearing a conversation among several people and are unable to read a daily newspaper without difficulty. Women and men aged 65–74, 75–84, and 85+, in 2002–2003. Subjects interviewed directly and indirectly. Age group
Impaired hearing
Impaired vision
Impaired hearing and vision
years
Women
Men
Women
Men
Women
Men
65–74 75–84 85+
18 28 53
31 40 58
3 11 27
2 7 19
1 4 18
1 3 14
Source: Survey of Living Conditions (ULF), Statistics Sweden.
people and being able to read a daily newspaper. People suffering from these functional impairments find communicating highly troublesome. They also have a poorer sense of direction. The result is a general deterioration in their ability to function well in daily life. One per cent of women and men in the 65–74 age group report having both a vision and a hearing impairment. In the over-85 age group, the figure rises to 18 and 14 per cent among women and men respectively. Lung function The SWEOLD studies include a test for lung function. The PEF (peak expiratory flow) test checks the peak expiratory flow in litres per minute with the aid of a simple measurement device. The test, which was developed for clinical use, is used for following up on
asthma therapy. Peak expiratory flow has been shown to be strongly linked to people’s general state of health and performance. A link with mortality rates has also been found [8]. Expiratory capacity declines with age, as does the ability to perform the test correctly. The study shows that women in all three age groups developed poorer lung function between 1992 and 2002 (Table VI). For men, mean values from 2002 were nearly the same as in 1992 [7]. Smoking has become more common among elderly women with each succeeding generation, which is probably why lung function in this group has worsened over time. Chapter 10, Tobacco Habits and Tobacco-Related Diseases, cites a rise in mortality among women from chronic lung diseases – mainly induced by smoking – which take a long time to develop.
Elderly people’s health 105 Table VI. Peak Expiratory Flow Rate. Mean/average (in liters/minute) of the peak expiratory flow rate. Women and men aged 77–79, 80–84, or 85+, in 1992 and 2002. Sex
Average (liters/minute)
Age group (years)
1992
2002
302 292 239 279
269* 259** 215 247***
450 398 351 403 331
408 384 371 386 307**
Women 77–79 80–84 85+ Alla Men 77–79 80–84 85+ Total Both sexes
Levels of significance: * 5%, ** 1%, *** 0.1%. Source: SWEOLD/Aging Research Center (ARC)/Center for Health Equity Studies (CHESS). Table VII. Incontinence problems. Percentage of people with incontinence problems. Women and men aged 77–79, 80–84, and 85+, in 1992 and 2002. Subjects interviewed directly and indirectly. Age group
Women
Men
years
1992
2002
1992
2002
77–79 80–84 85+ Totals
32 28 43 34
42 54 63 56
18 28 32 26
42 44 55 47
Source: SWEOLD/Aging Research Center (ARC)/Center for Health Equity Studies (CHESS).
Urinary incontinence Urinary incontinence (involuntary leakage of urine) is a common problem among elderly people according to the 2002 SWEOLD study (Table VII). Moreover, the condition had become more prevalent since the same study was conducted in 1992. A possible explanation for this is that urinary incontinence has become less embarrassing, thereby encouraging more people to report the problem. However, it is likely that many cases still go unreported. Urinary incontinence is more prevalent among women as the muscles in the perineum are often weakened by childbirth and are then further weakened when oestrogen levels fall after menopause. The mucous membranes in the perineum become more fragile after menopause, which increases the risk of urinary leakage. Among elderly men, benign prostate enlargement is a common cause of incontinence. In addition, neurological diseases, dementia,
multiple sclerosis (MS) and Parkinson’s disease can, for example, give rise to incontinence in women and men. Discomfort and feelings of shame can lead elderly people suffering from urinary incontinence to isolate themselves. It also appears that they do not have access to medical examination and treatment to the extent they need [9]. Mental ill-health Aging increases the risk of mental ill-health, a process in which a variety of social, psychological, and biological factors play a part. Elderly people may suffer from states of depression and anxiety due to a loss of social identity after retirement, diminished functional capacity or the loss of a life companion. Mental illness in this context encompasses everything from self-reported mental problems or complaints such as anxiousness, nervousness, anxiety and sleeping problems, to psychiatric disorders such as psychosis or depression. Self-reported mental illness. The Survey of Living Conditions (ULF) includes a number of questions concerning mental health (Table VIII). These show, for example, that problems such as anxiousness, nervousness and difficulty sleeping increase with age and, as in younger age groups, that more women than men are affected. Among the oldest old (over 85), almost one in every three women and nearly one in every five men reports experiencing anxiousness, nervousness or anxiety. Depression, anxiety, and other mental health problems can be normal reactions to mental stress. If the problems become worse or prolonged, they may also be symptoms of a psychiatric disorder. Although sleeping problems may be a sign of worry or anxiety, among older people they are also frequently attributable to various illnesses, urinary incontinence or chronic pain, for example. Apart from a number of relatively marked fluctuations, no clear trend can be observed with regard to the development of feelings of anxiousness, nervousness or anxiety (Figure 9), among elderly men since the 1980s. Among elderly women the prevalence of these health problems has been declining. Elderly people differ in this respect from younger age groups, for which the trend has been significantly less favorable since the mid 1990s. These problems are now about as common among younger as among the elderly people, although impaired mental wellbeing was previously significantly more prevalent among the older fragment of
106 C. Lennartsson and I. Heimerson Table VIII. Self-reported mental health problems. Percentage of people who reported feelings of anxiousness, nervousness or anxiety in the past two weeks; sleeping problems; chronic fatigue; feeling felt sad or down; feeling lonely or forlorn; feeling worthless or inferior. Women and men aged 65–74, 75–84, or 85+, averages for 2002–2005*. Direct interviews only. Complaint
Women
Men
65–74 yrs
Per cent
Nervousness, apprehension, anxiety Sleeping problems Chronic fatigue Sad or down (1) Lonely and forlorn Worthless or inferior (2)
24 35 7 23 10 8
75–84 yrs
85+ yrs
65–74 yrs
75–84 yrs
85+ yrs
15 21 4 15 9 6
17 25 6 20 19 9
Per cent 29 40 9 29 20 10
30 37 12 33 28 12
11 18 3 9 5 3
*In 2002–2003, the wording was as follows: (1) “unhappy or depressed”; (2) “inferior and not worth as much as others.”. Source: Survey of Living Conditions (ULF), Statistics Sweden.
