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Chapter 39
Old Age and Aging
Eda ÜNAL1, Aysel ÖZDEMİR2
1PhD Candidate; Uludağ University, Institute of Health Sciences, Public Health Nursing, Bursa,Turkey
2Assoc. Prof. Dr., Uludag University Faculty of Health Sciences Department of Public Health Nursing,
Bursa, Turkey
INTRODUCTION
Old age is a natural process which starts with intrauterine life, continues until death and is caused
by irreversible degeneration of cells and systems (Özel et al., 2014). Old age is not a pathological
process and it consists of physiological, psychological, sociological and chronological changes
(Karagülle 2008; Hoca, Türker, 2017; Yıldız et al., 2017). Thus, the definition of old age is quite
broad and complex. Physiological old age is used for expressing structural and functional losses;
psychological old age for expressing the decreases in perception, learning and problem solving
ability; and sociological old age for expressing the decreases and losses in the values given by
society to individuals (Tekin and Kara, 2018).
According to the World Health Organization (WHO), old age denotes the decrease in an
individual’s environmental compliance ability out of her/his control and chronologically defines
individuals aged 65 years and older. According to the WHO, chronological old age is classified as
follows: 65-75 years define young old ages and a transition period from working life to retirement;
75-85 years define advanced old ages and a period where functional losses begin to be observed;
85 years and older define very advanced old ages and a period that requires special care and support
(Beğer and Yavuzer, 2012).
OLD AGE EPIDEMIOLOGY IN THE WORLD AND IN TURKEY
In 2015, the population older than 65 years constituted 8,5% (617 million) of the world population.
According to the report “An Aging World: 2015”, it is estimated that this rate will increase to 17%
and the number of the elderly will reach 1.6 billion in 2050. The population older than 65 years
which is 48 million in the USA is estimated to reach 88 million in 2050. In the European Union
countries, on the other hand, the rate of the population older than 65 years within the total
population was 18% in 2010 and is estimated to reach 30% in 2060. Japan was determined to be
the oldest country (83,7 years) in 2015 (An Aging World, 2015).
According to the World Health Organization, 12% of the world population (900 million) consisted
of the population aged 60 years and older in 2015. It is estimated that the world population (2
billion) will increase to 22% in 2050. It is also indicated that the rate of the population aged 60
years and older will be higher than the rate of the child population younger than 5 years in 2020.
13,8% of the population aged 60 years and older in 2015 were 80 years and older. It is indicated
that 21,7% of the world population
415
will consist of the population aged 80 years and older and 6% of them will be in China in 2050. It
is estimated that 80% of the elderly population will live in low and middle income countries in
2050 (World Health Organization 2018).
It is estimated that the European population (894 million) will continue to increase (910 million)
until 2020 and then remain at certain levels until 2050. It is estimated that the rate of the population
aged 65 years and older will almost double between 2010 and 2050 and the population aged 85
years and older will increase from 14 million to 19 million in 2020 and to 40 million in 2050
(World Health Organization 2012).
According to the WHO, it is stated that the European Region whose population ages rapidly has
the highest middle age in the world. It is estimated that the population aged 65 years and older in
Europe which was 14% in 2010 will increase to 25% in 2050.
While the increase rate of the total population in the world is 1,2%; the increase rate of the geriatric
population is 2,1%. It is estimated that the world population will increase four times and the
geriatric population ten times from 1950 until 2050 (Yiğitbaş and Develi, 2016).
According to the data of the Turkish Statistical Institute (TSI); it has been determined that the
population older than 65 years in Turkey increased 17,1% and reached approximately 6,5 million
in 2016, compared to 2012. 43,9% of the elderly population consists of men and 56,1% of women.
In Turkey, the geriatric population rate within the total population was 3,5% in 1940, 4,4% in 1970,
7,5% in 2012 and 8,3% in 2016 (TUIK, 2013, 2017). According to the population projections, it is
estimated that the geriatric population rate in Turkey will increase to 10,2% in 2023, 20,8% in 2050
and 27,7% in 2075 (TUIK, 2015).
