TABLE 4-2-PERSONAL HEALTH CHARACTERISTICS FOR PERSONS 18 AND OVER: 1985

Source: U.S. National Center for Health Statistics, unpublished data. Based on National Health Interview Survey.

CHRONIC CONDITIONS AND HEALTH PROBLEMS

CHRONIC CONDITIONS, ALTHOUGH NOT NECESSARILY LIMITING, ARE THE BURDEN OF OLDER AGE

The pattern of illness and disease has changed in the past 80 years. Acute conditions were predominant at the turn of the century, while chronic conditions are now the more prevalent health problem for elderly persons. There has also been a change in the pattern of wellness within an individual's lifetime. As individuals grow older, acute conditions become less frequent and chronic conditions become more prevalent. Cross-sectional data have shown that the likelihood of suffering from a chronic illness or disabling condition increases rapidly with age. More than four out of five persons 65 and over have at least one chronic condition and multiple conditions are commonplace among older persons.

The leading chronic conditions for the elderly in 1987 were arthritis, hypertensive disease, heart disease, and hearing impairments (table 4-3 and chart 4-2). In most cases, the rates for these diseases increase with age. For instance the rate for arthritis among persons age 45 to 64 is 273 per 1,000; for persons age 65 to 74 it is 464 per 1,000, and for persons 75 and over it is 512 per 1,000.

3 Lawrence, Linda and Thomas McLemore. "1981 Summary: National Ambulatory Medical Care Survey." Advance Data No. 88, National Center for Health Statistics (March 16, 1983).

0 100 200 300 400 500 600

Source: National Center for Health Statistics, Health Interview Survey, 1987

TABLE 4-3.-TOP TEN CHRONIC CONDITIONS FOR PERSONS 65 AND OVER 1

Source: National Center for Health Statistics. "Current Estimates from the National Health Interview Survey, United States, 1987." Vital and Health Statistics Series 10, No. 166 (September 1988).

Most visits to the hospital by older persons are for chronic conditions. Heart disease and other circulatory problems, diseases of the digestive and respiratory systems, and cancer are the leading causes of hospitalization among the elderly. Likewise, most physi

* National Center for Health Statistics. "Detailed Diagnoses and Procedures for Patients Discharged from Short-Stay Hospitals: United States, 1985." Vital and Health Statistics Series 13, No. 90 (April 1987).

cian visits by older persons are for such chronic conditions as circulatory problems, diabetes, arthritis, and eye problems.5

The types of conditions experienced by older people vary by sex and race. Older men are more likely than women to experience acute illnesses that are life threatening, while elderly women are more likely to have chronic illnesses that cause physical limitations. Arthritis and osteoporosis, for example, are much more common among older women than men, while coronary heart disease is much more common among older men. The health situation of elderly blacks is generally poorer than that of elderly whites. For example, rates for hypertension are 20 percent higher for elderly blacks than elderly whites according to the 1987 Health Interview Survey.

The severity of certain chronic diseases may be reduced in the near future by new technologies. Such clinical innovations as renal dialysis, insulin pumps, and medications to reduce vascular spasming after a stroke are examples of recent advances that could benefit older persons.

HEART DISEASE IS THE LEADING HEALTH PROBLEM FOR THE ELDERLY

Heart disease leads all other conditions in each of four major indicators of mortality or health care use by the elderly. It is the leading diagnosis for short-stay hospital visits for persons 65 or older as well as the leading cause of death. Sex differences in heart disease mortality are dramatic. In 1987, the age-adjusted death rate for white males was 381.1 per 100,000 compared to 223.6 per 100,000 for white women. However, although heart disease remains the major contributor to poor health and death in old age, the past three decades have shown a marked decline in death rates for heart disease. One probable contributing factor to the overall decline has been an increase in the control of hypertension, a major risk factor in heart disease.6

Heart disease, cancer, and stroke are the leading causes of death in the United States. Together they account for over three-quarters of all deaths among the elderly. They also are responsible for about 20 percent of doctor visits, 40 percent of hospital days, and 50 percent of all days spent in bed. Arthritis and rheumatism, on the other hand, account for relatively few deaths and only 2 percent of hospital days. They do, however, account for 16 percent of days spent in bed, nearly as much as for heart disease.

MENTAL HEALTH PROBLEMS OF THE ELDERLY ARE SIGNIFICANT IN THEIR IMPACT ON MENTAL STATUS AND EMOTIONAL STATE IN LATER LIFE

The mental health problems of the elderly are significant in frequency, in their impact on mental status in later life, and in their potential influence on the course of physical illness in older adults. Studies over the last several decades have documented that be

5 National Center for Health Statistics. "The National Ambulatory Medical Care Survey, United States, 1979 Summary. "Vital and Health Statistics Series 13, No. 66 (September 1982). 6 National Center for Health Statistics. Health, United States, 1985. DHHS Pub. No. (PHS) 86-1232, Washington: Department of Health and Human Services, December 1985.

tween 15 and 25 percent of older persons have serious symptoms due to mental disorders. More recent reports have continued to document comparably high levels of major disorders, symptoms, and suicide. The number of persons with mental disorders living in nursing homes continues to rise. At the same time, 27 percent of state mental hospital patients are 65 years of age or older.

