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December 2017 | Volume 5 | Article 3351
MINI REVIEW
published: 11 December 2017
doi: 10.3389/fpubh.2017.00335
Frontiers in Public Health | www.frontiersin.org
Edited by:
Gerry Leisman,
University of Haifa, Israel
Reviewed by:
Eli Carmeli,
University of Haifa, Israel
Chris Fradkin,
University of California, Merced,
United States
*Correspondence:
Efraim Jaul
jaul@zahav.net.il
Specialty section:
This article was submitted to
Child Health and Human
Development,
a section of the journal
Frontiers in Public Health
Received: 03October2017
Accepted: 24November2017
Published: 11December2017
Citation:
JaulE and BarronJ (2017)
Age-Related Diseases and Clinical
and Public Health Implications for the
85Years Old and Over Population.
Front. Public Health 5:335.
doi: 10.3389/fpubh.2017.00335
Age-Related Diseases and Clinical
and Public Health Implications for
the 85Years Old and Over Population
Efraim Jaul1,2* and Jeremy Barron3,4
1 Skilled Nursing Department, Herzog Hospital, Jerusalem, Israel, 2 Hebrew University of Jerusalem, Jerusalem, Israel,
3 Johns Hopkins University, Baltimore, MD, United States, 4 Herzog Hospital, Jerusalem, Israel
By 2050, the American 85years old and over population will triple. Clinicians and the
public health community need to develop a culture of sensitivity to the needs of this
population and its subgroups. Sensory changes, cognitive changes, and weakness
may be subtle or may be severe in the heterogeneous population of people over age
85. Falls, cardiovascular disease, and difficulty with activities of daily living are common
but not universal. This paper reviews relevant changes of normal aging, diseases, and
syndromes common in people over age 85, cognitive and psychological changes,
social and environmental changes, and then reviews common discussions which clini-
cians routinely have with these patients and their families. Some hearing and vision loss
are a part of normal aging as is decline in immune function. Cardiovascular disease and
osteoporosis and dementia are common chronic conditions at age 85. Osteoarthritis,
diabetes, and related mobility disability will increase in prevalence as the population
ages and becomes more overweight. These population changes have considerable
public health importance. Caregiver support, services in the home, assistive technolo-
gies, and promotion of home exercise programs as well as consideration of transpor-
tation and housing policies are recommended. For clinicians, judicious prescribing and
ordering of tests includes a consideration of life expectancy, lag time to benefit, and
patient goals. Furthermore, healthy behaviors starting in early childhood can optimize
quality of life among the oldest-old.
Keywords: oldest-old, medical decision-making, public policy, aging, longevity
BACKGROUND
e percentage of national populations over age 65 has been increasing in the last 10years and
will continue to rise for another 20years due to improved life expectancies and a post-World War
2 baby boom. Beginning in 2030, the numbers of adults over age 85 will rise quickly. By 2050, the
number of adults over age 80 around the globe will triple from 2015 numbers (1). Some nations are
aging even faster. Now is the time for the public health community to plan for the “older-older age
wave.” Many cities have begun to explore how to make themselves more “elder-friendly.” As the baby
boom-generation ages from 65 to 85, there will be a more intense need for services in the home and
in community and institutional settings.
e aging process currently encompasses more than a generation and exceeds three decades.
e common framework for describing dierent older adult populations is “young-old” (2), “old”
(3), and “old-old.” e “young-old” are people in their 60s and early 70s who are active and healthy.
2
Jaul and Barron Over Age 85 Population: Clinical Decision-Making
Frontiers in Public Health | www.frontiersin.org December 2017 | Volume 5 | Article 335
e “old” are people in their 70s and 80s who have chronic ill-
nesses and are slowing down with some bothersome symptoms.
e “old-old” or “oldest-old” (4) are oen sick, disabled, and
perhaps even nearing death.
When caring for older adults as a clinician or as a caregiver,
predicting the future and then planning for the most likely aging
trajectories are key steps. is paper presents a model for the
clinical and public health needs of adults over age 85.
e changes associated with a chronologic age of 85 can be
divided into a few domains: normal aging, common diseases, and
functional, cognitive/psychiatric, and social changes.
NORMAL AGING
Although changes can be described in every organ system,
this review will address changes with public health and clinical
decision-making implications.
