EPIDEMIOLOGY OF STROKE

Stroke is the most common neurologic disease and the leading cause of adult disability in Western countries. The number of patients affected by stroke will increase by the effect of aging. Mainly due to increased life expectancy, the proportion of individuals over 65 years in the L'Aquila district showed an increase of 18.3% in a 10 years period (1981-1991). Among the resident population, in a five-year period (1994-1998) we collected all the patients with a first-ever stroke, and we found high crude and standardized (European population 1996) incidence rates. There was a significant correlation between crude and standardized incidence rates and proportion of individuals aged 65 and over, suggesting that the high incidence was due to an increased stroke risk linked to aging. As a cosequence, the number of subjects with atherosclerotic comorbidity will increase and the quality of life will worsen.     

Rapidly changing myeloma epidemiology in the general population: Increased incidence,older patients,and longer survival

The incidence of multiple myeloma is characterized by a steep increase with advancing age. Dramatic improvements in survival have been reported in clinical trials; however, elderly patients are generally underrepresented in these. The aims of this study are to review patterns of incidence and survival in multiple myeloma in the general population. We searched PubMed for population‐based studies on trends in incidence and survival published between January 1, 2000 and June 30, 2017 and based on regional or national cancer registries and report the following results of the review. The age‐adjusted incidence of multiple myeloma has increased during the second half of the twentieth century in some countries but remained stable in areas with high case ascertainment and access to universal medical care. The crude incidence is increasing globally due to an aging population. Survival rates have improved, and 5‐year relative survival rates are now around 50% and over 60% in patients 65‐70 years or younger. Preliminary data suggest a 3‐fold increase in the prevalence of multiple myeloma. We conclude that the number of multiple myeloma patients is increasing in the general population due to (i) aging populations and (ii) more patients living longer due to modern drugs.     

Epidemiology of atrial fibrillation

The incidence and prevalence of atrial fibrillation (AF) increase progressively with age, and approximately 50% of patients with AF are 75 years of age or older. Advanced age is also a potent risk factor for stroke in patients with AF, and the proportion of strokes attributable to AF increases exponentially with age. In addition, AF contributes incrementally to health care utilization and costs, and decrementally to survival and quality of life in older adults. Furthermore, the societal impact of AF will likely double over the next three decades due to the aging of the population. For these reasons, it is essential to develop more effective strategies for the prevention and treatment of AF in older individuals. This work was supported by a grant from the National Institute on Aging (R13 AG23743, Michael W. Rich, MD, PI)     

Trends in physician-diagnosed osteoarthritis incidence in an administrative database in British Columbia, Canada, 1996-1997 through 2003-2004

OBJECTIVE: Prevalence of osteoarthritis (OA) is expected to increase due to population aging. However, there is little information on the trends in the incidence of OA over time. The purpose of this study was to describe changes in physician-diagnosed OA incidence rates between 1996-1997 and 2003-2004 in British Columbia (BC), Canada. METHODS: We used data on all visits to health professionals and hospital admissions covered by the Medical Services Plan of BC (population approximately 4 million) for the fiscal years 1991-1992 through 2003-2004. Rates were standardized to the BC population in 2000. We used 2 definitions of OA: 1) at least 1 visit or hospitalization with a diagnostic code for OA, and 2) at least 2 visits or 1 hospitalization with a code for OA. Incidence rates were calculated with a 5-year run-in period to exclude prevalent cases. RESULTS: Between 1996-1997 and 2003-2004, crude incidence rates of OA based on definition 1 increased from 10.5 to 12.2 per 1,000 in men and from 13.9 to 17.4 per 1,000 in women. The age-standardized rates did not change in men and increased from 14.7 to 16.7 per 1,000 in women. Incidence rates based on definition 2 were almost 50% lower, but the trends were similar. CONCLUSION: We observed an increase in the incidence of OA in both men and women due to population aging and an additional increase in women beyond the effect of aging. These trends have important implications for public health and provision of health services to this very large group of patients.     

