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Public Health Report

Health and ageing in Norway

The risk of disease and disability increases with age. However, many elderly people consider themselves to be in good health.

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Main points 

A significant increase in the number and proportion of elderly people in the population is expected in the future. 

  • Life expectancy is increasing. 
  • This increase in life expectancy can be a challenge for Norwegian society. 
  • More people will live with chronic diseases. 
  • More people will live with cancer and fewer will die of heart disease. 
  • More people will develop dementia. 
  • The prevalence of fractures is particularly high in Norway.
  • Education and financial situation play a role in elderly health. 
  • Both genes and the environment are important for healthy and active ageing.
  • Four key factors are important for healthy ageing: high cognitive activity, physical activity, an active social life and a healthy diet.

Life expectancy increasing

Life expectancy has risen by about two-three months per year in recent decades. The increase has been greatest among men in recent years. Increased smoking-related mortality among women may have contributed to the reduction in the gender gap in life expectancy.

Forecasts indicate that life expectancy will continue to increase in the coming decades among both women and men (Brunborg, 2012). A continued increase in life expectancy in Norway will be achieved as the oldest age groups live longer. Mortality among the younger age groups is so low that any improvement in these age groups will have a minor effect on the life expectancy of the Norwegian population overall. For example, estimates show that if nobody died before 50 years of age, the population's life expectancy would only increase by one to two years on average (Brunborg, 2012).

Number of elderly in population will increase significantly from 2025

The combination of living longer and the post-war baby boom means that there will be a larger proportion of elderly people in the years to come.

Before 2100, we will probably see the following trends in the number of elderly over 70, 80 and 90 years, according to forecasts of medium growth in life expectancy (Brunborg, 2012), see Figure 1: 

  • The number of people aged over 80 years will increase by six-seven per cent annually in the period 2025-29, and the number of 80-89-year-olds will quadruple by the end of this century. 
  • The number of 90-year-olds will grow rapidly by a factor of ten before 2100. 
  • The number of people over 100-years-old was 736 at the start of 2012 and will grow to 12,500 in 2100. 
FHR2014 - Eldres helse - Fig 1. Norsk Epidemiologi
FHR2014 - Eldres helse - Fig 1. Norsk Epidemiologi

Figure 1. Number of elderly people in ten year age groups with three different prognosis variants, 1950-2100 (Figure 4 in Brunborg, 2012). Used with permission from the Norwegian Journal of Epidemiology.

We are living longer lives, but is health improving?

Are we healthier than before?

We are living longer but it is uncertain whether these extra life years are associated with good health. Research literature shows contradictory findings, which may be due to differences in the time periods, health targets and data quality measured in the studies. Studies among elderly people often have high dropout rates and the study sizes are small. There are also few studies with objective measures of health and function, and most studies are based on self-reporting.

Nevertheless, results from studies in Sweden, UK, USA and Norway indicate that elderly people are healthier and have better functional abilities and memory than earlier generations (Christensen, 2009; Falk, 2014; Fors, 2013; Moe, 2011; Parker, 2005; Skirbekk, 2013; Vaupel, 2010). However, a large national health study among elderly people in Sweden (SWEOLD) showed the opposite for some health outcomes among the oldest individuals (77 years and older) (Fors 2013).

Data from Norwegian health and social surveys of elderly people living at home show that the percentage who consider their health as good or very good increased slightly in the period 1998-2008 (Mørk, 2011). The Survey of Living Conditions in Norway and international studies also show that even though the disease prevalence is increasing, the proportion of elderly people who require assistance fell slightly or has remained stable over the last 20 to 30 years (Fors 2013, Mørk, 2011).

More people will live with chronic diseases

Although more elderly people than previously report good functional ability and that they can cope with everyday life, there are also many who live for many years with chronic diseases. The risk of some of these diseases increases with age.

The diseases that previously led to premature death, such as type 2 diabetes, heart disease and cancer now belong to the category of chronic diseases. An ageing population will therefore have more chronically ill people. The elderly often have several concomitant diseases, which together affect functional ability, quality of life and mental health.

More people will live with cancer

The cancer risk increases with age, and with an ageing population there will be more elderly people with a cancer diagnosis.

When adjusted for the number of elderly, statistics from the Cancer Registry show that the number of new cancer cases has been stable for the oldest age groups in recent decades, with the exception of breast cancer and prostate cancer which have increased (partly as a result of screening) (Syse, 2012).

However, the proportion of people living with cancer has increased in the population. This is due to better treatment, and improved survival rates have led to more people living longer with cancer. It is estimated that the increase in cancer incidence will continue, especially from 2030.

The predicted number of people over 80 years with cancer is estimated to be 71,000 in 2030 and almost 100,000 in 2040 (Syse, 2012).

