Demographic Characteristics and Healthcare Use of Centenarians: A Population-Based Cohort Study Paula A. Rochon, MD, MPH,a,b,c,d Andrea Gruneir, PhD,a,c,d Wei Wu, MSc,a Sudeep S. Gill, MD, MSc,d,e,f Susan E. Bronskill, PhD,c,d Dallas P. Seitz, MD,g Chaim M. Bell, MD, PhD,b,c,d,h Hadas D. Fischer, MD, MSc,d Anne L. Stephenson, MD, PhD,b,i Xuesong Wang, MSc,d Andrea S. Gershon, MD, MSc,b,c,d,j and Geoffrey M. Anderson, MD, PhDa,c,d
OBJECTIVES: To better understand how centenarians use the healthcare system as an important step toward improving their service delivery. DESIGN: Population-based retrospective cohort study using linked health administrative data. SETTING: Ontario—Canada’s largest province. PARTICIPANTS: All individuals living in Ontario aged 65 and older on April 1 of each year between 1995 and 2010 were identified and divided into three age groups (65–84, 85–99, ≥100). A detailed description was obtained on 1,842 centenarians who were alive on April 1, 2010. MEASUREMENTS: Sociodemographic characteristics and use of health services. RESULTS: The number of centenarians increased from 1,069 in 1995 to 1,842 in 2010 (72.3%); 6.7% were aged 105 and older. Over the same period, the number of individuals aged 85 to 99 grew from 119,955 to 227,703 (89.8%). Women represented 85.3% of all centenarians and 89.4% of those aged 105 and older. Almost half of centenarians lived in the community (20.0% independently, 25.3% with publicly funded home care). Preventive drug therapies (bisphosphonates and statins) were frequently dispensed. In the preceding year, 18.2% were hospitalized and 26.6% were seen in an emergency department. More than 95% saw a primary care provider, and 5.3% saw a geriatrician.
From the aWomen’s College Research Institute, Women’s College Hospital, bDepartment of Medicine, University of Toronto, cInstitute of Health Policy, Management and Evaluation, University of Toronto, d Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; e St. Mary’s of the Lake Hospital, fDepartment of Medicine, Queen’s University, gDepartment of Psychiatry, Queen’s University, Kingston, Ontario, Canada; hMount Sinai Hospital, iKeenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, and jSunnybrook Health Sciences Centre, Toronto, Ontario, Canada. Address correspondence to Paula A. Rochon, Women’s College Research Institute, Women’s College Hospital, 790 Bay Street Toronto, Ontario, Canada. E-mail: [email protected] DOI: 10.1111/jgs.12613
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CONCLUSION: The number of centenarians in Ontario increased by more than 70% over the last 15 years, with even greater growth among older people who could soon become centenarians. Almost half of centenarians live in the community, most are women, and almost all receive care from a primary care physician. J Am Geriatr Soc 62:86–93, 2014.
Key words: centenarians; health service use; advanced age
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nowledge about centenarians comes primarily from national census data like those available in Canada1 and the United States2 and from detailed studies of select groups of centenarians such as those from Australia,3 China,4–6 Denmark,7Greece,8 Italy,9,10 Sweden,11 the United Kingdom,12 and the United States.13,14 There are gaps in the existing information on centenarians. Census data provide demographic information on large populations.15,16 Observational studies generally study smaller numbers of individuals and focus primarily on factors associated with exceptional longevity and health status.4–6,9,10,12 Less focus has been given to understanding patterns of health service use in a large population of centenarians.7,17,18 The current article describes a large geographically based population of centenarians and links their sociodemographic information to their health services use. A better understanding of who centenarians are and how and when they use the healthcare system is an important step toward improving service delivery. This article also provides an important glimpse of what might be expected in the future, when becoming a centenarian may not be a rarity. Although this projection is controversial, one group has suggested that more than 50% of babies born in developed countries since 2000 will live to be more than 100 years old.19 Others have a less-optimistic view.20 A population-based study of centenarians was conducted using an estimated 1.8 million individuals aged 65 and older to document changes in the size of the centenarian population over the past 15 years.
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The health conditions and use of health services of all centenarians were profiled to better understand this special segment of the older population.
METHODS This was a population-based retrospective cohort study using health administrative data from Ontario, Canada’s largest province. The research ethics board of Sunnybrook Health Sciences Centre approved the study.
Data Sources All older adults in Ontario have universal access to medically necessary health services, including prescription drug therapy. The single-payer system provides the ability to compile service details from an extensive range of health administrative databases using unique individual-level identification so that a comprehensive health profile can be created. This study used the encrypted linkable administrative healthcare databases housed at the Institute for Clinical Evaluative Sciences, as described in Appendix 1. To meet the first objective, all individuals aged 65 and older on April 1 of each year between 1995 and 2010 were identified and divided into three age groups (65–84, 85–99, ≥100). To meet the second objective, all centenarians alive on the cohort entry date of April 1, 2010, were studied to obtain a detailed description of their sociodemographic characteristics and use of health services. Centenarians were divided into three subgroups (100, 101–104, ≥105). To be certain that centenarians were alive and that the number of centenarians was not overestimated, all individuals were followed for a 2-year period from April 1, 2010, through March 31, 2012. Healthcare contact or date of death was looked for. Those without any subsequent record were excluded. Date of death was recorded for those who died.
Centenarian Descriptors Sociodemographic Characteristics The age, sex, and income status of the study population were measured. Low-income status was identified according to eligibility for a low-income subsidy in the provincial drug benefit program and defined as an annual income of C$16,018 or less per individual or C$24,175 per couple.21 All older residents of long-term care homes were identified using the Continuing Care Reporting System database. Long-term care includes chronic care facilities. Comorbidity was measured using the Charlson Comorbidity Index,22,23 the frequency of 11 age-related conditions (dementia, asthma, chronic obstructive pulmonary disease (COPD), congestive heart failure, diabetes mellitus, arthritis, ischemic heart disease, stroke, hypothyroidism, cancer, hip fracture) and drug therapy dispensed in the previous year. The Charlson Comorbidity Index was constructed using data available from hospital admission and same-day
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surgery in the past 5 years.22,23 Scores were grouped into three categories (0, 1, ≥2), with higher scores indicating greater comorbidity. Appendix S2 describes how the 11 age-related health conditions were defined using established algorithms derived from administrative records for each of these conditions. As such, the time frames and approach used to identify the health conditions varied according to condition and availability of data. Dementia was selected because good cognitive function is fundamental to healthy aging.24 Physician-diagnosed dementia was defined using in- and outpatient diagnosis codes in the past 5 years and use of dementia-specific drugs (donepezil, rivastigmine, galantamine) in the past 1 year, as has been done in previous work.25 Eight chronic medical conditions were selected because they are common in older people and have been defined using validated (asthma,26 COPD,27 congestive heart failure,28 diabetes mellitus29) or previously published (arthritis,25 ischemic heart disease,30 stroke31) algorithms. Hypothyroidism was defined according to the dispensing of drug therapy32 in the prior year specific for the treatment of hypothyroidism. Cancer was included because cancer incidence increases with age and is a leading cause of death. Cancer was identified using the Ontario Cancer Registry containing information on cancers (excluding non-melanoma skin cancer) diagnosed since 1964.33 Hip fractures were included because they are a sentinel event for older people, leading to a cascade of undesirable outcomes, including up to 24% 1-year mortality rate.34 Hip fractures were identified from hospital admission codes.25 Drug therapy use was assessed using three measures. First, the number of distinct drug therapies dispensed in the year before cohort entry35 was counted as a measure of comorbidity. Next, the drug therapies were grouped into subclasses to identify those most frequently dispensed for noninfectious conditions to assess the use of drug therapy for chronic health conditions. Then, to evaluate use of preventive drug therapy at advanced age, the use of two common therapies was measured (5-hydroxy-3-methylglutarylcoenzyme A reductase inhibitors (statins) and bisphosphonates).36 Finally, the use of antipsychotic and benzodiazepine therapy listed in the 2012 American Geriatrics Society update of the Beers Criteria for potentially inappropriate medication use in older adults was measured.37
Health Service Use Home care support in the community was defined as the use of at least one publicly funded home care service captured in the Home Care database. Acute care hospital admission was measured in two ways; all older adults in an acute care hospital on April 1, 2010, and those with an acute care admission or an emergency department visit during the previous year. All visits in the previous year to primary care physicians and to specialists, including geriatricians, neurologists, psychiatrists, cardiologists, and ophthalmologists, were identified.
