Aging in Arizona Health Status of Older Arizonans Bureau of Public Health Statistics 4/16/2014 Janice K. Brewer, Governor State of Arizona Will Humble, Director Arizona Department of Health Services Authors: Nicholas Bishop, PhD Arizona Vital Statistician The Bureau of Public Health Statistics Arizona Department of Health Services 150 N 18th Ave, Suite 550 Phoenix, AZ 85007 Acknowledgements: The Department acknowledges Dr. Babak Nayeri, Dr. Khaleel Hussaini, and Kerry Fehr-Snyder for their contributions to this report. We also appreciate Jim Chang and Thara MacLaren of the Department of Administration for their development of the population projections reported herein. This publication can be made available in alternative format. Please contact the Bureau of Public Health Statistics at (602) 542-1242 (voice) or 1-800-367-8939 (TDD). Permission to quote from or reproduce materials from this publication is granted if the source is acknowledged. Table of Contents Page Executive Summary ............................................................................................................. 1 1. Introduction ............................................................................................................... 3 1.1 Overview of Aging in Arizona ............................................................................ 3 1.2 Methodology ....................................................................................................... 3 2. Population Projections.............................................................................................. 5 2.1 Introduction ........................................................................................................... 5 2.2 Methodology ........................................................................................................ 5 2.3 Results ................................................................................................................... 6 2.4 Conclusion……………………………………………………………………… 9 3. Health Behaviors and Chronic Diseases among Aging Arizonans ...................... 10 3.1 Introduction ……………………………………….………………… ................. 10 3.2 Methodology ........................................................................................................ 10 3.3 Results ................................................................................................................... 11 3.4 Conclusion .............................................................................................................. 18 4. Emergency Room and Hospital Inpatient Discharges among Aging Arizonans 19 4.1 Introduction ……………………………………….……………………. ............ 19 4.2 Methodology ........................................................................................................ 19 4.3 Results ................................................................................................................... 20 4.4 Conclusion .............................................................................................................. 24 5. Patterns of Mortality among Aging Arizonans ...................................................... 26 5.1 Introduction ……………………………………….…………………… ............. 26 5.2 Methodology ........................................................................................................ 26 5.3 Results ................................................................................................................... 27 5.4 Conclusion .............................................................................................................. 36 6. Conclusion ................................................................................................................ 38 7. Appendices A. Glossary ................................................................................................................ 40 B. Bibliography ......................................................................................................... 42 Page | i List of Tables Page 1. Projection of Arizona’s Total Population and Population age 65 and Older by Race/Ethnicity, 2010 – 2050………………………………………………………... 6 2. Arizona Behavioral Risk Factor Surveillance System (BRFSS) Estimates of Sociodemographics among Adults age 65 and Older, 2012 ....................................... 12 3. Arizona Behavioral Risk Factor Surveillance System (BRFSS) Estimates of Health Behaviors among Adults age 65 and Older, 2012.………………………………….. 13 4. Arizona Behavioral Risk Factor Surveillance System (BRFSS) Estimates of Population Morbidity, 2012 ....................................................................................... 16 5. Demographic Characteristics of Arizona Resident Emergency Room Discharges and Emergency Room Discharge Rates for adults Age 65 and Older by Age Group, 2012 ..................................................................................................................................... 20 6. Emergency Room Discharges and Emergency Room Discharge Rates among Arizona Residents Age 65 and Older by First-listed Diagnosis and Age Group, 2012 ........... 22 7. Inpatient Discharges and Inpatient Discharge Rates among Arizona Residents Age 65 and Older by First-listed Diagnosis and Age Group, 2012 ............................ 23 8. Deathsa among Arizona Residents 65 Years and Older by Gender and Age Group, 2012............................................................................................................................. 28 9. Deaths and Death Ratesa for the Ten Leading Causes of Deathb among Adults Age 65 and Older, Arizona 2012 and United States 2011 (Preliminary) .................. a 10. Specific Leading Causes of Deaths Among All Arizona Residents, 2012 ................ 29 31 11. Specific Leading Causes of Death among Arizona Resident Femalesa 65 Years and Older, 2012 ........................................................................................................... 32 12. Specific Leading Causes of Death among Arizona Resident Malesa 65 Years and Over, 2012 ............................................................................................................ 33 a 13. Specific Leading Causes of Death among Arizona Resident Females, 65 Years and Older, 2002 - 2012 ............................................................................................. 34 14. Specific Leading Causes of Deatha among Arizona Resident Males, 65 Years and Older, 2002 – 2012 ..................................................................................................... 36 Page | ii List of Figures Page 1. Projections of Arizona’s Population of Adults Age 65 and Older by Race/Ethnicity, 2010 – 2050...................................................................................................................... 7 2. Population Pyramid and Dependency Ratios for Arizona, 2010 ................................ 8 3. Population Pyramid and Dependency Ratios for Arizona, 2050 (Projection) ............ 9 4. Estimates of Population Health Behaviors with 95% Confidence Intervals, Arizona and National Males Age 65 and Older, BRFSS 2012 ................................................. 13 5. Estimates of Population Morbidity with 95% Confidence Intervals, Arizona and National Females Age 65 and Older, BRFSS 2012 .................................................... 14 6. Estimates of Population Health Behaviors with 95% Confidence Intervals, Arizona Males and Females Age 65 and Older, BRFSS 2012 ................................................. 15 7. Estimates of Population Morbidity with 95% Confidence Intervals, Arizona and National Males Age 65 and Older, BRFSS 2012 ....................................................... 17 8. Estimates of Population Morbidity with 95% Confidence Intervals, Arizona and National Females Age 65 and Older, BRFSS 2012 .................................................... 17 9. Estimates of Population Morbidity with 95% Confidence Intervals, Arizona Males and Females Age 65 and Older, BRFSS 2012 ............................................................ 18 10. Death Rates with 95% Confidence Intervals for 10 Leading Causes of Death among Adults age 65 and Older, Arizona 2012 and United States 2011 (Preliminary) .............................................................................................................. 29 11. Specific Leading Causes of Death Among Arizona Resident Females, 65 Years and Older, 2002 – 2012 ............................................................................................... 35 12. Specific Leading Causes of Death Among Arizona Resident Males, 65 Years and Older, 2002 – 2012……….…………………………………………………… .. 37 Page | iii Executive Summary Aging in Arizona: Health Status of Older Arizonans provides a comprehensive view of the health status, morbidity, and mortality among Arizonans 65 years of age and older. Designed to be a resource for those tasked with developing and implementing health policy for an increasingly aged populace, this report draws from multiple resources on the health, illness, and mortality of Arizona’s older adults. Population estimates and projections were used to examine Arizona’s current population composition by age and race/ethnicity as well as to estimate how Arizona’s population structure will change over the next 40 years. Next, the health behaviors and chronic disease burden experienced by Arizona’s seniors were examined using the 2012 Behavioral Risk Factor Surveillance System (BRFSS). Moving from population prevalence of health-related behaviors and morbidities to healthcare utilization among Arizona’s aging adults, 2012 Hospital Discharge Data (HDD) was used to summarize emergency room (ER) and inpatient discharges by first-listed diagnosis separated by gender. Finally, the leading causes of death for Arizonans age 65 and older were identified separately by gender in 2012, with recent trends (2002 – 2012) in the leading causes of deaths also being analyzed. Based on a number of social and epidemiological factors, the coming half century will see an unprecedented shift in the age structure of our society. In Arizona, the total population is expected to increase about 80 percent from 6,401,568 in 2010 to a projected 11,562,584 in 2050, while the number of Arizonans age 65 and older is expected to increase 174 percent from 883,014 in 2010 to 2,422,186 in 2050. As the proportion of Arizonans age 65 and over increases, so will the racial/ethnic diversity of our population as a whole. The increasing number and proportion of older adults in our state will necessitate the strategic planning of cost-effective health and social services to properly care for our older population. Understanding the health of Arizona’s current elderly population provides guidance in preparing for the coming growth of our older population. Compared to older adults nationally, a smaller percentage of Arizona’s older population reported prior year flu shots, and this held true for prior year checkups among Arizona’s older males. A significantly lower proportion of older Arizonans had been diagnosed with diabetes than nationally, but a greater percentage of Arizona males reported a skin cancer diagnosis than comparably aged males nationally. Comparisons of older adults within Arizona by gender revealed that Arizona’s elderly males have a higher prevalence of heart attack and skin cancer diagnoses than Arizona’s older females, but elderly females had a greater percentage reporting being diagnosed with asthma. These results suggest that focusing on increasing access to preventative health checkups and flu shots for older Arizonans should become a priority, as should greater attention to cardiovascular health and skin protection among aging men, and treatment of asthma among older women. Focusing on the current utilization of emergency room (ER) and inpatient hospital services provides another lens to view our current population of older adults and to prepare for their progression in the coming years. According to hospital discharge records from Arizona’s Page | 1 Hospital Discharge Data (HDD), the demographic characteristics of aging Arizonans being discharged from hospitals becomes less diverse with age, reflecting that minority groups have worse health and experience mortality earlier in life than White non-Hispanics, and that female life expectancy tends to be greater than male life expectancy. Among older Arizonans, the overall counts of ER and inpatient discharges were higher for adults in the youngest old (ages 65 – 74), but the rate of discharges increased for the oldest Arizonans (age 85 and older), and in some cases, this increase was substantial. The overall rate of discharges was more than 100% higher for Arizonans in the oldest versus the youngest age group, and this held true for both ER and inpatient discharges. The results indicate that Arizona’s older White females experience some of the most severe morbidities and chronic diseases associated with aging and warrant increased attention when developing future policy concerning health and aging. On the other hand, attention to the socioeconomic factors associated with health disparities and earlier mortality among racial/ethnic minorities should become a focus for those developing general policies aimed at promoting health for all Arizonans. Finally, increasing the quality of life for Arizona’s older adults now and into the future requires addressing existing causes and patterns of mortality among the state’s aging population. Chronic diseases that are currently most detrimental to the oldest Arizonans, exemplified by Alzheimer’s disease among females, will become increasingly problematic as the population of older Arizonans expands. Alternatively, the mortality rates for a number of the leading causes of death have decreased substantially among Arizona’s older adults, namely atherosclerotic heart disease and cardiovascular disease among both men and women, stroke among women, and both lung and prostate cancer among men. The decrease in leading causes of death that are somewhat preventable and treatable foretell the increased burden that will be exerted in the future by Alzheimer’s disease and dementia, which currently have no known cure. While continuing to reduce the number of deaths caused by the current leading causes of death, it is crucial to begin preparing Arizona’s healthcare infrastructure to handle the coming influx of older adults experiencing cognitive