Fewer dying from cardiovascular disease

In recent decades, mortality from cardiovascular diseases in the elderly has declined in Norway (Mørk, 2011). It is therefore expected that more will live with cardiovascular disease because of improved survival rates.

A Swedish study estimated that the number of new stroke patients each year will increase by 59 per cent by 2050 if the number of new stroke cases in the various age groups remains constant (Hallstrom, 2008). The reason for this is that there will be more elderly people. Even with a decline in new cases of two per cent in each age group every five years, there would still be an annual increase of 33 per cent in the number of new stroke patients, up to the year 2050 (Hallstrom, 2008).

Many stroke patients have disabilities and need assistance in everyday life (Engstad, 2012). We lack Norwegian studies on developments in the number of new cases of cardiovascular disease among the elderly and how comorbidity between cancer and cardiovascular disease will affect both life expectancy and ability to function.

Many fractures due to falls and osteoporosis

In 2012, 479 people died as a result of falls and subsequent fractures and 70 per cent of them were over 80 years old (Statistics Norway, 2014).

Every year, about a third of those who are over 65 years-old fall, and half of those who are over 80 years-old.

The reasons for falls are complex, but there are some established risk factors (Bergland, 2012): 

  • Previous falls 
  • Advancing age 
  • Poor balance and mobility 
  • Poor vision 
  • Cognitive impairment (dementia and precursors) 
  • Diseases such as stroke and Parkinson's disease 
  • Use of multiple drugs simultaneously

The incidence of fractures in Norway is among the highest in the world, and the reasons for this are largely unknown. Climatic conditions can only explain part of the high incidence (Solbakken, 2014). Hip fractures are the most serious and the majority of fractures happen after a fall at home. About 70 per cent of all hip fractures occur in women.

In 2008, 4403 women aged 75 years and older had their first hip fracture, and of these, 26 per cent died within a year of the fracture.

Many fractures are caused by decreased bone mass (osteoporosis) combined with a fall. Loss of bone mass occurs gradually, with no symptoms until a fracture occurs. Many will therefore have osteoporosis without being aware of it.

Infections and antibiotic resistance

The risk of developing an infection requiring antibiotic treatment is relatively high among the elderly. It is estimated that antibiotic prescription in nursing homes makes up 6 per cent of antibiotic use in Norway, despite the fact that less than 40,000 people live in such institutions (Blix, 2007).

The elderly often have an impaired immune system due to the ageing process. In addition, chronic diseases and malnutrition may weaken the immune system further.

Infections often entail serious consequences, for example, infection with antibiotic-resistant bacteria which is a growing problem.

Everyone over 65 years of age is recommended to take the pneumococcal vaccine and influenza vaccine to prevent infection. All adults are also recommended to take a booster dose of the pertussis vaccine every ten years.

Vaccination against pneumococcal infection in children has also reduced the incidence of this infection among the elderly. This is an excellent example of herd immunity, where vaccination in one group benefits the entire population. The pneumococcus bacteria can cause pneumonia.

Mental health and diseases of the nervous system

The Survey of Living Conditions by Statistics Norway indicates that mental health problems are less prevalent among older than younger people. In 2008, six per cent of those over age 67 reported psychological distress compared with nine per cent of the 50-66 year age group (Mørk, 2011).

Anxiety and depression

The prevalence of anxiety and depression disorders is evenly spread through adulthood. The incidence declines slightly after the retirement age, and there is a slight increase towards the end of life (Norwegian Institute of Public Health, 2011). Loss of close contacts, weak social networks and loneliness are risk factors for anxiety and depression that are particularly significant among the elderly.

Dementia and cognitive impairment

It is estimated that about 70,000 people in Norway have dementia (Engedal, 2009; Norwegian Directorate of Health, 2014a). The proportion with dementia increases with age, see Table 1.

Table 1. Dementia prevalence (%) in different age groups. Source: (Engedal, 2009; Norwegian Directorate of Health, 2014)

Age group

Percentage

65-69 years

1

70-74 years

2

75-80 years

6

81-85 years

18

86-90 years

32

90 years and older

41

Dementia causes memory impairment, particularly for short-term memories. In addition, dementia affects the ability for abstract thinking and leads to poor emotional control. The disease cannot be cured. The same risk factors that are related to cardiovascular disease, such as physical activity and diet, are also linked to dementia. This gives hope for prevention. Nevertheless, we must expect a sharp increase in prevalence as a result of increased life expectancy.

Dementia - Chapter in Public Health report 2014

Parkinson's disease

Parkinson's disease affects about one per cent of the population aged 50-70 years, rising to just over three per cent for those over 85 years. The disease is incurable and results in brain damage that deteriorates over time. Symptoms include twitching and reduced motor control, with gradually weakening of cognitive functions. After a few years, over half of the cases will develop dementia.