Per cent 40
Women
Per cent 40
35
35
30
30
25
25
20
20
15
15
10
10
5
5
0
0
1980 1985 1990 1995 2000 2005 2010
65–74 years
Men
1980 1985 1990 1995 2000 2005 2010
75–84 years
85 + years
Figure 9. Problems of anxiousness, nervousness or anxiety. Percentage of people who experience feelings of anxiousness, nervousness or anxiety. Women and men aged 65–74 and 75–84 in 1980– 1981*, 1988–1989*, and 1994–2005**, and the 85+ age group in 1988–1989* and 2002–2005**. Direct interviews only. *Averages for 1980–1981 and 1988–1989. **Three-year moving averages. The Survey on Living Conditions (ULF) changed from on-site to telephone interviews in 2006, which could have an impact on comparisons over time. Source: Survey of Living Conditions (ULF), Statistics Sweden.
the population. Mental ill-health is also more common among people who live alone or who have a poor social network. Psychiatric disorders. It is estimated that 10–15 per cent of people aged 65 and over suffer from depression. Some 5 per cent of these suffer from severe depression. Approximately 2 per cent are estimated to have a psychotic disorder and 3–5 per cent a generalised anxiety disorder [10, 11]. The populationbased H70 study in Gothenburg found that approximately 30 per cent of all people over the age of 70 had a mental illness of a more or less severe
nature [6]. However, depression, anxiety, psychotic symptoms and personality changes may be early signs of dementia. Conversely, mental illness in elderly people can also be mistaken for dementia. Consumption of psychopharmaceutical drugs. More women than men purchase psychopharmaceutical drugs to treat depression, anxiety and sleeping problems, according to Apoteket AB’s sales figures (Figure 10). Most of these drugs are purchased by people 85 years or older. Sleeping pills are the most frequently bought medication. Approximately 30 per cent of women and 20 per cent of men in the over-85
Elderly people’s health 107 Per cent
Women
50
Per cent 50
40
40
30
30
20
20
10
10
0
0
65–74 yrs
Men
75–84 yrs
85+ yrs
Figure 10. Psychopharmaceutical drugs purchased on prescription. Percentage of people who have purchased neuroleptic or antidepressant drugs, tranquilisers or sleeping pills on prescription at a pharmacy. Women and men aged 65–74, 75–84, and 85+, 2007. Source: Swedish Prescribed Drug Register, Swedish National Board of Health and Welfare.
age group purchase some form of antidepressant, and tranquilisers are almost as common. In the over85 age group, 10 per cent of women and 8 per cent of men purchase neuroleptic (antipsychotic) drugs on prescription. The Swedish National Board of Health and Welfare has noted that many elderly people are prescribed an inordinately large number of medications, in exceptionally high doses (see Chapter 18, Prescription Drugs). The risk of over-medication is especially high in the case of treatment with psychopharmaceutical drugs as states of depression and anxiousness are common among older people and difficult to assess, and specialised knowledge in geriatric psychiatry is limited. There are also considerable regional disparities in prescribing psychopharmaceutical drugs for the elderly. Figure 11 shows the percentage by county of all prescription drug users in the over-80 age group who have purchased at least three different kinds of psychopharmaceutical drugs. While many elderly people are being over-medicated numerous cases of mental ill-health among the older people are going undetected. One reason is the notion that it is natural to feel tired of life as one grows old. Moreover, many – not least the elderly people themselves – experience mental illness as stigmatising and may therefore seek help for physical symptoms instead. Thus mental illness can heighten the need for other types of care and attention [12]. The Swedish National Board of Health and Welfare considers that insufficient care and attention has been given to elderly people with mental illnesses and complaints and has therefore proposed a series of measures that include a common strategy for improving care [11].
Norrbotten Gotland Kalmar Jämtland Örebro Västmanland Södermanland Dalarna Stockholm Östergötland Västernorrland Jönköping Gävlebrog Värmland SWEDEN Västerbotten Blekinge Uppsala Skåne Halland Kronoberg V. Götaland 0
2
4
6
8 10 Per cent
Figure 11. Psychpharmaceutical drug consumption – a regional perspective. Percentage of people prescribed three or more psychopharmaceutical drugs, by county. People aged 80+, October–December 2007. Source: Official comparisons of the quality and effectiveness of health and medical care in 2008, Swedish National Board of Health and Welfare [13].
