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Surveillance for Morbidity and Mortality Among Older Adults -- United States, 1995-1996

Please note: An erratum has been published for this article. To view the erratum, please click here.

Mayur M. Desai, Ph.D., M.P.H.1,2
Ping Zhang, Ph.D.3
Catherine Hagan Hennessy, Dr.P.H., M.A.4

1Epidemic Intelligence Service, Epidemiology Program Office, CDC
2Office of Analysis, Epidemiology, and Health Promotion,
National Center for Health Statistics, CDC
3Department of Agricultural Economics, Kansas State University
4Division of Adult and Community Health,
National Center for Chronic Disease Prevention and Health Promotion, CDC

Abstract

Problem/Condition: During the twenty first century, growth in the number of older adults (persons aged greater than or equal to 65 years) in the United States will produce an unprecedented increase in the number of persons at risk for costly age-associated chronic diseases and other health conditions and injuries.

Reporting Period: 1995-1996.

Description of Systems: This report uses data from CDC's National Center for Health Statistics (NCHS) to report on leading causes of death in 1996 (from the National Vital Statistics System), major causes of hospitalization (1996 National Hospital Discharge Survey [NHDS]), and major chronic conditions (1995 National Health Interview Survey [NHIS]). The National Vital Statistics System compiles information regarding all death certificates filed in the United States. NHDS is an annual probability sample of discharges from nonfederal, short-stay hospitals. NHIS is an ongoing annual cross-sectional household survey of the U.S. civilian, noninstitutionalized population. In addition, health-care expenditures for older adults are examined by using information obtained from published reports from the U.S. Health Care Financing Administration (HCFA) and health-services literature.

Results: The leading causes of death among adults aged greater than or equal to 65 years were heart disease (1,808 deaths/100,000 population), malignant neoplasms (1,131/100,000), and cerebrovascular disease (415/100,000). Several leading causes of mortality among older adults differed by race, with deaths caused by Alzheimer's disease more frequent among whites and deaths caused by diabetes, kidney diseases, septicemia, and hypertension more frequent among blacks. Rates of hospitalization and length of hospital stays increased with age. Hospitalizations for heart disease represented the highest proportion of all discharges among older adults (23%). Discharge rates for malignant neoplasms, stroke, and pneumonia were similar for adults aged greater than or equal to 65 years and, as with heart disease, were higher for men than for women. However, the rate of hospitalization for fractures among women exceeded the rate among men. Arthritis was the most prevalent chronic condition among adults aged greater than or equal to 65 years (48.9/100 adults), followed by hypertension (40.3/100) and heart disease (28.6/100). In 1995, adults aged greater than or equal to 65 years comprised 13% of the population but accounted for 35% of total personal health-care dollars spent ($310 billion), and real per capita personal health-care expenditure for this age group increased at an average annual rate of 5.8% during 1985-1995. Projections for future medical expenditures for older adults vary; however, all project substantial increases after the year 2000. Hip fracture, dementia, and urinary incontinence are discussed as examples of prevalent and costly health conditions among older adults that differ in potential for prevention. These conditions were selected because they result in substantial medical and social costs and they differ in potential for prevention.

Interpretation: The higher prevalence of serious and costly health conditions among adults aged greater than or equal to 65 years highlights the importance of implementing preventive health measures in this population.

Public Health Actions: Data regarding causes of morbidity, mortality, and health-care expenditures among older adults provide information for measuring the effectiveness of public health efforts to reduce modifiable risk factors for morbidity and mortality in this population.

INTRODUCTION

The U.S. population of adults aged greater than or equal to 65 years is growing rapidly in number and proportion to the overall population (1). During 1995-2030, this population is expected to double from approximately 33.5 million in 1995 to 69.4 million in 2030. This increase will be the result of the aging of persons born during 1945-1965 (i.e., baby boomers) and increased life expectancy. During 1995, the proportion of adults aged greater than or equal to 65 years was 12.8% compared with an anticipated 20% during 2030. Adults aged greater than or equal to 85 years are the fastest-growing segment of the population; during 1995-2030, their numbers are projected to increase from 3.6 million to 8.5 million. Because health-care use and expenditures for older adults are disproportionate to their numbers among the population, the aging of the population has important implications for the health-care system.

Mortality statistics are used to describe the overall health status of a population; therefore, the leading causes of death among older adults (adults aged greater than or equal to 65 years) are presented first in this report. Elderly persons are disproportionately hospitalized for several chronic conditions and account for substantial health-care expenditures. Therefore, this report presents the major causes of hospitalization for older adults as well as prevalence estimates for major chronic conditions. Statistics for the age group 55-64 years is also included for comparative purposes for the leading causes of death, major causes of hospitalization, and major chronic conditions among older adults. Other significant impairments among older adults (e.g., hearing and visual impairments) are addressed in the last report in this publication. In addition, the economic burden of morbidity among older adults is summarized. In addressing the last topic, this report presents information regarding current health expenditures and projected trends in spending for geriatric care. The health-care costs of three age-associated health problems -- hip fracture, dementia, and urinary incontinence -- are presented to illustrate the economic burden of late-life morbidity. These conditions were selected because they result in substantial medical and social costs and they differ in potential for prevention.

METHODS

Leading Causes of Death

The 1996 mortality data presented in this report were collected from all 50 states and the District of Columbia. Of deaths occurring in the United States, greater than 99% are registered; all death certificates filed in the United States are provided to the National Center for Health Statistics (NCHS) through the National Vital Statistics System (2).

