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Americans Living Longer, Not Necessarily Healthier, Lives
Questions about the health
of older people have arisen as mortality at older ages has decreased
remarkably over the last 30 years. Reductions in mortality from heart
disease are the major reason for this trend, but death rates from almost
all major diseases typically experienced at older ages also have declined.
Consequently, there has been an increase in life expectancy after age 65
and even after age 85. But are older Americans healthier today than they
were a generation ago? The answer depends on which indicator of health is
used to measure change.
We know heart disease death
rates have fallen dramatically (Figure 1). It is possible that
this has come about because heart disease has been prevented or because
people are experiencing its onset at older ages. But most of the evidence
so far indicates that falling mortality rates are due to better treatment,
allowing people to live longer following the onset of heart disease. As
people live longer with the disease, the number of older people reporting
that they have it has increased. Improvement in health does
not necessarily accompany an increase in life expectancy since only about
half of the disability and functioning loss at older ages is caused by
lethal diseases. The other half is caused by conditions that are not
linked to mortality trends, including arthritis, vision loss, and
Alzheimer's disease. This means that some people are surviving heart
disease but suffering from crippling arthritis or dementia (Figure
2). Nonlethal diseases are thus going to
become increasingly important causes of disability and functioning loss in
old age unless they too can be delayed or eliminated.
Health care for older
people is moving toward delaying the onset and progression of both lethal
and nonlethal diseases and providing people with the personal and home
care they need to cope with the disabilities that stem from these
conditions. Delaying onset and progression requires both pharmaceutical
and behavioral interventions. Many people from advanced middle age onward
are using drugs to control both hypertension and cholesterol in the hope
of delaying or preventing the onset of clinical heart disease. New
generations of drugs have been developed to control the loss of
functioning and disability associated with arthritis. Because
approximately half the older population has this condition, for which
there is no cure, a large proportion of people are likely to use these
drugs for some period of their lives. The use of medication to delay the
disability connected with diseases such as Alzheimer's is going to
increase markedly in the near future. Current approaches to
disease control are the result of the expansion of biological knowledge of
the basic disease processes. Continued growth in this knowledge — some
of it coming from better understanding of the human genome — will
greatly increase our ability to intervene early in the prevention of
disease and disability. The overall reduction in
mortality, increasing life expectancy from 40 to 75 years, is regarded by
many as the central accomplishment of the 20th century. In 1900, we would
not have predicted our ability to so effectively reduce death at younger
ages from infectious diseases. The development of the germ theory of
disease at the end of the 19th century laid the groundwork for this marked
improvement in life expectancy. Deeper understanding of the human genome
and of the biology of aging at the end of the 20th century has similarly
provided a foundation for the delay and prevention of the major diseases
and conditions of old age. By the end of this century,
we will certainly live longer, and we should not suffer from heart disease
or cancer until much later in life. However, unless we die in perfect
health, we will still have a period of disease and disability before
death. As life expectancy has
increased, emphasis has shifted from quantity to quality of life.
Researchers and policymakers are increasingly focusing on how to extend
healthy and active life. This has resulted in a growing use of measures of
expected healthy life or life without disease or disability, in addition
to traditional measures of life expectancy, to monitor health trends and
health differences.
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