8

Alzheimer's disease is the leading cause of cognitive impairment in old age. Alzheimer's disease and other organic mental disorders affect more than 6 percent of older adults. Cognitive impairment, whether from Alzheimer's or other causes, is one of the principal reasons for institutionalization of the elderly.

Suicide is a more frequent cause of death among the elderly than among any other age group, although this is due primarily to the relatively high suicide rate among older white men. In 1986, the suicide rate for white men 65 years to 74 (59 deaths per 100,000 population) was nearly five times the national rate (12), four times the rate for older black men (16), seven times the rate for older white women (8), and 23 times the rate for older black women (3).9 The relationship between mental and physical health is particularly significant among older persons. There is a growing body of knowledge pointing out the adverse affects of mental problems on the course of illness in later life. 10 For example, psychiatric consultation has had a positive effect on the length of stay and outcome for cardiac surgery patients. 11

Depression plays an important role in the overall health status of older persons. Symptoms of depression have been described in as many as 15 percent of older persons living in the community. While differing rates of depression have been reported to describe the profile of mental health in old age, these rates may be misleading because they often reflect only "primary" depressions-depressions that occur for other than physical causes or drug side effects. When the numbers of those who suffer from "secondary" depression are factored in, a more accurate picture of depression in later life emerges. Older people are more at risk for secondary depressions than any other age group because they suffer from more physical illness and take more medication than other age groups. Mental health problems have always been common among nursing home residents. For example, cognitive impairments are frequently important factors in the decision to place someone in a nursing home. In 1985, about 63 percent of the 1.3 million older residents of nursing homes were disoriented or memory impaired to the extent that their basic daily functioning was hindered. Twothirds of these impaired residents were reported to have senile dementia or chronic organic brain syndrome. The incidence of disori

Roth, Martin. "The Psychiatric Disorders of Later Life." Psychiatric Annals Vol. 6, No. 9 (September 1976).

8 Mortimer, J.A. "Alzheimer's Disease and Senile Dementia: Prevalence and Incidence." Alzheimer's Disease: The Standard Reference. Edited by Barry Reisberg. New York: The Free Press, 1983, pages 141-148.

National Center for Health Statistics. Health, United States, 1988. DHHS Pub. No. (PHS) 89-1232, Washington: Department of Health and Human Services, December 1988.

10 Cohen, Gene. "Toward an Interface of Mental and Physical Health Phenomena in Geriatrics: Clinical Findings and Questions.” Aging 2000: Our Health Care Destiny, Vol. I, New York: Springer-Verlag, 1985.

11 Levitan, Stephan J. and Donald S. Kornfeld. "Clinical and Cost Benefits of Liaison Psychiatry." American Journal of Psychiatry, Vol. 138, No. 6 (1981).

entation or memory impairment increased with age, with a growing majority of all age groups among older nursing home residents exhibiting these symptoms (table 4-4). Several studies have found as many as 70 to 80 percent of residents experience psychiatric problems. One recent study identified 94 percent of the residents of a nursing home as having mental disorders.

12

TABLE 4-4-PERCENT OF ELDERLY NURSING HOME RESIDENTS WITH COGNITIVE IMPAIRMENT BY AGE, SEX AND RACE: 1985

Source: Hing, Esther. "Use of Nursing Homes by the Elderly: Preliminary Data from the National Nursing Home Survey." Advance Data No. 135, National Center for Health Statistics (May 14, 1987).

ACTIVITY LIMITATION

ONE OF FOUR ELDERLY PERSONS HAS SOME DEGREE OF LIMITATION WHILE A SMALL PROPORTION ARE SEVERELY DISABLED

The severity of any disease can differ tremendously from person to person, causing varying degrees of limitation in activity. For example, one person with arthritis may become housebound, while another only suffers from occasional bouts with very limited loss of mobility.

A widely used measure of disability among older persons is the degree of functional limitation or difficulty individuals experience in performing personal care or home management activities. Personal care activities include bathing, dressing, eating, getting in and out of bed and chairs, walking, going outside, and using the toilet-also known as "activities of daily living" or ADL's. Home management activities include preparing meals, shopping for personal items, managing money, using the telephone, doing heavy housework, and doing light housework-activities termed "instrumental activities of daily living" or IADL's. 13 ADL's and IADL's

12 Rovner, Barry W., Stephanie Kafonek, Laura Filipp, Mary Jane Lucas, and Marshall F. Folstein. "Prevalence of Mental Illness in a Community Nursing Home." American Journal of Psychiatry, Vol. 143, No. 11 (November 1986).

13 Dawson, Deborah; Gerry Hendershot; and John Fulton. "Aging in the Eighties: Functional Limitations of Individuals 65 and Over." Advance Data Number 133, National Center for Health Statistics (June 10, 1987).