1. The Implications of an Aging Population
Steven P. Wallace, Ph.D.
Professor, UCLA School of Public Health
Assoc. Dir., UCLA Center for Health Policy Research
The reading for today is now 10 years old, but unfortunately the trends and issues it raises are still relevant today.
Key points:
Demography Is Not Destiny
Medicare: Myth versus Reality (not affluent beneficiaries, not overgenerous benes, not inefficient; restructuring?)
LTC & end of life need work
Can Promote health of older adults
Challenges – shared prosperity, pt centered care,
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2. Today’s talk Why is American growing older? Should we care?
Nation’s health promotion goals
Public health approach to aging

3. 1. Why is American growing older?
The Implications of an Aging Population
1. Why is American growing older?
Population versus individual aging
How Many People have Family age 65+, 75+, 85+
How Many aspire to live to at least 65? How many want a sick and dependent old age?
Interests in child health, AIDS, environmental health, etc ... all work to help people live to old age... so don't stop!
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4. The Implications of an Aging Population
Fertility changes past century Annual live births per 1,000 women aged years
Note high rates at beginning of 1900s 127/1000 in 1910
Depression bottom 76
Baby boom generation ( )
Stable birth rates since mid-60s
2008
SOURCE: NCHS, &
& Health U.S., 2011
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5. Total fertility Number expected lifetime births per woman
The Implications of an Aging Population
Total fertility Number expected lifetime births per woman
How many of you are only children?
Children ever born, women age 40-45
SOURCE: NCHS,
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6. Percent women 40-45 w/o kids
The Implications of an Aging Population
Percent women w/o kids
About half wanted children & did not have them; the other half never wanted kids
SOURCE: Pew Research Center, 2010
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7. = Fewer babies

8. The Implications of an Aging Population
Concentration of death in old age In 1900, 41% live to old age, in % do
* In 1900, 1/5 white and 1/3 black children did not survive their 10th birthdays. Only 41% newborns made it to age 65; today 83% do. Over 1/3 make it to 85 (vs. under 1/10 in 1900). [Table 10]
* Improvements in survival post 1950 MOSTLY among older adults
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9. The Implications of an Aging Population
Life expectancy at age 65
50% increase in last century
white total life expectancy 1900=49.6 years, 2004=78.3
Black total life expectancy 1900=33.8 years, 2004=73.1
IMPORTANT to add life to years, not just years to life
Source:
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10. The Implications of an Aging Population
Life expectancy at age 65
Racial disadvantage continues into old age
Source:
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11. The Implications of an Aging Population
Why is America aging?
Declining birth rates = fewer kids
Declining mortality rates = more elderly
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12. Population, Number Kids & Elders, 1900 - 2050
The Implications of an Aging Population
Population, Number Kids & Elders,
Number of elderly will double in 30 years
2040=81.2 million
2010=40.2 million elderly
Relatively easy to predict the # of elders in the future
2010 forward:
Source: U.S. Bureau of the Census, p & historical statistics
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13. Minority elderly population, 2000-2010
The Implications of an Aging Population
Minority elderly population,
Numbers triple 30 years
2030=17.6 million
Relatively easy to predict the # of elders in the future
2000=5.6 million
Source: U.S. Bureau of the Census, p & historical statistics
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14. The Implications of an Aging Population
Percent 65+, 1950 to 2050
Baby boom
1950: China, Japan, Egypt all had low % (5) elderly. Japan changed fastest, China coming on soon as one-child policy works into adulthood. Will be first country to become “old” before it becomes “rich.” Egypt still very young!
US 8% to 16% in 70 years( )
Italy 8% - 16% in 45 years
Japan 8% to 16% in 25 years
China 8% to 16% in 20 years ( )!
2000
Source: World Population Prospects: The 2008 Revision,
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15. Growing Diversity of Elderly in California, % nonLatino white
The Implications of an Aging Population
Growing Diversity of Elderly in California, % nonLatino white
The composition of California’s elders is also changing rapidly. Not long ago it was 2/3 nonLatino white. The latest projections show a pretty linear decline in the coming years in the proportion white.
Source: California Department of Finance, January 2013
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16. Growing Diversity of Elderly in California
The Implications of an Aging Population
Growing Diversity of Elderly in California
By 2050, the largest group of elders in the state will be Latinos. Not shown are Asian elders (18% in 2050) and African Americans (5%). This means that the way services WERE designed need to be adapted to address an increasingly diverse population of elders.
2000 from: California Department of Finance, July
Source: California Department of Finance, January 2013
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17. The Implications of an Aging Population
2. Should we care?
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18. The Implications of an Aging Population
2012 Elections
Romney
The tease. Age & race in politics. Common pattern.