Causes of death were classified according to the International Classification of Diseases, 9th Revision (ICD-9) (3). Many elderly adults suffer from two or more comorbidities before death, often making the exact cause of death difficult to determine. The cause-of-death data reported here reflect the underlying cause of death, which is defined as ". . . the disease or injury that initiated the sequence of events leading directly to death or as the circumstances of the accident or violence that produced the fatal injury" (2). For cases that have more than one cause entered in the cause-of-death section of the death certificate, the underlying cause is determined by the sequence of conditions on the certificate and established rules and algorithms (3). Death rates per 100,000 population for the leading causes of death are presented by age, sex, and race.* Midyear U.S. population estimates for 1996 were used in the calculation of death rates.

Major Causes of Hospitalization

The 1996 hospital discharge data were collected from the National Hospital Discharge Survey (NHDS), which is conducted annually by NCHS (4). NHDS collects data from a sample of inpatient records acquired from a national probability sample of nonfederal, short-stay hospitals. Data from NHDS represent a sample of hospital discharges, not a sample of persons (i.e., one person with multiple discharges during the year might be counted more than once).

In 1996, data were collected for approximately 282,000 patient discharges from 480 participating hospitals. Hospital records were abstracted, and diagnoses were coded according to the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) (5). The first-listed diagnosis is defined as the principal diagnosis or, if one is not specified, the first diagnosis listed on the face sheet or discharge summary of the medical record (4). Hospital discharge rates are presented in this report by age and sex; data are not presented by race because, during 1996, information regarding race was missing for 23% of sampled records. The survey data were weighted to produce national estimates of hospital discharge.

Major Chronic Conditions

Prevalence estimates for selected chronic conditions were collected from the 1995 National Health Interview Survey (NHIS) (6). Conducted by NCHS, NHIS is an ongoing annual cross-sectional household survey that is administered annually to a nationally representative, multistage probability sample of the U.S. civilian, noninstitutionalized population. NHIS data are obtained through personal interview with household members. Whenever possible, all available adult family members participate in the interview; proxy interviews are allowed for older adults who are unable to participate because of illness or impairment. The 1995 NHIS consisted of two parts -- a set of basic health and demographic inquiries and questions regarding current health topics.

Six checklists of chronic conditions are included in NHIS. The six lists cover

  • selected skin and musculoskeletal conditions (e.g., arthritis, acne, or skin cancer);
  • impairments (e.g., deafness, mental retardation, or color blindness);
  • selected digestive conditions (e.g., gallstones, ulcers, or cancers of the intestines);
  • selected conditions of the genitourinary, nervous, endocrine, metabolic, and blood and blood-forming systems (e.g., diabetes, epilepsy, or breast cancer);
  • selected circulatory conditions (e.g., angina pectoris, hypertension, or stroke); and
  • selected respiratory conditions (e.g., asthma, emphysema, or lung cancer).

Determining the prevalence of conditions excluded from the checklists (e.g., depression) is not possible.

The time frame or reference period of interest was not the same for all six lists. For conditions in the first, third, fourth, and sixth lists, respondents were asked, "During the past 12 months, did anyone in the family have . . .?" For conditions in the second list, respondents were asked, "Does anyone in the family now have . . .?" For the fifth list, lifetime prevalence was assessed by asking respondents, "Has anyone in the family ever had . . .?"

Only one of the lists, which is chosen on a predetermined basis, is administered per interview; therefore, each list of chronic conditions is administered to only one sixth of sampled households. For this report, prevalence estimates were stratified by age (i.e., 55-64, 65-74, and greater than or equal to 75 years), race/ethnicity (non-Hispanic white and non-Hispanic black), and sex. Data were not reported when the standard error equaled greater than or equal to 30% of the prevalence estimate. SAS software (i.e., an integrated system for data access, management, analysis, and presentation) was used to calculate prevalence estimates, and SUDAAN was used to calculate 95% confidence intervals.

Economic Burden of Morbidity

The information regarding health-care expenditures for older adults presented in this report synthesizes published data from the Health Care Financing Administration (HCFA) and other studies from the health services literature. The studies cited in this section should be referred to for details regarding the costing methodologies and associated assumptions employed in each study.

RESULTS

Leading Causes of Death

During 1996, approximately 2.3 million deaths were reported in the United States, the majority (74%) of which were among adults aged greater than or equal to 65 years. For each of 12 leading causes of death, mortality rates increased with age (Table 1). The leading cause of death for adults aged greater than or equal to 65 years was heart disease (1,808 deaths/100,000 population). With a rate of 6,314/100,000 population, deaths from heart disease accounted for 41% of all deaths among adults aged greater than or equal to 85 years. Deaths caused by malignant neoplasms ranked as the second leading cause of death among older adults, but first among those aged 65-74 years. Across age groups, the cancer death rate was higher among blacks than whites and considerably higher among men.

Cerebrovascular diseases represent the third leading cause of death for older adults. The proportion of deaths caused by cerebrovascular diseases increased with age, doubling from 5.3% among adults aged 65-74 years to 10.5% among those aged greater than or equal to 85 years. The death rate for malignant neoplasms was approximately sixfold higher than that for cerebrovascular diseases among adults aged 65-74 years. Among adults aged greater than or equal to 85 years, the two death rates were similar; however, for white women aged greater than or equal to 85 years, deaths caused by cerebrovascular diseases outnumbered deaths caused by malignant neoplasms.

The importance of pneumonia and influenza as a cause of death increased with age. Pneumonia and influenza ranked as the sixth leading cause of death among older adults aged 65-74 years, fifth among those aged 75-84 years, and fourth among those aged greater than or equal to 85 years. This pattern was observed across sex and race categories.

Differences exist between whites and blacks for several leading causes of death. Notably, the Alzheimer's disease death rate was higher among whites (66/100,000) than among blacks (38/100,000). The highest rate was observed among white women aged greater than or equal to 85 years (313/100,000 population), among whom Alzheimer's disease ranked as the sixth leading cause of death. In contrast, the death rates for diabetes, kidney diseases, septicemia, and hypertension were approximately 2-2.5 times higher among blacks than among whites; this pattern generally held true across age and sex categories.

