Aging: a subject that must be at the top of world agendas

Today we join some 100 other medical journals from over 30 countries in publishing an issue devoted to aging. Our aims are to alert readers, the public, and governments to the radical changes being created across the world by the aging of populations and to contribute a substantial body of research and information on all aspects of aging. Aging emerged as the favoured subject for the global theme issue after a two stage voting process among editors of medical journals. Research has shown that readers also rank it as the top issue. One reason that aging emerged in first place is that it affects everything—cells, physiological systems, clinical medicine, society, economics, ethics. This theme issue—in the tradition of the BMJ—tries to reflect that broad impact.

Aging has become an important issue because of dramatic changes in life expectancy. Only one in six Britains born 150 years ago reached 75, whereas two thirds of those born today will. People over 60 currently constitute a fifth of the British population but will be a third by 2030. Those aged over 80 are the fasting growing section of the population. In 1951 Britain had 300 people aged over 100; by 2031 it will have 34 000. Other developed countries have seen the same growth in numbers of elderly people, while countries that have more recently become industrialised are going through a much more rapid transition in their age structure (p 1037). Yet—because most of the population lives there—60% of people over 60 are in the developing world, and it will be 80% by the middle of the next century (p 1082). We have much still to learn about the impact of aging on the developing world.

We are thus moving to a world where older people will outnumber children—and we are not well prepared. Our lack of preparedness is illustrated by every country in the world having well developed paediatrics but only Britain (in the words of Robert Butler, an American expert on aging (p 1082)) having well developed geriatrics. We don't want children fighting elderly people for limited resources, but our societies need to change as birth rates fall and life expectancy rises. Britain is about to begin a major process to try and achieve this change—through the Debate of the Age, which its organisers hope will involve 80% of the population (p 1034).

Basic scientists have played a central part in increasing life expectancy and are now busy trying to understand aging. David Mann describes the impact that molecular biology is having on the study of aging and makes clear that aging and the disorders of later life are not the same thing (p 1078). Richard Doll and Richard Peto explore a similar theme in an editorial (p 1030). Death is inevitable but disease is not. Aging is unlikely to be explained by one theory. It probably results from an accumulation of unrepaired damage to DNA, mitochondria, and other structures and is clearly a function of both genetic inheritance and environmental factors, including lifestyle.

The aim of science and medicine is less to lengthen life and more to reduce the number of years that people spend diseased or disabled. Kay-Tee Khaw points out that those aged 60 in Britain currently must expect to spend about a quarter of their remaining years with some disability (p 1090). Yet healthy aging is clearly possible, and those who are rich, well educated, don't smoke, and are physically active do seem to be experiencing a “compression of morbidity”—their extra years of life are largely healthy. There are wide variations in the prevalence of chronic disease in different communities, and Khaw describes important measures people can take to help maintain their health. Simple measures, such as a healthy diet and exercise, are often under-rated by doctors and patients. But healthy aging will always be difficult for the many elderly people around the world living in poverty and poor housing. Public health measures are as important for promoting the health of elderly people as for promoting the health of those of any age.

Some features of promoting health in elderly people do not, however, seem to be well understood. For instance, coronary artery disease is seen by many as a disease of middle aged men, but—as Nanette Wenger makes clear (p 1085)—it is more common in elderly women than in any other group. Women are usually 10 years older than men when they first show signs of coronary artery disease. More women than men die of coronary artery disease in the United States, and a white postmenopausal woman in the United States is 10 times more likely to die of heart disease than of breast cancer or hip fracture. Furthermore, mortality and morbidity after myocardial infarction and coronary revascularisation are greater in women than men. Another public health issue that does not receive enough emphasis is smoking. Antismoking messages are often directed at the young with the aim of trying to stop them starting to smoke, but numbers of elderly smokers are increasing in many societies—and smoking remains the leading cause of chronic illness and premature death among elderly adults. A special issue of Tobacco Control (which is published by the BMJ Publishing Group) explores strategies to reduce tobacco harm among older adults.

Clinical medicine has much to offer elderly people, and doctors in most specialties find that their patients are becoming steadily older. Marco Pahor and William Applegate review recent advances in geriatric medicine and discuss the possibility that non-steroidal anti-inflammatory drugs may help prevent dementia and cancer, and that antioxidants may protect against some age related disorders, urge doctors to treat high systolic blood pressure, and show how targeted and coordinated home health care can improve the health of elderly people and reduce admissions to hospital (p 1071). A randomised controlled trial from New Zealand shows how a tailored exercise programme can reduce falls at home among elderly women (p 1065), while a study from London describes a tool to help predict which elderly inpatients are likely to fall (p 1049). Unfortunately, disorders in elderly people are commonly iatrogenic, and a Dutch study shows that two of five elderly patients admitted to a general medical ward experience adverse drug reactions (p 1057). Paula Rochon and Jerry Gurwitz alert doctors to the need to consider any new medical symptom as a possible adverse drug event (p 1096). In this way, we can avoid treating adverse drug events with further medication.

A final recurrent theme of this special issue is discrimination against elderly people. A British study confirms previous evidence—summarised by Jerry Avorn (p 1033)—showing that elderly people are regularly excluded from clinical trials (p 1059). Yet it is often difficult to extrapolate the results of trials conducted in younger people to older people. Graham Sutton argues that agism has led the British to exclude women over 65 from breast screening (p 1032), although they have the highest incidence of the disease. A British study finds that doctors rarely examine the breasts of older women even when there are strong clinical reasons for doing so (p 1058). Two other studies show that elderly people often miss out on chiropody (p 1058) and influenza vaccination (p 1060), which may in part be due to discrimination. Two personal views illustrate the way that elderly people may be patronised or neglected by health professionals (p 1100 and 1101), and the British newspaper, the Observer, has just begun a campaign to highlight the way that elderly people are too often badly treated in hospital.

If the world is to cope with the dramatic aging of populations, changes in attitude, organisation, and behaviour are needed. We hope that the material in this issue of the BMJ will contribute to that change.

Editors, BMJ Aging issue