Elsevier

The Lancet

Volume 385, Issue 9967, 7–13 February 2015, Pages 549-562
The Lancet

Series
The burden of disease in older people and implications for health policy and practice

https://doi.org/10.1016/S0140-6736(14)61347-7Get rights and content

Summary

23% of the total global burden of disease is attributable to disorders in people aged 60 years and older. Although the proportion of the burden arising from older people (≥60 years) is highest in high-income regions, disability-adjusted life years (DALYs) per head are 40% higher in low-income and middle-income regions, accounted for by the increased burden per head of population arising from cardiovascular diseases, and sensory, respiratory, and infectious disorders. The leading contributors to disease burden in older people are cardiovascular diseases (30·3% of the total burden in people aged 60 years and older), malignant neoplasms (15·1%), chronic respiratory diseases (9·5%), musculoskeletal diseases (7·5%), and neurological and mental disorders (6·6%). A substantial and increased proportion of morbidity and mortality due to chronic disease occurs in older people. Primary prevention in adults aged younger than 60 years will improve health in successive cohorts of older people, but much of the potential to reduce disease burden will come from more effective primary, secondary, and tertiary prevention targeting older people. Obstacles include misplaced global health priorities, ageism, the poor preparedness of health systems to deliver age-appropriate care for chronic diseases, and the complexity of integrating care for complex multimorbidities. Although population ageing is driving the worldwide epidemic of chronic diseases, substantial untapped potential exists to modify the relation between chronological age and health. This objective is especially important for the most age-dependent disorders (ie, dementia, stroke, chronic obstructive pulmonary disease, and vision impairment), for which the burden of disease arises more from disability than from mortality, and for which long-term care costs outweigh health expenditure. The societal cost of these disorders is enormous.

Introduction

The greatly increased expectancy of survival into old age is one of humanity's major achievements.1 To the contrary, worldwide population ageing and the attendant increases in public spending on health and social care are seen as a threat to worldwide economic stability in the 21st Century.2 Informed policy making and planning necessitates an understanding of the present and probable future distribution of morbidity and its effect on mortality, disability, and dependence. Several effects need to be considered; demographic and epidemiological transitions and secular changes in the effectiveness and coverage of disease control measures. Effects will vary between disorders and regions.

The worldwide epidemic of chronic diseases is strongly linked to population ageing. Disorders with a strong age-dependent relation will increase in prevalence in parallel with the absolute and relative numbers (relative to the total population size) of older people (≥60 years). In high-income countries, population ageing persists as fertility continues to fall and life expectancy increases slowly. For many middle-income countries mortality has decreased over much of the 20th century, and decreasing fertility is now ushering in unprecedented rapid population ageing. The doubling in the proportion of the population aged 65 years and older from 7% to 14%, accomplished in 46 years in the UK, 68 years in the USA, and 116 years in France, will be completed in just 26 years in China and 21 years in Brazil.3 The appendix reviews the implications for China and national policy directions.

The epidemiological transition from the age of pestilence and famine to the age of degenerative and man-made diseases is near complete in most high-income countries. Low-income and middle-income countries face various gradations of a double burden of infectious and non-communicable diseases, the balance shifting inexorably towards non-communicable diseases. A globalisation of risk behaviours; including diets rich in saturated fat and increase of tobacco use and underactivity, with consequent obesity; partly causes the rapid increase in burden of chronic diseases in these regions. After the transition, in high-income countries, cardiovascular risk factors and diseases are typically associated with economic disadvantage and low levels of education, but the trend is often in the opposite direction in low-income and middle-income countries.

Key messages

  • 23% the global burden of disease arises in older people (nearly half the burden in high-income countries and a fifth in low-income and middle-income countries)

  • Chronic non-communicable diseases account for most of the burden; leading contributors are cardiovascular diseases, cancer, chronic respiratory diseases, musculoskeletal diseases, and mental and neurological disorders

  • Population ageing will be the major driver of projected increases in disease burden in older people, most evident in low-income and middle-income countries and for strongly age-dependent disorders (dementia, stroke, chronic obstructive pulmonary disease, and diabetes). These are also the disorders for which chronic disability makes a substantial contribution to burden

  • Primary and secondary prevention for cardiometabolic disorders is probably as effective in older people as it is in younger people, and the benefit is increased in view raised levels of absolute risk of adverse outcomes. Nevertheless, access and coverage is especially poor in older people

  • Effective intervention in older people is complicated by ageism, complex multimorbidity, and no access to age-appropriate care, and is exacerbated by user fees, inadequate income security and social protection. Assessment and treatment needs to be holistic, coordinated and person-centred. Home-based outreach, and multidimensional assessment of frailties that might be treated or mitigated might help to reduce individual and societal effects on disability and dependence

In high-income countries, mortality from cardiovascular disease has been decreasing in all age groups. The average age of first onset and death from cardiovascular disease has been increasing and shifting the burden into older age. Decreasing incidence plays a part, but case fatality rates have also fallen with improved acute hospital management. Since prevalence is a product of incidence and duration, long survival for these and other chronic diseases has a profound effect on population burden, particularly on years lived with disability and needs for care.

In this Review, we trace these changing patterns examining present and future burden of major chronic diseases of particular relevance to older people (cardiovascular diseases [stroke and ischaemic heart disease], cancer, diabetes, chronic respiratory diseases, visual impairment, dementia, and musculoskeletal disorders) across world regions by income level and their underlying risk factors and evidence-based treatments. We complement this disorder-based approach by reviewing three cross-cutting themes; fraility, multimorbidity, and ageism in the provision of service; that distinctively characterise the interaction of ageing and health and pose challenges and opportunities to strengthen health systems to meet the needs of older people.