108 C. Lennartsson and I. Heimerson Number per 100,000 80
Women
Number per 100,000 80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
0 1970
Men
0 1980
1990
2000
2010
1970
65–74 yrs
1980
1990
2000
2010
75+ yrs
Figure 12. Suicide. Number of deaths by suicide (conclusive and inconclusive cases) per 100,000. Women and men aged 65–74 and 75 or older, 1970–2010. Source: Cause of Death Register, Swedish National Board of Health and Welfare.
Suicide In 2010, 80 women and 208 men over the age of 65 committed suicide. Suicide is more common among men who have reached the age of 75 than in the 65– 74 age group. Among women, however, there is no appreciable difference between these age groups. Nevertheless, the suicide rate among elderly people is declining, especially among men (Figure 12). A quarter of all suicides occur among people over the age of 65.
Table IX. Prevalence of dementia. Percentage of women and men, in 1993, who suffer from some form of dementia. Various age groups over the age of 75. Age group
Percentage with dementia
years
Per cent
75–79 80–84 85–89 90–94 95+
14 19 25 37 48
Source: von Strauss, Viitanen, De Ronchi, Winblad, Fratiglioni.
Dementia Dementia is a common cause of functional impairments and dependency of elderly people on the help of others. Dementia also frequently contributes to other health problems among the elderly people, e.g. falling accidents, burn injuries and urinary incontinence. In Sweden, roughly half of all people who suffer from dementia live in special housing. Dementia can manifest itself in different ways, but all those who develop the disease suffer a gradual deterioration of their intellectual functions. Among the symptoms are personality changes, depressive or psychotic episodes (chiefly delusions), and behavioral disorders such as aggressiveness, screaming, or wandering. The severity of the symptoms depends on the extent of brain damage and on the individual’s interaction with their surroundings. Assisting a person suffering from dementia therefore requires knowledge and commitment. It is estimated that some 142,000 people suffer from some form of dementia in Sweden. The percentage of
elderly people with a dementia disorder doubles with each successive 5-year age group over the age of 65 (Table IX). It is estimated that 1.5 per cent of people in the 60–64 age group suffer from dementia, while nearly half of those over the age of 95 have the disorder. Women run a greater risk of developing dementia than men of the same age. As the proportion of women in the very oldest age groups is considerably larger than that of men, significantly more women than men suffer from senile dementia. Studies from different parts of the world have not demonstrated any clear-cut differences in the geographical distribution of dementia. Nor has it been possible to determine whether the risk of developing the disease has increased or decreased. However, the number of people suffering from dementia will probably continue to grow given the rise in the number of elderly people [15–18]. Alzheimer’s disease is the most common form of dementia; it accounts for 50–60 per cent of all cases. Approximately 20–25 per cent of dementia cases are
Elderly people’s health 109 Table X. Protective and risk factors for dementia.
Strong scientific evidence Weaker scientific evidence
Protective factors
Risk factors
Physical activity Mental activity late in life Treatment of hypertension Dietary factors Moderate alcohol consumption Good social network late in life Physical activity in middle age Antioxidants
Diabetes Strokes Hypertension in middle age High cholesterol Smoking Obesity Hypertension late in life Low blood pressure late in life Heart failure “Silent” strokes Depression Low socioeconomic status Head trauma Inflammation markers Vitamin A, B12, C, E or folic acid deficiency
Source: Fratiglioni, L. et al., 2007; Qiu, C et al., 2007.
caused by arteriosclerosis. The remainder is the result of other neurological diseases such as Parkinson’s disease. Some of the protective and risk factors associated with dementia are shown in Table X. The most important strategies for preventing dementia involve the prevention and treatment of risk factors for cardiovascular diseases, such as hypertension, diabetes, overweight, smoking, etc., along with the promotion of an active and stimulating lifestyle for elderly people. Neuroleptics are a group of drugs mainly intended for the treatment of psychoses. However, it is not uncommon for people suffering from dementia to be prescribed these medications for the treatment of nervous conditions. Recently, however, treatment with neuroleptics has been called into question as the drugs can have serious side effects in elderly people. The Swedish National Board of Health and Welfare has developed guidelines on the treatment of dementia. These recommend reduced use of such drugs. Better psychosocial care may in certain cases reduce the need for psychopharmaceutical drugs. Falling injuries, fractures, and osteoporosis Falling injuries are common among elderly people. Every year, approximately one in three people aged 60 years or older, and one in two over the age of 80 sustain such injuries [15]. These accidents can – particularly among the oldest old – cause injuries resulting in impaired physical mobility and increased dependency on others. At a time when a growing number of diseases are being treated successfully,
musculoskeletal functioning is becoming increasingly important to the quality of life of elderly people and to their ability to manage everyday tasks. Dizziness is fairly common among elderly people and can be a cause of falling accidents. Problems with dizziness and balance can be a consequence of natural aging and declining muscle strength. However, it is often also the result of acute or chronic illness or drug treatment. Even relatively mild illnesses such as urinary tract infections can impair balance in an elderly and frail person. Nearly 40 per cent of all hip fractures occur in homes for the elderly or in hospitals [16]. A large number of falling accidents in hospitals are the result of acute states of confusion, which are in turn caused by other acute illnesses or the side-effects of medication [15]. Many falling accidents and fractures are also caused by slipping on or tripping or stumbling over ‘hazards’ such as loose rugs, doorsteps or slippery indoor or outdoor surfaces. Osteoporosis is an important reason why elderly people suffer fractures in falling accidents more easily than younger people. Bone density declines with age and the skeleton becomes increasingly brittle. This process begins at the age of 30, but individuals vary widely. Steps can be taken, however, to prevent the condition; physical activity appears to have a preventive effect, while smoking and high alcohol consumption increase the risk of osteoporosis. The development of osteoporosis is hastened in women due to declining oestrogen levels. People with a high risk of fractures can be treated with calcium and vitamin D or other preventive medicines. In cases of severe osteoporosis, even a mild trauma is sufficient for a person to sustain bone cracks or
110 C. Lennartsson and I. Heimerson Women
Number 6,000
Number 6,000
5,000
5,000
4,000
4,000
3,000
3,000
2,000
2,000
1,000
1,000 0
0 1994
Men
1998
2002
2006
2010
65–74 yrs
1994
1998
75–84 yrs
2002
2006
2010
85+ yrs
Figure 13. Hip fractures. Number of hip fracture surgeries (first-time cases). Women and men aged 65–74, 75–84 and 85+, 1994–2010. Source: Swedish National Patient Register, Swedish National Board of Health and Welfare.
