Series 20

No. 28

Mortality Trends for Alzheimer’s

Disease, 1979–91

January 1996

Vital and

Health Statistics

From the CENTERS FOR DISEASE CONTROL AND PREVENTION / National Center for Health Statistics

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Centers for Disease Control and Prevention

National Center for Health Statistics
Copyright Information

All material appearing in this report is in the public domain and may be

reproduced or copied without permission; citation as to source, however, is

appreciated.

Suggested Citation

Hoyert DL. Mortality trends for Alzheimer’s disease, 1979–91. National Center

for Health Statistics. Vital Health Stat 20(28). 1996.

Library of Congress Cataloging-in-Publication Data

Hoyert, Donna L.

Mortality trends for Alzheimer’s disease, 1979–91 / [by Donna L. Hoyert].

p. cm. — (Vital and health statistics. Series 20, Data from the national

vital statistics system ; no. 28) (DHHS publication ; no. (PHS) 96–1856)

‘‘January, 1996.’’

Includes bibliographical references.

ISBN 0–8406–0511–0

1. Alzheimer’s disease—United States—Mortality—Statistics. I. National

Center for Health Statistics (U.S.) II. Title. III. Series. IV. Series: DHHS

publication ; no. (PHS) 96–1856.

RA645.A49H69 1995

614.5’992—dc20 95–50806

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Mortality Trends for Alzheimer’s

Disease, 1979–91

Series 20:

Data From the National Vital

Statistics System

No. 28

This report presents mortality patterns for Alzheimer’s disease, on the basis of

both underlying and multiple causes of death. Deaths and death rates are

shown by age, race, sex, and State.

Hyattsville, Maryland

January 1996

DHHS Publication No. (PHS) 96-1856

Vital and

Health Statistics

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Centers for Disease Control and Prevention

National Center for Health Statistics
National Center for Health Statistics

Jack R. Anderson, Acting Director

Jennifer H. Madans, Ph.D., Acting Deputy Director

Jacob J. Feldman, Ph.D., Associate Director for Analysis,

Epidemiology, and Health Promotion

Gail F. Fisher, Ph.D., Associate Director for Planning and

Extramural Programs

Jack R. Anderson, Acting Associate Director for

International Statistics

Stephen E. Nieberding, Associate Director for

Management

Charles J. Rothwell, Associate Director for Data

Processing and Services

Monroe G. Sirken, Ph.D., Associate Director for Research

and Methodology

Division of Vital Statistics

Mary Anne Freedman, M. A., Director

James A. Weed, Ph.D., Deputy Director

Harry M. Rosenberg, Ph.D., Chief, Mortality Statistics

Branch

Robert J. Armstrong, Acting Chief, Statistical Resources

Branch

Joseph D. Farrell, Chief, Systems and Programming Branch
Contents

Highlights .............................................................................................. 1

Introduction............................................................................................. 2

Data source........................................................................................... 2

Diagnosis ............................................................................................ 3

Reporting Alzheimer’s disease on the death certificate ........................................................ 3

Implications of composition change in the population ........................................................ 3

Trends, 1979–91 ......................................................................................... 4

Sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Race ................................................................................................ 4

Geographic differentials, 1989–91......................................................................... 4

Multiple causes of death ................................................................................ 6

A broader grouping of dementing conditions................................................................ 6

Discussion .............................................................................................. 8

References.............................................................................................. 9

List of detailed tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Appendix

Technical notes on methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Text figures

1. Medical certification of death (Cause of Death) section of the U.S. Standard Certificate of Death ................... 2

2. Death rates for Alzheimer’s disease by age: United States, 1979–91............................................ 5

3. Age-adjusted death rates by sex for Alzheimer’s disease for persons 65 years of age and over: United States, 1979–91 . 5

4. Age-adjusted death rates by race for Alzheimer’s disease for persons 65 years of age and over: United States, 1979–91 . 6

5. Alzheimer’s disease death rates by State, 1989–91.......................................................... 7

Text tables

A. Age-adjusted death rates for Alzheimer’s disease for decedents 65 years of age and over and annual percent change:

United States, 1979–91 ................................................................................ 4

B. Age-specific and age-adjusted death rates for Alzheimer’s disease for decedents 65 years of age and over: United States,

1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

iii
Symbols

- - - Data not available

. . . Category not applicable

– Quantity zero

* Figure does not meet standard of

reliability or precision (estimate is based

on fewer than 20 deaths in numerator or

denominator )

*– Figure does not meet standard of

reliability and quantity zero

iv
Mortality Trends for

Alzheimer’s Disease,

1979–91

by Donna L. Hoyert, Ph.D., Division of Vital Statistics

Highlights

In 1991 a record 14,112 Alzheimer’s deaths were reported

in the United States, 13,768 of which were to persons 65 years

of age and older. Alzheimer’s disease would have been the

11th leading cause of death for individuals 65 years of age and

older if it were separately identified in the standard tabulation

list used to rank leading causes.

Death rates increased with age for this cause. The agespecific death rates for persons 85 years and over were about

19 times greater than those for persons 65–74 years of age.

The age-adjusted death rate for this cause, which eliminates

the effects of the aging of the population, increased each year

from 1979 to 1988. However, from 1988 to 1991 there was no

statistically significant single-year increase. The increasing

trend may reflect improvements in diagnosis, awareness of the

condition within the medical community, and other unidentified factors rather than substantial changes in the risk of dying

from Alzheimer’s disease.

Age-adjusted death rates for Alzheimer’s disease are

greater for men than women and for the white than the black

population. During the period from 1979 to 1991, the mortality sex ratio for the elderly decreased from 1.6 to 1.1 and the

ratio of the rates by race decreased from 2.6 to 1.7. Geographic differentials also occur in death rates for Alzheimer’s

disease.

In addition to the deaths for which Alzheimer’s disease is

reported as the underlying or initiating cause of death, Alzheimer’s disease is mentioned on many other death certificates as

an additional condition contributing to death. A similar increase

has occurred between 1979 and 1991 for reporting Alzheimer’s disease as an additional cause as for when it is reported

as the underlying cause of death.

Increases also occurred over this period for a broader

group of dementing conditions, including Alzheimer’s disease.

Among these, variations occurred in both the patterns and

trends of mortality.

Notes: This report was prepared in the Division of Vital Statistics under the

general direction of Harry M. Rosenberg, Chief of the Mortality Statistics

Branch. Gopal K. Singh, Ph.D., Mortality Statistics Branch, and Joan Van

Nostrand, M.P.A., NCHS Coordinator of Data on Aging, peer-reviewed this

report. Betty L. Smith of the Statistical Resources Branch provided content

review. Staff of the Registration Methods Branch and the Technical Services

Branch provided consultation to State vital statistics offices regarding collection of the death certificate data on which this report is based. This report was

edited by Gail V. Johnson and typeset by Annette F. Holman of the

Publications Branch, Division of Data Services.

1
Introduction

This report presents basic data on Alzheimer’s disease

mortality between 1979–91. Alzheimer’s is a progressively

debilitating disease that falls within a class of disorders,

generally referred to as dementia. These disorders, characterized by cognitive and mental deterioration, may manifest in

sudden or progressive forms. Within the class of disorders, the

major type of progressive dementia is Alzheimer’s disease (1).

In addition to memory loss and increasing difficulty in

doing cognitive tasks, persons with Alzheimer’s disease also

have problems with emotional outbursts, personal care, disrupted sleep patterns, and control of bodily functions (2). The

timing of the progression of this disease to death varies widely

for individuals. In the end, death has been reported in clinical

texts to occur because of pulmonary infections, urinary tract

infections, decubitus ulcers or bed sores, or iatrogenic disorders (3).

The purpose of this report is to describe trends for this

cause of death by age, race, and sex; to describe geographic

differentials; to discuss Alzheimer’s disease as a multiple

cause of death; and to present mortality data on other dementing conditions. Data are shown for all ages, but as this

condition primarily affects the older population, patterns for

those 65 years of age and older are emphasized.

Data source

The mortality data in this report are from the National

Vital Statistics System. The medical information collected on

the death certificate focuses on the sequence of medical

conditions that result in death and is provided in a two-part

format as recommended by the World Health Organization

(WHO)(4). The U.S. Standard Certificate of Death (figure 1) is

designed principally to elicit a single disease or injury that

started the morbid process that lead to death; this disease or

injury is usually reported on the bottom line of part I and is

called the underlying cause of death. Traditionally, the underlying cause is the datum by which mortality statistics are

tabulated in both the United States and other countries. Other

conditions are usually reported on the death certificate in

either part I of the certificate—representing the sequence of

conditions leading to death, or part II—representing other

conditions that the physician felt had a bearing on the death

but were not part of the direct causal sequence. The totality of

all conditions on the death certificate, either underlying or

nonunderlying, is called multiple causes of death. The United

States is one of a few countries that routinely and annually

produce both underlying and multiple cause-of-death statistics

(for additional information, see Technical notes).

Figure 1. Medical Certification of Death (Cause of Death) section of the U.S. Standard Certificate of Death

2
Cause-of-death information is completed by a qualified person: physician, medical examiner, or coroner. The person filling out

the cause-of-death section of the death certificate is asked to

provide, to the best of his or her knowledge and based on available

medical history and clinical and pathological evidence, the sequence

of conditions that caused death. The death certificate includes a

statement about medical certification being to the best of his or her

knowledge in recognition of the fact that determination of cause

may be difficult, but that the physician is in the best position to

make a judgment about the chain of events leading to death (5).

The medical conditions reported by physicians, medical examiners, and coroners on the death certificate are translated into

medical codes for statistical use. The translation is made using the

classification structure and the selection and modification rules

contained in the applicable revision of the International Classification of Diseases (ICD), published by WHO (for additional information, see Technical notes). Use of the ICD promotes comparability

of mortality statistics worldwide. In this classification, Alzheimer’s

disease (ICD–9 No. 331.0) is found in Chapter VI ‘‘Diseases of the

Nervous System and Sense Organs.’’Alzheimer’s disease might be

reported as either an underlying or nonunderlying cause of death,

reflecting the physician’s judgment about this medical condition’s

role in the death.

Cause-of-death data from the death certificate are the most

widely available, timely, and geographically comparable data on

health available for the United States and many other countries.

However, the reliability and accuracy of cause-of-death statistics

are dependent upon the ability of the certifier to make the proper

diagnosis and the care with which he or she records this information on the death certificate (5).

Diagnosis

Many mental and cognitive exams have been used to diagnose

Alzheimer’s disease, with the National Institute of Neurological

and Communicative Disorders and Stroke and the Alzheimer’s

Disease and Related Disorders Association (NINCDS-ADRDA)

criteria being most widely used (6–8). The NINCDS-ADRDA

specify criteria for clinical diagnosis of possible, probable, and

definite Alzheimer’s disease. Criteria for possible Alzheimer’s

disease are least discriminating and those for definite Alzheimer’s

disease are most discriminating. Definite Alzheimer’s disease criteria include the clinical criteria used to diagnose probable Alzheimer’s disease plus anatomical evidence available only upon an

autopsy (7,8). The accuracy of diagnosing Alzheimer’s disease has

improved over time, largely because of the development of the

NINCDS-ADRDA criteria. Research in the 1970’s found that

Alzheimer’s disease was confirmed in 60–70 percent of suspected

cases; more recent research reports verification of more than

90 percent of suspected Alzheimer’s disease cases (9). Improved

diagnoses have a number of potential benefits, including promoting

comparability of research on treatment and enhancing statistical

estimates of morbidity and mortality.

