Population aging should be a priority for public policy

A long-range survey begun in 2000 is mapping the health and living conditions of people aged 60 years and older in São Paulo City, Brazil.

By José Tadeu Arantes

Agência FAPESP – “Brazil should recognize that its population is rapidly aging and make this a priority for both public policy and resource allocation,” said Maria Lúcia Lebrão, Senior Full Professor at the University of São Paulo’s School of Medicine (FM-USP).

Lebrão is the principal investigator in Brazil for the Survey on Health, Well-Being & Aging in Latin America and the Caribbean (Project SABE), a multiple-cohort longitudinal study of the health and living conditions of people aged 60 years and older in seven cities in the region, including São Paulo. It was conducted under the aegis of the Pan American Health Organization (PAHO) from 1999 to 2000, with follow-up surveys in São Paulo supported by FAPESP in 2006, 2010 and 2015.

“In 2000, we visited almost 6,000 homes and interviewed 2,143 people as cohort A,” Lebrão told Agência FAPESP. “In 2006, we went back to the homes of the people visited previously and managed to re-interview 1,115 from cohort A, as well as interviewing a new contingent in the 60-64 year age group as cohort B. In 2010, we again returned to the homes of the people in both cohorts we’d visited in 2006, as well as interviewing a new contingent aged 60-64 years as cohort C. The same procedure is being used in the ongoing round, which is the third follow-up survey. So SABE is a longitudinal study that is monitoring the same sample of seniors over a fairly long period, and it’s also a multi-cohort study because a new contingent is added with each follow-up survey.”

Because of the long period and several cohorts involved, the survey is able to map both the changes experienced by the subjects as they age and the changes undergone by society during the same period, as well as the possible connections between the two types of change.

“Cohort A is made up of more traditional seniors,” she said. “Most have little schooling, with 50% having dropped out after three years or less. Many are from the countryside, with 70% having spent their working lives doing manual labor, and accustomed to a very different way of life from today’s. For example, smoking and drinking were considered normal, and work was their only physical exercise. Today, the situation is completely different.”

The new generation of seniors is more concerned about health and well-being. They try not to smoke. They drink less. They try to stay fit and walk instead of riding. “Above all, they’re people with a higher level of schooling,” she said.

These positive traits contrast with the huge challenges presented to Brazilian society by the aging of its population. The proportion of seniors has risen from 4.1% in 1940 to 10.8% in 2010 and is forecasted to reach 12.0% in 2020.

“Our demographic transition took place in three main stages,” Lebrão explained. “Throughout the nineteenth century and in the twentieth until 1940, we had a high birth rate as well as high mortality, so the size and makeup of the population remained fairly stable, with a large proportion of children and young people. Between the mid-1940s and the end of the 1960s, the birth rate remained high, but mortality fell, leading to population growth and an increase in the proportion of children and young people. Stage three, which actually dates from the mid-1960s, saw a fall in the birth rate in conjunction with falling mortality, so population growth slowed down and the proportions of young adults and elderly people increased.”

Fertility rate

The Brazilian fertility rate fell from 5.8 children per woman of childbearing age in 1970 to 1.8 in 2010. This is insufficient to replace the population. “If the downtrend continues, our population will peak at 218 million in 2035, after which it will start to fall,” Lebrão said. Thus, Brazil is aligned with the global trend, led by the developed countries, whereby the proportion of over-65s will surpass the under-fives worldwide before 2020.

In global terms, this aging process has led to an epidemiological transition in which the prevalence of infectious diseases, which used to predominate, is being overtaken by non-transmissible chronic diseases. However, like other Latin American and Caribbean countries, Brazil has not had such a linear epidemiological transition as the developed countries. “Our epidemiological transition is more like a zigzag,” Lebrão said. “We do have many older people with non-transmissible chronic diseases, but at the same time, we still have high rates of infectious diseases, such as dengue, yellow fever, and malaria. For example, we thought yellow fever had been eradicated, and suddenly, we found it had come back. This seesawing movement overburdens the health system because the available resources have to be deployed to combat a double load of diseases.”

Another problem, with an even more significant impact on the health system, is that while the mortality curve is shifting toward ever-older age groups, the morbidity curve is hardly changing at all. People are living longer but still tend to fall ill at the same age as before, so the gap between the two curves is steadily widening, and this mismatch also overburdens the health system.

“Life expectancy rose from 52.6 years in 1970 to 73.4 years in 2010, but people have continued to contract diabetes or heart disease in or around their fifth decade. This is placing huge demand on health services,” Lebrão said. “What we have to do is promote health and well-being so that people don’t fall ill so early.”

Incapacity

The growing gap between the mortality and morbidity curves also drives up the incapacity rate. Sick people are living longer but without avoiding the incapacitating effects of sickness, which impair the quality of life and constitute another severe economic and social problem. “Public services are not at all equipped to respond to this new situation,” Lebrão said. “Sick or incapacitated people become dependent on their families, which are smaller in size, so there are fewer people to care for dependent relatives. The extended family has been replaced by the nuclear family. In 1970, we had eight young people for every older person; in 2020, there will be only two.”

Alzheimer’s disease and other forms of dementia are increasingly common afflictions of old age. “Our survey of the same people in cohort A since 2000 shows the proportion affected by cognitive impairment as they age, rising from 13.2% to 14.3% in 2006 and 18.7% in 2010,” Lebrão said.

In 2010, the most frequently cited chronic conditions for all interviewees (cohorts A, B and C) were high blood pressure (66.7%), joint diseases (31.8%), diabetes (25.0%), and heart problems (22.9%).

“It’s important to bear in mind that diseases are often not diagnosed or correctly identified,” Lebrão said. “This is particularly the case with joint diseases. There’s a false belief that joint pain is normal for seniors. ‘It’s old age,’ the doctor says, as if pain and incapacity were unavoidable. That’s completely untrue. Joint diseases can be avoided, and they most certainly can be treated.”

Depression and related disorders also often go unrecognized. “They’re harder for surveys to detect because depression isn’t a fixed condition. A person may be depressed but in a good mood on the day of the interview, or their condition may be masked by medication,” Lebrão said. “So in the SABE survey, we use two assessment criteria: subjects are scored on the Geriatric Depression Scale (GDS) and asked whether they’ve ever been told by a doctor or nurse that they had depression. In 2010, about 17% of all interviewees said they had. The proportion was even higher for women.”

Depression is often associated with loneliness. The SABE survey shows that 16.5% of people aged 60 years and over in the city of São Paulo live alone, with women in the majority. For the over-80s, the proportion rises to 25%, or one in four. “We urgently need to create support networks with integrated services,” Lebrão said. “People can go on living alone, but they should be able to rely on rapid assistance if something goes wrong and on long-term support for some day-to-day activities. This already exists in the developed countries. Why can’t it be introduced here in Brazil?”