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RACGP aged care clinical guide (Silver Book)

Silver Book - Part B

Epidemiology of ageing

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Last revised: 13 Jan 2020

  • The general practice population is ageing, and the older population is also ageing.
  • Chronic disease, multimorbidity, frailty and geriatric syndromes will be increasingly seen in general practice.
  • The prevalence of dementia is increasing, and the need to manage cognitive and behavioural related disorders will increase.
  • Dementia and depression are common in residential aged care facilities (RACFs), and residents without cognitive impairment have high levels of physical disability.
  • Consultations will be more complex, take longer and require effective communication.
  • Effective coordination of care, comprehensive and regular review, and thorough medical documentation will be required to manage the needs of older people.
  • There will be an increasing need to work collaboratively with other medical specialists, allied health professionals and pharmacists to enable best outcomes for older people.
  • General practitioners (GPs) need to proactively focus on maintaining maximum functionality of patients to maintain their dignity and autonomy.
  • GPs must advocate and demonstrate leadership in shaping the best care for older people within the community and RACFs.
  • Some groups of older Australians face disadvantages that affect their mental and physical health – GPs should take a proactive approach to address the care needs of these populations.

The older population is defined as those in the general population who are aged ≥65 years. A higher proportion of people are living to an older age due to the success of medicine and science.

The World Health Organization (WHO) notes that society’s ageing population presents, and will continue to present, both challenges and opportunities. Importantly for general practitioners (GPs), there will be an increase in demand for primary healthcare and long-term care. This means that it is important to have an appropriately trained workforce and the construction of age-friendly environments.1

An important focus will be to allow older people to age well, and continue to contribute to their family, local community and society.

The WHO stresses that societies that invest in the healthy ageing of its citizens will allow them to live longer and healthier lives. In turn, older people will be able to continue to contribute and participate in society, and help to better societies as a result.

The 2015 World report on ageing and health outlines a framework for action to foster healthy ageing, focusing on functional ability and intrinsic capacity. This proposed shift in focus means that health systems will need to change from disease-based curative models to the provision of person-centred and integrated care for older patients.

Globally, the following trends have been found.

  • The older population is ageing; worldwide, the number of people aged ≥85 years is expected to reach 377 million by 2050.
  • There has been an exponential increase in the number of centenarians in some countries (eg Japan, France, UK); in addition, the emergence of supercentenarians (>110 years) continues globally.
  • The modal age at death (a measure of average lifespan) has been increasing steadily for men and women.
  • Not all countries are ageing at the same pace – it took France 110 years for its older population to rise by 7% to 14%; Sweden took 80 years; the UK 50 years; while Brazil and South Korea are expected to do this in 20 years.
  • In developing countries, the political and societal adjustments to demographic ageing will need to take place more rapidly than in developed countries.
  • The dependency ratio (ratio of the dependent population to the economically active or working population) is increasing because of the ageing population and lower fertility rates. This may change due to increases to the retirement age around the world.
  • Many older people contribute economically and socially to the community through unpaid work; grandparents contribute significantly to child care for working family members.
  • Older people (especially women) care for relatives who are either very old or have a disability.

The WHO has drafted a list of 10 facts on ageing and health that is highly applicable to GPs and the general practice profession (Box 1).