Considering the distribution of the elderly population in Turkey according to age groups; it is seen
that there is a change according to years. It was determined that the young elderly population rate
increased from 60,3% in 2012 to 61,5% in 2016; the middle elderly population rate decreased from
32,5% in 2012 to 30,2% in 2016 and the very elderly population rate increased from 7,1% to 8,2%
in 2012 (TUIK, 2017).
In 2016, 8,7% of the world population consisted of the elderly population. Ranking the countries
in the world according to elderly population rates in societies; Monaco ranks first (31,3%), Japan
second (27,3%) and Germany third (21,8%). Turkey ranks 66th with 8,3% elderly population
(TUIK, 2017).
One of the indicators of old age is median age value. Median age was reported to be 31,4 years for
Turkey and 29,4 years for the world population in 2016. Ranking the countries in the world
according to median age rates; Monaco ranks first (50,5 years), Japan second (45,8 years) and
Germany third (45,7 years). Turkey ranks 104th (TUIK, 2014).
The TSI (2015) reported the length of life expected from birth as; 75,3 years for men, 80,7 years
for women and 78 years for everyone in Turkey (TUIK, 2017).
According to the results of the income and living conditions research; the poverty in the geriatric
population was 17% in 2011 and increased to 18,3% in 2015. According to the results of the
household labor force research in 2015; the rate of the elderly population to join labor force was
found to be 11,9%. Examining the sectoral distribution of the elderly population which was
employed in 2015; it was determined that 72,8% of them were in the agricultural sector and 20,4%
in the service sector. It is
416
indicated that unemployment rate in the elderly population is 2,4% (TUIK, 2017).
Another parameter of the population aging is that the rate of the elderly population within the total
population is over 10%. The United Nations define countries where the geriatric population is over
10% as countries with a very elderly population (Yılmaz and Çolak, 2018). It is stated that Turkey
will be among the very old countries in 2023 (TUIK, 2013). The geriatric population increases
more rapidly than other age groups. Although Turkey which is in a demographic change process
seems to have young population, the absolute number of the elderly is too great (TUIK, 2013).
In a study which was conducted in 2013, Turkey’s aging index was determined to be 45,9 and
potential support rate 5.6. It is seen that aging index is lower, whereas potential support rate is
higher compared to the European Union countries. It has been determined that aging index is higher
in the western and northern provinces and lower in the eastern and southeastern provinces in
Turkey. On the other hand, potential support rate is lower in the west and higher in the east and
southeast. It has been determined that there is a significant correlation between aging index and net
immigration rate. It has also been determined that there is a positive correlation between the
decrease of population growth rate and potential support rate (Ünal 2015). Gradual increase of the
elderly population in the world and in Turkey not only indicates that health problems encountered
in old age will increase, but also stresses what needs to be done for preventing or impeding the
diseases (Gökbunar and Gündüz, 2014).
EPIDEMIOLOGY OF HEALTH PROBLEMS THAT MAY DEVELOP IN OLD AGE
Aging brings along a decrease of functional reserves in organs and systems, as well as geriatric
syndromes that emerge with multifactorial parameters, incontinence, sleep disorders, malnutrition,
delirium, pressure sores, pain and falls, which are associated with mortality (Liang et al., 2018;
Gökçe-Kutsal and Eyigör, 2012:50).
Old Age and Fragility
Fragility is a geriatric syndrome which is characterized by negative health outcomes such as
decrease in physiological reserves and body mass index, physical deformity, slowness, weakness,
lower level of physical activity and stress intolerance, burnout, and may result in death (Wehbe et
al., 2013; Forman and Alexander, 2016). Sick and fragile elder individuals become more sensitive
towards geriatric syndromes (Fried et al., 2001; Polidoro et al., 2011). The rate of fragility is 20-
30% in individuals aged 75 years and older and 30-45% in individuals aged 85 years and older
(Schoufour et al., 2014). Fragility prevalence increases with age and it has been reported that being
a woman and having a lower socioeconomic level increase fragility. Fragility prevalence is 12%
(Aygör 2013) in Turkey 11-14,9% (Chang et al., 2011) in Taiwan and 9,6% (Jürschik et al., 2012)
in Spain.