Reporting Alzheimer’s disease on the

death certificate

Research on reporting dementia on death certificates shows

that substantial numbers of death certificates for persons diagnosed

with dementia have no mention of the condition, but the percentage

depends on the specific type of dementia (10–13). Burns et al. (12)

and Newens et al. (13) report that neither Alzheimer’s disease nor

any other type of dementia is mentioned on a quarter to a third of

death certificates for diagnosed persons.

Upon death, Alzheimer’s disease might not be mentioned on a

death certificate for several reasons, including the following: the

condition was not diagnosed, Alzheimer’s was diagnosed but was

not considered to contribute to death, and the condition was not

reported although it may have contributed to death. Aside from an

item that identifies decedents for whom an autopsy was conducted,

no further information is available on the death certificate that

would indicate if Alzheimer’s disease was diagnosed or what

diagnostic tests had been performed or even if the autopsy results

were used in completing the death certificate. Such information

could only be obtained by further inquiry, or by linking the death

certificate to other sources of information such as a patient’s

medical records or hospital discharge records.

If the medical personnel reporting the cause of death

believe that the person had Alzheimer’s disease, but that this

was not relevant in the person’s death, then not mentioning

Alzheimer’s disease on the death certificate would be an

acceptable procedure. In fact, the death certificate only asks

for those causes of death that contribute to the individual’s

death. For this reason, death certificates would underestimate

the number of decedents who have Alzheimer’s disease at the

time of death, as with other chronic conditions (14).

With respect to the possibility of a reporting problem when

Alzheimer’s disease is diagnosed and does contribute to death,

some evidence suggests that reporting of dementing conditions on

death certificates is improving over time (13). When the course of

a dementing condition has progressed so that the person is more

severely affected cognitively, Alzheimer’s disease and infectious

conditions are reported with greater frequency (15).

Another reporting artifact that has been suggested as

contributing toward the increase in Alzheimer’s disease deaths

is an increasing preference for the term ‘‘Alzheimer’s disease’’

over other terms (16). Depending on the terms used, a death

could be classified under other titles in the ICD.

Implications of composition change in the

population

The burden of Alzheimer’s disease is expected to increase

because of changes in the population composition (8). Because of

lower fertility rates in recent decades and declines in death rates,

the proportion of the population 65 years of age and older has

grown substantially. Within the elderly population, the distribution

has changed to reflect aging within the elderly subpopulation

(17–19). The proportion of the elderly population 85 years of age

and over is projected to continue to increase until the large baby

boom cohort begins to move into age groups 65 years and older

(18,19).

3
Trends, 1979–91

In 1991 a total of 14,112 deaths from Alzheimer’s disease

were reported in the United States, an increase of 13,255

(about sixteenfold) from the 857 reported in 1979 (table 1). By

and large, this is a condition of the elderly population; of the

14,112 deaths in 1991, a total of 13,768 (or 98 percent) were

to people aged 65 years and over (table 1).

Between 1979 and 1991 the age-adjusted death rate for

Alzheimer’s disease increased twelvefold, from 2.5 to 29.3 per

100,000 population 65 years of age and over, while mortality

from all causes decreased 8.5 percent (table 2). Rates for

persons 65 years and over increased each year until 1988

when the rates reached a plateau. Differences in rates for

successive years between 1988 and 1991 were not statistically

significant, although the increase during the 3-year period

1988–91 was statistically significant. The average annual

increase was 50 percent between 1979 and 1983, 22 percent

between 1983 and 1987, and 2 percent between 1987 and 1991

(table A).

Mortality for Alzheimer’s disease, like that of most

chronic diseases, increases with age. In the case of Alzheimer’s disease, this pattern became more pronounced between

1979 and 1991 (figure 2). In 1979 rates for individuals 85

years and over were 2.0 times greater than the rates for

individuals 65–74 years of age. By 1991, rates for the oldest

age group were 19.3 times that for individuals 65–74 years of

age (table 3).

The divergence in rates by age reflects a slower increase

in mortality for the younger age groups, 65–74 and 75–84

years of age compared with persons 85 years of age and over.

Since 1988, rates have decreased for the 65–74 year age group

and stabilized for the 75–84 year age group while rates for the

85 years and over group have continued to increase. While

recent increases have occurred within the open-ended category

of 85 years and over and rates do indeed increase for 10-year

age groups within the 85 years and over category (table B),

changes in the composition of this segment of the population

have not affected the age-adjusted rate.

Sex

Age-adjusted death rates for Alzheimer’s disease are

somewhat greater for men than for women (figure 3). In 1991,

the rate for men age 65 years and over was 30.8 compared

with 28.1 for women, a difference of 10 percent (table 2). For

women, rates increased almost every year from 1979 to 1991

while for men increases appear to have stopped around 1987.

Throughout the period, rates were consistently greater for

males than females; however, the mortality sex ratio decreased

from 1.6 in 1979 to 1.1 in 1991. In comparison, the ratio for

all causes was 1.7 in 1979 and 1.6 in 1991.

Race

Age-adjusted death rates are greater for the white than for

the black population (table 2 and figure 4). In 1991 the ageadjusted death rate for Alzheimer’s disease for the elderly

white population (30.6) was 1.7 times that of the black

population (18.5). Between 1979 and 1991, this ratio decreased

from 2.6 to 1.7. For all causes, the ratio was 0.9 in 1979 and

0.8 in 1991.

Geographic differentials, 1989–91

Age-adjusted death rates for Alzheimer’s disease by State

of residence are shown for the 3-year period 1989–91 in

table 4. Rates differ by State, with the largest rates being

observed for persons 65 years of age and over in States in the

northwestern and northeastern areas of the United States

(figure 5). The lowest rates are for States in the Middle

Atlantic region. The rate for the State with the greatest rate is

about five times that for the State with the lowest rate. For all

Table A. Age-adjusted death rates for Alzheimer’s disease for

decedents 65 years of age and over and annual percent change:

United States, 1979–91

[Age-adjusted rates per 100,000 U.S. standard million population; see appendix]

Year

All races

Age-adjusted

rate1

Confidence

interval

Annual

percent change

1991 ............... 29.3 (28.8,29.8) –1.0

1990 ............... 29.6 (29.1,30.1) 1.4

1989 ............... 29.2 (28.7,29.7) 2.5

1988 ............... 28.5 (28.0,29.0) 5.2

1987 ............... 27.1 (26.6,27.6) 14.3

1986 ............... 23.7 (23.2,24.2) 9.7

1985 ............... 21.6 (21.1,22.1) 27.1

1984 ............... 17.0 (16.6,17.4) 36.0

1983 ............... 12.5 (12.1,12.9) 68.9

1982 . . . . . . . . . . . . . . . 7.4 (7.1, 7.7) 48.0

1981 . . . . . . . . . . . . . . . 5.0 (4.7, 5.3) 31.6

1980 . . . . . . . . . . . . . . . 3.8 (3.6, 4.0) 52.0

1979 . . . . . . . . . . . . . . . 2.5 (2.3, 2.7) - - -

1Includes age not stated.

4
causes, the rate for the State with the greatest rate is only 1.4

times that for the State with the lowest rate. It seems improbable that there would be a fivefold variation in the incidence of

Alzheimer’s disease but more likely that there are reporting

differences across States.

By race, the geographic pattern for the white population is

generally the same as for all races. One difference is for

Hawaii, which has a low age-adjusted rate for the elderly of all

races relative to the rate for the United States as a whole but a

high rate for the white population. For the black population,

few differences in State rates are statistically significant from

the rate for the United States as a whole. In those specific

States—Illinois, Massachusetts, Michigan, Missouri, New York,

New Jersey, and Texas—the rates are in the same direction as

for the white population, but the northeastern and northwestern pattern of the highest rates observed for the entire United

States is not evident for the black population.

Table B. Age-specific and age-adjusted death rates for

Alzheimer’s disease for decedents 65 years of age and over:

United States, 1990

[Age-adjusted rates per 100,000 U.S. standard million population; see appendix]

Age

Age-specific

death rate1

65 years and over ................. 43.1

65–74 ....................... 10.2

75–84 ....................... 58.6

85 years and over ................. 187.8

85–94 ....................... 176.5

95 years and over ............... 319.6

Age-adjusted

death rate1

Based on 10-year age groups up

to 85 years and over .............. 29.6

Based on 10-year age groups up

to 95 years and over .............. 29.5

1Includes age not stated.

45 54 55 64 65 74 75 84 85 and over

Age

0

0.1

1.0

10.0

100.0

1,000.0

 Rate per 100,000 population

1979

1985

1988

1991

1982

Figure 2. Death rates for Alzheimer’s disease by age: United States, 1979–91

+ +

+ + + + + + + +

1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991

Year

1.0

10.0

100.0

 Rate per 100,000 U.S. standard million population

Female

Male

+

+

+

Figure 3. Age-adjusted death rates by sex for Alzheimer’s disease for persons 65 years of age and over: United States, 1979–91

5
Multiple causes of death

On a multiple-cause basis, age-adjusted death rates for

Alzheimer’s disease have also increased. In 1979 the rate for

the total population was 4.9 per 100,000 population 65 years

of age and over compared with 66.6 in 1991, approximately a

thirteenfold increase (table 5). The ratio of the multiple-cause

rate to the underlying cause rate has been stable at about 2.3

for the last 8 years.

A broader grouping of dementing

conditions

The perspective can be broadened to include additional

medical conditions that are grouped together in this report and

referred to as dementing conditions. These ICD–9 categories

include Alzheimer’s disease (ICD–9 No. 331.0), Senility (ICD–9

No. 797), Senile and presenile organic psychotic conditions

(ICD–9 No. 290), and Other cerebral degenerations (ICD–9

No. 331.1–331.9). The rationale for considering a broader

group of conditions includes the following:

+ deaths reported to be caused by Alzheimer’s disease prior

to the introduction of ICD–9 in 1979 were classified under

Senile and presenile dementia (ICDA–8 No. 290) (20)

+ it has been suggested that the increasing trend for Alzheimer’s disease may reflect increasing preference for the

term Alzheimer’s disease over terms that would be classified under other titles in ICD–9 (16)

+ it is possible that some Alzheimer’s deaths end up being

classified under other titles even with a separate title

introduced in ICD–9

For all of these conditions combined, death rates also

increased between 1979 and 1991 (table 6). In 1979, the rate

was 13.3 per 100,000 population 65 years and over compared

with 52.7 in 1991, a fourfold increase. However, trends differ

for specific dementing conditions resulting in a smaller increase

over the time period than was observed for Alzheimer’s

disease by itself.