fractures. At current risk levels, one in every two middle-aged women and one in every four men will sustain a fracture as a result of osteoporosis at some time in their lives. People with osteoporosis often undergo a kind of ‘fracture career’. Wrist fractures are most frequent in the 55–65 age group, while vertebra and hip fractures usually occur approximately 15 years later. Between 5 and 10 per cent of people who have had a hip fracture also suffer a second hip fracture [17]. The risk of sustaining a hip fracture has declined in all elderly age groups: 65–74, 75–84, and over 85, since the mid 1990s. Surgery is performed on nearly all hip fractures. The number of women and men over the age of 85 receiving surgery for first time hip fractures has steadily risen since at least 1994, despite the reduction in the risk of hip fractures (Figure 13). This is because the population in this age group has also increased. Although the number of women in the entire over-65 age group who sustain first-time hip fractures today is approximately the same as at the beginning of the 1990s, their average age has increased. Hip fractures are followed by an extended period of rehabilitation to allow the patient to regain muscle strength and function. In a study based on casualty records from Södersjukhuset in Stockholm, only half the hip fracture patients regained their previous functional status one year after the fracture was sustained [12]. The RIKSHÖFT national quality register for hip fracture patients and their treatment has shown that only 75 per cent of those who were living in their own homes at the time of the fracture, were able to return 120 days after the fracture occurred [16].
Cardiovascular diseases Cardiovascular diseases cause more deaths than any other disease group. Most such deaths affect people over retirement age. Ninety-six per cent of women and 89 per cent of men who die of a cardiovascular disease – of which the most commonly occurring are heart attacks and strokes – have reached their 65th birthday. Cardiovascular diseases are also a common cause of functional impairments among the elderly people [18]. Strokes in particular often lead to permanently impaired mobility in the arms and legs, aphasia or other symptoms. Heart failure, angina pectoris and claudication (constriction of the leg arteries with ensuing exertion-related cramps) also reduce mobility. However, it is easier to measure cardiovascular mortality than to determine the prevalence of functional impairments resulting from these diseases. As we have seen, cardiovascular mortality has declined in the elderly population. The risk of developing a heart attack or stroke has also declined in each given age group, and morbidity has shifted to the older age groups (Figure 14). The figure shows that the most frequent age for a first-time heart attack shifted from 82 to 84 years for women and from 74 to 83 years for men in the period from 1994–1996 to 2004–2006. The most frequent age for first-time stroke morbidity remains the same, at 83 years for women, while for men it has shifted from 75 to 81 years. Thus people are more likely to have heart attacks and strokes when they are significantly older. This constitutes a public health gain as more healthy years have been added to people’s lives. However, this shift does not necessarily mean that fewer people overall
Elderly people’s health 111 Myocardial infarctions Number
Number 800
Women
800
600
600
400
400
200
200
0
Men
0 65
70
75
80
85
90
95
100
65
70
75
80
85
90
95
100 Age
85
90
95
100 Age
Strokes Number
Number 800
Women
800
600
600
400
400
200
200
0
Men
0 65
70
75
80
85
90
95
100
1994–1996
65
70
75
80
2004–2006
Figure 14. First-time myocardial infarctions and first-time strokes in various age groups. Number of people who suffered first-time myocardial infarctions and first-time strokes in various age groups. Women and men aged 65–100, averages for 1994–1996 and 2004–2006. Source: Swedish National Patient Register and Cause of Death Register, Swedish National Board of Health and Welfare.
