Living Longer, Living Better?

Norma E. Davis, MD.,Sammons Financial Group

March 26, 2012

Objectives

• Review survival data 1850 – 2004.• Discuss some predictors of survival.• Discuss the impact of science and technology

of survival.• Discuss the impact of life style on survival.• Discuss current markers for longer survival.• Looking ahead.

Life Expectancy 1850 -2004• Male Life Expectancy:

– An American male born is 1850 could expect to live for 38.3 years.– If he survived to age 20 years, his life expectancy was 40.1 years.– If he celebrated his 60th birthday, on average he looked forward to another 15.6 years– Age 70, he could anticipate another 10.2 years– By age 80, potential life expectancy was 5.9 years.

• Fast forward to 1900:– Life expectancy at 50 was 20.76 years.– At age 60 years survival had declined to 14.35 years– At 80 years, projected survival was 5.10 years

• Life expectancy trends at birth improved significantly between 1900 and 1950, from 48.23 years in 1900 to 66.31 years in 1950.

– Life expectancy at age 60 was 15.76 years, at 70 years 10.07 years and age 80 years 5.88 years• By 2004, life expectancy at birth was 75.7 years• Life expectancy at the other end of the spectrum

– Age 60 - 20.9 years– Age 70 - 13.7 years– Age 80 - 8.1 years

• Women survived longer but the pattern of increased survival was similar to that of males.

Life Expectancy by Sex, Age, and Race: 2008(Average number of years of life remaining, Excludes deaths of nonresidents of the United States. Data are preliminary)

Age Total Male FemaleWhiteTotal

WhiteMale

WhiteFemale

BlackTotal

BlackMale

Black Female

60…………. 22.6 20.9 24.0 22.6 21.0 24.0 20.9 18.7 22.7

65…………. 18.7 17.2 19.9 18.7 17.3 19.9 17.5 15.5 18.9

70…………. 15.0 13.7 16.0 15.0 13.7 16.0 14.3 12.6 15.4

75…………. 11.7 10.6 12.5 11.6 10.6 12.4 11.3 10.0 12.2

80…………. 8.8 7.9 9.4 8.8 7.9 9.3 8.8 7.8 9.5

85…………. 6.5 5.8 6.8 6.4 5.7 6.8 6.8 6.0 7.1

90…………. 4.6 4.1 4.8 4.5 4.1 4.8 5.1 4.6 5.3

95…………. 3.2 2.9 3.3 3.2 2.9 3.3 3.8 3.5 3.8

100……….. 2.3 2.1 2.3 2.2 2.0 2.2 2.8 2.6 2.8

Includes races other than White and BlackSource: U.S. National Center for Health Statistics, National Vital Statistics Reports (NVSR), Deaths: Preliminary Data from 2008, Vol.59, No. 2, December 2010.

Improvements in Survival

Age 60 years 70years 80 years

1950 15,76 10.07 5.88

1980 17.56 11.35 6.76

1990 18.7 12.1 7.1

2000 20.0 13.0 7.6

2004 20.9 13.7 8.1

2010 N/A

Age 60 years 70 years 80 years

1950 18.64 11.68 6.59

1980 22.45 14.89 8.65

1990 23.0 15.5 9.0

2000 23.2 15.5 9.1

2004 24.1 16.2 9.7

2010 N/A

Men Women

Survival Projections

Population Distribution by Age

Source:CensusScope.org

Changing Age Distribution of U.S. Population 1950 -2050

Economist’s View September 2005

Expectation of Life at Birth, Projections, 2010 to 2020(In years. Excludes deaths of nonresidents of the United States. See Appendix II)

Year Total Male Female WhiteTotal

WhiteMale

WhiteFemale

BlackTotal

BlackMale

BlackFemale

2010………. 78.3 75.7 80.8 78.9 76.5 81.3 73.8 70.2 77.2

2015………. 78.9 76.4 81.4 79.5 77.1 81.8 75.0 71.4 78.2

2020………. 79.5 77.1 81.9 80.0 77.7 82.4 76.1 72.6 79.2

• Life Expectancies for 2000-2008 were calculated using a revised methodology and may differ from those previously published. Multiple-race data were bridged to the single-race categories of the 1977 OMB standards for comparability with other reporting areas. Data are preliminary. Based on middle mortality assumptions ; for details. See source: U.S. Census Bureau. 2008 National Population Projects, released August 2008, http://www.census.gov/population/www/projections/2008projections.html

• Source: Except as noted U.S. National Center of Health Statistics, National Vital Statistics Reports (NVSR), Deaths: Preliminary Data for 2008, Vol.59, No. 2, December 2010.

The Result

• More people are living longer.• Does this mean more people will live forever?

Why Not?

• We are programmed to survive for a finite period.• Current evidence suggests a maximum survival of 120 years in a

perfect world.• Maximum survival is genetically predetermined.• Ultimate survival is strongly influenced by:

– Diet– Education– Life style practices – Income– Inherited Disorders

• But always against the backdrop of Genetics • Very few of us will make it to age 120 years and very, very few

to 150.

Why Are We Living Longer?

• Improved Hygiene• The Introduction of Antimicrobial Agents• Improved Nutrition• Preventive Public Health Programmes

– Universal Immunization– Screening Programmes – Early Diagnosis

• Improvements in Disease Treatment and Management

Diseases Impacted by Improvements in Management

• Coronary Artery Disease• Cerebrovascular Disease• Cancers : Breast, Prostate, Colon• Autoimmune Disorders – Rheumatoid Arthritis

Leading Causes of Death age 65+, 2007

• Cardiovascular Disease – Heart Disease – 496,095– Cerebrovascular Disease – 115,961

• Cancers – 389,730• Chronic Obstructive Lung Disease – 109,562• Complications of Diabetes Mellitus – 51,528

– Cardiovascular Disease– Renal Failure– Stroke

• Alzheimer’s Disease/Dementia - 73,797• Respiratory Infections – 45,941• Accidents/Unintentional Injury – 38,292• Septicemia – 26,362

Cardiovascular Disorders• Mortality related to Coronary Artery Disease has improved significantly

over the last 50 years due to:– Recognition of risk factors accompanied by aggressive treatment .– Control of Blood Pressure– Lowering of Lipids – Total Cholesterol, Low Density Lipoproteins, Triglycerides– Smoking Cessation– Monitoring of Dietary Intake including Sodium– Encouragement of Physical Activity

• Control of these factors also improved mortality due to Stroke.• Normal ranges for measurable risk factors have all been lowered.

– Hypothesis – Lower ranges =Tighter Control = Improved Survival due to slower disease progression

• These changes have also impacted survival for Ischemic Heart Disease and Stroke.

Impact of Life Style and Diet on Older Age Survival (HALE Project)

• 1507 apparently healthy men and 832 women (2339 lives) aged 70 to 90 years followed for 10+ years

• Information collected included:– Body Mass index– Years of education– Diet based on intake of fruits, vegetables, legumes/nuts, meat and poultry, fish, dairy products,

grains (Mediterranean Diet based)– Intake of monounsaturated vs saturated fats. – Alcohol consumption– Smoking History (never smoked or ceased more than 15 year prior)– Physical Activity

• Scores were given for diet, level of physical activity, smoking status and alcohol consumption – 1 for each low risk factor and 0 for high factor.

• Each participants could score up to 4 points: 1 for diet and 3 for lifestyle factors.

Kaplan-Meier Curves for Number of Healthful Lifestyle Factors The lifestyle score was calculated by adding the individual scores for diet, physical activity level, smoking status,

and alcohol intake.

Knoops, K. T. B. et al. JAMA 2004;292:1433-1439

Cox Proportional Hazard Ratios for Dietary Pattern and 3 Lifestyle Factors for 10-Year All-Cause and Cause-Specific Mortality in Elderly Europeans.

Knoops, K. T. B. et al. JAMA 2004;292:1433-1439

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Click on image to view larger version.

                                                                                                                                                           

Knoops, K.T.B.et al, JAMA 2004; 292:1433-1439

Table 2. Percentage of Observed (Crude) and Standardized Mortalitya.

Jernberg, T. et al. JAMA 2011;305:1677-1684

Long-term Mortality following ST Elevation Acute Myocardial Infarction

Jernberg, T. et al. JAMA 2011;305:1677-1684

Cancers and Survival• Breast Cancer

– Lifetime Risk : 1 in 8.– Incidence increases after age 61 years– Risk increase with age.– Risk of advanced cancer has decreased with increased screening.– Survival for Early Stage Breast cancer has improved due to improved understanding of the disease.

• Prostate Cancer– Most men will develop Prostate Cancer if they live long enough.– 68% of cases are diagnosed after age 65 years and account for 92% of the mortality.– Prostate Cancer is a very slow growing cancer. – PSA Testing done in the industry has been effective in identifying potential applicants with

undiagnosed cancer.– Early diagnosis, careful monitoring and availability of effective therapies have decreased mortality.

• Colon Cancer – Still associated with relatively high mortality.– At risk persons who are monitored for pre-malignant lesions and appropriately managed experience

good survival

Table 1. Estimated New Female Breast Cancer Cases and Deaths by Age, United States, 2011*

Age In Situ Cases Invasive Cases Deaths

•* Rounded to the nearest 10.•Source: Total estimated cases are based on 1995-2007 incidence rates from 46 states as reported by the North American Association of Central Cancer Registries. Total estimated deaths are based on data from US Mortality Data, 1969-2007, National Center for Health Statistics, Centers for Disease Control and Prevention.