Old Age and Pain
Pain is a multidimensional, complex and an unpleasant feeling which occurs as a result of tissue
damage, originates from nociceptive and neuropathic signals, predicts possible physiological
dangers and is affected by psychosocial factors and the person’s past experiences (Belfer 2013;
Öztürk Birge and Mollaoğlu, 2018). One of the most
417
common syndromes encountered in the elderly is pain. When individuals exceed the age 60, the
pain incidence doubles and increases every ten year (Miaskowski 2000). It has been determined
that pain prevalence in the elderly varies between 88,5%-99,7% (Blyth et al., 2001; Gökkaya et
al., 2012). While acute pain is encountered at similar rates in all age groups, chronic pain generally
increases with age, peaks in the age range of 65-70 years, remains stable in the age range of 70 -
75 years and decreases after 75 years (Öztürk and Karan, 2009). Epidemiological studies show that
25% and 70% of the elderly population try to cope with chronic pain (Gökçe-Kutsal and Eyigör,
2012:50). Joint pain is two times greater in individuals older than 65 years than young adults. Acute
visceral pains such as headache, ischemic chest pain, stomach ache, pneumothorax, peptic ulcer,
intestinal obstruction and peritonitis are encountered less frequently in the elderly than other age
groups (Moore and Clinch, 2004). However, the elderly face osteoarthritis, spinal canal stenosis,
diabetic peripheral neuropathy myofascial pain, fibromyalgia, postherpetic neuralgia, poststroke
pain and malignancy, which are among the common causes of pain (Öztürk and Karan, 2009).
Although not known precisely yet, women are more sensitive towards pain arising from hormonal,
endogenous, exogenous, psychosocial factors and cognitive/affective variables than men (Belfer
2013).
In a study conducted by Özel et al., it was determined that the elderly experienced knee pain
(64,6%) and headache (58,5%) the most and backache (7,3%) the least.
In another study, it was found that 74,2%-78,2% of the elderly experienced joint pain and 50,5%
common pain (Gökkaya et al., 2012; Hwang et al., 2010).
Old Age and Sleep
Sleeplessness is a feeling of inadequacy in transiting to sleep and falling asleep, difficulty in
sustaining sleep, state of waking up early and failure of resting in the daytime due to sleeping too
much during the day outside the night’s sleep (Mousavi et al., 2012). It is stated that prevalence of
sleep problems in the population aged 60 years and older is around 50% (Silva et al., 2016). In a
study conducted by Silva et al. (2013) with the elderly in Brasil, it was determined that 37,7% of
the elderly had sleep problems (Silva et al., 2013). In another study, it was determined that the
elderly had sleep problems such as falling asleep, impaired sleep and waking up early (Mousavi et
al., 2012). In a meta-analysis study, it was determined that sleeping more than 7-8 hours increased
the death risk 33% (Silva et al., 2016). The studies conducted in Turkey show that 60-77% of the
elder adults living in nursing homes have sleep problems (Dolu and Nahcivan, 2019; Fadıloglu et
al., 2006).
Old Age and Incontinence
Urinary incontinence is defined as a condition in which the person fails to keep her/his urine
regardless of amount (Varlı et al., 2009). It is an unpleasant condition with a clinical, psychological
and social dimension whose prevalence increases with aging. As elder individuals usually do not
talk about this condition very much, it makes it hard to define it (Ceyhan et al., 2018). Incontinence
prevalence varies between 8% and 18% in the elderly. It is reported that incontinence prevalence
is two times higher in women than men. The rate of incontinence has reached 40-70% in individuals
who are hospitalized and 40-50% in those living in nursing homes (Landi et al., 2003; Ceyhan et
418
al., 2018). In a study conducted in Turkey, it was determined that almost all of the elder individuals
had sleep problems and 20% of them had incontinence (Ceyhan et al., 2018). In a study conducted
by Morena et al. (2019) with 1.334 elder individuals, it was determined that 44,9% of them had
sleep problems and sleep problems were more common among women (51,5%) and the age range
of 75-79 years (48,2%). Gender, joint diseases and urinary incontinence were found to be
associated with nocturia and sleep disorder (Morena et al., 2019). In a cohort study conducted by
Kim et al. with 39.854 adults in the age range of 66-80 years, it was determined that women with
elderly urinary incontinence had significantly higher prevalence of osteoporotic fragility fractures
than men and elder women had a higher fall risk (Kim et al., 2018).