are developing these diseases. Since elderly people make up an ever greater percentage of the population, more will suffer from these diseases unless the risk of morbidity changes. Although the risk of disease is declining somewhat, the real number of cases could actually be on the increase [19]. However, the risk of suffering a stroke has declined so significantly that the morbidity rate has also fallen, despite an aging population. The number of cases of first-time stroke among people aged 65–100, dropped by 8 per cent for women and 9 per cent for men between 1994–1996 and 2004–2006. In the same period, the actual number of first-time myocardial infarctions among men also declined by 6 per cent, while the number for women increased by 4 per cent in the 65–100 age group. Among the likely explanations for the reduced risk of suffering a heart attack or stroke are decline in the prevalence of smoking, lower blood fat levels and lower blood pressure in the population. Medical care
following a stroke or heart attack has also improved in recent years, leading to a higher survival rate, with fewer functional impairments and a better quality of life [20, 21]. A detailed discussion of cardiovascular diseases can be found in Chapter 7, Overweight, Cardiovascular Disease and Diabetes. Cancer among older people Approximately two-thirds of all people who develop cancer are 65 years or older. The most common forms of cancer among women over the age of 65 are breast cancer, colon and rectal cancer, lung cancer and uterine cancer (Table XI). Men suffer mainly from prostate cancer, colon and rectal cancer, lung cancer and urinary bladder cancer. Cancer is more frequent among men than women over the age of 65, mainly due to the prevalence of prostate cancer among older men.
112 C. Lennartsson and I. Heimerson Table XI. Cancer in people aged 65 or older. Cancer morbidity in 2006 and cancer mortality in 2005 for some common types of cancer among women and men aged 65 or older. Number and number per 100,000 inhabitants, and percentage of all cancer diagnoses and cancer deaths in this age group. Women Number Cancer diagnoses Cancer deaths Per cent of total Cancer diagnoses Cancer deaths Number per 100,000 Cancer diagnoses Cancer deaths Men Number Cancer diagnoses Cancer deaths Percent of total Cancer diagnoses Cancer deaths Number per 100,000 Cancer diagnoses Cancer deaths
All cancers Breast
Colo-rectal Malignantskin Lungs tumorsexcl. melanoma
14,010 7,761
3,144 964
2,036 1,028
100 100
22 12
15 13
1,575 877
353 109
229 116
1,522 17 11 0.2 171 2
Uterus Malignant Ovary melanoma
Pancreas
927 1,043
871 142
524 120
392 386
290 631
7 13
6 2
4 2
3 5
2 8
104 118
98 16
59 14
44 44
33 71
All cancers Breast
Colo-rectal Malignantskin Lungs tumorsexcl. melanoma
Uterus Malignant Pancreas melanoma
17,806 9,126
6,314 2,296
2,186 1,057
2,048 24
1,269 412
1,202 1,432
618 165
271 519
100 100
36 25
12 12
12 0,3
7 5
7 16
4 2
2 6
2,604 1,353
923 340
320 157
300 4
186 61
176 212
90 25
40 77
Source: Cancer Register, Swedish National Board of Health and Welfare.
Significantly more people develop cancer than die of it. Some are cured while others die of some other cause. Mortality varies with different types of cancer: among women most deaths result from lung cancer and colon and rectal cancer, although more women develop breast cancer, which has a better prognosis. Prostate cancer is the most common form of cancer among men over the age of 65, both in terms of incidence and mortality. The percentage of men aged 65 or older who develop cancer has risen, while cancer mortality has remained essentially the same since the mid 1980s (Figure 15). The increase in the incidence of cancer among men is largely because more men are diagnosed with prostate cancer. Cancer morbidity among women has also risen slightly, although mortality has remained the same. The rise in the incidence of prostate cancer is probably due mainly to the introduction of a new diagnostic method, the PSA test (prostate specific antigen). A simple blood sample can give a good indication of whether prostate cancer should be suspected. A definitive diagnosis can then be made through a tissue biopsy from the prostate gland. Increased use of the PSA test has led to the detection of more patients with prostate tumors that grow so slowly that they will not lead to premature death. Increased testing has also meant that younger men
are being diagnosed with early prostate cancer, which has to a certain extent brought about a decrease in the number of more advanced cases of the disease. The prostate cancer mortality rate has largely remained the same since the end of the 1990s. Women frequently develop breast cancer before the age of 65. The incidence in this age group has risen, a subject discussed in Chapter 4, Health in the Working-Age Population. The percentage of women aged 65 or older who develop breast cancer has also increased, although breast cancer mortality has declined. On the other hand, lung cancer morbidity and mortality have increased among elderly women, and cases have doubled since the 1970s. The number of men who develop lung cancer has, however, fallen since the 1980s. These developments reflect trends in tobacco smoking; smoking has declined among elderly men but increased among elderly women (see below and Chapter 10, Tobacco Habits and Tobacco-Related Diseases). However, it is still the case that more men than women in the over-65 age group develop lung cancer. Approximately the same number of men and women develop the disease in the population as a whole. Colorectal cancer morbidity has increased somewhat among the elderly people. However, mortality has declined probably due to improved treatment methods [22].