Sensory Changes
Hearing Loss
Hearing loss (presbycusis) and increased cerumen production
with aging contribute to diculty hearing. e prevalence of
hearing loss increases as a function of age and accumulating risk
factors and has a high association with reduced quality of life
(5). Approximately one-half of adults over age 85 have hearing
impairment (6). Mild hearing loss can impair speech processing,
particularly if speech is rapid or if multiple talkers in large rooms
generate reverberant noise. erefore, verbal communication
diculties are most prominent in settings where people gather.
Increased social isolation mediates the observed associations
between hearing loss and depression, cognitive decline, and
reduced quality of life.
e use of hearing aids could reverse adverse eects on
the quality of life, and cognitive function in elderly adults (7).
Unfortunately, among individuals with hearing loss in one study,
only 14.6% reported currently using a hearing aid (8). Oen,
health insurance does not oer coverage for these devices.
Visual Acuity
Visual acuity decreases normally with age (presbyopia). Older
adults will oen have problems with glare, making night driving
riskier. A (strike in) longitudinal survey conducted in the UK on
the population aged 75 and older found that prevalence of severe
visual impairment was 23% at ages 85–89 and increased to 37%
at age over 90 (9). Visual acuity deteriorates faster at higher ages.
Cataract surgery is typically safe and sometimes helps function.
Vestibular Function
Dizziness is a common multifactorial geriatric syndrome con-
tributing to falls. Vestibular function declines subtly with age.
Vestibular rehabilitation can be an eective treatment (10).
Muscle Strength and Fat Changes
Muscle mass and strength decline starting in the fourth decade
of life. By age 85, approximately 20% of people meet criteria
for sarcopenia (meaningful loss of muscle mass and strength)
(11). Chronic inammation, declining hormone levels, impaired
muscle mitochondrial function, and impaired muscle stem
cell function all probably contribute to sarcopenia (12). is
decline in muscle mass and increase in fat mass contributes to
important changes in pharmacokinetics. Older adults may need
lower medication doses than younger adults. Muscle weakness
(13) and rapid rate of strength decline (14) both predict future
mortality.
Immunosenescence
ere are a wide variety of age-related changes in the immune
system, some mediated by chronic inammation and a chronic
pro-inammatory state. ere is a decline in Bcell function, a
decline in Tcell generation, altered Tcell activation, and dysfunc-
tion of innate immunity (including impaired neutrophil function
and chemotaxis and a dysregulated proinammatory monocyte
response). ese changes (15) weaken the body’s capacity to ght
infection. For example, inuenza infections are more common
and more serious in older adults while the vaccine is less eective.
Cellular immune dysfunction also contributes to the prevalence
of herpes zoster among older adults. Vaccines are generally not
as eective for older adults. High doses of the inuenza vaccine
may be more helpful than standard doses (16). Chronically
slowed inammatory processes also contribute to slow wound
healing in older adults (17).
Urologic Changes
e urinary bladder is oen not sterile in older adults but rather
is colonized with bacteria not causing infection. Asymptomatic
bacteriuria is more common in women than men and is most
frequent among hospitalized patients and residents of long-term
care facilities (up to 50% of women in these high risk groups)
(18). Use of antibiotics in this situation is inappropriate (19) and
may contribute to antimicrobial resistance.
SOMATIC DISEASE AND MULTIPLE
CHRONIC CONDITIONS
Cardiovascular Disease
Cardiovascular disease remains the most common cause of
death of older adults, although death rates have dropped in
the last 20years. is category includes chronic ischemic heart
disease, congestive heart failure, and arrhythmia. Ischemic heart
disease may be underdiagnosed in the oldest-old (20). Normal
aging includes vascular remodeling and vascular stiness (21).
Atherosclerosis causes inammation and further vascular
changes (22) increasing risk for cardiac events, cerebrovascular
events, peripheral vascular disease, cognitive impairment, and
other organ damage.
Hypertension
Hypertension, a major contributor to atherosclerosis, is the most
common chronic disease of older adults (23). Isolated systolic
hypertension is particularly common among older adults and
is associated with mortality even at advanced ages. e value of
intensive pharmacotherapy for hypertension in people over age
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75 remains controversial. Evidence seems to suggest that aggres-
sive treatment should be oered (24) and continued as long as it
is well-tolerated and consistent with the patient’s goals.
Cancer
Cancer is the second leading cause of death in older adults.
However, by age 85, the death rate from cancer begins to fall (25).
Slow-growing tumors seem to be common in this population.