BUT – there is NO difference by age among groups other than whites. REPEAT.
Obama
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19. Total Dependency Ratio [0-18 + 65&up / (19-64)]*100
The Implications of an Aging Population
Total Dependency Ratio [ &up / (19-64)]*100
What does this tell us? Highest TOTAL dependency will be lower than peak of baby boom. But more will be made up of older adults.
Sources: U.S. Census, P (1996)
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20. Labor Force Participation Rates
The Implications of an Aging Population
Labor Force Participation Rates
Rising Women’s LFP means more workers per nonelderly adult in both young & middle age!
Source: Fullerton, Monthly Labor Review, Dec 1999
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21. Percent GDP spending on health vs. % population age 65+, 2006
The Implications of an Aging Population
Percent GDP spending on health vs. % population age 65+, 2006
U.S.
Germany
Canada
France
Italy
Australia
What is the relationship between the % elderly and the % of national wealth spent on health care? None! Countries with the highest % elderly (Italy & Japan) have among lowest spending. Japan has HIGHEST life expectancy! UK
Spain
Japan
Sources: Older Americans 2008 and
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22. Leading causes of death falling Persons Age 75-84, U.S.
The Implications of an Aging Population
Leading causes of death falling Persons Age 75-84, U.S.
++ Health of elderly is IMPROVING
Why use DEATH???
CBV = stroke
Lower Respir ~ COPD, includes chronic bronchitis, emphysema, asthma, and other
SOURCE: NCHS,
And Health US 2008.
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23. Disease patterns of the elderly U.S. 2010-11
The Implications of an Aging Population
Disease patterns of the elderly U.S
Note arthritis is common…. Not cause of death but high cause of disability.
Increase in Diabetes
Also Hypertension 46% - 56%
Cause for concern!!!
Source:
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24. Disability at age 65+ is decreasing
The Implications of an Aging Population
Disability at age 65+ is decreasing
Age-adjusted disability rates falling: 35% in 1992 to 29% in 2009
ADLs: getting out of bed/chair, walking, bathing, dressing, eating, using the toilet
May be a combination of changing disease patterns, medical technology (hip, knee replacements), assistive technology (speaker phones), early diagnosis & treatment.
Source:
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25. Fair/poor self-assessed health at ages 65 -75 decreasing
The Implications of an Aging Population
Fair/poor self-assessed health at ages decreasing
Fair & poor (versus excellent, very good, & good) self assessed health declining, i.e. good health improving!
SRH is excellent indicator of global health status
Source: NCHS, Health U.S. 2008,
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26. The Implications of an Aging Population
Help With Daily Activities, Community Residents W/2+ ADLs, By Age
Source: Kaye H S et al. Health Affairs 2010;29:11-21
Major Sources Of Help With Daily Activities Among Community Residents With Two Or More Activities Of Daily Living (ADL) Needs, By Age
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27. Demography is not destiny
The Implications of an Aging Population
Demography is not destiny
Proportion of the elderly population does not necessarily determine health care spending
Higher rates of illness & disability, but…
Continued health improvements can counter increased needs caused by growing population
Public health approaches are the most promising to improve health outcomes of the elderly
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28. 3. Nation’s health promotion goals
The Implications of an Aging Population
3. Nation’s health promotion goals
#1-Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death
Focus on the quality of the years, not just their quantity
4 goals:
Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.
Achieve health equity, eliminate disparities, and improve the health of all groups.
Create social and physical environments that promote good health for all.
Promote quality of life, healthy development, and healthy behaviors across all life stages.
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29. Beyond disease: Geriatric health
The Implications of an Aging Population
Beyond disease: Geriatric health
Chronic conditions: Falls, Disability, Urinary incontinence, Oral Health
Environment: Food insecurity, Social support, Polypharmacy, Healthy communities
See Wallace, Steven P. “The Public Health Perspective on Aging.” Generations. 29:2(2005)
Everyone worries about Alzheimers … or cancer… or a stroke, BUT many issues that are not diseases impact healthy aging
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30. Multiple falls by age, California
The Implications of an Aging Population
Multiple falls by age, California
Not only are falls most common among the oldest adults, but the oldest are also the most likely to suffer from injuries and even death as a result of their falls.
Source: California Health Interview Survey
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31. Food insecurity by income, age 65+ California
The Implications of an Aging Population
Food insecurity by income, age 65+ California
It is particularly concerning that almost one quarter of low-income older adults with diabetes report food insecurity—a group that has the most difficult dietary requirements. Adults with diabetes living in food-insufficient households have been shown to have greater risk of complications from their diabetes and higher utilization of medical care.
