Continued Reductions in Mortality at Advanced Ages

Mortality data for 30 mostly developed countries available in the Kannisto–Thatcher Database on Old‐Age Mortality (KTDB) are drawn on to assess the pace of decline in death rates at ages 80 years and above. As of 2004 this database recorded 37 million persons at these ages, including 130,000 centenarians (more than double the number in 1990). For men, the probability of surviving from age 80 to age 90 has risen from 12 percent in 1950 to 26 percent in 2002; for women, the increase has been from 16 percent to 38 percent. In the lowest‐mortality country, Japan, life expectancy at age 80 in 2006 is estimated to be 6.5 years for men and 11.3 years for women. For selected countries, average annual percent declines in age‐specific death rates over the preceding ten years are calculated for single‐year age groups 80 to 99 and the years 1970 to 2004. The results are presented in Lexis maps showing the patterns of change in old‐age mortality by cohort and period, and separately for men and women. The trends are not favorable in all countries: for example, old‐age mortality in the United States has stagnated since 1980. But countries with exceptionally low mortality, like Japan and France, do not show a deceleration in death rate declines. It is argued that life expectancy at advanced ages may continue to increase at the same pace as in the past.     

Trends in Causes of Death in Low‐Mortality Countries: Implications for Mortality Projections

This study examines the potential role that information about trends in causes of death could have in improving projections of mortality in low‐mortality countries. The article first summarizes overall trends in mortality by cause since the middle of the twentieth century. Special attention is given to the crucial impact of the smoking epidemic on mortality and on cause‐of‐death patterns. The article then discusses the implications for projections and reaches two conclusions. First, mortality projections can be improved by taking into account the distorting effects of smoking. Mortality attributable to smoking has risen in the past but has now leveled off or declined, thus boosting improvements in life expectancy. Second, making cause‐specific projections is not likely to be helpful. Trends in specific medical causes of death have exhibited discontinuities in the past, and future trends are therefore difficult to predict.     

Adult mortality differentials associated with cigarette smoking in the USA

Although cigarette smoking has been extensively researched, surprising little knowledge has been produced by demographers using demographic perspectives and techniques. Thus, this paper contributes to the literature by extending a demographic framework to an important behavior for mortality research: cigarette smoking. In earlier works, the authors used nationally-representative data to show that cause of death patterns varied by smoking status and that multiple causes of death characterized smokers moreso than non-smokers. The present work extends previous analysis by estimating smoking status mortality differentials by underlying and multiple causes of death and by age and sex. Data from the 1986 National Mortality Followback Survey are related to data from the 1985 and 1987 National Health Interview Survey supplements to assess the smoking-related mortality differentials. We find that cigarette smoking is associated with higher mortality for all population categories studied, that the smoking mortality differentials vary across the different smoking status categories and by demographic group, and that the mortality differentials vary according to whether underlying cause or multiple cause patterns of death are examined. Moreover, the multiple cause analysis highlights otherwise obscured smoking-mortality relations and points to the importance of respiratory diseases and cancers other than lung cancer for cigarette smoking research.     

Mortality,past and future

The study of mortality in previous centuries and of the trends in recent decades helps to elucidate some present-day medical problems and to contribute to their solution. The author considers, from a historical and socio-economic point of view, the factors which, during the last 200 years, have influenced the trends of mortality. This analysis indicates the lines along which present research, aimed at reducing mortality and extending expectation of life, should be directed.

Infancy (0–1 year): In backward countries, the whole of infancy is a period of high mortality. In progressive countries, on the other hand, the main reproductive wastage is in the ‘perinatal’ period, that is to say, covering stillbirths and deaths during the first week of life. For example, even in New Zealand, the death risk per day is more than eighty times as high during the first week of life than in the following 358 days.

Historical studies and social class comparisons suggest that further reduction of perinatal mortality is likely to depend on socio-economic, housing and cultural factors rather than on improvements in obstetric skill. Evidence cited by the author indicates that a crucial factor may be to provide expectant mothers with adequate rest during the weeks immediately prior to delivery. In general, research into mortality in infancy is too much bounded by a purely medical point of view whereas a socio-medical approach is needed.

