Best Practice & Research Clinical Obstetrics & Gynaecology
1The clinical consequences of an ageing world and preventive strategies
Introduction
Human populations grew at about 0.05% annually for 10,000 years such that, by the year 1500, the global population was around 400 million people. A significant increase in population growth occurred in the 17th and 18th centuries, with the growth rate increasing to about 0.5% annually and reaching 1 billion at the start of the 19th century. The population growth rate continued to increase to 0.7% after 1900, and to 2% in the 1960s, with 1.6 billion worldwide in the beginning of the 20th century.1 By the year 2000, 6.1 billion people inhabited our planet. The United Nations projects that, by 2100, the world population will reach 11.5 billion people,2 an increase of almost 5 billion3 people between 2000 and 2100.
The four most important elements in determining population growth and ageing in any country or region are fertility rate, life expectancy, migration, and emigration.4
Women's role in society has changed. They have more access to education and greater choice in careers; childcare outside of the home is associated with a decrease in fertility rate. Improvements in healthcare are one of the important factors increasing life expectancy. Population ageing is a direct result of the decrease in the fertility rate and the increase in life expectancy. Migration within and emigration from a country or region are the most important factors affecting demographic change; however, as mostly younger people migrate or emigrate, this will influence the ageing pattern of these countries (Fig. 1).
Immigration has increasingly become perceived as a potential means of preventing population decline, maintaining a sufficient labour force and support ratio, and thus slowing down structural population ageing. In particular, immigration has a potentially strong and long-lasting affect on population growth and composition through the interaction among the number of migrants, their relatively younger age, and their higher fertility, according to Harper.4 Uncontrolled immigration could, however, result in demographic changes that may influence social, cultural, and economic stability, and may lead, in extreme conditions, to discontent.
The increase in world population from 1.6 billion in 1900 to 6.1 billion in 2000 arose primarily from population growth in less developed countries that experienced a significant increase in life expectancy. While rising life expectancy occurred over centuries in Europe, many less developed countries accomplished it in decades. As growth rates in less developed countries rose to levels never experienced in more developed countries, many countries implemented policies to lower the birth rate to adjust for rapidly declining death rates, especially related to lower rates of perinatal and infant mortality. Although some less developed countries had dramatic declines in birth rates, others had a somewhat more gradual decline, and some experienced almost no decline at all.
Overall, the total fertility rate in less developed countries declined from about 6.0 in the early 1950s to about 2.5 today, a much more rapid decrease than that of Europe from 2.5 in 1960 to 1.55 in 2011, and North America from 3.7 in 1960 to 2.16 in 2011. Thus, although less developed countries continue to have population growth, the EU27 countries, in particular, will see population shrinkage of around 0.2% per year between 2020 and 2045. Italy and Germany will be particularly affected, with projected falls from 60 million to 57 million in Italy between 2010 and 2050, and 82 million to 79 million for Germany.3 Italy will need to raise its retirement age to 77 or admit 2.2 million young immigrants annually to maintain its worker to retiree ratio, at the expense of a significant change in its demography.
The past century has witnessed a transition from a high mortality and high fertility pattern to one of historically unprecedented declines in mortality rates followed by equally unprecedented declines in fertility rates. This change has resulted in a rapidly ageing world population. The 20th century was the century of population growth; the 21st century will be remembered as the century of ageing.
In 2010, the world population has reached a transition point. The rapid growth of the second half of the 20th century has slowed, but factors such as continuously increasing longevity and slower-than-expected declines in birth rates, guarantee continued growth for decades.
Section snippets
Life expectancy
Humans had a life expectancy of about 30 years for about 99.9% of the time we inhabited this planet (Fig. 2). Today, in developed countries, more than 75% die after the age of 75 years. In the record-holding country, Japan, female life expectancy was 86 years in 2007,7 surpassing the 85-year limit to human life expectancy proposed by Fries et al.8
In 1900 in Europe, life expectancy was around 45 years,9 and health expectancy, the ability to live independently, was similar between men and women
An ageing world
Improved health care, increased access to education, and economic growth, has led to longer life expectancy in every region and across most socioeconomic groups. The proportion of elderly population has been rising and will continue to grow from 8% (551 million people over 65 years) in 2010 to 21% (1964 million people over 65 years) by 2050. The projected two billion elderly people of the year 2050 are already around us as teenagers and young people.