Disability

Studies of the trends in function and disability among the elderly in Norway and other countries have not shown consistent results (Christensen, 2009; Falk, 2014; Fors, 2013; Moe, 2011; Vaupel, 2010). Disability among the elderly will affect both the costs of geriatric care and retirement pensions, as well as the demand for labour. It is therefore important to identify factors that can contribute to better functioning among the elderly.

Impaired vision and hearing

Impaired vision and hearing are common in older age groups, and can reduce social contact and opportunities to function well in everyday life (Borchgrevink 2005; Tambs 2004).

  • Nearly one in ten over 66 years report visual problems, even with spectacles.
  • One in five over 66 years report that they have difficulty hearing, even with a hearing aid.
  • Almost half of the population aged from 65 to 74 years, and approximately three-quarters of the population over 74 have a hearing impairment.
  • Nevertheless, a large Norwegian study only shows a weak effect of hearing loss on mental health and well-being among the elderly.

Have several concomitant diseases

Better treatment and rising life expectancy increases the risk of several diseases occurring at the same time. Many elderly people use multiple drugs to treat various diseases, which increases the risk of side effects and adverse interactions.

There is great potential for prevention to reduce the risk factors shared by several common diseases (Norwegian Directorate of Health, 2013b):

  • Lack of physical activity
  • Obesity
  • Unhealthy diet
  • Smoking, drug abuse
  • Bullying and social exclusion

Smoking: The percentage of smokers among the elderly has declined in recent years and there are currently fewer elderly than younger smokers (Mørk, 2011).

Alcohol: Both younger and older people drink more alcohol than before (Mørk, 2011).

Physical activity: In 2008, 69 per cent of those over 50 years reported that they exercised weekly. This is a doubling from the previous decade.

In the age group 66 years and older, the percentage who exercised weekly was also high; 62 per cent exercised once a week or more in 2008 (Mørk, 2011).

Obesity: In 2008, the proportion with obesity and overweight was slightly lower among those aged over 66 years than in the 50-66 year age group (Mørk, 2011).

Differences between population groups

Education and financial situation important for health in the older years

There are huge social differences in life expectancy among the elderly. In groups with a longer education and a good financial situation, life expectancy is higher than in groups with lower education and a poor financial situation. This applies both in Norway and other countries (Huisman, 2005).

Differences in life expectancy: In the period 1961-2009 the differences in life expectancy increased between educational groups, including the over-70 age group (Moe, 2012).

Differences in health: Among those who only had a primary education, 14 per cent reported poor or very poor health when they were aged 67 years and older. However, among those who had a college or university education, this proportion was only nine per cent (Mørk, 2011).

Differences in health problems: Figures from five counties in the period 2000-2003 show that those with higher education had fewer health problems than those with lower levels of education (NIPH, 2007). These differences were found for self-reported general health, heart attacks, diabetes, chronic bronchitis and chronic pain. The pattern was evident for both men and women.

Life expectancy varies between counties

The expected remaining years of life after 65 years of age varies by county of residence. Life expectancy is highest in Sogn og Fjordane for both men and women. At 65 years of age, women in this county can expect to live for 22 years, and men for 18 years, see Figure 2. This is two years longer than for men and women in Finnmark, which has the lowest remaining life expectancy in Norway.

After Sogn og Fjordane, the 65 year-olds in the counties of Akershus, Hordaland, Møre and Romsdal, and Rogaland have the longest expected remaining years of life. This applies for both men and women. 

Expected remaining life years

 

Which causes do the elderly die of?

The same diseases that cause impaired health towards the end of life are frequent causes of death.

Results from the Global Burden of Disease project in 2010 show that chronic diseases claim many life years among the elderly, (IHME, 2013).

In the age group over 70 years, these diseases claim most life years:

  • Heart disease
  • Stroke
  • COPD
  • Alzheimer's disease
  • Pneumonia

In the over-80 age group, heart disease and stroke are found in the top two spots for both men and women, see Table 2.

 

Table 2. Ranking of the ten major causes of death by their significance for the number of life years lost for those over 80 years old in 2010 in Norway. Source: IHME, 2013.
 

Men

 

Women

1

Ischaemic heart disease

1

Ischaemic heart disease

2

Stroke

2

Stroke

3

Pneumonia

3

Alzheimer’s disease

4

COPD

4

Pneumonia

5

Prostate cancer

5

COPD

6

Alzheimer’s disease

6

Other cardiovascular disease

7

Colon cancer

7

Falls

8

Lung cancer

8

Colon cancer

9

Falls

9

Atrial fibrillation

10

Atrial fibrillation

10

Diabetes

Challenges and opportunities for prevention and health promotion

There are large individual differences in physical and mental function among the elderly. Are physical and mental impairments natural consequences of ageing, or can they be influenced or prevented to some degree? Research shows that some of these processes can be influenced and that they are related to lifestyle and influences throughout life (Morgan, 2011).

