Lancet 2015 (Feb 7); 385 (9967): 549–562 ~ FULL TEXT
Martin J Prince, Fan Wu, Yanfei Guo, Luis M Gutierrez Robledo, Martin O’Donnell, Richard Sullivan, Salim Yusuf
King's College London,
London, UK. Electronic address: firstname.lastname@example.org.
23% of the total global burden of disease is attributable to disorders in people aged 60 years and older. Although the proportion of the burden arising from older people (≥60 years) is highest in high-income regions, disability-adjusted life years (DALYs) per head are 40% higher in low-income and middle-income regions, accounted for by the increased burden per head of population arising from cardiovascular diseases, and sensory, respiratory, and infectious disorders. The leading contributors to disease burden in older people are cardiovascular diseases (30·3% of the total burden in people aged 60 years and older), malignant neoplasms (15·1%), chronic respiratory diseases (9·5%), musculoskeletal diseases (7·5%), and neurological and mental disorders (6·6%). A substantial and increased proportion of morbidity and mortality due to chronic disease occurs in older people. Primary prevention in adults aged younger than 60 years will improve health in successive cohorts of older people, but much of the potential to reduce disease burden will come from more effective primary, secondary, and tertiary prevention targeting older people. Obstacles include misplaced global health priorities, ageism, the poor preparedness of health systems to deliver age-appropriate care for chronic diseases, and the complexity of integrating care for complex multimorbidities. Although population ageing is driving the worldwide epidemic of chronic diseases, substantial untapped potential exists to modify the relation between chronological age and health. This objective is especially important for the most age-dependent disorders (ie, dementia, stroke, chronic obstructive pulmonary disease, and vision impairment), for which the burden of disease arises more from disability than from mortality, and for which long-term care costs outweigh health expenditure. The societal cost of these disorders is enormous.
23% the global burden of disease arises in older people (nearly half the burden in high income
countries and a fifth in low-income and middle-income countries)
Chronic non-communicable diseases account for most of the burden; leading
contributors are cardiovascular diseases, cancer, chronic respiratory diseases,
musculoskeletal diseases, and mental and neurological disorders
Population ageing will be the major driver of projected increases in disease burden in
older people, most evident in low-income and middle-income countries and for
strongly age-dependent disorders (dementia, stroke, chronic obstructive pulmonary
disease, and diabetes). These are also the disorders for which chronic disability makes a
substantial contribution to burden
Primary and secondary prevention for cardio-metabolic disorders is probably as
effective in older people as it is in younger people, and the benefit is increased in view
raised levels of absolute risk of adverse outcomes. Nevertheless, access and coverage is
especially poor in older people
Effective intervention in older people is complicated by ageism, complex
multimorbidity, and no access to age-appropriate care, and is exacerbated by user
fees, inadequate income security and social protection. Assessment and treatment
needs to be holistic, coordinated and person-centred. Home-based outreach, and
multidimensional assessment of frailties that might be treated or mitigated might
help to reduce individual and societal effects on disability and dependence
From the FULL TEXT Article:
The greatly increased expectancy of survival into old age
is one of humanity’s major achievements.  To the
contrary, worldwide population ageing and the attendant
increases in public spending on health and social care
are seen as a threat to worldwide economic stability in
the 21st Century.  Informed policy making and planning
necessitates an understanding of the present and
probable future distribution of morbidity and its effect
on mortality, disability, and dependence. Several effects
need to be considered; demographic and epidemiological
transitions and secular changes in the effectiveness and
coverage of disease control measures. effects will vary
between disorders and regions.
The worldwide epidemic of chronic diseases is strongly
linked to population ageing. Disorders with a strong age-dependent
relation will increase in prevalence in parallel
with the absolute and relative numbers (relative to the
total population size) of older people (≥60 years). In highincome
countries, population ageing persists as fertility
continues to fall and life expectancy increases slowly. For
many middle-income countries mortality has decreased
over much of the 20th century, and decreasing fertility is
now ushering in unprecedented rapid population ageing.
The doubling in the proportion of the population aged
65 years and older from 7% to 14%, accomplished in
46 years in the UK, 68 years in the USA, and 116 years in
France, will be completed in just 26 years in China and
21 years in Brazil.  The appendix reviews the implications
for China and national policy directions.
The epidemiological transition from the age of
pestilence and famine to the age of degenerative and
man-made diseases is near complete in most highincome
countries. Low-income and middle-income
countries face various gradations of a double burden of
infectious and non-communicable diseases, the balance
shifting inexorably towards non-communicable diseases.
A globalisation of risk behaviours; including diets rich in
saturated fat and increase of tobacco use and underactivity,
with consequent obesity; partly causes the rapid
increase in burden of chronic diseases in these regions.
After the transition, in high–income countries,
cardiovascular risk factors and diseases are typically
associated with economic disadvantage and low levels of
education, but the trend is often in the opposite direction
in low–income and middle–income countries.
In high–income countries, mortality from cardiovascular
disease has been decreasing in all age groups.
The average age of first onset and death from
cardiovascular disease has been increasing and shifting
the burden into older age. Decreasing incidence plays a
part, but case fatality rates have also fallen with improved
acute hospital management. Since prevalence is a
product of incidence and duration, long survival for these
and other chronic diseases has a profound effect on
population burden, particularly on years lived with
disability and needs for care.
In this Review, we trace these changing patterns
examining present and future burden of major chronic
diseases of particular relevance to older people
(cardiovascular diseases [stroke and ischaemic heart
disease], cancer, diabetes, chronic respiratory diseases,
visual impairment, dementia, and musculoskeletal
disorders) across world regions by income level and their
underlying risk factors and evidence–based treatments. We
complement this disorder–based approach by reviewing
three cross–cutting themes; fraility, multimorbidity, and
ageism in the provision of service; that distinctively
characterise the interaction of ageing and health and pose
challenges and opportunities to strengthen health systems
to meet the needs of older people.