Old Age and Fall Risk
Fall is defined as touching the ground in an unexpected and unprepared way due to a loss of balance
as a result of the individual’s inattentiveness (Kuhırunyaratn et al., 2019; Kılınç et al., 2017). Loss
of functions in old age increases the frequency of falling. According to the global report by the
World Health Organization (WHO), it is stated that individuals aged 65 years and older fall at a
rate of 28-35% every year and this rate increases in parallel with the increase of age and fragility
level (World Health Organization, 2007). Primary cause of death in individuals older than 65 years
in the United States of America is falls (Kuhırunyaratn et al., 2019). In a study conducted in Japan,
it was determined that 16% of men and 22% of women would fall at least once (Mizukami et al.,
2013). In a cohort study conducted in Boston with the elderly who had been followed for nearly
4.3 years, 1680 falls were reported (786 outdoors, 894 indoors). During the 4.3-year follow-up
(663 in men, 1017 in women), a total of 1680 falls were reported (786 outdoors, 894 indoors). The
rate of reporting; no fall was 37,3% in men and 36,4% in women; one fall was 20,3% in men and
20,8% in women, two falls was 13,8% in men and 13,1% in women, three or more falls was 28,6%
in men and 29,7% in women. It was seen that the rates of falling on the pavements, streets and
outdoors were similar in women and men, whereas the rates of falling indoors (especially in the
kitchen) were almost two times higher in women than men (Duckham et al., 2013). In a study
conducted in Samsun, it was determined that 43,3% of the elderly fell indoors and consequently
16,4% of them had internal organ injuries, 53,2% bone fractures and 41,5% femur fractures the
most (Kılınç et al., 2017). In a study conducted by Schluter et al. (2018) with patients suffering
from incontinence in New Zealand, it was determined that 42,7% of men fell and 2,5% of them
had fractures as a result of falling. In the study, it was also determined that 39,1% of women fell
and 3,7% of them had fractures as a result of falling. In a study conducted by Pitchai et al. (2019),
it was determined that fall prevalence was 24,98%. It was determined that 44,92% of the falls
occurred in the morning, majority of them (65,43%) took place indoors and 56,45% were caused
by slipping. Among the individuals who fell; 60,55% had a permanent disability and 34,70%
developed fear of falling.
Old Age and Chronic Diseases
Molecular degenerations in old age cause cellular damages and become a primary risk factor for
major human pathologies including cancer, diabetes, cardiovascular diseases and
neurodegenerative diseases (Lo´ pez-Otı´n et al., 2013). Thus, the
419
prevalence of non-communicable diseases increases in old age. Cardiovascular diseases (heart
failure, coronary artery disease, hypertension), cancer, COPD, diabetes, renal failure, anemia,
dementia, stroke, osteoporosis, Parkinson’s disease, vision problems and arthritis have an
important place among the health problems encountered in the elderly.
Multimorbidity is directly associated with increasing disability, decreasing functional capacity and
higher mortality. Among the studies on hypertension prevalence which is one of cardiovascular
problems; according to the Turkish Hypertension Prevalence (Paten T) study which was
implemented in 2003, hypertension (HT) prevalence in the population aged 65 years and older was
reported to be 67,2% in men, 81,7% in women and 75,1% in general (Arıcı et al., 2005). As a result
of the PatenT-2 which was implemented approximately 10 years after the aforementioned study, it
was determined that the population aged 60 years and older was 40% hypertensive (Şengül et al.,
2016).
