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Last scene of all,

That ends this strange eventful history,

Is second childishness and mere oblivion,

Sans teeth, sans eyes, sans taste, sans everything.

— William Shakespeare, As You Like It, Act II, Scene VII

The idea of economic worthlessness instills a spirit of irritability if not positive enmity against the helplessness of the aged. — Ignatz Nascher, US pioneer     geriatrician

If there were no old men there would be no civilized states at all. — Marcus Tullius Cicero, philosopher, politician         and gossip

In this editorial, I hope to address two questions relevant to the ageing patient and healthcare: what are the outcomes from peri-operative care in the elderly; and will the increasingly aged population necessitate substantially greater investment in the National Health Service (NHS)?

Outcomes in the elderly

  1. Top of page
  2. Outcomes in the elderly
  3. Money, money, money
  4. Competing interests
  5. References

It has been known for some time that elderly patients frequently do not receive optimal care. The National Confidential Enquiry into Patient Outcome and Death report of 2010 identified several areas of concern and noted that over 90% of the elderly patients included had some accompanying co-morbidity [1]. Failure to involve physicians, delays to surgery and inadequate postoperative care were amongst the concerns. A number of suggestions have been made to try and improve this situation [2], but elderly patients will inevitably experience greater morbidity and mortality than will younger patients. The fitter the patient, the less likely he/she is to experience complications, and this is true for both cardiac and non-cardiac surgery [3, 4]. Outcomes are considerably worse if the surgery is unplanned; one study in the over-80s showed that the six-month mortality rate after discharge from intensive care units (ICUs) was 30% for patients having planned surgery compared with 76% for those having emergency surgery [5]. Elderly patients presenting as emergencies have been eloquently described as ‘a heterogeneous cohort of both potentially treatable patients and those who are dying[6]. Separating the treatable from the futile is difficult across all age groups, but particularly so in the elderly, where limited life expectancy is usual and severe but unrecognised co-morbidity may exist.

The effect of age itself on outcomes after ICU admission is also confusing. It is worth noting that Acute Physiology and Chronic Health Evaluation scoring attributes only 7% of the outcome's predictive power to age alone. Studies of ICU patients do point to poorer outcomes in the elderly, but only because age is a surrogate for co-morbidity. In one representative study of over 15 000 elderly patients compared with non-elderly ICU admissions, the elderly were more likely to have greater co-morbid illnesses and higher illness severity scores, leading to a higher ICU mortality; these patients were also more likely to be discharged to either rehabilitation or long-term care [7].

It seems clear that there is room for improvement in the decision-making around both the suitability for surgery and the suitability of surgery. Admission to the ICU or high dependency unit can also be improved – should we admit fewer frail, elderly patients with significant co-morbidities or should we admit more? If surgeons continue to operate on such patients, then intensivists would seem obliged to provide postoperative critical care. The organisational and financial consequences of such isolated surgical decisions have ongoing and far-reaching implications for the care of other inpatients, hence the need to involve senior medical and allied healthcare professionals in multidisciplinary decision-making about treatment, or its withdrawal.

Money, money, money

  1. Top of page
  2. Outcomes in the elderly
  3. Money, money, money
  4. Competing interests
  5. References

Complications and co-morbidities cost money. If a greater proportion of the population is elderly, then providing a health service is bound to cost substantially more – isn't it? Amongst the more immediate worries occupying politicians in the developed economies is the apocalyptic prediction known as the ‘demographic time-bomb’ [8]. The UK House of Lords Committee on Public Service and Demographic Change has warned the government that ‘… as many more people live into advanced years, the numbers with several long-term conditions are soaring, piling pressure on the National Health Service, for which it is unprepared[9]. The most recent data show that there are around seven million surgical procedures performed each year in the UK, 49% of which involve the over-60 age group. Nearly a quarter of operations (22%) are performed on patients 75 years of age or older [10].

