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SUNDAY, SEPTEMBER 19, 2010 Can someone simply die of ‘old age’?
Experts ask question as more people live to very advanced years
Our philosophy is simple: Walkability. BY DAVID BROWN You know the cartoon where a
character is driving an old car that suddenly falls apart, every bolt sprung,with the last hubcap rattling in a circle until it comes to rest? Some people die like that, too.
The trouble is there’s not a good name for it. Is there a single problem that
with
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gets the final chain of events going? Or should “old age” under some circumstances be consid-
ered an actual cause of death, equal to lung cancer, leukemia and diabetes? Those questions are becoming
increasingly important as more and more people die at very advanced ages without an obvi- ous cause that can be confidently entered on the death certificate. The difficulty of naming a
cause of death in the very old is becoming enough of a problem in the industrialized world that theWorldHealthOrganization is likely to address it head-on it in the next year. “If we can’t find a way of
dealing with this, then I think mortality statistics will lose much of their value,” said Lars Age Johansson, who chairs the WHO’s Mortality Reference
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Group and is a biostatistician with Sweden’s National Board of Health andWelfare. “I see this as very, very important.” Mortality statistics are the
backbone of public health. Without knowing how the
members of a population die, and at what ages, epidemiolo- gists can only guess how many deaths are potentially prevent- able. On the other hand, good mor-
tality data can identify over- looked problems and help public health agencies decide where to direct effort andmoney. The issue is especially topical
because experts fromaround the world next year will start updat- ing the International Classifica- tion of Diseases, medicine’s offi- cial list of more than 14,000 diagnoses. “Each revision of the ICD is
the right moment to reconsider this question,” said Gerard Pavil- lon, a French biostatistician who will co-lead the mortality statis- tics committee.
The official list of causes Some places began recording
all deaths and their causes in the early 1800s. The original list, called the International List of Causes of Death, was adopted in 1893. It had 161 headings, with more specific causes falling un- der some of them. It was proba- bly easier for a physician to choose a cause of death then than it is now, though farmore is known about the complicated physiology of dying. Today, doctors are expected to
list both “immediate” and “un- derlying” causes of death and howlong diseases had been pres- ent. They are also asked to list “significant conditions contrib- uting to death” but not causing it directly. But picking the “under- lying cause” — the most impor- tant one — when a patient has several chronic illnesses, such as hypertension, dementia and cor- onary heart disease, is often difficult. Many physicians find the task
even harder when a very old person declines over a few weeks ormonths and then dies. The steps of that process often
include muscular weakness that leads to inactivity and increased susceptibility to infection, or poor intake of food and fluid that leads to dehydration and electro- lyte imbalances in the blood and a final fatal heart rhythm. The “underlying cause” is hard to find even with an autopsy. What’s certain is that the num-
ber of these older people is growing. Consider a hypothetical group
of 100,000 people born in 1901. If they experienced the mortality rates in all age groups present at the turn of the 20th century, then only 31 would be expected to reach age 100. On the other hand, in a group of 100,000 people born in 2006 and experi- encing our era’s mortality rates, 1,737 would live to 100. However, giving “old age”
greater legitimacy in the lexicon of 21st-century medicine has risks, especially beyond the in- dustrialized world. A 2005 study found that
“death registration” is complete in only 64 of 115 countries report- ing data to the WHO. Only one-third of the 57million deaths that will occur this year around the world will be assigned a cause and reported to a govern- ment bureau of vital statistics. Furthermore, the fraction of
deaths ascribed to ill-defined causes that provide little useful medical information — “cardiac arrest,” “failure to thrive” or “multi-organ failure”—is high in a surprising variety of countries. Such vague causes appear on 26 percent of death certificates in Greece, 37 percent in South Afri- ca, 40 percent in Egypt, 49 percent in Thailand.
The potential drawbacks Giving old age greater credi-
bility could make mortality data in much of the world even more muddy. It might also provide a reason for overlooking the health problems of very old people, some experts believe. “It’s kind of a tricky issue,” said
Robert N. Anderson, chief of mortality statistics at theNation- al Center for Health Statistics. “If someone is over 100, I
wouldn’t quibble with old age as a cause of death,” Anderson said. “But I certainly wouldn’t like to see ‘old age’ as a cause of death in someone who is 75. Even 85 would be pushing it.”
“We as human organisms sometimes just run out of energy and shut down.”
—Cheryl Phillips, a San Francisco doctor and chairman of the American Geriatrics Society.
In fact, terms such as “senes-
cence,” “debility” and “old age” are already in the ICD catalogue, and physicians sometimes enter themon death certificates.But in many states the terms aren’t accepted. The vital-statistics of- fice kicks such certificates back to the doctor with a request for a more precise cause of death. How often that happens dif-
fers greatly fromstate to state. In the period 1999 through
2006, the rate at which “senility” or one of its subcategories ap- peared on death certificates in Florida was 100 times the rate in California. In Virginia it was used at a rate below the national average. It was essentially never used in Maryland and the Dis- trict. If senility is accepted more
widely, it will probably be under very specific circumstances. A person will have to be beyond a certain age and have no serious chronic illness, for example. But few people doubt that old age is sometimes a cause of death. “We as human organisms
sometimes just run out of energy and shut down,” said Cheryl Phillips, a San Francisco doctor and chairman of the American Geriatrics Society. Johansson, the Swedish expert
inmortality statistics, said that is what happened to his grand- mother, a farm wife who died several years ago at age 107. “She just withered away. No-
body could find anything wrong with her,” he said. “There was nothing wrong with her except her age.”
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