Anticipated Increase in the Number of Patients Who Require Dialysis Treatment Among the Aging Population of Japan

The aging population is anticipated to have a large impact on the number of incident dialysis patients, as the risk of end‐stage kidney disease increases with age. This study aimed to examine trends in the sex‐ and age‐specific incidence rates of dialysis between 2008 and 2012, and to assess the impact of population aging on the number of incident dialysis patients over the next decade in Japan. Incidence was calculated using published data and Japan's population statistics. The 2012 incidence was extrapolated, and projected future demographic changes within the Japanese population were used to estimate the number of incident dialysis patients in 2020 and 2025. As a general trend, the sex‐ and age‐specific incidence rates of dialysis decreased gradually between 2008 and 2012, except among men aged ≥80 years. The total number of incident dialysis patients was projected to increase by 12.8% from 36 590 in 2012 to 41 270 in 2025. Greater increases were observed in the oldest age group (≥85 years). In 2025, the number of incident dialysis patients in this group was projected to increase by 92.6% in men and 62.2% in women. This study shows the number of patients who initiate dialysis treatment is projected to increase over the next decade in Japan due to aging of the population. Effective strategies are needed to offset the challenges faced by the aging population, with a particular focus on octogenarians and older, given the notable proportion of patients requiring dialysis treatment in the future.     

Trends in physician‐diagnosed osteoarthritis incidence in an administrative database in British Columbia,Canada, 1996–1997 through 2003–2004

Objective

Prevalence of osteoarthritis (OA) is expected to increase due to population aging. However, there is little information on the trends in the incidence of OA over time. The purpose of this study was to describe changes in physician‐diagnosed OA incidence rates between 1996–1997 and 2003–2004 in British Columbia (BC), Canada.

Methods

We used data on all visits to health professionals and hospital admissions covered by the Medical Services Plan of BC (population ～4 million) for the fiscal years 1991–1992 through 2003–2004. Rates were standardized to the BC population in 2000. We used 2 definitions of OA: 1) at least 1 visit or hospitalization with a diagnostic code for OA, and 2) at least 2 visits or 1 hospitalization with a code for OA. Incidence rates were calculated with a 5‐year run‐in period to exclude prevalent cases.

Results

Between 1996–1997 and 2003–2004, crude incidence rates of OA based on definition 1 increased from 10.5 to 12.2 per 1,000 in men and from 13.9 to 17.4 per 1,000 in women. The age‐standardized rates did not change in men and increased from 14.7 to 16.7 per 1,000 in women. Incidence rates based on definition 2 were almost 50% lower, but the trends were similar.

Conclusion

We observed an increase in the incidence of OA in both men and women due to population aging and an additional increase in women beyond the effect of aging. These trends have important implications for public health and provision of health services to this very large group of patients.     

Aging‐ and vascular‐related pathologies

Our aging population is set to grow considerably in the coming decades. In fact, the number of individuals older than 65 years will double by 2050. This projected increase in people living with extended life expectancy represents an inevitable upsurge in the presentation of age‐related pathologies. However, our current understanding of the impact of aging on a number of biological processes is unfortunately inadequate. Cardiovascular, cerebrovascular, and neurodegenerative diseases are particularly prevalent in the elderly population. Intriguingly, these pathologies are all associated with vascular dysfunction, suggesting that the process of aging can induce structural and functional impairments in vascular networks. Together with elevated cell senescence, pre‐existing comorbidities, and the emerging concept of age‐associated inflammatory imbalance, impaired vascular functions can significantly increase one's risk in acquiring age‐related diseases. In this short review, we highlight some current clinical and experimental evidence of how biological aging contributes to three vascular‐associated pathologies: atherosclerosis, stroke, and Alzheimer's disease.     

Mortality trends of elderly people in Taiwan from 1974 to 1994.

BACKGROUND: the hypothesis that disability and death will eventually be compressed to a period late in life needs empirical confirmation. OBJECTIVES: we have examined the secular trends of life expectancy and common causes of death in the aged population of Taiwan. METHOD: we compared the life expectancy, causes of death and probability of death for people at birth, at age 65 and at age 85 for both sexes from 1974 to 1994 using data from Taiwan government statistics. RESULTS: there has been a substantial gain in life expectancy, especially for men age 85 and over, in the past 20 years. .Mortality due to stroke, ischaemic heart disease, hypertension and chronic pulmonary disease has declined. There has been a steep increase in cancer deaths and deaths associated with diabetes mellitus. Tuberculosis and injury-related deaths have declined but pneumonia deaths have increased. For elderly people, the probability of dying from cancer and ischaemic heart disease increased with time. However, the probability of dying from stroke decreased. Although there was a decrease in probability of deaths associated with falls, there was an increase of deaths due to 'frailty' (as judged by falls, pneumonia and septicaemia). CONCLUSIONS: cancer is a major cause of death in the elderly population of Taiwan. This rapidly expanding elderly population seemed to suffer from poorer health in the later period of their life.     