Overview of burden of disease in older people
According to the Global Burden of Disease (GBD)
estimates for 2010, 23·1% of the total disease burden
(574 million of the 2490 million DALYs) is attributable to
disorders in people aged 60 years and older, 49·2% of the
burden in high–income regions, and 19·9% in low–income
and middle–income regions.  For the disorder
clusters (figure 1, table), the leading contributors to
disease burden in older people are cardiovascular
diseases, malignant neoplasms, chronic respiratory
diseases, musculoskeletal diseases, mental and
neurological disorders, infectious and parasitic diseases,
unintentional injuries, diabetes mellitus, digestive
diseases, respiratory infections, and sense organ diseases
(table). The rank order does not vary greatly by region
income, but infectious and parasitic diseases make a
more prominent contribution in low–income and middle–income
regions, and mental and neurological disorders
and musculo–skeletal diseases make a more prominent
contribution in high–income regions. The disease burden
per person in older people is higher in low–income and
middle–income regions (827 DALYs per 1000) than in
high–income regions (590 DALYs per 1000) which is
accounted for by the increased burden per head from
cardiovascular disease, chronic respiratory, and infectious
disorders in low–income and middle–income regions
For older people, the 15 most burdensome disorders
are ischaemic heart disease (77·7 million DALYs); stroke
(66·4 million); chronic obstructive pulmonary disease
(COPD, 43·3 million); diabetes (22·6 million); low back
pain (19·1 million); cancer of the trachea, bronchus; or
lung (18·6 million); falls (12·4 million); visual
impairment (10·4 million); dementia (10·0 million);
tuberculosis (9·2 million); hypertensive heart disease
(9·5 million); stomach cancer (8·6 million); hearing loss
(7·5 million); osteoarthritis (7·5 million); and major
depressive disorder (7·5 million).
Social and demographic determinants
The appendix summarises the results of a meta–analysis
modelling the independent effects of age, sex, and
education on the prevalence of obesity, hypertension,
diabetes, ischaemic heart disease, stroke, depression, and
dementia from 10/66 Dementia Research Group  and
WHO–SAGE  population surveys in 12 low–income and
middle–income countries in Africa, Asia, and Latin
America. Stroke was more common in men than in
women, but the prevalence of other disorders was
consistently higher in women. Age dependency was most
evident for dementia (prevalence ratio per 5–year
increment in age 1·61, 95% CI 1·57–1·66) and stroke
(1·15, 1·11–1·19), and, to a lesser extent, ischaemic heart
disease (1·06, 1·03–1·09). The prevalence of diabetes and
obesity decreased slightly with increasing age. Prevalence
of depression and dementia was higher in those with
lower levels of education in all settings. For cardio–metabolic
disorders (obesity, hypertension, diabetes, stroke, and
ischaemic heart disease), the association with educational
level depended on development status. For urban and
more developed settings, prevalence was higher in those
with lower education levels, whereas for less advanced
settings, the association was in the opposite direction.
The profile of lifestyle–related risk factors is much the
same across the most burdensome disorders for older
people. Dyslipidaemia, hypertension, diabetes, smoking,
and obesity are the major modifiable risk factors for
cardiovascular diseases.  Smoking is also the main
modifiable risk factor for cataract and age–related
macular degeneration,  COPD,  and lung cancer  in old
age. A review  of risk factors for Alzheimer’s disease
identified consistent evidence from cohort studies to
accord with a causal role for smoking, physical inactivity,
midlife hypertension, obesity, and diabetes.
The prevalence of most of these risk factors rises with
increasing age. In the US National Health and Nutrition
Examination Survey (NHANES) 2003–08, this pattern was
apparent for physical inactivity, total cholesterol, fasting
blood glucose, and blood pressure.  Only smoking was
less common in older adults than in adults younger than
60 years. The age gradient for hypertension is especially
steep. For NHANES 1999–2004, 60% of people aged
60–69 years were hypertensive, which rose to 72% for
people aged 70–79 years and 77% for people aged 80 years
and older.  In low–income and middle–income countries,
prevalence of hypertension also increased steadily with
age, with half or more of people aged 60 years and older
affected. [14–18] Risk exposures are probably higher in urban
than rural settings in low–income and middle–income
countries, as shown in the 10/66 DRG surveys for
hypertension  (urban sites range 52·6–79·8%, rural sites
range 42·6–56·9%), which accords with a pattern
previously reported in Bangladesh and India. 
Cardiovascular risk factors operate into old age, although
relative risks might be attenuated. Thus in the
INTERHEART  and INTERSTROKE  case–control studies
hypertension was an independent risk factor for acute
myocardial infarction and stroke in older people in all
countries. In the USA, hypertension in older people is
also an independent risk factor for mortality  and is
inversely associated with healthy ageing.  The Prospective
Studies Collaboration meta–analyses  support associations
of lower than usual systolic blood pressure with reduced
stroke (relative risk 0·67, 95% CI 0·63–0·71) and
ischaemic heart disease mortality (0·67, 0·64–0·70), and
of decreased total cholesterol (RR per 1 mmol/L reduction
0·85, 0·82–0·89) with ischaemic heart disease mortality. 
Although these relative risks were attenuated compared
with younger age groups, absolute risk differences are
more enhanced in view of increased mortality due to
cardiovascular disease in older people. In European cohort
studies, continued smoking, poor quality diet,  and
physical inactivity [21, 22] were independently associated with
increased mortality into the eighth decade of life. However,
in India the strength of the association of smoking with
mortality attenuates sharply into older age, [23, 24] and
undernutrition  rather than obesity  is more consistently
associated with increased mortality.
