The Oldest Old: Missed Public Health Opportunities

The fastest growing segment of our population is the “oldest old,” usually defined as those 85 years and older. In 2005, this group numbered more than 5 million persons, or about 1.7% of the US population, a 40% increase since 1990. Because the oldest old carry a greater burden of disease and disability, they account for a substantial proportion of health care spending, with total annual per capita health care costs of $25691. A higher proportion of health care spending in this population is partially attributable to long-term services—most notably, nursing home care. As our population ages, substantial concerns have been expressed regarding the future ability of the health care system to provide needed care. Much of this analysis, however, has failed to consider the potential impact of public health strategies to promote health and reduce disability among the old and very old in our population. There is promising evidence that rates of disability and functional dependence among older persons have been decreasing over the last 2 decades, and continue to fall. In this issue of the Journal, Murabito et al. provide data from the Framingham study to show a significant decline in disability among community-dwelling elders from the 1970s to the 1990s. Unfortunately, there are important missed public health opportunities to improve the health and function of older populations. Vaccination for influenza is provided to less than 75% of older persons, and even fewer (60%) have ever received a pneumococcal vaccine. Promotion of healthy behaviors is also crucial. The Type II Diabetes Prevention Trial demonstrated that older persons were able to follow diet and exercise regimens, and that these behavior changes resulted in significant success in prevention of type II diabetes. However, despite the fact that physical activity is associated with important health outcomes at all ages, physical activity declines with age. Only 1 in 5 persons aged 45–64 years engages in vigorous physical activity, and this drops to about 1 in 20 for those over the age of 75 years. To achieve the potential of improved health among the oldest old, as a society we would do well to work together to (1) change public perceptions regarding the benefits of promoting health among older persons, (2) encourage elders to engage in healthier behaviors, (3) improve the practices of health providers, (4) stimulate health departments and service agencies to provide health promotion services, and (5) include public health and aging in education of public health professionals. Despite the importance of improving health behaviors across the life span to achieve optimal health and function in old age, a recent survey of schools of public health reported that fewer than 6% of students participated in a public health and aging course. Moreover, the majority of schools lack a comprehensive and integrated curriculum that adequately addresses health issues in the aging. We have the opportunity to do better for our older population and for ourselves as we age. My 93-year-old grandmother illustrated this perfectly. As she showed us around her senior housing, she pointed out the congregate meals site that she visited on Tuesdays and Thursdays. When I asked if she enjoyed the meals, she pulled herself up to her full 4 feet, 10 inches to indignantly declare that she did not go to eat, but to “help serve the old people.”