diseases. Overall, the findings of this report suggest that as Arizona’s older population grows in both size and proportion of the overall population, primary prevention strategies focused on reducing socioeconomic health disparities and increasing the availability and success of physical, intellectual, and social activities will become increasingly important as means of reducing the population health burden of chronic diseases associated with aging. Further developing our capacity to provide health services to older adults also will increase in importance, but the ability to prevent the development of costly chronic diseases and morbidities associated with aging will be the most successful method of reducing the overall costs of maintaining a healthy aging population. Page | 2 1. Introduction 1.1 Overview of Aging in Arizona The current state of health and longevity among aging adults is unprecedented, providing realities that are both exciting and troublesome. Due mainly to broad public health initiatives, the major causes of death in developed countries have shifted from infectious to chronic diseases over the past century. As chronic diseases typically manifest among older adults, this transition has increased overall life expectancies, meaning a greater proportion of the population is living longer than ever before (CDC 2013). Coupled with increasing longevity, birth rates in the United States spiked after World War II but decreased sharply by the mid-1970s (CDC 2003). The combination of increased longevity and changing birth rates has caused our population’s agestructure to shift, increasing the proportion of older adults experiencing the costs of chronic diseases, while simultaneously decreasing the number of younger working adults who contribute to Social Security and welfare systems through wage deductions. As the baby boom generation is just beginning to reach older adulthood, the impact of these population dynamics has yet to be fully realized. Arizona’s population of older adults represents a diverse set of perspectives coming from a wide variety of backgrounds. With increased longevity and the ability to be productive for more years of life than previous generations, Arizona’s aging adults are an increasingly valuable resource. At the same time, health problems associated with aging present difficult realities that Arizonans must face together. In coming years, the composition of Arizona’s older adult population will shift, increasing in overall numbers, representing a larger proportion of our population, and becoming more racially/ethnically diverse than at present. To prepare for the changing landscape of Arizona’s older adults, it is imperative to understand the existing health characteristics of Arizona’s older adult population. 1.2 Methodology This report aims to provide relevant information on the current state of health among Arizona’s older adults to those tasked with the planning and development of the public policy, healthcare infrastructure, and social support systems needed to address the changing needs of Arizona’s older adults. To aid in these efforts, we provide analysis of Arizona’s changing population structure, the prevalence of common chronic diseases among aging Arizonans, trends in utilization of emergency room and inpatient hospital services by older adults, and finally trends in mortality among older Arizonans. It is our hope to support the healthy aging of Arizona’s older adults by providing information important to those working with and for Arizona’s seniors. This report summarizes data from multiple sources and across multiple years. Population projections were developed by the Arizona Department of Administration’s (ADOA) Office of Employment and Population Statistics (http://azstats.gov/population-estimates.aspx). Information Page | 3 on the prevalence of health behaviors and common chronic diseases was derived from the Behavioral Risk Factor Surveillance System (BRFSS), a survey conducted in Arizona and across the United States that provides population-level estimates of important health indictors. Counts of hospital emergency room and inpatient healthcare utilization were drawn from the Arizona Department of Health Services’ (ADHS) Hospital Discharge Data (HDD). Finally, morality rates were calculated using data from the ADHS Office of Vital Records death database. Each section of this report includes a thorough introduction of the topic being discussed, complete descriptions of the data and analytic methods used, descriptions of the demographic characteristics of those included in each study (excluding the population projections section), analysis of the results, and a brief discussion of the results. The separate sections were designed so users could interpret each section independently without needing to reference other sections. It is our hope to benefit the health of all Arizonans through providing information to assist the coordinated planning of programs and interventions designed to effectively address the realities of our aging population. Page | 4 2. Population Projections 2.1. Introduction Two essential tasks involved in planning health policy and social services for Arizona’s aging adults are the assessment of Arizona’s current population age structure and the development of projections describing the characteristics of Arizona’s future population. In 2010, about 14 percent of Arizonans were 65 years of age or older, with about 83 percent of these residents being White non-Hispanic. Changes in aspects of fertility, mortality, and immigration will affect the age-structure of Arizona’s population, placing increasing stress on welfare systems designed to care for older adults. For example, the entire population of Arizona is projected to increase by more than 80 percent from the 6,401,568 residents estimated to have lived in Arizona on July 1st, 2010 to a projected 11,562,584 by 2050. The number of Arizonans age 65 and older is expected to increase 174 percent from 883,014 in 2010 to 2,422,186 in 2050. The age structure of our population also will shift, increasing the proportion of adults age 65 and older in the population to an estimated 21 percent of the entire population. This will be accompanied by a decrease in the proportion of working-age Arizonans who help support older adults in numerous ways including paying taxes on wages that help fund Social Security and Medicare. Along with an increase in the overall number and proportion of residents represented by adults age 65 and older, Arizona’s population will become more heterogeneous and diverse in terms of race/ethnicity. The interplay of these factors presents a difficult scenario for those tasked with planning health policy to accommodate the changing characteristics of Arizona’s older adult population. 2.2 Methodology The population projections used in this report were developed by the Arizona Department of Administration’s Office of Employment and Population Statistics (http://azstats.gov/populationestimates.aspx). Using adjusted 2010 census counts as a baseline, the cohort-component method was used to create population projections by age, sex, race, and ethnic group for each year from 2011 through 2050. The cohort-component method of population projection is designed to estimate projected populations by taking into account multiple inputs to population change including current population, rates of fertility, mortality, and migration, as well as special populations such as military and college students. The ADOA population projections were aggregated every 10 years to create projected population estimates by age and racial/ethnic group. These estimates were used to compare the racial/ethnic distribution of Arizona’s total population to the population of adults age 65 and older. Population pyramids were created to visually compare the population distribution of Arizonans by 5-year age group and sex for 2010 and 2050, and dependency ratios were used to compare the number of economically inactive residents to the number of economically active residents (calculated as the sum of Arizona residents age 0 – 14 and age 65 and older divided by the number of Arizona residents age 15 – 64). Page | 5 2.3 Results Table 1 provides counts from the Arizona July 1st, 2010 population estimates and population projections for each decade from 2020 – 2050 separately for all Arizonans and for Arizonans ages 65 and older by race/ethnicity. Beginning with the projected population for all Arizona residents, Arizona’s overall population is expected to increase 81 percent from the 6,401,568 residents estimated in 2010 to a projected 11,562,584 in 2050. Compared to the population as a whole, the population of older adults is expected to increase at a much faster pace. By 2050, Arizona’s older adult population is projected to be 2,422,186, a 174 percent increase from the 883,014 measured in 2010. Table 1. Projection of Arizona’s Total Population and Population age 65 and Older by Race/Ethnicity, 2010 – 2050 Arizona Population 2010 2020 2030 2040 2050 Population Population Population Population Population Race/Ethnicity Estimate % Projection % Projection % Projection % Projection % White non-Hispanic 3,824,322 60% 4,148,309 55% 4,525,074 51% 4,827,968 47% 5,070,854 44% Hispanic or Latino 1,839,016 29% 2,421,104 32% 3,197,808 36% 4,037,115 40% 4,911,772 42% Black or African American 259,432 4% 312,413 4% 378,459 4% 443,674 4% 507,959 4% American Indian or Alaskan Native 297,038 5% 345,293 5% 393,011 4% 434,629 4% 472,728 4% Asian or Pacific Islander 181,760 3% 258,044 3% 358,293 4% 475,022 5% 599,271 5% Total 6,401,568 7,485,163 8,852,645 10,218,407 11,562,584 Percent Change from 2010 17% 38% 60% 81% Arizona Population 65 and older 2010 2020 2030 2040 2050 Population Population Population Population Population Race/Ethnicity Estimate % Projection % Projection % Projection % Projection % White non-Hispanic 736,572 83% 1,028,631 79% 1,331,559 73% 1,433,756 67% 1,460,620 60% Hispanic or Latino 94,706 11% 176,710 14% 317,485 18% 490,430 23% 666,309 28% Black or African American 17,349 2% 29,815 2% 50,243 3% 66,464 3% 79,718 3% American Indian or Alaskan Native 20,047 2% 34,006 3% 55,140 3% 69,576 3% 81,764 3% Asian or Pacific Islander 14,339 2% 31,579 2% 59,084 3% 95,565 4% 133,775 6% Total 883,014 1,300,742 1,813,511 2,155,790 2,422,186 Percent Change from 2010 47% 105% 144% 174% Proportion of population age 65+ 14% 17% 20% 21% 21% In addition to a disproportionate increase in the growth of Arizonans age 65 and older, the racial/ethnic distribution of Arizona’s older adult population is projected to undergo substantial change. Arizona’s older resident population was fairly homogenous in terms of race/ethnicity in 2010, with about 83 percent of Arizona’s older adult residents being White non-Hispanic. About 11 percent of Arizona residents age 65 and older in 2010 were Hispanic or Latino, with Blacks or African Americans, American Indians or Alaskan Natives, and Asians or Pacific Islanders each accounting for about 2 percent of the total population of Arizona’s older adults. Page | 6 The observed racial/ethnic status of Arizona’s older adults in 2010 stands in contrast to the projected racial/ethnic composition of Arizona’s older adults in 2050. As displayed in Table 1 and Figure 1, the proportion of older Arizonans who are White non-Hispanic is expected to decrease 23 percent from 2010 to 2050, with the proportion of the population being Hispanic or Latino increasing by 17 percent. The percentage of Arizona’s older adult population who are Asian or Pacific Islander, Black or African American, and American Indian or Pacific Islander also is expected to increase, but at a much lower rate than that of Hispanics. Figure 1. Projections of Arizona’s Population of Adults Age 65 and Older by Race/Ethnicity, 2010 – 2050 Finally, Figures 2 and 3 provide representation of Arizona’s population age distribution by gender and age-group for 2010 and 2050. Included in the figures are the dependency ratios for 2010 and 2050, expressing the ratio of dependent individuals (the young and old who typically do not work) to working members of society (those aged 15 – 64 who typically do work). In 2010, the population pyramid can be described as roughly stationary, meaning birth rates have remained stable over recent years (indicated by the fairly even distribution of population by age group and gender from age 5 and under to age 50 – 54) and that death rates among older adults were relatively low. The dependency ratio in 2010 was fairly balanced at 53.9, meaning for every 100 working individuals there were about 54 individuals who were likely not working. Page | 7 Figure 2. Population Pyramid and Dependency Ratios for Arizona, 2010 Dependency Ratioa = 53.9 Notes: a Dependency ratio = (Arizona residents 0 – 14 years + Arizona residents 65 + years)/ Arizona residents 15 – 64. In comparison, the population pyramid representing Arizona’s projected population age composition in 2050 can be described as contractive, meaning the birth rate (represented by those under the age of 5) is low (compared to 2010), and the dependency ratio is high. In 2050, it is projected that there will be nearly 67 individuals dependent on the wages and taxes of every 100 working individuals in Arizona. Looking closer at the distribution of Arizonans age 65 and older in 2010 and 2050, it is clear that a greater proportion of the population will be age 65 and older in 2050 than were in 2010. Specifically, the proportion of adults age 65 and older in 2010 was about 14 percent while the projected proportion of the population ages 65 and older in 2050 will be about 21 percent. This is especially transparent at the oldest ages, with the percent of the population represented by men and women age 85 and older in 2050 being 2.7 percent greater than in 2010. This means that by 2050, not only will a greater proportion of Arizona’s population be among Arizona’s older adults, but also that a greater proportion of Arizona’s older adult population will be represented in the oldest age groups. Page | 8 Figure 3. Population Pyramid and Dependency Ratios for Arizona, 2050 (Projection) Dependency Ratioa = 66.6 Notes: a Dependency ratio = (Arizona residents 0 – 14 years + Arizona residents 65 + years)/ Arizona residents 15 – 64. 