Measuring population aging as a function of fertility,mortality, and migration

Researchers often describe population aging with measures such as proportion of population under 15 years of age, proportion of population 65 years and over, the aged-child ratio (a ratio of the first two measures), median age, and mean age. Investigators of cross-cultural gerontology, too, use such measures to compare population aging between populations. While insights from comparing only the values of an aging measure between two populations may be helpful, results from such comparison can be misleading due to the influences of fertility, mortality, and migration. To show the effects of these demographic processes on measures of population aging, rates of change in five measures of population aging as a function of fertility, mortality, and migration are developed. These rates of change are estimated for various stable populations, for stable populations disequilibrated by fertility and mortality declines and by net migration, and for the population in Japan, 1988–1989. The findings demonstrate that the five aging measures, in general, do not give consistent rate-of-change estimates; they also suggest that directly comparing values of aging measures without considering the levels and patterns of fertility, mortality and migration will lead to misleading conclusions.     

Diabetes trends in Latin America

The incidence of type 1 diabetes in Latin America ranges from 0.4 to 8.3 cases per 100000 children under 15 years of age, and the prevalence of type 2 diabetes ranges from 1.2% to 8%, with higher prevalence rates in urban areas. The frequency of diabetes in Latin America is expected to increase by 38% over the next 10 years, compared with an estimated 14% increase in the total population. The total number of cases of diabetes is expected to more than double and to exceed the number of cases in the US, Canada, and Europe by 2025. Factors underlying this increase include aging and increased life expectancy of the population, increased urbanization, and lifestyle changes among Native American populations. In many places, only a minority of individuals currently receives treatment for diabetes. Furthermore, the diagnosis of type 2 diabetes often occurs late in the course of the disease, with the result that 10-40% of patients have chronic complications at the time of diagnosis. Hospital costs account for most direct expenditures associated with treatment, and mortality associated with diabetes has increased markedly in some areas over the past 2 decades.     

A marked increase of ischemic stroke incidence between 1980 and 1994 in S. Caterina, Sicily

Stroke death rates have been declining for some decades in most of the industrialized countries. It is not clear, whether this has been associated with a decrease in stroke incidence. We studied temporal trends in stroke incidence in a rural community in Sicily, during two periods 1980-84 and 1990-94. There was a total of 231 patients (120 of them women). The diagnosis of stroke was based on the clinical evaluation and CT scan since 1982 and onward. There were 109 ischemic strokes (51 women) mean age 72.7 years, in 1980-84 period; 122 ischemic strokes (69 women) mean age 75.1, in 1990-94 period. Cardiovascular risk factor rates did not change in the two periods considered. The relative annual stroke incidence rate increased 37.0%; (2.7 in 1980-84 to 3.7/1000 inhabitants in 1990-94, p = 0.0161. In the population older than 65 years, the same parameter increased by 21.1% between the two periods; (16.1 in 1980-84 to 19.5/1000 inhabitants in 1990-94, not significant). This increase was due mainly to a 45.3% significant relative increase in women, from 7.5 to 11.0/1000 inhabitants (p = 0.039). These findings suggest a need of the reconsideration of effective strategies for the prevention of stroke.     

