ISI Impact Factor (2004): 1.096

Editor-in-Chief
Prof. Yi-Fei WANG,

Aging men - Challenges ahead

Bruno Lunenfeld

Faculty of Life Sciences, Bar-Ilan University, Israel

Asian J Androl  2001 Sep; 3: 161-168

Keywords:  aging; life expectancy; health expectancy; fertility;  HRT  (hormone replacement therapy); quality of life; preventive strategies

Abstract

1 An aging world

“First we were obsessed with the challenge of  “population explosion”, then we shifted our concern to the problems of global aging, and only now do we start to grasp the future consequences of a rapid fertility decline.”  E. Diczfalusy, 2000.

The human race entered the 19th century with a global population of 978 million, the 20th century with 1650 million and the 21st century with a worldwide population of 6168 million. The estimates and projections of the United Nations indicate that between 1900 and 2100, world population will increase seven-fold, from 1.65 billion to 11.5 billion: an increase of almost 10 billion people.  This rapid increase in world population is in spite the fact that effective family planning has significantly reduced fertility rates. In 1970, there were 22 countries with a total fertility rate at or below the replacement of 2.1.  In the year 1999 it was 68 countries, and it is projected that by 2020, 121 countries representing 75% of the global population will have birthrates below the replenishment level.

Human had a life expectancy of about 30 years for about 99.9% of the time we inhabit this planet. Today more then 75% of all human death in developed countries occur after the age of 75. The last century has been marked by the triumph of partially preventing the premature termination of life. During the past 50 years infant mortality rates declined from 155/1000 to 52/1000 in the world and from 72/1000 to 11/1000 in Europe^[1]. During the same time frame, a significant decline in over all mortality rates was also seen. This declines was mainly due to the development of antibiotics, vaccines, safer water, better sanitation and personal hygiene^[2]. These events were responsible for the decrease in the appearance of epidemics and the control of most infectious diseases. Acute disease is not any more the major cause of death. Today one dies from or with chronic illnesses, degenerative diseases, metastatic cancer, immune-deficiencies and other diseases which prolong disability, immobility and dependency.  Dying has become in most instances a long, painful, and expensive procedure^[2].

The worldwide prolongation of the mean life expectancy and the drastic reduction of fertility rate resulted in a rapidly aging world population (Fig.1).  Table 1 describes the total fertility rates in Europe and Table 2 demonstrated the effect of decrease in fertility rates and increase in life expectancy in selected Asian countries/district on the increase of its population above the age of 65. It is projected that in general, the elderly (above 65) will increase within the next 25 years by 82%, whereas the new born only by 3%. The working age population will increase by only 46%. The UN^[3] projects that by 2050, the proportion of  persons above 60 will exceed for the first time the proportion of children below 15, and  13 countries will iave more than 10% of the oldest old (> 80 years old) in their population. Italy will be leading with 14%.

Figure 1.  Aging population.

By the year 2050 Asia will be inhabited by almost 1 billion people aged 65 and above. China (including Hong Kong and Macao), Japan and Singapore will have become members of the “club of 14” with more than 10% of their population aged 80 and above. Since the last years of life are accompanied by an increase of disability and sickness, the demand to the social and health services will increase immensely. The high cost in relation to these services will strain to the limit the ability of health, social and even political infrastructures. By the year 2050 Asia will be inhabited by almost 1 billion people aged 65 and above. China (including Hong Kong and Macao), Japan and Singapore will have become members of the “club of 14” with more than 10% of their population aged 80 and above. Since the last years of life are accompanied by an increase of disability and sickness, the demand to the social and health services will increase immensely. The high cost in relation to these services will strain to the limit the ability of health, social and even political infrastructures.

Table 1. Total Fertility rates in Europe 1995.

Table 2. Effects of decrease in fertility rate and increase in life expectancy.

Table 3. Life expectancy of males at different ages.

Courtesy of the Registrar General for Scotland (From “cheating time by Roger Gosden”).

Table 4. Occupational handicap-free life expectancy in Canada (Wilkins & Adamas  1983).

Table 5. Health expectancy (WHO 2000).

The majority of older men today reside in developing countries. As the demographic transition gathers pace in the poorer regions of the world, an even greater proportion of the world's older men will live in countries and regions that have the least resources to respond to their needs.

The communication revolution and its consequence globalization which started at the end of the last century will peak during this century. But if we will not learn to share the resources and wealth of mother earth, poverty will remain enemy number one. It must be our honest aim to achieve the goal that every human being on this earth should be able to age in health and with dignity. The cost of caring for the increasing population of senior citizens will become prohibitive with its attendant socio-economic consequences. To the prudent health care administrators, the establishment of preventive measures, rather than concentration on interventive care is an important strategic thrust in overall management of the aging population^[4]. Frailty, disability and dependency will increase immensely the demand to the social and health services. The very high cost in relation to these services may strain to the limit the ability of health, social and even political infrastructures not only of developing but also of the most developed and industrialized nations. The ability to permit men to age gracefully, maintain independent living, free of disability, for as long as possible is a crucial factor in aging with dignity and would furthermore reduce health service costs significantly. To achieve this objective, a holistic approach to the management of aging has to be adopted^[4].

The promotion of healthy aging and the prevention, or drastic reduction of morbidity and disability of the elderly must assume a central role in the formulation of the health and social policies of many, if not all, countries in the next century. It must emphasize  an all encompassing  life long approach to the aging process  beginning with pre-conceptual events and focus on appropriate interventions at all stages of life.

Life-history studies of childhood and adolescence demonstrate clearly that social factors probably operate in a cumulative fashion.  There are significant social class differences in height growth and other aspects of physical development, as well as in incidence of infectious and other diseases and risk of injury.  For example, the nutritional status of the mother is now known to influence intrauterine growth rates, birth weights, and the later life risks of several important health problems. In addition, a whole host of factors influence growth and development and in turn these factors influence the health status of men in the latter decades of their lives. Vulnerability to physical ill health in childhood and later adult life is associated with poor parental socio-economic circumstances and low levels of parental education and concern.  Cross-sectional studies show differences in mortality and morbidity as a function of socio-economic status, across various disease categories throughout the life span. Poverty has a significant impact on both life and health expectancy. It should not only be measures in terms of property, employment, wages and income, but also in terms of basic education, healthcare nutrition, water and  sanitation. Educational attainment and marital status have also been shown in several longitudinal studies to be powerful predictors of morbidity, health expectancy and mortality.  In addition, age, gender and socio-economic status influence disability-free life expectancy. The economic consequences of retirement place many older citizens in positions of financial vulnerability. As populations age, in both the developing and the developed worlds, the issue becomes how to keep older persons economically viable within their respective societies. No community is exempt from the financial hardships experienced by aging populations.

The life course perspective leads to important policy and strategy decisions. Firstly, it is clearly possible and desirable to improve the health status of men when they are old, although this approach is still not fully implemented. Secondly, a complementary approach to improving the health of older men would focuson appropriate interventions at all stages of their lives. The determinants of “aging” and of “life expectancy” extend from genetic and molecular determinants to the increasingly powerful forces of environmental, economical, technological and cultural globalization. Specific measures for the promotion of healthy aging should include:
1. the promotion of a safe envirment,
2. healthy lifestyle including proper nutrition, 
3. appropriate exercise, 
4. avoidance of smoking, 
5. avoidance of drug and alcohol abuses,
6. social interactions to maintain good mental health, 
7. and medical health care including the control of chronic illnesses. 

If done effectively, it should result in a significant reduction of the health and social costs, reduce pain and suffering, increase the quality of life of the elderly and enable them to remain productive and contribute to the well-being of society. The medical and socioeconomic implication of a demographic reality of a new world, will be very different from all preceding epochs in history, indeed so new that most people, their governments, national and private pension funds as well as most health insurers did not yet have sufficient time vision, determination or courage to face up to this immediate challenge. The medical profession, pharmaceutical and health industries are not yet prepared for these emerging markets.

2 Men, aging and health

Before a thing has made its appearance, order should be secured before this order has begun.  Lao Zi

It is impossible to understand aging and health without a gender perspective. Both from a physiological and from a psychosocial point of view, the determinants of health as we age are intrinsically related to gender.  There is increasing recognition that unless research and programmes-on both clinical science and public health - acknowledge these differences, they will not be effective.  While women experience greater burdens of morbidity and disability, men die earlier, yet the reasons for such premature mortality are not fully understood.  The rapidity with which the world-wide population is aging will require a sharp focus on gender issues if meaningful policies are to be developed.  Yet so often gender in the health context is taken as being synonymous only with women's issues^[8].

In contrast  to the recent and much needed attention to the social position and health status in women, men health concerns have been relatively neglected. Men continue to have a higher morbidity and higher mortality rate^[8]. Life expectancy for men is significant  shorter then that for women in most regions of the world^[2].  The course of disease, response to disease and societal response to illness exhibit gender differences and often result in different treatments and different access to health care. The conventional  approach   of  the medical,  behavioral  and social sciences  to  the problem of male aging has been for a  long  time subject of oversight, absence of focusing, disconnection and most of all lack of interdisciplinary  collaboration.

The major causes of morbidity and mortality all take effect over extended periods. DNA is constantly  being damaged and being repaired,  Bones are constantly worn away and rebuilt and atheromas  are constantly  accumulating in side arteries, and are constantly being removed . If the rate of decay is faster then the rate of repair, healthy tissue will be lost  until damage will  produce in symptoms and finally  result in disease. Therefore, primary prevention strategies will be most effective when initiated at the earliest opportunity. Prevention of ischemic heart disease, hypertension and stroke as well as lung cancer, are diseases which primary prevention needs to be addressed.  When problems are more prevalent at older ages, as with prostate and colorectal cancers and osteoporosis early diagnostic tests, such as appropriate  and periodic  use  of  laboratory  tests (e.g. PSA) and screening  procedures can play an important role  in secondary prevention and self care strategies^[9].

Significant numbers of male related  health  problems such as:

• changes  in body  constitution,

• fat distribution, 

• muscle  weakness,

• urinary incontinence, 

• loss of cognitive functioning, 

• reduction in well being, 

• depression,

• as well as  sexual dysfunction,  could  be  detected and  treated in  their  early  stage if  both physicians and public   awareness of  these  problems  was  more pervasive. This could effectively decrease morbidity, frailty and dependency, increase quality of life and reduce health service costs. Women visit the doctor 150% as often as men, enabling them to detect health problems in their early stages. However usually men cost the health services more then women since they seek the medical services  at a more  advanced stage of disease. While women are geared to preventive care, men generally come for “reparation”.

When discussing age related problems, it is often difficult to separate and to distinguish between
1) the natural aging process, primarily genetically determined (which today can not be changed), 
2)  aging amplifiers determined by environmental and developmental factors (which can be  modified) and 
3)  an acute or chronic illness or intercurrent diseases (which can be prevented, delayed or  cured). 

It must not be forgotten, that aging by itself is associated with reduced productivity, decreased general vigor (“frailty of the aged”) as well as with increased incidence of defined diseases.  These include:

• cardiovascular diseases,

• malignant neoplasm,

• chronic obstructive pulmonary diseases;

• degenerative and metabolic diseases (arthrosis, diabetes, osteoporosis, etc.)

• visual  loss (macular degeneration, cataract)

• hearing loss

• anxiety,  mood, depression and sleep disorders

• sexual dysfunction

• various dementia (i.e., Alzheimer disease).

• Endocrine deficiencies

Five of six men in their sixties have one or more of these diseases. The chronic degenerative diseases have a long latency period before symptoms appear, and adiagnosis is finally made. Once the diagnosis is made, drugs may alleviate symptoms, but are not very effective to alter the underlying disease which unfortunately usually continues to deteriorate.

Heart disease and stroke are the major causes of death and disability in aging men. Approximately 52 million deaths occur worldwide each year; 39 million occurring in developing countries. About one-quarter of all deaths in developing countries and half of all deaths in developed countries are attributed to cardiovascular disease (CVD). Globally, there are more deaths from coronary heart disease (5.2 million) than from stroke (4.6 million). Age specific death rates from cardiovascular disease increase dramatically with age. Within each country, age-specific death rates for all cardiovascular diseases increase at least twofold between the age groups 65- 74 years and 75-84 years in both sexes, with consistently at least 50% higher rates for elderly men then for women. Morbidity and disability from these diseases are also high. For example, the Global Burden of Disease project estimates that by 2020, coronary heart disease and stroke will be the first and second leading cause of death. Lack of exercise, smoking and obesity are recognized risk factors for CVD. A significant relationship exists between body fat mass and both cardiovascular and overall mortality in men. The increased mortality as observed in obese men was inversely related with physical fitness.

Worldwide, more than nine million people developed cancer in 1997 and more than six million died of cancer. Cancer deaths increased from 6% to 9% of total deaths from 1985 to 1997 in developing countries, but remained about constant at 21% of total deaths in developed countries. The highest mortality rate was observed for lung cancer with approximately 790,000 deaths in 1997, followed by stomach, liver, colorectal, esophageal, and prostate cancer.

For men, prostate cancer is the most prevalent malignancy and the third leading cause of cancer death. In 1990, worldwide, there were 193,000 deaths from prostate cancer, with 127,000 of those deaths occurring amongst those aged 70 years and over and 51,000 amongst those aged 60-69. Since prostate cancer is primarily a disease affecting men over 50, the worldwide trend towards an aging population means that the number