Under 40 1,780 11,330 1,160

Under 50 14,240 50,430 5,240

50-64 23,360 81,970 11,620

65+ 20,050 98,080 22,660

All ages 57,650

Table 1. Estimated New Female Breast Cancer Cases and Deaths by Age, United States, 2011*

DeSantis, C. et al; (2011) Breast cancer statistics,2011.CA,61:408-418

Stage 5-year relative survival

local nearly 100%

regional nearly 100%

distant 29%

Prostate Cancer – 5 year Survival by stage at Diagnosis

Stage 5-year Survival Rate

I 74%

IIA 67%

IIB 59%

II C 37%

IIIA 73%*

IIIB 46%

IIIC 28%

IV 6%

Survival rates for colon cancer by stage*In this study, survival was better for some stage IIIA than for some stage IIB. The reasons for this are not clear.

Age and Obesity• Is build a major concern in the older population?• Several studies indicate that overweight appears to be protective in

older populations• Obesity does carry some excess risk.• Definitions Based on BMI:

– Normal adult weight - 18.5 – to 25– Overweight - 25 – less than 30– Obese - 30 and above.

• The NHANES populations were further subdivided into:– Grade 1: 30 - <35– Grade 2: 35 - <40– Grade 3: 40 and greater

• Underweight in the elderly is generally associated with significant co-morbidity and should not be disregarded. It is usually associated with excess mortality

Table 1. Surveys Providing Mortality Data.

Flegal, K. M. et al. JAMA 2005;293:1861-1867

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Table 3. Prevalence of BMI Levels in 1999-2002 (From NHANES 1999-2002), by Age Group.

Flegal, K. M. et al. JAMA 2005;293:1861-1867

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Figure 1. Relative Risks of Mortality by BMI Category, Survey, and Age BMI indicates body mass index, measured as weight in kilograms divided by the square of height in meters.

Flegal, K. M. et al. JAMA 2005;293:1861-1867

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Table 2. Relative Risks by Age Group and BMI Level From the Combined NHANES I, II, and III Data Set.

Flegal, K. M. et al. JAMA 2005;293:1861-1867

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Diabetes and the Elderly• In the U.S,up to 11 million persons above age 65

years have diabetes.• Type 2 Diabetes is often associated with

immediate causes of death in persons above age 65

• 2004 diabetes related deaths at 65 years and above:– Heart Disease 68%. Death rate 2-4 times that of non-

diabetics. – Stroke 16%. Death rate 2-4 times that of persons

without diabetes.

Other Complications of Diabetes

• Diabetes is almost always accompanied by:– Hypertension – 67% have BPs. greater that 140/90– Kidney Disease – The leading cause of kidney disease progressing to

kidney failure.• Other significant complications of Diabetes include ;

– Neuropathy 60 -70% have mild to severe nervous system damage.– Leading cause of blindness.– Cause of 60% of non-traumatic amputations

• Diabetes is associated with:– Increased incidence of cancers– Accelerated cognitive Decline– Depression– Infection

Dementias and the Elderly

• Several Types of Dementia:– Alzheimer’s Disease 60 -80 %– Vascular dementia – usually related to a history of

Stroke both Ischemic and Hemorrhagic– Dementia with Lewy Bodies– Parkinson’s Disease– Frontotemporal Lobar Degeneration– Normal Pressure Hydrocephalus

Prevalence of Alzheimer’s

• 1 in 8 persons above age 65 years• 50% of persons aged 85 and above• Among persons with Alzheimer’s Disease 6% are

between 65 and 74 years, 44% are between 75 and 84 years.

• 65% of those affected by Alzheimer’s Disease are women

• It is estimated that 16% of women over age 71 years have Alzheimer’s Disease

Progressive Decline Observed in Alzheimer Disease Reprinted with permission from Volicer and Hurley.17.

Hurley, A. C. et al. JAMA 2002;288:2324-2331

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Diagnosing Alzheimer’s Disease

• There are now specific biochemical markers identified in the Cerebrospinal fluid which may be specific for Alzheimer’s Disease.

• Brain Scans reveal changes which are indicative of Alzheimer’s disease. These changes may be present even before the individual presents with symptoms.

• A positive family history increases the risk significantly.

Protective Factors• There are now well recognized factors which provide some

protection:– Level of education. The higher the level of education the more slowly

the disease progresses.– Social status– Regular physical activity– A diet high in fresh fruits and vegetables.

Challenges to Assessing at Older Ages• We know that cognitive function is as important

as physical health in the elderly.• Should cognitive function be assessed?• How comprehensive should it be?• How has their health been up to now?• Are there any currently controlled risk factors

with “long tails”?• What should the assessment profile look like?• How important is family history in the elderly?• How important is social engagement in the

elderly?

Some Thoughts

• Who is the Preferred 70 year old?• Do we have the correct products for older

insureds?• When should cognitive assessment begin?• We need to bear in mind that up to 65% of

persons above age 65 have at least 3 co-morbidities. Some are additive while others do not increase mortality.

Conclusion

• We have not yet found the “Fountain of Eternal Youth.”• With the correct risk assessment tools, products and pricing

the Senior population should be profitable.• Calculating survival at older ages appears to be a work in

progress.• Death rates from some common diseases have declined but

are being replaced by others.

Thank you