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What is old age?
Public Health (1996) 110, 209-210 © The Societyof Public Health,1996
Discussion Paper What is old age ? M C Robertson MA, BM, BCh
Department of Public Health, Oxfordshire Health Authority, Old Road, Iteadington, Oxford OX3 7LG Use of the term 'old age' in notifying deaths of residents in Oxfordshire nursing homes between 1984 and 1994 was matched with recorded age. 2264 records covering 44 registered nursing homes were looked at. The oldest person referred to as dying from old age was 106, the youngest 69 years. The most general starting point for a diagnosis of old age was 77 though the years from the mid-eighties through the early nineties were taken by the majority of notifiers as fitting this description. Key words: old age, nursing homes, elderly assessment. Introduction A coroner spoke to a group of doctors a b o u t completing death certificates. 'Old age' he observed gently 'is a perfectly respectable diagnosis'. A young m e m b e r of his audience was not so sure. 'What is old age ?' he asked. Judges in the U K are to be compulsorily retired at 70. Women's pensionable age is to be increased from 60 to 65. Averaged out, does this indicate a view that old age starts around 67? The Bible sets the span of m a n at three score years and ten. ~ In 1963 the World Health Organization identified three groups: 'middle aged' (45-59) °elderly' (60-74) and 'aged' (75 and over). Requirements of these last two groups were seen as different. It was the aged who would need assistance and use resources. The elderly n:fight themselves be a resource, providing knowledge, skills and experience for those who wanted to use it. 2 The general practitioners' contract introduced in 1990 selected 75 as the age above which people should be offered an annual assessment or health c h e c k ) A Swedish study selected 76-year-old citizens to l o o k at health-related quality of life. 4 Finnish work on the prognosis of depression in old age had as subjects those over 60. 5,6 In reviewing strength and p o w e r in old age Young and Skelton ranged from age 65 to 84, 7 while a G e r m a n investigation of speed and intelligence in old age looked at those beyond 7 0 ) The Berlin Aging Study (BASE) consists of a representative sample of elderly aged 70 to 105 years stratified by age and gender. 9 'Older w o m e n ' are defined as greater than, or equal to, 65 years of age in an American review of breast cancer care in old age. 1° There is evidently still a great variation in the perception of old age. Life expectancy has gone up in the twentieth century. Has there been a corresponding change in the Cold age' concept? W h a t age is n o w regarded as old? The following study was an attempt to answer this question. Correspondence to: Dr M Carote Robertson, Department of PuNic Health, Oxfordshire Health Authority, Old Road, Headington, Oxford, OX3 7LG. Accepted t May 1996.
Registered nursing homes in the U K are h o m e s to m a n y old people. They are obliged to notify their registering authority of the deaths of residents, within 24 hours of the death. Age is stated on the forms submitted. They therefore provide a concentrated source for what is regarded as old age. The term is likely to be used here, though doctors in general have tended to avoid it in an effort to be scientifically precise. 11 A study of these nursing h o m e death notifications can thus provide a current view as to what is regarded as old, and a possible means of answering the question. Method Available forms notifying the registering authority of deaths in nursing homes from June 1984 to the end of M a y 1994 were inspected for Oxfordshire, central England. A record was m a d e of the n u m b e r of occasions the term 'old age' or a related term was used (senile, debility, frailty, elderly, aged). This was then checked against the recorded age of the person concerned. 'Dementia' and 'Alzheimer's disease' were not included. F o r the first 8 years of the study original forms were available and it was possible to identify when 'old age' was considered an antecedent cause of death as well as where it was said to be the 'Disease or condition directly leading to death'. F o r 1993 and 1994 a t r a n scribed computerised format was supplied, where only the main condition was shown. During the ten years covered by the study the n u m b e r of nursing homes and notifications steadily increased. By t994 there were 44 homes; ten years previously there were only 5 f r o m which forms were available, p a p e r w o r k from others n o t having survived. N o m i n a l l y these notifications are c o m pleted by proprietors. In practice this was not always the case, some being written by m a t r o n or the nurse in charge, and some by the h o m e doctor. Results Records were found to be incomplete and not always relevant. Two homes dealt only with young people and could not contribute to the study. The term 'old age' or anything similar was not used in records pertaining to 13 homes, of which two were
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210
What is old age? MC Robertson
hospices where cancer was mostly the direct cause of death. A further three homes never used the exact words 'old age' but expressions which had been treated as similar: 'senility', 'senile decay', 'general frailty'. Like terms were additionally used ('senile debility', 'senile degeneration', 'senescence', 'aged', 'elderly') by homes which also made use of the words 'old age' (sometimes, "extreme old age'). 'Dementia' and 'Alzheimer's disease' were mentioned separately as a different entity and it proved practical to exclude this, i.e. 'senility' was not used as a synonym for these. A total of 2264 records covering the 44 homes as available from the 10 years studied, were examined 1,791 coming from the 29 homes which proved relevant to the study. Of these, 165 mentioned 'old age' or one of the alternative terms above, The oldest person referred to in this way was 106, the youngest (as 'senile debility') was 69. But 69 was one of only two records for those under 77, the other being 73. The maximum number related to the decade 86-95. Ages 89 and 92 years had eleven records each, 89 years being the average for the whole series. Despite its being necessary information, age was omitted in four cases. Fourteen records indicated an age of 100 or over. Conclusion The difference between the two extremes for 'old age' (69 and 106) in this study was an incredible 37 years. But analysis showed that 77 was a more general starting point, and the majority felt the years from the mideighties through the early nineties fitted this description.