2.4 Conclusion Based on the population projections analyzed here, Arizona can expect a rapidly increasing number of residents age 65 and older who will come to account for a greater proportion of the overall population than they currently do. This increasing percentage of Arizonans age 65 and older will be more racially and ethnically diverse than the current population of older adults, meaning specialized courses of intervention and treatment will need to be developed to address health outcomes that disproportionately affect Hispanic and Latino older adults. The confluence of these forces requires targeted and effective policies that will help reduce the costs of the healthcare burden posed by a greater proportion of adults living with chronic diseases associated with aging. To help guide these discussions, this report attempts to describe the current health of Arizona’s older adult population, the patterns of their interactions with the healthcare system, and the common causes of mortality they must face. In doing so, we hope to offer useful information to support the progression of health and wellness among Arizona’s aging population. Page | 9 3. Health Behaviors and Chronic Diseases among Aging Arizonans 3.1 Introduction Estimating the population prevalence of health risk factors and common chronic diseases is a crucial step in the planning of targeted and effective healthcare policy. The use of survey methodology provides an accurate and cost-effective means of estimating the population prevalence of health indicators without the burden of interviewing every state resident. The Behavioral Risk Factor Surveillance System (BRFSS) is a survey conducted in Arizona and across the United States to provide population-level estimates of important health indictors. To better understand the health behaviors of Arizona’s aging population, the 2012 Arizona BRFSS survey was used to estimate the percentage of Arizona adults age 65 and older with healthrelated behaviors known to either harm or protect health, including exercise and obesity, routine checkups, smoking, and heavy drinking. The percentage of Arizonans living with common morbidities and chronic disease including poor mental or physical health, mobility limitations, cardiovascular diseases, cerebrovascular diseases, cancers, and pulmonary diseases was also estimated and compared to national estimates. 3.2 Methodology The BRFSS, a telephone survey that uses random-digit dialing of both landlines and cellphones, is conducted in all 50 U.S. states as well as the District of Columbia and 3 U.S. territories (http://www.cdc.gov/brfss/about/brfss_faq.htm). The Centers for Disease Control (CDC) partners with U.S. states and territories to conduct the BRFSS survey. The survey is designed to measure the prevalence of behavioral risk factors of adults age 18 and older at the household level and to provide estimates of morbidity prevalence that are both nationally and locally representative of non-institutionalized adult populations. Sampling at the household level means older adults living in retirement facilities or nursing homes are not included in the BRFSS population. More detailed information on the survey design and execution can be found at the following address: http://www.cdc.gov/brfss/annual_data/2012/pdf/Overview_2012.pdf. To examine health behaviors and chronic diseases among Arizona’s non-institutionalized older adults, data collected in the 2012 BRFSS was restricted to adults age 65 and older. Demographic and socioeconomic characteristics of Arizona’s older adult population are reported initially. Arizona’s older adult residents were compared to the national population of adults age 65 and older on a number of health behaviors including physical activity or exercise within the past month, being either overweight or obese (having a body mass index (BMI) of 25 or greater), having routine health checkups, dental checkups, and receiving a flu shot in the past year. For males, having received a prostate specific antigen (PSA) test in the past year, and for females, having received a breast exam in the past year, also are examined. Additional measures included being a current smoker and engaging in heavy drinking (> 2 drinks a day for males and > 1 drink a day for females). Indicators of broad health status included poor mental or physical health for all of the past 30 days, activity limitations, and use of special equipment. Common chronic Page | 10 diseases examined included any of the following conditions: angina or coronary heart disease, heart attack, stroke, diabetes, skin cancer, non-skin cancer, asthma, and chronic obstructive pulmonary disease (COPD). Weighted percentages were produced for Arizona and the U.S. for each health indicator, then the standard error of the weighted percent was used to construct 95% confidence intervals. For each indicator, the confidence interval around the estimated percentage for Arizonans was compared to the estimate and confidence interval for the U.S. In this method, if the 95% confidence interval for Arizona and the U.S. did not overlap, it can be stated that there was a statistically significant difference between Arizona and the U.S. on the given indicator. The weighted estimates and confidence intervals were calculated separately by gender to account for health disparities between genders that widen with age and also allowing for comparison of older adults within Arizona by gender. 3.3 Results Socioeconomic and Demographic Characteristics Table 2 provides the number of unweighted completed BRFSS interviews, weighted frequencies, percentages, and standard errors for the sociodemographic characteristics of Arizona residents age 65 and older in 2012. It was estimated that about 55 percent of Arizona’s population of noninstitutionalized older adults were female. About 82 percent of Arizona residents age 65 and over were White non-Hispanic and about 10 percent were Hispanic, with Asians/Pacific Islanders, American Indians, or adults of other racial/ethnic backgrounds, each accounting for approximately 1.5 percent of Arizona’s older population each. Concerning education, 11 percent of older Arizonans had less than a high school education, about 26 percent had earned a high school degree, and more than 60 percent reported having either attended college/technical school without earning a degree or had graduated from college/technical school. The majority of Arizonans age 65 and older were retired (72.8%), about 9 percent were employed, about 7 percent reported employment as homemakers, or being self-employed, out of work, unable to work, or students, representing a small proportion of older Arizonans. Likely related to the high percentage of retired older Arizonans, Arizonans making less than $25,000 per year (26.2%) accounted for the greatest percentage of any income group. For other income groups, the remaining Arizonans were distributed fairly evenly, with 11 to 15 percent of respondents falling within each group. A large percentage of respondents (20.6%) reported their income as either unknown or had refused to answer the income question. Health Behaviors among Arizona’s Older Adults The current health behaviors of Arizona’s older adult population are leading indicators of morbidities and chronic diseases that can result from health maintenance behavior. Table 3 provides estimates of 10 health-related behaviors, which are then depicted in Figures 4 through 6. Comparing Arizona’s older adult males to older males nationally, Arizona males were generally comparable to males of the same age nationally, excluding their use of preventative health services. More than 72 percent of Arizona’s older males reported having some physical activity or exercise within the past month, but nearly 70 percent of Arizona’s males 65 and older had a BMI of 25 or greater, indicating being either overweight or obese. Within a year of being interviewed, nearly 80 percent of Arizona’s older males had a routine health checkup, about 50 Page | 11 Table 2. Arizona Behavioral Risk Factor Surveillance System (BRFSS) Estimates of Sociodemographics among Adults age 65 and Older, 2012 SE of Weighted % Gender Male 1,064 410,268 45.46 1.48 Female 1,678 492,224 54.54 1.48 Race White Non-Hispanic 2,295 736,896 81.65 1.33 Black 22 13,989 1.55 0.40 Asian/PI 16 10,908 1.21 0.48 American Indian 39 13,435 1.49 0.39 Other 53 11,660 1.29 0.28 Hispanic 253 93,673 10.38 1.12 Missing 64 21,930 2.43 0.47 Education Did not graduate high school 251 97,425 10.80 1.09 Graduated high school 769 236,005 26.15 1.27 Attended college/tech school 828 337,190 37.36 1.46 College/tech school graduate 881 223,680 24.78 1.12 Refused 13 8,191 0.91 0.42 Employment Employed for wages 212 82,912 9.19 0.89 Self employed 118 38,683 4.29 0.59 Out of work 42 18,633 2.06 0.45 Homemaker 202 70,230 7.78 0.82 Student 3 1,123 0.12 0.08 Retired 2,037 656,737 72.77 1.34 Unable to Work 112 30,407 3.37 0.56 Refused 16 3,766 0.42 0.16 Income <$25,000 830 236,537 26.21 1.28 $25,000-$34,999 340 102,437 11.35 0.87 $35,000-$49,999 412 140,826 15.60 1.09 $50,000-$74,999 327 119,016 13.19 1.02 $75,000+ 330 117,382 13.01 0.95 Unknown/Refused 503 186,294 20.64 1.89 Notes: Mean age for resident males 65 and over = 73.9 years, mean age for resident females = 74.4 years. Freq Weighted Freq Weighted % percent had received a flu shot, nearly 65 percent had a dental checkup, and about 80 percent had a PSA test. As identified in Figure 4, a significantly lower percentage of Arizona males reported having routine health checkups and flu shots in the prior year than comparably aged males nationally. Nearly 10 percent of Arizona’s males age 65 and older reported being a current smoker, only 3.8 percent reported having more than two drinks every day, and nearly 90 percent reported always wearing a seatbelt when they drive. Regarding Arizona’s females, about 70 percent of Arizona’s older females reported having some exercise or physical activity in the past 30 days and just over 50 percent had a BMI identifying them as either overweight or obese. A significantly lower percentage of Arizona’s older females had a BMI identifying them as either overweight or obese (Est. = 53.4%, 95% C.I. = .50-.57) than older females nationally (Est. = 60.0%, 95% C.I. = .59-.61). In the year prior to Page | 12 Table 3. Arizona Behavioral Risk Factor Surveillance System (BRFSS) Estimates of Health Behaviors among Adults age 65 and Older, 2012 Physical activity past 30 days a Overweight or obese Health checkup past year Flu shot within past year Dental checkup past year PSAb test past year Breast exam past year Current smoker Heavy drinkerc Always wears seat belt Arizona male Est SE 95% CI 72.9% .02 .69-.77 68.8% .02 .65-.73 79.6% .02 .76-.84 51.7% .02 .47-.56 64.4% .02 .60-.69 79.1% .02 .75-.83 10.1% .02 .07-.13 3.8% .01 .02-.05 87.8% .01 .85-.91 National male Est SE 95% CI 72.8% .00 .72-.74 71.9% .00 .71-.73 86.4% .00 .86-.87 58.2% .00 .57-.59 64.9% .00 .64-.66 77.7% .00 .77-.78 9.4% .00 .09-.10 4.2% .00 .04-.05 86.2% .00 .86-.87 Arizona female Est SE 95% CI 69.4% .02 .66-.73 53.4% .02 .50-.57 84.9% .01 .82-.87 52.8% .02 .49-.57 66.6% .02 .63-.70 62.5% .02 .59-.66 9.0% .01 .07-.11 4.5% .01 .03-.06 92.4% .01 .91-.94 National female Est SE 95% CI 65.5% .00 .65-.66 60.0% .00 .59-.61 87.7% .00 .87-.88 59.4% .00 .59-.60 67.4% .00 .67-.68 63.1% .00 .62-.64 8.0% .00 .08-.08 3.5% .00 .03-.04 92.9% .00 .93-.93 Notes: a (BMI) greater than or equal to 25 (overweight or obese); b Prostate specific antigen; c (Men > 2 drinks per day, Women > 1 drink per day). interview, nearly 85 percent of Arizona’s females age 65 and older had a routine health checkup, about 53 percent had a flu shot, around 67 percent had a dental checkup, and about 63 percent had a breast exam. Similar to Arizona’s older males, a significantly lower percentage of Arizona’s females reported receiving a flu shot in the past year (Est. = 52.8%, 95% C.I. = .49.57) than comparably aged females nationally (Est. = 59.4%, 95% C.I. = .59-.60). Nine percent or Arizona’s older females reported being a current smoker, about 5 percent were classified as heavy drinkers, and more than 90 percent reported always wearing a seatbelt when in an automobile. Figure 4. Estimates of Population Health Behaviors with 95% Confidence Intervals, Arizona and National Males Age 65 and Older, BRFSS 2012 Notes: * indicates statistically significant difference at p < .05 level. Page | 13 When comparing Arizona’s older males to Arizona’s older females, the only difference that was statistically significant was for the percentage classified as overweight or obese based on BMI. A significantly higher percentage of Arizona’s males age 65 and older were either overweight or obese (Est. = 68.8%, 95% C.I. = .65-.73) than Arizona’s older females (Est. = 53.4%, 95% C.I. = .50-.57). While statistically significant, BMI is a crude measure of one’s body composition that does not account for factors such as muscle mass or bone density that may vary by gender. Though this difference does raise some concern that Arizona’s older males may be at risk for weight-related health issues, it also should be interpreted cautiously due to the imprecision of BMI as a measure of healthy weight, which may differ for males and females. Morbidity among Arizonans Age 65 and Older Table 4 provides weighted estimated percentages with standard errors for 12 common morbidities faced by older adults reported for Arizona and the U.S. by gender. These estimates are included in Figure 7 for males, Figure 8 for females, and Figure 9 compares Arizona’s older males to Arizona’s older females. Beginning with Arizona males age 65 and older in 2012, about 4 percent reported having poor mental health all 30 days prior to being interviewed. In contrast, approximately 28 percent of Arizona males age 65 and older reported experiencing poor physical health all 30 days prior to being interviewed. About 29 percent of Arizona’s older males reported activity limitations due to health problems (physical, mental, or emotional), and about 14 percent reported health problems requiring the use of special equipment such as a cane, wheelchair, or special bed. The estimates for Arizona males on these health indicators were similar to national estimates. Figure 5. Estimates of Population Morbidity with 95% Confidence Intervals, Arizona and National Females Age 65 and Older, BRFSS 2012 Notes: * indicates statistically significant difference at p < .05 level. Page | 14 Figure 6. Estimates of Population Health Behaviors with 95% Confidence Intervals, Arizona Males and Females Age 65 and Older, BRFSS 2012 Notes: * indicates statistically significant difference at p < .05 level. Moving to specific chronic diseases among Arizona’s older male population, about 15 percent of Arizona males age 65 and older reported being diagnosed with angina or coronary heart disease, and about 16 percent reported having a heart attack. More than 6 percent of Arizona males reported being diagnosed as having a stroke. Nearly 20 percent of Arizona males age 65 and older reported having diabetes (Est. = 19.5%, 95% C.I. = .16-.23), which was significantly lower than the percent of males age 65 and over reporting diabetes nationally (Est. = 24.2%, 95% C.I. = .23-.25). A significantly greater percentage of Arizona’s older males reported having skin cancer (Est. = 25.1%, 95% C.I. =.21-.29) than the national average (Est. = 19.8%, 95% C.I. =.19-.20), but percentages for cancers other than skin were similar (Arizona male = 17.6%, national male = 17.8%). Regarding pulmonary issues, about 8 percent of Arizona’s older males reported being diagnosed with asthma and 11 percent reported being diagnosed with chronic obstructive pulmonary disease (COPD). Morbidity among Arizona’s Females age 65 and Older Arizona’s population of females age 65 and older had a significantly lower percentage reporting poor mental health 30 days prior to interview (Arizona Est. = 2.4%, 95% C.I. =.01-.03; U.S. Est. = 3.9%, 95% C.I. =.04-.04), which was also true for poor physical health (Arizona Est. = 19.4%, 95% C.I. =.15-.24; U.S. Est. = 25.1%, 95% C.I. =.24-.26). About 29 percent of Arizona’s older females reported some activity limitations, and nearly 19 percent reported the need to use special equipment. Page | 15 Table 4. Arizona Behavioral Risk Factor Surveillance System (BRFSS) Estimates of Population Morbidity, 2012 Poor mental health Poor phsyical health Activity Limitations Require Special Equipment Angina or CHDa Heart Attack Stroke Diabetes Skin Cancer Non-skin cancer Ashtma COPDb Arizona male Est SE 95% CI 3.6% .01 .02-.05 27.6% .04 .20-.35 28.5% .02 .25-.33 14.0% .01 .11-.17 14.9% .02 .12-.18 16.3% .02 .13-.20 6.4% .01 .04-.08 19.5% .02 .16-.23 25.1% .02 .21-.29 17.6% .02 .14-.21 8.5% .01 .06-.11 10.9% .01 .08-.14 National male Est SE 95% CI 3.4% .00 .03-.04 27.5% .01 .26-.29 28.3% .00 .27-.29 15.3% .00 .15-.16 17.0% .00 .16-.18 16.2% .00 .16-.17 7.7% .00 .07-.08 24.2% .00 .23-.25 19.8% .00 .19-.20 17.8% .00 .17-.18 9.0% .00 .08-.09 10.8% .00 .10-.11 Arizona female Est SE 95% CI 2.4% .00 .01-.03 19.4% .02 .15-.24 29.4% .02 .26-.33 18.6% .01 .16-.22 10.2% .01 .08-.13 9.4% .01 .07-.12 6.3% .01 .04-.08 15.9% .01 .13-.19 17.4% .01 .15-.20 16.9% .01 .14-.20 13.8% .01 .11-.17 12.7% .01 .10-.15 National female Est SE 95% CI 3.9% .00 .04-.04 25.1% .00 .24-.26 30.2% .00 .30-.31 20.3% .00 .20-.21 9.6% .00 .09-.10 8.1% .00 .08-.08 6.9% .00 .07-.07 19.4% .00 .19-.20 14.4% .00 .14-.15 16.0% .00 .16-.17 12.7% .00 .12-.13 12.3% .00 .12-.13 Notes: a Coronary heart disease; b Chronic obstructive pulmonary disease. For the specific chronic diseases being examined, about 10 percent of Arizona’s female population age 65 and older reported being diagnosed with angina or coronary heart disease and about 9 percent reported having been diagnosed as having had a heart attack. Less than 6 percent of Arizona’s older females reported having a prior stroke, with nearly 16 percent reporting being diagnosed with diabetes. The prevalence of diabetes among Arizona females age 65 and older (Est. = 15.9%, 95% C.I. =.13-.19) was significantly lower than for comparable females nationally (Est. = 19.4%, 95% C.I. =.19-.20). The percentage of Arizona’s females reporting skin cancer (17.4%) was higher than the national average (14.4%), but this difference was not statistically significant. The prevalence of being diagnosed with a non-skin cancer was similar among Arizona’s older females (16.9%) and females of similar ages nationally (16.0%). About 14 percent of Arizona’s older female population reported being diagnosed with asthma and nearly 13 percent reported a diagnosis of chronic obstructive pulmonary disease (COPD). Comparing Arizona’s Male and Female Aging Adults There was a significant difference between males and females for only 3 of the 12 indicators of morbidity examined among Arizona’s aging adults. A significantly higher percentage of males reported being diagnosed with having a heart attack (Est. = 16.3%, 95% C.I. =.13-.20) than did females (Est. = 9.41%, 95% C.I. =.07-.12). A greater percentage of Arizona’s older males (Est. = 25.1%, 95% C.I. =.21-.29) reported a diagnosis of skin cancer than Arizona’s older females (Est. = 17.4%, 95% C.I. =.15-.20). Finally, among adults age 65 and older, Arizona females had a significantly greater percentage reporting asthma (Est. = 13.8%, 95% C.I. =.11-.17) than Arizona’s males (Est. = 8.5%, 95% C.I. =.06-.11). Page | 16 Figure 7. Estimates of Population Morbidity with 95% Confidence Intervals, Arizona and National Males Age 65 and Older, BRFSS 2012 Notes: * indicates statistically significant difference at p < .05 level. Figure 8. Estimates of Population Morbidity with 95% Confidence Intervals, Arizona and National Females Age 65 and Older, BRFSS 2012 Notes: * indicates statistically significant difference at p < .05 level. Page | 17 Figure 9. Estimates of Population Morbidity with 95% Confidence Intervals, Arizona Males and Females Age 65 and Older, BRFSS 2012 Notes: * indicates statistically significant difference at p < .05 level. 3.4 Conclusion Analysis of the BRFSS survey provided information that will aid in the development of health policies driving community interventions to produce more favorable health outcomes for Arizona’s aging population. Regarding health behaviors, Arizona’s older adults were comparable to similarly aged adults nationally, excluding routine health checkups for males and receiving flu shots for both males and females. These preventative health services play an important role in health maintenance, and increasing older Arizonan’s access and use of these services should be a priority of Arizona’s health community. While a significantly higher percentage of older Arizonan males were either overweight or obese than were Arizona’s older females, the difference here may be based on inconsistencies across genders in the validity of BMI. Compared to national estimates for older adults, Arizona’s aging population has both strengths and limitations in terms of morbidities and chronic diseases. For example, Arizona’s population of older males had a significantly lower prevalence of diabetes in 2012 than the national average, although our resident older males had a significantly greater prevalence of skin cancer than older males nationally. Arizona’s resident females had a significantly lower occurrence of mental health problems, physical health problems, and diagnosis of diabetes than older females nationally, and had similar outcomes on the remaining health indicators. When comparing Arizona’s resident males to Arizona’s resident females, Arizona’s older males had a significantly higher percentage of heart attack and skin cancer diagnoses than resident females, but a greater percent of Arizona’s females reported having asthma. These differences suggest that Arizona’s older male population may benefit from targeted interventions regarding heart and skin health, and Arizona’s female population may benefit from attention to pulmonary health and asthma. Page | 18 4. Emergency Room and Hospital Inpatient Discharges among Aging Arizonans 4.1 Introduction Hospital Discharge Data (HDD) provides a useful source of information on a population’s utilization of hospital emergency room (ER) and inpatient healthcare services. Among the uses of HDD data are the surveillance of injury and chronic disease, allowing for informed planning of public health policy and legislation. While HDD data does not include other information on healthcare utilization such as data from primary care physicians or urgent care clinics, HDD does provide a snapshot of Arizona’s usage of emergency health services as well as treatment for more complicated and severe health problems occurring in an inpatient setting. These healthcare settings are especially important to Arizona’s aging population as the impact of accidents, infectious diseases, and chronic diseases can become both more common and severe with age. 4.2 Methodology The Arizona Department of Health Services (ADHS) collects hospital discharge records for inpatient and ER department visits from all Arizona licensed hospitals. This collection is required by Arizona Revised Statute (A.R.S.) § 36-125-05, and Arizona Administrative Code Title 9, Chapter 11, Articles 4 and 5. The records are collected twice each year based on patient discharge date, January 1 through June 30 discharges comprising the first data reporting and July 1 through December 31 comprising the second. Approximately 3 million discharge records are collected annually. Accuracy and completeness in reporting are required and enforced. All Arizona licensed hospitals (i.e. regulated by the Arizona Department of Health Services) are required to report. Therefore, hospitals such as Veteran’s Administration, Department of Defense, and those located on tribal land are not included in the reporting. This report examines 2012 HDD data for Arizona residents age 65 and older. A discharge occurs when a person admitted to a hospital ER or for inpatient care leaves that hospital. A person admitted more than once in a given calendar year will be counted multiple times, meaning the numbers in this report are for discharges, not persons. Discharge rates were calculated as the number of discharges for a given event divided by Arizona’s population within that age group. All rates represent the number of discharges per 10,000 residents and the age group. The population denominators used to calculate rates can be found at the ADHS Health Status and Vital Statistics website (http://www.azdhs.gov/plan/menu/info/pop/pop12/pd12.htm). Demographic characteristics including gender, race/ethnicity, marital status, and source of payment were summarized for all ER and inpatient discharges occurring among Arizona residents age 65 and older in 2012. The first-listed diagnosis reported for a discharge was categorized and reported by common condition, meaning that less-common disorders may not have been summarized in this report. Counts are reported for all Arizona residents age 65 and older as well as by three age groups: 65 – 74 years, 75 – 84 years, and 85 years and older. Page | 19 4.3 Results Demographic Characteristics Table 5 provides demographic information on Arizona residents age 65 and older who were discharged from an ER or as a hospital inpatient in 2012. Beginning with ER discharges among Arizonans age 65 and older, there were 286,938 total ER discharges, with adults ages 65-84 accounting for about 81 percent of all ER discharges. Concerning costs, the average overall cost of an ER discharge for an Arizonan age 65 and older in 2012 was $6,175 and the average cost for an inpatient hospital discharge for the same group was $53,956. Interestingly, the average cost of an ER discharge slightly increased with age group, but for inpatient discharges, price per discharge decreased substantially with age. By gender, females accounted for 168,254, or roughly 59 percent, of all ER discharges. Considering age group, females accounted for 57 percent, 58 percent, and 65 percent of ER discharges among adults age 65 – 74, 75 – 84, and 85 and older, respectively. White non-Hispanics accounted for 81 percent (233,013) of all ER discharges, with an increasing percentage of White non-Hispanics in each increasing age group. The majority of Arizonans age 65 and older discharged from an ER were married (51 percent), Table 5. Demographic Characteristics of Arizona Resident Emergency Room Discharges and Emergency Room Discharge Rates for adults Age 65 and Older by Age Group, 2012 Total discharges Average cost per discharge ($) Emergency Room Discharges Inpatient Discharges 65 - 74 75 - 84 65 - 74 75 - 84 85 + Total Total Years Years Years Years Years 286,938 131,827 101,434 53,677 239,851 104,501 88,068 6,175 5,999 6,268 6,431 49,920 54,842 49,626 85 + Years 47,282 39,590 Gender Female Male 168,254 118,681 74,750 57,074 Race/Ethnicity American Indian or Alaska Native 5,317 2,783 Asian or Pacific Islander 2,869 1,513 Black or African American 7,794 4,470 Hispanic or Latino 35,884 18,920 White non-Hispanic 233,013 103,074 Other 146 87 Refused 1,915 980 Marital Status Single 35,366 21,756 Married 145,342 74,950 Separated 1,585 1,117 Divorced 25,108 15,519 Widowed 78,144 17,826 Unknown 1,393 659 Not Applicable 0 0 Payee Self 4,248 2,491 Private insurance (indemnity, HMO, PPO) 21,791 14,513 AHCCCS Medicaid/AHCCCS HCG 4,488 2,737 Medicare 191,113 83,790 Other 65,298 28,296 58,843 42,591 34,661 128,513 19,016 111,338 52,687 51,814 46,825 41,243 29,001 18,281 1,934 982 2,489 12,272 83,052 43 662 600 4,433 374 2,430 835 5,744 4,692 24,055 46,887 200,931 16 210 273 2,048 2,231 1,109 2,953 11,686 85,463 100 959 1,639 939 2,059 8,831 73,778 69 753 563 382 732 3,538 41,690 41 336 9,921 52,792 369 7,393 30,525 434 0 3,689 27,394 17,600 123,392 99 1,083 2,196 20,235 29,793 65,977 300 1,769 0 0* 15,752 61,218 699 12,168 13,951 713 0 8,271 46,689 305 6,236 25,931 635 0* 3,371 15,485 79 1,831 26,095 421 0 1,258 5,371 1,336 68,566 24,903 499 1,562 1,907 13,296 415 3,582 38,757 167,455 12,099 53,956 840 9,283 1,906 70,713 21,759 514 2,852 1,243 61,905 21,554 208 1,161 433 34,837 10,643 Notes: * Cell suppressed due to non-zero count less than 6. Page | 20 but when taken by age group, 57 percent of adults age 65-75 were married and 14 percent widowed, but only 33 percent of adults age 85 and older were married while 56 percent were widowed. The majority (67 percent) of ER discharges were paid for by Medicare, with this percentage increasing by age group. In 2012, there were 239,851 total inpatient discharges of Arizonans age 65 and older. Arizonans age 65 – 74 accounted for 44 percent, those age 75 -84 accounted for 37 percent, and those age 85 and older accounted for 20 percent of inpatient discharges, respectively. Females accounted for 128,513, or roughly 54 percent, of all inpatient discharges. This percentage of female inpatient discharges increased with each age group. White non-Hispanics accounted for 84 percent (200,931) of all inpatient discharges, which again increased with age group. Among