Descriptive Analyses To document growth in different age categories within the older adult population, the growth rate between 1995 and
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each subsequent year was calculated, until 2010. The growth rate was calculated separately in each of three age categories (65–84, 85–99, ≥100) and compared between the groups. A retrospective cohort approach was used to describe all centenarians in the community and in long-term care on April 1, 2010. Descriptive statistics were used to describe participants according to their sociodemographic profile and use of health services within three centenarian subgroups (100, 101–104, ≥105). These groups were selected because 100 represents the initial centenarian milestone and 105 a milestone of exceptional age called semisupercentenarians.38 The analyses were stratified according to sex.
RESULTS Growth in Number of Centenarians In Ontario, the number of centenarians increased from 1,069 in 1995 to 1,842 in 2010 (72.3%) (Figure 1). During the same time period, the number aged 85 to 99 increased from 119,955 to 227,703 (89.8%). The data were compared with census data obtained for similar time periods, and the results were consistent (Appendix S3).
Centenarian Descriptors Sociodemographic Characteristics Based on 15,259,908 individuals living in Ontario in 2010, centenarians represented 1.21 per 10,000 people. Of the 1,842 centenarians alive in Ontario on April 1, 2010, more than 60% were aged 101 or older; 123 (6.7%) were semisupercentenarians (≥105) (Table 1). Women represented 85.3% of those centenarians and almost 90% of semisupercentenarians (Figure 2). Slightly more than half (51.4%) had a low income.
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On the index date, 19 (1.0%) centenarians were in an acute care hospital, 834 (45.3%) were living in the community, and 989 (53.7%) were in long-term care; 466 (25.3%) lived in the community with publicly funded home care.
Prevalence of Treated Comorbid Conditions and Prescription Drug Use in Centenarians in 2010 Three hundred five (16.6%) centenarians had a Charlson Comorbidity Index of 2 or more. Scores were not available for 329 in the community and 378 in long-term care because these individuals had not had an acute care hospitalization or same-day surgery in the prior 5 years. For age-related conditions, physician-diagnosed dementia was identified in 1,068 (58.0%) of centenarians and was more frequent in women (59.6%) than men (48.3%). Arthritis (n = 1,003, 54.5%), congestive heart failure (n = 641, 34.8%), and COPD (n = 498, 27.0%) were the other most-common conditions; 267 (14.5%) centenarians had a history of cancer, and 11.7% had had a prior hip fracture, more frequently women. Centenarians had been dispensed a mean of 9.2 5.3 different therapies in the previous year, most frequently diuretics (n = 963, 52.3%), followed by laxatives. Bisphosphonates were dispensed to 18.0% of centenarians and 10.6% of those aged 105 and older. Statins were dispensed to 10.6% of all centenarians and 8.9% of those aged 105 and older. Women were more likely than men to have bisphosphonates dispensed (19.5% vs 8.9%) and less likely to receive a statin (10.0% vs 14.0%). Antipsychotic drug therapy was dispensed to 16.2% of the centenarians and benzodiazepine therapies to 24.4%. The use of these therapies was concentrated in those with dementia. Within the subsequent 2 years, 58.1% of centenarians died (Table 2). The death rate was lowest for those living without home care in the community and without
Figure 1. Growth rate of the older adult population between 1995 and each subsequent year until 2010 in three age categories (65–84, 85–99, ≥100). The data were derived from the Registered Persons Database for demographic data housed at the Institute for Clinical Evaluative Sciences.
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Table 1. Descriptive Characteristics of Centenarians on April 1, 2010 Sex
Characteristic
Sociodemographic Age, mean SD Low income, n (%) Setting of care on index date, n (%) Community With home care Without home care Long-term care Acute-care hospitala Comorbidity measures, n (%) Charlson Comorbidity index (prior 5 years) No scoreb 0 1 ≥2 Age-related conditions, n (%) Dementia (prior 5 years) Chronic conditions Arthritis (prior 5 years) Congestive heart failure (since 1991) Chronic obstructive pulmonary disease (since 1991) Hypothyroidism therapy (prior 1 year) Ischemic heart disease (prior 5 years) Diabetes mellitus (since 1991) Asthma (since 1993) Stroke (prior 5 years)a Cancer (since 1964) Hip fracture (prior 5 years) Drugs taken in previous year, mean SD Most frequent noninfectious drugs, n (%) Diuretics Laxatives, cathartics, stool softeners Preventive drugs, n (%) Bisphosphonates Statins Mental health drugs, n (%) Antipsychotic Benzodiazepine derivative Antidepressant Health service use In previous year Acute care admission, n (%) Emergency department visit, n (%) Number of physician visits, mean SD, median (interquartile range) Specialist visits, n (%) General practitioner or family physician Geriatrician Neurologista Psychiatrista Cardiologist Ophthalmologist
Age
Total, N = 1,842
Female, n = 1,571
Male, n = 271
100, n = 704
101–104, n = 1,015
≥105, n = 123
101.4 1.7 946 (51.4)
101.4 1.7 830 (52.8)
101.2 1.6 116 (42.8)
370 (52.6)
492 (48.5)
84 (68.3)
834 466 368 989 19
(45.3) (25.3) (20.0) (53.7) (1.0)
680 392 288 877
(43.3) (25.0) (18.3) (55.8)
154 74 80 112
(56.8) (27.3) (29.5) (41.3)
349 192 157 347
(49.6) (27.3) (22.3) (49.3)
442 247 195 565
(43.5) (24.3) (19.2) (55.7)
43 27 16 77
(35.0) (22.0) (13.0) (62.6)
707 528 302 305
(38.4) (28.7) (16.4) (16.6)
617 455 261 238
(39.3) (29.0) (16.6) (15.1)
90 73 41 67
(33.2) (26.9) (15.1) (24.7)
261 198 110 135
(37.1) (28.1) (15.6) (19.2)
382 301 177 155
(37.6) (29.7) (17.4) (15.3)
64 29 15 15
(52.0) (23.6) (12.2) (12.2)
1,068 (58.0)
937 (59.6)
131 (48.3)
405 (57.5)
584 (57.5)
79 (64.2)
1,003 (54.5) 641 (34.8) 498 (27.0)
858 (54.6) 541 (34.4) 390 (24.8)
145 (53.5) 100 (36.9) 108 (39.9)
396 (56.3) 259 (36.8) 216 (30.7)
548 (54.0) 336 (33.1) 250 (24.6)
59 (48.0) 46 (37.4) 32 (26.0)
459 (24.9) 298 (16.2)
407 (25.9) 247 (15.7)
52 (19.2) 51 (18.8)
179 (25.4) 127 (18.0)
260 (25.6) 163 (16.1)
20 (16.3) 8 (6.5)
289 (15.7) 179 (9.7) 71 (3.9) 267 (14.5) 215 (11.7) 9.2 5.3
245 (15.6) 143 (9.1) 57 (3.6) 217 (13.8) 193 (12.3) 9.2 5.3
44 (16.2) 36 (13.3) 14 (5.2) 50 (18.5) 22 (8.1) 9.2 5.5
133 (18.9) 81 (11.5)
144 (14.2) 86 (8.5)
12 (9.8) 12 (9.8)
106 (15.1) 78 (11.1) 9.6 5.5
148 (14.6) 121 (11.9) 9.1 5.3
13 (10.6) 16 (13.0) 7.8 4.8
963 (52.3) 881 (47.8)
833 (53.0) 754 (48.0)
130 (48.0) 127 (46.9)
393 (55.8) 331 (47.0)
510 (50.2) 491 (48.4)
60 (48.8) 59 (48.0)
331 (18.0) 195 (10.6)
307 (19.5) 157 (10.0)
24 (8.9) 38 (14.0)
146 (20.7) 86 (12.2)
172 (16.9) 98 (9.7)
13 (10.6) 11 (8.9)
298 (16.2) 449 (24.4) 506 (27.5)
267 (17.0) 392 (25.0) 443 (28.2)
31 (11.4) 57 (21.0) 63 (23.2)
