Aging of our population is one of the success stories of modern social policy and medicine. The gain in average life expectancy over the last century is perhaps the best measure of effectiveness of modern medicine.
Since the early 1900s, Western societies, including NZ, have seen the life expectancies of their populations increase on average 2.5 years per decade, from approximately 50 years (male and female) in 1900 to the current 78 for males, 82 for females. This increase has yet to show signs of slowing, though there still is no reason to suspect that the ultimate human lifespan is anything but finite!
In the future, only an exceptional person will still survive beyond 110 years, whilst there are good theoretical grounds to believe each of us could expect to live on average for 85 years or so.
Effective medical treatment on a scale sufficient to impact human longevity began in the 20th century. Public health services, improved nutrition, eradication and treatment of infectious diseases in the earlier part of the century improved life expectancy mainly by reducing deaths in the younger population.
However, since about 1970 improved longevity has arisen more from effective management of chronic disease in our older population, achieved mainly by improving risk factors for cardiovascular disease within our population (such as reduced smoking and cholesterol, and increased physical activity), together with effective medical treatments for individuals.
Apart from antibiotics introduced in the late 1930s, drug treatments were not known to be effective in terms of improving survival until a number of important medical studies were published in the 1980s. Until then, treatments were limited to control of symptoms of disease without necessarily changing long-term outlook.
Amongst the most important of current ‘effective’ medications are ACE inhibitors (used for high blood pressure and heart disease), beta-blockers (blood pressure, heart disease), statins (high cholesterol, vascular disease) and warfarin (anticoagulant, stroke prevention), all of which have been introduced into widespread clinical practice. Such medications have unquestionably improved both population and individual health outlook by reducing the rate of premature deaths from vascular disease (heart attack and stroke) as well as adding to life expectancy.
Despite improvement in our population’s average lifespan, the importance of social determinants of health cannot be overlooked. Major disparities persist within our society. Life expectancy for Mãori is less than for Pakeha (8 years less on average). Lower educational attainment and social deprivation also impact negatively on an individual’s prospects for longevity.
Chronic diseases now the issue
Although we have reduced the risk of early and sudden death, our aging population is now subject to an accumulation of chronic diseases (such as diabetes, heart disease, stroke, chronic lung disease, osteoporosis, dementia). Towards the end of life, these diseases are associated not only with a greater need for acute medical care, but also the potential for loss of independence and a need ‘to be cared for’ either at home or in residential care … a major driver of cost to society for effective ageing of its people.
In Hawke’s Bay (and the rest of NZ), currently about 15% of our population is over the age of 65; by 2041 this will rise to 25% of our population (as baby boomers mature). However the greatest percentage growth of population will be seen in the over 85 year age group, whose numbers will more than double from current 2% to 5% of total population over this same period.
For the first time in history we are faced with the ‘creation’ of such large numbers of population surviving close to limits of human lifespan. Consequently, a number of unprecedented challenges will need to be addressed in the not too distant future by medicine, society and all of us as individuals.
For medicine these challenges will include:
- trying to minimise disability and dependency towards the end of life;
- attempting to ensure that investigation and intervention for people is appropriate at a time where quality of life is most important near the end of life; and,
- developing acceptable alternatives to acute hospital care in the community or home appropriate to personal need and our community’s wishes.
Perhaps counter-intuitively, anticipation of imminent death remains a difficult challenge for clinicians and their patients, though there are often indicators that a person may well be approaching the last months or so of their life.
Many chronic diseases are characterised by recurrent hospitalisations towards the end of life (during which time a large proportion of total lifetime health costs are incurred), any one of which may not be survived, despite survival being expected by all involved, including the person and their family. Treatment of a worsening of a chronic disease may be straightforward and relatively quick. However, such hospitalisations can be beset by a number of complications arising from treatment and hospital environment (including acute confusion, falls, infections, pressure areas) and may incur significant personal cost in terms of loss of independence by the time of leaving hospital, requiring additional support at home or quite possibly a move to residential care.