all Arizonans age 65 and older, the majority of inpatient discharges were to those who were married (51 percent), but when taken by age group, adults age 65-75 were about 59 percent married and about 13 percent widowed, but only 33 percent of adults age 85 and over were married while 55 percent were widowed. The majority (70 percent) of inpatient discharges were paid for by Medicare, with this percentage increasing slightly with increasing age group. First-listed Diagnosis for Emergency Room Discharges Table 6 contains counts and rates of ER discharges of Arizona residents age 65 and older by agegroup in 2012. There was a total of 286,938 ER discharges among Arizona residents age 65 and older, meaning there were approximately 3,051 ER discharges for every 10,000 elderly residents in Arizona. For ER discharges, the two largest groups of conditions identified as the first-listed diagnosis were symptoms, signs, and ill-defined conditions (n = 88,513), followed by injury and poisoning (n = 59,288). These two categories of conditions accounted for 51.5 percent of the 286,398 total ER discharges for Arizonans age 65 and older. Examining the difference in ER discharge rates among Arizona’s youngest and oldest old reveals the health burdens endured by those in the latest years of life. The overall rate of ER discharges among Arizonans age 85 and older (4,949.1/10,000) was 102 percent greater than the rate of ER discharges for all causes among residents age 65-74 (2,447.0/10,000). Specific causes that had especially high discharge rates when comparing the oldest to the youngest old were fractures, which were 206 percent greater for adults age 85 and older (253.4/10,000) than for adults age 6574 (82.8/10,000), discharges related to the circulatory system (including heart disease), which were 137 percent greater for the oldest Arizonans (467.3/10,000) than for those age 65-74 (197.3/10,000), and endocrine nutritional metabolic and immunity diseases, which were 108 percent greater for Arizona’s oldest old (135.4/10,000) than for Arizona’s youngest old (65.0/10,000). First-listed Diagnosis for Inpatient Discharges Table 7 contains counts and rates of inpatient discharges of Arizona residents age 65 and older by age group in 2012. In 2012, 239,851 Arizona residents age 65 and older were discharged from Arizona hospitals as inpatients. Arizonan adults age 65-74 accounted for the largest proportion of inpatient discharges (43.6 percent), followed by adults age 75-84 (36.7 percent), and those age Page | 21 Table 6. Emergency Room Discharges and Emergency Room Discharge Rates among Arizona Residents Age 65 and Older by First-listed Diagnosis and Age Group, 2012 Emergency Room Discharges Total Total, all causes Infectious and parasitic diseases Septicemia Enterocolitis due to Clostridium difficile Neoplasms Malignant neoplasms Large intestine Prostate Trachea bronchus and lung Breast Benign neoplasms Endocrine nutritional metabolic and immunity diseases Diabetes mellitus Volume depletion Morbid obesity Diseases of the blood and blood forming organs Mental disorders Psychoses Alcoholic psychoses Drug psychoses Schizophrenic disorders Manic-depressive disorders Neurotic disorders Anxiety states Depression Drug dependence Nondependent abuse of drugs Alcohol dependence syndrome Diseases of the nervous system Diseases of the circulatory system Heart disease Acute myocardial infarction Coronary artherosclerosis Other ischemic heart disease Cardiac dysrythmias Cardiac arrest Congestive heart failure Cerebrovascular disease Diseases of the respiratory system Acute bronchitis and bronchiolitis Pneumonia Chronic bronchitis Asthma Diseases of the digestive system Appendicitis Noninfectious enteritis and colitis Diverticula of intestine Cholelithiasis Diseases of the genitourinary system Calculus of kidney and ureter Diseases of the skin and subcutaneous tissue Cellulitis and abscess Diseases of the musculoskeletal system Osteoarthrosis and allied disorders Invertebral disc disorders Congenital anomalies Symptoms signs and ill-defined conditions Injury and poisoning Fractures, all sites Fracture of neck of femur Poisonings 286,938 2,615 244 118 839 642 26 43 142 40† 75 7,851 2,474 64 0† 1,603 5,294 1,991 100† 233 70† 156 3,303 1,368 505 30† 593 210† 9,834 25,381 10,818 689 933 787 5,778 1,242 1,771 3,280 16,880 2,271 2,920 3,084 1,282 15,674 123 1,845 1,471 738 16,502 2,164 6,703 4,301 24,241 714 554 50† 88,513 59,288 11,065 489 1,408 65 - 74 Years 131,827 1,313 83 54 418 315 12 17 72 19 41 3,503 1,262 27 * 647 2,801 800 86 134 57 121 2,001 760 289 20 441 173 5,301 10,630 4,522 296 474 385 2,502 483 549 1,297 8,662 1,157 1,355 1,617 753 7,257 86 962 865 432 7,608 1,546 3,485 2,239 11,371 281 288 28 40,652 25,524 4,462 117 803 Emergency Room Discharge Rates 75 - 84 85 Years 65 - 74 75 - 84 85 Years Total Years and Over Years Years and Over 101,434 53,677 3050.9 2447.0 3458.0 4949.1 892 410 27.8 24.4 30.4 37.8 101 60 2.6 1.5 3.4 5.5 41 23 1.3 1.0 1.4 2.1 293 128 8.9 7.8 10.0 11.8 230 97 6.8 5.8 7.8 8.9 8 6 0.3 0.2 0.3 0.6 18 8 0.5 0.3 0.6 0.7 54 16 1.5 1.3 1.8 1.5 13 * 0.4 0.4 0.4 ** 19 15 0.8 0.8 0.6 1.4 2,879 1,469 83.5 65.0 98.1 135.4 909 303 26.3 23.4 31.0 27.9 18 19 0.7 0.5 0.6 1.8 0 0 ** ** 0.0 0.0 622 334 17.0 12.0 21.2 30.8 1,655 838 56.3 52.0 56.4 77.3 698 493 21.2 14.9 23.8 45.5 15 * 1.1 1.6 0.5 ** 82 17 2.5 2.5 2.8 1.6 8 0 0.7 1.1 0.3 0.0 29 6 1.7 2.2 1.0 0.6 957 345 35.1 37.1 32.6 31.8 442 166 14.5 14.1 15.1 15.3 157 59 5.4 5.4 5.4 5.4 * * 0.3 0.4 ** ** 123 29 6.3 8.2 4.2 2.7 29 * 2.2 3.2 1.0 ** 3,176 1,357 104.6 98.4 108.3 125.1 9,683 5,068 269.9 197.3 330.1 467.3 4,065 2,231 115.0 83.9 138.6 205.7 229 164 7.3 5.5 7.8 15.1 332 127 9.9 8.8 11.3 11.7 259 143 8.4 7.1 8.8 13.2 2,212 1,064 61.4 46.4 75.4 98.1 472 287 13.2 9.0 16.1 26.5 691 531 18.8 10.2 23.6 49.0 1,277 706 34.9 24.1 43.5 65.1 5,756 2,462 179.5 160.8 196.2 227.0 781 333 24.1 21.5 26.6 30.7 1,053 512 31.0 25.2 35.9 47.2 1,078 389 32.8 30.0 36.8 35.9 403 126 13.6 14.0 13.7 11.6 5,583 2,834 166.7 134.7 190.3 261.3 27 10 1.3 1.6 0.9 0.9 621 262 19.6 17.9 21.2 24.2 471 135 15.6 16.1 16.1 12.4 223 83 7.8 8.0 7.6 7.7 5,801 3,093 175.5 141.2 197.8 285.2 523 95 23.0 28.7 17.8 8.8 2,178 1,040 71.3 64.7 74.3 95.9 1,387 675 45.7 41.6 47.3 62.2 8,633 4,237 257.7 211.1 294.3 390.7 271 162 7.6 5.2 9.2 14.9 189 77 5.9 5.3 6.4 7.1 16 * 0.5 0.5 0.5 ** 31,955 15,906 941.1 754.6 1089.4 1466.6 20,347 13,417 630.4 473.8 693.7 1237.1 3,855 2,748 117.6 82.8 131.4 253.4 171 201 5.2 2.2 5.8 18.5 440 165 15.0 14.9 15.0 15.2 Notes: * Cell suppressed due to non-zero count less than 6; ** Cell suppressed due to rate/ratio/percent based on non-zero count less than 6; † Sum rounded to nearest tens unit due to non-zero addend less than 6; 1Rates calculated using female-specific population denominator. Page | 22 Table 7. Inpatient Discharges and Inpatient Discharge Rates among Arizona Residents Age 65 and Older by First-listed Diagnosis and Age Group, 2012 Inpatient Discharges Total Total, all causes Infectious and parasitic diseases Septicemia Enterocolitis due to Clostridium difficile Neoplasms Malignant neoplasms Large intestine Prostate Trachea bronchus and lung Breast Benign neoplasms Endocrine nutritional metabolic and immunity diseases Diabetes mellitus Volume depletion Morbid obesity Diseases of the blood and blood forming organs Mental disorders Psychoses Alcoholic psychoses Drug psychoses Schizophrenic disorders Manic-depressive disorders Neurotic disorders Anxiety states Depression Drug dependence Nondependent abuse of drugs Alcohol dependence syndrome Diseases of the nervous system Diseases of the circulatory system Heart disease Acute myocardial infarction Coronary artherosclerosis Other ischemic heart disease Cardiac dysrythmias Cardiac arrest Congestive heart failure Cerebrovascular disease Diseases of the respiratory system Acute bronchitis and bronchiolitis Pneumonia Chronic bronchitis Asthma Diseases of the digestive system Appendicitis Noninfectious enteritis and colitis Diverticula of intestine Cholelithiasis Diseases of the genitourinary system Calculus of kidney and ureter Diseases of the skin and subcutaneous tissue Cellulitis and abscess Diseases of the musculoskeletal system Osteoarthrosis and allied disorders Invertebral disc disorders Congenital anomalies Symptoms signs and ill-defined conditions Injury and poisoning Fractures, all sites Fracture of neck of femur Poisonings 239,851 15,794 12,040 1,650 11,383 9,786 1,440 683 1,521 441 1,033 7,575 2,612 42 200† 2,940 3,567 2,904 316 219 190† 1,270 662 126 199 20† 50† 120† 4,980 57,032 36,907 6,039 5,069 465 10,544 95 1,548 11,592 26,434 594 9,068 6,107 1,322 24,626 559 2,298 2,956 2,382 14,391 989 4,493 3,807 21,039 12,438 1,447 207 9,627 25,082 10,993 5,218 903 65 - 74 Years 104,501 6,446 4,876 603 6,341 5,458 667 587 793 273 618 3,562 1,439 15 190 1,219 2,023 1,652 250 122 155 862 371 63 108 12 31 97 2,069 22,851 14,935 2,632 2,802 211 4,115 33 478 4,271 10,934 197 3,256 2,918 681 11,143 337 1,023 1,207 1,119 5,494 605 1,932 1,633 12,370 7,740 968 129 4,029 9,877 3,011 1,056 526 Inpatient Discharge Rates 75 - 84 85 Years 65 - 74 75 - 84 85 Years Total Years and Over Years Years and Over 88,068 47,282 2550.2 1939.8 3002.4 4359.5 5,893 3,455 27.8 24.4 30.4 37.8 4,498 2,666 2.6 1.5 3.4 5.5 641 406 1.3 1.0 1.4 2.1 3,779 1,263 8.9 7.8 10.0 11.8 3,234 1,094 6.8 5.8 7.8 8.9 511 262 0.3 0.2 0.3 0.6 78 18 0.5 0.3 0.6 0.7 593 135 1.5 1.3 1.8 1.5 120 48 0.4 0.4 0.4 ** 333 82 0.8 0.8 0.6 1.4 2,588 1,425 83.5 65.0 98.1 135.4 850 323 26.3 23.4 31.0 27.9 17 10 0.7 0.5 0.6 1.8 * 0 ** ** 0.0 0.0 1,090 631 17.0 12.0 21.2 30.8 1,046 498 56.3 52.0 56.4 77.3 827 425 21.2 14.9 23.8 45.5 56 10 1.1 1.6 0.5 ** 63 34 2.5 2.5 2.8 1.6 34 * 0.7 1.1 0.3 0.0 305 103 1.7 2.2 1.0 0.6 218 73 35.1 37.1 32.6 31.8 53 10 14.5 14.1 15.1 15.3 63 28 5.4 5.4 5.4 5.4 * 0 0.3 0.4 ** ** 17 * 6.3 8.2 4.2 2.7 21 * 2.2 3.2 1.0 ** 1,920 991 104.6 98.4 108.3 125.1 22,018 12,163 269.9 197.3 330.1 467.3 14,132 7,840 115.0 83.9 138.6 205.7 2,182 1,225 7.3 5.5 7.8 15.1 1,852 415 9.9 8.8 11.3 11.7 169 85 8.4 7.1 8.8 13.2 4,131 2,298 61.4 46.4 75.4 98.1 46 16 13.2 9.0 16.1 26.5 585 485 18.8 10.2 23.6 49.0 4,613 2,708 34.9 24.1 43.5 65.1 9,967 5,533 179.5 160.8 196.2 227.0 208 189 24.1 21.5 26.6 30.7 3,487 2,325 31.0 25.2 35.9 47.2 2,345 844 32.8 30.0 36.8 35.9 444 197 13.6 14.0 13.7 11.6 8,933 4,550 166.7 134.7 190.3 261.3 170 52 1.3 1.6 0.9 0.9 851 424 19.6 17.9 21.2 24.2 1,145 604 15.6 16.1 16.1 12.4 854 409 7.8 8.0 7.6 7.7 5,406 3,491 175.5 141.2 197.8 285.2 290 94 23.0 28.7 17.8 8.8 1,550 1,011 71.3 64.7 74.3 95.9 1,332 842 45.7 41.6 47.3 62.2 7,009 1,660 257.7 211.1 294.3 390.7 4,112 586 7.6 5.2 9.2 14.9 388 91 5.9 5.3 6.4 7.1 66 12 0.5 0.5 0.5 ** 3,566 2,032 941.1 754.6 1,089.4 1,466.6 9,096 6,109 630.4 473.8 693.7 1,237.1 4,012 3,970 117.6 82.8 131.4 253.4 1,921 2,241 5.2 2.2 5.8 18.5 282 95 15.0 14.9 15.0 15.2 Notes: * Cell suppressed due to non-zero count less than 6; ** Cell suppressed due to rate/ratio/percent based on non-zero count less than 6; † Sum rounded to nearest tens unit due to non-zero addend less than 6. Page | 23 85 and older (19.7 percent). Taking into account the size of the underlying population of each age group, adults age 85 and older had the greatest inpatient discharge rate (4,359.5/10,000), followed by those age 75-84 (3,002.4/10,000), and finally adults age 65 – 74 (1,939.8/10,000). Unlike ER discharges in which either ambiguous symptoms or acute injury accounted for the largest number of discharges, the single highest first-listed principal diagnosis for inpatient discharges were diseases of specific body systems, including the circulatory (n = 57,032), respiratory (n = 57,032), digestive (n = 24,626), and musculoskeletal (n = 21,039) systems. A number of inpatient discharge rates were drastically greater for the oldest Arizonans compared to those ages 65-74. For the first-listed diagnosis of all fractures, the rate for the oldest old (206.6/10,000) was 829 percent greater than the rate for the youngest old (19.6/10,000). Inpatient discharges for diseases of the genitourinary system were 216 percent greater for Arizonans age 85 and older (321.9/10,000) than for Arizonans ages 65-74 (102.0/10,000). For disease of the circulatory system including heart disease, the inpatient discharge rate of the oldest Arizonans (510.2/10,000) was 151 percent higher than was the inpatient discharge rate of adults ages 65 – 74 (203.0/10,000). Finally, inpatient hospitalizations for pneumonia were 255 percent greater for Arizona’s oldest old (214.4/10,000) as compared to Arizona’s youngest old (60.4/10,000). 4.4 Conclusion Analysis of demographic characteristics and first-listed diagnoses on ER and inpatient HDD data provides a useful snapshot of the impact of aging on those utilizing the healthcare system in Arizona. According to the HDD data, the demographic characteristics of aging Arizonans being discharged from hospitals becomes less diverse with age, meaning that adults in older age groups were more likely to be White non-Hispanic and female. These results reflect that minority groups have worse health and experience mortality earlier in life than White non-Hispanics, and that female life expectancy tends to be greater than male life expectancy. The fact that females tend to live longer than males helps explain the fact that the number of hospital discharges to widowed Arizonans increases with age. Another fact associated with the increased rate of inpatient and ER discharges among the oldest Arizonans is that morbidity rates increase in the latest years of life, which are disproportionately experienced by White non-Hispanic females. These Arizonans experience some of the most severe morbidities associated with aging and chronic disease and warrant increased attention when developing future policy concerning health and aging. Examining first-listed diagnosis on HDD ER and inpatient discharges gives us information on what specific morbidities are being experienced by Arizona’s aging population. Among older Arizonans, the overall counts of ER and inpatient discharges were higher for adults in the youngest old (ages 65 – 74), but the rate of discharges increased for the oldest Arizonans (age 85 and older), and in some cases, this increase was substantial. The overall rate of ER discharges was more than 100 percent higher for Arizonans in the oldest versus the youngest age group, and this held true for both ER and inpatient discharges. Specific morbidities were especially prevalent among Arizona’s oldest adults, with both ER and inpatient discharges reflecting higher rates of fractures and many chronic diseases including those of the circulatory and genitourinary Page | 24 systems. These results help to better explain the healthcare needs of Arizona’s aging population. While the overall numbers of older adults being discharged from Arizona’s hospitals tended to be the greatest among the youngest old, Arizona’s oldest old are those who most often experience health issues requiring hospitalization. With the projected increase in Arizona’s elderly population, the burdens faced by Arizona’s residents and their healthcare providers will pose a greater burden on Arizona’s residents and healthcare system. Page | 25 5. Patterns of Mortality among Aging Arizonans 5.1 Introduction Consistent with national trends, Arizona’s older adult population is both increasing in number and coming to represent a greater proportion of the total population. As the number and proportion of older Arizonans increase, it becomes ever more important to understand the leading causes of mortality among this age group. To illustrate the impact of longer lifespans on mortality, from 2002 and 2012, deaths among residents 65 years and older increased 16 percent. Deaths among persons in the oldest portion of this population, residents 85 years and older, showed the highest percent increase of 33.5 percent. Analyzing how chronic diseases, infectious diseases, and other causes of death influence patterns of mortality among older adults provides information that can be used to plan for the increasing societal costs associated with the mortality of an aging population. 