Source: California Health Interview Survey
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32. Disability – Long term care
The Implications of an Aging Population
Disability – Long term care
Does Medicare cover prolonged nursing home care? (35% correct)
Does Medicare cover in-home personal care aid for chronic conditions? (21% correct)
Voters age Most do not know coverage!
NH no=35%
Home Care no=21%
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33. Geriatric Issues - Summary
The Implications of an Aging Population
Geriatric Issues - Summary
Several challenges to healthy aging are common among the oldest and poorest elders
Healthy aging is more than avoiding disease
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34. 4. Public health approach
The Implications of an Aging Population
4. Public health approach
Definition of Public Health = Assuring the conditions under which people can be healthy (Institute of Medicine, Committee for the Study of the Future of Public Health. The future of public health. Washington, DC: National Academy Press, 1988)
Population / community / system focus
Interest in prevention vs. cure
Emphasis on health vs. disease
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35. The Implications of an Aging Population
Types of prevention
Primary – prevent problem from happening, e.g. immunizations
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36. The Implications of an Aging Population
Types of prevention
Primary
Secondary – detect problem early and treat before serious harm results, e.g. blood pressure or breast cancer screening
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37. The Implications of an Aging Population
Types of prevention
Primary
Secondary
Tertiary – after a health problem has happened, maximize independence & quality of life, e.g. rehab, in-home supportive services
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38. Falls - a public health approach
The Implications of an Aging Population
Falls - a public health approach
Primary – Promote physical activity, reduce polypharmacy, universal housing design (for all older adults)
Secondary - Strength training, environmental modifications (for at-risk older adults)
Tertiary – Counseling to decrease fear of falling, improve primary care ID/treatment of falls, social support interventions
Note – most prevention activities are most effective when promoted at a community or group level, eg providing safe/interesting places for exercise (not just individual information); instituting pharmacy monitoring systems
See Rizzo J, Baker D, McAvay G, Tinetti M. The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly persons. Medical Care 1996; 34(9):
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39. Poverty – a cross cutting risk
The Implications of an Aging Population
Poverty – a cross cutting risk
Primary – Assure a living wage with adequate health care and pension
Secondary – Maintain the communal risk feature & disability benefits of Social Security
Tertiary – Provide public assistance (SSI) at the Elder Economic Security Standard level
project at the UCLA CHPR is to calculate the EESS for California.
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40. Poor and near poor, Age 65 & Over, California 2010
The Implications of an Aging Population
Poor and near poor, Age 65 & Over, California 2010
* nonLatino # may be of any race
Source: U.S. Census, 2011 American Community Survey
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41. Distribution of household expenditures, 2010
The Implications of an Aging Population
Distribution of household expenditures, 2010
Source: 2012 AgingStats.gov
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42. The Problem: Federal Poverty Guideline
The Implications of an Aging Population
The Problem: Federal Poverty Guideline
The current measure needs to be revised: it no longer provides an accurate picture of the differences in the extent of economic poverty among population groups or geo-graphic areas of the country, nor an accurate picture of trends over time. The current measure has remained virtually unchanged over the past 30 years. Yet during that time, there have been marked changes in the nation’s economy and society .... (National Research Council, 1995, page 1)
The federal standard of “poverty” is outdated, inaccurate, and inadequate
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43. Elder Economic Security Standard (EESS)
The Implications of an Aging Population
Elder Economic Security Standard (EESS)
Adjusted for local (county) costs of living versus national average
Takes actual costs of basic necessities for older households
Includes housing, food, transportation, health care, and other costs
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44. The Implications of an Aging Population
Elder Standard Index 2011, Single older adult , LA City & Humboldt County
Monthly Expenses
Los Angeles City
Humboldt County
Owner w/o Mortgage
Renter, One Bedroom
Renter,
One Bedroom
Housing
$496
$1,137
$358
$688
Food
258
253
Transportation
239
Health Care=Good
182
403
Miscellaneous
237
251
Elder Index Per Month
$1,422
$2,053
$1,504
$1,833
Elder Index Per Year
$17,062
$24,640
$18,049
$22,001
Humboldt costs MORE for owner w/o mortgage because of higher HEALTH CARE costs. RENTER higher in LA.
Health care costs are higher than rent for couples in 16 California counties where HMOs are not common.
FPL = $10,980
Note: Numbers may not add up to total due to rounding.
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45. The Implications of an Aging Population
Conclusions
The U.S is becoming older as a nation
Demography is not destiny with improving health and changing medical practice
Healthy aging goes beyond adding years to life and focuses on adding life to years – involves increased attention to chronic and nonfatal conditions
Public health approaches to prevention using multilevel interventions are possible to reduce challenges to healthy aging… including using a more realistic assessment of “poverty”
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46. The Implications of an Aging Population
Thank you
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