Major Causes of Hospitalization

Rates of hospitalization and length of hospital stays increase with age. During 1996, adults aged greater than or equal to 65 years comprised approximately 13% of the U.S. population but accounted for an estimated 38% of all discharges from and 48% of all days of care in nonfederal, short-stay hospitals. During 1996, an estimated 11.7 million hospitalizations occurred among adults aged greater than or equal to 65 years.

Hospitalizations for heart disease accounted for approximately one fourth (23.2%) of all discharges among older adults (Table 2). The rate of discharge for heart disease increased with age. Among adults aged 65-74 years, the discharge rate was 62.4/1,000 population; the rate was approximately twofold higher (117.9/1,000 population) among those aged greater than or equal to 85 years. Within each age category, the rate of hospitalization for heart disease was higher among men.

The overall rates of discharge for malignant neoplasms, stroke, and pneumonia were similar for adults aged greater than or equal to 65 years. For all three conditions, the rates were higher among men. The rate of discharge for malignant neoplasms was similar across older age groups. In contrast, the rates for stroke and pneumonia increased substantially with age; this increase was true of discharge rates for pneumonia among elderly men in particular, where the rate rose from 13.0/1,000 population among men aged 65-74 years to 73.3/1,000 population among men aged greater than or equal to 85 years. Among adults aged greater than or equal to 85 years, pneumonia was the second major cause of hospitalization, preceded by heart disease.

The rate of hospitalization for fractures was higher among women; this rate was true across all age groups. Hip fractures accounted for the majority (60.5%) of hospitalizations for fractures. Among adults aged greater than or equal to 85 years, hip fractures were responsible for two thirds of all fracture-related discharges. Among women aged greater than or equal to 85 years, fractures were the second major cause of hospitalization.

Men and women had similar rates of discharge for bronchitis, osteoarthritis, diabetes, and diseases of the central nervous system and sense organs. Sex- and age-specific analyses revealed that discharge rates for bronchitis and diabetes increased with age among men but not among women. Among adults aged greater than or equal to 85 years, the rate of discharge for bronchitis was twofold higher among men (21.4/1,000 population) than among women (9.6/1,000 population). Among elderly men, hospitalization for hyperplasia of the prostate increased with age, doubling from 5.0/1,000 population among men aged 65-74 years to 9.9/1,000 population among those aged greater than or equal to 85 years.

Major Chronic Conditions

During 1995, of those conditions covered by NHIS, arthritis was the leading chronic condition among older adults (Table 3); the prevalence of arthritis increased with age. Hypertension also was highly prevalent among older adults, with a rate of 40.3/100 adults aged greater than or equal to 65 years. A minor difference in prevalence of hypertension was observed between adults aged 65-74 years and adults aged greater than or equal to 75 years. The prevalence of both arthritis and hypertension was higher among women and higher among blacks than whites.

The prevalence of heart disease increased with age, doubling from 16.7/100 adults aged 55-64 years to 33.9/100 adults aged greater than or equal to 75 years. Among adults aged greater than or equal to 65 years, the prevalence of heart disease was approximately 40% higher among men (34.2/100 persons) than among women (24.6/100 persons). This prevalence estimate reflects the number of conditions per 100 persons, not the number of persons with these conditions; therefore, given that some overlap exists among heart disease conditions, the estimate is approximately 12% higher than the number of persons with the conditions.

During the 12 months before the interview, the combined prevalence of chronic bronchitis, asthma, and emphysema was 13.8/100 among adults aged greater than or equal to 65 years. The prevalence of these respiratory diseases was constant across age, sex, and race groups. As with heart disease, this prevalence estimate reflects the number of conditions per 100 persons, not the number of persons with these conditions; therefore, given that some overlap exists among respiratory conditions, the estimate is approximately 12% higher than the number of persons with the conditions. A similar, overall prevalence rate (12.6/100 persons) was found for diabetes. The prevalence of diabetes was similar among men and women; however, substantial difference existed between black and white older adults, with blacks having a twofold higher prevalence rate than whites (21.9 versus 11.9/100 persons).

NHIS did not assess the prevalence of all cancers. Rather, through four of the six lists of chronic conditions, NHIS asked questions regarding the following major cancers: skin, intestine, female breast, female genital organs, prostate, lung/bronchus, and other respiratory sites. During the 12 months before the interview, the combined prevalence of these cancers among those adults aged greater than or equal to 65 years was 7.4/100 persons (3.9/100 persons, excluding skin cancer). Lifetime prevalence of cancer was not assessed by NHIS. The lifetime prevalence of cerebrovascular diseases quadrupled from 2.5/100 adults aged 55-64 years to 9.9/100 adults aged greater than or equal to 75 years. The lifetime prevalence of atherosclerosis also increased with age.

Current Level and Distribution of Health-Care Expenditures for Older Adults

Per capita health-care expenditure in the United States is the highest in the world. In this report, health-care expenditure refers to personal health-care expenditure or spending, including hospital care, physicians' services, nursing home care, and other personal health care. During 1996, the U.S. per capita personal health-care expenditure was $3,708, approximately one third higher than in the second highest ranking country, Switzerland (7). During 1995, personal health-care expenditures accounted for 12.1% of the U.S. gross domestic product (GDP) (8). The amount of national medical care resources consumed by elderly adults is disproportionate to their numbers among the population. During 1995, approximately 33.5 million adults in the United States aged greater than or equal to 65 years represented 12.8% of the total population, but they accounted for approximately one third (35.3%) of total personal health-care dollars ($310 billion).