Section snippets

Overview of burden of disease in older people

According to the Global Burden of Disease (GBD) estimates for 2010, 23·1% of the total disease burden (574 million of the 2490 million DALYs) is attributable to disorders in people aged 60 years and older, 49·2% of the burden in high-income regions, and 19·9% in low-income and middle-income regions.4 For the disorder clusters (figure 1, table), the leading contributors to disease burden in older people are cardiovascular diseases, malignant neoplasms, chronic respiratory diseases,

Social and demographic determinants

The appendix summarises the results of a meta-analysis modelling the independent effects of age, sex, and education on the prevalence of obesity, hypertension, diabetes, ischaemic heart disease, stroke, depression, and dementia from 10/66 Dementia Research Group5 and WHO-SAGE6 population surveys in 12 low-income and middle-income countries in Africa, Asia, and Latin America. Stroke was more common in men than in women, but the prevalence of other disorders was consistently higher in women. Age

Risk exposures

The profile of lifestyle-related risk factors is much the same across the most burdensome disorders for older people. Dyslipidaemia, hypertension, diabetes, smoking, and obesity are the major modifiable risk factors for cardiovascular diseases.7 Smoking is also the main modifiable risk factor for cataract and age-related macular degeneration,8 COPD,9 and lung cancer10 in old age. A review11 of risk factors for Alzheimer's disease identified consistent evidence from cohort studies to accord with

Cardiovascular diseases

The profile of cardiovascular disease develops gradually with the epidemiological transition.32 As mortality decreases, nutrition improves and infections are controlled, and hypertension, ischaemic heart disease, and stroke become more prevalent, with ischaemic heart disease contributing most to mortality. As high-income countries advance into the so-called age of delayed degenerative diseases, age-adjusted mortality due to cardiovascular disease decreases with effective primary and secondary

Cancer

Malignant neoplasms accounted for 87·0 million DALYs in older people in 2010, 67% of the burden arising in low-income and middle-income regions. Burden in older people is forecast to increase by 69% to 2030. Cancer is a leading cause of mortality, accounting for 9·9 million deaths yearly of which 5·4 million (54%) occur in people aged 60 years and older.

The incidence of many cancers rises with age. In the UK (2007–09), incidence increases exponentially for men from 116 men per 100 000 at age

Diabetes

Diabetes mellitus accounted for 22·6 million DALYs in older people in 2010, 80% of the burden arising in low-income and middle-income regions. Burden in older people is forecast to increase by 96% from 2004 to 2030. In NHANES 1999–2002,68 the prevalence of total (diagnosed and undiagnosed) diabetes increases sharply with age, from 2·4% in people aged 20–39 years to 21·6% in people aged 65 years and older. Prevalence of total diabetes had risen from 5·1% (1988–94) to 6·5% (1999–2002), with the

Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) accounted for 43·3 million DALYs in older people in 2010, 86% of the burden arising in low-income and middle-income regions. The global burden was forecast to increase by 89% from 2004 to 2030. In an international multisite survey,72 the prevalence of COPD was around 10% for people aged 40 years and older, nearly doubling with every 10-year increment of age, to reach 19–47% for men and 6–33% for women aged 70 years and older. The projected large

Visual impairment

Visual impairment (blindness or low vision) accounted for 10·4 million DALYs among older people in 2010, 86% of the burden arising in low-income and middle-income regions. This is a very substantial reduction from the 30·9 million DALYs in the WHO 2004 GBD estimates, which was forecast to increase by 86% by 2030. 186 million of the world's 285 million visually impaired (65%), and 32 million of the world's 39 million blind people (82%) are estimated to be older adults aged 50 years and older;

Dementia

Dementia accounted for 10·0 million DALYs in older people in 2010, 44% of the burden arising in low-income and middle-income regions. This is a substantial reduction from the 18·8 million DALYs in WHO GBD 2004 estimates, which was forecast to increase by 86% by 2030. Dementia is characterised by progressively disabling impairment of several cognitive functions. However, behavioural and psychological symptoms affect quality of life, are an important cause of carer strain,87 and are a common

Musculoskeletal disorders

Musculoskeletal disorders accounted for 43·3 million DALYs in older people in 2010, 66% of the burden arising in low-income and middle-income regions. This is a very substantial increase from the 12·1 million DALYs in WHO 2004 GBD estimates, which were forecast to increase by 70% by 2030. The main contribution from musculoskeletal disorders arises from low-back pain (19·1 million DALYs) followed by osteoarthritis (7·5 million DALYs).

Low-back pain is a syndrome based mainly on self-reported

Health care

The Madrid International Plan of Action on Ageing called for the elimination of social and economic inequalities in access to health care and the development of healthcare and long-term care to meet the needs of older people.1 To achieve these needs, age discrimination should be countered and the challenges posed by multimorbidity and frailty addressed. The fitness for purpose of health services and systems for older adults and their complex, interacting, chronic medical and social difficulties

Conclusion

The worldwide epidemic of chronic disease is, to a large and increasing extent, concentrated in older people and people living in low-income and middle-income countries. Global burden of disease in older people is projected to increase more or less in line with the increase in the older population, consistent with population ageing being the most important driver of the chronic disease epidemic.135 The largest increases in disease burden will occur for those disorders that are particularly

Search strategy and selection criteria

We analysed Disability Adjusted Life Years (DALYs) data for people aged 60 years and older from the Global Burden of Disease (GBD) estimates generated by the Institute of Health Metrics and Evaluation (IHME GBD—1990 and 2010),4 and WHO (WHO GBD—2004 update with projections to 2030) 5 Although priority is given throughout to the present IHME estimates, this approach enabled us to critically examine the effects of the previous WHO6 and IHME7 disability weights on the relative burden of different

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