The number of elderly over 65 years in the population is increasing. Until 2020, the number of young elderly aged 65 -74 years will increase. After that, the number of elderly over 80 years will increase.
A third of the elderly will have no significant functional impairment until shortly before they die. More than half will need assistance for four or five years because of dementia (20 per cent) or other diseases (36 per cent). This comes from a study among elderly people in Larvik (Romøren, 2006).
Even though more people will need healthcare in old age, the majority are in good or very good health. Among women and men aged 65-79 years, two-thirds consider their health to be good or very good (Figure 1). The proportion has risen over the past 20 years.
At 75 years of age, approximately one in five people has impaired function that requires assistance (Daatland, 2009. Public Health Report 2010, p. 47). At 80 years of age, every third person has impaired function. This implies that two-thirds of 80-year-olds are coping well. Although statistics from Western countries in the 1980s and 1990s show that an increasing proportion of the elderly have heart disease, rheumatism and diabetes, it seems that early diagnosis and better treatment results in many living for a long time with their diseases and maintaining good physical function into old age (Christensen, 2009, Daatland, 2009).
Women develop more and earlier health problems than men. In health studies, older men report better health than older women (Figure 2).
Living conditions such as education and income affect health. An increasing proportion of elderly people have a higher education. In 2009, 20 per cent of men who were 65 years and older were university or college educated, compared to 9 per cent in 1990. For women the corresponding figures are 13 per cent and 5 per cent (Norhealth.no).
Fewer men smoke today than a few decades ago. In 2009, 18 per cent of 65-74 year-old men smoked daily, down from 41 per cent in 1973. However, there are more 65-74 year old women who are daily smokers than before - 13 per cent compared to 11 per cent (Fact sheet: Smoking and smokeless tobacco). Smoking habits affect mortality from cardiovascular disease, lung cancer and COPD, see below. Only six per cent in the age group 65-97 years meet the recommendation of at least 30 minutes of physical activity per day, according to a study of over 3770 elderly people in Norway (Loland, 2004).
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Impaired vision and hearing can reduce social contact and opportunities to function well in everyday life. Nearly one in ten aged 67 and older say they have vision problems, even though they wear spectacles. In the same age group, one in five report hearing difficulties, even if they use a hearing aid. Most people with impaired sight or hearing, however, report that they are in good health (SSB, 2009).
The elderly often have several diseases simultaneously. These diseases may affect function, quality of life and mental health and will also lead to more medical consultations, higher consumption of drugs, longer hospital stays and higher mortality. The health service often treats each disease with a risk that patients with multiple diseases will not receive a proper and suitable provision of health services (Gijsen, 2001).
Most chronic pain conditions become more common with increasing age. This is mainly due to increased morbidity, but there is also evidence that the mechanisms that suppress pain (e.g. endorphins) are less effective in the elderly and may contribute to increased pain sensitivity (Edwards, 2003). There is also a correlation between depression and chronic pain, both among the elderly and in younger patients with pain (Lunde, 2008). 60-80 per cent of nursing homes patients are in pain (Kongsgaard, 2008).
Clinical guidelines often recommend using several drugs to treat or prevent disease. With several diseases, the elderly may often use many drugs simultaneously. Almost 60 per cent of drug users over 70 years were dispensed more than five different drugs at a pharmacy in 2008. Every fifth person was prescribed more than 10 different drugs. The elderly mainly use drugs to prevent and treat cardiovascular diseases. Other drugs that are frequently used include cholesterol-lowering agents, analgesics, antibiotics, sedatives and medicines for mental disorders.
The proportion of hospital admissions is much higher for 85 year-olds than for 75 and 65 year-olds, see figure 4. Older men are more likely to be hospitalised than older women. In 2001, people aged 67 years and over accounted for use of about 47 per cent of bed capacity in Norwegian hospitals.
From 2007 to 2009 there was a five per cent increase in nursing and care services in the municipalities, according to figures from Statistics Norway.
The dental health of the elderly today is partly affected by growing up in a time without access to fluoride toothpaste and other fluoride supplements. Many could not afford regular dental treatments. However there have been major changes in geriatric dental health in the last 30 years. One in five 70-79 year olds is now toothless, compared to more than half in 975, see table 1.