Response to cancer treatment depends on functional status
rather than age. Individuals in their ninth or tenth decade should
not be denied aggressive cancer treatment simply due to age.
Screening is not recommended for breast cancer aer age 75,
due to insucient evidence for benet, although there may be
benet for women with a long life expectancy (26, 27). Similarly,
for people over age 75 in the US, colon cancer screening is only
recommended in cases where there is a long predicted life expec-
tancy and a perceived strong capacity to tolerate cancer treatment,
if needed (27, 28). At any age, life expectancy is quite variable in
older adults, based on comorbidities and other factors (29).
Screening for prostate cancer is not recommended due to fre-
quent false positives, which are burdensome, and to identication
of slow-growing tumors (30).
Osteoarthritis
Osteoarthritis is the second most common chronic condition
(23) among American older adults and a common cause of
chronic pain and disability. Fiy-two percent of 85-year olds had
a diagnosis of osteoarthritis in one study (20). e prevalence
of osteoarthritis seems to be higher among women than men.
Obesity is a risk factor for osteoarthritis and as the population
ages (and particularly as the overweight population ages), the
rate of severe hip, and knee arthritis will increase. Pain manage-
ment will continue to be a vexing clinical and health policy
problem as virtually all analgesics have remarkable risks in older
adults. Osteoarthritis treatments also include costly joint replace-
ment surgery, which is oen accompanied by intensive reha-
bilitative therapies. Low back pain is itself a common symptom
particularly in older women and the cause is oen multifactorial.
Non-pharmacologic treatments can help.
Diabetes Mellitus
Diabetes rates have been increasing as populations age and
become more overweight. e prevalence of diabetes among
American older adults may increase more than 400% by 2050
(31). Diabetes remains a strong risk factor for cardiovascular
disease at age 85 (32). Diabetes is also associated with peripheral
arterial disease and peripheral neuropathy, contributing to dia-
betic foot ulcers and amputations. Diabetic foot ulcers occur in
6% of diabetic patients annually and amputations in about 0.5%.
Management approaches in diabetes should be individualized.
Sulfonylureas and insulin carry a substantial risk of hypo-
glycemia and use should be weighed carefully in vulnerable
older adults. Transitions from hospital to home or post-acute care
are risky times for patients treated with hypoglycemic agents as
dosing needs may uctuate (31). Regular foot examinations are
critical for people with diabetes to prevent amputations. Regular
walking can improve circulation in the legs.
Osteoporosis
Osteopenia is normal loss of bone density with aging. Many
85-year-old adults have osteoporosis, a more severe weakening
of bone density. Osteoporosis is associated with an increased rate
of bone fractures, while osteopenia is not. Bone density screen-
ing is recommended for women over age 65 (33). Although the
prevalence of fractures in men increases by age 85, the value of
osteoporosis screening for men has not been clearly demonstrated.
e eectiveness and safety of calcium and vitamin D supple-
mentation in order to prevent fractures remains controversial.
Multiple Chronic Conditions
Sixty two percent of Americans over 65 have more than one
chronic condition (34) and the prevalence of multiple chronic
conditions is increasing (35), due to aging of populations and
to increasing diabetes rates. Older adults with multiple chronic
conditions account for a large percentage of health spending (36).
Targeting this population for research and for quality improve-
ment should improve care and reduce costs.
PHYSICAL FUNCTION
Normal age-related changes and accumulated pathology contrib-
ute to functional changes seen with aging.
Walking Speed
Walking speed declines with normal aging but will decline addi-
tionally due to disease. Walking speed measurements can be used
to predict future community ambulation, falls, disability (37), and
risk of mortality (38). Measurement of walking speed is quick,
safe, requires no special equipment, and adds no signicant cost
to clinical care. In one study, the average walking speed for the age
group of 85–89 is 1.1m/s for men and 0.8m/s for women. Aer
age 90years, mean waking speed decreased to 0.9 m/s for men
and 0.8m/s for women (39). Physical activity interventions can
improve walking speed.
Mobility Disability
Seventy-three percent of Americans over age 85 have some dif-
culty with walking according to a US Census study. Mobility
disability is associated with social isolation, falls, and depres-
sion. One-third of people over age 85 with a disability live
alone (40).
Disability in Activities of Daily Living
Disability rates are relatively high among adults over age 85.
Rates of disability in activities like dressing and bathing, and dis-
ability in instrumental activities of daily living such as cooking,
all rise with age over 80. Diculty with bathing typically pre-
cedes diculty with dressing or diculty with using the toilet.