115 (16.3) 181 (25.7) 209 (29.7)
161 (15.9) 245 (24.1) 274 (27.0)
22 (17.9) 23 (18.7) 23 (18.7)
336 (18.2) 490 (26.6) 20.1 20.0, 14 (8–24)
279 (17.8) 399 (25.4) 19.9 20.2, 14 (8–23)
57 (21.0) 91 (33.6) 20.8 19.0, 14 (8–27)
132 (18.8) 215 (30.5) 20.5 21.1, 14 (9–24)
183 (18.0) 252 (24.8) 20.0 19.5, 14 (8–24)
21 (17.1) 23 (18.7) 18.2 18.0, 13 (6–21)
1,756 98 31 53 406 246
1,496 (95.2) 80 (5.1)
260 (95.9) 18 (6.6)
681 (96.7) 43 (6.1)
959 (94.5) 49 (4.8)
116 (94.3) 6 (4.9)
339 (21.6) 201 (12.8)
67 (24.7) 45 (16.6)
159 (22.6) 114 (16.2)
217 (21.4) 126 (12.4)
30 (24.4) 6 (4.9)
(95.3) (5.3) (1.7) (2.9) (22.0) (13.4)
SD = Standard Deviation. a The number and percentage could not be reported in the sex and age groups based on the Small Cell Policy from the Institute for Clinical Evaluative Sciences. b During the period of Charlson Comorbidity Index calculation, the participant had no hospital admission or same-day surgery.
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Figure 2. Number of centenarians and their sex distribution at each year of age for the 1,842 individuals identified as aged 100 and older in Ontario on April 1, 2010.
Table 2. Recorded Deaths Among Centenarians Between April 1, 2010, and March 31, 2012, Stratified According to Dementia Status and Location of Residence Without Dementia
With Dementia
Community
Characteristic
Recorded death, n (%)
Community
Total, N = 1,842
Without Home Care, n = 276
With Home Care, n = 290
Long-Term Care, n = 208
Total, n = 774
Without Home Care, n = 94
With Home Care, n = 191
Long-Term Care, n = 783
Total, n = 1,068
1,070 (58.1)
107 (38.8)
145 (50.0)
132 (63.5)
384 (49.6)
55 (58.5)
116 (60.7)
515 (65.8)
686 (64.2)
Nineteen individuals were in acute care on April 1, 2010. This table reflects their location of residence before the acute care admission.
dementia (38.8%) and highest for those with dementia living in long-term care (65.8%).
Health Service Use by Centenarians in 2010 During the year before cohort entry, 18.2% of the 1,842 centenarians had a hospitalization and 26.6% had an emergency department visit. In contrast, 63.9% had neither a hospitalization nor an emergency department visit. Almost all centenarians (95.3%) visited a primary care physician, and only 5.3% were assessed by a geriatrician.
DISCUSSION Older people are living longer. More people are now likely to reach the age of 100, making the study of those who reach the extremes of longevity more relevant. To the knowledge of the authors, this is one of the few studies to examine all centenarians in a large geographic population.7,17,18 The current study provides detailed information about the current sociodemographic profile of centenarians and captures all of their publicly funded health services use. The predominance of women at this age, the fact that many centenarians are living in the community, and the use of preventive drug therapy at advanced age are described. This study provides an understanding of centenarians and the formal healthcare services they receive.
Centenarians represent only a small portion of the older population. For every centenarian, 120 times as many people aged 85 to 99 were identified, many of whom may become the centenarians of the future. A more than 70% increase in older individuals reaching 100 in the past 15 years was found. This growth is even more dramatic given that formal documentation of the existence of centenarians started in around 1800.39 Most older people40 and centenarians1,2 are women. In the current study, this is magnified in semisupercentenarians (≥105), more than 90% of whom were female. The data are consistent with international data indicating that women have outlived men in Sweden since 1751, the Netherlands since 1860, and Italy since 1889.41 The predominance of older women has important health service implications. Women generally outlive their spouses because they live longer than men and because they tend to marry men who are older than they are.42 Women have traditionally been the caregivers, so their spouses may be less well equipped to take on caregiving responsibilities.42 Accordingly, a higher proportion of women receiving formal home care or living in long-term care was found. The predominance of women among those of advanced age challenges us to consider customizing health and social care to meet their particular needs. The data highlight the central role of primary care physicians in providing health care for those of advanced
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age. More than 95% of centenarians had at least one visit with a primary care physician in the prior year. In contrast, only 5% saw a geriatrician. This finding may relate to their general good health or a preference to obtain their care from their primary care provider or may reflect the scarcity of geriatricians. In Ontario, there are five geriatricians per 100,000 population aged 65 and older.42 The findings of the current study support the Public Policy and Aging Report from 2003,43 which recommends that every healthcare worker receive training in geriatrics. The current study demonstrates that almost half of centenarians are living in the community. More than 40% do not receive publicly funded home care support, suggesting that they retain functional independence or receive caregiving supports outside this system. The data do not capture the substantial amount of informal care that family members and friends provide44 or care that is paid for privately. Close to 60% of centenarians died within 2 years of the study date. Although most centenarians did not require acute care, many did. Emergency departments may not be the best environment to evaluate vulnerable older adults, particularly those living in a long-term care setting. For nonurgent medical conditions, alternative strategies should be explored that meet their health needs and avoid potentially burdensome interventions.36 The death rate was highest among centenarians with dementia living in longterm care, 66% of whom died within the subsequent 2 years. This is consistent with information indicating that individuals with advanced dementia have high mortality.24 Little is known about appropriate prescribing at very advanced age and particularly about the role of preventive therapy. Bisphosphonates and statins, therapies generally used for primary and secondary prevention, were frequently dispensed to centenarians, including those aged 105 and older. Although they have been proven effective in younger populations, their benefit in centenarians has not been established. Frequent dispensing of therapies considered inappropriate for frail older people as indicated by the 2012 Beers criteria list was also identified.37 Antipsychotic therapy was dispensed to more than 15% and benzodiazepines to almost 25% of centenarians. Antipsychotic therapy has been linked to serious events, including hospitalization and death,45 raising questions about appropriate use in advanced age.