Health-care expenditure increases with age (Table 4) (9). During 1987, per capita expenditures ranged from $3,728 among adults aged 65-69 years to $9,178 among adults aged greater than or equal to 85 years. Overall, spending on hospital care consumed the largest proportion (41.9%) of total expenditure. In addition, approximately one fifth of total personal health-care expenditures went to physician services and another one fifth to nursing home care. For adults aged greater than or equal to 85 years, nursing home expenditures represented the largest share of health-care expenditures.

Increases in functional impairment affecting the capacity for self-care result in higher use of long-term care (LTC) services among older adults. LTC includes all social, personal, and supportive services needed during a prolonged period for persons incapable of sustaining themselves without this care (10). During 1994, approximately $103 billion (or 13% of total personal health-care expenditures) was spent on LTC. Of the 12.6 million persons requiring LTC, 57.9% were aged greater than or equal to 65 years (11). During 1994, approximately 89.2% of nursing home residents were among this age group (12). A person's risk for being institutionalized at age greater than or equal to 65 years is approximately 40% (13).

During 1992, a small proportion of very ill persons accounted for a large proportion of total Medicare costs (Table 5) (14). Among the highest 1% of spenders, mean spending ranged from $52,464 to $61,866; in contrast, mean spending ranged from $44 to $204 for the lowest 50% of Medicare beneficiaries. Across age groups, the highest 6% of those persons purchasing health care among Medicare enrollees accounted for approximately 40% of Medicare spending, whereas the lowest 50% required less than 2% of expenditures. Cumulative distribution of Medicare expenditures within an age group were less skewed with increasing age.

Approximately 40% of personal health care for older adults is paid for by private sources (Table 6). The majority of health care for older adults is publicly funded through Medicare and Medicaid programs. The proportion from Medicare tends to decrease with age, whereas the proportion from Medicaid increases with age.

Changes in Health-Care Expenditures for Older Adults

Health-care expenditures for older adults have increased at a faster rate than spending for the total population. During recent decades, the rate of increase in personal health-care expenditure for older adults living in the United States outpaced the rate of increase in GDP by 3.5%-4% per annum (15). As a share of GDP, personal health-care expenditure for older adults increased from 3.0% during 1985 to 4.3% during 1995. Real per capita personal health-care expenditure for adults aged greater than or equal to 65 years rose at an average annual rate of 5.8%, increasing from $6,088 during 1985 to $9,231 during 1995 (1995 U.S.$). Although a portion of the rise in spending can be attributed to the aging of the population, the majority of the increase is attributable to higher medical care consumption by older adults (15). Advances in medical technology have resulted in substantial increases in at least seven common, costly procedures (Table 7). For several procedures (e.g., angioplasty), the rate of increase was higher at older ages.

Projection of Future Health-Care Expenditure for Older Adults

Estimates of future spending vary from study to study because each projection is based on a different set of assumptions and scenarios. One researcher has projected that personal health-care expenditure for older adults will double during 1994-2030 (12) (Table 8), assuming a constant level of real age-specific spending. In contrast, another study (15) assumes an annual spending increase of 5.8% (the average annual rate increase observed during 1985-1995) and projects that total personal health-care expenditure for older adults will quadruple from $310 billion to $1.3 trillion by the year 2020. This projection also indicates that per capita expenditure for older adults will reach $24,391 and that personal health-care expenditure for older adults will account for 9.9% of GDP by 2020. Medicare is the major payer of health-care expenditures for adults aged greater than or equal to 65 years (Table 6). HCFA estimates that total Medicare payments as a percentage of GDP will increase from 2.6% during 1997 to 5.9% during 2030 (16) (Table 9).

EXPENDITURES FOR SELECTED CONDITIONS AMONG OLDER ADULTS

Hip Fractures

In the United States, adults aged greater than or equal to 65 years account for approximately 88% of all health-care expenditures for fractures resulting from loss of bone density (17). Hipfracture is among the most frequently occurring, devastating, and costly type of fracture for older adults. In this publication, the epidemiology of hip fracture among older adults is discussed in the report regarding injuries and violence among older adults.

Estimates of total health-care expenditure for hip fracture among adults aged greater than or equal to 65 years are not available, although a recent study (17) indicated that, among adults aged greater than or equal to 45 years, hip fractures accounted for 63% of all health-care costs for osteoporotic fractures. During the first 12 weeks after hip fracture, Medicare costs averaged $191/day, which is the highest for all fracture types examined (18). During the first year after hip fracture, total excess costs (i.e., postfracture health-care costs minus health-care costs during the 6 months before fracture) were greater than $15,000/person. If extrapolated to the total Medicare population aged greater than or equal to 65 years, total excess costs were $2.9 billion during the first year after hip fracture. Projections for the cost of hip fracture indicate that, by the year 2040, approximately 512,000 hip fractures could occur annually, with an estimated cost of $16 billion (1984 U.S.$) (19).

Dementia

Senile dementia refers to several impairing diseases and disorders, a small proportion of which are potentially reversible. The most common form of dementia among older adults is Alzheimer's disease. The prevalence of dementia increases with age, from 2.8% among adults aged 65-74 years to 28% among those aged greater than or equal to 85 years (20). Approximately half of elderly nursing home residents have severe dementia (21).

Persons with dementia often need costly acute and long-term care services. During 1991, the medical care costs of severe dementia were estimated to be $28.5 billion (22). Per capita Medicare expenditure during 1992 was $6,208 for patients with dementia of the Alzheimer type (DAT), which is approximately twofold higher than for all Medicare beneficiaries without DAT (23). Compared with elderly adults without this diagnosis, those with DAT had higher expenditures for hospital inpatient services (2.2 times), physician and ancillary provider services (1.6 times), and hospital outpatient services (1.4 times). Researchers project that from $92 billion to $149 billion will be spent on an estimated 6.1 million-9.8 million persons with dementia during 2040 (20).