In one study, 75% of people aged 85 had diculty or disability
with bathing and 25% had diculty or disability with using
the toilet (41). People with disabilities oen also struggle with
chronic pain, depression, and complex medication regimens
(42). e percentage of older adults with disabilities has modestly
decreased in recent decades.
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Falls
Falls are a major cause of morbidity and disability among older
adults. 30–40% of adults over age 70 fall each year and rates are
particularly high for older adults in long-term care facilities.
Falls account for more than half of injuries among older adults.
Fall-related death rates are higher for adults over age 85 than for
other age groups (43). Physical activity, vitamin D supplementa-
tion, balance exercise, and home safety assessment as a part of
a multifactorial fall prevention program have been shown to
reduce the incidence of falls (44). Individuals with balance prob-
lems or falls should have a multifactorial falls risk assessment (45).
Frailty
Frailty is dened as special vulnerability to stressors and is sug-
gested by weakness, slowness, exhaustion, and weight loss (46).
In one study, 38% of people aged 85–89 were frail (47). Frailty
status can be assessed easily and the frail state predicts future
disability, falls, hospitalizations, and poor surgical outcomes.
Targeted interventions for frail populations would likely include
physical activity and nutritional components (48) as well as
medication reviews.
Continence
irty percent of women over age 65 and 50% of older adults in
nursing facilities have urinary incontinence (49). Common causes
for incontinence among women include overactive bladder, stress
incontinence, and functional incontinence. Urinary incontinence
reduces well-being and quality of life (50). However, common
incontinence medications cause burdensome side eects.
PSYCHOLOGICAL AND COGNITIVE
Cognitive Aging
Mild short-term memory loss, word-nding diculty, and
slower processing speed are normal parts of aging that are oen
noticeable by age 85. Changes from normal brain aging can aect
driving safety and increase risk for nancial exploitation. ese
changes can also reduce capacity to understand complicated
medical information. Brain aging does not happen at a uniform
rate and genetic and social factors (like education and occupa-
tion) may be protective (51). Normal cognitive aging does not
lead to dementia.
Not all brain functions decline with age. Wisdom and knowl-
edge are known to increase with normal aging, contributing to
the appropriate respect aorded to community elders. Empathy
and altruism also may increase with age (52).
Dementia
Rates of dementia increase with age. Death rates from Alzheimer’s
disease have been rising while death rates for cardiovascular dis-
ease have been falling. Worldwide dementia prevalence may rise
from 47 million in 2015 to 131 million in 2050. e estimated cost
of dementia worldwide was $818 billion in 2015 and is expected
to grow to $2 trillion by 2030 (53). Although dementia screening
may have limited clinical benet because medications are only
marginally eective, screening may have public health benet.
Many older adults with dementia have unmet needs and may be
living or driving unsafely (54). e Folstein Mini-Mental State
Examination is the most commonly used instrument to diagnose
dementia but has several limitations including an educational
adjustment. For example, in the Irish Longitudinal Study on
Aging, mean MMSE scores for 85-year olds with poor education
was 25.2 while mean score for 85-year olds with good education
was 28.0 (55). People with dementia need opportunities for
cognitive stimulation, caregiver support, and possibly assistive
technologies to improve safety and independence.
Depression
Depression is not a normal consequence of aging. Grief can be
a normal response to life events that occur with aging such as
bereavement; retirement/loss of income; and loss of physical,
social, or cognitive function from illness. Major depression is
common throughout adulthood but incidence rates drop aer
age 60 and then rise again aer age 80. Depression prevalence
for adults over age 85 is double the rate seen at age 70–74 (23).
Depression is even more common among institutionalized older
adults and those with disabilities (56). Aggressive approaches
to diagnosis and treatment are warranted to minimize suer-
ing, improve overall functioning, and prevent suicide. Suicide
among older American adults is most common in 85-year-old
white men (57).
SOCIAL/ENVIRONMENTAL
Being married and being wealthy predict longer survival. e
benet of marriage seems stronger for men than women. Alter-
natively, social isolation predicts mortality and other adverse
outcomes in older adults (58). Five percent of older adults are
home bound, rarely leaving the home except for important medi-
cal appointments (59). Most of these older adults are >80. ese
older adults who live alone and are in poor health are vulnerable
during a natural disaster (60).