Like Alzheimer’s disease, rates for Senile and presenile

organic psychotic conditions increased throughout the period,

from 4.1 to 19.2 per 100,000 population 65 years and over. In

contrast, for Senility and Other cerebral degenerations, the

rates decreased from 2.9 to 2.3 and 3.8 to 2.0 for the two

causes, respectively. Because Senility is considered an illdefined condition, a death certificate would normally be

queried if this is reported as the underlying cause. Because of

the query process, the certifying physician may provide more

detailed information on the medical conditions resulting in

death. Therefore, decreases in the death rate for this cause may

reflect better medical certification practices over time rather

than real reductions in the incidence of this condition as a

reported cause of death.

+

+

+

+

+

+

+

+ + + +

1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991

0.1

1.0

10.0

100.0

 Rate per 100,000 U.S. standard million population

White

+ +

All races

Black

Figure 4. Age-adjusted death rates by race for Alzheimer’s disease for persons 65 years of age and over: United States, 1979–91

6
Rate significantly higher

than United States:

Rate not significantly

different from United States:

Rate significantly lower

than United States:

Other than 10 lowest rates

Other than 10 highest rates 10 lowest rates

10 highest rates

Figure 5. Alzheimer’s disease death rates by State, 1989–91

7
Discussion

Although the number of deaths caused by Alzheimer’s

disease is much less than the numbers for heart disease and

cancer (21), many deaths are reported to be caused by

Alzheimer’s disease. Furthermore, death from Alzheimer’s

disease increased significantly from 1979 to 1988 and was

stable from 1988 to 1991. Given the number of deaths,

Alzheimer’s disease would be the 11th leading cause of death

for individuals 65 years of age and over each year from 1987

to 1991 if it were ranked according to NCHS standards (see

Technical notes). In the future, Alzheimer’s disease will be a

rankable cause. The increasing trend in the number of reported

deaths from Alzheimer’s disease may reflect improvements in

diagnosis and reporting, wider knowledge of the condition

within the medical community, and other unidentified factors

rather than substantial changes in the risk of dying from

Alzheimer’s disease.

Possible reasons for the increase in the number of reported

deaths from Alzheimer’s disease include the changing age

composition of the population, improving medical technology

for diagnosis, and expanding awareness of the condition. As

more of the population survives to very old ages, Alzheimer’s

disease has increased because the condition is more prevalent

at very old ages. In addition, as medical technology can

control other morbid and mortal conditions, Alzheimer’s disease may be observed in a population that might have died

earlier at ages when the risk for Alzheimer’s disease was

lower. In a death rate measure, changes in the age composition

of the population can be taken into account. Death rates from

Alzheimer’s disease continue to increase when adjusted to

account for changes in the age distribution of the population.

Therefore, changes in age composition may contribute to

increases in the number of deaths but do not fully explain the

increase as is clear from examining age-adjusted death rates.

The increasing trend in the number of deaths and rates

may, in part, be explained by a change toward using the term

‘‘Alzheimer’s disease’’ rather than terms that would be classified to other titles in the ICD–9. Although decreases in the use

of the term, Senility, for example, may contribute to an

increase in the number of deaths from Alzheimer’s disease, the

broader group of dementing conditions is also increasing.

Consequently, a shift in terms written on the death certificate

does not completely account for the increase. The increase

also cannot be explained by changes in the selection of

Alzheimer’s disease as the underlying cause of death by

certifying physicians, since similar increases occurred for

Alzheimer’s disease as both an underlying and as a multiple

cause of death.

Increased awareness and publicity of Alzheimer’s disease

could motivate the medical community to examine individuals

specifically for the condition or to encourage them to diagnose

the condition without appropriate diagnostic measures. The

potential contribution of either of these possible reporting

artifacts to increasing the number of deaths and rates from

Alzheimer’s disease remains unknown because death certificates do not contain any information to make this type of

estimate.

Databases with information on diagnostic methods used

and more detail on individual medical histories could shed

some light on issues relating reporting artifacts. The best

check on the quality of the data in the vital statistics data files

is the subset of records for which the death was autopsied. A

comparison was made between trends and patterns in mortality from Alzheimer’s disease between those records that

showed an autopsy was done and those records that showed no

autopsy was done. The patterns between the two sets were

similar (22) suggesting that the reasons for an increase have

nothing to do with the evidence obtained at the autopsy. For

instance, increased acceptance of Alzheimer’s disease as a

condition that contributes to death could result in general

changes in reporting practices. That is, Alzheimer’s disease

might be reported more frequently for both deaths that are and

deaths that are not autopsied if medical personnel become

more willing to consider this condition a cause of death.

Consequently, trend data on Alzheimer’s disease show an

increasing trend but the source of the increase is not as clear.

Increases in Alzheimer’s disease seems to result from improved

reporting, possibly because of several factors—including diagnostic improvements (9), increases in awareness of the condition, changes in terminology used, or changes in the acceptance

of Alzheimer’s disease as a cause of death. Changes in

terminology and medical practices have been linked to increases

in other causes of death (23,24).

8
References

1. Lampe TH. The nature of Alzheimer’s disease. In: O’Connor K

and Prothero J, eds. Alzheimer’s caregiver: Strategies for support. Seattle: University of Washington Press. 1987.

2. Lee PN. Smoking and Alzheimer’s disease: A review of the

epidemiological evidence. Neuroepidemiology 13:131–44. 1994.

3. Ebersole P, Hess P. Toward healthy aging: Human needs and

nursing response. 4th ed. St. Louis: Mosby. 1994.

4. World Health Organization. Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death,

based on the recommendations of the Ninth Revision Conference, 1975. Geneva: World Health Organization. 1977.

5. National Center for Health Statistics. Report of the workshop on

improving cause-of-death statistics. Virginia Beach: Oct 15–17.

1989.

6. Blass JP, Black RS, Nolan KA, Kurita A. Diagnosis of Alzheimer disease. 121–33. In: Becker RE, Giacobini E, eds. Alzheimer Disease: Current research in early diagnosis. New York:

Taylor and Francis. 1990.

7. Evans DA, Smith LA, Scherr PA, Albert MS, Funkenstein HH,

Hebert LE. Risk of death from Alzheimer’s disease in a

community population of older persons. Am J Epidemiol

134:403–12. 1991.

8. Jorm AF. The epidemiology of Alzheimer’s disease and related

disorders. London: Chapman and Hall. 1990.

9. Kawas CH. Early clinical diagnosis: Status of NINCDS-ARDA

criteria. In: Becker RE, Giacobini E, eds. Alzheimer’s Disease:

Current research in early diagnosis. New York: Taylor and

Francis. 1990.

10. Macera CA, Sun RK, Yeager KK, Brandes DA. Sensitivity and

specificity of death certificate diagnoses for dementing illnesses,

1988–90. J Am Geriatr Soc 40:479–81. 1992.

11. Martyn CN, Pippard EC. Usefulness of mortality data in

determining the geography and time trends of dementia. J

Epidemiol Community Health. 42:134–7. 1988.

12. Burns A, Jacoby R, Luthert P, Levy R. Cause of death in

Alzheimer’s disease. Age-Ageing 19:341–4. 1990.

13. Newens AJ, Forster DP, Kay DWK. Death certification after a

diagnosis of presenile dementia. J Epidemiol and Community

Health 47:293–7. 1993.

14. Israel RA, Rosenberg HM, Curtin LR. Analytical potential for

multiple cause-of-death data. Am J Epidemiol 124(2):161–79.

1986.

15. Kukull WA, Brenner DE, Speck CE, Nochlin D, et al. Causes of

death associated with Alzheimer’s disease: Variation by level of

cognitive impairment before death. J Am Geriatr Soc 42(7):723–6.

1994.

16. Centers for Disease Control. Morbidity and mortality weekly

report; vol 39 no 43. Washington: Public Health Service. 1990.

17. U.S. Bureau of the Census. Current population reports, special

studies, P23–178, Sixty-Five plus in America.Washington: U.S.

Government Printing Office. 1992.

18. Siegel JS. A generation of change: A profile of America’s older

population. New York: Russell Sage. 1993.

19. Rosenwaike I. The extreme aged in America: A portrait of an

expanding population. Westport: Greenwood Press. 1985.

20. World Health Organization. Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death,

based on the recommendations of the Eighth Revision Conference, 1965. Geneva: World Health Organization. 1967.

21. Kochanek KD, Hudson BL. Advance report of final mortality

statistics, 1992. Monthly vital statistics report; vol 43 no 6,

suppl. Hyattsville, Maryland: National Center for Health Statistics. 1995.

22. Hoyert DL. Increases in Alzheimer’s as a cause-of-death. Paper

presented at the annual meeting of the Gerontological Society

of America, Nov 23, New Orleans. 1993.

23. MacDorman MF, Rosenberg HM. Trends in infant mortality by

cause of death and other characteristics, 1960–88. National

Center for Health Statistics. Vital Health Stat 20(20). 1993.

24. Rosenberg HM. Cause of death as a contemporary problem.

Paper presented at the Conference on the History of Registration of Causes of Death, Nov 11–14, Bloomington. 1993.

25. Tolson GC, Barnes JM, Gay GA, Kowaleski JL. The 1989

revision of the U.S. standard certificates and reports. National

Center for Health Statistics. Vital Health Stat 4(28). 1991.

26. National Center for Health Statistics. Vital statistics of the

United States, 1990, vol II, mortality, part A. Washington:

National Center for Health Statistics. 1994.

27. Klebba AJ, Scott JH. Estimates of selected comparability ratios

based on dual coding of 1976 death certificates by the Eighth

and Ninth Revisions of the International Classification of Diseases. Monthly vital statistics report; vol 28 no 11, suppl.

Hyattsville, Maryland: Public Health Service. 1980.

28. Klebba AJ, Dolman AB. Comparability of mortality statistics

for the Seventh and Eighth Revisions of the International

Classification of Diseases, United States. National Center for

Health Statistics. Vital Health Stat 2(66). 1975.

29. National Center for Health Statistics. Comparability of mortality statistics for the Sixth and Seventh Revisions, United States,

1958. Vital statistics—Special reports; vol 51 no 4. Washington:

Public Health Service. 1965.

30. National Center for Health Statistics. Vital statistics, instructions for classifying the underlying cause of death. NCHS

instruction manual; part 2a. Hyattsville, Maryland: Public Health

Service. Published annually.

31. National Center for Health Statistics. Vital statistics, instructions for classifying multiple causes of death. NCHS instruction

9
manual; part 2b. Hyattsville, Maryland: Public Health Service.

Published annually.

32. National Center for Health Statistics. Vital statistics, nonindexed terms, standard abbreviations, and State geographic codes

used in mortality data classification. NCHS instruction manual;

part 2e. Hyattsville, Maryland: Public Health Service. Published

annually.

33. National Center for Health Statistics. Vital statistics, ICD-9

ACME decision tables for classifying underlying causes of

death. NCHS instruction manual; part 2c. Hyattsville, Maryland: Public Health Service. Published annually.

34. National Center for Health Statistics. Vital statistics, data entry

instructions for the mortality medical indexing, classification,

and retrieval system (MICAR). NCHS instruction manual; part

2g. Hyattsville, Maryland: Public Health Service. Published

annually.

