academic research aimed at improving the quality
of life and the prolongation of active old age. It will
be interesting to see whether a more extended life
expectancy, over and above the current projections,
will reverse the depopulation trend.
15.2 Impact of an aging
population on the societyIn developed countries, by 2020, the working
population aged 15–65 years will fall from 22%
in 1996 to 16%. Those aged 65 years and over will
increase to 20 from 16% (US Bureau of Census,
1996). In the United States, 60 years ago, the
retirement age for Social Security ‘pension’ was
designed for an expected average lifespan of
65 years. Already this has been pushed back to
67 years by year 2004, and additional legislation
will probably push the age requirements back to 70
in 10 years’ time, when the ‘baby-boomers’ swell
the retired population.
To encourage the healthy older person to con-
tinue working beyond 65 years, legislation was
passed to remove the penalty (in workers 65–70
years) of the loss of $1 for every $2 earned from
Social Security benefits in the United States. In
1999, it was proposed that, because of the high
cost of medication and because the older people
were the greatest users, they be eligible for drug
cost reimbursement under Medicaid. This would
give the US Government reimbursement control on
more than 58% of drugs prescribed and the power
to ‘set prices’, as in other countries (e.g. Canada,
the UK, France, Italy, Germany). This has sent a
chill through the US pharmaceutical industry. The
current situation is that the government will not use
this volume to drive prices down. How long this
legislation will remain unamended is to be seen.
Of great concern is the social and financial
impact of Alzheimer’s disease, whose incidence
per capita increases to 32% of the surviving popu-
lation at ages 80–85 (and declines rapidly after age
85). Many live with this disease for five to eight
years before succumbing. This causes enormous
detriment to the surviving spouse and family and
to family finances, and must eventually impact
Medicaid and Medicare Federal and State budgets.
The duration of financial burden of terminal care
is 1–4 months in general (1–18 months for
Alzheimer’s patients) and, even with what would
normally be an adequate pension, this burden can
financially ruin the surviving spouse. In the United
States alone, Alzheimer’s disease will affect 16
million people by 2050 (Tauzin, 1995).
Immigration from the Third World to the devel-
oped countries will increase as countries of aging
populations try to replace the loss of their labor
pool. This is already happening in Europe and in
the United States. This again will put further pres-
sure on Medicare and Medicaid, as many of these
immigrants will suffer from tuberculosis, hepatitis
and intestinal disease, endemic to many of their
home countries. In 1997, 39% of tuberculosis cases
in the United States were in foreign-born parents;
in California, this rose to 67% (Satcher, 1999) and
the annual cost of diagnosis and treatment of the
1 million immigrants was $40 million (Muenning
et al., 1999). This will cause further competition
for available health dollars.15.3 Prescribing and adverse
eventsStudies of drug utilization in the elderly showed
that older people receive disproportionate amounts
of medication (Rochon and Gurwitz, 1995). A
study in rural persons 65 years or older showed
that, of 967 interviewed, 71% took at least one
prescription drug and 10% took five or more pre-
scription medications. Again, women took more
medications than men, and in both groups, the
number of drugs increased with age. The elderly
comprised 18% of the population but received 45%
of all prescription items (Lassilaet al., 1996).
One in 10 admissions to acute geriatric units
was caused or partly caused by adverse drug reac-
tions. The drugs involved most commonly were
benzodiazepines, warfarin, digoxin and nonster-
oid anti-inflammatories (Denham and Barnet,
1998). Tamblyn (1996), in his review article,
cited reports of adverse events causing 5–23% of
hospitalizations, nearly 2% of ambulatory visits
and 1 in 1000 deaths in the general population.
These rates increase in the elderly. Errors in194 CH15 DRUG RESEARCH IN OLDER PATIENTS