Urinary Incontinence

Urinary incontinence (UI) (i.e., the involuntary loss of urine to the extent that it constitutes a social or hygienic problem) is a disorder that typically occurs among older adults, particularly among women. UI is associated with physical and psychologic morbidity as well as a higher risk for nursing home placement. The prevalence of UI is from 15% to 30% among elderly adults living in the community and greater than or equal to 50% among those residing in nursing homes (24).

During 1995, an estimated 6.3 million community-dwelling older adults and 1.2 million elderly nursing home residents were living with UI (25). The direct costs related to the diagnosis, treatment, and routine care (i.e., use of pads and briefs, laundry costs, and catheterization) of UI totaled $23.6 billion (25). An additional $2 billion in direct costs for UI went to other related care requirements (e.g., skin conditions) and longer periods of inpatient care. Indirect costs (i.e., for home care services associated with the management of UI) totaled $704 million. Therefore, during 1995, the total cost of UI among older adults was an estimated $26.3 billion, or $3,565/person (25).

DISCUSSION

Information is presented in this report regarding the leading causes of morbidity and mortality among older adults. In addition, the current and projected economic burden of morbidity among older adults are examined. Special attention is focused on hip fracture, dementia, and UI. Limitations of this report are the exclusion of information regarding chronic conditions among older adults in nursing homes and other institutional settings and data regarding other indicators of the burden of these conditions on the health-care system (e.g., use of long-term care services).

Cardiovascular disease is a major cause of death among older adults in the United States. Modifiable risk factors that account, in part, for this premature mortality during later life include smoking (26,27), excessive alcohol consumption (28), physical inactivity (29,30), obesity (31,32), dyslipidemia (33,34), and poor control of hypertension (35,36) and diabetes (37). These risk factors are interrelated and often act synergistically to produce several adverse health outcomes. Cardiovascular risk reduction has been reported to be cost-effective (38) and should be emphasized throughout the life course, from childhood (39) to old age (40). Smoking cessation interventions are also highly cost-effective (38,41).

Pneumonia and influenza are important causes of hospitalization and death among older adults. All adults aged greater than or equal to 65 years should receive influenza vaccinations annually; pneumococcal vaccination should be administered once, but can be repeated for certain groups at high risk after 5 years (42,43). Influenza and pneumococcal vaccinations are cost-effective compared with other preventive measures and can be cost-saving (44,45); in addition, they have been reported to be effective in reducing serious complications and hospitalizations by approximately one half (44,46). Nevertheless, during 1997, 65% of older adults reported receiving influenza vaccination in the past 12 months, and only 45% reported ever receiving pneumococcal vaccination (47). Every effort should be made to increase vaccination coverage among older adults, particularly among those who suffer from chronic illnesses.

As the data throughout this report demonstrate, fractures (particularly hip fractures) are a leading cause of hospitalization and health-care expenditure for older adults. The following strategies aid primary prevention of hip fracture:

  • maximizing bone density during adolescence and early adulthood through adequate consumption of dietary calcium and regular, weight-bearing physical activity;
  • avoiding behavior risks (e.g., smoking and excessive alcohol consumption); and
  • reducing the risk for falls by older adults (e.g., through use of assistive devices such as canes and walkers and environmental modifications such as the elimination of household obstacles or the installation of bathroom grab bars).

Strategies for secondary prevention of hip fracture include bone-density screening of postmenopausal women at high risk, hormone replacement therapy, and medications to arrest bone loss (18).

Alzheimer's disease is a leading cause of death among older adults, particularly among women. Although researchers have begun to identify various genetic (48,49) and social (50) risk factors for Alzheimer's disease, data are not available to guide prevention strategies. Currently, curative treatment is not available for Alzheimer's disease; however, certain therapies have been successful in producing temporary improvement in dementia symptoms (22). Until new, effective treatments are developed, the costs of dementia care will continue to increase (51).

UI is a serious, nonfatal health problem among older adults, resulting in billions of dollars of health-care costs annually. Researchers estimate that approximately one third of all cases of UI can be resolved and another one third improved through proper management of the condition (52). Appropriate, timely therapy (e.g., bladder training, pelvic exercises, and behavioral modification) can slow or even improve the course of UI (53-56). However, despite the potential for effective intervention, UI is under-reported by elderly adults and inadequately diagnosed and treated by health-care providers (52,57). Achieving reductions in the morbidity and costs associated with UI will require more education and awareness among patients and health-care providers.

Health-care expenditures are projected to increase during the next three decades as the U.S. population ages. Concern has been growing regarding the future affordability of geriatric care. Because of limited health-care resources, the incorporation of results of economic evaluations (e.g., cost-effectiveness analyses) into public health decision-making is increasingly important.