Seventy per cent of all older people now live
Life course perspective
The life course perspective considers the gap between onset of debilitating illness and death, and illustrates that women die after the age of 80 years in many regions in the world mostly from non-communicable diseases (Fig. 4). This life course perspective leads to important policy and strategy decisions. Cross-sectional studies show differences in mortality and morbidity as a function of socioeconomic status, across various disease categories throughout the life span. Ageing successfully
Clinical consequences of an ageing world
Since now increased disability and sickness often accompany the last years of life, the demands for social and health services will increase immensely. The high cost of these services will strain the health, social and even political infrastructures of developing, and most developed and industrialised nations. Less developed countries—which have much lower levels of economic development and access to adequate health care than more developed countries—will be hard-pressed to meet the challenges
The promotion of a safe environment
A basic requirement of a supportive physical environment is the provision of a safe and accessible living environment. Falls are the most common, and preventable, threat to senior independence and also account for significant morbidity, including fracture, impaired mobility, depression, admission to long-term care facilities, decreased quality of life due to fear of falling, and death.23
As a person ages, they are more likely to have risk factors that contribute to falling, such as loss of
Healthy lifestyle, including proper nutrition and avoidance of drug and alcohol abuses
Two-third of adults27 and nearly one-third of children21 are overweight or obese in the USA, resulting in concurrent epidemics of diabetes and its complications, and other serious health conditions such as hypertension, hypercholesterolaemia, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnoea, and respiratory problems, as well as contributing to the risk of endometrial, breast, and colon cancers.
A healthy lifestyle includes regular physical activity, balancing the
Preventive strategies for cancers
Key cancer preventive strategies are to (1) reduce exposure to tobacco to the lung, oral cavity and pharynx to decrease respiratory cancers; (2) reduce salt intake and identify and treat Helicobacter pylori infections to decrease gastrointestinal cancers and heart disease36; (3) reduce food intake, improve diet and increase exercise to decrease colon-rectum, kidney, breast, ovary and endometrial cancer; (4) increase water intake, particularly to decrease urinary bladder cancer.37
Lung cancer and chronic respiratory diseases
Cigarette smoking is the most common preventable cause of lung cancer, the leading cause of cancer death in both men and women in our society. Clinicians are uniquely positioned to affect smoking rates. In all countries, implementation of comprehensive tobacco control policies, including prohibition of cigarette advertising, tax increases and health promotion strategies, have the potential to reduce lung-cancer mortality. Anti-smoking policies may contribute to other health gains, including the
Colorectal cancer
Primary prevention of colorectal cancer is accomplished by life-style factors, such as limiting obesity and excessive alcohol consumption. Dietary principles that decrease colorectal cancer risk entail increasing vegetables and fruit while reducing meat and refined carbohydrate consumption. An added benefit arises from ingesting olive oil and other unsaturated fats, common to the Mediterranean diet rather than using animal and saturated fats.39 Tobacco and dietary carcinogens may be secondary
Cervical cancer
Cervical cancer screening has begun to include human papillomavirus testing as a complement to cytology testing, as this testing has identified women at risk of developing cervical cancer.43 In recognition of new technologies and research on cervical cancer screening, the US Guidelines for the Prevention and Early Detection of Cervical Cancer now recommend that women aged 30–65 years may be screened every 5 years by co-testing with cervical cytology and high-risk human papillomavirus testing,
Breast cancer
Nulliparity, younger age of menarche, older age at menopause and late age at first birth and infertility are known potential risk factors for breast cancer.46 Pregnancy and breast feeding, combined with regular exercise, maintaining a healthy weight, and avoiding alcohol can help lower the risk.