The benefits of risk factor modification in older people
are most clear for control of hypertension and
hypercholesterolaemia. In a meta–analysis of 15 trials of
diuretics or β blockers in people aged 60 years or older,
event rates per 1000 people during a period of 5 years
were reduced by 18 (95% CI 4–28) for all deaths, by
19 (9–31) for cardiovascular deaths, and by 51 (31–73) for
cardiovascular morbidity and mortality combined. 
benefits were apparent for isolated systolic and diastolic
hypertension.  Numbers needed to treat to avoid an event
are much smaller than at younger ages.  In a meta–analysis
of results of cholesterol–lowering treatment from
14 randomised trials of statins, the benefits were apparent
for patients aged 75 years and older, with reduction of the
risk of major vascular and major coronary events. 
In the US NHANES surveys 1999–2004, control of
hypertension in patients treated was especially
suboptimum in older age groups, with only 47%
controlled in patients aged 60–79 years and 36% in
patients aged 80 years and older.  The situation is likely
to be much worse in low–income and middle–income
countries. [15, 31] In the 10/66 DRG surveys, in most
Latin American centres and urban China, 40–50% of
people reporting a diagnosis of hypertension were
controlled; however, control was especially poor in rural
China (5%), urban India (30%), rural India (31%), and
Cuba (32%); control of hypertension, rather than
compositional factors (age, sex, education, and obesity),
explained most of the variation between sites in systolic
blood pressure levels. 
The profile of cardiovascular disease develops gradually
with the epidemiological transition.  As mortality
decreases, nutrition improves and infections are
controlled, and hypertension, ischaemic heart disease,
and stroke become more prevalent, with ischaemic heart
disease contributing most to mortality. As high–income
countries advance into the so–called age of delayed
degenerative diseases, age–adjusted mortality due to
cardiovascular disease decreases with effective primary
and secondary prevention and better acute hospital
management. Cardiovascular disease, particularly
ischaemic heart disease, is still the leading cause of
death. However, the effects of congestive heart failure
and atrial fibrillation, strongly associated with older age
and ischaemic heart disease, increase greatly with
population ageing and improved survival from
myocardial infarction. [33, 34] A growing urgency exists to
tackle cardiovascular diseases in low–income and middle–income
countries through effective prevention and
treatment, guided and monitored by robust estimates of
disease prevalence and burden. Although much of the
evidence refers to young and middle–aged adults, [35–37]
older people account for most cardiovascular disease
morbidity and mortality in these regions.
Ischaemic heart disease accounted for 77·7 million
DALYs in older people in 2010, 78% of the burden arising
in low–income and middle–income regions.  DALY
burden in older people was forecast to increase by 35%
from 2004 to 2030. Lifetime prevalence of ischaemic
heart disease rises largely with age; population data from
US NHANES 1988–94 show a 2–4–times increase in
prevalence from the age group of 40–64 years to that of
65–74 years: from 4·5% to 6·7% for self–reported angina
pectoris, from 3·8% to 11·0% for self–reported myocardial
infarction, and from 1·3% to 5·5% for electrocardiography
confi rmed myocardial infarction.  Between 1980 and
2000, age–standardised ischaemic heart disease mortality
rates almost halved in the USA, with nearly threequarters
of the deaths prevented or postponed being in
people aged 65 years and older.  This reduction was
evenly attributed to improvements in medical care and
reduced exposure to risk factors, despite increases in
obesity and diabetes. Nevertheless, similar lifetime
prevalence of myocardial infarction across successive
NHANES cohorts suggests that a reduction in incidence
of the disorder was offset by increased survival. 
In low–income and middle–income countries, ischaemic
heart disease episodes seem to occur at younger ages; 
8% of deaths from ischaemic heart disease in highincome
countires and 21% in low–income and middle–income
countries were in people younger than 60 years of
age. The trend in many low–income and middle–income
countries is towards a rise of morbidity and mortality. In
Beijing, China, age–adjusted mortality due to ischaemic
heart disease increased by 50% in men and 27% in
women over a similar period to that of decreasing
mortality due to ischaemic heart disease in the USA. This
increase was attributable to substantial rises in serum
cholesterol, diabetes prevalence, and obesity and only
partly offset by advances in medical care.  For men, the
rise in mortality due to ischaemic heart disease was much
greater at younger ages than at older ages; nevertheless,
40% of the additional deaths in men and 87% in women
occurred in people aged 65–74 years.  In India, prevalence
of ischaemic heart disease rose from 2% to 5% in rural
settings and from 7% to 11% in urban settings in the last
three decades of the past century.  Although mortality
due to ischaemic heart disease in Russia and some parts
of eastern Europe has increased and is still among the
highest in the world, mortality in the regions that have
undergone rapid economic and social transformation has
fallen to a similar extent as in developed democracies. 
Effective ischaemic heart disease interventions target
primary prevention, treatment for acute myocardial
infarction, secondary prevention after myocardial
infarction, and congestive heart failure. These interventions
mainly include drug therapy, which, although not
costly, might not always be available.  Most interventions
included in a WHO–CHOICE  modelling exercise for the
African and southeast Asian regions were highly cost
effective (< Int$2000 per DALY averted).  Tobacco control
is probably the most cost–effective prevention strategy,
alongside combination drug therapy (statin, diuretic,
β blocker, and aspirin) for individuals with an absolute risk
of having a cardiovascular event in the next 10 years greater
than 25%.  This group includes a high proportion of older
people. For acute myocardial infarction, the benefits of
treatment in hospital with aspirin alone are doubled when
combined with streptokinase and tripled with percutaneous
transluminal coronary angioplasty.  Rapid access to
facilities that do these procedures is not yet feasible in
most low–income and middle–income countries. Secondary
prevention is most effective through a combination of
aspirin, β blocker, statin, and angiotensin–convertingenzyme
(ACE) inhibitor. Treatment of chronic heart failure
with loop diuretics is highly cost–effective and might be
usefully supplemented with β blocker and ACE inhibitors, 
and, possibly, digoxin. 