5.2 Methodology To investigate patterns of morality among Arizona’s older adults, we examined the leading causes of death among Arizonans age 65 and older, both as a whole as well as by age group (65 – 74 years, 75 – 84 years, and 85 + years) and gender. Initially, demographic characteristics of decedents were reported and include race/ethnicity, educational attainment, marital status, and urban or rural residence location (urban counties include Maricopa, Pinal, Pima, and Yuma counties and rural counties include Apache, Cochise, Coconino, Gila, Graham, Greenlee, La Paz, Mohave, Navajo, Santa Cruz, and Yavapai counties). Next, mortality counts and rates among Arizonans age 65 and older in 2012 based on combined causes of death (common descriptions capturing broad disease categories such as diseases of the heart, all cancers, and chronic lower respiratory diseases) were compared to national death counts from 2011, which were the most recent available national death data. Individual causes of death represented by single ICD-10 codes were then used to assess the specific causes responsible for the greatest number of deaths and highest mortality rates among Arizona’s older adults. Finally, trends in the leading specific causes of death identified for older Arizonans in 2012 were examined from 2002 – 2012. Data in this section reported for Arizonans were collected from information reported on death certificates submitted to the Arizona Office of Vital Records by funeral directors, medical examiners, coroners, and physicians. Cause-of-death classifications are in accordance with the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), 2008 Edition. Leading causes of death among Arizona residents 65 years and older were compiled based on 2012 death data and individual ICD-10 codes. Population denominators used to calculate death rates were produced by the Arizona Department of Health Services’ (ADHS) Population Health and Vital Statistics Section in collaboration with the Arizona Department of Economic Security (AZDES) and the Office of Employment and Population Statistics within the Arizona Department of Administration (ADOA). Page | 26 5.3 Results Overall Mortality Rates and Demographic Characteristics Table 8 presents the total mortality counts, rates, and demographic statistics for deaths among Arizonans who died in 2012 by gender and age group. In 2012, 48,459 Arizona residents died, with about 72 percent (n = 34,959) of these deaths occurring to Arizonans 65 years and older. The overall mortality rate was 3,490.1 per 100,000 resident females age 65 and older and 3,987.4 per 100,000 males. With each increasing age group, the mortality rate increased at an exponential rate for both males and females. Additional analyses (not shown here) revealed that among Arizona adults age 65 years and older in 2012, the average age at death was 81.6 years, with the mean age at death being 80.0 years for males and 83.0 years for females. Notably, 40.6 percent of the roughly 35,000 Arizonans age 65 and over who died in 2012 were 85 years and older, a 5.3 percent increase from 2002. In 2012, Arizona resident females represented 51 percent (n = 17,856) of deaths among persons 65 years and older. The largest proportion of deaths among women 65 years and older was among women 85 years and older (n=8,522, 47.7 percent). Arizona resident males represented 49 percent (n = 17,101) of deaths among Arizonans 65 years and older in 2012. Sixty percent of the 14,186 death among Arizonans age 85 and older in 2012 were to females. Interestingly, deaths among elderly men were more evenly distributed than deaths among elderly women. Unlike resident women, the largest proportion of deaths among men occurred among men 65 -74 years (n = 6,427, 37.5 percent). For both males and females, the vast majority of deaths among older Arizona residents occurred to White non-Hispanics. For both genders and all age groups, more than 80% of deaths in 2012 were to White non-Hispanics. With increasing age, the race/ethnicity of decedents become even more homogenous, with deaths to all racial/ethnic minorities representing only 15 percent of all deaths among Arizonans age 85 and older in 2012. Among older Arizonans who died in 2012, males tended to have somewhat higher educational attainment than females. For example, about 43 percent (n = 7,631) of decedent females had earned a high school diploma and about 36 percent reported having some college education (n = 6,386). For male decedents age 65 and older, 32 percent reported earning a high school degree (n = 5,436) and 49 percent reported having attended some college (n = 8,124). Concerning marital status, widows represented the largest proportion of deaths among resident females 65 years and older (58.6 percent) while married males represented the largest proportion of resident males (57.4 percent). The majority of widowed females were 85 years and older, reaffirming the relatively long lifespan of females compared to males. Finally, the majority of Arizona residents age 65 and older who died in 2012 lived in areas defined as urban. For both male and female decedents, about 80 percent resided in urban settings. Page | 27 Table 8. Deathsa among Arizona Residents 65 Years and Older by Gender and Age Group, 2012 Females Males 65 – 74 75 – 84 85 + 65 – 74 75 – 84 85 + Years Years Years Total Years Years Years Total 3,662 5,672 8,522 17,856 5,010 6,427 5,664 17,101 1,286.7 3,582.2 12,409.0 3,490.1 1,971.6 4,761.1 14,237.8 3,987.4 Total Deaths Overall Mortality Rate Race and Ethnicity Asian and Pacific Islander 48 78 86 212 58 48 American Indian/Alaskan Native 128 142 138 408 135 140 Black/African American 121 150 144 415 165 139 Hispanic/Latino 394 622 681 1,697 531 641 White Non-Hispanic 2971 4680 7473 15,124 4,121 5,459 Educational Attainment No High School Diploma 618 1,143 1,743 3,504 807 1,208 High School Diploma 1,405 2,437 3,789 7,631 1,669 1,984 Some College 1,557 1,984 2,845 6,386 2,355 3,094 Unknown or Missing 81 108 145 335 178 140 Marital Status Married 1,586 1,755 988 4,329 2,959 4,078 Widowed 931 2,867 6,681 10,479 415 1,233 Divorced 922 856 623 2,401 1,224 846 Never Married 193 177 216 586 312 206 Unknown or Missing 30 17 14 61 98 64 Location Urban 2,871 4,565 7,064 14,500 3,761 4,970 Rural 789 1,098 1,450 3,337 1,214 1,440 Unknown/Other 2 9 8 19 35 17 Notes: a Based on death certificates submitted to the Arizona Office of Vital Records. 39 145 74 349 65 369 466 1,638 5,020 14,600 1,126 1,783 2,675 80 3,141 5,436 8,124 400 2,786 2,412 331 120 15 9,823 4,060 2,401 638 179 4,593 13,324 1,066 3,720 5 57 Combined Leading Causes of Death Table 9 lists the ten leading combined causes of death among persons 65 years and older in Arizona for 2012 and for the United States in 2011 (2011 national data was preliminary and national data for 2012 was not yet available; Hoyert and Xu 2012). Both for Arizona in 2012 and for the U.S. for 2011, diseases of the heart, malignant neoplasms, and chronic lower respiratory diseases were the three leading causes of death. Heart disease and cancer have consistently been the two leading causes of death in the U.S. since 1935 (Hoyert 2012). Alzheimer’s disease was the 4th leading cause of death among Arizona’s elderly adults, where Alzheimer’s disease was ranked as the 5th leading cause of death for elderly adults nationally. Cerebrovascular diseases including stroke were the 5th leading cause of death for older Arizonans in 2012, where this group of diseases was ranked 4th for older adults nationally in 2011. Influenza and pneumonia were the 6th leading cause, and diabetes was the 7th leading cause of death for Arizonans age 65 and older in 2012, where the order of rankings for these disease grouping were opposite for similarly aged adults nationally. Accidents, nephritis, and septicemia were the 8th, 9th, and 10th leading causes of death for both Arizonan elderly in 2012 and national elderly in 2011. Page | 28 Table 9. Deaths and Death Ratesa for the Ten Leading Causes of Deathb among Adults Age 65 and Older, Arizona 2012 and United States 2011 (Preliminary) Arizona 2012 Rankc Rank (AZ) (US) … 1 2 3 4 5 6 7 8 9 10 … All causes 1 Diseases of heart 2 Malignant neoplasms 3 Chronic lower respiratory diseases 5 Alzheimer's disease 4 Cerebrovascular diseases 7 Influenza and pneumonia 6 Diabetes Mellitus 8 Accidents (unintentional injuries) 9 Nephritis, nephrotic syndrome and nephrosis 10 Septicemia National 2011 (prelim) Count Rate SE Count Rate SE 34,958 3,716.9 19.9 1,830,553 4,422.3 3.3 8,449 898.3 9.8 476,220 1,150.5 1.7 7,729 821.8 9.3 396,126 957.0 1.5 2,746 292.0 5.6 122,381 295.6 0.8 2,129 226.4 4.9 83,746 202.3 0.7 1,774 188.6 4.5 109,393 264.3 0.8 1,210 128.7 3.7 45,321 109.5 0.5 1,148 122.1 3.6 52,068 125.8 0.6 999 106.2 3.4 42,635 103.0 0.5 373 39.7 2.1 37,927 91.6 0.5 238 25.3 1.6 26,596 64.3 0.4 Notes: a Rates per 100,000 population in specified group; b Diseases of heart: I00–I09, I11, I13, I20–I51;Malignant neoplasms: C00–C97, Chronic lower respiratory diseases: J40–J47;Cerebrovascular diseases: I60–I69;Alzheimer’s disease: G30; Diabetes mellitus: E10–E14; Influenza and pneumonia: J09–J18; Accidents (unintentional injuries): V01–X59, Y85–Y86; Nephritis, nephrotic syndrome and nephrosis: N00–N07,N17–N19,N25–N27;Septicemia: A40–A41; c Rank based on number of deaths in Arizona; Adapted from Deaths: Preliminary Data for 2011: NVSR v61(6), p.31 October 10, 2012. Figure 10. Death Rates and 95% Confidence Intervals for 10 Leading Causes of Death among Adults age 65 and Older, Arizona 2012 and United States 2011 (Preliminary) Notes: * Indicates significant difference in rate at p < .05. Page | 29 Figure 10 depicts the combined cause mortality rates and 95 percent confidence intervals for Arizona’s older adults in 2012 and comparably aged adults nationally in 2011. As indicated by the asterisks, a number of mortality rates for Arizona’s older adults in 2012 were significantly different than national estimates taken from 2011 data. Mortality rates for diseases of the heart, malignant neoplasms (cancer), cerebrovascular disease (stroke), nephritis (kidney disease), and septicemia (blood infection) were all significantly lower among Arizona’s older adults in 2012 than they were among older adults nationally in 2011. Only the mortality rates for Alzheimer’s disease and influenza and pneumonia were higher among Arizona’s older adults in 2012 than for comparably-aged adults nationally in 2011. Specific Leading Causes of Death This section presents the ten leading causes of death for Arizona residents 65 years and older in 2012 by gender. As previously mentioned, leading causes of death among residents 65 years and older are generally consistent with national data. Table 10 presents the ten specific leading causes of death for all Arizona residents 65 years and older in 2012 by age group. When comparing the specific leading causes of death to the grouped leading causes of death among Arizonans age 65 and older in 2012, there is a number of interesting findings. First, a number of specific causes of death that are components of the grouped leading causes of death are indicated, including atherosclerotic heart disease, acute myocardial infarction, and atherosclerotic cardiovascular disease (diseases of the heart), and both malignant neoplasms of the bronchus and lung and of the pancreas (malignant neoplasms). Second, dementia is identified as the 5th leading cause of death among Arizona’s elderly in 2012, but this classification is not included in the grouped leading causes of death originally identified by the National Center for Health Statistics (Hoyert and Xu 2012). Finally, other ill-defined and unspecified causes of mortality are identified as the 9th specific leading cause of death among Arizona’s older adults in 2012, but this classification is not mentioned in the NCHS-defined grouped leading causes. Focusing on the specific leading causes of death among Arizona’s elderly in 2012, the mortality rates for each specific cause are strikingly higher for Arizona’s older adults (age 85 and older). For example, the morality rate for atherosclerotic heart disease is more than 13 times higher for Arizonans age 85 and older than for Arizonans age 65-74. Another example is for Alzheimer’s disease and dementia, with mortality rates almost 55 and 59 times higher among Arizonans age 85 and over than for those age 65 – 74, respectively. The large discrepancies between age groups in mortality rates for these causes of death indicate the rapidly increasing toll that select chronic diseases take on adults among the oldest old. Page | 30 Table 10: Specific Leading Causes of Deathsa Among All Arizona Residents, 2012 Counts by Cause of Death Atherosclerotic heart disease Chronic Obstructive