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  21. National Center for Health Statistics. Mental illness in nursing homes: United States, 1985. Washington, DC: US Department of Health and Human Services, Public Health Service, CDC, 1991; DHHS publication no. (PHS)91-1776.(Vital and health statistics; vol 13, no. 105)
  22. Manton KG, Corder LS, Clark R. Estimates and projections of dementia-related service expenditures. In: Manton KG, Singer BH, Suzman RM, eds. Forecasting the health of elderly populations. New York, NY: Springer-Verlag, 1993:207-38.
  23. Weiner M, Powe NR, Weller WE, Shaffer TJ, Anderson GF. Alzheimer's disease under managed care: implications from Medicare utilization and expenditure patterns. J Am Geriatr Soc 1998; 46:762-70.
  24. Urinary Incontinence Guideline Panel. Urinary incontinence in adults [clinical practice guideline]. Rockville, MD: Agency for Health Care Policy and Research, 1992; AHCPR publication no. 92-0038.
  25. Wagner TH, Hu TW. Economic costs of urinary incontinence in 1995. Urology 1998;51:355-61.
  26. Manley AF. Cardiovascular implications of smoking: the surgeon general's point of view. J Health Care Poor Underserved 1997;8:303-10.
  27. Tresch DD, Aronow WS. Smoking and coronary artery disease. Clin Geriatr Med 1996;12:23-32.
  28. Dufour M, Fuller RK. Alcohol in the elderly. Annu Rev Med 1995;46:123-32.
  29. Cherubini A, Lowenthal DT, Williams LS, Maggio D, Mecocci P, Senin U. Physical activity and cardiovascular health in the elderly. Aging 1998;10:13-25.
  30. Miller TD, Balady GJ, Fletcher GF. Exercise and its role in the prevention and rehabilitation of cardiovascular disease. Ann Behav Med 1997;19:220-9.
  31. Solomon CG, Manson JE. Obesity and mortality: a review of the epidemiologic data. Am J Clin Nutr 1997;66(suppl):1044S-1050S.
  32. Tanaka K, Nakanishi T. Obesity as a risk factor for various diseases: necessity of lifestyle changes for healthy aging. Appl Human Sci 1996;15:139-48.
  33. Grundy SM. Role of cholesterol management in coronary disease risk reduction in elderly patients. Endocrinol Metab Clin North Am 1998;27:655-75.
  34. Williams MA. Cardiovascular risk-factor reduction in elderly patients with cardiac disease. Phys Ther 1996;76:469-80.
  35. Abrams J, Vela BS, Coultas DB, Samaan SA, Malhotra D, Roche RJ. Coronary risk factors and their modification: lipids, smoking, hypertension, estrogen, and the elderly. Curr Probl Cardiol 1995;20:533-610.
  36. Corti MC, Guralnik JM, Bilato C. Coronary heart disease risk factors in older persons. Aging 1996;8:75-89.
  37. Samos LF, Roos BA. Diabetes mellitus in older persons. Med Clin North Am 1998;82:791-803.
  38. Kupersmith J, Holmes-Rovner M, Hogan A, Rovner D, Gardiner J. Cost-effectiveness analysis in heart disease. Part II: preventive therapies. Prog Cardiovasc Dis 1995;37:243-71.
  39. Berenson GS, Srinivasan SR, Bao W. Precursors of cardiovascular risk in young adults from a biracial (black-white) population: the Bogalusa heart study. Ann N Y Acad Sci 1997;817:189-98.
  40. Kannel WB. Cardiovascular risk factors in the elderly. Coron Artery Dis 1997;8:565-75.
  41. Eagles CJ, Martin U. Non-pharmacological modification of cardiac risk factors. Part 3: Smoking cessation and alcohol consumption. J Clin Pharm Ther 1998;23:1-9.
  42. CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1999;48 (No. RR-4).
  43. CDC. Prevention and control of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997;46 (No. RR-8).
  44. Fiebach N, Beckett W. Prevention of respiratory infections in adults: influenza and pneumococcal vaccines. Arch Intern Med 1994;154:2545-57. [Published erratum in Arch Intern Med 1995;155:218.]
  45. Sisk JE, Moskowitz AJ, Whang W, et al. Cost-effectiveness of vaccination against pneumococcal bacteremia among elderly people. JAMA 1997;278:1333-9.
  46. Glck R, Wegmann A. Influenza vaccination in the elderly. Dev Comp Immunol 1997;21:501-7.
  47. CDC. Influenza and pneumococcal vaccination among adults aged greater than or equal to 65 years--United States, 1997. MMWR 1998;47:797-802.
  48. Jonker C, Schmand B, Lindeboom J, Havekes LM, Launer LJ. Association between apolipoprotein E 4 and the rate of cognitive decline in community-dwelling elderly individuals with and without dementia. Arch Neurol 1998;55:1065-9.
  49. Slooter AJC, van Duijn CM. Genetic epidemiology of Alzheimer disease. Epidemiol Rev 1997;19:107-19.
  50. Stern Y, Gurland B, Tatemichi TK, Tang MX, Wilder D, Mayeux R. Influence of education and occupation on the incidence of Alzheimer's disease. JAMA 1994;271:1004-10.
  51. Wimo A, Ljunggren G, Winblad B. Costs of dementia and dementia care: a review. Int J Geriatr Psychiatry 1997;12:841-56.
  52. CDC. Knowledge, attitudes, and practices of physicians regarding urinary incontinence in persons aged greater than or equal to 65 years--Massachusetts and Oklahoma, 1993. MMWR 1995;44:747-54.
  53. Cella M. Nursing costs of urinary incontinence in a nursing home population. Nurs Clin North Am 1988;23:159-68.
  54. Pannill FC, Williams TF, Davis R. Evaluation and treatment of urinary incontinence in long term care. J Am Geriatr Soc 1988;36:902-10.
  55. Schnelle JF, Sowell VA, Hu TW, Traughber B. Reduction of urinary incontinence in nursing homes: does it reduce or increase costs? J Am Geriatr Soc 1988;36:34-9.
  56. Baigis-Smith J, Smith DAJ, Rose M, Newman DK. Managing urinary incontinence in community-residing elderly persons. Gerontologist 1989;29:229-33.
  57. Fantl JA, Newman DK, Colling J, et al. Urinary incontinence in adults: acute and chronic management [clinical practice guideline, no. 2, 1996 update]. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1996; AHCPR publication no. 96-0682.

* Race/ethnicity data are presented only for non-Hispanic whites and non-Hispanic blacks because sample sizes for other racial/ethnic groups were too small for meaningful analysis.