So the starting age of 75 for 'elderly assessment' of patients by GPs may be about right in chronology, if it is meant to be done before 'old age' starts. In practice, due to individual variation, and healthily for those concerned, 75 can be much too soon.
References 1 King James' Authorised version of the Bible, Psalm 90. 2 Anderson F (Sir), (ed Pratley MS J). Principles and Practice of Geriatric Medicine. John Wiley and Sons Ltd: UK, 1991, p 1435. 3 Chew CA, Wilkin D, Glendenning C. Annual assessment of patients aged 75 years and over: general practitioners' and practice nurses' views and experiences. British Journal Gen Practice 1994, June, 263-267. 4 Grimby A, Wiklund I. Health-related quality of life in old age: a study among 76-year-old Swedish urban citizens. Scandinavian Journal of Social Medicine 1994; 22: 714. 5 Kivela SL et al. Five-year prognosis for depression in old age. International Psychogeriatrics 1944; 6: 69-78. 6 Kivekla SL. Depression and physical and social functioning in old age. Acta Psychiatrica Scandinavica 1994; Supplementum 377: 73-76. 7 Young, A, Skelton DA. Applied physiology of strength and power in old age. International Journal of Sports Medicine 1994; 15: 149-151. 8 Lindenberger U, Mayr U, Kliegl R. Speed and intelligence in old age. Psychology and Aging 1993; 8: 207-220. 9 Wernicke TF, Reischies FM. Prevalence of dementia in old age: clinical diagnoses in subjects aged 95 years and older. Neurology 1994; 44: 250-253. t0 Silliman RA, Balducci L, Goodwin JS, et al. Breast cancer care in old age: what we know, don't know and do. Journal of the National Cancer Institute 1993 ; 85: 190-199. 11 WHO. International Classification of Diseases. Tenth Revision (ICD 10) in 3 volumes, WHO: Geneva.
Discussion Paper What is old age ? M C Robertson MA, BM, BCh
Department of Public Health, Oxfordshire Health Authority, Old Road, Iteadington, Oxford OX3 7LG Use of the term 'old age' in notifying deaths of residents in Oxfordshire nursing homes between 1984 and 1994 was matched with recorded age. 2264 records covering 44 registered nursing homes were looked at. The oldest person referred to as dying from old age was 106, the youngest 69 years. The most general starting point for a diagnosis of old age was 77 though the years from the mid-eighties through the early nineties were taken by the majority of notifiers as fitting this description. Key words: old age, nursing homes, elderly assessment. Introduction A coroner spoke to a group of doctors a b o u t completing death certificates. 'Old age' he observed gently 'is a perfectly respectable diagnosis'. A young m e m b e r of his audience was not so sure. 'What is old age ?' he asked. Judges in the U K are to be compulsorily retired at 70. Women's pensionable age is to be increased from 60 to 65. Averaged out, does this indicate a view that old age starts around 67? The Bible sets the span of m a n at three score years and ten. ~ In 1963 the World Health Organization identified three groups: 'middle aged' (45-59) °elderly' (60-74) and 'aged' (75 and over). Requirements of these last two groups were seen as different. It was the aged who would need assistance and use resources. The elderly n:fight themselves be a resource, providing knowledge, skills and experience for those who wanted to use it. 2 The general practitioners' contract introduced in 1990 selected 75 as the age above which people should be offered an annual assessment or health c h e c k ) A Swedish study selected 76-year-old citizens to l o o k at health-related quality of life. 4 Finnish work on the prognosis of depression in old age had as subjects those over 60. 5,6 In reviewing strength and p o w e r in old age Young and Skelton ranged from age 65 to 84, 7 while a G e r m a n investigation of speed and intelligence in old age looked at those beyond 7 0 ) The Berlin Aging Study (BASE) consists of a representative sample of elderly aged 70 to 105 years stratified by age and gender. 9 'Older w o m e n ' are defined as greater than, or equal to, 65 years of age in an American review of breast cancer care in old age. 1° There is evidently still a great variation in the perception of old age. Life expectancy has gone up in the twentieth century. Has there been a corresponding change in the Cold age' concept? W h a t age is n o w regarded as old? The following study was an attempt to answer this question. Correspondence to: Dr M Carote Robertson, Department of PuNic Health, Oxfordshire Health Authority, Old Road, Headington, Oxford, OX3 7LG. Accepted t May 1996.