Ageing processes are controlled by chronological age, biology and lifestyle. This means that tomorrow's elderly are probably not directly comparable with yesterday's elderly. Better living conditions, a change in lifestyle with regard to physical activity and changes in smoking habits, and better health are important reasons for this. Perhaps the elderly in the future will be generally healthier and more functional than the previous generation of elderly people (Christensen, 2009; Vaupel, 2010)?

More active and healthy years

Research on the health of elderly people has largely covered diseases and disability. Less research has been carried on the part of the population with good health and function, even in old age. Concepts such as successful or optimal ageing were introduced by Rowe & Kahn in the 1980s (Rowe, 1987). We have no clear definition for this, but the terms are usually defined as the absence of physical and mental illness, as well living an active life. The concepts have gained renewed interest in politics and research in recent years, including the World Health Organization (WHO, 2002). 2012 was the European Year for Active Ageing (Walker, 2012).

The Research Council of Norway has active ageing as a main priority in a major initiative "More active and healthy years (FASE)" (Research Council of Norway, 2013).

The following conditions are likely to affect the number of active and healthy years:

Family situation

The family situation can particularly affect the elderly men’s health (Grundy, 2008; Tomassini, 2004). Family support can also be crucial when an elderly person moves to a nursing home.

The elderly often play a key role when it comes to caring for grandchildren and assistance to working parents (Daatland, 2011; Herlofson, 2011). Grandchildren are also important for many older people's quality of life. With declining fertility and increased average age of first birth, fewer experience being grandparents (Lappegård, 2011; Priskorn, 2012).

A significant proportion of the population will be single when they are older (Christiansen, 2013).

Environment and lifestyle

Research shows that both genes and the environment are important for a healthy and active ageing (Stordal, 2012). However, the exact mechanisms of "successful ageing" are largely unknown. In the large Swedish Betula study, a correlation was found between genes and cognitive function (Nilsson, 1997). In addition, twin studies have shown that genetic factors determine a significant part of cognitive function in old age, but much is also unexplained (Daffner, 2010).

Other studies have found that genes play a lesser role as we age (Rowe, 1997). It has been shown that cognitive health in old age is influenced by external factors throughout life, such as physical activity, smoking, intellectually stimulation, diet and alcohol consumption (Daffner, 2010; Di Marco, 2014). An active and social life also seems to prevent dementia (Fratiglioni, 2004).

Many of the same lifestyle factors that increase the risk of cardiovascular disease also increase the risk of reduced cognitive function and dementia (Solomon, 2014). This is also found in more recent Norwegian studies (Arntzen, 2011; Rosness, 2014; Strand, 2013; Strand, 2014).

Four key factors are highlighted as being particularly important in terms of ageing well:

  • High cognitive activity
  • High physical activity
  • An active social life
  • A healthy diet

The same factors may protect against some forms of dementia. Also education, mastery and control have proved to be important protective factors (Stordal, 2012).

Physical activity and exercise

Physical activity is one of the keys to a long life in good health (Lohne-Seiler, 2012; Voelcker-Rehage, 2011). The effect of physical activity is just as good in the elderly as in younger people. Physical activity increases muscle strength and this may improve balance, prevent falls and provide a better quality of life.

Physical activity is also beneficial for cognitive function (Daffner, 2010) and dementia (Rosness, 2014).

A large international study examined the effects of physical activity and exercise on elderly health and function. The results showed that exercise had a beneficial effect on walking ability and led to reduced disability (Pahor 2014). The study is one of the largest of its kind and included 1,635 people aged 70-89 years who were followed over a four year period.

Challenges

The increase in life expectancy and the proportion of elderly in the population is a success story. However, this can be a challenge to Norwegian society. In 2012 there were approximately five people of working age per pensioner. If there is a trend with a medium increase in life expectancy, this number will drop to 2.1 by year 2100, see Figure 3 (Brunborg, 2012). Neither immigration nor fertility changes may change these prospects to any extent (United Nations, 2007). This underlines how important it is to ensure that most elderly experience a positive old age with good health and function, so that they can continue to work for longer and require less help.

By the end of 2013, there were 800,400 people receiving retirement pensions in Norway (Amundsen, 2014). Data from Statistics Norway indicate that there was a slight increase among the 62-67-year olds who were in employment in the period 2008-2012 (Brunborg, 2012).

FHR2014 - Eldres helse - Fig 3. Norsk Epidemiologi
FHR2014 - Eldres helse - Fig 3. Norsk Epidemiologi

Figure 3. Potential old age support ratio (PSR) 1950-2100. Population 19-66 years in relation to population 67 years and over. Population projections 2012-2100 by Statistics Norway. Source: Figure 3 in Brunborg, 2012. Published with the approval of the Norwegian Journal of Epidemiology

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