Elderly people’s health 113 Number per 100,000 3,000
Cancer totals
Number per 100,000 300
2,500
250
2,000
200
1,500
150
1,000
100
500
50 0
0 1960
Lung cancer
1970
1980
1990
2000
2010
1960
1970
1980
1990
2000
2010
Prostate cancer
Breast cancer
Number per 100,000 1,200
Number per 100,000 450 400
1,000
350 800
300 250
600
200 400
150 100
200
50 0
0 1960
1970
1980
1990
2000
2010
1960
1970
1980
Incidence, women
Incidence, men
Mortality, women
Mortality, men
1990
2000
2010
Figure 15. The cancer trend among the elderly. Total cancer incidence (number per 100,000) and total cancer mortality, including prostate cancer, breast cancer, and lung cancer, among women and men aged 65 or older, in 1960–2010. Note the different ranges*. Standardised by age. *The higher incidence of cancer in the 1970s is attributable to the broader definition of cancer in use at the time; thus cancer was more frequently identified as the underlying cause of death. Source: Cancer Register, Swedish National Board of Health and Welfare.
Multiple morbidity and prescription drug consumption The probability of developing several illnesses concurrently (so-called multiple morbidity) increases with age. Having many illnesses at the same time affects a person’s quality of life, her/his ability to function physically and her/his health and medical care needs [23]. People suffering from multiple illnesses often require help from a number of caregivers. However, major deficits exist in terms of coordinating the interventions necessary for those suffering from concurrent illnesses [23]. Moreover, benefit systems in primary care that encourage many brief patient visits
can aggravate the clinical conditions of people with several, often complex, health problems. As noted previously, there has been an increase in recent decades in the percentage of elderly people who report having a longstanding illness. At the same time, a decreasing proportion is reporting diseases and problems which interfere with their daily lives. The percentage who report having three or more illnesses or health problems has risen more than the proportion who report having only a single disease or complaint (Figure 16) [5]. Elderly people suffering from multiple illnesses often take many different medications daily, in some cases more than ten, thus inducing a heightened risk of over-medication, drug interactions and side effects.
114 C. Lennartsson and I. Heimerson Per cent
Men
Per cent
Women
45
45
40
40
35
35
30
30
25
25
20
20
15
15
10
10
5
5
0
0
1980
1985
1990
1995
2000
2005
65–74 years
1980
1985
1990
75–84 years
1995
2000
2005
85+ years
Figure 16. Three or more longstanding illnesses or complaints. Percentage of people with at least three longstanding illnesses or problems. Women and men aged 65–74 and 75–84, in 1980–2005*, and 85+ in 1988–1989** and 2002–2005*. Subjects interviewed directly and indirectly. *Three year moving averages. **Averages for 1988–1989. Source: Survey of Living Conditions (ULF), Statistics Sweden.
Per cent
Women
Men
60 50 40 30 20 10 0 65–74
75–84
1980/81
85+
1988/89
65–74
1996/97
75–84
2004/05
85+
Age
Figure 17. Regular exercise. Percentage of people who exercise regularly at least once a week. Women and men aged 65–74, 75–84 and 85+, in 1980–1981, 1988–1989, 1996–1997 and 2004–2005. Direct interviews, except for subjects residing in an institution. Source: Survey of Living Conditions (ULF), Statistics Sweden.
With many medicines to keep track of, the risk of error when handling and administering medication also increases. Wrong treatment and drug side effects are common causes of hospitalisation among elderly people [24]. Quality indicators have been jointly developed by the Swedish National Board of Health and Welfare and the Swedish Association of Local Authorities and Regions (SALAR) [25] and the quality of drug therapy for elderly people has been evaluated and discussed in a number of reports, [1, 26,
27]. Drug therapy for elderly people is also discussed in Chapter 18, Prescription Drugs. Lifestyle habits Healthy lifestyle habits reduce the risk of contracting most of the major national diseases. They also have an immediate positive effect on wellbeing and help ensure that people remain healthy and vigorous well into old age.
Elderly people’s health 115 Per cent
Women
Men
60 50 40 30 20 10 0 65–74
75–84
1980/81
85+
1988/89
65–74
1996/97
75–84
2004/05
85+
Age
Figure 18. Overweight. Percentage of people who are overweight or obese (BMI* 25 or higher). Women and men aged 65–74, 75–84 and 85+, in 1980–1981, 1988–1989, 1996–1997, and 2004–2005. Direct interviews only. Source: Survey of Living Conditions (ULF), Statistics Sweden.
Elderly people exercising more Elderly people today exercise more than earlier generations (Figure 17), and the percentage of wholly inactive people has declined. More people are devoting time to gardening, walking or rambling in the fields or woods [28]. Elderly people may be growing more active thanks to an improved ability to function physically. Conversely, physical activity enables people to maintain good functional capacity. Men exercise more than women in all age groups above retirement age. One reason may be that impaired mobility and pain are more common among women (see above). Importance of tasty food and well-balanced diets Although the body’s energy requirements decline with age, elderly people require nutrients just as much as younger people. It is therefore even more important for elderly people to eat food containing plenty of nutritional value in relation to its energy (caloric) content. It may be difficult for some elderly people to adapt to a reduced energy requirement – an inability that increases the risk of overweight. Obesity places a heavy burden on the heart and the body’s musculoskeletal system. Among the older adults in particular, obesity can reduce their ability to exercise and cope with their daily activities. However, moderate overweight should rather be seen as a sign of health in elderly people as serious illnesses often lead to weight loss. The 2005 Survey of Living Conditions (ULF) found that just over half of all women and men above retirement age were overweight, i.e. had a BMI of 25 or above (Figure 18). Approximately 10 per cent of
men and nearly 20 per cent of women suffered from obesity (BMI of 30 or above). There are more overweight people among the elderly than among younger people. However, after retirement age the percentage of overweight people declines with age. Overweight has become more prevalent among older adults, as it has in the population at large, although it has not increased as much as it has among the younger members of the population. Underweight is often a sign of ill-health among elderly people. A common cause of underweight is lack of appetite, which may be due to a variety of causes including poor dental health, medication, sedentariness, difficulty in swallowing, constipation, lack of social contacts and/or a diminished sense of smell and taste. Serious illnesses also often involve loss of appetite and weight loss. At the same time, sick people find shopping and cooking more difficult. It is therefore particularly important that the food provided by elderly care services are well balanced, appetizing, and tasty. Smoking on the decline among men but not among women Smoking among elderly men has been declining steadily for many years now (Figure 19). A gradual decline among women aged 65–74 has also been observed since the early 1990s. However, the percentage of smokers among women over the age of 75 continues has been rising, except for the last few years. Thus at the start of the 2000s, the number of men and women smokers in the 65–84 age group was approximately equal.