Registered nursing homes in the U K are h o m e s to m a n y old people. They are obliged to notify their registering authority of the deaths of residents, within 24 hours of the death. Age is stated on the forms submitted. They therefore provide a concentrated source for what is regarded as old age. The term is likely to be used here, though doctors in general have tended to avoid it in an effort to be scientifically precise. 11 A study of these nursing h o m e death notifications can thus provide a current view as to what is regarded as old, and a possible means of answering the question. Method Available forms notifying the registering authority of deaths in nursing homes from June 1984 to the end of M a y 1994 were inspected for Oxfordshire, central England. A record was m a d e of the n u m b e r of occasions the term 'old age' or a related term was used (senile, debility, frailty, elderly, aged). This was then checked against the recorded age of the person concerned. 'Dementia' and 'Alzheimer's disease' were not included. F o r the first 8 years of the study original forms were available and it was possible to identify when 'old age' was considered an antecedent cause of death as well as where it was said to be the 'Disease or condition directly leading to death'. F o r 1993 and 1994 a t r a n scribed computerised format was supplied, where only the main condition was shown. During the ten years covered by the study the n u m b e r of nursing homes and notifications steadily increased. By t994 there were 44 homes; ten years previously there were only 5 f r o m which forms were available, p a p e r w o r k from others n o t having survived. N o m i n a l l y these notifications are c o m pleted by proprietors. In practice this was not always the case, some being written by m a t r o n or the nurse in charge, and some by the h o m e doctor. Results Records were found to be incomplete and not always relevant. Two homes dealt only with young people and could not contribute to the study. The term 'old age' or anything similar was not used in records pertaining to 13 homes, of which two were
~
210
What is old age? MC Robertson
hospices where cancer was mostly the direct cause of death. A further three homes never used the exact words 'old age' but expressions which had been treated as similar: 'senility', 'senile decay', 'general frailty'. Like terms were additionally used ('senile debility', 'senile degeneration', 'senescence', 'aged', 'elderly') by homes which also made use of the words 'old age' (sometimes, "extreme old age'). 'Dementia' and 'Alzheimer's disease' were mentioned separately as a different entity and it proved practical to exclude this, i.e. 'senility' was not used as a synonym for these. A total of 2264 records covering the 44 homes as available from the 10 years studied, were examined 1,791 coming from the 29 homes which proved relevant to the study. Of these, 165 mentioned 'old age' or one of the alternative terms above, The oldest person referred to in this way was 106, the youngest (as 'senile debility') was 69. But 69 was one of only two records for those under 77, the other being 73. The maximum number related to the decade 86-95. Ages 89 and 92 years had eleven records each, 89 years being the average for the whole series. Despite its being necessary information, age was omitted in four cases. Fourteen records indicated an age of 100 or over. Conclusion The difference between the two extremes for 'old age' (69 and 106) in this study was an incredible 37 years. But analysis showed that 77 was a more general starting point, and the majority felt the years from the mideighties through the early nineties fitted this description.
So the starting age of 75 for 'elderly assessment' of patients by GPs may be about right in chronology, if it is meant to be done before 'old age' starts. In practice, due to individual variation, and healthily for those concerned, 75 can be much too soon.
References 1 King James' Authorised version of the Bible, Psalm 90. 2 Anderson F (Sir), (ed Pratley MS J). Principles and Practice of Geriatric Medicine. John Wiley and Sons Ltd: UK, 1991, p 1435. 3 Chew CA, Wilkin D, Glendenning C. Annual assessment of patients aged 75 years and over: general practitioners' and practice nurses' views and experiences. British Journal Gen Practice 1994, June, 263-267. 4 Grimby A, Wiklund I. Health-related quality of life in old age: a study among 76-year-old Swedish urban citizens. Scandinavian Journal of Social Medicine 1994; 22: 714. 5 Kivela SL et al. Five-year prognosis for depression in old age. International Psychogeriatrics 1944; 6: 69-78. 6 Kivekla SL. Depression and physical and social functioning in old age. Acta Psychiatrica Scandinavica 1994; Supplementum 377: 73-76. 7 Young, A, Skelton DA. Applied physiology of strength and power in old age. International Journal of Sports Medicine 1994; 15: 149-151. 8 Lindenberger U, Mayr U, Kliegl R. Speed and intelligence in old age. Psychology and Aging 1993; 8: 207-220. 9 Wernicke TF, Reischies FM. Prevalence of dementia in old age: clinical diagnoses in subjects aged 95 years and older. Neurology 1994; 44: 250-253. t0 Silliman RA, Balducci L, Goodwin JS, et al. Breast cancer care in old age: what we know, don't know and do. Journal of the National Cancer Institute 1993 ; 85: 190-199. 11 WHO. International Classification of Diseases. Tenth Revision (ICD 10) in 3 volumes, WHO: Geneva.