Box 1. Ten facts on ageing and health2

  1. The world’s population is rapidly ageing The number of people aged 60 years or older will rise from 900 million to two billion between 2015 and 2050 (moving from 12% to 22% of the total global population). Population ageing is accelerating.
  2. There is little evidence that older people today are in better health than their parents The proportion of older people in high-income countries needing help with basic activities (eg eating, washing) has declined slightly in recent times. There has been little change in the prevalence of less severe limitations in functioning.
  3. The most common health conditions in older people are non-communicable diseases – Heart disease, stroke and chronic lung disease. The greatest causes of disability are sensory impairments, back and neck pain, chronic obstructive pulmonary disease, depressive disorders, falls, diabetes, dementia and osteoarthritis.
  4. When it comes to health, there is no 'typical' older person – Biological ageing varies from person to person.
  5. Health in older age is not random – An older person from a disadvantaged background is more likely to experience poor health and less likely to have access to the services and the care that they may need.
  6. Ageism may now be more pervasive than sexism or racism – Ageism is discrimination against a person on the basis of their age, which has serious consequences for older people and societies at large. Ageism can take many forms, including prejudicial attitudes, discriminatory practices, or policies that perpetuate ageist beliefs, and can significantly undermine the quality of health and social care that older people receive.
  7. Comprehensive public health action will require fundamental shifts in how we think about ageing and health – Healthy ageing is a process that enables older people to continue to do the things that are important to them. Health and social care expenditures should be understood as investments in realising opportunities and enabling older people to continue to make positive contributions.
  8. Health systems need to be realigned to the needs of older people – Most health systems around the world are ill-prepared to address the needs of older people who often have multimorbidities or geriatric syndromes. Systems must be capable of providing older person-centred and integrated care, and focus on maintaining capacities as people age.
  9. In the 21st century, all countries need an integrated system of long-term care – In some countries, this means building a system from almost nothing. In others, it means rethinking long-term care, from a basic safety net for the most vulnerable, towards a broader system that maximises older people’s functional ability and upholds their autonomy and dignity.
  10. Healthy ageing involves all levels and sectors of government.

It has been found that between 2012 and 2015, older Australians demonstrated:3

  • increased engagement in physical activity from 44.5% to 49.2%
  • decreased prevalence of disability from 52.7% to 50.7%.

More than two-thirds of older Australians (67.3%) who reported their income lived in a household with an equivalised gross household income that was in the lowest two quintiles. This proportion decreased from 74.6% in 2012. The older person’s income can be a significant consideration when out-of-pocket costs are involved, including the use of allied health professionals.3 The Australian Bureau of Statistics (ABS) also found that:

  • approximately 95% of older Australians lived in households; just over 5% lived in RACFs or hostels.
  • almost 27% of all older Australians lived alone.
  • one-third of older Australians needed assistance with daily activities.
  • Tasmania and South Australia had significantly higher proportions of older people than the rest of the country, while the Northern Territory had the smallest proportion of older people (Figure 1).
Proportion of total population by state and territory of people aged 65 years and older

Figure 1.

Proportion of total population by state and territory of people aged 65 years and older3

 

Figures 2 and 3 illustrate Australia’s standing in the world in terms of life expectancies and health-adjusted life expectancy.

Life expectancy at birth, both sexes, 2016

Figure 2.

Life expectancy at birth, both sexes, 2016
Reproduced with permission from World Health Organization. Life expectancy at birth, both sexes, 2016. Geneva: WHO, 2016. [Accessed 19 November 2019].

Health-adjusted life expectancy (HALE) at birth, both sexes, 2016

Figure 3

Health-adjusted life expectancy (HALE) at birth, both sexes, 2016
 
Reproduced with permission from World Health Organization. Health Adjusted Life Expectancy (HALE) at birth, both sexes, 2016. Geneva: WHO, 2016.  [Accessed 19 November 2019].

According to the ABS,3 there were around 3.5 million older Australians in 2015, which represents one in every seven people, or 15.1% of the population. This number is predicted to increase to an estimated 7.5 million by 2047, which represents around 20% of the population (Figure 4).
Proportion of the Australian population aged 65 years and older

Figure 4.

Proportion of the Australian population aged 65 years and older4
Reproduced with permission from Australian Institute of Health and Welfare. Older Australia at a glance. Cat. no. AGE 87. Canberra: AIHW, 2018. [Accessed 19 November 2019].