The elderly in institutions often have impaired health and therefore reduced ability to care for their teeth. However, there are fewer and fewer toothless elderly in institutions (Norwegian Directorate of Health, 2006). The fact that more people still have their own teeth in old age also means there will be more cases of cavities and gum disease, although this does not seem to apply to those who care for themselves (Samson, 2008, Holst, 2004). Chronic disease and high drug consumption can have adverse effects on dental health among the elderly. Poor dental health can cause discomfort, pain and eating problems, which can affect nutrition and quality of life (Henriksen, 2003).
80 years +
All over 20 years
In the future there will probably be a large group of relatively healthy senior citizens and another group who will need treatment for chronic diseases or assistance due to disability.
The elderly of the future will have other diseases than those of today. If diabetes incidence is increasing, cardiovascular disease development will be unstable, so that we may again see an increase in heart disease among the “young elderly” – i.e. before 70 and 80 years of age.
Due to current and former smoking habits, rates of chronic obstructive pulmonary disorder (COPD) and lung cancer will continue to increase. Many women who began to smoke in the 1970s and 1980s will develop COPD.
Since many people are living until they are 80 and 90 years, there will be more cases of dementia and cancer. We will also have new groups: senior citizens with mental retardation, drug addiction and serious mental disorders. Elderly people with different cultural backgrounds will also increase in number.
The World Health Organisation considers the ageing population to be both a challenge and an opportunity.
Their strategy will provide all future generations of elderly people with the opportunity to experience active ageing by preventing and detecting chronic disease early and providing quality care in an age-friendly, primary health care service.
An age-friendly environment, both physically and socially, can give people the opportunity to actively participate despite illness or disability.
Weight relative to height (body mass index) increases throughout life, falling slightly in old age. About 23 per cent of 60-year-olds are obese. Among 75 year-olds, more women than men are obese - 24 per cent compared to 17 per cent, according to county health surveys (Norhealth: County health studies in five counties, 2000-2003).
Approximately five per cent of 60-year-olds and eight per cent of 75 year-olds report that they have diabetes (Graff-Iversen, 2007). In addition, many have diabetes without being aware of it. Type 2 diabetes gives an elevated risk of developing cardiovascular disease. Overweight and obesity increase the risk of diseases such as osteoarthritis. Being overweight does not seem to increase mortality in the oldest age group (Christensen, 2009).
The risk of cancer increases sharply with age, but a 70- or 80 year-old does not have a higher cancer risk today than 30-40 years ago. The number of people who develop cancer is increasing because more are reaching an age at which cancer risk is increased. In men, 85 per cent of cancer cases occur in people over 55 years, in women the proportion is 76 per cent. Two out of ten people aged over 75 die of cancer. In recent years, overall mortality from cancer has declined in men aged 65-79 years. In men over 80 years cancer mortality increased until the mid-1990s, but has not increased since then (Figure 5). In women, there have been smaller changes over time (Figure 6).
The lung cancer picture is changing. Over the last 30-40 years, mortality from lung cancer in the elderly has increased in both sexes. In the years ahead, lung cancer will remain a major health problem in the elderly, but we see differences between the sexes. The probable reason is that many women first began to smoke in 1970s and 1980s, and that the reduction in smoking occurred later in women than in men. Figure 7.
Morbidity and mortality of COPD (chronic obstructive pulmonary disease) is largely a result of tobacco use. About the same number die from COPD as lung cancer in the age group over 65 years, see Figure 8. We must expect that the mortality of COPD will continue to increase among women and men who have smoked for many years.
Many elderly people are living with one or more cardiovascular diseases, including high blood pressure. In 2008, it was reported by 43 per cent of the elderly over 67 years that they had these diseases (SSB, 2009). Women have their first heart attack on average ten years later than men. Among today's elderly, there are many who live for a long time with heart disease. After many years with this disease heart failure often develops, and it is therefore assumed that the number of people with heart failure will increase in the years ahead (Ezekowitz, 2009). In the 1950s and 1960s there were many who died of a heart attack before the normal retirement age. Today, cardiovascular diseases are a cause of death mainly after 80 years, but even in the oldest age groups, mortality from heart disease (heart attacks and angina) and stroke has fallen. The elderly have had a very favourable trend in mortality (Figure 9), more favourable than that for the middle-aged. The decline in mortality from cardiovascular disease in the elderly may be about to stop. This would then mean that in the future we will see the same mortality as today for both heart attack and stroke.