Aging with HIV: a practical review

The worldwide elderly population is expected to grow by an additional 694 million people by 2025. By that time, there will be approximately two billion elderly people in the world, most of whom (80%) will be living in developing countries. Based on recent estimates, this population will number over 40 million in 2030 in Brazil and a consequent increase in governmental spending for this population can be expected. Since highly active antiretroviral therapy became available in the mid-1990s, the life expectancy of people living with HIV has increased significantly. Approximately 12 million life years were added to the world between 1996 and 2008 as a consequence of wider access to highly active antiretroviral therapy. In Brazil, the incidence of AIDS among the population aged ≥50 years doubled between 1996 and 2006. The development of antiretroviral therapy has allowed individuals diagnosed at a younger age to live longer, which partially explains the aging tendency associated with the HIV/AIDS epidemic. It is estimated that by 2015, subjects aged ≥50 years will represent 50% of the people living with HIV undergoing clinical treatment. This scenario presents some challenges, including the fact that the diagnosis of HIV tends to be delayed in older patients compared to younger patients because the symptoms of HIV can be confused with those of other common diseases among the elderly and also because healthcare professionals do not consider this population to be at high risk for HIV infection. In regard to the individuals diagnosed with HIV, a further challenge is presented by the morbidity normally associated with aging. Finally, the elderly also exhibit higher susceptibility to the toxic effects and pharmacological interactions of medications. The present article reviews the literature regarding the profile of HIV infection among individuals aged ≥50 years focusing on practical features related to the clinical approach and long-term follow-up of this population.     

Epidemiology of heart failure

Of all persons aged over 40 years, approximately 1% have heart failure. The prevalence of heart failure doubles with each decade of life, and is around 10% in persons over 70 years of age. In Spain, heart failure causes nearly 80,000 hospital admissions every year. As in other developed countries, heart failure is the most frequent cause of hospitalization among persons 65 years of age and over, and is responsible for 5% of all hospitalizations. The incidence of heart failure increases with age, and reaches 1% per year in those over 65. Heart failure is a progressive, lethal disorder, even with adequate treatment. Five-year survival is around 50%, which is no better than that for many cancers. In Spain, heart failure is the third leading cause of cardiovascular mortality, after coronary disease and stroke. In 2000, heart failure caused 4% of all deaths and 10% of cardiovascular deaths in men; the corresponding figures for women were 8% and 18%. In recent decades the prevalence and number of hospitalizations due to heart failure have increased steadily in developed countries. Heart failure will probably continue to increase in coming years: although its incidence has not materially decreased, survival is increasing due to better treatment. The control of risk factors for hypertension and ischemic heart disease, the main causes of heart failure in Spain, is the only method to halt the foreseeable increase in heart failure in the near future.     

The incidence of hip fractures in The Netherlands

The number of hip fractures in women 65 yr of age and over increased from 3416 in 1972 to 8075 in 1987. In men of the same age group the number of hip fractures increased from 1167 in 1972 to 2285 in 1987. This increase can only in part be explained by the increase in the proportion of aged people in the Dutch population. The age-adjusted incidence of hip fractures in The Netherlands rose linearly from 479/100,000 to 669/100,000 per year in women aged 65 yr and over during the period 1972-1987. In men of the same age group the age-adjusted incidence of hip fractures increased linearly from 198/100,000 to 308/100,000 per year over the period studied. The total number of hip fractures in the year 2010 has been estimated at 22,726. The mean duration of a hospital stay because of a hip fracture was 30 days in 1987. The annual need for hospital beds in 1987 for the treatment of hip fractures was calculated at 851. For the year 2010, the annual need for hospital beds, based on a 30-day hospital stay, has been estimated at 1866. Should the duration of a hospital admission due to a hip fracture be reduced to 20 days, then the annual need for hospital beds in 2010 would be 1244.     

Mortality postponed and the unmasking of age-dependent non-fatal conditions

Mortality occurs at older ages in our growing and salubrious population. At present, fewer than 20% of all deaths, in Sweden, occur before age 65 with 18% of the Swedish population 65 and over. In the United States, 24% of deaths occur before age 65 with only 12% of the population age 65 and over. All countries in the developed world will have approximately 20% of their populations age 65 and over by about 2020. At that time, the percentage of deaths occurring prior to age 65 should range from 14%-16%. Thus future gains in morbidity and mortality will be influenced, to a lesser extent, by events prior to age 65 and prevention and health promotion strategies post age 65 become increasingly important. Active life expectancy, a developing concept, refers to the years lived in good health with no functional limitations. The period after active life expectancy consists of years of compromised health and well being. At present, each year gained of active life expectancy incurs almost four years of compromised health. A group of age-dependent nonfatal conditions are largely responsible for increased prevalence of social and physical deficits with age. These include dementia, osteoarthritis, diminished hearing and visual acuity, incontinence, depression, widowhood, isolation and institutionalization. Age-specific incidence of most of these conditions is unknown. There is little evidence, however, that adding years to life has postponed their age at onset. For these conditions, postponement is the major mechanism of prevention. We are attempting to construct time trends concerning the age-specific incidence and the ability to postpone age-dependent conditions.(ABSTRACT TRUNCATED AT 250 WORDS)     