Sex

The ABS estimates that in 2016, approximately half of all people aged 65–74 years (51%) and 75–84 years (54%) were women; however, in those aged ≥85 years, 63% were women.5 The proportion of women aged ≥85 years has been on the decline, from a peak of 73% in 1982.6

Diverse groups of older Australians

Most older Australians are living longer and in better health than the previous generations. Some groups face disadvantages that affect their mental and physical health as well as opportunities for social and economic engagement within their communities.

The Aged Care Act 1997 describes some populations as people with care needs that should be taken into consideration, including:

Aboriginal and Torres Strait Islander peoples

In 2016, Aboriginal and Torres Strait Islander peoples accounted for 3% (650,000) of the total Australian population (Figure 5; refer to Part B. Older Aboriginal and Torres Strait Islander peoples). Of these:4,7

  • 17% (108,000) were aged ≥50 years
  • 5% (31,000) were aged ≥65 years (compared with 16% of non-Indigenous Australians)
  • <1% (<6500) were aged ≥85 years (compared with 2.1% of non-Indigenous Australians).
Figure 5.

Figure 5.

Distribution of reported Aboriginal and Torres Strait Islander people and non-Indigenous Australians by sex and age, 2011–157
Reproduced with permission from: Australian Institute of Health and Welfare. Trends in Indigenous mortality and life expectancy 2011–2015 – Evidence from the enhanced mortality database. Canberra: AIHW, 2017.


Culturally and linguistically diverse populations

Australia has a multicultural community (refer to Part B. Multiculturalism in aged care) where in people aged ≥65 years in 2016:4,8

  • one-third (33%) were born overseas, compared with 25% in 1981
  • one-fifth (20%) were born in a non-English speaking country
  • 10% were born in the UK and Ireland
  • the most common non–English speaking countries of birth were Italy (3%), Greece (2%) and Germany (0.91%)
  • the most common non-English languages spoken were Italian, Greek and Chinese.

Geographical distribution

In 2016, older Australians were living as follows:4,8

  • 66% (2.4 million) in major cities
  • 32% (1.2 million) in inner regional and outer regional areas
  • 1% (52,600) in remote or very remote areas
  • 33% in New South Wales
  • 25% in Victoria

Older Australians make up:

  • 19% of Tasmania’s population
  • 18% of South Australia’s population
  • 16% of New South Wales’s population
  • 15% of Queensland’s population
  • 7% of Northern Territory’s population, which reflects larger Aboriginal and Torres Strait Islander populations.

Disability

The prevalence of disability among older people has decreased from 52.7% in 2012 to 50.7% in 2015 (refer to Part B. Disability in aged care). 9

The proportion of older people with a profound or severe limitation decreased from 38.5% in 2012 to 36.4% in 2015. The proportion of older people with a moderate limitation remained stable between 2012 and 2015 (15.5% and 14.0%). The proportion of older people with a mild limitation increased from 37.4% in 2012 to 39.7% in 2015.9

In 2015, people aged ≥80 years represented almost three-quarters (72.1%) of all residents in care accommodation. The clear majority (96.5%) of older residents in cared accommodation had some disability, most with profound or severe disability.

The proportion of older people who need assistance is also steadily rising, particularly in the healthcare sector (Figure 6).9

Persons aged ≥65 years who needed assistance, type of assistance needed, by sex, 20189

Figure 6.

Persons aged ≥65 years who needed assistance, type of assistance needed, by sex, 20189
 
Reproduced with permission from: Australian Bureau of Statistics. Disability, ageing and carers, Australia: Summary of findings, 2015. Canberra: ABS, 2015. [Accessed 1 May 2019].


Dementia

In 2017, dementia was the second leading cause of death in Australia; in 2015, it was the fourth leading cause of disease and injury burden in Australia (refer to Part A. Dementia). A majority (71%) of dementia hospitalisations are of the highest complexity. This reflects the fact that people with dementia have other health conditions and are more likely to have high-care needs. 