Limitations A strength of this study was access to comprehensive data on health services use. Because of Canada’s universal healthcare system, data were obtained on all centenarians, not only those linked to a particular health plan or willing to enroll in a prospective cohort study. Because each centenarian has a unique health card number that provides access to a range of health services, data can be linked. Several limitations deserve discussion. First, it is possible that some people identified as being 100 in the data set were no longer alive. Steps were taken to ensure that the data were correct by requiring evidence of subsequent healthcare contact or death to be included in the cohort. The number of centenarians was also compared with Canadian census data for Ontario
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(Appendix S3), and the numbers were similar. Second, some birth dates may be incorrectly recorded, leading to an overestimate of age. There have been reports that some immigrants increased their age to make them eligible for immigration and employment.16 Finally, it is not certain that individuals who were classified as living independently in the community did not receive care. The database captures publicly funded home care services and does not capture informal or privately funded care that is provided to this group. It was expected that most individuals requiring home care support would also access some care from publicly funded sources. Understanding the sociodemographic profile and health service use of centenarians is important to inform strategies to improve the delivery of health services for many individuals who will approach or achieve this milestone in the future. The number of centenarians in Ontario has grown more than 70% within the past 15 years, and there is even faster growth among those aged 85 to 99. Almost half of current centenarians live in the community, most are women, and almost all receive care from a primary care physician. Better understanding the health services use of centenarians assists healthcare providers in informing their care decisions and policy-makers in planning for the delivery of healthcare services.
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. This work was supported by Team Grant OTG-88591 from the Canadian Institutes of Health Research (CIHR) Institute of Nutrition, Metabolism, and Diabetes and by Interdisciplinary Capacity Enhancement Grant HOA80075 from the CIHR Institute of Gender and Health and the CIHR Institute of Aging. Drs. Gill and Bronskill are supported by CIHR New Investigator Awards in the Area of Aging. Dr. Bell is supported by a CIHR and Canadian Patient Safety Institute chair in Patient Safety and Continuity of Care. This study was supported by the Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results, and conclusions reported in this article are those of the authors and are independent from the funding sources. No endorsement by the Institute for Clinical Evaluative Sciences or the Ontario MOHLTC is intended or should be inferred. Author’s Contributions: Rochon: conception and design, acquisition of data, analysis and interpretation of data, drafting of article, final approval of version to be published. Gruneir, Gill, Bronskill, Seitz, Bell, Fischer, Stephenson, Gershon, Anderson, Wu, Wang: conception and design, interpretation of data, revision of article critically for important intellectual content, final approval of version to be published. Wang: acquisition and analysis of data. Sponsor’s Role: The funding sources had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript.
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REFERENCES 1. Statistics Canada. Centenarians in Canada: Age and Sex, 2011;2012. 2. U.S. Census Bureau. 2010 Census Special Reports, Centenarians: 2010. Washington, DC: US Government Printing Office; 2012. 3. Richmond RL. The changing face of the Australian population: Growth in centenarians. Med J Aust 2008;188:720–723. 4. Zeng Y, Shen K. Resilience significantly contributes to exceptional longevity. Curr Gerontol Geriatr Res 2010;2010:525693. 5. Qiu L, Sautter J, Liu Y et al. Age and gender differences in linkages of sleep with subsequent mortality and health among very old Chinese. Sleep Med 2011;12:1008–1017. 6. Lv J, Wang W, Li Y. Effects of environmental factors on the longevous people in China. Arch Gerontol Geriatr 2011;53:200–2005. 7. Engberg H, Oksuzyan A, Jeune B et al. Centenarians—a useful model for healthy aging? A 29-year follow-up of hospitalizations among 40,000 Danes born in 1905. Aging Cell 2009;8:270–276. 8. Darviri C, Demakakos P, Charizani F et al. Assessment of the health status of Greek centenarians. Arch Gerontol Geriatr 2008;46:67–78. 9. Vasto S, Scapagnini G, Rizzo C et al. Mediterranean diet and longevity in Sicily: Survey in a Sicani Mountains population. Rejuvenation Rex 2012;15:184–188. 10. Motta M, Ferlito L, Magnolfi SU et al. Cognitive and functional status in the extreme longevity. Arch Gerontol Geriatr 2008;46:245–252. 11. Hagberg B, Samuelsson G. Survival after 100 years of age: A multivariate model of exceptional survival in Swedish centenarians. J Gerontol A Biol Sci Med Sci 2008;63A:1219–1226. 12. Xie J, Matthews FE, Jagger C et al. The oldest old in England and Wales: A descriptive analysis based on the MRC Cognitive Function and Ageing Study. Age Ageing 2008;37:396–402. 13. Evert J, Lawler E, Bogan H et al. Morbidity profiles of centenarians: Survivors, delayers, and escapers. J Gerontol A Biol Sci Med Sci 2003;58A: 232–723. 14. Poon LW, Clayton GM, Martin P et al. The Georgia Centenarian Study. Int J Aging Hum Dev 1992;34:1–17. 15. Krach CA, Velkoff VA. Bureau of the Census, Current Population Reports, Centenarians in the United States 1990. Washington, DC: U.S. Government Printing Office, 1999. 16. Willcox DC, Willcox BJ, He Q et al. They really are that old: A validation study of centenarian prevalence in Okinawa. J Gerontol A Biol Sci Med Sci 2008;63A:338–349. 17. Mandawat A, Mandawat A, Mandawat MK et al. Hospitalization rates and in-hospital mortality among centenarians. Arch Intern Med 2012;172:1179–1180. 18. Perls TT. Acute care costs of the oldest old. Hosp Pract 1997;32:123–124, 37. 19. Christensen K, Doblhammer G, Rau R et al. Ageing populations: The challenges ahead. Lancet 2009;374:1196–1208. 20. Olshansky SJ, Passaro DJ, Hershow RC et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med 2005;352:1138–1145. 21. Ontario Public Drug Programs. Ontario Ministry of Health and Long-Term Care. Available at http://www.health.gov.on.ca/en/public/programs/drugs/ programs/odb/opdp_pay.aspx Accessed February 25, 2013. 22. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992;45:613–619. 23. Quan H, Sundararajan V, Halfon P et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 2005;43:1130–1139. 24. Mitchell SL, Teno JM, Kiely DK et al. The clinical course of advanced dementia. N Engl J Med 2009;361:1529–1538. 25. Gruneir A, Bronskill SE, Poss JW. Older Women: A Look at Gender Differences in Health System Use. Health System Use by Frail Ontario Seniors —An In-Depth Examination of Four Vulnerable Cohorts. Toronto, ON: Institute for Clinical Evaluative Sciences, 2011. 26. Gershon AS, Wang C, Guan J et al. Identifying patients with physiciandiagnosed asthma in health administrative databases. Can Respir J 2009;16:183–188. 27. Gershon AS, Wang C, Guan J et al. Identifying individuals with physician diagnosed COPD in health administrative databases. COPD 2009;6:388–394. 28. Schultz SE, Rothwell DM, Chen Z et al. Identifying cases of congestive heart failure from administrative data: a validation study using primary care patient records. Chronic Dis Inj Can 2013;33(3):160–166. 29. Hux JE, Ivis F, Flintoft V et al. Diabetes in Ontario: Determination of prevalence and incidence using a validated administrative data algorithm. Diabetes Care 2002;25:512–516.