Stroke accounted for 66·4 million DALYs in older
people in 2010, 86% of the burden arising in low–income
and middle–income regions. Burden in older people was
predicted to increase by 44% from 2004 to 2030 (table).
Stroke contributed 5·9 million deaths in 2010, 5·0 million
(85%) occurring in people aged 60 years and older. In
2005, 62 million were estimated to be survivors of stroke
worldwide.  Many survivors are likely to be disabled; [48, 49] in low–income and middle–income countries, stroke was the
second leading contributor (after dementia) to disability 
and dependence in older people. 
In high–income–country studies,  age–standardised
prevalence of stroke for people aged 65 years or older
ranged from 4·6% to 7·3%. US NHANES 1999–2006
reported a prevalence of 6–8% for people aged 65–74 years
and about 12% for those aged 75 years and older.  In the
10/66 DRG surveys in seven low–income and middle–income
countries,  prevalence was similar to that in the
US NHANES survey in urban sites in Latin America and
China (6·2–8·4%), but much lower in rural Peru, rural
China, and urban and rural India. Ascertainment based
on self–report will underestimate prevalence when stroke
awareness is low, and in such settings, post–stroke
mortality might be raised, perhaps accounting for low
prevalence. More detailed ascertainment protocols
yielded prevalences of 6·9% (65 years and older) in a
rural district of Beijing,  and of 3·4% (60 years and older)
in Kolkata. 
A review  of population–based studies of stroke
incidence and case fatality in the late 20th century
reported little variation in age–standardised incidence
(4·2–6·5 per 1000 person years) in those done in Europe,
North America, and Australasia, but higher rates in
Japan, Russia, and the Ukraine. Stroke incidence was
strongly age–dependent, doubling with every 10–year
increment in age. The case–fatality proportion (23%
within 1 month) also increased with age. Between 1970
and 2008, age–adjusted stroke incidence fell by 42% in
high–income countries (–1·0% per year), but more than
doubled in low–income and middle–income countries
(+5·6% per year), and quadrupled in people aged 75 years
or older. Since 2000, stroke incidence in low–income and
middle–income countries exceeded that of high–income
countries. A non–significant trend towards decreasing
case fatality in all world regions was reported,  from
35·9% in the 1970s to 19·8% in the 2000s (–1·1% per
year) in high–income countries, and from 35·2% in the
1980s to 26·6% in the 2000s (–0·6% per year) in low–income
and middle–income countries. A review  of
population–based studies reported clear inverse
associations between gross domestic product per head
and stroke incidence, and case fatality and the proportion
of haemorrhagic strokes. The adverse trends in poor
countries are consistent with trends in blood pressure
level, which have been falling in high–income countries
but increasing in many low–income and middle–income
Actions suggested for stroke prevention are the same
as those for ischaemic heart disease. effective
components of acute treatment include antithrombotic
treatment with aspirin or thrombolytic treatment (in
which case neuroimaging is needed to exclude
haemorrhagic stroke). In high–income countries,
specialist stroke units provide the best general
management of acute stroke. Rehabilitation, including
physical, speech, and occupational therapy and
counselling, can reduce deaths, disability, and the need
for long–term institutional care. However, in the WHOCHOICE
modelling exercise for African and southeast
Asian regions, acute treatment for stroke and organised
stroke unit care were associated with slight benefits and
were not cost effective (>Int$6000 per DALY averted).
Greater yields would be obtained through secondary
prevention (aspirin, a statin, and an ACE inhibitor and
diuretic for greatest gains),  but coverage is low in low–income
and middle–income countries. 
Malignant neoplasms accounted for 87·0 million DALYs
in older people in 2010, 67% of the burden arising in low–income
and middle–income regions. Burden in older
people is forecast to increase by 69% to 2030. Cancer is a
leading cause of mortality, accounting for 9·9 million
deaths yearly of which 5·4 million (54%) occur in people
aged 60 years and older.
The incidence of many cancers rises with age. In the
UK (2007–09), incidence increases exponentially for men
from 116 men per 100 000 at age 40–44 years to 3398 men
at age 85 years and older, and from 245 per 100 000 women
at age 40–44 years to 2082 women at age 85 years and
older; 63% of all cancers were diagnosed in people aged
65 and older.  For four cancer sites, most of the DALY
global burden is in older people: prostate (89%),
oesophagus (52%), colon and rectum (57%), and trachea,
bronchus, and lung (57%). The high background
prevalence of multimorbidity in older people leads to
inadequate suspicion of symptoms. Frailty is rarely
assessed in older patients with cancer, but this frailty,
rather than age, should inform treatment decisions; agerelated
variables such as cognitive impairment, falls, and
malnutrition have negative associations with cancer
survival that are rarely factored into management plans.