116 C. Lennartsson and I. Heimerson Per cent 35
Men
Per cent 35
Women
30
30
25
25
20
20
15
15
10
10
5
5
0
0
1980 1985 1990 1995 2000 2005 2010
1980 1985 1990 1995 2000 2005 2010
75–84 years
65–74 years
85+ years
Figure 19. Smoking on a daily basis. Percentage of women and men aged 65–74 and 75–84 in 1980–2010* and aged 85+ in 1988–1989** and 2002–2005* who smoked on a daily basis. Direct interviews only. *Three-year moving averages. The Survey on Living Conditions (ULF) changed from on-site to telephone interviews in 2006, which could have an impact on comparisons over time. **Averages for 1988–1989. Source: Survey of Living Conditions (ULF), Statistics Sweden.
Table XII. Self-assessed alcohol consumption. Self-assessed alcohol consumption (in litres of 100 per cent alcohol per person), women and men aged 65-80, 2004–2010. 100% alcohol (in liters/person)
2004
2005
2006
2007
2008
2009
2010
Women Men
1.5 3.3
1.6 3.9
1.5 4.2
1.6 3.7
1.7 4.2
1.7 4.2
1.7 4.2
Source: Ramstedt et al.
Elderly people drink less alcohol than younger people People over retirement age drink significantly less alcohol than younger people. As is also the case in other age groups, however, men drink more than women. Studies of self-assessed alcohol consumption show that consumption among elderly people has risen in recent years (Table XII). However, selfassessed alcohol consumption tends to be lower than actual alcohol consumption as many people underestimate the amount they drink. The self-assessments of all age groups combined only add up to approximately 30–40 per cent of the volume of alcohol actually sold [29]. Mortality from alcohol-related diagnoses has steadily increased among women and men aged 65–74 since the beginning of the 1990s (see also Chapter 11, Health Consequences of Alcohol and Narcotics Abuse). Alcohol-related mortality is also significantly more frequent among men.
Social factors Socioeconomic differences in health Today’s elderly people have grown up in more favorable conditions than earlier generations; they have a higher level of education, greater financial wealth, and a higher material standard of living. With a larger proportion of the population in gainful employment, the percentage of people who receive only a national basic pension has declined. These are probably some of the more important factors behind the favorable health trend that has been evident in Sweden for some considerable time. Economic trends in the past decade have also favored the older more than younger age groups. Elderly people were less hard hit by the economic crisis at the beginning of the 1990s and the generational gap in terms of financial prosperity has increased since then [30]. However, gender and socioeconomic disparities in living conditions continue after retirement age. For example, men’s pensions are about 60 per cent larger on average than
Elderly people’s health 117 Per cent
Severe pain in the shoulders or back
Poor state of health
30 25 20 15 10 5 0
Women
Men
Women
Manual workers
Men
Non-manual workers
Figure 20. Socioeconomic disparities in health. Percentage of people who reported a poor or very poor state of health or severe pain in the shoulders or back, among blue- or white-collar workers. Women and men aged 65–84, averages for 2000–2005. Direct interviews only. Source: Survey of Living Conditions (ULF), Statistics Sweden.
Number 600,000 500,000 Home-help users in regular housing
400,000
People aged 80+ 300,000 200,000
People in special housing
100,000
Total number of help users
0 1960
1970
1980
1990
2000
2010
Figure 21. Home-help service users and people in special housing. Number of home-help service users in regular housing, number of people in special housing for the elderly, and number of people in the population aged 80 or over, 1960–2010. Source: Swedish National Board of Health and Welfare [34].
women’s, according to Statistics Sweden’s Household Budget Survey (HBS). Socioeconomic health inequalities, in terms of most illnesses and health problems, exist among older, as they do among younger people. Figure 20 shows that a poor general state of health and severe pain are more common among elderly people who were formerly blue-collar workers than among former white-collars. The SWEOLD study, too, shows significant health inequalities between blue- and white-collar workers. Almost twice as many retired blue-collar workers view their health as worse than “good,” compared
with retired upper-level and mid-level white-collar workers. Moreover, blue-collar workers were more likely than white-collar workers to report impaired mobility, poor self-rated health, problems with pain and psychological distress. Social class inequalities with respect to these health problems have remained the same between 1991–1992 and 2000–2002 [31]. Housing and assistance needs A growing number of elderly people remain in their own homes well into old age. In the 1960s and 1970s, the number of places in special housing for the oldest
118 C. Lennartsson and I. Heimerson Per cent 40
Women
Men
35 30 25 20 15 10 5 0 65–74
75–84
85+
Age
2000
65–74
75–84
85+ Age
2007
Figure 22. Special housing for the elderly. Percentage of people in special housing for the elderly as of October 31, 2000 and October 31, 2007. Women and men aged 65–74, 75–84 and 85+. Source: Swedish National Board of Health and Welfare [35, 36].