35. National Center for Health Statistics. Vital statistics, dictionary

of valid terms for the mortality medical indexing, classification,

and retrieval system (MICAR). NCHS instruction manual; part

2h. Hyattsville, Maryland: Public Health Service. Published

annually.

36. U.S. Bureau of the Census. U.S. Population estimates, by age,

sex, race, and Hispanic origin: 1980–91. Current Population

Reports, P25–1095. Washington: U.S. Government Printing

Office. 1993.

37. U.S. Bureau of the Census. Unpublished estimates for 1991, by

State; consistent with U.S. Department of Commerce Press

Release CB92–93.

38. World Health Organization: International statistical classification of diseases and related health problems. Tenth revision.

Geneva: World Health Organization. 1992.

39. Feinleib M, Zarate AO, eds. Reconsidering age adjustment

procedures: Workshop proceedings. National Center for Health

Statistics. Vital Health Stat 4(29). 1992.

40. Grove RD, Hetzel AM. Vital statistics rates in the United States,

1940–60. National Center for Health Statistics. Washington:

Public Health Service. 1968.

41. Chiang CL. Standard error of the age-adjusted death rate. Vital

statistics-Special reports. 47(9). National Office of Vital Statistics. Washington: Public Health Service. 1961.

42. Seal HL. Mortality data and the binomial probability law.

Skand. Actuar 33:188–216. 1949.

43. Haenszel W, Loveland DB, Sirken MG. Lung cancer mortality

as related to residence and smoking histories. I. White males.

JNCI 28: 947–1001. 1962.

10
List of detailed tables

1. Deaths for Alzheimer’s disease by race, sex, and age:

United States, 1979–91 . . . . . . . . . . . . . . . . . . . . . . . . . . 12

2. Age-adjusted death rates for Alzheimer’s disease by race,

sex, and age: United States, 1979–91 . . . . . . . . . . . . . . . . 13

3. Age-specific death rates for Alzheimer’s disease by race,

sex, and year: United States, 1979–91 . . . . . . . . . . . . . . . 14

4. Death rates and age-adjusted death rates for Alzheimer’s

disease by State: United States, 1989–91 . . . . . . . . . . . . . 17

5. Age-adjusted multiple cause death rates for Alzheimer’s

disease; and ratio of multiple cause rates to underlying

cause rates by race and age: United States, 1979–91 ..... 18

6. Deaths and age-adjusted death rates for Alzheimer’s disease

and selected dementing conditions among the elderly: United

States, 1979–91 ................................ 19

11
Table 1. Deaths for Alzheimer’s disease by race, sex, and age: United States, 1979–91

[Alzheimer’s disease deaths are those assigned to ICD–9 category number 331.0]

Year and age

All races White Black

Both sexes Male Female Both sexes Male Female Both sexes Male Female

All ages1

1991 .................... 14,112 5,070 9,042 13,401 4,787 8,614 660 265 395

1990 .................... 13,744 4,992 8,752 13,020 4,675 8,345 662 281 381

1989 .................... 13,110 4,970 8,140 12,443 4,692 7,751 618 259 359

1988 .................... 12,281 4,732 7,549 11,730 4,515 7,215 499 193 306

1987 .................... 11,311 4,545 6,766 10,801 4,329 6,472 463 193 270

1986 .................... 9,426 3,862 5,564 9,037 3,708 5,329 347 130 217

1985 .................... 8,258 3,523 4,735 7,917 3,383 4,534 310 121 189

1984 .................... 6,250 2,803 3,447 6,032 2,712 3,320 197 81 116

1983 .................... 4,434 2,021 2,413 4,256 1,935 2,321 156 74 82

1982 .................... 2,627 1,208 1,419 2,533 1,166 1,367 87 37 50

1981 .................... 1,757 831 926 1,691 797 894 61 30 31

1980 .................... 1,314 653 661 1,258 619 639 53 31 22

1979 . . . . . . . . . . . . . . . . . . . . 857 429 428 818 408 410 33 18 15

65 years and over1

1991 .................... 13,768 4,913 8,855 13,089 4,643 8,446 630 253 377

1990 .................... 13,391 4,822 8,569 12,693 4,518 8,175 639 270 369

1989 .................... 12,734 4,783 7,951 12,105 4,521 7,584 585 244 341

1988 .................... 11,842 4,518 7,324 11,322 4,309 7,013 470 185 285

1987 .................... 10,877 4,328 6,549 10,401 4,132 6,269 438 177 261

1986 .................... 8,984 3,650 5,334 8,631 3,513 5,118 318 117 201

1985 .................... 7,819 3,323 4,496 7,513 3,202 4,311 277 104 173

1984 .................... 5,846 2,615 3,231 5,649 2,533 3,116 177 72 105

1983 .................... 4,039 1,842 2,197 3,882 1,764 2,118 136 66 70

1982 .................... 2,261 1,029 1,232 2,175 993 1,182 79 31 48

1981 .................... 1,473 685 788 1,420 659 761 49 22 27

1980 .................... 1,037 526 511 996 500 496 39 24 15

1979 . . . . . . . . . . . . . . . . . . . . 653 329 324 629 315 314 22 12 10

1Includes age not stated.

12
Table 2. Age-adjusted death rates for Alzheimer’s disease by race, sex, and age: United States, 1979–91

[Alzheimer’s disease deaths are those assigned to ICD–9 category number 331.0. Age-adjusted rates per 100,000 U.S. standard million population; see appendix]

Year and age

All races White Black

Both sexes Male Female Both sexes Male Female Both sexes Male Female

All ages1

1991 . . . . . . . . . . . . . . . . . . . . 2.1 2.2 2.1 2.2 2.3 2.2 1.4 1.6 1.3

1990 . . . . . . . . . . . . . . . . . . . . 2.2 2.3 2.1 2.3 2.4 2.2 1.4 1.8 1.2

1989 . . . . . . . . . . . . . . . . . . . . 2.1 2.3 2.0 2.2 2.4 2.1 1.4 1.7 1.2

1988 . . . . . . . . . . . . . . . . . . . . 2.1 2.3 2.0 2.2 2.4 2.1 1.2 1.2 1.1

1987 . . . . . . . . . . . . . . . . . . . . 2.0 2.3 1.8 2.1 2.4 1.9 1.1 1.3 1.0

1986 . . . . . . . . . . . . . . . . . . . . 1.8 2.0 1.6 1.9 2.1 1.7 0.9 0.9 0.9

1985 . . . . . . . . . . . . . . . . . . . . 1.6 1.9 1.5 1.7 2.0 1.5 0.8 0.9 0.8

1984 . . . . . . . . . . . . . . . . . . . . 1.3 1.6 1.1 1.4 1.7 1.2 0.5 0.6 0.5

1983 . . . . . . . . . . . . . . . . . . . . 1.0 1.2 0.9 1.1 1.3 0.9 0.4 0.5 0.4

1982 . . . . . . . . . . . . . . . . . . . . 0.6 0.7 0.6 0.7 0.8 0.6 0.3 0.3 0.2

1981 . . . . . . . . . . . . . . . . . . . . 0.5 0.5 0.4 0.5 0.6 0.4 0.2 0.2 0.2

1980 . . . . . . . . . . . . . . . . . . . . 0.4 0.4 0.3 0.4 0.5 0.3 0.2 0.3 0.1

1979 . . . . . . . . . . . . . . . . . . . . 0.2 0.3 0.2 0.3 0.3 0.2 0.1 * *

65 years and over1

1991 .................... 29.3 30.8 28.1 30.6 32.2 29.5 18.5 21.7 16.5

1990 .................... 29.6 31.6 28.3 30.9 32.6 29.7 19.1 24.1 16.1

1989 .................... 29.2 32.1 27.3 30.5 33.5 28.6 18.4 22.3 16.0

1988 .................... 28.5 31.3 26.7 30.0 33.0 28.1 15.3 17.1 14.3

1987 .................... 27.1 31.0 24.6 28.5 32.7 25.9 14.8 16.7 13.6

1986 .................... 23.7 27.2 21.5 25.0 28.9 22.6 11.5 11.9 11.1

1985 .................... 21.6 25.7 18.9 22.8 27.3 19.9 10.3 10.7 9.9

1984 .................... 17.0 20.9 14.6 18.1 22.3 15.4 6.8 7.3 6.4

1983 .................... 12.5 15.3 10.7 13.2 16.2 11.3 5.3 6.9 4.3

1982 . . . . . . . . . . . . . . . . . . . . 7.4 8.9 6.3 7.9 9.5 6.8 3.2 3.3 3.2

1981 . . . . . . . . . . . . . . . . . . . . 5.0 6.2 4.1 5.4 6.5 4.5 2.0 2.5 1.7

1980 . . . . . . . . . . . . . . . . . . . . 3.8 4.9 3.0 4.0 5.2 3.2 1.7 2.6 *

1979 . . . . . . . . . . . . . . . . . . . . 2.5 3.1 2.0 2.6 3.3 2.2 1.0 * *

1Includes age not stated.

13
Table 3. Age-specific death rates for Alzheimer’s disease by race, sex, and year: United States, 1979–91

[Alzheimer’s disease deaths are those assigned to ICD–9 category number 331.0. Age-specific rates per 100,000 population in specified group; age-adjusted rates per

100,000 U.S. standard million population; see appendix]

Race, sex, and age

65 years and over

All

ages

Under

1 year

1–4

years

5–14

years

15–24

years

25–34

years

35–44

years

45–54

years

55–64

years Total

65–74

years

75–84

years

85 years

and over

All races

Both sexes:

1991 . . . . . . . . . . . . . . 5.6 * * * * * * 0.1 1.5 43.4 9.9 57.4 190.7

1990 . . . . . . . . . . . . . . 5.5 * * * * * * 0.1 1.5 43.1 10.2 58.6 187.8

1989 . . . . . . . . . . . . . . 5.3 * * * * * * 0.1 1.7 41.5 10.6 58.6 170.4

1988 . . . . . . . . . . . . . . 5.0 * * * * * * 0.1 1.9 39.3 11.3 57.2 151.2

1987 . . . . . . . . . . . . . . 4.7 * * * * * * 0.1 1.9 36.7 11.1 54.7 135.4

1986 . . . . . . . . . . . . . . 3.9 * * * * * * 0.1 1.9 31.0 10.9 46.9 103.7

1985 . . . . . . . . . . . . . . 3.5 * * * * * * 0.2 1.8 27.5 10.5 42.2 86.1

1984 . . . . . . . . . . . . . . 2.7 * * * * * * 0.1 1.6 21.0 9.3 31.8 59.8

1983 . . . . . . . . . . . . . . 1.9 * * * * * * 0.1 1.6 14.8 7.8 21.4 37.8

1982 . . . . . . . . . . . . . . 1.1 * * * * * * 0.1 1.5 8.4 5.1 12.2 17.9

1981 . . . . . . . . . . . . . . 0.8 * * * * * * 0.2 1.1 5.6 3.8 7.2 12.2

1980 . . . . . . . . . . . . . . 0.6 * * * * * * 0.1 1.1 4.1 3.2 4.8 7.6

1979 . . . . . . . . . . . . . . 0.4 * * * * * * 0.1 0.8 2.6 2.1 3.0 4.3

Male:

1991 . . . . . . . . . . . . . . 4.1 * * * * * * * 1.5 38.4 10.8 62.2 184.6

1990 . . . . . . . . . . . . . . 4.1 * * * * * * 0.2 1.5 38.6 11.6 63.3 182.6

1989 . . . . . . . . . . . . . . 4.1 * * * * * * * 1.7 38.8 11.8 67.5 165.9

1988 . . . . . . . . . . . . . . 4.0 * * * * * * * 1.9 37.3 12.2 65.5 152.5

1987 . . . . . . . . . . . . . . 3.9 * * * * * * * 1.9 36.4 12.9 64.4 138.6

1986 . . . . . . . . . . . . . . 3.3 * * * * * * * 1.9 31.4 12.6 55.1 108.5

1985 . . . . . . . . . . . . . . 3.0 * * * * * * * 1.8 29.2 12.8 50.8 93.7

1984 . . . . . . . . . . . . . . 2.4 * * * * * * * 1.6 23.4 11.2 40.2 69.5

1983 . . . . . . . . . . . . . . 1.8 * * * * * * * 1.6 16.8 9.2 28.0 42.8

1982 . . . . . . . . . . . . . . 1.1 * * * * * * * 1.6 9.6 5.9 15.7 18.8

1981 . . . . . . . . . . . . . . 0.7 * * * * * * * 1.2 6.5 4.7 9.3 12.7

1980 . . . . . . . . . . . . . . 0.6 * * * * * * * 1.1 5.1 4.3 5.9 9.4

1979 . . . . . . . . . . . . . . 0.4 * * * * * * * 0.8 3.2 2.6 3.8 7.1

Female:

1991 . . . . . . . . . . . . . . 7.0 * * * * * * * 1.5 46.7 9.2 54.6 193.1

1990 . . . . . . . . . . . . . . 6.9 * * * * * * * 1.5 46.1 9.2 55.8 189.9

1989 . . . . . . . . . . . . . . 6.4 * * * * * * * 1.6 43.3 9.7 53.4 172.2

1988 . . . . . . . . . . . . . . 6.0 * * * * * * * 1.8 40.6 10.5 52.2 150.8

1987 . . . . . . . . . . . . . . 5.4 * * * * * * * 1.8 36.9 9.7 48.9 134.1

1986 . . . . . . . . . . . . . . 4.5 * * * * * * * 1.8 30.7 9.5 42.1 101.8

1985 . . . . . . . . . . . . . . 3.9 * * * * * * * 1.8 26.4 8.7 37.2 83.1

1984 . . . . . . . . . . . . . . 2.8 * * * * * * * 1.7 19.3 7.8 26.9 55.8

1983 . . . . . . . . . . . . . . 2.0 * * * * * * * 1.7 13.4 6.8 17.5 35.7

1982 . . . . . . . . . . . . . . 1.2 * * * * * * * 1.4 7.8 4.3 10.1 17.6

1981 . . . . . . . . . . . . . . 0.8 * * * * * * * 1.0 4.9 3.0 6.0 12.0

1980 . . . . . . . . . . . . . . 0.6 * * * * * * * 1.1 3.4 2.3 4.1 6.8

1979 . . . . . . . . . . . . . . 0.4 * * * * * * * 0.8 2.2 1.8 2.6 3.0

White

Both sexes:

1991 . . . . . . . . . . . . . . 6.4 * * * * * * 0.1 1.5 45.8 10.4 59.9 200.4

1990 . . . . . . . . . . . . . . 6.2 * * * * * * 0.2 1.5 45.3 10.7 61.0 196.4

1989 . . . . . . . . . . . . . . 6.0 * * * * * * * 1.7 43.7 11.1 61.1 179.2

1988 . . . . . . . . . . . . . . 5.7 * * * * * * 0.2 2.0 41.6 11.8 60.3 159.1

1987 . . . . . . . . . . . . . . 5.3 * * * * * * 0.1 1.9 38.9 11.6 57.5 142.6

1986 . . . . . . . . . . . . . . 4.4 * * * * * * 0.1 1.9 32.9 11.4 49.6 109.8

1985 . . . . . . . . . . . . . . 3.9 * * * * * * 0.2 1.9 29.2 11.0 44.9 90.8

1984 . . . . . . . . . . . . . . 3.0 * * * * * * 0.1 1.7 22.4 9.9 33.8 63.5

1983 . . . . . . . . . . . . . . 2.1 * * * * * * 0.1 1.7 15.7 8.3 22.6 39.5

1982 . . . . . . . . . . . . . . 1.3 * * * * * * 0.2 1.6 9.0 5.5 12.8 19.0

1981 . . . . . . . . . . . . . . 0.9 * * * * * * 0.2 1.2 6.0 4.1 7.7 12.8

1980 . . . . . . . . . . . . . . 0.6 * * * * * * 0.1 1.2 4.3 3.4 5.1 7.9

1979 . . . . . . . . . . . . . . 0.4 * * * * * * 0.1 0.8 2.8 2.3 3.2 4.4

14
Table 3. Age-specific death rates for Alzheimer’s disease by race, sex, and year: United States, 1979–91—Con.

[Alzheimer’s disease deaths are those assigned to ICD–9 category number 331.0. Age-specific rates per 100,000 population in specified group; age-adjusted rates per

100,000 U.S. standard million population; see appendix]

Race, sex, and age

65 years and over

All

ages

Under

1 year

1–4

years

5–14

years

15–24

years

25–34

years

35–44

years

45–54

years

55–64

years Total

65–74

years

75–84

years

85 years

and over

White–Con.

Male:

1991 . . . . . . . . . . . . . . 4.6 * * * * * * * 1.5 40.2 11.3 64.5 194.9

1990 . . . . . . . . . . . . . . 4.6 * * * * * * 0.2 1.5 40.0 11.9 64.9 192.5

1989 . . . . . . . . . . . . . . 4.6 * * * * * * * 1.8 40.6 12.2 70.1 176.4

1988 . . . . . . . . . . . . . . 4.5 * * * * * * * 2.0 39.4 12.7 69.1 162.2

1987 . . . . . . . . . . . . . . 4.3 * * * * * * * 2.0 38.4 13.5 68.0 146.7

1986 . . . . . . . . . . . . . . 3.7 * * * * * * * 2.0 33.4 13.2 58.5 117.3

1985 . . . . . . . . . . . . . . 3.4 * * * * * * * 1.8 31.1 13.3 54.5 100.9

1984 . . . . . . . . . . . . . . 2.8 * * * * * * * 1.7 25.1 12.0 43.0 74.7

1983 . . . . . . . . . . . . . . 2.0 * * * * * * * 1.7 17.8 9.7 29.6 45.4

1982 . . . . . . . . . . . . . . 1.2 * * * * * * * 1.7 10.2 6.3 16.7 20.2

1981 . . . . . . . . . . . . . . 0.8 * * * * * * * 1.3 6.9 5.0 9.8 13.5

1980 . . . . . . . . . . . . . . 0.7 * * * * * * * 1.2 5.4 4.6 6.2 9.5

1979 . . . . . . . . . . . . . . 0.4 * * * * * * * 0.9 3.4 2.8 4.1 7.1

Female:

1991 . . . . . . . . . . . . . . 8.0 * * * * * * * 1.5 49.6 9.7 57.1 202.5

1990 . . . . . . . . . . . . . . 7.8 * * * * * * * 1.6 48.8 9.7 58.6 197.9

1989 . . . . . . . . . . . . . . 7.3 * * * * * * * 1.6 45.9 10.3 55.7 180.4

1988 . . . . . . . . . . . . . . 6.8 * * * * * * * 1.9 43.1 11.0 55.2 157.9

1987 . . . . . . . . . . . . . . 6.2 * * * * * * * 1.9 39.2 10.2 51.3 140.9

1986 . . . . . . . . . . . . . . 5.1 * * * * * * * 1.9 32.6 10.0 44.4 106.9

1985 . . . . . . . . . . . . . . 4.4 * * * * * * * 1.9 28.0 9.1 39.3 86.8

1984 . . . . . . . . . . . . . . 3.2 * * * * * * * 1.8 20.6 8.3 28.4 59.1

1983 . . . . . . . . . . . . . . 2.3 * * * * * * * 1.8 14.3 7.3 18.6 37.1

1982 . . . . . . . . . . . . . . 1.3 * * * * * * * 1.6 8.1 4.8 10.5 18.5

1981 . . . . . . . . . . . . . . 0.9 * * * * * * * 1.1 5.4 3.4 6.4 12.5

1980 . . . . . . . . . . . . . . 0.6 * * * * * * * 1.2 3.6 2.5 4.4 7.2

1979 . . . . . . . . . . . . . . 0.4 * * * * * * * 0.8 2.3 1.9 2.7 3.3

Black

Both sexes:

1991 . . . . . . . . . . . . . . 2.1 * * * * * * * 1.4 24.7 7.0 37.9 96.6

1990 . . . . . . . . . . . . . . 2.2 * * * * * * * 1.1 25.6 7.1 39.3 102.9

1989 . . . . . . . . . . . . . . 2.1 * * * * * * * 1.6 23.7 7.4 38.9 81.4

1988 . . . . . . . . . . . . . . 1.7 * * * * * * * 1.4 19.4 7.6 28.5 68.2

1987 . . . . . . . . . . . . . . 1.6 * * * * * * * 1.2 18.4 7.0 29.6 58.7

1986 . . . . . . . . . . . . . . 1.2 * * * * * * * 1.4 13.6 6.6 21.2 36.8

1985 . . . . . . . . . . . . . . 1.1 * * * * * * * 1.5 12.0 6.7 15.8 37.4

1984 . . . . . . . . . . . . . . 0.7 * * * * * * * * 7.8 3.9 12.7 19.5

1983 . . . . . . . . . . . . . . 0.6 * * * * * * * * 6.1 3.4 8.8 17.4

1982 . . . . . . . . . . . . . . 0.3 * * * * * * * * 3.6 2.0 6.2 *

1981 . . . . . . . . . . . . . . 0.2 * * * * * * * * 2.3 1.5 * *

1980 . . . . . . . . . . . . . . 0.2 * * * * * * * * 1.9 * * *

1979 . . . . . . . . . . . . . . 0.1 * * * * * * * * 1.1 * * *

Male:

1991 . . . . . . . . . . . . . . 1.8 * * * * * * * * 25.8 8.6 46.1 100.0

1990 . . . . . . . . . . . . . . 1.9 * * * * * * * * 28.2 9.5 53.8 95.1

1989 . . . . . . . . . . . . . . 1.8 * * * * * * * * 25.7 9.4 49.8 75.8

1988 . . . . . . . . . . . . . . 1.4 * * * * * * * * 19.7 8.0 35.1 64.6

1987 . . . . . . . . . . . . . . 1.4 * * * * * * * * 19.1 8.2 33.3 60.9

1986 . . . . . . . . . . . . . . 0.9 * * * * * * * * 12.8 7.3 23.3 *

1985 . . . . . . . . . . . . . . 0.9 * * * * * * * * 11.5 7.7 16.3 *

1984 . . . . . . . . . . . . . . 0.6 * * * * * * * * 8.1 4.3 13.1 *

1983 . . . . . . . . . . . . . . 0.6 * * * * * * * * 7.4 4.0 13.8 *

1982 . . . . . . . . . . . . . . 0.3 * * * * * * * * 3.5 * * *

1981 . . . . . . . . . . . . . . 0.2 * * * * * * * * 2.5 * * *

1980 . . . . . . . . . . . . . . 0.2 * * * * * * * * 2.8 * * *

1979 .............. * * * * * * * * * * * * *

15
Table 3. Age-specific death rates for Alzheimer’s disease by race, sex, and year: United States, 1979–91—Con.

[Alzheimer’s disease deaths are those assigned to ICD–9 category number 331.0. Age-specific rates per 100,000 population in specified group; age-adjusted rates per

100,000 U.S. standard million population; see appendix]

Race, sex, and age

65 years and over

All

ages

Under

1 year

1–4

years

5–14

years

15–24

years

25–34

years

35–44

years

45–54

years

55–64

years Total

65–74

years

75–84

years

85 years

and over

Black–Con.