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30. Tu K, Mitiku T, Lee DS et al. Validation of physician billing and hospitalization data to identify patients with ischemic heart disease using data from the Electronic Medical Record Administrative data Linked Database (EMRALD). Can J Cardiol 2010;26:e225–e228. 31. Kokotailo RA, Hill MD. Coding of stroke and stroke risk factors using International Classification of Diseases, Revisions 9 and 10. Stroke 2005;36:1776–1781. 32. Turner MR, Camacho X, Fischer HD et al. Levothyroxine dose and risk of fractures in older adults: Nested case-control study. BMJ 2011;342: d2238. 33. Robles SC, Marrett LD, Clarke EA et al. An application of capture-recapture methods to the estimation of completeness of cancer registration. J Clin Epidemiol 1988;41:495–501. 34. Kadowaki M, Kono M, Nishiguchi K et al. Mortality in patients with hip fracture aged over 90 years: A report from a progressively aging island. Arch Gerontol Geriatr 2012;54:e113–e117. 35. Schneeweiss S, Seeger JD, Maclure M et al. Performance of comorbidity scores to control for confounding in epidemiologic studies using claims data. Am J Epidemiol 2001;154:854–864. 36. Holmes HM, Hayley DC, Alexander GC et al. Reconsidering medication appropriateness for patients late in life. Arch Intern Med 2006;166: 605–609. 37. American Geriatrics Society. Beers Criteria update expert panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012;2012:616–631. 38. Bilal E, Rabadan R, Alexe G et al. Mitochondrial DNA haplogroup D4a is a marker for extreme longevity in Japan. PLoS ONE 2008;3:e2421. 39. Jeune B. In search of the first centenarians. In: Jeune B, Vaupel JW, editors. Exceptional Longevity: From Prehistory to the Present: Odense Monographs on Population Aging 2. Odense, Denmark: Odense University Press, 2005: pp. 11–24. 40. Howden LM, Meyer JA. 2010 Census Briefs, Age and Sex Composition: 2010. Washington, DC: U.S. Census Bureau, 2011. 41. Barford A, Dorling D, Davey Smith G et al. Life expectancy: Women now on top everywhere. BMJ 2006;332:808. 42. Rochon PA, Bronskill SE, Gruneir A et al. Older Women’s Health. Project for an Ontario Women’s Health Evidence-Based Report. Toronto, ON: St. Michael’s Hosptial and the Institute for Clinical Evaluative Sciences, 2011. 43. O’Neill G, Barry PP. Training physicians in geriatric care: Responding to critical need. Public Policy Aging Rep 2003;13:17–21. 44. Wiles J. Informal caregivers’ experiences of formal support in a changing context. Health Soc Care Community 2003;11:189–207. 45. Rochon PA, Normand SL, Gomes T et al. Antipsychotic therapy and shortterm serious events in older adults with dementia. Arch Intern Med 2008;168:1090–1096.
APPENDIX 1: LIST OF NINE LINKABLE ADMINISTRATIVE HEALTHCARE DATABASES HOUSED AT THE INSTITUTE FOR CLINICAL EVALUATIVE SCIENCES 1 Registered Persons Database for demographic data. 2 Ontario Health Insurance Plan for physician visits. 3 Canadian Institute for Health Information Discharge Abstract Database for information on hospital admissions. 4 Ontario Drug Benefit Database for prescription drug benefit claims. 5 National Ambulatory Care Reporting System for emergency department visits. 6 Home Care database to identify people receiving publicly-funded long-stay home care services. 7 Continuing Care Reporting System to identify patients in complex continuing care and long-term care facilities. 8 Institute for Clinical Evaluative Sciences Physician database to describe physician specialty. 9 Ontario Cancer Registry for a record of close to 50 years of cancer history.
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SUPPORTING INFORMATION Additional Supporting Information may be found in the online version of this article: Appendix S2. The 11 Age-Related Health Conditions and the Data Sources and Codes Used to Identify These Conditions
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Appendix S3. (a) Ontario Residents 65 Years and Older (ICES vs. Census) (b) Ontario Residents 100 Years and Older (ICES vs. Census) Please note: Wiley-Blackwell is not responsible for the content, accuracy, errors, or functionality of any supporting materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.
OBJECTIVES: To better understand how centenarians use the healthcare system as an important step toward improving their service delivery. DESIGN: Population-based retrospective cohort study using linked health administrative data. SETTING: Ontario—Canada’s largest province. PARTICIPANTS: All individuals living in Ontario aged 65 and older on April 1 of each year between 1995 and 2010 were identified and divided into three age groups (65–84, 85–99, ≥100). A detailed description was obtained on 1,842 centenarians who were alive on April 1, 2010. MEASUREMENTS: Sociodemographic characteristics and use of health services. RESULTS: The number of centenarians increased from 1,069 in 1995 to 1,842 in 2010 (72.3%); 6.7% were aged 105 and older. Over the same period, the number of individuals aged 85 to 99 grew from 119,955 to 227,703 (89.8%). Women represented 85.3% of all centenarians and 89.4% of those aged 105 and older. Almost half of centenarians lived in the community (20.0% independently, 25.3% with publicly funded home care). Preventive drug therapies (bisphosphonates and statins) were frequently dispensed. In the preceding year, 18.2% were hospitalized and 26.6% were seen in an emergency department. More than 95% saw a primary care provider, and 5.3% saw a geriatrician.
From the aWomen’s College Research Institute, Women’s College Hospital, bDepartment of Medicine, University of Toronto, cInstitute of Health Policy, Management and Evaluation, University of Toronto, d Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; e St. Mary’s of the Lake Hospital, fDepartment of Medicine, Queen’s University, gDepartment of Psychiatry, Queen’s University, Kingston, Ontario, Canada; hMount Sinai Hospital, iKeenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, and jSunnybrook Health Sciences Centre, Toronto, Ontario, Canada. Address correspondence to Paula A. Rochon, Women’s College Research Institute, Women’s College Hospital, 790 Bay Street Toronto, Ontario, Canada. E-mail: [email protected] DOI: 10.1111/jgs.12613
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CONCLUSION: The number of centenarians in Ontario increased by more than 70% over the last 15 years, with even greater growth among older people who could soon become centenarians. Almost half of centenarians live in the community, most are women, and almost all receive care from a primary care physician. J Am Geriatr Soc 62:86–93, 2014.
Key words: centenarians; health service use; advanced age
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nowledge about centenarians comes primarily from national census data like those available in Canada1 and the United States2 and from detailed studies of select groups of centenarians such as those from Australia,3 China,4–6 Denmark,7Greece,8 Italy,9,10 Sweden,11 the United Kingdom,12 and the United States.13,14 There are gaps in the existing information on centenarians. Census data provide demographic information on large populations.15,16 Observational studies generally study smaller numbers of individuals and focus primarily on factors associated with exceptional longevity and health status.4–6,9,10,12 Less focus has been given to understanding patterns of health service use in a large population of centenarians.7,17,18 The current article describes a large geographically based population of centenarians and links their sociodemographic information to their health services use. A better understanding of who centenarians are and how and when they use the healthcare system is an important step toward improving service delivery. This article also provides an important glimpse of what might be expected in the future, when becoming a centenarian may not be a rarity. Although this projection is controversial, one group has suggested that more than 50% of babies born in developed countries since 2000 will live to be more than 100 years old.19 Others have a less-optimistic view.20 A population-based study of centenarians was conducted using an estimated 1.8 million individuals aged 65 and older to document changes in the size of the centenarian population over the past 15 years.