The US Preventive Services Task Force recommends that women aged between 50 and 74 years be screened for breast cancer by mammography every 2 years. The adjunctive use of ultrasound may be useful in
Endometrial cancer
Early menarche, late menopause, nulliparity, obesity, increased body mass index, and unopposed oestrogen in anovulatory women (e.g. polycystic ovary syndrome) are all associated with developing endometrial cancer.47, 48 Compared with the general population, the risk of endometrial cancer is increased nine-fold in infertile women with chronic anovulatory disorders.49, 50 Long-term use of combined oral contraceptive use decreases the risk of endometrial cancer as does the use of oral progestins
Ovarian cancer
Nulliparity, and, for some women, genetic defects such as BRCA, are risk factors for epithelial ovarian cancer. ‘Incessant ovulation’ and associated alteration in endogenous hormones during reproductive years have been theorised as increasing ovarian cancer risk.∗52, 53 Use of combined oral contraceptives has a significant protective effect on the ovarian cancer risk,54, 55 by preventing ovulation and also in preventing retrograde menstruation.51 The protection increases with duration of use
Preventive medical strategies to maintain quality of life, and delay, decrease or prevent frailty and disabilities
Longevity has increased so rapidly during the last century that menopause is now a mid-life, rather than end-of-life event. Menopausal symptoms of hot flushes, night sweating, insomnia, panic attacks, depressive moods, and loss of libido significantly affect quality of life. Genitourinary symptoms developing early in the menopause transition add to a woman's distress. An appropriately adjusted oestrogen regimen treats most menopausal symptoms, protects against osteoporosis and, when used in
Medical health care, including the control of chronic illnesses and cardiovascular disease
A healthy life style, including limiting salt from processed foods, may be a cost-effective preventive measure to reduce cardiovascular disease, and thus will lead to improvements in population health,61 especially if begun early in life. Similarly, reducing high cholesterol levels to the normal range even in people who do not yet have cardiovascular disease has contributed most to the decline in coronary heart disease mortality in some European countries62 and in the USA. Consequently,
Subclinical hyperthyroidism
Several changes in thyroid hormone secretion, metabolism, and action occur with increasing age. Ageing is associated with a decrease in serum thyroid stimulating hormone and T3 levels, whereas serum free T4 levels sometimes remain unchanged.66 The prevalence of thyroid dysfunction is higher in elderly people compared with younger people. It is thus warranted to check thyroid-stimulating hormone, T3 and T4 periodically. In elderly individuals, non-specific clinical manifestations of thyroid
Frailty
Fried et al.71 described frailty as a state of global deficiency of physiological reserves and functional dysregulation involving multiple organ systems, resulting in poor homeostasis and increased vulnerability when faced with stressors. The frailty phenotype is a clinical syndrome characterised by shrinking (unintentional weight loss and sarcopaenia and muscle wasting), weakness, and exhaustion. Frailty and sarcopaenia are associated, but distinct, correlates of musculoskeletal ageing that
Urinary tract infection and incontinence
Urinary tract conditions can profoundly affect the quality of life of post-menopausal women. Urinary tract infection is the most common bacterial infection in women in general and in postmenopausal women in particular. Fifteen to 20% of women aged 65–70 years and 20–50% of women older than 80 years old have bacteriuria.76 Oestrogen deficiency may contribute to bacteriuria in postmenopausal women. Oestrogen stimulates the proliferation of lactobacillus on the vaginal epithelium, reduces pH, and
Social interactions to maintain good mental health
Mental health plays a major role in women of any age. Depression is the most common mental health problem among older people, critically affecting their sense of well-being and quality of life. A critical aspect of care of any age, especially in elderly people, is distinguishing which women will benefit from behavioural and lifestyle changes from those who will benefit from pharmacological intervention.
Research has shown that both general practitioners and specialists lack training in mental
Osteoporosis
The World Health Organization identifies osteoporosis as one of the leading health problems in the Western world. Osteoporosis is common among all racial groups, is most common in white people and increases with age. Despite the availability of effective preventive treatments, osteoporosis is frequently underdiagnosed and undertreated, particularly among elderly people who are also at greatest risk. In addition, the presence of co-morbid medical conditions may be a barrier to osteoporosis care
Conclusion
A better understanding of molecular mechanisms of ageing, embedded in a translational matrix of gerontology and geriatric medicine, will enable the development of new clinical strategies to prevent and manage age-associated dysfunctions and diseases. Moreover, placing greater emphasis and increasing research on public health issues, including health-promotion strategies, prevention of disease, disability and frailty, and improving quality of life, quality of care, healthcare organisation and
Acknowledgement
This work was supported in part by the Intramural Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the NIH Clinical Center. We thank Nancy Terry, MLS, informationist at the NIH Clinical Center for her assistance in formatting the references for publication.
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