More than 50% of residents in RACFs have dementia, with a large proportion of the remaining residents experiencing some form of cognitive impairment. Those residents without cognitive impairment experience even higher levels of physical disability. The number of people with dementia is expected to increase.10

Mental health

In 2018, it was found that 50% of people in RACFs experience depression. The majority of residents in RACFs are diagnosed with at least one mental health or behavioural disorder (refer to Part A. Mental health).11

Service use

In 2015, 1.2 million older people living in households needed assistance with everyday activities. The provision of that support was undertaken by:4

  • informal assistance
    • spouse or partner (35.0%)
    • daughter (21.0%)
  • formal assistance
    • private commercial organisations (38.5%)
    • government organisations (27.3%)

The most common informal assistance was for reading or writing tasks (91.3%), communication (90.5%) and mobility (88.3%). Formal assistance was most commonly required for healthcare (64.8%) and household chores (48.1%).

Long-term health conditions

A little more than 87% of older Australians reported that they had one or more long-term health conditions in 2015. The most commonly reported conditions were arthritis and related disorders (16.0%), hypertension (9.2%) and back problems (9.2%).4

The proportion of older Australians with a mental or behavioural disorder as their main condition was 6.5%, with 2.8% of all older people reporting dementia or Alzheimer’s disease as their main long-term health condition.4

Social participation

Many older Australians demonstrate strong social participation. In 2015, almost all (97.9%) older Australians participated in one or more social activities in the preceding three months. Older people interacted with their family or friends through telephone calls (93.2%), being visited at home (90.7%) or visiting them (85.8%). More than three-quarters (76.8%) participated in at least one cultural or physical activity outside of the home environment in the preceding 12 months.3

Older Australians’ physical activity levels increased in 2015. Those who lived in households who participated in physical activities for exercise or recreation increased from 44.5% in 2012 to 49.2% in 2015. In 2015, 23.4% of older men participated in sport in 2015, an increase from 2012 (21.3%). In contrast, older women’s participation in sport was stable 13.1% (2015) compared to 12.2% (2012).3

Older people are active participants in cultural activities, where half of older people (47.8%) attended a movie, concert, theatre or performing arts event in the 12 months before the survey, and almost a quarter (23.5%) had visited a museum or art gallery. In 2015, almost 20% of Australian older people were involved in voluntary and community activities.3

  1. World Health Organization. Ageing and life course. Geneva: WHO, 2019. [Accessed 1 May 2019].
  2. World Health Organization. 10 facts on ageing and health. Geneva: WHO, 2017. [Accessed 1 May 2019].
  3. Australian Bureau of Statistics. Older people. Canberra: ABS, 2015. [Accessed 1 May 2019].
  4. Australian Institute of Health and Welfare. Older Australia at a glance. Canberra: AIHW, 2018. [Accessed 1 May 2019].
  5. Australian Bureau of Statistics. Australian demographic statistics, June 2016. Canberra: ABS, 2017. [Accessed 1 May 2019].
  6. Australian Bureau of Statistics. Australian historical population statistics. Canberra: ABS, 2014. [Accessed 1 May 2019].
  7. Australian Institute of Health and Welfare. Trends in Indigenous mortality and life expectancy 2011–2015 – Evidence from the enhanced mortality database. Canberra: AIHW, 2017. [Accessed 1 May 2019].
  8. Australian Bureau of Statistics. Census of population and housing: Reflecting Australia – Stories from the Census, 2016. Canberra: ABS, 2018. [Accessed 1 June 2019].
  9. Australian Bureau of Statistics. Disability, ageing and carers, Australia: Summary of findings, 2015. Canberra: ABS, 2015. [Accessed 1 May 2019].
  10. Australian Institute of Health and Welfare. Dementia in Australia. Canberra: AIHW, 2012. [Accessed 4 November 2019].
  11. Australian Institute of Health and Welfare. People’s care needs in aged care. Canberra: AIHW, 2019. [Accessed 4 November 2019].