Female:

1991 . . . . . . . . . . . . . . 2.4 * * * **** * 24.0 6.0 33.3 95.1

1990 . . . . . . . . . . . . . . 2.4 * * * **** * 24.0 5.5 31.1 106.2

1989 . . . . . . . . . . . . . . 2.3 * * * **** * 22.5 6.1 32.7 84.3

1988 . . . . . . . . . . . . . . 2.0 * * * * * * * 1.8 19.2 7.4 24.7 69.8

1987 . . . . . . . . . . . . . . 1.7 * * * **** * 17.9 6.1 27.4 57.6

1986 . . . . . . . . . . . . . . 1.4 * * * **** * 14.1 6.0 20.0 44.2

1985 . . . . . . . . . . . . . . 1.3 * * * **** * 12.4 6.0 15.5 42.1

1984 . . . . . . . . . . . . . . 0.8 * * * * * * * * 7.7 3.6 12.5 17.8

1983 . . . . . . . . . . . . . . 0.6 * * * * * * * * 5.2 2.9 5.7 18.5

1982 . . . . . . . . . . . . . . 0.3 * * * * * * * * 3.7 * 6.4 *

1981 . . . . . . . . . . . . . . 0.2 * * * * * * * * 2.1 * * *

1980 . . . . . . . . . . . . . . 0.2 * * * * * * * * ** * *

1979 .............. * * * * * * * * * ** * *

16
Table 4. Death rates and age-adjusted death rates for Alzheimer’s disease by State: United States, 1989–91

[Rates per 100,000 population in specified group and area. Age-adjusted rates per 100,000 U.S. standard million population; see appendix. Decedents with not stated

age are excluded. Data by place of residence exclude deaths occurring in the United States to nonresidents]

State

Death rate Age-adjusted death rate

All ages Age 65 and over All ages Age 65 and over

All races White Black All races White Black All races White Black All races White Black

Alabama . . . . . . . . . . . . . 6.3 7.6 2.9 47.4 53.1 26.3 2.6 2.9 1.3 34.8 39.5 18.0

Alaska .............. * * * * * * * * * * * *

Arizona . . . . . . . . . . . . . 5.6 6.1 * 41.6 42.9 * 2.2 2.3 * 30.6 31.5 *

Arkansas . . . . . . . . . . . . 5.8 6.7 * 38.1 41.5 * 2.0 2.3 * 28.4 31.2 *

California . . . . . . . . . . . . 3.9 4.5 2.0 35.9 38.8 26.7 1.9 2.0 1.7 25.1 26.7 21.6

Colorado . . . . . . . . . . . . 5.3 5.6 * 53.1 53.7 * 2.5 2.6 * 36.6 36.8 *

Connecticut . . . . . . . . . . . 6.0 6.6 * 43.0 44.0 * 2.1 2.1 * 28.6 29.0 *

Delaware . . . . . . . . . . . . 4.7 5.3 * 38.4 40.1 * 2.1 2.1 * 29.7 30.7 *

District of Columbia . . . . . . 4.1 7.3 2.7 32.4 57.0 21.3 1.5 2.0 1.2 21.7 29.4 16.9

Florida . . . . . . . . . . . . . . 6.7 7.7 1.8 36.1 37.0 24.1 1.8 1.9 1.4 25.1 25.5 18.4

Georgia . . . . . . . . . . . . . 5.7 7.1 2.1 55.0 62.7 25.9 3.0 3.4 1.5 40.2 46.0 19.5

Hawaii . . . . . . . . . . . . . . 3.6 6.2 * 31.9 68.5 * 1.6 3.4 * 22.9 49.3 *

Idaho . . . . . . . . . . . . . . . 7.1 7.3 * 57.9 58.3 * 2.9 2.9 * 39.0 39.1 *

Illinois . . . . . . . . . . . . . . 5.8 6.5 2.9 45.0 46.4 37.3 2.2 2.2 1.9 30.8 31.5 28.2

Indiana . . . . . . . . . . . . . 6.0 6.3 2.3 46.2 47.6 23.0 2.5 2.5 1.3 32.6 33.6 15.4

Iowa . . . . . . . . . . . . . . . 9.7 9.9 * 62.3 62.5 * 2.5 2.5 * 35.3 35.3 *

Kansas . . . . . . . . . . . . . 6.9 7.2 * 49.0 49.2 * 2.2 2.2 * 30.8 30.8 *

Kentucky . . . . . . . . . . . . 6.3 6.6 * 48.5 50.3 * 2.5 2.5 * 34.1 35.4 *

Louisiana . . . . . . . . . . . . 4.5 5.8 2.0 39.2 45.1 20.9 2.2 2.6 1.3 29.3 33.7 16.3

Maine .............. 10.1 10.2 * 74.5 74.4 * 3.5 3.5 * 47.2 47.3 *

Maryland . . . . . . . . . . . . 5.2 6.5 1.8 46.7 51.0 26.4 2.4 2.6 1.4 33.5 35.9 20.8

Massachusetts . . . . . . . . . 8.2 8.8 3.5 59.3 59.7 57.6 2.7 2.7 3.0 36.9 36.9 42.8

Michigan . . . . . . . . . . . . 3.9 4.4 1.6 31.9 33.7 17.6 1.7 1.8 1.1 23.3 24.4 14.7

Minnesota . . . . . . . . . . . . 7.9 8.3 * 62.5 63.3 * 2.6 2.6 * 36.4 36.8 *

Mississippi . . . . . . . . . . . 4.5 5.7 2.5 34.2 38.4 24.2 2.0 2.2 1.5 25.5 28.8 18.1

Missouri . . . . . . . . . . . . . 5.7 6.2 2.2 39.5 41.0 20.0 1.8 1.9 1.2 25.7 26.6 11.7

Montana ............. 12.0 12.9 * 88.5 90.6 * 4.1 4.1 * 55.6 56.9 *

Nebraska . . . . . . . . . . . . 7.9 8.2 * 55.4 55.4 * 2.3 2.4 * 32.9 33.1 *

Nevada . . . . . . . . . . . . . 3.7 4.0 * 33.0 33.9 * 2.2 2.2 * 29.0 29.6 *

New Hampshire . . . . . . . . 8.7 8.8 * 75.8 76.2 * 3.3 3.3 * 46.7 46.7 *

New Jersey . . . . . . . . . . . 4.0 4.7 1.2 29.2 30.5 16.0 1.5 1.7 0.8 21.2 21.9 12.6

New Mexico . . . . . . . . . . 5.4 5.9 * 50.0 51.5 * 2.6 2.7 * 35.9 37.2 *

New York . . . . . . . . . . . . 2.4 2.9 0.6 17.6 19.0 7.3 0.9 0.9 0.4 12.1 12.9 5.8

North Carolina . . . . . . . . . 6.3 7.5 2.7 50.8 55.8 27.5 2.8 2.9 1.6 37.0 40.6 20.5

North Dakota . . . . . . . . . . 6.0 6.3 * 40.6 40.7 * 1.8 1.9 * 23.8 23.9 *

Ohio . . . . . . . . . . . . . . . 6.4 6.9 2.8 48.2 49.9 29.5 2.4 2.4 1.6 32.8 33.7 23.0

Oklahoma . . . . . . . . . . . . 5.3 6.1 * 38.1 40.9 * 1.9 2.0 * 26.0 27.7 *

Oregon ............. 10.1 10.6 * 72.8 73.8 * 3.3 3.4 * 47.5 48.0 *

Pennsylvania . . . . . . . . . . 4.9 5.2 2.6 31.0 31.5 24.1 1.6 1.6 1.3 22.3 22.5 19.3

Rhode Island . . . . . . . . . . 7.6 8.1 * 50.5 51.4 * 2.3 2.3 * 31.9 32.2 *

South Carolina . . . . . . . . . 5.5 6.9 2.5 46.9 53.4 26.5 2.8 3.1 1.9 37.2 41.9 22.9

South Dakota . . . . . . . . . 5.7 6.2 * 38.8 39.4 * 1.7 1.7 * 24.7 25.1 *

Tennessee . . . . . . . . . . . 6.4 7.2 2.5 49.7 53.2 24.9 2.5 2.7 1.3 35.7 38.4 16.3

Texas . . . . . . . . . . . . . . 4.8 5.3 2.6 46.3 48.0 32.9 2.4 2.6 1.7 32.6 33.6 22.9

Utah . . . . . . . . . . . . . . . 6.6 6.9 * 73.4 74.9 * 3.8 3.9 * 51.8 52.8 *

Vermont ............. 10.0 10.1 * 83.6 83.9 * 3.6 3.6 * 50.2 50.5 *

Virginia . . . . . . . . . . . . . 5.2 6.1 2.5 47.9 52.5 27.4 2.5 2.6 1.6 35.1 37.8 22.4

Washington . . . . . . . . . . . 8.6 9.3 * 71.6 73.6 * 3.3 3.4 * 46.9 47.7 *

West Virginia . . . . . . . . . . 5.4 5.4 * 35.0 34.7 * 1.8 1.8 * 25.5 25.2 *

Wisconsin . . . . . . . . . . . . 8.2 8.7 * 60.9 61.5 * 2.7 2.7 * 37.6 37.9 *

Wyoming . . . . . . . . . . . . 7.0 7.2 * 67.1 67.5 * 3.1 3.2 * 44.8 44.9 *

17
Table 5. Age-adjusted multiple cause death rates for Alzheimer’s disease; and ratio of multiple cause rates to underlying cause rates by

race and age: United States, 1979–91

[Alzheimer’s disease deaths are those assigned to ICD–9 category number 331.0. Age-adjusted rates per 100,000 U.S. standard million population; see appendix]