According to a Lancet Oncology commission in 2011, 
the ability of high–income countries to deliver aff ordable
cancer care is “at a crossroads” facing a perfect storm of
rapidly increased demand driven by population ageing
and evermore expensive treatment technologies. The
commission advocated policies based on fairness and
equity guided by evidence and a departure from an ethos
supporting the introduction of treatments providing
small incremental benefits irrespective of cost. Rapidly
ageing middle–income countries such as China
(appendix) face the daunting challenge of addressing the
emerging cancer burden in the older population,
alongside a growing disease burden from other noncommunicable
diseases and other pretransition traditional diseases. In China, opportunities for
prevention (eg, tobacco control) have not been optimised,
there are health–system constraints (restricted coverage
of radiotherapy centres) and out–of–pocket payments
restrict access to more effective but costly treatment
options.  In high–income countries, the costs of medical
care for older patients with cancer might be lower than
for their younger counterparts,  partly because
community social–care agencies and informal family
carers take more responsibility for long–term and end–of-life
care. In low-income and middle-income countries,
meeting these needs for large numbers of older patients
with cancer will place a strain on eroded traditional
family support systems, without substantial government
In view of the scarce evidence for cost-effectiveness of
cancer control and treatment programmes in low-income
and middle-income countries, policymakers have been
advised to “start small, scale smart”, [64, 65] gaining knowledge
from pilot programmes, carefully monitored for
efficiency, performance, and effectiveness. Surgical
treatment for treatable cancers, such as breast, cervical,
and colorectal cancer is likely to be cost effective, as might
be adjuvant therapy with conventional radiation and
drugs. The WHO-CHOICE economic modelling exercise
for African and southeast Asian subregions identified
potentially highly cost-effective intervention options for
colorectal cancer (screening at age 50 years with
colonoscopy followed by treatment) and breast cancer
(biannual mammography with treatment of all stages),
while acknowledging the health system constraints that
preclude scaling-up without substantial infrastructure
investment and training.  Palliative care, particularly
pain relief for patients with cancer in the last months of
life is also highly cost effective, with drug costs for oral
morphine amounting to only US$216–420 per year of
pain-free life gained. 
Diabetes mellitus accounted for 22·6 million DALYs in
older people in 2010, 80% of the burden arising in low-income
and middle-income regions. Burden in older
people is forecast to increase by 96% from 2004 to 2030.
In NHANES 1999–2002, 68 the prevalence of total
(diagnosed and undiagnosed) diabetes increases sharply
with age, from 2·4% in people aged 20–39 years to 21·6%
in people aged 65 years and older. Prevalence of total
diabetes had risen from 5·1% (1988–94) to 6·5%
(1999–2002), with the largest increases occurring in the
oldest age groups.  Few epidemiological studies of
diabetes in older people have been done in low-income
and middle-income countries. Nationally representative
surveys in China in 2007–08  and Mexico (Encuesta
Nacional de Salud 2000) [70, 71] provide age-stratified
estimates for older adults. In China, total diabetes
prevalence rose from 3·2% (20–39 years of age) to 20·4%
for people aged 60 or older.  Prevalence was lowest in the
least economically developed rural settings. In Mexico,
total diabetes prevalence was 1% at 20–29 years of age
rising to 23% at ages 60–79 years.  From these
prevalences, 933 000 (41%) of the 2·3 million people with
diabetes in Mexico were estimated to be aged 60 and
Diabetes is treated with diet, biguanide, or
sulphonylurea drugs or insulin. The WHO-CHOICE
modelling exercise identified intensive glycaemic control
(glycosylated haemoglobin <7%) combined with
retinopathy screening and photocoagulation as highly
cost effective for the African and southeast Asian
subregions.  The detection and control of diabetes in
older people is suboptimum. In the USA NHANES
surveys, in the proportion of cases that were diagnosed,
70% was similar across all age groups.  In the China
national survey, no age-stratified data were provided, but
in the sample as a whole, only 31% of cases were
diagnosed.  In a Mexican national survey, the proportion
of people diagnosed rose with age, from roughly two-thirds
of people under 50 years, reaching 86% of people
aged 60–69 years, 87% of people aged 70–79 years, and
80% of people aged 80 years or older. However, the
proportion of diagnosed cases controlled was lower in
older than in younger participants, 58% in those aged
60–69 years, 45% in those aged 70–79 years and 50% in
those aged 80 years or older. 
Chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease (COPD)
accounted for 43·3 million DALYs in older people in
2010, 86% of the burden arising in low-income and
middle-income regions. The global burden was forecast
to increase by 89% from 2004 to 2030. In an international
multisite survey,  the prevalence of COPD was around
10% for people aged 40 years and older, nearly doubling
with every 10–year increment of age, to reach 19–47% for
men and 6–33% for women aged 70 years and older. The
projected large increase in population burden is to be
driven, mainly, by population ageing.  Smoking is the
most important risk factor, according to some estimates, 
for 90% of the costs of illness. However, there is a
substantial prevalence of COPD in non-smokers, and
other risk factors such as exposure to biomass fuels and
tuberculosis might be important, particularly in low-income
and middle-income countries. 
The mainstay of treatment is inhaled β-agonists alone
or in combination with anticholinergics and inhaled or
systemic corticosteroids, with antibiotics for acute
exacerbations. [75, 76] In low-income and middle-income
countries, treatment recommendations have been
complicated by the high costs and low availability of
imported drugs, and the scarcity of spirometry to stage
the illness and monitor treatment responsiveness; 
however, these limitations might be easing.  Standard
treatment recommendations do not vary by age, but
corticosteroids should be used cautiously in older adults
and in settings with high prevalence of tuberculosis.
Adherence to inhaled drugs can be an issue too.  The
cost-effectiveness of standard treatments for COPD in
low-income and middle-income countries is low
(>Int$10 000 per DALY averted), a conclusion predicated
partly on an assumption of persistently high treatment
Visual impairment (blindness or low vision) accounted
for 10·4 million DALYs among older people in 2010, 86%
of the burden arising in low-income and middle-income
regions. This is a very substantial reduction from the
30·9 million DALYs in the WHO 2004 GBD estimates,
which was forecast to increase by 86% by 2030.