Table 1

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TABLE 1. Rates for selected leading causes of death among older adults, by sex, race, and age group >=65 years -- United States, 1996*

 

Adults aged >=65 yrs

 
   

Sex

Race

Age group (yrs)

Cause of death

Total

Male

Female

White

Black

55-64§

65-74

75-84

>=85

Heart disease (612,199)

1,808

1,983

1,686

1,820

1,937

315

776

2,010

6,314

Malignant neoplasms (382,988)

1,131

1,442

915

1,125

1,338

406

862

1,352

1,798

Cerebrovascular diseases (140,488)

415

374

443

412

479

45

136

477

1,612

COPD and allied conditions (91,470)

270

338

223

283

173

47

162

358

541

Pneumonia and influenza (74,797)

221

236

211

225

207

17

57

231

1,011

Diabetes mellitus (46,376)

137

139

136

127

255

39

89

166

288

Accidents and adverse effects (30,830)

91

109

78

92

90

32

47

102

276

Alzheimer's disease (21,077)

62

49

71

66

38

1

11

73

285

Kidney diseases** (20,869)

62

70

56

58

109

8

25

73

210

Septicemia (17,337)

51

50

52

48

96

8

22

59

173

Atherosclerosis (15,891)

47

41

51

49

37

3

10

43

242

Hypertension (11,061)

33

29

35

29

73

5

13

37

117

* Rate per 100,000 population; number of deaths for adults aged >= 65 years are in parentheses.
Based on the following: World Health Organization. Manual of the international statistical classification of diseases, injuries, and causes of death. 9th rev. Geneva, Switzerland: World Health Organization, 1977.
§ Provided for comparison purposes.
COPD: chronic obstructive pulmonary diseases.
** Kidney diseases include nephritis, nephrotic syndrome, and nephrosis.

Sources: CDC/National Center for Health Statistics, 1996 Mortality File (unpublished data) and Peters KD, Kochanek KD, Murphy SL. Deaths: final data for 1996. Hyattsville, MD: US Department of Health and Human Services, CDC, 1998; DHHS publication no. (PHS) 99-1120 (National Vital Statistics Reports; vol. 47, no. 9).


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Table 2

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TABLE 2. Rates of discharge for selected major causes of hospitalization among older adults, by sex and age group >=65 years -- United States, 1996*

 

Adults aged >=65 yrs

 
   

Sex

Age group (yrs)

Condition

Total

Male

Female

55-64§

65-74

75-84

>=85

Heart disease (2,721)

80.4

89.8

73.8

35.3

62.4

97.4

117.9

Malignant neoplasms (737)

21.8

25.3

19.3

12.9

21.4

22.7

20.6

Cerebrovascular diseases (727)

21.5

22.5

20.7

5.5

13.5

28.5

39.6

Pneumonia (702)

20.7

23.1

19.1

4.7

11.8

24.6

53.8

Fractures (523)

15.4

7.8

20.7

3.3

7.0

18.4

48.7

Bronchitis (318)

9.4

9.8

9.2

4.2

7.8

10.9

12.9

Osteoarthritis (293)

8.6

7.1

9.7

3.0

8.3

10.6

4.6

Diabetes mellitus (198)

5.8

5.5

6.1

4.1

5.4

6.3

6.8

Diseases of the nervous system and sense organs (187)

5.5

5.6

5.5

2.1

4.1

6.9

8.5

Hyperplasia of prostate (85)

6.1

6.1

N/A

1.7

5.0

7.2

9.9

* Rate per 100,000 population; total number of hospital discharges (in thousands) for adults aged >=65 years are in parentheses.
† Based on the following: Public Health Service and Health Care Financing Administration. International classification of diseases, 9th rev, clinical modification. 4th ed. Washington, DC: Public Health Service, 1991. DHHS publication no. (PHS) 91-1260. The ICD-9 codes for each major cause of hospitalization listed are heart disease (391-392.0, 393-398, 402, 404, 410-416, 420-429); malignant neoplasms (140-208, 230-234); cerebrovascular diseases (430-438); pneumonia (480-486); fractures (800-829); bronchitis (466, 490-491); osteoarthritis (715); hyperplasia of prostate (600); diabetes mellitus (250); and diseases of the nervous system and sense organs (320-389).
§ Provided for comparison purposes.
¶ Not applicable.

Source: CDC/National Center for Health Statistics, 1996 National Hospital Discharge Survey (unpublished data).


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Table 3

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TABLE 3. Prevalence of selected major chronic conditions among older adults, by sex, race and age group >=65 years -- United States, 1995*

 

Adults aged >=65 yrs

 
   

Sex

Race

Age group (yrs)

Condition

Total

Male

Female

White

Black

55-64

65-74

>=75

Arthritis (15,402)

48.9

40.5

55.0

48.7

57.3

32.8

44.8

54.8

Hypertension (12,692)

40.3

34.9

44.2

39.5

53.3

28.9

39.2

42.0

Heart disease (9,682)

30.8

36.2

26.9

31.5

26.1

18.0

26.8

36.4

Selected respiratory diseases§ (4,343)

13.8

14.4

13.4

13.7

14.7

13.7

14.8

12.4

Diabetes mellitus (3,978)

12.6

12.4

12.8

11.9

21.9

9.7

13.3

11.7

Selected malignant neoplasms (2,324)

7.4

8.7

6.4

7.9

--**

5.0

6.0

9.3

Cerebrovascular diseases (2,243)

7.1

7.9

6.5

7.1

--**

2.5

5.2

9.9

Atherosclerosis (1,294)

4.1

4.5

3.9

4.5

--**

1.8

2.9

5.9

* Number of conditions per 100 persons; total number of conditions (in thousands) for adults aged >= 65 years are in parentheses.
† Provided for comparison purposes.
§ Selected respiratory diseases include chronic bronchitis, asthma, and emphysema.
¶ Selected malignant neoplasms include cancers of the skin, intestine, female breast, female genital organs, prostate, lung/ bronchus, and other respiratory sites.
** Estimate is statistically unreliable.