As a result of the TEKHARF study which was implemented in Turkey in 2013, it was determined
that type-2 diabetes mellitus (DM) prevalence increased from 15% to 26,1% for the age group of
60–69 years, from 11,3% to 25,8% for the age group of 70–79 years and from 7,7% to 16,7% for
the age group of 80 years and older. In the TEKHARF cohort, it was determined that metabolic
syndrome prevalence increased from 60,2% to 66,8% for the age group of 60–69 years and from
56,3% to 59,3% for the age group of 70 years and older (Onat et al., 2013). In the Prospective
Urban Rural Epidemiology (PURE) study, it was determined that diabetes prevalence increased
from 23,4% to 27,6%, hypertension prevalence from 69,4% to 79,2% and metabolic syndrome
prevalence from 49,3% to 53,9% in the geriatric group older than 65 years, which constituted
12,8% of the entire population (Oğuz et al., 2018).
In Turkey, Turkoz et al. examined 90.472 patients with cancer retrospectively and determined that
10 leading types of cancer in the population older than 70 years were; breast (15,8%), prostate
(9,9%), colorectal (9,6%), lung (9,4%), skin (6,7%), gastric (6,6%), bladder (6,3%) and non-
hodgkin’s lymphoma (6,6%), respectively (Turkoz et al., 2013).
Pneumonia prevalence is 18,2% in the age group of 65-69 years and 52,3% in the age group of 85
years and older, which is almost three times greater (Küçükardalı et al., 2001). COPD prevalence
has been found to be 11,5% in the age group older than 45 years (Gökçe-Kutsal and Eyigör,
2012:56).
In a 12-year cohort study which was implemented with elder individuals older than 65 years who
had no disability in France, it was determined that there was a correlation between low and
moderate physical activity, low fruit-vegetable diet, smoking and increasing disability; the increase
of the number of unhealthy behaviors increased the risk of disability; and individuals with three
unhealthy behaviors had a disability potential two times greater (Artaud et al., 2013).
Old Age and Polypharmacy
Polypharmacy is the multiple use of more than two drugs (Öztürk and Uğraş, 2017). Increase of
the prevalence of chronic diseases in aging also increases drug utilization (Yılmaz and Çolak,
2018). According to the results of a research conducted by the Ministry of Health, 90% of the
elderly population aged 65 years and older in
420
Turkey has one chronic disease, 35% two chronic diseases, 23% three chronic diseases and 14%
four or more chronic diseases. Presence of multiple chronic diseases in the elderly causes
polypharmacy. In a study conducted in Turkey, it was determined that 10,5% of the elderly used
one drug, 13,7% two drugs, 11,3% three drugs, 8,7% four drugs and 38% five and more drugs
together (Öztürk and Uğraş, 2017). It is known that unless polypharmacy is managed by patients
properly, complication and mortality rates will increase. In a systemic analysis, it was indicated
that unconformity prevalence in geriatric patients receiving polypharmacy varied between 6-55%
(Zelko et al., 2016). As a result of a study conducted in Turkey, it was determined that among elder
individuals with chronic diseases, 72,6% were unable to comply with medication. It was also
determined that multiple drug utilization complicated the compliance to treatment (Cicolini et al.,
2016; Yılmaz and Çolak., 2018; Zelko et al., 2016).
Old Age and an Approach to Old Age Problems
Aging individuals make demands on the delivery and facilities of healthcare services in order to
protect their health and increase their life quality. These demands are aimed at protecting physical,
bodily and mental health. In old age, preventing the development of diseases with the help of
primary protection, early diagnosis and efficient treatment methods, as well as taking protection
precautions and sustaining disability and life quality are very important for a healthy and successful
aging. Precautions such as adequate and balanced nutrition, sufficient physical activities and
reducing tobacco and alcohol use may protect from geriatric syndromes and non-communicable
diseases brought by old age.
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