Special Report
Survival after the Age of 80 in the United States, Sweden, France, England, and Japan
N Engl J Med 1995; 333:1232-1235November 2, 1995
- Abstract
Background
In many developed countries, life expectancy at birth is higher than in the United States. Newly available data permit, for the first time, reliable cross-national comparisons of mortality among persons 80 years of age or older. Such comparisons are important, because in many developed countries more than half of women and a third of men now die after the age of 80.
Methods
We used extinct-cohort methods to assess mortality in Japan, Sweden, France, and England (including Wales) and among U.S. whites for cohorts born from 1880 to 1894, and used cross-sectional data for the year 1987. Extinct-cohort methods rely on continuously collected data from death certificates and do not use the less reliable data from censuses.
Results
In the United States, life expectancy at the age of 80 and survival from the ages of 80 to 100 significantly exceeded life expectancy in Sweden, France, England, and Japan (P<0.01). This finding was confirmed with accurate cross-sectional data for 1987. The average life expectancy in the United States is 9.1 years for 80-year-old white women and 7.0 years for 80-year-old white men.
Conclusions
For people 80 years old or older, life expectancy is greater in the United States than it is in Sweden, France, England, or Japan.
Media in This Article
Figure 1
Probability of Survival after the Age of 80 among U.S. Whites and Japanese, Swedish, French, and English and Welsh Persons Born from 1885 to 1889.Table 1
Five-Year Survival at Various Ages and Life Expectancy at 80 for U.S. Whites and for Japan, Sweden, France, and England for Cohorts Born in 1880–1884, 1885–1889, and 1890–1894 and for the Year 1987.Article Activity
- Article
Americans under the age of 65 have a higher mortality rate than the citizens of many European countries and Japan.1 Between the ages of 65 and 80 the differences in mortality diminish. Until recently, lack of data precluded reliable comparisons at later ages. New data now permit comparisons among people 80 to 100 years old.2-4 This is important, because survival to the age of 80 and beyond has increased in many developed countries.2-7 Largely because of reductions in mortality, the number of people over the age of 80 — who are high per capita users of health services — is growing rapidly.2-4,8,9 We compared the survival of persons 80 or older in the United States with that in four other developed countries, using the most reliable data available.
Methods
We calculated death rates using age-specific numbers of deaths and numbers of people at risk. Age reporting is generally less accurate in periodic censuses than on continuously collected death certificates. By summing deaths from those of the oldest persons backward to estimate age-specific population sizes, we could calculate cohort life tables solely from mortality data.2,10 This “extinct cohort” method was used to estimate survival at 80 and older in Japan, Sweden, France, and England (including Wales).2,3 The same method was applied to all U.S. death certificates filed between 1962 and 1990 for white men and women 80 or older who were born from 1880 through 1894.
The accuracy of U.S. death rates for those over 80 has been questioned.5 Research suggests that published mortality rates are reasonably reliable for U.S. whites up to the age of 100.5,11 The reliability of death rates for U.S blacks is less certain,12 although recent studies of mortality10 and Medicare13 data have confirmed the lower mortality among blacks than whites over the age of 85 that has been reported in vital-statistics data. Factors that have improved the reporting of ages on U.S. death certificates include the completion of the vital-registration, Medicare, and Social Security systems and their computerization, along with rising educational levels among the elderly.11,14,15
U.S. death rates in 1987 have been calculated for Medicare Part B enrollees.13 Because Part B coverage is purchased with monthly premiums, the data are of high quality. We compared these rates with Japanese, Swedish, French, and English rates for 1987.
Results
Life expectancies at the age of 80 and five-year survival probabilities at the ages of 80, 85, 90, and 95 are shown in Table 1Table 1
Five-Year Survival at Various Ages and Life Expectancy at 80 for U.S. Whites and for Japan, Sweden, France, and England for Cohorts Born in 1880–1884, 1885–1889, and 1890–1894 and for the Year 1987. for the 1880–1894 birth cohorts and for 1987 for the United States, Japan, Sweden, France, and England. Life expectancy and survival are significantly better for these cohorts in the United States than in the other countries at all ages and for both sexes (P<0.01). In all the countries, life expectancy at the age of 80 increased from the 1880–1884 cohort to the 1890–1894 cohort. In 1987 only the survival of Japanese 80-year-old men exceeded that of comparable U.S. men (P not significant).Figure 1Figure 1
Probability of Survival after the Age of 80 among U.S. Whites and Japanese, Swedish, French, and English and Welsh Persons Born from 1885 to 1889. shows survival curves for persons 80 to 100 years of age in the 1885–1889 birth cohort. The United States had the best survival, and Japan the worst. Whereas half of 80-year-old U.S. men survived to the age of 86, half of Japanese men survived only to the age of 84.5. For women, median survival was two years longer in the United States than in Japan.Discussion
As compared with mortality in Sweden, France, England, and Japan, mortality in the United States is relatively high before the age of 65 and relatively low at the age of 80 and after. Possible reasons include both current health-related policies and conditions and lingering cohort effects of earlier conditions.
