Demography
This short chapter summarises some of the findings of the Information and Statistics Division (ISD) Report "The Health and Well-Being of Older People in Scotland".
Scotland's population is changing. This is dramatically illustrated in the four sections of fig-1, each a snapshot of the size, age and gender structure of the population, at forty-year intervals and covering the 120 years from 1911.
Fig-1
In 1911, high fertility and high mortality combined to give a young population structure, tapering off rapidly in middle age, with only small numbers reaching what we now think of as old age. By 1951 the decline in mortality in younger age groups has led to a growth in the total population, and more and more people are living into their 60s and 70s.
The sustained high birth rates of the 1950s and 60s - the baby boom - are reflected in the 1991 picture, and again the numbers of people living into their 70s and 80s has increased. And the projection for 2031 shows significant mass ageing, and the consequences of lower fertility in the 1970s and beyond - Scotland's ageing population.
Between 2000 and 2031 the numbers of people over 65 is expected to increase from 787,000 to 1,200,000; and those over 85 from 84,000 to 150,000.
In general, populations are ageing more rapidly in Scotland's rural areas, with over-65s, currently accounting for less than 20%, rising to 22-24% in Borders, Dumfries and Galloway, Highland, Orkney and Western Isles by the year 2016 and Scotland's ethnic minorities, though currently mainly younger than the majority, share in this process of population ageing too. In coming decades the numbers of people from ethnic minorities will figure more prominently among Scotland's older people.
Older people in Scotland today: their use of health services
Older Scots, the 787,000 over 65s, make considerable use of health services. Each year NHSScotland provides for them:
Around a third of a million Scots are over 75. In general terms, they are the group most likely to have higher dependency and more complex health needs.
The health of older people in Scotland varies according to social circumstances. The least well off and those in the most deprived areas have poorer health and shorter life expectancy.
Trends in Elective Care
Much of the elective - i.e. non-emergency - work carried out by surgeons in
NHSScotland is for the benefit of older patients. Cataract surgery restores
vision and enables older people to resume a more active lifestyle. Hip and knee
replacement
surgery restores lost mobility, relieves pain and also enhances quality of life.
The volume of such surgery has risen greatly in response to the needs of growing numbers of older people. This is illustrated in fig-2.
Fig-2
Total Hip Replacements, Scotland 1978-1999
Clearly the further growth in numbers of older people must be met by further increases in the provision of such surgery and the related rehabilitation, and as more older people remain healthier and more active, their expectations of such life-enhancing interventions will rise, again increasing demand.
Trends in Acute Care
In recent years emergency admissions to acute care have increased markedly,
and the increase has been most marked in the oldest age groups, as illustrated
in
fig-3. There are particular concerns about the care of the rapidly rising numbers
of old and very old people who are unwell but for whom no clear acute diagnosis
can be established.
Fig-3
Trends in emergency admission rates by age group, Scotland 1981-1999
Another recent trend in acute admissions documented by the Information and Statistics Division (ISD) is the rising number of individual patients - many of them old or very old - who are admitted as an emergency several times over a limited period. Between 1995 and 1999, one in ten people aged 85 and over was admitted four times or more. And the number of such patients with multiple emergency admissions aged 65 and over doubled in a ten-year period, as illustrated in fig-4.
Fig-4
Patients with 4 or more emergency admissions as a proportion of population.
1985-89, 1990-94, 1995-99.
Such patients are often frail and have a number of long-standing health problems. Their admission is commonly wholly or partly determined by concerns about their dependency and support. Their diagnosis and treatment may be relatively straightforward. Successful management of such patients - whether in hospital or at home - is essential in the avoidance of unnecessary long-term care as a result of short-term illness.
These trends should be seen in the context of Scotland's ageing population, and pose a considerable challenge in the management of episodes of acute illness in older people now and in the future. The hospital sector should plan for increasing numbers of older acute admissions.
However, there is now growing recognition that better community support - encompassing nursing and domiciliary care as well as medical and rehabilitation inputs - for older people at home will allow more to remain there through an episode of acute or sub-acute illness.
Recommendations: