Trends in the Health of Older People in Developing Countries

and Minority Populations

Kyriakos S. Markides, PhDUniversity of Texas Medical Branch

Galveston, Texas, USA

Adelaide, Australia, June 30 2011

Overview of research on trends in Western Countries over the last three decades.

Data regarding older Hispanics in the United States.

Data from developing countries, especially Asia.

Summary/Conclusions.

Outline

Lively interest in Western countries within the last three decades.

Significant policy implications.

Limited research on minority populations within Western countries, as well as developing countries, primarily due to absence of data.

Studies have focused primarily on trends in disability.

Study of Trends

James Fries (1980), presented an optimistic scenario on the future of health status (and health care) in U.S. and other Western countries.

The idea of the “Compression of Morbidity” basically stated that increases in life expectancy would be accompanied by a compression of morbidity and disability into a shortened span of time at the end of life.

Advances in medical care and improvements in health behaviors would postpone the onset of disability and chronic disease to later in life. Because life expectancy would be approaching its biological limits (maximum life span) disease and disability would be compressed into a shorter amount of time.

There would be significant implications for the cost of medical care and quality of life.

The Compression of Morbidity

Lively response to the compression of morbidity thesis. Mostly critical.

Studies of trends in the 1970’s to the early 1980’s found that increased life expectancy and increased survival into advanced old age were accompanied by an increasing concentration of disease and disability in old age (Colvez & Blanchet, 1981; Markides, 1993. Verbrugge 1984).

Similar evidence also found in Europe (Markides 1993). Questions were raised about the biological maximum life span of 85 to 90 years.

Response to the Compression Thesis

Accumulating evidence suggested declines in disability in old age in the U.S. during the 1980s and 1990s.

Initially, the decline was in instrumental activities of daily living (IADL’s) such as using the telephone, handling money, shopping, etc.

By the 1990s declines were noted in basic activities of daily living (ADL’s) capturing more severe personal limitations such as eating, bathing, walking, and eating.

Declines also observed in Finland (Sulander et al, 2006); Spain (Sagardu; 2005); Sweden (Parker, et al, 2008), Italy, Denmark, and the Netherlands; and stability in Australia and Canada (Matthews et al, 2007).

Trends in the 1980s and 1990s

U.S. data on trends in disability,1988-1994, and1999-2005, showed increases in ADLs, IADLs, and instrumental activities of daily mobility among those aged 60-69. Greater increases observed among Blacks and the obese or overweight. No changes among those aged 70-79, and some improvements among those aged 80 and over in functional limitation, (Seeman et al., 2010).

Rising obesity rates among those entering old age in more recent years.

Diabetes—Massive numbers of the baby boom generation are entering old age with a higher prevalence of obesity and diabetes. Costs of medical care and disability. Costs of medical care and quality of life implications.

Trends in the 1980s and 1990s (continued)

Increased prevalence of chronic conditions and disability in the UK among persons 65-69 from early to late 1990s.

Improvements in Spain from 1986 to 1999, especially among men. All ages: 65 and 80-plus.

Some increases in mild limitations in Japan from 1995-2004 (Hashimoto et al, 2010), and declines in IADL’s and ADL’s from 1993 to 2002 (Schoeni et al, 2006).

Evidence from Other Western Countries

There were consistent increases in disability in most countries during the 1970s and early 1980s.

There appear to have been declines in disability in the majority of countries from the early 1980s to the 1990s.

In the U.S. and possibly the UK and Sweden, there appear to have been increases in disability among the young-old (aged 60-70), possibly due to increases in the prevalence of obesity and diabetes.

SUMMARY:Western Countries

Because many developing countries have recently reached the point in their epidemiologic transition, (where the West was in the 1960s and 1970s), it could be predicted that they are currently experiencing increases in disability accompanying rapidly aging populations, rising life expectancy, and increased survival into old age.

The same could be predicted for major minority populations as well as less educated and poorer segments within the populations of Western countries.

Are we seeing increased survival with poorer health and disability in minority populations and in developing counties?

A Theoretical Perspective and Expected Trends in Developing

Countries

A Hispanic Epidemiologic Paradox in the United States

Hispanics (exceptCuban Americans)are socioeconomicallydisadvantaged, buthave favorable overallmortality.

Risk factor profiles: High rates of DIABETES High rates of OBESITY Similar rates of

hypertension/cholesterol Rising SMOKING rates among

men, lower among women (fewer cigarettes). Cuban American males smoke the most.

High ALCOHOL (binge) drinking rates among men, low among women.

Alcohol consumption in women increases with acculturation.

Low rates of physical ACTIVITY Strong families Migration selection

Markides and Coreil (1986)

UNITED STATES LIFE TABLES BY HISPANIC ORIGIN (2006)

E. Arias, NCHS, 2010Life Expectancy at Birth

Total Male Female

Hispanic: 80.6 77.9 83.1

Non-Hispanic White

78.1 75.6 80.4

Non-Hispanic Black

72.9 69.2 76.2

Adjusted for misclassification of race and Hispanic origin on death certificates.80+ rates for Hispanics based on Non-Hispanic White rates.

Trends in the health of older Mexican Americans aged 75 +

Men Women

Health Conditions

1993-4 2004-5 1993-4 2004-5

Depressive symptoms (CESD ≥ 16)

75(18.6%)

121(16.1)

181(30.3)

291(24.1)

ADL Disability (≥ 1)

93(20.2)

237(29.7)

176(26.8)

524(41.2)

Diabetes mellitus

100(21.3)

248(31.3)

142(21.5)

442(34.8)

Hypertension 233(49.8)

435(61.7)

399(60.5)

780(69.6)

Stroke 45(9.6)

118(14.9)

66(10.0)

164(12.9)

Obesity (BMI ≥ 30)

72(18.0)

148(22.8)

153(26.7)

313(31.5)

Cognitive impairment (MMSE < 21)

96(23.2)

310(41.3)

157(26.0)

477(40.3)

Total N 469 797 662 1272

Data clearly show an increase in ADL disability from 1993-1994 to 2004-2005 in Mexican Americans aged 75 and over, especially women.