Greater heterogeneity in social and economic status and health insurance coverage in the United States may account for much of the disadvantage at younger ages in this country.16-19 Medicare, Medicaid, and Social Security reduce this heterogeneity at older ages. Whereas 84.3 percent of Americans under 65 had health insurance in 1991,20 98.4 percent of the elderly had Medicare coverage.21 Reduced survival of disadvantaged groups also decreases heterogeneity at older ages.
More than in Japan or Europe, the elderly in the United States may demand high-quality health services and may modify their behavior to limit their risk factors. More rapid reductions in cholesterol levels, hypertension, and smoking in the United States may reflect this.22-26
In the United States, elderly patients may receive more effective medical care than elderly patients in Japan or Europe. The United States devoted 12.4 percent of its gross national product to health care in 1990, as compared with 5 to 8 percent in Japan and Europe, where cost control produces de facto rationing of health care for the elderly.27 Japan, with the world's highest life expectancy at birth (76.2 years for boys and 83.0 years for girls) and a rapidly aging population, spent only 6 percent of its gross national product on health care in 1990. Copayments impede access to care and increase rates of illness among elderly Japanese with low incomes. Shortages of long-term care facilities and rehabilitation services also adversely affect the health of elderly Japanese. In 1987, 29 percent of hospital stays were for more than six months; the majority of these hospitalized patients were elderly (69 percent), many of them (40 percent) with strokes.28 In Denmark, where health care spending is limited to 5.9 percent of the gross national product, there are 6-to-12-month waits for cataract and hip surgery. The wait for cardiac procedures exceeds three months. The effects of such delays are not benign for persons who are 80 or older.
Four persistent cohort effects may also be important. First, the well-educated tend to be relatively healthy. Elderly people in the United States may be better educated than those in Europe or Japan.14 Second, immigrants may be healthier than the contemporaries they left behind.29 Descendants of immigrants may also be relatively healthy. Many elderly people in the United States are either immigrants or the children of immigrants. Third, high mortality at younger ages may leave a select group of robust survivors at advanced ages. This may contribute to the U.S. advantage over Sweden at older ages.30 Fourth, adverse health conditions at younger ages may increase impairment among the survivors and elevate subsequent mortality rates.31 The relatively high mortality at older ages in Japan could be a legacy of poor health conditions before the 1950s. Because few severely debilitated people will survive into their 80s, however, this effect may be less important at advanced ages.32
The plausibility of most of these explanations depends on whether medical care and personal behavior can substantially improve health among the very old. Health changes once accepted as normal features of aging (e.g., frailty and senility) are now viewed as age-related diseases (e.g., osteoporosis and the dementias).8,9 New estimates of the age-related loss of physiologic functions are lower than earlier ones.33 Decreases in mortality in recent decades and differences in survival between subpopulations suggest that medical and public health interventions substantially affect survival at older ages.2-4,8,9,34
Increasing longevity may not raise costs disproportionately.35 In 1989–1990, the Medicare cost for those who died at the age of 70 was $6,457 in each of the last five years of life. The corresponding cost for those who survived to 100 was $1,800 per year, because their costs, both in and before the final year of life, were low. Cost-effective therapies are emerging, including antibiotics for ulcers,36 exogenous estrogen for postmenopausal women,37,38 angiotensin-converting–enzyme inhibitors,39 and geriatric-evaluation units.40
The U.S. success in increasing survival after the age of 80 was neglected in the debates over health care reform in this country. To understand the strengths and weaknesses of the U.S. system, it is important to consider the causes of success at older ages as well as the problems at younger ages.
Supported by grants from the National Institute on Aging (AG08761 and AG01159) and the Danish Research Council.
We are indebted to Kirill Andreev, who did the programming for the life-table and standard-error calculations.
Source Information
From the Center for Demographic Studies (K.G.M.) and the Sanford Institute of Public Policy (J.W.V.), Duke University, Durham, N.C.; and Odense University Medical School, Odense, Denmark (J.W.V.).
Address reprint requests to Dr. Manton at Duke University, Center for Demographic Studies, 2117 Campus Dr., Box 90408, Durham, NC 27708-0408.
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