0002-8614/14/$15.00
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The health conditions and use of health services of all centenarians were profiled to better understand this special segment of the older population.
METHODS This was a population-based retrospective cohort study using health administrative data from Ontario, Canada’s largest province. The research ethics board of Sunnybrook Health Sciences Centre approved the study.
Data Sources All older adults in Ontario have universal access to medically necessary health services, including prescription drug therapy. The single-payer system provides the ability to compile service details from an extensive range of health administrative databases using unique individual-level identification so that a comprehensive health profile can be created. This study used the encrypted linkable administrative healthcare databases housed at the Institute for Clinical Evaluative Sciences, as described in Appendix 1. To meet the first objective, all individuals aged 65 and older on April 1 of each year between 1995 and 2010 were identified and divided into three age groups (65–84, 85–99, ≥100). To meet the second objective, all centenarians alive on the cohort entry date of April 1, 2010, were studied to obtain a detailed description of their sociodemographic characteristics and use of health services. Centenarians were divided into three subgroups (100, 101–104, ≥105). To be certain that centenarians were alive and that the number of centenarians was not overestimated, all individuals were followed for a 2-year period from April 1, 2010, through March 31, 2012. Healthcare contact or date of death was looked for. Those without any subsequent record were excluded. Date of death was recorded for those who died.
Centenarian Descriptors Sociodemographic Characteristics The age, sex, and income status of the study population were measured. Low-income status was identified according to eligibility for a low-income subsidy in the provincial drug benefit program and defined as an annual income of C$16,018 or less per individual or C$24,175 per couple.21 All older residents of long-term care homes were identified using the Continuing Care Reporting System database. Long-term care includes chronic care facilities. Comorbidity was measured using the Charlson Comorbidity Index,22,23 the frequency of 11 age-related conditions (dementia, asthma, chronic obstructive pulmonary disease (COPD), congestive heart failure, diabetes mellitus, arthritis, ischemic heart disease, stroke, hypothyroidism, cancer, hip fracture) and drug therapy dispensed in the previous year. The Charlson Comorbidity Index was constructed using data available from hospital admission and same-day
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surgery in the past 5 years.22,23 Scores were grouped into three categories (0, 1, ≥2), with higher scores indicating greater comorbidity. Appendix S2 describes how the 11 age-related health conditions were defined using established algorithms derived from administrative records for each of these conditions. As such, the time frames and approach used to identify the health conditions varied according to condition and availability of data. Dementia was selected because good cognitive function is fundamental to healthy aging.24 Physician-diagnosed dementia was defined using in- and outpatient diagnosis codes in the past 5 years and use of dementia-specific drugs (donepezil, rivastigmine, galantamine) in the past 1 year, as has been done in previous work.25 Eight chronic medical conditions were selected because they are common in older people and have been defined using validated (asthma,26 COPD,27 congestive heart failure,28 diabetes mellitus29) or previously published (arthritis,25 ischemic heart disease,30 stroke31) algorithms. Hypothyroidism was defined according to the dispensing of drug therapy32 in the prior year specific for the treatment of hypothyroidism. Cancer was included because cancer incidence increases with age and is a leading cause of death. Cancer was identified using the Ontario Cancer Registry containing information on cancers (excluding non-melanoma skin cancer) diagnosed since 1964.33 Hip fractures were included because they are a sentinel event for older people, leading to a cascade of undesirable outcomes, including up to 24% 1-year mortality rate.34 Hip fractures were identified from hospital admission codes.25 Drug therapy use was assessed using three measures. First, the number of distinct drug therapies dispensed in the year before cohort entry35 was counted as a measure of comorbidity. Next, the drug therapies were grouped into subclasses to identify those most frequently dispensed for noninfectious conditions to assess the use of drug therapy for chronic health conditions. Then, to evaluate use of preventive drug therapy at advanced age, the use of two common therapies was measured (5-hydroxy-3-methylglutarylcoenzyme A reductase inhibitors (statins) and bisphosphonates).36 Finally, the use of antipsychotic and benzodiazepine therapy listed in the 2012 American Geriatrics Society update of the Beers Criteria for potentially inappropriate medication use in older adults was measured.37
Health Service Use Home care support in the community was defined as the use of at least one publicly funded home care service captured in the Home Care database. Acute care hospital admission was measured in two ways; all older adults in an acute care hospital on April 1, 2010, and those with an acute care admission or an emergency department visit during the previous year. All visits in the previous year to primary care physicians and to specialists, including geriatricians, neurologists, psychiatrists, cardiologists, and ophthalmologists, were identified.
Descriptive Analyses To document growth in different age categories within the older adult population, the growth rate between 1995 and
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each subsequent year was calculated, until 2010. The growth rate was calculated separately in each of three age categories (65–84, 85–99, ≥100) and compared between the groups. A retrospective cohort approach was used to describe all centenarians in the community and in long-term care on April 1, 2010. Descriptive statistics were used to describe participants according to their sociodemographic profile and use of health services within three centenarian subgroups (100, 101–104, ≥105). These groups were selected because 100 represents the initial centenarian milestone and 105 a milestone of exceptional age called semisupercentenarians.38 The analyses were stratified according to sex.
RESULTS Growth in Number of Centenarians In Ontario, the number of centenarians increased from 1,069 in 1995 to 1,842 in 2010 (72.3%) (Figure 1). During the same time period, the number aged 85 to 99 increased from 119,955 to 227,703 (89.8%). The data were compared with census data obtained for similar time periods, and the results were consistent (Appendix S3).
Centenarian Descriptors Sociodemographic Characteristics Based on 15,259,908 individuals living in Ontario in 2010, centenarians represented 1.21 per 10,000 people. Of the 1,842 centenarians alive in Ontario on April 1, 2010, more than 60% were aged 101 or older; 123 (6.7%) were semisupercentenarians (≥105) (Table 1). Women represented 85.3% of those centenarians and almost 90% of semisupercentenarians (Figure 2). Slightly more than half (51.4%) had a low income.
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On the index date, 19 (1.0%) centenarians were in an acute care hospital, 834 (45.3%) were living in the community, and 989 (53.7%) were in long-term care; 466 (25.3%) lived in the community with publicly funded home care.
Prevalence of Treated Comorbid Conditions and Prescription Drug Use in Centenarians in 2010 Three hundred five (16.6%) centenarians had a Charlson Comorbidity Index of 2 or more. Scores were not available for 329 in the community and 378 in long-term care because these individuals had not had an acute care hospitalization or same-day surgery in the prior 5 years. For age-related conditions, physician-diagnosed dementia was identified in 1,068 (58.0%) of centenarians and was more frequent in women (59.6%) than men (48.3%). Arthritis (n = 1,003, 54.5%), congestive heart failure (n = 641, 34.8%), and COPD (n = 498, 27.0%) were the other most-common conditions; 267 (14.5%) centenarians had a history of cancer, and 11.7% had had a prior hip fracture, more frequently women. Centenarians had been dispensed a mean of 9.2 5.3 different therapies in the previous year, most frequently diuretics (n = 963, 52.3%), followed by laxatives. Bisphosphonates were dispensed to 18.0% of centenarians and 10.6% of those aged 105 and older. Statins were dispensed to 10.6% of all centenarians and 8.9% of those aged 105 and older. Women were more likely than men to have bisphosphonates dispensed (19.5% vs 8.9%) and less likely to receive a statin (10.0% vs 14.0%). Antipsychotic drug therapy was dispensed to 16.2% of the centenarians and benzodiazepine therapies to 24.4%. The use of these therapies was concentrated in those with dementia. Within the subsequent 2 years, 58.1% of centenarians died (Table 2). The death rate was lowest for those living without home care in the community and without
Figure 1. Growth rate of the older adult population between 1995 and each subsequent year until 2010 in three age categories (65–84, 85–99, ≥100). The data were derived from the Registered Persons Database for demographic data housed at the Institute for Clinical Evaluative Sciences.