Modeling of the aging-cancer interface: some thoughts on a complex biological dynamics

Major US demographers predict that, by the year 2010, the United States will have attained zero population growth. They further predict that, by that time, more than half the U.S. population will be over the age of 40. Along with this dynamic change in the underlying age structure of the population comes an increasing body of evidence which supports the correlation between chronological age of the host and incidence of a variety of human cancers. Not only does cancer affect the older age group in a disproportionate manner but, as we have already noted, our nation's number of older individuals is increasing. In 1900, the number of individuals over 65 years of age was 3.1 million. By 2030 this number is expected to reach 55 million. Hence, there will be an increasing need for cancer treatment and cancer care among the older segment of the population. This chapter addresses some of the issues of the modeling and the simulation of the interplay of aging normal tissues and cancer processes. We will illustrate some simply preliminary results and will show how these might be extended to address some of the more complex questions arising in this intriguing interface.     

Perioperative care of the geriatric patient for noncardiac surgery

Adults age 65 and over are the fastest growing segment of the population in the United States and around the world. As the size of this population expands, the number of older adults referred for surgical procedures will continue to increase. Due to the physiologic changes of aging and the increased frequency of comorbidities, older adults are at increased risk for adverse outcomes, and perioperative care is inherently more complex than in younger individuals. In this review, we discuss the physiologic changes of aging relevant to the surgical patient, comprehensive preoperative assessment, and postoperative management of common complications in older adults in order to promote optimal clinical outcomes both perioperatively and long-term.     

Reappraisal of the epidemiology of giant cell arteritis in Olmsted County, Minnesota, over a fifty-year period

OBJECTIVE: To investigate time trends in the incidence and survival of giant cell arteritis (GCA) over a 50-year period in Olmsted County, Minnesota. METHODS: Using the unified record system at the Mayo Clinic, we identified all incident cases of GCA first diagnosed between 1950 and 1999. Incidence rates were estimated and adjusted to the 1980 United States white population for age and sex. The annual incidence rates were graphically illustrated using a 3-year centered moving average. Survival rates were computed and compared with the expected rates in the population. RESULTS: There were 173 incident cases of GCA during the 50-year study period. Of these, 79% were women and the mean age at diagnosis was 74.8 years. The overall age- and sex-adjusted incidence per 100,000 persons 50 years of age or older was 18.8 (95% confidence interval [95% CI] 15.9-21.6). Incidence was higher in women (24.4; 95% CI 20.3-28.6) than in men (10.3; 95% CI 6.9-13.6). Incidence rates increased significantly over the study period (P = 0.017); in particular, a progressive increase was observed from 1950 to 1979; subsequently, no substantial increases in incidence rates were observed. A cyclic pattern of annual incidence rates was apparent, with evidence of 6 peak periods. Survival among individuals with GCA was not significantly different from that expected in the population (P = 0.80). CONCLUSIONS: The incidence of GCA increased over the first 3 decades of the study, then remained stable over the last 20 years. The previously observed cyclic pattern of annual incidence rates was still apparent over a 50-year period. Overall survival in GCA was similar to that in the population.     