Source: CDC/National Center for Health Statistics, 1995 National Health Interview Survey (unpublished data).


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Table 4

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TABLE 4. Per capita personal health-care expenditure,* by age group and spending category -- United States, 1987

 

Expenditure

Age group (yrs)

Total ($)

Hospital care (%)

Physician services (%)

Nursing home (%)

Other (%)

Overall

5,360

41.9

20.7

20.2

17.2

65-69

3,728

45.1

26.1

4.4

24.3

70-74

4,424

46.6

24.5

8.1

20.7

75-79

5,455

46.5

21.8

14.7

17.0

80-84

6,717

43.7

18.5

23.9

13.9

>=85

9,178

35.2

13.8

40.7

10.3

* Personal health-care expenditure is defined as spending for the direct consumption of goods and services.
† Percentages might not total 100% because of rounding.

Source: Adapted from Waldo DR, Sonnefeld ST, McKusick DR, Arnett RH III. Health expenditures
by age group, 1977 and 1987. Health Care Financing Rev 1989;10(4):111-20.


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Table 5

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TABLE 5. Distribution of Medicare spending, by age group >=65 years and spending level -- United States, 1992

 

Age group (yrs)

 

65-69

70-74

75-79

80-84

>=85

Spending level

Mean spending ($)

%*

Mean spending ($)

%*

Mean spending ($)

%*

Mean spending ($)

%*

Mean spending ($)

%*

Top 1%

58,740

27

52,464

21

60,996

20

53,317

15

61,866

15

95%-99%

19,840

62

22,054

54

24,301

49

24,539

42

27,155

40

90%-94%

7,441

78

9,913

72

12,944

69

14,116

62

15,379

57

70%-89%

1,917

95

2,882

94

3,894

93

5,227

91

7,091

90

50%-70%

399

99

601

99

810

98

1,146

98

1,608

98

0%-50%

44

100

74

100

114

100

161

100

204

100

* Cumulative percentage.

Source: Cutler D, Sheiner L. Demographics and medical care spending: standard and non- standard effects. Cambridge, MA: National Bureau of Economic Research, 1998; Working paper no. 6866.


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Table 6

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TABLE 6. Distribution of per capita personal health-care expenditure, by age group and source of funding -- United States, 1987

 

Public source

Age group (yrs)

Private source* (%)

Total (%)

Medicare (%)

Medicaid (%)

Other (%)

Overall

37.4

62.6

44.6

12.0

6.0

65-69

38.4

61.6

49.6

6.6

5.5

70-74

35.4

64.6

50.5

8.1

6.1

75-79

33.8

66.2

49.2

10.4

6.6

80-84

34.7

65.3

45.0

13.5

6.7

>=85

39.6

60.4

35.0

19.0

6.4

* Principal private sources include private health insurance, out-of-pocket payment, and other private sources.
† Percentages might not total 100% because of rounding.

Source: Adapted from Waldo DR, Sonnefeld ST, McKusick DR, Arnett RH III. Health expenditures
by age group, 1977 and 1987. Health Care Financing Rev 1989;10(4):111-20.


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Table 7

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TABLE 7. Average annual percentage rate of change in age-specific use of seven medical procedures among adults aged >=65 years, by sex and age group -- United States, 1987-1995

 

Age group (yrs)

 

65-69

70-74

75-79

80-84

>=85

Procedure

Men

Women

Men

Women

Men

Women

Men

Women

Men

Women

Angioplasty

13.1

12.6

15.7

14.9

19.7

17.1

21.3

18.4

22.3

20.0

Coronary artery bypass graft

3.7

4.4

5.5

7.3

8.5

10.7

11.1

13.3

14.6

11.0

Cardiac catheterization

4.4

5.3

6.2

7.1

10.0

9.9

13.4

16.9

16.0

15.7

Carotid endarterectomy

7.1

8.6

5.9

6.9

10.1

9.1

11.4

10.3

10.6

11.8

Hip replacement

14.9

18.3

16.3

17.0

17.7

18.7

20.1

21.4

25.8

28.9

Knee replacement

11.5

10.9

12.1

10.8

11.8

9.1

8.2

8.4

10.6

10.7

Laminectomy

3.9

4.9

5.0

6.6

8.0

6.5

10.1

4.1

8.4

7.2

Source: Fuchs VR. Health care for the elderly: How much? Who will pay for it? Cambridge, MA: National Bureau of Economic Research, 1998; Working Paper no. 6755.


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Table 8

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TABLE 8. Projected personal health-care expenditure (in constant 1994 billions of U.S.$) for adults aged >=65 years, by age group and year -- United States, 1994-2030

Age group (yrs)

1994

2000

2010

2020

2030

Overall

311

309

384

496

665

65-74

136

135

152

224

276

>=75

175

175

231

271

389

Note: Because of rounding, numbers for age groups 65-74 and >=75 years might not total the number for age group >=65 years.

Source: Rice DP. Beneficiary profile: yesterday, today, and tomorrow. Health Care Financing Rev 1996;18(2):23-46.


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Table 9


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TABLE 9. Projected Medicare (hospital insurance and supplemental medical insurance) disbursements* as a percentage of gross domestic product (GDP) -- United States, 1997-2030

Year

Hospital insurance (% GDP)

Supplemental medical insurance (% GDP)

Total

1997

1.69

0.93

2.62

2000

1.61

1.07

2.68

2010

1.78

1.67

3.46

2020

2.22

2.48

4.70

2030

2.79

3.06

5.85

* Disbursements are the sum of benefit payments and administrative expenses.
† Percentages might not total because of rounding.

Source: Health Care Financing Administration. 1998 Annual report of the board of trustees of the Federal Hospital Insurance Trust Fund. Available at <http://www.hcfa.gov/pubforms/tr/default.htm>. Accessed July 1999.


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