Increasing concern about the implications of the ageing population for healthcare systems and the nation's economic capacity is based on a number of premises. More people are surviving longer. Individuals accumulate more co-morbidities as they age and, coupled with an increasing willingness to undertake more intensive and complex treatments in progressively older patients, the NHS will be treating greater numbers of older, sicker patients [11], which will increase healthcare costs. However, at the other end of the age spectrum, at least in developed countries, the birth rate has been falling, such that the number of ‘economically active’ adults paying tax as a ratio of the number of ‘economically inactive’ elderly adults (the ‘old-age dependency ratio’) will continue to decline, unless the state pension age is altered:

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Although this calculation does not take into account economically inactive non-tax paying adults, the old-age dependency ratio for the UK in 2014 (333) indicates that there are just over three pensioners ‘supported’ by every 10 taxpayers. In 25 years’ time, without changes in the State Pension Age, every 10 taxpayers will be ‘supporting’ at least one extra pensioner (dependency ratio 469) [12].

The national and global rates of population expansion among the elderly since 1950 are sobering. When the NHS began in 1948, there were only 200 000 people in the UK aged over 85 years. In 2014, the number is 1.4 million, and this is expected to rise to almost 3 million by 2050 [13]. The proportion of the British population projected to be over 65 by 2060 is 26% [14]. Globally, the number of people aged over 60 is projected to reach one billion by 2020 and almost two billion by 2050, equivalent to 22% of the world's population, with the proportion aged over 80 rising from ~1% to 4% [15]. Those aged over 60 will outnumber those aged under 15 for the first time ever in 2047 [12]. Demographic changes will result in higher rates of age-related co-morbidity. For example, the global estimate of the number of people with dementia, currently ~27 million, will double every 20 years, to ~80 million by 2040 [16], incurring additional health and social care costs (currently £34 billion (€40 billion, $55 billion) annually in the UK [17]).

The case would appear to be clear-cut: people are living longer; healthcare demands and costs will rise; and the diminished economically active workforce will not support this burden without politically suicidal increases in taxation. So far, so bad.

This conclusion, known as the ‘morbidity expansion model’ or the ‘failure of success’ [18], has the virtue of being a logical extrapolation of known demographic trends and truisms borne of medical experience, but is only one out of three postulated viewpoints that have been advanced in debates about the demographic time-bomb. It infers that increasing life expectancy will only lead to additional years of chronic illness and misery, particularly if patients require hospitalisation or surgery [2].

However, the economic ramifications of an ageing population could be ameliorated by better therapeutic decision-making and higher quality care, as proposed by two other models, namely the ‘morbidity compression’ model, in which people experience longer, but morbidity-free, lives, and the ‘dynamic equilibrium’ model, in which an ageing population will experience a similar rate of co-morbidities, but less severely [19, 20].

If current trends continue, the population will contain proportionally more elderly people, although increasing longevity is not guaranteed [21] and remains constantly threatened by war, global pandemic and environmental catastrophe. Nevertheless, it is safe to assume that, whilst the elderly will be growing in absolute numerical terms, they also appear to have become substantially healthier. In most countries within the Organisation for Economic Cooperation and Development (OECD), late-life disability rates have declined and this appears to be as a result of the socioeconomic improvements [22]. In a phenomenon referred to by demographers and health specialists as the ‘compression of morbidity’, the duration of healthy old age appears to be increasing, attributable partly to increases in the length of life, and partly to shorter and later periods of illness. The net effect is an increase in the number of years lived at old age without major health problems. Indeed, it has been argued that the threshold for defining old age should be the age at which the average life expectancy is 15 years or less [23].

Even if people are set to remain healthier for longer, ultimately they will need the services of the NHS (or its equivalent in other countries). A report by the Nuffield Trust identified an increase in UK emergency admissions from 2004 to 2009 and attributed around 40% of this to elderly patients, but – and this is crucial – found that more admissions survived and left hospital more quickly, implying that patients were less sick on admission [24], a trend that was seen across all age groups (but might also be explained by limited access to primary care services). The question then is whether healthcare spending will decrease because there are fitter elderly patients, or whether costs will rise as the elderly present later in life than at present. Approximately a quarter of healthcare expenditure occurs in the last year of an individual's life [25], but those costs are going to be higher the younger the individual is. This is not surprising – younger patients are more likely to be offered expensive diagnostics and therapeutics. Developing diseases much later in life means that you are less likely to be offered expensive treatments than if you were younger. On a like-for-like basis, greater numbers may acquire the disease, but they would be offered less expensive treatments, hence the net effect may be no greater expenditure at all.