old increased (Figure 21) but no new places have been added since the mid 1980s. In recent years, moreover, the number of places has declined by over 20 per cent. Reduced access to special housing has not been matched by a corresponding decline in the need for healthcare and social services. Rather the halt in construction of special housing in the 1980s is viewed as a reaction against the very considerable expansion in institutional living that took place in the 1960s and 1970s, described in contemporary studies as “unnecessary” referrals to institutions [32]. Since then, the trend has been driven by a combination of weaker public finances and changing views on how best to care for elderly people in need of assistance [33]. Approximately 6 per cent of women and 5 per cent of men in the 75–84 age group lived in special housing in 2007 (Figure 22). In the over-85 age group, 12 per cent of women and 17 per cent of men lived in institutional housing. This represents a decline of approximately 22 per cent for women and 8 per cent for men since 2000. This decline is the result of a deliberate policy of reducing institutional living and investing in home healthcare and social services instead. Thus more women than men live in institutions, and institutional living is more common among people from working-class backgrounds than among those from white-collar backgrounds. Institutions today only provide places for the seriously ill, which means that the burden of care for the oldest old in special housing has increased markedly [37]. Currently, most places are reserved for people suffering from dementia and are unable to fend for themselves at home. Moreover, significantly more women than men require, and receive, old age care.
More women live alone when they grow old and need assistance, while men are likelier to have a wife during the period in their lives when they have difficulty fending for themselves. The number of care places in hospitals has also declined significantly as a result of efficiency enhancements and spending cuts. Between 1992 and 2006, the number of beds in geriatric wards and hospital wards declined by 74 per cent and 31 per cent respectively. Many elderly people are consequently being discharged from hospital, despite their relatively large need for medical care and rehabilitation, thereby adding to the burden of care in special housing accommodation for the oldest old. Elderly people who would previously have been offered places in special housing are now living at home or relying on home-help services instead. Home-help services consequently have to care for more people with substantial needs. Figure 21 shows that the actual number of people receiving home-help assistance has declined significantly since the 1980s, despite the rise in the number of people aged 80 or older by more than 20,000 in the same period. Many elderly people want to be cared for at home as long as possible. Others, particularly those who live alone, may experience considerable apprehension and anxiety about not having access to around-theclock attention when they feel they are no longer able to fend for themselves. However, loneliness, along with depression and feelings of insecurity, are rarely taken into account when processing applications for municipal old age care, Instead, applications are mainly assessed on the basis of applicants’ functional
Elderly people’s health 119 capacity, their physical needs and the municipality’s ability to provide home-help services [1]. A good deal of formerly publicly financed and remunerated care is now being provided by the family in the form of “unpaid care”, and through privately purchased services. This change reveals a clear gender and social class bias: poorly educated older people often have family members as caregivers, and daughters in working class families have assumed increased responsibility for family members. Purchasing private care services is more common among well-educated elderly people [38]. International perspectives There are major disparities between European countries in how elderly people perceive their own general state of health. In Lithuania and Hungary, for example, less than 9 per cent of people in the 65–74 age group report having good or very good health. Only 6 per cent do so in Latvia, which ranks bottom of the list. These figures can be compared with Denmark, Ireland, Sweden, and Great Britain, where over 60 per cent view their own health as good or very good. In the EU27 region, period life expectancy at 65 is longest in France: 23 years for women and just over 18 years for men respectively. The shortest period life expectancy at age 65 is 16 years (among Bulgarian women) and 13 years (among Latvian men). As stated earlier, Swedish women live an average of 21 years after reaching the age of 65. The corresponding figure for Swedish men is 18 years. Acknowledgments The authors wish to acknowledge the help of Laura Fratiglioni and Mats Thorslund. Funding This research received no specific grant from any funding agency in the public, commercial or not-forprofit sectors. References [1] Socialstyrelsen (The National Board of Health and Welfare). Vård och omsorg om äldre [Elder Care and Attention]. Stockholm: 2008. Lägesrapporter 2007. [2] Statistiska centralbyrån (Statistics Sweden). Sveriges framtida befolkning 2008–2050 [Sweden’s Estimated Future Population, 2008–2050]. Stockholm: 2008. Statistiska meddelanden BE 18 SM0801. [3] Blaxter M. Health and Lifestyles. London and New York: Routledge, 1990. [4] Parker MG, Schön P and Thorslund M. Utvecklingen av äldres funktionsförmåga [Trends in the Functional Capacity of the Elderly]. In: Vogel J, Häll L, ed. Äldres levnadsförhållanden; Arbete, ekonomi, hälsa och sociala nätverk 1980– 2003 [The Elderly’s Living Conditions: Work, Finances,
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