Incidence of stroke in the diabetic compared with the non‐diabetic population: A systematic review protocol

People with diabetes have a largely increased risk of stroke compared with people without diabetes. Exact data on incidence of stroke in people with and without diabetes are important for improvements in preventive diabetes care, avoidance of fatal outcomes and as a solid basis for health policy and the economy. However, published data are conflicting, underlining the necessity for this systematic review of population‐based studies on incidence, relative risks (RRs) and changes in stroke rates over time. The purpose of our review is to evaluate the incidence of stroke in the diabetic population and its differences with regard to sex, ethnicity, age and regions; to compare the incidence rate (IR) in the diabetic and non‐diabetic populations and to investigate time trends. We will perform a systematic literature search in MEDLINE, Embase and LILACS designed by an experienced information scientist. Two review authors will independently screen the abstracts and full texts of all references on the basis of inclusion criteria regarding types of study, types of population and the main outcome. Data extraction and assessment of risk of bias will be undertaken by two review authors working independently. We will assess IR or cumulative incidence (CumI) and RR of stroke comparing the diabetic and non‐diabetic populations. The attributable risk (AR = proportion of stroke among persons with diabetes that is attributable to diabetes) and the population attributable risk (PAR = proportion of stroke in the whole population that is attributable to diabetes) will be considered where available. In conclusion, this review will help to summarize the available evidence for incidence of stroke in the diabetic and nondiabetic population. The publication of this protocol will contribute to making the search strategy, methods, and assessment of reviews transparent and accessible for all involved professional groups.     

Estimation of the future epidemiological situation of tuberculosis in Japan

OBJECTIVE: To estimate the future trends of all forms of tuberculosis (TB) and sputum smear positive pulmonary TB in order to consider the emerging issues of TB control and eliminating TB in Japan. MATERIALS AND METHODS] Annual reports of TB registrations were used for observing past trends of TB, and predictions were then made assuming that past trends would continue. At first, to obtain the number of TB patients by sex and age-group, sex-age-specific incidence rates were estimated for the years 2010, 2015, 2020, 2025 and 2030, and then applied to a sex-age-specific population which was projected by the National Institution of Population and Social Security Research. According to the different methods used to calculate the reduction rates of incidence, we adopted model A and model B. In model A, the reduction rate was calculated by using two groups of the same age group but different members by calendar year. In model B, the reduction rate was calculated by using the same birth cohort but different age by calendar year. We also adopted two sub-models by the observation period of past trends. The incidence rates for the period from 1987 to 2005 were used in model 1 and the incidence rates for the period from 1998 to 2005 were used in model 2. The incidence rate in 1999 was excluded from both model 1 and 2, because the TB incidence rate increased abnormally due to the declaration of a state of emergency concerning tuberculosis in 1999. The speed of decline among particular several sex-age-groups was weighted taking into account the influence of foreign, homeless and elderly cases. The future number of sex-age-specific sputum smear positive pulmonary patients was estimated by applying various parameters, i.e. pulmonary TB rate, sputum smear positive rate and its trend, to the estimated future number of TB incidence. RESULTS: The TB incidence rate, which was 22.2 per 100,000 population as of 2005, would reach 9.8 in model A-1, 5.4 in model A-2, 7.5 in model B-1 and 3.2 in model B-2 by 2030. On the other hand, the sputum smear positive pulmonary incidence rate, which was 8.9 per 100,000 population as of 2005, would decline to 5.5 in model A-1, 3.0 in model A-2, 4.2 in model B-1 and 1.7 in model B-2 by 2030. The future number of TB patients and incidence rates by sex and age were discussed based on a mixed model which used the middle series of estimates, and was obtained by combining model A-2 and model B-1. The number of TB patients by the mixed model will become about 12 thousand with 10.1 per 100,000 population in 2020, and about 7.4 thousand with 6.5 per 100,000 population in 2030. From 2005 to 2020, the age composition of TB patients will change from 0.4% to 0.2% at 0-14 years old, 4% to 4% at 15-24 years old, from 10% to 11% at 25-34 years old, 8% to 11% at 35-44 years old, from 9% to 12% at 45-54 years old, from 15% to 10% at 55-64 years old, 18% to 15% at 64-74 years old, from 24% to 17% at 75-84 years old, and from 11% to 20% at 85 years of age or older. Although the proportion of the elderly aged 65 years or higher will not be so different, the proportion of TB patients aged 85 years or older will almost double. CONCLUSION: The year when the TB incidence rate will reach the level of low-incidence countries, which is defined as a country with a TB incidence rate of less than 10 per 100,000 population, might be around 2020 in Japan. At that time, the age composition of TB patients will tend to be very old patients, and the young adult and middle-aged patients. Problems such as delay in diagnosis and difficulty of treatment are expected among very old patients.