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Table 1. Descriptive Characteristics of Centenarians on April 1, 2010 Sex
Characteristic
Sociodemographic Age, mean SD Low income, n (%) Setting of care on index date, n (%) Community With home care Without home care Long-term care Acute-care hospitala Comorbidity measures, n (%) Charlson Comorbidity index (prior 5 years) No scoreb 0 1 ≥2 Age-related conditions, n (%) Dementia (prior 5 years) Chronic conditions Arthritis (prior 5 years) Congestive heart failure (since 1991) Chronic obstructive pulmonary disease (since 1991) Hypothyroidism therapy (prior 1 year) Ischemic heart disease (prior 5 years) Diabetes mellitus (since 1991) Asthma (since 1993) Stroke (prior 5 years)a Cancer (since 1964) Hip fracture (prior 5 years) Drugs taken in previous year, mean SD Most frequent noninfectious drugs, n (%) Diuretics Laxatives, cathartics, stool softeners Preventive drugs, n (%) Bisphosphonates Statins Mental health drugs, n (%) Antipsychotic Benzodiazepine derivative Antidepressant Health service use In previous year Acute care admission, n (%) Emergency department visit, n (%) Number of physician visits, mean SD, median (interquartile range) Specialist visits, n (%) General practitioner or family physician Geriatrician Neurologista Psychiatrista Cardiologist Ophthalmologist
Age
Total, N = 1,842
Female, n = 1,571
Male, n = 271
100, n = 704
101–104, n = 1,015
≥105, n = 123
101.4 1.7 946 (51.4)
101.4 1.7 830 (52.8)
101.2 1.6 116 (42.8)
370 (52.6)
492 (48.5)
84 (68.3)
834 466 368 989 19
(45.3) (25.3) (20.0) (53.7) (1.0)
680 392 288 877
(43.3) (25.0) (18.3) (55.8)
154 74 80 112
(56.8) (27.3) (29.5) (41.3)
349 192 157 347
(49.6) (27.3) (22.3) (49.3)
442 247 195 565
(43.5) (24.3) (19.2) (55.7)
43 27 16 77
(35.0) (22.0) (13.0) (62.6)
707 528 302 305
(38.4) (28.7) (16.4) (16.6)
617 455 261 238
(39.3) (29.0) (16.6) (15.1)
90 73 41 67
(33.2) (26.9) (15.1) (24.7)
261 198 110 135
(37.1) (28.1) (15.6) (19.2)
382 301 177 155
(37.6) (29.7) (17.4) (15.3)
64 29 15 15
(52.0) (23.6) (12.2) (12.2)
1,068 (58.0)
937 (59.6)
131 (48.3)
405 (57.5)
584 (57.5)
79 (64.2)
1,003 (54.5) 641 (34.8) 498 (27.0)
858 (54.6) 541 (34.4) 390 (24.8)
145 (53.5) 100 (36.9) 108 (39.9)
396 (56.3) 259 (36.8) 216 (30.7)
548 (54.0) 336 (33.1) 250 (24.6)
59 (48.0) 46 (37.4) 32 (26.0)
459 (24.9) 298 (16.2)
407 (25.9) 247 (15.7)
52 (19.2) 51 (18.8)
179 (25.4) 127 (18.0)
260 (25.6) 163 (16.1)
20 (16.3) 8 (6.5)
289 (15.7) 179 (9.7) 71 (3.9) 267 (14.5) 215 (11.7) 9.2 5.3
245 (15.6) 143 (9.1) 57 (3.6) 217 (13.8) 193 (12.3) 9.2 5.3
44 (16.2) 36 (13.3) 14 (5.2) 50 (18.5) 22 (8.1) 9.2 5.5
133 (18.9) 81 (11.5)
144 (14.2) 86 (8.5)
12 (9.8) 12 (9.8)
106 (15.1) 78 (11.1) 9.6 5.5
148 (14.6) 121 (11.9) 9.1 5.3
13 (10.6) 16 (13.0) 7.8 4.8
963 (52.3) 881 (47.8)
833 (53.0) 754 (48.0)
130 (48.0) 127 (46.9)
393 (55.8) 331 (47.0)
510 (50.2) 491 (48.4)
60 (48.8) 59 (48.0)
331 (18.0) 195 (10.6)
307 (19.5) 157 (10.0)
24 (8.9) 38 (14.0)
146 (20.7) 86 (12.2)
172 (16.9) 98 (9.7)
13 (10.6) 11 (8.9)
298 (16.2) 449 (24.4) 506 (27.5)
267 (17.0) 392 (25.0) 443 (28.2)
31 (11.4) 57 (21.0) 63 (23.2)
115 (16.3) 181 (25.7) 209 (29.7)
161 (15.9) 245 (24.1) 274 (27.0)
22 (17.9) 23 (18.7) 23 (18.7)
336 (18.2) 490 (26.6) 20.1 20.0, 14 (8–24)
279 (17.8) 399 (25.4) 19.9 20.2, 14 (8–23)
57 (21.0) 91 (33.6) 20.8 19.0, 14 (8–27)
132 (18.8) 215 (30.5) 20.5 21.1, 14 (9–24)
183 (18.0) 252 (24.8) 20.0 19.5, 14 (8–24)
21 (17.1) 23 (18.7) 18.2 18.0, 13 (6–21)
1,756 98 31 53 406 246
1,496 (95.2) 80 (5.1)
260 (95.9) 18 (6.6)
681 (96.7) 43 (6.1)
959 (94.5) 49 (4.8)
116 (94.3) 6 (4.9)
339 (21.6) 201 (12.8)
67 (24.7) 45 (16.6)
159 (22.6) 114 (16.2)
217 (21.4) 126 (12.4)
30 (24.4) 6 (4.9)
(95.3) (5.3) (1.7) (2.9) (22.0) (13.4)
SD = Standard Deviation. a The number and percentage could not be reported in the sex and age groups based on the Small Cell Policy from the Institute for Clinical Evaluative Sciences. b During the period of Charlson Comorbidity Index calculation, the participant had no hospital admission or same-day surgery.
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Figure 2. Number of centenarians and their sex distribution at each year of age for the 1,842 individuals identified as aged 100 and older in Ontario on April 1, 2010.
Table 2. Recorded Deaths Among Centenarians Between April 1, 2010, and March 31, 2012, Stratified According to Dementia Status and Location of Residence Without Dementia
With Dementia
Community
Characteristic
Recorded death, n (%)
Community
Total, N = 1,842
Without Home Care, n = 276
With Home Care, n = 290
Long-Term Care, n = 208
Total, n = 774
Without Home Care, n = 94
With Home Care, n = 191
Long-Term Care, n = 783
Total, n = 1,068
1,070 (58.1)
107 (38.8)
145 (50.0)
132 (63.5)
384 (49.6)
55 (58.5)
116 (60.7)
515 (65.8)
686 (64.2)
Nineteen individuals were in acute care on April 1, 2010. This table reflects their location of residence before the acute care admission.
dementia (38.8%) and highest for those with dementia living in long-term care (65.8%).