Most older adults, even at advanced ages, live in the commu-
nity. By 2035, the number of American households with someone
over age 80 will double (61).
Approximately 13% of women and 8% of men over age 85 live
in nursing facilities or other institutional settings (62). ese rates
have fallen in recent decades presumably due to less disability and
better care options in the home. Support for home caregivers and
promotion of home medical and social work services can further
minimize institutionalization. More than 17 million Americans
served as family caregivers to an older adult in 2011 (63). Being
a caregiver is typically a prolonged responsibility although the
number of hours of work involved markedly varies based on the
needs of the care recipient. Older adults with dementia have the
highest needs for caregiver time. Opportunities to support family
caregivers can include formal training, peer counseling, stress
management, legal advice, and employment-exibility (64).
MEDICAL DECISIONS
Starting or stopping medications, ordering screening tests, send-
ing people to the hospital, and advising families about placement
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or end of life care are complex discussions which health provid-
ers have with people over age 85. Oen, family members play a
central role in these complex discussions. e patient may have
hearing impairment, cognitive impairment, or communication
impairment. Life expectancy is oen a major consideration;
however, many patients are skeptical of life expectancy estimates
and don’t like to talk about it (65).
Polypharmacy
Polypharmacy is dened as the use of concomitant use of ve or
more medications by a single patient. When taking ve medica-
tions, the risk of an adverse drug event or drug-drug interaction
is very high. Polypharmacy increases the risk of falls, disability
(66), and other negative outcomes. Providers must weigh time to
benet, burden, risks of adverse eects, and goals of care when
choosing to start or stop medications in people over age 85 (67).
Hospitalization
Hospitalizations are common among people over age 85 (68) and
associated with functional decline (69). Providing more acute
care in the home could help to prevent hospital complications
such as functional decline and iatrogenic infection. Attention to
transitional care and rapid post-hospital medical follow-up visits
can minimize medication errors and rehospitalization.
Institutional Placement
Many older adults value their ability to continue living in their
own homes as they age. Home-based interventions may slow the
progression of disability and prevent the need for institutionaliza-
tion (70). Discussions with families review all of the options for
living arrangements and then assess safety and preferences.
Advance Directives and End of Life Care
Many 85-year olds with multiple chronic conditions will die within
a few years. Advance directives on life-sustaining therapies such
as cardiopulmonary resuscitation, mechanical ventilation, and
tube feeding enable patients to exert some control over their end
of life care. Every 85-year-old adult should appoint a health-care
agent who can make complicated decisions in an emergency.
As people approach the end of life, medical discussions tend
to focus more on quality of life and symptom management.
However, thes e “palliative” conversations are not only appropriate
near the end of life. Clinicians should routinely assess symptoms
and evaluate which problems aect a person’s quality of life.
CONCLUSION
e aging process is universal but not uniform. Awareness of
age-related physiological changes, such as reduced acuity of
vision and hearing, slow reaction time, and impaired balance, will
prepare patients and caregivers to manage risks, make informed
decisions, and perhaps prevent falls and medication adverse
eects.
Functional deterioration in an elderly person can also arise
from social and mental health problems. Awareness of these
problems may prevent age-related deterioration, such as atten-
tion to depression and suicide risk in men during the rst year
following the death of a spouse or depression aer hip fracture
or stroke.
Optimizing vision and hearing can prevent isolation, depression,
and cognitive impairment. Lower extremity strength especially
of the quadriceps muscle is critical for basic activities of daily
living, especially bathing, walking, and performing transfers.
People over age 85 need these muscles for stability and preventing
falls. Walking speed is a helpful measure. Resistance exercise such
as regular walking is recommended to help maintain strength
and prevent cardiovascular disease. Maintaining a healthy body
weight throughout the life span likewise can prevent diabetes,
osteoarthritis, and other chronic diseases.
Decisions to prescribe medications or order screening tests
should take into account goals of care, burden, risks, and lag time
to benet. In the future, more adults over age 85 will benet from
home-based services and technologies and will benet from crea-
tive transportation and housing services opportunities for social
participation, as well as programs to support family caregivers.
AUTHOR CONTRIBUTIONS
EJ and JB both contributed to the conception and writing of the
paper.
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Conict of Interest Statement: e authors declare that the research was con-
ducted in the absence of any commercial or nancial relationships that could be
construed as a potential conict of interest.
e reviewer EC and handling editor declared their shared aliation.
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