It also seems likely that the older we become the greater our need for such acute hospital care and the longer each stay will be. And the cost of supportive care relates directly to absolute numbers of people needing this care … numbers expected to grow for at least the next 40 years.
As early as 2021 it is also expected that there may well be a shortage of caregivers needed to provide support for a frail population, unless demands can be significantly decreased.
Society must therefore grapple with demands from an aging population that might not be readily met, given both the actual dollar cost and the human resource required to provide basic as well as more specialised care. Decisions may need to be made about possible limitations of treatment (explicit rationing) as hospitals adjust to cope with increasing numbers and complexity of acute hospital admissions, potentially at the expense of beds otherwise needed for activities such as joint replacement surgery.
Ending of life
Perhaps most contentious, however, may be the wish to revisit decisions regarding explicit premature ending of life – euthanasia and physician-assisted suicide. As all will know, these two ‘activities’ are currently illegal in NZ and will remain so for the foreseeable future.
However, the most difficult challenges may remain those at a personal level – either for ourselves or as spokespeople for our ageing relatives or friends. The end of life for many of us is unknowable. Our actions and wishes when the time comes may be unpredictable and possibly contrary to our previously stated position. Our broad concepts of limitations of care we would wish to receive at the end of our life can be stated in a legally binding ‘Advance Directive’ but circumstances can and do sometimes change. Increasingly, specific requests within an advance directive risk being difficult to interpret and apply in precise circumstances that might not be foreseen.
On the other hand, some of us may wish to have as much done as possible to prolong our life or that of our aged friend or relative, despite such intervention having little, if anything, to offer in the circumstances. It is understandable that demand for this type of treatment is not necessarily rational; it is a reflection of our most basic need for survival. Still, such requests can heavily tax the act of dying.
Trying to match expectations with clinical ‘reality’ can be a delicate process. Negotiating an understanding of treatment (or limitation of treatment) appropriate to a particular situation is perhaps the art rather than the science of medicine.
Anticipating the future for many of our older, sicker people is impossible without good understanding of their overall health and wishes, and being aware of likely effects of treatment on dependency and outlook beyond the immediate future. If this perspective is lacking at times, such as admission to hospital, there is a risk of inappropriate investigation or treatment, a risk that might be compounded by the raising of false hopes and denying of an opportunity to understand real implications of the illness.
Minimising the risk of unwarranted intervention can be more difficult than you might imagine. Accepting limits to care can only occur after considered discussion between individuals, their family and their health professionals, preferably before an acute complication arises. These conversations can be confronting, but are important in preparing us all for our end, particularly when this is foreseeable. As the end of life approaches many of us would opt for limited intervention and a focus on quality of time remaining. The next challenge is that of ensuring these wishes are known and respected when we present for care in an unfamiliar setting such as the acute hospital.
Continuity of care is at the heart of ‘good medicine’ for an aging population, but is increasingly difficult to achieve in our current health system and acute hospitals. If we are able to accept that minimisation of intervention for many older people is not only appropriate but desirable, we as a society can look to developing community resources as viable alternatives to acute hospitalisation. This has the real potential to focus on care and rehabilitation rather than ‘treatment’, allow the care to be provided by health professionals including the GP most familiar with an individual’s needs, and deliver the care in a more suitable environment, whether this is within a specifically staffed local care facility or possibly one’s own home. This challenge is perhaps the real frontier of medicine for an aged population.
Despite these worrisome ruminations there is much to celebrate. For the first time in history we live in a world where the majority of us can expect to live to near our biologic potential. And enjoy retained independence for the majority, but not necessarily all, of our allocated time. But death is still assured and disparities are yet to be addressed.
We can improve the likelihood of getting to and maintaining healthy old age with relatively simple lifestyle measures – a healthy diet, no smoking, regular exercise, a little alcohol, something to occupy our time and our mind and a good social network. On achieving such an age, however, there is much progress yet to be made in accommodating our health needs and demands. We’re not quite ready
for old age.