From the Editors’ Desk: Growing Old in America: Lessons From Our Japanese Obaachan
All developed nations face the challenges brought on by an aging population coupled with shrinking health care resources. In Japan, where I have been living for the past 8 months as a Fulbright research scholar, the population aged 65 years and older now stands at 23%, the highest proportion of any nation in the world. By 2050, this figure is expected to rise to 40%; an astounding statistic given that as recently as 1990 only 12% of the Japanese population was over 65 years of age.
The rapid growth of the older population in Japan is due in part to a low birth rate (the second lowest in the world), but also to tremendous gains in life expectancy. For the past 25 years, Japan has ranked first in female life expectancy at birth (86 years); and 83% of Japanese women 65 years and older can expect to live to age 80 compared to 70% in the U.S. In addition, by many measures, the Japanese are not only living longer, but living better than their peers in other developed nations. Healthy life expectancy is higher in Japan averaging 78 years for women and 73 years for men, in spite of health expenditures that are 8.5% of the gross domestic product, about half that of the USA.
Figure 1. Y. Tanaka – Our obaachan.
What are the lessons to be learned from obaachan, and more generally from Japan’s success in health outcomes over the past 30 years? This issue of JGIM features a number of papers that focus on older adults in the U.S. In a longitudinal, community based study of more than 18,000 persons age 50 and older, Sun et al. found that more than 1/3 of U.S. older adults perceived their neighborhood safety to be less than very good or excellent, and that this perception was associated with 10 year functional decline. Interventions that promote physical activity while addressing neighborhood safety may help to combat functional decline in U.S. elders
Currently, people 65 years of age and older represent about 13% of the U.S. population; by the year 2030 this is expected to grow to just under 20%. Most have at least one chronic health condition, with arthritis, hypertension and heart disease topping the list. In this issue, Ahluwalia et al. report on the impact of comorbidity on mortality among older persons with heart failure. They found that comorbidity confers a significantly increased mortality risk even among those patients with an overall high mortality, and conclude that clinicians should consider the impact of comorbidity in their management of older patients with advanced heart failure.
Several papers in this issue deal with the importance of health care communication with older adults. Ahalt et al. report on a qualitative investigation of diverse older adults preferences for discussing prognosis. When presented with different scenarios of a less than 5-year or less than 1-year prognosis, most (65% to 75%), said that they would want to discuss prognosis with their doctor. The authors conclude that clinicians should not make assumptions but first should inquire about patient preferences before discussing prognosis. Stepanikova et al. add to the body of research that examines the impact of race on doctor-patient communication, in this case, non-verbal communication. They examined video-recordings of visits of 209 patients 65 years of age or older and found that indeed race does play a role in non-verbal communication patterns between doctors and patients, but not always in the ways we expect. Non-verbal communication in the African-American concordant dyads was more positive, a finding that confirms what others have reported on racial concordance and communication. However, African-American physicians with older white patients had both positive and negative non-verbal communication patterns. The authors interpret this as a conflicted pattern of communication, perhaps reflecting a lack of social ease.
Other papers in this issue address the performance of health literacy tests among older adults with diabetes (Kirk et al.) and report on a randomized controlled trial of the efficacy of a clinical decision support system to improve the quality of care for hospitalized older adults with cognitive impairment (Boustani et al.) Together, these papers contribute to our understanding of growing old in America and increase the prospects that more Americans will experience a future like obaachan’s.
This work supported in part by the Japan-US Educational Commission, Fulbright Japan.