Year and age

All races White Black

Multiple

cause Ratio

Multiple

cause Ratio

Multiple

cause Ratio

All ages1

1991 . . . . . . . . . . . . . . . . . . . . . . . . . 4.8 2.29 5.0 2.27 3.6 2.57

1990 . . . . . . . . . . . . . . . . . . . . . . . . . 4.9 2.23 5.1 2.22 3.4 2.43

1989 . . . . . . . . . . . . . . . . . . . . . . . . . 4.8 2.29 5.0 2.27 3.3 2.36

1988 . . . . . . . . . . . . . . . . . . . . . . . . . 4.9 2.33 5.1 2.32 3.1 2.57

1987 . . . . . . . . . . . . . . . . . . . . . . . . . 4.5 2.25 4.7 2.24 2.7 2.45

1986 . . . . . . . . . . . . . . . . . . . . . . . . . 4.0 2.23 4.2 2.21 2.2 2.46

1985 . . . . . . . . . . . . . . . . . . . . . . . . . 3.6 2.25 3.8 2.24 1.8 2.29

1984 . . . . . . . . . . . . . . . . . . . . . . . . . 2.9 2.24 3.1 2.20 1.3 2.66

1983 . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 2.12 2.2 2.00 0.9 2.35

1982 . . . . . . . . . . . . . . . . . . . . . . . . . 1.3 2.18 1.4 1.99 0.6 2.00

1981 . . . . . . . . . . . . . . . . . . . . . . . . . 0.9 1.82 1.0 1.92 0.5 2.45

1980 . . . . . . . . . . . . . . . . . . . . . . . . . 0.7 1.73 0.7 1.83 0.3 1.45

1979 . . . . . . . . . . . . . . . . . . . . . . . . . 0.5 2.40 0.5 1.67 0.2 2.40

65 years and over

1991 ......................... 66.6 2.27 69.0 2.25 48.4 2.62

1990 ......................... 67.6 2.28 70.3 2.28 46.3 2.42

1989 ......................... 66.8 2.29 69.5 2.28 44.2 2.40

1988 ......................... 67.1 2.35 70.1 2.34 41.2 2.69

1987 ......................... 61.9 2.28 64.8 2.27 35.5 2.40

1986 ......................... 55.0 2.32 57.8 2.31 29.2 2.54

1985 ......................... 49.0 2.27 51.8 2.27 22.8 2.21

1984 ......................... 38.4 2.26 40.7 2.25 17.0 2.50

1983 ......................... 27.2 2.18 28.8 2.18 11.7 2.21

1982 ......................... 15.8 2.14 16.7 2.12 7.5 2.34

1981 ......................... 10.8 2.16 11.3 2.09 5.4 2.70

1980 . . . . . . . . . . . . . . . . . . . . . . . . . 7.5 1.97 8.0 2.00 2.8 1.64

1979 . . . . . . . . . . . . . . . . . . . . . . . . . 4.9 1.96 5.2 2.01 2.1 2.11

1Includes age not stated.

18
Table 6. Deaths and age-adjusted death rates for Alzheimer’s disease and selected dementing conditions among the elderly:

United States, 1979–91

[Alzheimer’s disease deaths are those assigned to ICD–9 category number 331.0; Other cerebral degenerations 331.1–331.9; Senile and presenile organic psychotic

conditions 290.0–290.9; Senility 797. Age-adjusted rates per 100,000 U.S. standard million population; see appendix]

Year

Alzheimer’s disease

Other cerebral

degenerations

Senile and presenile

organic psychotic

conditions Senility Total

Number Rate Number Rate Number Rate Number Rate Number Rate

1991 .................... 13,768 29.3 833 2.0 9,957 19.2 1,412 2.3 25,970 52.7

1990 .................... 13,391 29.6 863 2.1 8,750 17.4 1,303 2.2 24,307 51.3

1989 .................... 12,736 29.2 859 2.1 7,967 16.2 1,271 2.2 22,831 49.7

1988 .................... 11,842 28.5 925 2.3 6,608 13.9 1,411 2.5 20,786 47.2

1987 .................... 10,877 27.1 982 2.5 5,471 11.8 1,191 2.1 18,521 43.5

1986 .................... 8,984 23.7 946 2.6 4,296 9.5 1,286 2.4 15,512 38.2

1985 .................... 7,819 21.6 1,025 2.8 3,737 8.6 1,343 2.5 13,924 35.5

1984 .................... 5,846 17.0 1,042 2.9 3,083 7.1 1,261 2.4 11,232 29.5

1983 .................... 4,039 12.5 1,128 3.3 2,624 6.4 1,266 2.5 9,057 24.6

1982 .................... 2,261 7.4 1,101 3.4 2,208 5.6 1,178 2.5 6,748 18.9

1981 .................... 1,473 5.0 1,109 3.6 2,022 5.3 1,062 2.3 5,666 16.2

1980 .................... 1,037 3.8 1,159 3.9 1,644 4.5 1,223 2.8 5,063 15.0

1979 . . . . . . . . . . . . . . . . . . . . 653 2.5 1,094 3.8 1,435 4.1 1,229 2.9 4,411 13.3

19
Appendix

Contents

Technical notes on methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Nature and sources of data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Cause-of-death classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Multiple causes of death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Quality of reporting of cause of death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Population bases for computing rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Cause-of-death rankings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Age-adjusted rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Random variation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

State map . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Rates, proportions, and ratios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

20
Appendix

Technical notes on methods

Nature and sources of data

Data in this report are based on information from all death

certificates filed in the 50 States and the District of Columbia.

The State death certificates conform closely to the U.S.

Standard Certificate of Death, which is developed in a cooperative effort between the National Center for Health Statistics

(NCHS) and the States. The U.S. Standard Certificate of Death

was revised in 1989. For additional details see the 1989

revision of the U.S. standard certificates and reports and

Technical Appendix of Vital Statistics of the United States,Volume II, Mortality (25,26).

Mortality statistics are based on information coded by the

States and provided to NCHS through the Vital Statistics

Cooperative Program (VSCP) and from copies of the original

certificates received by NCHS from the State registration

offices. In 1991 all the States and the District of Columbia

participated in this program and submitted part or all of the

mortality data for 1991 on computer tape to NCHS. The 31

States in the VSCP that submitted precoded medical data for

all deaths on computer tapes are Alaska, Arkansas, California,

Colorado, Delaware, Florida, Georgia, Idaho, Indiana, Iowa,

Kansas, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Nebraska, New Hampshire, New

York State (excluding New York City), North Carolina, North

Dakota, Pennsylvania, South Carolina, Texas, Vermont, Virginia, Washington, Wisconsin, and Wyoming. In 1991 Delaware, Idaho, Maine, North Dakota, Vermont, and Wyoming

contracted with a private company to provide NCHS with

precoded medical data. Kansas continued to provide the

medical data for Alaska. The remaining 19 VSCP States, New

York City, and the District of Columbia submitted copies of

the original certificates from which NCHS coded the medical

data. For 1991 all States submitted precoded demographic data

for all deaths.

Data for the entire United States refer to events occurring

within the United States. Data shown for geographic areas are

by place of residence. Beginning with 1970, mortality statistics exclude deaths of nonresidents of the United States. All

data exclude fetal deaths.

Cause-of-death classification

The mortality statistics presented here were compiled in

accordance with the World Health Organization (WHO) regulations, which specify that member nations classify causes of

death by the current Manual of the International Statistical

Classification of Diseases, Injuries, and Causes of Death (4).

Causes of death for 1979–91 were classified according to the

Ninth Revision of the manual (ICD–9). For earlier years

causes of death were classified according to the revisions then

in use—1968–78, Eighth Revision; 1958–67, Seventh Revision; and 1949–57, Sixth Revision. Changes in classification

of causes of death due to these revisions may result in

discontinuities in cause-of-death trends. Consequently, causeof-death comparisons among revisions require consideration

of comparability ratios and, where available, estimates of their

standard errors. Comparability ratios between the Eighth and

Ninth Revisions, between the Seventh and Eighth Revisions,

and between the Sixth and Seventh Revisions may be found in

other NCHS reports (27–29).

Besides specifying the classification, WHO regulations

outline the form of medical certification and the procedures to

be used in coding cause of death. Cause-of-death data presented in this publication were coded by procedures outlined

in annual issues of the NCHS Instructional Manual (30–32).

Prior to data for 1968, mortality medical data were based

on manual coding of an underlying cause of death for each

certificate in accordance with WHO rules. Effective with data

year 1968, NCHS converted to computerized coding of the

underlying cause and manual coding of all causes (multiple

causes) on the death certificate. In this system, called ‘‘Automated Classification of Medical Entities’’ (ACME) (33), the

multiple cause codes serve as inputs to the computer software

that employs WHO rules to select the underlying cause. Many

States also have implemented ACME and provide multiple

cause and underlying cause data to NCHS in electronic form.

Beginning with data year 1990, another computer system

was implemented. This system, called ‘‘Mortality Medical

Indexing, Classification, and Retrieval’’ (MICAR) (34,35),

automates coding multiple causes of death. In addition, MICAR

can provide more detailed information on the conditions

reported on death certificates than is available through the

International Classification of Diseases (ICD) code structure.

In the first year of implementation, only about 5 percent

(94,372) of the Nation’s death records were coded using

MICAR with subsequent processing through ACME. For 1991

approximately 26 percent (573,416) of the Nation’s death

records were coded using MICAR. The following States

implemented MICAR on at least a portion of their 1991 data:

Arkansas, Florida, Indiana, and Washington. NCHS expanded

the use of MICAR to code at least a portion of the records

21
from the following States: Alabama, Connecticut, Hawaii,

Kentucky, Missouri, Montana, Nevada, New Mexico, Ohio,

Oregon, Rhode Island, South Dakota, Tennessee, Utah, West

Virginia, the District of Columbia, and New York City. The

remainder of the national file was processed by either NCHS

or the States using only the ACME system.

The underlying cause is defined by WHO 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. It is selected from the conditions

entered by the physician in the cause-of-death section of the

death certificate. When more than one cause or condition is

entered by the physician, the underlying cause is determined

by the sequence of conditions on the certificate, provisions of

the ICD, and associated selection rules. Generally, more

medical information is reported on death certificates than is

directly reflected in the underlying cause of death.

Multiple causes of death

Multiple cause-of-death data allow for the maximum use

of medical information reported on the death certificate depending on the certifying physician’s evaluation of the part each

condition played in the death and on the physician’s desire and

ability to report that evaluation on the death certificate.

Multiple cause data provide information on diseases that are a

factor in death whether or not they are the underlying cause of

death; on associations among diseases; and on injuries leading

to death. They also give information that will aid in the

evaluation and strengthening of the certification process, thereby

improving the quality of the medical information entered on

the death certificate. However, it is reasonable to assume that

not all conditions present at death are reported on the death

certificate and that variation in reporting depends on a number

of factors, including the nature of the conditions that brought

about death.