The elderly are more susceptible to infections such as influenza than younger people. It is estimated that on average 1000 elderly people die each year as a result of influenza. Elderly people with impaired heart or lung function are especially vulnerable. Influenza can be prevented with a vaccine, and the Norwegian Institute of Public Health recommends everyone 65 years and older to be vaccinated.
The proportion with musculoskeletal disorders increases with age more for women than for men. In the age group 67 years and over, 45 per cent of women and 26 per cent of men have a muscle or bone disease.
The most common skeletal disease is osteoporosis, which weakens the bone structure and increases the risk of fracture. Most common fractures occur in the wrist, hip and back. Spinal fractures such as vertebral compression fracture can lead to chronic pain.
Both hip and wrist fractures occur frequently in connection with falls and can cause severe disability. One-third of people over 84 years in Oslo had to move to a nursing home after a fall, and 65 per cent lost the ability to go outside afterwards (Osnes, 2004). Among those who could walk without assistance before the fracture, 80 per cent needed a walking stick, walking frame/rollator or wheelchair afterwards.
In Norway there are an estimated 9000 new hip fractures per year. Nearly 90 per cent of these happen among people over 70 years. In Oslo, the number of hip fractures increased fivefold from 1950 to the 1990s. Since then there has been no further increase (Falch, 1993).
One year after a hip fracture, there is an excess mortality of about 20 per cent (Forsén, 1999). Figure 10 shows how deaths after a fall increase with age. The risk of death from an accidental fall, however, decreased significantly for both sexes in recent decades. For women, there has been a decline since the beginning of the 1960s, especially in women over 65 years. For men, the decline first came in the second half of the 1980s. We do not know the cause of this decline. Men now have higher death rates from accidental falls than women.
The risk of falling increases with deterioration of vision, mobility and balance, as well as chronic diseases and the use of four or more medicines (Pettersen, 2002).
Fire- and traffic accidents are also more frequent among the elderly than among younger people.
The most frequent mental disorders among the elderly are depression and anxiety. Depression increases with age. Both anxiety and depression are more prevalent among women than among men.
In the last decade there has been a positive development in such mental health problems in older age groups. In 2008, about five per cent of the elderly aged 65-74 years had such complaints compared with 11 per cent in 1998. Among women over 75 years, 12 per cent had problems in 2008 (14 per cent in 1998). Physical health problems, especially reduced function, vision or hearing, contribute to anxiety or depression (Stordal, 2005).
Impaired health and functional ability in old age can affect opportunities for social contact and can lead to loneliness. There seems to be a stronger relationship between loneliness and mental health than between loneliness and physical health. Loneliness is more common among older than among younger people, and more than three out of ten over-80 year olds say they are lonely (Thorsen, 2009).
While one in 100 in the age group 60-64 years suffers from dementia, one in four people over 85 years of age are affected.
Dementia is characterised by the emergence of extensive failure of several brain functions. The condition worsens progressively, and eventually most become dependent on assistance. Many need care. The burden of disease is high both for the sick and their families, and care needs are a challenge for care services.
Since more people live until they are 80 and 90 years, there will be more elderly people with these diseases in the future (Ott, 1995). The number with dementia is likely to increase from approximately 70 000 people at present to more than double over the next 30-40 years.
In all the Nordic countries, there is a higher incidence of suicide among persons over 65 years than among younger people, but Norway has slightly lower rates than other Nordic countries. The incidence of suicide has declined since 1995 in all ages, including the elderly.
A study of suicide among the elderly in the period 1992-2000 has shown that a high proportion of elderly people who died in this way had a psychiatric disorder (62 per cent), while physical illness was the cause of a minority of the suicides (22 per cent). The majority had been in contact with health professionals, and many had expressed suicidal thoughts or attempted suicide previously (Kjølseth, 2002).