In 2013, expenditure on health in the UK was average for countries in the OECD at 9.8% of gross domestic product (GDP), compared with 9.5% in Japan and 17.7% in the USA [15]. Some projections estimate that the ageing population will cause an increase in NHS spending of around 1% a year this decade, or just short of £1 billion (€1.2 billion, $1.6 billion) a year on top of the costs of social care. However, estimating future healthcare costs is unreliable and subject to numerous unpredictable factors, not least of which is political whim. For example, the Guillebaud Committee predicted an increase in NHS healthcare costs of 11.2% between 1951 and 1971, when the actual rise was 71% [26]. As confronting the demographic time-bomb has moved up the political agenda, the UK, Canada and the USA have all predicted that significant extra expenditure will be required on healthcare. However, the assumptions underpinning the predictive models are not as robust as they might appear. Other studies have failed to show a significant impact of demographic change on healthcare costs [27, 28]. Absolute age is not the major determinant of healthcare costs: proximity to death is. Actuarially, the chances of dying increase with age, but it is not age per se that is the cause of increased health costs so much as how that money is spent in the last year of a dying person's life [29].

The economic impact of demographic change on national productivity has also been assumed to be detrimental, but the situation may be more complex than this. Firstly, fertility rates have been declining in all developed and developing economies, and a GDP dividend results from lower state expenditure (on schools, benefits, etc), and the availability of potential parents (taxpayers) to work. In both developed and developing countries that achieved lower fertility rates between 1960 and 1995, output growth increased by 20% per capita, and poverty was reduced [30]. Thus, the rising old-age dependency ratio may be offset by the falling child dependency ratio that results from low population fertility. Some estimates conclude that the total population of Europe will not change by much over the next century, excepting significant inward migration from outside Europe [31].

Secondly, the ratio of consumption to production is highest in the young and the elderly, and lowest in the working population, and so it is assumed that a population with higher numbers of elderly individuals will experience lower economic growth as a result. Modelling the economic effect of an ageing population has relied upon determining age-specific behaviours and then seeing what happens when changes in the relative size of different age cohorts within the total population are imposed, but this could lead to quite inaccurate conclusions. Behaviours may change if people feel more confident of living longer and healthier lives. People may retire later and preserve their savings until later in life, for example, which could have noticeably different outcomes for the national income. Partly as a result of the 2008 financial crisis, some countries have already increased the statutory age for retirement, and others, including the USA, Australia, New Zealand, Japan and most of Europe, have recently moved towards increasing their retirement age. Other areas of the world with lower life expectancy may have to consider such measures as their own population ages [32].

Thirdly, the elderly make important financial contributions. In most developed countries, old people make net financial transfers to their families and only become net receivers of financial support either very late in life or, in the example of Austria and the USA, not at all [33]. The wealthy elderly population also contributes to the economy by virtue of its age, creating an ‘elderly market’ as Tom Singer, a financial director for BUPA (a private healthcare insurer), has noted: ‘The City views [BUPA] as a very stable and attractive investment proposition because they know the background factors – ageing population, growing burden of chronic disease, are long-term trends that will only go one way. We'll move and exploit those trends[34].

Finally, one cannot discount innovation. We already possess drugs that have modified the course of diseases, such as diabetes and atherosclerosis. Alzheimer's disease, Parkinson's disease, arthritis, stroke, cancer and chronic obstructive pulmonary disease are the subject of intensive research and newer medications are appearing all the time. These may well lead to further compression of morbidity and longer, healthier lives – or at least less unhealthy lives – than in the past. The most recent estimations of the maximal attainable average life expectancy point to around 90 years of age, and there does appear to be a ceiling on how much older we can get [35, 36].

In summary, the ageing population is going to present health services with a challenge. Consensus points to a compression of morbidity, but considerable financial strain will still be exerted on health services, without structural and clinical changes. Anaesthetists need to become better at identifying higher risk (and therefore more costly) patients, and intervening as part of multidisciplinary team both to improve and to reinvent peri-operative care for the ‘third age’. Society in general, and politicians in particular, needs to understand the positive economic and societal contributions that elderly people make, and see them as a demographic dividend rather than an increasing burden. We should be overjoyed at the prolongation of active adult life, and there's every chance that we won't cost anything like as much as we expect, when we retire.

Competing interests

  1. Top of page
  2. Outcomes in the elderly
  3. Money, money, money
  4. Competing interests
  5. References

No external funding and no competing interests declared.

References

  1. Top of page
  2. Outcomes in the elderly
  3. Money, money, money
  4. Competing interests
  5. References