Pulmonary Disease Malignant neoplasm of bronchus and lung Alzheimer's Disease Dementia Acute Myocardial Infarction Atherosclerotic Cardiovascular Disease Stroke Other Ill-Defined and Unspecified causes of mortality Malignant neoplasm of pancreas Total 85 Years and Over All Adults 65+ 65 - 74 Years 75 - 84 Years 551 613 905 120 98 307 410 126 89 240 3,459 949 867 867 624 469 442 379 360 159 221 5,337 1,462 679 333 1,329 1,160 520 431 556 423 121 7,014 2,962 2,159 2,105 2,073 1,727 1,269 1,220 1,042 671 582 15,810 102.3 113.8 168.0 22.3 18.2 57.0 76.1 23.4 16.5 44.6 323.5 1,348.0 295.6 626.1 295.6 307.0 212.7 1,225.4 159.9 1,069.5 150.7 479.5 129.2 397.4 122.7 512.6 54.2 390.0 75.3 111.6 314.9 229.6 223.8 220.4 183.6 134.9 129.7 110.8 71.3 61.9 Mortality Ratesb Atherosclerotic heart disease Chronic Obstructive Pulmonary Disease Malignant neoplasm of bronchus and lung Alzheimer's Disease Dementia Acute Myocardial Infarction Atherosclerotic Cardiovascular Disease Stroke Other Ill-Defined and Unspecified causes of mortality Malignant neoplasm of pancreas Notes: a Leading Causes of Death are conditions defined by the International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), 2008; b Age-specific and crude mortality rates represent the number of deaths per 100,000 persons 65 years of age and older. Individual Leading Causes of Death by Gender and Age Group Table 11 presents the number of deaths and mortality rates for the ten leading causes of death among Arizona resident females 65 years and older during 2012. In 2012, deaths from Alzheimer’s disease ranked first among all causes occurring among elderly females. Among females 85 years and older, 68 percent of deaths were from Alzheimer’s disease. Dementia ranked third, accounting for 225.4 deaths per 100,000 resident females 65 years and older. Proportionately, this represents 6.45 percent of deaths among resident females 65 years and over. Deaths from breast cancer ranked ninth and were evenly distributed across age groups. Page | 31 Table 12 presents the number of deaths and mortality rates for the top ten leading causes of death among Arizona resident males 65 years and older during 2012. The first three leading causes of death (atherosclerotic heart disease, lung cancer, and chronic obstructive pulmonary disease) among Arizona resident males 65 years and older were identical with published national data and consistently remain among the leading causes. Three conditions - Alzheimer’s disease, prostate cancer, and Parkinson’s disease - are specifically noted. In 2012, Alzheimer’s disease ranked fourth, representing 167.2 deaths per 100,000 resident males 65 years and older. The mortality rate for Alzheimer’s disease was 36.9 percent lower for males than for females. Prostate cancer ranked eighth. The largest number of males who died from prostate cancer were from 75 to 84 years of age (n = 206), but males 85 years and older had the highest mortality rate due to prostate cancer (460 deaths per 100,000). Finally, males 85 years and older had the highest rate of morality due to Parkinson’s disease, but the age group with the greatest number of deaths due to Parkinson’s diseases was males 75-84 years of age. Table 11. Specific Leading Causes of Death among Arizona Resident Femalesa 65 Years and Older, 2012 Counts by Cause of Death Alzheimer's Disease Atherosclerotic Heart Disease Dementia Chronic Obstructive Pulmonary Disease (COPD) Malignant Neoplasm of Bronchus and Lung (Lung Cancer) Stroke Acute Myocardial Infarction Atherosclerotic Cardiovascular Disease Malignant Neoplasm of Breast (Breast Cancer) Other Ill-Defined and Unspecified Causes of Mortality Total Mortality Ratesb Alzheimer's Disease Atherosclerotic Heart Disease Dementia Chronic Obstructive Pulmonary Disease (COPD) Malignant Neoplasm of Bronchus and Lung (Lung Cancer) Stroke Acute Myocardial Infarction Atherosclerotic Cardiovascular Disease Malignant Neoplasm of Breast (Breast Cancer) Other Ill-Defined and Unspecified Causes of Mortality 85 Years and Over All Females 65+ 65 - 74 Years 75 - 84 Years 62 156 51 306 411 51 100 125 165 35 1,462 368 374 285 414 388 188 202 157 145 91 2,612 926 780 817 383 165 383 303 249 120 286 4,412 1,356 1,310 1,153 1,103 964 622 605 531 430 412 8,486 21.8 54.8 17.9 107.5 144.4 17.9 35.1 43.9 58.0 12.3 232.4 236.2 180.0 261.5 245.0 118.7 127.6 99.2 91.6 57.5 1,348.4 1,135.8 1,189.6 557.7 240.3 557.7 441.2 362.6 174.7 416.4 265.0 256.0 225.4 215.6 188.4 121.6 118.3 103.8 84.0 80.5 Notes: a Leading Causes of Death are conditions defined by the International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), 2008; b Age-specific and crude mortality rates represent the number of deaths per 100,000 persons 65 years of age and older. Page | 32 Mortality Trends among Arizona Resident Females Age 65 and Older Table 13 presents the 2012 leading causes of death as mortality trends for resident females 65 years and older from 2002 to 2012, with trends in the mortality rates among females from 2002 – 2012 depicted in Figure 11. Overall, the number of deaths among females age 65 and older increased 14 percent from 2002 (n = 15,614) to 2012 (n = 17,856). The greatest percent increase in number of deaths occurred to females 85 years and over, displaying a 30 percent increase from 2002 (n = 6,549) to 2012 (n = 8,522). Of specific mention are the increases in the number and rate of deaths from Alzheimer’s disease, dementia, and ill-defined/unspecified causes. Alzheimer’s disease became the leading cause of death among Arizona’s older female residents in 2010 when 1,505 deaths were reported. From 2002 to 2012, there was a 20 percent increase in the number of deaths due to Alzheimer’s, but more troublesome, the mortality rate for Alzheimer’s disease among females 65 and older increased 55 percent during the same period. Table 12. Specific Leading Causes of Death among Arizona Resident Malesa 65 Years and Older, 2012 Counts by Cause of Death Atherosclerotic Heart Disease Malignant Neoplasm of Bronchus and Lung- (Lung Cancer) Chronic Obstructive Pulmonary Disease - (COPD) Alzheimer's Disease Atherosclerotic Cardiovascular Disease Acute Myocardial Infarction Dementia Malignant Neoplasm of Prostate - (Prostate Cancer) Stroke Parkinson's Disease Total Mortality Ratesb Atherosclerotic Heart Disease Malignant Neoplasm of Bronchus and Lung- (Lung Cancer) Chronic Obstructive Pulmonary Disease - (COPD) Alzheimer's Disease Atherosclerotic Cardiovascular Disease Acute Myocardial Infarction Dementia Malignant Neoplasm of Prostate - (Prostate Cancer) Stroke Parkinson's Disease 85 Years and Over All Males 65+ 65 - 74 Years 75 - 84 Years 395 494 307 58 285 207 47 124 75 59 2,051 575 479 453 256 222 240 184 206 172 160 2,947 682 168 296 403 182 217 343 183 173 139 2,786 1,652 1,141 1,056 717 689 664 574 513 420 358 7,784 155.4 194.4 120.8 22.8 112.2 81.5 18.5 48.8 29.5 23.2 426.0 354.8 335.6 189.6 164.5 177.8 136.3 152.6 127.4 118.5 1,714.4 422.3 744.1 1,013.0 457.5 545.5 862.2 460.0 434.9 349.4 385.2 266.0 246.2 167.2 160.7 154.8 133.8 119.6 97.9 83.5 Notes: a Leading Causes of Death are conditions defined by the International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), 2008; b Age-specific and crude mortality rates represent the number of deaths per 100,000 persons 65 years of age and older. Page | 33 Similarly, the number of deaths reported from dementia increased by 84 percent during the period, representing a 43 percent increase in the mortality rate due to dementia. Also noteworthy is the disturbing increase in the number of deaths from ill-defined/unspecified causes, representing a 1,426 percent increase from 2002 (n = 27) to 2012 (n = 412). Countering these results are several significant decreases for the period. Reductions in the number of deaths associated with three diseases are noteworthy: 1) a 51 percent decrease in the mortality rate from acute myocardial infarction, 2) a 42 percent decrease in the mortality rate from atherosclerotic cardiovascular disease, and 3) a 41 percent decrease in the mortality rate from stroke among females 65 years and over. Mortality Trends among Arizona Resident Males Age 65 and Over Based on the leading causes of death in 2012, Table 14 and Figure 12 present mortality trends for resident males 65 years and older from 2002 to 2012. From 2002 – 2012, the greatest number of deaths occurred among males ages 75 - 84 years of age (n = 68,426), although males ages 85 and older experienced the greatest percent increase (39 percent) in number of deaths over this period (2002 n = 4,080, 2012 n = 5,664) . Table 13. Specific Leading Causes of Deatha among Arizona Resident Females, 65 Years and Older, 2002 - 2012 2002 Counts by Age Group 65-74 Years 75-84 Years 85 Years and Over Total (All Females 65 Years and Older) Counts by Cause of Death Alzheimer's Disease Atherosclerotic Heart Disease Dementia Chronic Obstructive Pulmonary Disease (COPD) Malignant Neoplasm of Bronchus and Lung (Lung Cancer) Stroke Acute Myocardial Infarction Atherosclerotic Cardiovascular Disease Malignant Neoplasm of Breast (Breast Cancer) Other Ill-Defined and Unspecified Causes of Mortality Total Mortality Rates b Alzheimer's Disease Atherosclerotic Heart Disease Dementia Chronic Obstructive Pulmonary Disease (COPD) Malignant Neoplasm of Bronchus and Lung (Lung Cancer) Stroke Acute Myocardial Infarction Atherosclerotic Cardiovascular Disease Malignant Neoplasm of Breast (Breast Cancer) Other Ill-Defined and Unspecified Causes of Mortality 2003 2004 2005 3,057 3,059 3,116 3,229 6,008 6,015 5,813 6,012 6,549 6,823 6,786 7,379 15,614 15,897 15,715 16,620 2006 2007 2008 2009 3,159 3,039 3,266 3,357 6,118 5,844 5,656 5,636 7,506 7,612 7,670 7,671 16,783 16,495 16,592 16,664 2010 2011 2012 Total 3,293 3,411 3,662 35,648 5,524 5,652 5,672 63,950 8,129 8,749 8,522 83,396 16,946 17,812 17,856 182,994 877 1,346 626 865 846 823 953 709 361 27 7,433 1,066 1,396 618 876 825 811 965 789 387 50 7,783 1,053 1,407 624 877 875 763 833 734 374 102 7,642 1,149 1,453 690 1,070 846 755 795 764 387 131 8,040 1,338 1,424 825 1,043 888 731 756 701 416 219 8,341 1,330 1,343 876 986 847 710 676 577 403 217 7,965 1,342 1,397 917 977 873 621 598 613 429 133 7,900 1,325 1,423 865 1,033 956 618 632 558 425 163 7,998 1,505 1,379 934 1,011 921 683 606 510 402 216 8,167 1,512 1,410 1,041 1,119 910 741 601 539 441 272 8,586 1,356 1,310 1,153 1,103 964 622 605 531 430 412 8,486 221.3 339.6 158.0 218.3 213.5 207.7 240.5 178.9 91.1 6.8 261.5 342.4 151.6 214.9 202.4 198.9 236.7 193.5 94.9 12.3 251.2 335.6 148.8 209.2 208.7 182.0 198.7 175.1 89.2 24.3 264.1 334.0 158.6 245.9 194.5 173.5 182.7 175.6 89.0 30.1 302.8 322.2 186.7 236.0 200.9 165.4 171.1 158.6 94.1 49.6 288.2 291.0 189.8 213.6 183.5 153.8 146.5 125.0 87.3 47.0 286.1 297.9 195.5 208.3 186.1 132.4 127.5 130.7 91.5 28.4 280.0 300.7 182.8 218.3 202.0 130.6 133.6 117.9 89.8 34.4 313.5 287.2 194.5 210.6 191.8 142.3 126.2 106.2 83.7 45.0 312.7 291.7 215.3 231.5 188.2 153.3 124.3 111.5 91.2 56.3 265.0 256.0 225.4 215.6 188.4 121.6 118.3 103.8 84.0 80.5 13,853 15,288 9,169 10,960 9,751 7,878 8,020 7,025 4,455 1,942 88,341 Percent Change 2002 - 2012 20 -6 30 14 55 -3 84 28 14 -24 -37 -25 19 1,426 14 20 -25 43 -1 -12 -41 -51 -42 -8 1,082 Notes: a Leading Causes of Death are conditions identified as the top conditions for 2012 and defined by the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), 2008 Edition; b Age-specific crude mortality rates represent the number of deaths per 100,000 resident females, 65 years of age and over. Page | 34 Figure 11. Specific Leading Causes of Death Among Arizona Resident Females, 65 Years and Older, 2002 – 2012 The greatest increase in mortality rate of all the causes examined was for dementia, representing a 54 percent increase from 2002 (87.1 per 100,000) to 2012 (133.8 per 100,000). Similarly, the number of deaths from Alzheimer’s disease rose 72 percent during the period, representing a 27 percent increase in the Alzheimer’s mortality rate. The mortality rate increased slightly for Parkinson’s disease from 2002 (78.8 per 100,000) to 2012 (83.5 per 100,000). Contrary to previously mentioned increases, there were several noteworthy decreases. While rates for all causes considered diseases of the heart showed significant reductions, the largest decrease was a 53 percent decrease in the rate of death from acute myocardial infarction, followed by a 26 percent decrease in the rate of death from atherosclerotic cardiovascular disease. Finally, the rate of death from stroke declined by 41 percent for resident males 65 years and over during the period. Page | 35 Table 14. Specific Leading Causes of Deatha among Arizona Resident Males, 65 Years and Older, 2002 – 2012 2002 Counts by Age Group 65-74 Years 75-84 Years 85 Years and Over Total (All Males 65 Years and Older) Counts by Cause of Death Atherosclerotic Heart Disease Malignant Neoplasm of Bronchus and Lung (Lung Cancer) Chronic Obstructive Pulmonary Disease (COPD) Alzheimer's Disease Atherosclerotic Cardiovascular Disease Acute Myocardial Infarction Dementia Malignant Neoplasm of Prostate (Prostate Cancer) Stroke Parkinson's Disease Total 2003 2004 2005 2006 2007 2008 2009 4,256 4,211 4,164 4,345 4,298 4,225 4,365 4,481 6,172 6,298 6,064 6,383 6,204 6,046 6,259 6,068 4,080 4,057 4,176 4,473 4,620 4,604 4,917 4,960 14,508 14,566 14,404 15,201 15,122 14,875 15,541 15,509 1,452 1,022 883 417 684 1,047 275 510 525 249 7,064 1,490 1,111 870 494 724 966 309 507 454 224 7,149 1,485 1,086 776 504 690 896 321 495 464 241 6,958 1,590 1,060 897 547 679 883 325 512 458 285 7,236 1,441 1,109 964 601 674 753 409 458 399 287 7,095 1,401 1,046 967 605 643 690 435 505 368 259 6,919 1,500 1,100 858 644 688 717 433 500 401 296 7,137 1,502 1,119 903 674 724 685 414 498 414 273 7,206 2010 2011 2012 Total 4,622 4,767 5,010 48,744 6,163 6,342 6,427 68,426 5,228 5,423 5,664 52,202 16,013 16,532 17,101 169,372 1,534 1,091 917 738 661 599 509 508 403 290 7,250 1,645 1,138 963 749 731 717 560 519 393 309 7,724 1,652 1,141 1,056 717 689 664 574 513 420 358 7,784 16,692 12,023 10,054 6,690 7,587 8,617 4,564 5,525 4,699 3,071 79,522 Percent Change 2002 - 2012 18 4 39 18 14 12 20 72 1 -37 109 1 -20 44 10 b Mortality Rates Atherosclerotic Heart Disease Malignant Neoplasm of Bronchus and Lung (Lung Cancer) Chronic Obstructive Pulmonary Disease (COPD) Alzheimer's Disease Atherosclerotic Cardiovascular Disease Acute Myocardial Infarction Dementia Malignant Neoplasm of Prostate (Prostate Cancer) Stroke Parkinson's disease Total a 459.6 458.4 440.8 454.9 404.0 374.3 394.0 391.1 381.9 406.7 385.2 323.5 341.8 322.4 303.3 311.0 279.5 289.0 291.4 271.6 281.3 266.0 279.5 267.7 230.3 256.6 270.3 258.4 225.4 235.1 228.3 238.1 246.2 132.0 152.0 149.6 156.5 168.5 161.6 169.2 175.5 183.7 185.2 167.2 216.5 222.7 204.8 194.3 189.0 171.8 180.7 188.5 164.6 180.7 160.7 331.4 297.2 266.0 252.6 211.1 184.4 188.3 178.4 149.1 177.3 154.8 87.1 95.1 95.3 93.0 114.7 116.2 113.7 107.8 126.7 138.4 133.8 161.4 156.0 146.9 146.5 128.4 134.9 131.3 129.7 126.5 128.3 119.6 166.2 139.7 137.7 131.0 111.9 98.3 105.3 107.8 100.3 97.2 97.9 78.8 68.9 71.5 81.5 80.5 69.2 77.8 71.1 72.2 76.4 83.5 2,236.1 2,199.5 2,065.4 2,070.1 1,989.4 1,848.7 1,874.8 1,876.3 1,804.9 1,909.5 1,815.0 -16 -18 -12 27 -26 -53 54 -26 -41 6 -19 Notes: Leading Causes of Death are conditions identified as the top conditions for 2012 and defined by the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), 2008 Edition; b Age-specific crude mortality rates represent the number of deaths per 100,000 resident females, 65 years of age and older. 