186 million of the world’s 285 million visually impaired
(65%), and 32 million of the world’s 39 million blind
people (82%) are estimated to be older adults aged
50 years and older; cataracts are the leading cause of
blindness in the world, and refractive errors are the
leading cause of low vision. 
The prevalence of cataracts is strongly age-associated.
In most world regions, adults aged 80 years and older
either have a cataract or have had cataract surgery.
However, prevalence in older people aged 60–64 years
seems to be higher in Asian studies than in other
regions.  The prevalence of unoperated cataracts in
people aged 60 years and older was 57·8% (north India
site) and 52·9% (south India site) in two large population-based
studies.  Smoking cessation is the main viable
strategy at present for cataract prevention, although
several studies from India suggest that use of biomass
fuels might also be an important risk factor. 
The worldwide prevalence of visual impairment from
uncorrected refractive errors rises with increasing age
from around 1% at age 5–15 years to 8% for people aged
50 years and older, with a prevalence approaching 20% in
older people in south Asia.  This finding suggests that
95 million older adults have potentially correctable visual
impairment and 6·9 million (3·1 million in India) are
functionally blind. In countries where visual impairment
is highly prevalent, cataracts in older people from rural
areas are an important underlying factor, either due to
index myopia, uncorrected aphakia, or insufficient intraocular
lens correction. 
In the WHO-CHOICE cost-effectiveness analysis, 
extracapsular cataract extraction with posterior chamber
lens implantation was a highly cost-effective intervention,
Int$116 and Int$97 per DALY averted, respectively. 
Scaling up this intervention would also address much of
the uncorrected refractive errors within these
populations. Nevertheless, cataract surgery coverage is
generally low, although very variable between studies,
with rural populations and women being particularly
under served. [84, 85] The cost-effectiveness of screening for
and correcting refractive errors with glasses in older
people has not been specifically examined. This is a lowcost
intervention—for example, screening, refraction,
and dispensing costs in India (for schoolchildren but in
primary care) were estimated at US$31. 
Dementia accounted for 10·0 million DALYs in older
people in 2010, 44% of the burden arising in low-income
and middle-income regions. This is a substantial
reduction from the 18·8 million DALYs in WHO GBD
2004 estimates, which was forecast to increase by 86% by
2030. Dementia is characterised by progressively
disabling impairment of several cognitive functions.
However, behavioural and psychological symptoms affect
quality of life, are an important cause of carer strain, 
and are a common reason for institutionalisation.  In
population studies in low-income and middle-income
countries, dementia was consistently the leading
contributor to disability  and dependence. 
Early estimates of worldwide prevalence were
hampered by an absence of evidence from low-income
and middle-income countries. Primary research [89–91] from
the past 10 years with culturally valid methods suggests
that age-specific prevalence and incidence of dementia is
similar to that in high-income countries. As more data
emerge, systematic reviews [92, 93] show that age-standardised
prevalence varies little between world regions (between
5% and 8% of people aged 60 years and over). [93, 94]
Incidence doubles with every 5·9–year increase in age,
from 3 per 1000 person years at age 60–64 years to 175 per
1000 person years at age 95 and older; 7·7 million new
cases are expected each year. 
The number of people with dementia worldwide will
increase sharply, driven by worldwide patterns of
population ageing; 44·4 million people had dementia in
2013, with numbers nearly doubling every 20 years to
75·6 million in 2030 and 135·5 million in 2050. 
Proportionate increases in the next 20 years are predicted
to be much steeper in low-income and middle-income
countries than in high-income countries. 58% of people
with dementia worldwide live in low-income and middle-income
countries, which is expected to rise to 71% by
2050. The total estimated worldwide costs of dementia
were US$604 billion in 2010, equivalent to 1% of the
world’s gross domestic product.  In low–income
countries, informal care costs predominate (58% of all
costs in low–income countries and 65% of all costs in
middle–income countries, compared with 40% in highincome
countries). Conversely, in high–income countries,
the direct costs of social care (paid care in the community
or in care homes) account for 42% of total costs compared
with 14% in low–income countries.
The progressive course of dementia cannot be changed,
but symptomatic treatments and support are helpful.
Early diagnosis allows patients affected to participate in
advanced–care planning while they still have capacity to do
so.  Education, training, and support for carers is effective
in reducing carer strain and psychological morbidity, and,
in high–income countries, in delaying or avoiding
transition into care homes.  Such interventions might be
more effective early in the disease course. [97, 99] Early
diagnosis and intervention is likely to be cost–effective in
high–income countries, assuming delayed or averted
transfer into costly institutional–care settings.  The costeff
ectiveness of scaling up diagnosis and care in low–income
and middle–income countries is unknown.
However, the psychological and economic strain on
caregivers is substantial, and compensatory benefits
practically non–existent. [87, 94] Although worldwide awareness
of the need to invest in the development of treatment and
care for dementia is growing (eg, the 2013 G8 Summit was
devoted to the topic, setting an ambition to identify a
disease–modifying treatment for dementia by 2025),
substantial challenges in achieving acceptable levels of
coverage and access to care exist. At present, people with
dementia receive a diagnosis late in the disease course, if
at all; around half of the people affected are diagnosed in
high–income countries, the proportion falling to less than
10% in low–income and middle–income countries where
awareness is even less than in high–income countries. [97, 100]
Musculoskeletal disorders accounted for 43·3 million
DALYs in older people in 2010, 66% of the burden arising
in low–income and middle–income regions. This is a very
substantial increase from the 12·1 million DALYs in
WHO 2004 GBD estimates, which were forecast to
increase by 70% by 2030. The main contribution from
musculoskeletal disorders arises from low–back pain
(19·1 million DALYs) followed by osteoarthritis
(7·5 million DALYs).