Part of the increase can be attributed to increases in the prevalence of obesity and diabetes.

Data support the notion that the Mexican American population is at a stage of the epidemiologic transition when the general U.S. population was in the 1970’s—a period of rising life expectancy accompanied by increases in the prevalence of chronic diseases and disabilities.

DATA ON OLDER MEXICAN AMERICANS: Interpretation

Our prediction of increases is supported. Four of the five settings experienced increases in disability and functional limitations.

Increases observed in Beijing, Indonesia, Philippines, and Taiwan. No changes in Singapore (Note: Singapore is a developed country with a per capita income equal to that of the U.S. and a life expectancy comparable to that of Japan.

Much of Asia is at an epidemiologic transition stage similar to that of the U.S. in the 1970’s

(Ofstedal et al, 2007).

Short-Term Trends in Five Asian Settings (Ofstedal et al, 2007)

Zimmer et al (2002) found that prevalence of functional limitation increased from 1993-1996, and from 1996-1999.

Conclusion: “One possible reason in the change in old-age survival, which appears to have benefitted those who have functional limitations, especially those in a severe form. The Universal Health Insurance programme, established in 1995, may have increased access to care and thus the survival of those in poorest health.” (pg. 265).

Two Studies in Taiwan

Martin et al (2011), examined more comprehensive data over a longer period of time from 1989-2007 at ages 65 and over. They found improvements in vision, hearing and IADL’s (e.g. phoning), possibly due to increases in educational attainment and changes in the environment and technology.

Difficulty with any of seven physical functions increased from 1996-1999 but decreased from 1999-2007.

Difficulty with any of the six ADLs was flat, from 1999 to 2007. Relatively good news given increases in survival. Possible improvements in home environment.

Two Studies in Taiwan (continued)

Is China an exception? Given recent increases in life expectancy, increases in old-age disability could have been predicted.

Gu et al (2009), found improvements from 1992-2002 in overall health and disability. Improvements in disability (ADL) may reflect improvements in the home environment and use of assistive devices. More recent cohorts had healthier childhoods.

Chen et al (2009

Two Studies in China

Chen et al (2009), also found improvements in China from 1987 to 2006 in severe and very severe disability, but increases in mild and moderate disability. Improvements were confined to the very old (75+), with the young old (60-74) experiencing increases in disability (performance-based measures).

These young old were born in the 1930’s and 1940’s during war and extreme poverty. These early life conditions may have influenced their disability rates in 2006.

Two Studies in China (continued)

Data are virtually non-existent with the exception of one Brazilian study (Paratryba et al, 2009), which found disability reductions among higher income groups from 1998-2003. High income groups in Brazil are similar in many ways to middle and upper income groups in developed countries.

“The Tide to Come: Elderly Health in Latin America and the Carribbean.” (Palloni et al, 2006).

(The title is indicative of the perspective of scholars of aging in Latin America).

Trends in Latin America

Unprecedented speed of aging in the region compared to the experience of Western Europe and North America at a time of rapid change in traditional living arrangements that historically provided a safety net for older people

(Markides et al, 2010).

“…a highly compressed ageing process will take place in the midst of weak economic performance, tense intergenerational relations, fragile institutional contexts, and shrinking access to medical and health care services.”

(Palloni and McEniry, 2007)

Trends in Latin America (continued)

Although systematic data on trends are lacking, the literature typically assumes that much of Latin America began the epidemiologic transition 2-3 decades ago and that the current aging of the population is accompanied by increases in chronic conditions and disability.

(SABE studies in seven Latin American cities, 1999-2000):

Buenos Aires (Argentina); Montevideo (Uruguay); Havana (Cuba); Bridgetown (Barbados)-(Advanced stages of demographic transition).

Santiago (Chile), Mexico City (Mexico), and Sao Paulo (Brazil)-(Intermediate stage).

Poorer countries at the beginning of their demographic and epidemiologic transitions are not represented. (Peru, Bolivia, Ecuador, Guatemala (Wong, 2006).

Trends in Latin America (continued)

The Mexican Health and Aging Study (MHAS) was

conducted in 2001 and 2003 with over 15,000 subjects aged 50 and older. Wong and colleagues will continue the study in 2012 that includes follow-up of original subjects and addition of new cohorts to examine trends.

Relatively high life expectancy and high rates of disability that are only slightly higher than those for Mexican Americans (Patel, Peek, Wong, Markides, 2006).

AGING IN MEXICO

Older Mexicans are less likely to report chronic conditions than Mexican Americans, but that may result from lower contact with the formal medical care system.

Rising rates of obesity and diabetes which are also present in other Latin American countries (Al Snih et al, 2007).

AGING IN MEXICO (continued)

Theoretically, countries that are at a relatively advanced or intermediate stage in the demographic and epidemiologic transition (e.g., Taiwan, Mexico) should be experiencing increases in life expectancy and survival into older ages accompanied by increases in the prevalence of chronic conditions and disability.

Demographic and epidemiologic forces will challenge developing countries. Searching for a general theory of population aging and health (Robine and Michel, 2004).

IN DEVELOPING COUNTRIESSUMMARY/CONCLUSION

TRENDS

Evaluating trends in old-age disability, Michigan Center on Demography of Aging

http://trends.psc.isr.umich.edu/

IN DEVELOPING COUNTRIES

SUMMARY/CONCLUSION (continued)