Health Service Use by Centenarians in 2010 During the year before cohort entry, 18.2% of the 1,842 centenarians had a hospitalization and 26.6% had an emergency department visit. In contrast, 63.9% had neither a hospitalization nor an emergency department visit. Almost all centenarians (95.3%) visited a primary care physician, and only 5.3% were assessed by a geriatrician.
DISCUSSION Older people are living longer. More people are now likely to reach the age of 100, making the study of those who reach the extremes of longevity more relevant. To the knowledge of the authors, this is one of the few studies to examine all centenarians in a large geographic population.7,17,18 The current study provides detailed information about the current sociodemographic profile of centenarians and captures all of their publicly funded health services use. The predominance of women at this age, the fact that many centenarians are living in the community, and the use of preventive drug therapy at advanced age are described. This study provides an understanding of centenarians and the formal healthcare services they receive.
Centenarians represent only a small portion of the older population. For every centenarian, 120 times as many people aged 85 to 99 were identified, many of whom may become the centenarians of the future. A more than 70% increase in older individuals reaching 100 in the past 15 years was found. This growth is even more dramatic given that formal documentation of the existence of centenarians started in around 1800.39 Most older people40 and centenarians1,2 are women. In the current study, this is magnified in semisupercentenarians (≥105), more than 90% of whom were female. The data are consistent with international data indicating that women have outlived men in Sweden since 1751, the Netherlands since 1860, and Italy since 1889.41 The predominance of older women has important health service implications. Women generally outlive their spouses because they live longer than men and because they tend to marry men who are older than they are.42 Women have traditionally been the caregivers, so their spouses may be less well equipped to take on caregiving responsibilities.42 Accordingly, a higher proportion of women receiving formal home care or living in long-term care was found. The predominance of women among those of advanced age challenges us to consider customizing health and social care to meet their particular needs. The data highlight the central role of primary care physicians in providing health care for those of advanced
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age. More than 95% of centenarians had at least one visit with a primary care physician in the prior year. In contrast, only 5% saw a geriatrician. This finding may relate to their general good health or a preference to obtain their care from their primary care provider or may reflect the scarcity of geriatricians. In Ontario, there are five geriatricians per 100,000 population aged 65 and older.42 The findings of the current study support the Public Policy and Aging Report from 2003,43 which recommends that every healthcare worker receive training in geriatrics. The current study demonstrates that almost half of centenarians are living in the community. More than 40% do not receive publicly funded home care support, suggesting that they retain functional independence or receive caregiving supports outside this system. The data do not capture the substantial amount of informal care that family members and friends provide44 or care that is paid for privately. Close to 60% of centenarians died within 2 years of the study date. Although most centenarians did not require acute care, many did. Emergency departments may not be the best environment to evaluate vulnerable older adults, particularly those living in a long-term care setting. For nonurgent medical conditions, alternative strategies should be explored that meet their health needs and avoid potentially burdensome interventions.36 The death rate was highest among centenarians with dementia living in longterm care, 66% of whom died within the subsequent 2 years. This is consistent with information indicating that individuals with advanced dementia have high mortality.24 Little is known about appropriate prescribing at very advanced age and particularly about the role of preventive therapy. Bisphosphonates and statins, therapies generally used for primary and secondary prevention, were frequently dispensed to centenarians, including those aged 105 and older. Although they have been proven effective in younger populations, their benefit in centenarians has not been established. Frequent dispensing of therapies considered inappropriate for frail older people as indicated by the 2012 Beers criteria list was also identified.37 Antipsychotic therapy was dispensed to more than 15% and benzodiazepines to almost 25% of centenarians. Antipsychotic therapy has been linked to serious events, including hospitalization and death,45 raising questions about appropriate use in advanced age.
Limitations A strength of this study was access to comprehensive data on health services use. Because of Canada’s universal healthcare system, data were obtained on all centenarians, not only those linked to a particular health plan or willing to enroll in a prospective cohort study. Because each centenarian has a unique health card number that provides access to a range of health services, data can be linked. Several limitations deserve discussion. First, it is possible that some people identified as being 100 in the data set were no longer alive. Steps were taken to ensure that the data were correct by requiring evidence of subsequent healthcare contact or death to be included in the cohort. The number of centenarians was also compared with Canadian census data for Ontario
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(Appendix S3), and the numbers were similar. Second, some birth dates may be incorrectly recorded, leading to an overestimate of age. There have been reports that some immigrants increased their age to make them eligible for immigration and employment.16 Finally, it is not certain that individuals who were classified as living independently in the community did not receive care. The database captures publicly funded home care services and does not capture informal or privately funded care that is provided to this group. It was expected that most individuals requiring home care support would also access some care from publicly funded sources. Understanding the sociodemographic profile and health service use of centenarians is important to inform strategies to improve the delivery of health services for many individuals who will approach or achieve this milestone in the future. The number of centenarians in Ontario has grown more than 70% within the past 15 years, and there is even faster growth among those aged 85 to 99. Almost half of current centenarians live in the community, most are women, and almost all receive care from a primary care physician. Better understanding the health services use of centenarians assists healthcare providers in informing their care decisions and policy-makers in planning for the delivery of healthcare services.
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. This work was supported by Team Grant OTG-88591 from the Canadian Institutes of Health Research (CIHR) Institute of Nutrition, Metabolism, and Diabetes and by Interdisciplinary Capacity Enhancement Grant HOA80075 from the CIHR Institute of Gender and Health and the CIHR Institute of Aging. Drs. Gill and Bronskill are supported by CIHR New Investigator Awards in the Area of Aging. Dr. Bell is supported by a CIHR and Canadian Patient Safety Institute chair in Patient Safety and Continuity of Care. This study was supported by the Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results, and conclusions reported in this article are those of the authors and are independent from the funding sources. No endorsement by the Institute for Clinical Evaluative Sciences or the Ontario MOHLTC is intended or should be inferred. Author’s Contributions: Rochon: conception and design, acquisition of data, analysis and interpretation of data, drafting of article, final approval of version to be published. Gruneir, Gill, Bronskill, Seitz, Bell, Fischer, Stephenson, Gershon, Anderson, Wu, Wang: conception and design, interpretation of data, revision of article critically for important intellectual content, final approval of version to be published. Wang: acquisition and analysis of data. Sponsor’s Role: The funding sources had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript.
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APPENDIX 1: LIST OF NINE LINKABLE ADMINISTRATIVE HEALTHCARE DATABASES HOUSED AT THE INSTITUTE FOR CLINICAL EVALUATIVE SCIENCES 1 Registered Persons Database for demographic data. 2 Ontario Health Insurance Plan for physician visits. 3 Canadian Institute for Health Information Discharge Abstract Database for information on hospital admissions. 4 Ontario Drug Benefit Database for prescription drug benefit claims. 5 National Ambulatory Care Reporting System for emergency department visits. 6 Home Care database to identify people receiving publicly-funded long-stay home care services. 7 Continuing Care Reporting System to identify patients in complex continuing care and long-term care facilities. 8 Institute for Clinical Evaluative Sciences Physician database to describe physician specialty. 9 Ontario Cancer Registry for a record of close to 50 years of cancer history.
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SUPPORTING INFORMATION Additional Supporting Information may be found in the online version of this article: Appendix S2. The 11 Age-Related Health Conditions and the Data Sources and Codes Used to Identify These Conditions
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Appendix S3. (a) Ontario Residents 65 Years and Older (ICES vs. Census) (b) Ontario Residents 100 Years and Older (ICES vs. Census) Please note: Wiley-Blackwell is not responsible for the content, accuracy, errors, or functionality of any supporting materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.