Low–back pain is a syndrome based mainly on self–reported
symptoms, with many underlying pathological
changes, including mechanical causes (muscle and joint
strain, disc degeneration or prolapse, or osteoarthritic and
osteoporotic bone disease) with inflammatory back pain
accounting for up to a third of cases.  Psychosocial factors,
such as stress, anxiety, depression, job dissatisfaction, and
low social support, predispose to chronicity. In a review of
many studies done worldwide, the median (1–month
period) prevalence of activity–limiting low–back pain was
estimated at 23%, peaking in the working age population,
and then decreasing into older age.  In older people there
might be under ascertainment because of cognitive
impairment or an increased tolerance or decreased
perception of pain. The WHO Scientific Group on
Rheumatic Diseases estimated in 2003 that 10–20% of the
world’s population aged 60 years or older have significant
clinical problems attributed to osteoarthritis.  Prevalence
increases sharply with age, since osteoarthritis is
remorselessly progressive and cumulative. 
The outlook for chronic low–back pain is poor, and
treatment outcomes have not improved, despite
increased use of surgical and other invasive
techniques.  A holistic and conservative approach is
suggested by Morlion,  with due attention to
psychosocial factors. The mainstay of osteoarthritis
treatment is self–management (exercise, pacing of
activities, joint protection, weight reduction, and other
measures to unload damaged joints) and anti–inflammatory analgesics.  Paracetamol is the first line
pharmacological treatment for both osteaoarthritis and
low–back pain in older people, who might be especially
susceptible to cardiovascular and gastrointestinal adverse
effects of non–steroidal anti–inflammatory drugs
(NSAIDs). However, effectiveness of paracetamol for
chronic low–back pain has not been clearly proven. 
NSAIDs, if used at all, should be prescribed with a proton
pump inhibitor, or cyclo–oxygenase–2 selective drugs
should be considered. Joint replacement is cost–effective
for patients with severe symptoms or residual functional
impairment on conservative treatment;  however, access
to this intervention is restricted in resource–poor settings.
The Madrid International Plan of Action on Ageing
called for the elimination of social and economic
inequalities in access to health care and the development
of healthcare and long–term care to meet the needs of
older people.  To achieve these needs, age discrimination
should be countered and the challenges posed by
multimorbidity and frailty addressed. The fitness for
purpose of health services and systems for older adults
and their complex, interacting, chronic medical and
social difficulties is open to question.
Ageist attitudes and beliefs that ill health is inevitable,
intervention ineffective, and improved outcomes
inherently not valuable are widespread, even in older
people and health–care professionals.  However, the
association between age and health is much more
variable than is often realised, and age alone should not
determine access to treatment and care. Even in well
resourced countries, age discrimination is apparent in
primary and secondary prevention of cardiovascular
disease, [13, 108] treatment of stroke109 and acute coronary
stenosis,110 and access to surgical procedures.  In cancer
care, fewer diagnostic and staging procedures are done
and less evidence–based treatment is given to older
people, even when taking frailty into account.  Older
people tend to be excluded from clinical trials that would
generate specific evidence to inform their treatment,
even for drugs that are mainly prescribed in older age. 
Age discrimination is multifactorial, including demandside
and supply–side factors. Structural barriers are
implicated in view of striking differences in service use
between health systems that are not attributable to
morbidity patterns.  These barriers include the high cost
of chronic disease care when incomes are insecure;
health care is financed by out–of–pocket payments and
insurance coverage is incomplete. [114–116]
Multimorbidity increases sharply with age, with around
two–thirds of people aged 65 years and older affected, [117–120]
and is strongly associated with impaired quality of life, 
disability, dependence,  and mortality.  Patients with
multimorbidity account for 96% and people with more
than five disorders for 68% of USA Medicare
expenditure.  Care coordination is essential; unnecessary
hospital admissions increase exponentially in
the USA with increasing multimorbidity. [117, 123] Rigid
application of clinical practice guidelines for single
disorders might contribute to polypharmacy, adverse
drug interactions, and unnecessary cost.  Frailty
provides an attractive theoretical framework within
which practitioners can devise holistic assessment and
treatment of older people with complex co–morbidities in
a structured way. [125, 126] Frailty describes a process of
progressive age–related deterioration in physiological
systems with decreased functional reserve capacity, and
hence susceptibility for failure in the face of
environmental stressors. Frailty predicts adverse health
and social outcomes (morbidity, disability, hospital
admission, falls and fractures, dependence,
institutionalisation, and death) better than diagnostic
information alone. [127, 128] Originally defined as a largely
physical construct identified by five indicators
(exhaustion, weight loss, weak grip strength, slow
walking speed, and low energy expenditure), others have
widened the scope to include, for example, cognitive or
sensory domains. [129, 130] Clusters of frailties or disorders
might occur because of common risk factors or
underlying pathophysiologies, or because one disorder is
a complication of another, or its treatment.  Causal links
might have implications for primary prevention, disease
management and for the effi cient delivery of good quality
age–appropriate health care. [119, 132]
A holistic approach has been advocated, with
comprehensive assessment, leading to well integrated
continuing care, focusing first and foremost on patient
preferences in an effort to streamline care and enhance
its acceptability. [131, 132] The benefits of comprehensive
geriatric assessment and referral were most pronounced
in trials done in the 1980s and early 1990s, before such
approaches were institutionalised in many high–income
countries.  Exploration of the role of community–based
models of care, individually tailored multicomponent
interventions, and various approaches to integrated case
management are all active areas for research. Targeting
of these areas could be achieved by focusing on the
acquisition of frailties that confer risk for adverse
outcomes and that might, in principle, be delayed,
slowed, or even reversed; the present evidence base is
mainly restricted to nutritional and exercise interventions.  The added value of such assessments needs
to be tested formally, and more work needs to be done to
link assessment to evidence–based multi dimensional
The worldwide epidemic of chronic disease is, to a large
and increasing extent, concentrated in older people and
people living in low–income and middle–income
countries. Global burden of disease in older people is
projected to increase more or less in line with the increase
in the older population, consistent with population ageing
being the most important driver of the chronic disease
epidemic.  The largest increases in disease burden will
occur for those disorders that are particularly strongly
age–associated (dementia, stroke, COPD, and diabetes).
