Rory Fisher, MB, FRCP(Ed)(C), Director, Regional Geriatric Program of Toronto and Interdepartmental Division of Geriatrics, Faculty of Medicine, University of Toronto, Toronto, ON.

In Canada, the sustainability of the health care system is a major issue. Two commissions have been established to address the future of health care.^1,2 Improvements in technology and changes in the delivery of health care have led to major restructuring of the system. Acute hospital beds and the length of hospital stays have decreased with the concomitant expansion of ambulatory services. The aging population, which is increasing dramatically in Canada, particularly with regard to the oldest old, is a major priority policy issue in these discussions.³ However, the current management of the elderly in acute hospitals is of concern. In the United Kingdom, an enquiry into the care of older people in acute wards in general hospitals entitled "Not because they are old" found that problems existed with older patient and relatives' dissatisfaction with the care, numerous deficiencies in physical environments, clear evidence of staff shortages and concerns about nutrition.⁴ Problems were also identified with preserving dignity, interactions with staff, insufficient training, discharge planning and the accessibility of services in the community. In addition, a recent study by Health Canada on unmet needs for health care reported, an estimated 7% of Canadians, or about 1.

Alexandre Kalache, MD, PhD,
Chief, Ageing and Life Course (ALC),
World Health Organization,
Geneva, Switzerland.

Ingrid Keller, MSc, MPH
Associate Professional Officer, ALC,
World Health Organization,
Geneva, Switzerland.

Introduction
Within the next few decades, one of the defining features of the world population will be the rapid increase in the absolute and relative numbers of older people in both developing and developed countries. We are currently at the threshold of global aging. Worldwide, the total number of older people--defined as those over 60 years of age--is expected to increase from 605 million in 2000, to 1.2 billion by the year 2025.¹ Currently, approximately 60% of older persons live in the developing world, a number that is expected to increase to 75% (840 million) by the year 2025. Figure 1 shows the proportional increase of older persons among the total population for some developing countries as compared to the Canadian population.

In the year 2000, in a number of developed countries, there were, for the first time, more people aged 60 and older than there were children under the age of 14.¹ Population aging could be compared with a silent revolution that will impact on all aspects of society. It is imperative that we are adequately prepared for it: the opportunities and the challenges are multiple.

One of the most comprehensive demographic analyses of life expectancy in the major industrial countries suggests that average life expectancy has been miscalculated. The study examined mortality over five decades and found that "median forecasts of life expectancy are substantially larger than in existing official forecasts".

The paper, which appeared in the June 15th edition of Nature, suggests that Canadians can expect to live four years longer than previously estimated. Canada's previously estimated average life expectancy was 81.67 for the year 2050, the new estimate suggests that Canadians will live to be 85.26.

Sponsored by the US National Institute of Aging, the study is certain to have a wide impact in pension planning and healthcare policy circles. This miscalculation of life expectancy could throw off official calculations of various pension and health care costs by as much as 20%. It is suggested that long-term planners may have to go back to the blackboard and revise their models.

The study suggests that each additional year of life expectancy will add approximately 5% to the cost of programs for the elderly, i.e. those over 65. This cost is ascertained using the so-called 'dependency ratio', which is a measure of the population over 65 relative to the population between the ages of 20-65. This measure allows social planners to determine the relative numbers of working people required to support the retirement age population.

For Canadian Physicians the study suggests that their practices will become much 'grayer' than predicted and that geriatric management and clinical issues will predominate.

Source

1. Shripad T, Nan L, Carol B. A universal pattern of mortality decline in the G7 countries. Nature 405, 789-792 (2000).