Quality of reporting of cause of death

Although deaths occur for which the underlying causes

are impossible to determine, the proportion of death certificates coded to the Ninth Revision Chapter XVI, Symptoms,

signs, and ill-defined conditions (ICD–9 Nos. 780–799) shows

the care and consideration given to the certification by the

medical certifier. This proportion also may be used as a rough

measure of the specificity of the medical diagnoses made by

the certifier in various areas. In 1991, 1.12 percent of all

reported deaths in the United States were assigned to Symptoms, signs, and ill-defined conditions (ICD–9 Nos. 780–799),

the same as 1990.

Population bases for computing rates

The population used for computing death rates shown in

this report (furnished by the U.S. Bureau of the Census)

represents the population residing in the specified area. Death

rates for 1991 are based on population estimates as of July 1,

1991 (36,37). The estimates are based on the 1990 census

counts. Death rates for 1981–89 shown in the report have been

recomputed, based on revised populations for those years that

are consistent with the 1990 census levels (36). They are,

therefore, not comparable with death rates published in earlier

NCHS publications for those data years.

Cause-of-death rankings

Cause-of-death rankings by NCHS are based on the List

of 72 Selected Causes of Death and HIV infection (ICD–9

Nos. *042–*044). The List was developed for use with

mortality data beginning with the 1979 data year, when ICD–9

was implemented in the United States. At that time, deaths

from Alzheimer’s disease (ICD–9 No. 331.0) were not sufficiently important numerically to be included as a separate

category in the List; instead, they were combined with other

conditions in the residual category ‘‘All other diseases.’’

However, Alzheimer’s disease will appear as a separate category when ICD–10 is implemented in the United States (38).

Since 1979, a major change has been made in the list of

rankable causes, namely, that NCHS introduced category

numbers *042–*044 for classifying and coding Human immunodeficiency virus (HIV) infection, and it was added to the list

beginning with data for 1987. The asterisk before the category

numbers indicates that these codes are not part of the Ninth

Revision of the International Classification of Diseases(ICD–9).

The group titles Major cardiovascular diseases and Symptoms, signs, and ill-defined conditions are not ranked from the

List of 72 Selected Causes. In addition, category titles that

begin with the words ‘‘Other’’ and ‘‘All Other’’ are not ranked

to determine the leading causes of death. When one of the

titles that represents a subtotal is ranked (for example, Tuberculosis), its component parts are not ranked (in this case,

Tuberculosis of respiratory system and Other tuberculosis).

Age-adjusted rates

Age-adjusted death rates are used to make comparisons of

relative mortality risks across groups and over time. However,

they should be viewed as constructs or indexes rather than as

direct or actual measures of mortality risk. Statistically, they

are weighted averages of the age-specific death rates, where

the weights represent the fixed population proportions by age

(39). The age-adjusted rates presented in this report were

computed by the direct method, that is, by applying the

age-specific death rates for a given cause of death to the U.S.

standard million population (relative age distribution of 1940

enumerated population of the United States over 65 years of

age (40)). Using the same standard population, the rates for

the total population and for each race-sex group were adjusted

separately. The age-adjusted rates were based on 10-year age

groups. In table B, an age-adjusted rate is calculated with a

modified standard. The modification involved extending the

upper age limit from 85 years and over to 95 years and over. It

is important not to compare age-adjusted death rates with

crude rates.

22
Random variation

Although the mortality data in this report (except data for

1972) are not subject to sampling error, they may be affected

by random variation in the number of deaths involved. When

the number of events is small (perhaps less than 100) and the

probability of such an event is small, considerable caution

must be observed in interpreting the data. Such infrequent

events may be assumed to follow a Poisson probability

distribution. For this distribution, a simple approximation may

be used to estimate the confidence interval, as follows:

If N is the number of registered deaths in the population

and R is the corresponding rate, the chances are 19 in 20

(approximate 95-percent confidence interval) that

1. N – 2 'N and N + 2 'N

covers the ‘‘true’’ number of events.

2. R – 2 R

'N

and R + 2 R

'N

covers the ‘‘true’’ rate.

If the rate R1 corresponding to N1 events is compared with

the rate R2 corresponding to N2 events, the difference between

the two rates may be regarded as statistically significant if it

exceeds

2 ŒR1

2

N1

+

R2

2

N2

Additional information on random variation may be found

in the Technical Appendix of Vital Statistics of the United

States, Volume II, Mortality (26).

State map

Assigning the States into the given categories on the map

was carried out in two steps: first, determining whether the

State death rate differed significantly from the corresponding

U.S. rate at the 0.05 level of significance and second, grouping

the State rates found to be significantly different from the U.S.

rate into the four categories:

+ 10 highest State rates of those significantly greater than

the U.S. rate

+ remaining State rates significantly greater than the U.S.

rate

+ 10 lowest State rates of those significantly lower than the

U.S. rate

+ remaining State rates significantly lower than the U.S. rate

Different procedures were used to determine tests of statistical

significance and confidence intervals, depending on the number of deaths.

For 50 deaths or more, the standard normal Z statistic was

used to perform the significance test:

Z = ( R ′

S – R ′US ) / 'S2

( R ′

S )+S2

( R ′

US )

where

R′S = age-adjusted rate for 1989–91 for the given

State per 100,000 U.S. standard million

population

R′US = age-adjusted rate for 1989–91 for the United

States per 100,000 U.S. standard million

population

S2 ( R′S ) = estimated variance of the age-adjusted death

rate for 1989–91 for the State

S2 ( R′US ) = estimated variance of the age-adjusted death

rate for 1989–91 for the United States

The variance of the age-adjusted death rate was computed

in terms of the variances of age-specific death rates (41) under

the assumption that the age-specific death rates are binomial

proportions (42). The 95-percent confidence limits were estimated as follows:

Lower limit = R′

S – 1.96 * S ( R′S )

and

Upper limit = R′

S + 1.96 * S( R′S )

For 1–49 deaths, the lower and upper 95-percent confidence

limits were estimated as described elsewhere (43). The difference between the State and U.S. rates was determined to be

statistically significant at the 0.05 level if the rates’ respective

95-percent confidence limits did not overlap.

Rates, proportions, and ratios

Beginning with 1989 data, an asterisk is shown in place of

a rate based on fewer than 20 deaths. These rates have a

relative standard error of 23 percent or more and are, therefore, considered statistically unreliable. For age-adjusted death

rates, this criterion is applied to the sum of the age-specific

deaths.

23
Vital and Health Statistics

series descriptions

SERIES 1. Programs and Collection Procedures—These reports

describe the data collection programs of the National Center

for Health Statistics. They include descriptions of the methods

used to collect and process the data, definitions, and other

material necessary for understanding the data.

SERIES 2. Data Evaluation and Methods Research—These reports

are studies of new statistical methods and include analytical

techniques, objective evaluations of reliability of collected

data, and contributions to statistical theory. These studies also

include experimental tests of new survey methods and

comparisons of U.S. methodology with those of other

countries.

SERIES 3. Analytical and Epidemiological Studies—These reports

present analytical or interpretive studies based on vital and

health statistics. These reports carry the analyses further than

the expository types of reports in the other series.

SERIES 4. Documents and Committee Reports—These are final

reports of major committees concerned with vital and health

statistics and documents such as recommended model vital

registration laws and revised birth and death certificates.

SERIES 5. International Vital and Health Statistics Reports—These

reports are analytical or descriptive reports that compare U.S.

vital and health statistics with those of other countries or

present other international data of relevance to the health

statistics system of the United States.

SERIES 6. Cognition and Survey Measurement—These reports are

from the National Laboratory for Collaborative Research in

Cognition and Survey Measurement. They use methods of

cognitive science to design, evaluate, and test survey

instruments.

SERIES 10. Data From the National Health Interview Survey—These

reports contain statistics on illness; unintentional injuries;

disability; use of hospital, medical, and other health services;

and a wide range of special current health topics covering

many aspects of health behaviors, health status, and health

care utilization. They are based on data collected in a

continuing national household interview survey.

SERIES 11. Data From the National Health Examination Survey, the

National Health and Nutrition Examination Surveys, and

the Hispanic Health and Nutrition Examination Survey—

Data from direct examination, testing, and measurement on

representative samples of the civilian noninstitutionalized

population provide the basis for (1) medically defined total

prevalence of specific diseases or conditions in the United

States and the distributions of the population with respect to

physical, physiological, and psychological characteristics, and

(2) analyses of trends and relationships among various

measurements and between survey periods.

SERIES 12. Data From the Institutionalized Population Surveys—

Discontinued in 1975. Reports from these surveys are

included in Series 13.

SERIES 13. Data From the National Health Care Survey—These

reports contain statistics on health resources and the public’s

use of health care resources including ambulatory, hospital,

and long-term care services based on data collected directly

from health care providers and provider records.

SERIES 14. Data on Health Resources: Manpower and Facilities—

Discontinued in 1990. Reports on the numbers, geographic

distribution, and characteristics of health resources are now

included in Series 13.

SERIES 15. Data From Special Surveys—These reports contain

statistics on health and health-related topics collected in

special surveys that are not part of the continuing data

systems of the National Center for Health Statistics.

SERIES 16. Compilations of Advance Data From Vital and Health

Statistics—Advance Data Reports provide early release of

information from the National Center for Health Statistics’

health and demographic surveys. They are compiled in the

order in which they are published. Some of these releases

may be followed by detailed reports in Series 10–13.

SERIES 20. Data on Mortality—These reports contain statistics on

mortality that are not included in regular, annual, or monthly

reports. Special analyses by cause of death, age, other

demographic variables, and geographic and trend analyses

are included.

SERIES 21. Data on Natality, Marriage, and Divorce—These reports

contain statistics on natality, marriage, and divorce that are

not included in regular, annual, or monthly reports. Special

analyses by health and demographic variables and

geographic and trend analyses are included.

SERIES 22. Data From the National Mortality and Natality Surveys—

Discontinued in 1975. Reports from these sample surveys,

based on vital records, are now published in Series 20 or 21.

SERIES 23. Data From the National Survey of Family Growth—

These reports contain statistics on factors that affect birth

rates, including contraception, infertility, cohabitation,

marriage, divorce, and remarriage; adoption; use of medical

care for family planning and infertility; and related maternal

and infant health topics. These statistics are based on

national surveys of childbearing age.

SERIES 24. Compilations of Data on Natality, Mortality, Marriage,

Divorce, and Induced Terminations of Pregnancy—

These include advance reports of births, deaths, marriages,

and divorces based on final data from the National Vital

Statistics System that were published as supplements to the

Monthly Vital Statistics Report (MVSR). These reports provide

highlights and summaries of detailed data subsequently

published in Vital Statistics of the United States. Other

supplements to the MVSR published here provide selected

findings based on final data from the National Vital Statistics

System and may be followed by detailed reports in Series 20

or 21.

For answers to questions about this report or for a list of reports published

in these series, contact:

Data Dissemination Branch

National Center for Health Statistics

Centers for Disease Control and Prevention

Public Health Service

6525 Belcrest Road, Room 1064

Hyattsville, MD 20782

(301) 436–8500

E-mail: nchsquery@nch10a.em.cdc.gov

Internet: http://www.cdc.gov/nchswww/nchshome.htm
DHHS Publication No. (PHS) 96-1856, Series 20, No. 28

5-1659 (1/96)

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