5.4 Conclusion Mortality analyses of Arizona’s resident population of older adults reveals changes in mortality trends that can be used to inform and influence public policy as well as track the success of public health initiatives. Chronic diseases that are most detrimental to the oldest Arizonans, exemplified by Alzheimer’s disease among females, will become increasingly problematic as the population of older Arizonans expands. Alzheimer’s is currently an incurable disease that has few clear causal factors other than age, meaning our healthcare, welfare, and social support systems must prepare for the increasing monetary and social costs associated with caring for older adults experiencing Alzheimer’s disease. On the other hand, the mortality rates for a number of the leading causes of death have decreased substantially among Arizona’s older adults, namely atherosclerotic heart and cardiovascular disease among both men and women, stroke among women, and both lung and prostate cancer among men. These successes indicate that interventions designed to help older adults lead healthier lives and seek medical treatment when necessary have proven successful for chronic diseases that are somewhat preventable. Even the decrease in leading causes of death such as heart disease and cancer foretell the increased burden that will be exerted in the future by Alzheimer’s disease and dementia. Being spared by chronic diseases such as heart disease and cancer that typically cause mortality in the Page | 36 Figure 12. Specific Leading Causes of Death Among Arizona Resident Males, 65 Years and Older, 2002 2012 earlier stages of old age increases the likelihood of developing Alzheimer’s disease. While cognitive decline is an inevitable outcome of the aging process, multiple health-related factors including nutrition, physical activity, and tobacco and alcohol use have been related to cognitive decline (Alwin and Hofer 2008). By focusing on the prevention of age-related cognitive decline now, we can help to reduce the expense and difficulties we certainly will face as our population ages. Page | 37 6. Conclusion As the health and wellness of older Arizonans is the product of multiple components, developing informational resources to assist in the promotion of healthy aging of Arizona’s older adults must also draw from various sources. This report has taken a holistic approach to defining health among Arizona’s older adults, examining the role older adults play in the composition of our populace now and in the coming future, the demographic characteristics of our older population, as well as measures of health-related behaviors and the prevalence with common morbidities and chronic diseases. Hospital discharge data was used to assess how Arizona’s older population utilize emergency and inpatient hospital care, and finally current patterns and recent trends in mortality were provided to understand the leading causes of death in Arizona’s older population. Each of these data sources were analyzed with a focus on the coming population shift when Arizona’s older adults will come to represent a greater proportion of the population. As population projections highlighted, older adults will come to account for a greater proportion of our growing population in the future, making our ability to account for the health needs of this segment of the population even more critical. Arizona’s older adults were shown to have health behaviors similar to comparably aged adults nationally, but differed from national estimates on some chronic diseases, specifically a lower prevalence of diabetes, a lower percentage of women with consistent mental and physical health issues, and a higher percentage of men reporting being diagnosed with skin cancer. Indicators of health care utilization showed that that rate of both emergency room and inpatient visits increased with age, with fractures being the most common first-listed diagnosis among Arizona’s adults age 85 and over. While frailty may be somewhat inevitable as a result of the body’s biological senescence with age, programs that encourage seniors to participate in physical activities and to make changes to their living environments to reduce the risk of falls can help reduce the number of fractures among aging adults. The most exceptional trend observed in mortality among Arizona’s older population is the increasing number of deaths related to cognitive aging. For both males and females, the mortality rate for Alzheimer’s disease increased more than 20 percent and the mortality rate for dementia increased more than 40 percent from 2002 to 2012. Arizona’s older females bear the greatest burden of memory-related diseases, with both Alzheimer’s and dementia being in the top 3 causes of death for females 65 and over in 2012. As male longevity increases and mortality rates from heart disease and cancers continue to decrease, it can be expected that males will come to share increasingly in the proportion of all deaths due to memory-related disease. Page | 38 It again should be noted that the leading causes of death for males and females and subsequent trends were identified differently than other reports of mortality counts and rates. As shown in Tables 9 – 14, heart disease and cancer continue to be the overall leading causes of death for Arizonans age 65 and older, and this holds true for both males and females. Heart disease and cancer represent the greatest disease burden our older population must face, with memory-related diseases representing the causes of death that will claim the most rapidly increasing proportion of older Arizonans over the coming half-century. Finally, the role of this report was to summarize the current and future state of health among Arizona’s older adults. The information summarized herein represents only one step in the process of public health promotion. It is our hope that those tasked with the development of health policy to serve the needs of Arizona’s seniors will take the results of this report into account when deciding how to effectively plan and fund social services, community programs, and health delivery systems. The great increases in human health and longevity in the early 20th Century were related largely to public health programs that focused on the primary prevention of disease. In the 21st Century, a large body of research is emerging that suggests a healthy diet, physical activity, social engagement, and intellectual and creative pursuits can help prevent the development of a host of morbidities among older adults, reduce the impact of these diseases once they have developed, and reduce the risk of mortality due to these chronic diseases (Ford et al. 2011; Michael et al. 1999; National Institute on Aging 2008; Savica and Petersen 2011). Health-related behaviors present a great opportunity for those developing and implementing health policy aimed at increasing the health and wellbeing of seniors, as programs that promote these activities among seniors are relatively inexpensive compared to the costs of treating chronic diseases within the health care system. With that being said, more fundamental determinants of health such as access to socioeconomic resources including education, solid job opportunities, income equality, and strong social ties will persistently reduce our ability to prevent the development of morbidities across the lifecourse. To most effectively prevent the development of chronic diseases and disabilities associated with aging, policy makers must focus both on the larger socioeconomic determinants of health as well as the development and maintenance of healthy habits and behaviors at the individual level. Page | 39 Appendix A – Glossary Baby boom generation – Individuals born between 1946 and 1964. Behavioral Risk Factor Surveillance System (BRFSS) – A nationally representative telephone survey designed to measure the prevalence of behavioral risk factors and morbidities of noninstitutionalized adults age 18 and over. Body mass index (BMI) – A measure of body fat based on height and weight that applies to adult men and women. Calculated as weight in pounds divided by height in inches squared multiplied by a factor of 703 (mass (lb)/(height(in))2 X 703). Chronic disease – Long-lasting diseases that can be controlled but not cured including heart disease, stroke, cancer, diabetes, and arthritis. Dependency ratio – A comparison of the number of economically inactive residents to the number of economically active residents (calculated as the sum of adults age 0 – 14 and age 65 and older divided by the number of adults age 15 – 64). Elderly – An individual age 65 or older. Fertility – The production of offspring. First-listed diagnosis – The primary condition for which the patient required healthcare. Health behaviors – Activities or habits of an individual that are not directly related to health care but that can potentially influence later health outcomes. Examples include physical activity and exercise, diet, smoking, and alcohol use. Hospital Discharge Data (HDD) - Discharge records for inpatient and ER department visits from all Arizona licensed hospitals. Hospitals such as Veteran’s Administration, Department of Defense, and those located on tribal land are not included in the reporting. Morbidity –A general term used to describe any disease or disability. Mortality – Loss of life; death. Mortality rate – The number of deaths in the population divided by the total population for a specific time span. Usually expressed in units per 1,000, 10,000, or 100,000 individuals. Population projection – Methods and techniques used to predict future populations. The cohortcomponent method of population projection takes into account multiple inputs to population change including current population, rates of fertility, mortality, and migration, as well as special populations such as military and college students. Page | 40 Population pyramid – A graphical representation of a population’s age and sex distribution. Prevalence – Broadly the commonality of a given condition in the population. Usually expressed as a proportion of the population with a given health condition. Primary prevention – Public health efforts to prevent the development of disease before symptom onset. Proportion – A type of ratio in which the numerator is included in the population defined by the denominator. A proportion is often multiplied by 100 and expressed as a percentage. Rate – A rate is a ratio in which those in the numerator are also in the denominator, and those in the denominator are "at risk" of being in the numerator. The denominator is the sum of "at risk" person-time or, by convention, the count of individuals "at risk" in a given time period. Ratio – A ratio is any division of one number by another; the numerator and denominator do not have to be mutually exclusive. Socioeconomic status – A multifaceted construct representing one’s access to various resources. This construct often includes indicators such as income, assets, education, occupational prestige, and social involvement. Page | 41 Appendix B - Bibliography Alwin, DF, Hofer, SM. Opportunities and challenges for interdisciplinary research. In: Hofer S, Alwin D, eds. Handbook of Cognitive Aging: Interdisciplinary Perspectives. Thousand Oaks, CA: Sage Publications; 2008:2-31. Centers for Disease Control. 2003. Vital Statistics of the United States, 2003, Volume I, Natality. Centers for Disease Control Web site. http://www.cdc.gov/nchs/products/vsus/vsus_1980_2003.htm Centers for Disease Control and Prevention. The State of Aging & Health in America 2013. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2013. http://www.cdc.gov/aging/pdf/state-aging-health-in-america-2013.pdf Ford, ES, Zhao, G, Tsai, J, Li, C. Low-Risk Lifestyle Behaviors and All-Cause Mortality: Findings From the National Health and Nutrition Examination Survey III Mortality Study. Am J Public Health. 2011;101(10):1922–1929. Hoyert, DL. 75 Years of mortality in the United States, 1935 – 2010, NCHS data brief, no 88. Hyattsville, MD: National Center for Health Statistics. 2012. National Center for Health Statistics Web site: http://www.cdc.gov/nchs/data/databriefs/db88.pdf Hoyert, DL, Xu, J. Deaths: Preliminary Data for 2011. National Vita Statistics Reports; v 61(6). Hyattsville, MD: National Center for Health Statistics. 2012. National Center for Health Statistics Web site: http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_06.pdf Michael, YL, Colditz, GA, Coakley, E, Kawachi, I. Health behaviors, social networks, and healthy aging: Cross-sectional evidence from the Nurses’ Health Study. Quality of Life Research. 1999;8:711-722. National Institute On Aging- National Institutes of Health. Healthy Aging: Lessons From the Baltimore Longitudinal Study of Aging. National Institute On Aging- National Institutes of Health. US Dept of Health and Human Services; 2008 (Reprinted 2010). Publication Number 086440. National Institute on Aging Web site: http://www.nia.nih.gov/sites/default/files/healthy_aging_lessons_from_the_baltimore_longitudin al_study_of_aging.pdf Savica, R, Petersen, RC. 2011. Prevention of Dementia. Psychiatr Clin North Am. 2011;34(1):127-45 World Health Organization. Diet, Nutrition and the Prevention of Chronic Diseases: Report of a Joint WHO/FAO Expert Consultation. 2003; Jan 28th – Feb 1st 2002, Geneva, Switzerland. Page | 42