The association between biological age and morbidity and
loss of function underpins the link between population
ageing and increasing burden; however, this association
is neither constant nor immutable, leaving much scope
for intervention to promote health and prevent disease in
older people.  In low–income and middle–income
countries, the epidemiological transition will result in
growing exposure to cardiovascular risk factors in older
people, particularly in poor people, an increase in the
incidence and prevalence of cardiovascular diseases, and
a surge in health inequalities. To address this issue should
be a global health priority. In high–income countries,
socioeconomic gradients, once established, tend to
become entrenched, with poor people and people with
lower levels of education failing to benefit from
subsequent improvements in public health.  Hence,
there are two crucial and related public health challenges
for low–income and middle–income countries; can we
improve the health of successive cohorts of older people
as life expectancy increases (compression of morbidity),
and can this be achieved equitably? Monitoring of
progress will need increased and improved population–based
studies of the health of older people in low–income
and middle–income countries.
The age distribution of chronic disease is not
adequately shown in the prioritisation of present
strategies to combat the epidemic.  Although deaths
due to ischaemic heart disease occur at younger ages in
low–income and middle–income countries, most deaths,
and most opportunities to prolong life arise in older
people. The focus on primary prevention strategies to
reduce midlife mortality neglects the substantial
disability and dependence from increased survival with
cardiovascular disease. The focus also diverts attention
from other disorders such as dementia, stroke, COPD,
and vision impairment, for which the burden of disease
arises more from disability than from mortality,  and for
which costs of long–term care outweigh health
The societal costs of these disorders is enormous,
particularly in high–income countries with welfare–based
social care systems; in the UK, the societal cost of
dementia is estimated to exceed that of cardiovascular
disease, cancer, and diabetes combined.  The Institute
of Health Metrics and Evaluation (IHME) disability
weights used to compute years lived with disability (YLD)
have compounded this issue.  Seismic shifts in the
burden of disease between WHO 2004 estimates  and the
IHME 2010 estimates  have neither been highlighted
nor explained. Findings from this Review show that, in
older people for whom the discrepancies were most
striking, the burden of dementia has been cut by half, the
burden of visual impairment by two–thirds, and the
burden of musculoskeletal disorders has increased
nearly four times. This result is due to changes in
disability weights rather than in the estimates of the
frequency of these disorders. Disability weights will be
affected by choice of respondents used to measure them,
the information provided about the health states, and the
way that the questions are framed. WHO GBD weights 
were measured through a consensus of international
experts, whereas the IHME weights portrayed judgments
of the general public.  IHME weights link to relative
health rather than relative disability, and the extent to
which the IHME GBD notion of health loss maps on to
conventional notions of disability and dependence is
open to question.
Primary and secondary preventive interventions for
cardio–metabolic disorders are nearly as effective in older
people as in younger people. In view of the increased
incidence and prevalence of cardio–metabolic disorders
in older people, the relative efficiency of these
interventions is strengthened. This efficiency is
apparent in the much smaller numbers needed to treat
to prevent one adverse outcome in older people than in
younger people,  and is implicitly recognised in
treatment algorithms and prevention strategies
endorsed on the grounds of cost–effectiveness through
WHO–CHOICE modelling exercise.  Nevertheless,
these strategies are selectively underused in older
people. Control of hypertension in older people is a core
indicator of the functionality of primary care systems
for chronic disease management. Much work still needs
to be done to increase coverage, particularly in low–income
and middle–income countries,  although the
issue is not restricted to resource–poor settings. 
Whether universal or targeted approaches, fixed–dose
combination treatment, or antihypertensive drugs alone
are used, health–system strengthening is fundamental.
Effective intervention in older people is complicated by
ageism, complex multimorbidity, and poor access to ageappropriate
care, exacerbated by user fees, inadequate
income security, and social protection.  Age–appropriate
primary care services need to be reorganised and trained,
to better meet the needs of their increasingly aged
clientele. Reforms should include a commitment to
provide continuing care, capacity for outreach including
home–based assessments, and holistic integrated care for
patients with multimorbidities. Simple structured
assessment and attention to underlying frailties (little
mobility, undernutrition, pain, in continence, and
cognitive and sensory impairment) might promote
increased attention to the needs of older people and limit
disability and dependence. Family carers benefit from
advice and support, particularly when needs for care are
pronounced. The development and evaluation of such
models of care is urgently needed, particularly for their
All authors worked together to decide the scope and structure of the
Review. MP did the analyses of IHME GBD data and wrote the first draft
of the manuscript with particular inputs from SY (cardiovascular
diseases), M’OD (stroke), RS (cancer), LMGR (frailty and
multimorbidity), and FW and YG (China context). All authors reviewed,
edited, and approved the fi nal manuscript.
Declaration of interests
We declare no competing interests.
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