Caring for the oldest old
Authors: Domhnall MacAuley, Zoe Slote Morris
Journal: BMJ (2007)

When a 70 year old woman collects a prescription from the pharmacist, no one is surprised. But, it is for her mother. And she must rush back because her mother doesn't see very well, is a little confused, and her daughter doesn't like to leave her for too long on her own. Times change. We are all getting older and living longer so our traditional age structured model of society has had to evolve. No longer are people young, middle aged, and old, but increasingly they are also the “oldest old.” In this week's BMJ, Robine and colleagues present a “four age population model,” whereby the future long term care needs of the oldest people can be estimated.”1 These frail elderly people, whom we are likely to become, are increasingly important as consumers of health resources and a focus for future care.

The irony of longer life is an increasing burden of health. We do not know how ageing will affect health. Two competing theories exist. The first is the compression of morbidity,2 where we will live longer with fewer years of disability before we die. The second suggests an ageing population with more than one chronic condition (comorbidity).

The future is probably somewhere between the two. Coronary heart disease may have declined, but cancer, dementia, and HIV are increasing. And although coronary heart disease and cancer will still cause death, they will also become chronic managed diseases. Death from heart attack will be superseded by associated chronic conditions, such as angina and chronic health failure.3 The World Health Organization estimates a doubling of chronic disease in the over 65s by 2030.4 And a recent report commissioned by the Alzheimer's Society5 estimates that by 2025 more than a million people in the United Kingdom will have dementia, and by 2050 this figure will reach 1.7 million. This increase will create even greater demand for acute care, management of chronic disease, and social care with the inevitable increase in costs.

Caring is expensive. Informal care in the community is often unseen and unmeasured, yet the people who provide this care carry the greatest burden of all. We need to face up to the huge cost of care in both the formal and informal sector. In England it is estimated that 8.5 million people provided informal care in 2000, 3.4 million of whom cared for people over 65 years.6 This is a huge economic investment and these people do not appear in any economic balance sheet. Furthermore, as the retirement age increases and people have to work longer hours, this social capital will soon reach its limits. And with the crisis in pensions, there will be less money for people to buy additional care.

In the United Kingdom, an estimated 3.5 million more carers will be needed by 2037 to care for those aged 75 and over.7 Robine and colleagues, in their proposed four age model, introduce the concept of the oldest old support ratio. They make the assumption that the “sandwich age cohort”—the young retired—will care for the oldest people. The statistical model is attractive and is one measure of the burden of caring.

What this paper cannot tell us is if this generation will be around to help, or indeed, will be willing to help. The responsibility usually falls to families first of all, and the reality is that the carer is usually a daughter or daughter in law. But women have changing aspirations, and geographical and social mobility together with household restructuring mean that families are increasingly fragmented. Hundreds of miles often separate parents and children. If no family is available there are two alternatives: neglect or formal care.

Robine and colleagues are right to argue that policy makers need to anticipate trends in the number of oldest people. Demand for care is not about age in itself, and they point out that their cut off age of 85 and above is arbitrary. Forecasting care needs has less to do with how old people are than with who they are and how old they will be when they are expected to die. Major differences in rates of mortality and morbidity still occur between groups—for example, according to social class, sex, ethnic origin, and geographical region—and the oldest people in each group will vary in age. Those most in need of care will need care at an earlier age.

These problems are important not only in Switzerland and the United States but also in the UK and most Western states where life expectancy is increasing. Social change and economic wellbeing mean that wealthy countries have postponed their healthcare liabilities until later. First world countries have swapped infant mortality and childhood illness for the burden of care of the elderly. Caring for the oldest old is the price of affluence.