the implications of an aging population1. the u.s is becoming older as a nation 2. demography is not...

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 swallace@ucla.edu

Today’s talk

1. Why is American growing older?2. Should we care?3. Nation’s health promotion goals4. Public health approach to aging

1. Why is American growing older?

Population versus individual aging

Fertility changes past centuryAnnual live births per 1,000 women aged 15-44 years

SOURCE: NCHS, http://www.cdc.gov/nchs/data/statab/natfinal2001.annvol1_01.pdf & http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_07.pdf & Health U.S., 2011

2008

Total fertilityNumber expected lifetime births per woman

SOURCE: NCHS, http://www.cdc.gov/nchs/births.htm

Percent women 40-45 w/o kids

SOURCE: Pew Research Center, 2010www.pewsocialtrends.org/2010/06/25/childlessness-up-among-all-women-down-among-women-with-advanced-degrees/

= Fewer babies

Concentration of death in old ageIn 1900, 41% live to old age, in 2006 83% do

http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_09.pdf

Life expectancy at age 65

Source: http://www.agingstats.gov

50% increase in last century

Life expectancy at age 65

Source: http://www.agingstats.gov

Racial disadvantage continues into old age

Why is America aging?

• Declining birth rates = fewer kids• Declining mortality rates = more elderly

Population, Number Kids & Elders, 1900 - 2050

Number of elderly will double in 30 years

0

20

40

60

80

100

120

140

160

180

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

mill

ions

<18 65-84 age 85+

Source: U.S. Bureau of the Census, p25-1130 & historical statistics

2040=81.2 million

2010=40.2 million elderly

Minority elderly population, 2000-2010

Numbers triple 30 years

0

5

10

15

20

25

30

2000 2010 2020 2030 2040 2050

mill

ions

American IndianAsian/Pac IslanderLatinoAfrican American

Source: U.S. Bureau of the Census, p25-1130 & historical statistics

2000=5.6 million

2030=17.6 million

Percent 65+, 1950 to 2050

Source: World Population Prospects: The 2008 Revision, http://esa.un.org/unpp

2000

Baby boom

Growing Diversity of Elderly in California, % nonLatino white

Source: California Department of Finance, January 2013http://www.dof.ca.gov/research/demographic/reports/projections/P-2/

Growing Diversity of Elderly in California

Source: California Department of Finance, January 2013http://www.dof.ca.gov/research/demographic/reports/projections/P-2/

2. Should we care?

2012 Elections

http://elections.nytimes.com/2012/results/president/exit-ll

Obama

Romney

Total Dependency Ratio[0-18 + 65&up / (19-64)]*100

Sources: U.S. Census, P25-1130 (1996)

Labor Force Participation Rates

Source: Fullerton, Monthly Labor Review, Dec 1999

Percent GDP spending on health vs. % population age 65+, 2006

U.S.

AustraliaUK

France

Spain

Germany

Japan

ItalyCanada

Sources: Older Americans 2008 andhttp://www.who.int/whosis/whostat/EN_WHS09_Table7.pdf

Leading causes of death falling Persons Age 75-84, U.S.

SOURCE: NCHS, http://www.cdc.gov/nchs/datawh/statab/unpubd/natality/natab2003.htmAnd Health US 2008.

Disease patterns of the elderlyU.S. 2010-11

Source: http://www.agingstats.gov

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

Source: www.agingstats.gov

Fair/poor self-assessed health at ages 65 -75 decreasing

• Fair & poor (versus excellent, very good, & good) self assessed health declining, i.e. good health improving!

Source: NCHS, Health U.S. 2008, http://www.cdc.gov/nchs/hus.htm

Help With Daily Activities, Community Residents W/2+ ADLs, By Age

Source: Kaye H S et al. Health Affairs 2010;29:11-21

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

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

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) http://www.generationsjournal.org/generations/gen29-2/article_thepublichealth.cfm

Multiple falls by age, California

Source: 2010-11 California Health Interview Survey

Food insecurity by income, age 65+ California

Source: 2010-11 California Health Interview Survey

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)

Geriatric Issues - Summary

• Several challenges to healthy aging are common among the oldest and poorest elders

• Healthy aging is more than avoiding disease

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

Types of prevention

• Primary – prevent problem from happening, e.g. immunizations

Types of prevention

• Primary • Secondary – detect

problem early and treat before serious harm results, e.g. blood pressure or breast cancer screening

Types of prevention

• Primary • Secondary • Tertiary – after a

health problem has happened, maximize independence & quality of life, e.g. rehab, in-home supportive services

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

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

Poor and near poor, Age 65 & Over, California 2010

Source: U.S. Census, 2011 American Community Survey* nonLatino # may be of any race

Distribution of household expenditures, 2010

Source: 2012 AgingStats.gov

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)

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

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

Owner w/o Mortgage

Renter, One Bedroom

Housing $496 $1,137 $358 $688Food 258 258 253 253Transportation 239 239 239 239Health Care=Good 182 182 403 403Miscellaneous 237 237 251 251Elder Index Per Month $1,422 $2,053 $1,504 $1,833

Elder Index Per Year $17,062 $24,640 $18,049 $22,001Note: Numbers may not add up to total due to rounding.

Conclusions

1. The U.S is becoming older as a nation2. Demography is not destiny with

improving health and changing medical practice

3. Healthy aging goes beyond adding years to life and focuses on adding life to years – involves increased attention to chronic and nonfatal conditions

4. Public health approaches to prevention using multilevel interventions are possible to reduce challenges to healthy aging… including using a more realistic assessment of “poverty”

Thank you

www.healthpolicy.ucla.edu