Childhood (1–14 years): There has been an immense reduction in childhood mortality during the last 200 years. Less than 200 years ago the mortality among children aged 1–4 and 5–9 years was thirty-three times, and among those aged 10–14 years twelve times, that of the present day. Future reduction of mortality among children will be primarily a function of social factors and trends.

Adolescence and maturity (15–49 years): One of the outstanding trends of the last 200 years has been a relative increase in tuberculosis mortality among those aged 15–49 years, whereas among children tuberculosis has become relatively less important

as a cause of death. Recently, however, there has been a decline in the relative importance of tuberculosis as a cause of death among the adolescent and mature and, among New York males, it now takes second place to the cardiovascular

diseases. The total mortality of people in this age group has fallen, since the sixteenth century, by 77% for men and 81% for women. No spectacular discoveries are needed to reduce the mortality of this group by a further third; in doing this, control of environment will be the important factor.

Later maturity and old age (50 years and over): In the four centuries since the Renaissance the mortality of people over 50 years of age has been reduced by half. Among the factors contributing to this reduction is a fall in mortality due to tuberculosis. But even cancer, which is popularly supposed to have increased, used to be more common in the eighteenth century than it is now and to appear at an earlier. age. Moreover, there has been a change in the organs most commonly affected. The distribution of the greater proportion of cancer in a given population is a function of living conditions in the broadest sense of the term. Studies of groups exposed to carcinorelevant factors suggest that a high incidence of cancer in one organ is associated with a low incidence in other organs. But on many other causes of death at the older ages far more research is required, especially on the cardio-vascular-renal complex, and on the degenerative joint and bone diseases.     

Inequality in Life Spans and a New Perspective on Mortality Convergence Across Industrialized Countries

The second half of the twentieth century witnessed substantial convergence in life expectancy around the world. We examine differences in the age pattern of mortality in industrialized countries over time to show that inequality in adult life spans, which we measure with the standard deviation of life table ages at death above age 10 years, S₁₀, is increasingly responsible for the remaining divergence in mortality. We report striking differences in level and trend of S₁₀ across industrialized countries since 1960, which cannot be explained by aggregate socioeconomic inequality or differential external‐cause mortality. Rather, S₁₀ reflects both within‐ and between‐group inequalities in life spans and conveys new information about their combined magnitudes and trends. These findings suggest that the challenge for health policies in this century is to reduce inequality, not just lengthen life.     

Temporal trends in U. S. multiple cause of death mortality data: 1968 to 1977

An analysis is made of the mortality trends over the period 1968 to 1977 indicated by two types of cause-specific mortality data. The first type of data is “underlying cause” of death data—the data heretofore used in national vital statistics reports on cause-specific mortality. The second type of data is “multiple cause” data which contain a listing of all medical conditions recorded on the death certificate. A comparison of trends in the two types of data yields useful insights on mortality declines over the study period for two reasons. First, these declines were largely due to a reduction in the mortality rates of circulatory diseases. Second, the multiple cause data contain considerably more information than the underlying cause data on the role of circulatory diseases, and many other chronic diseases, in causing death. This additional information is especially useful in examining mortality patterns among the elderly, where the prevalence at death of chronic degenerative diseases is high.     

Underlying and multiple causes of death related to smoking

Although smoking has been linked to various causes of death, there is no systematic account of the underlying and multiple cause-of-death distributions associated with various smoking statuses. We analyze such patterns by age and gender for the USA in 1986. Our study is based on a one-percent random sample of decedents 25 and over in the USA for whom survey data from informants were linked to death certificate data. Smoking is related to several underlying causes of death, the most common being circulatory diseases. Lung cancer is less prevalent than circulatory diseases or other cancers among ever smokers. Multiple medical conditions are common for both smokers and nonsmokers, but particular combinations vary among persons with different smoking statuses. Former smokers who quit soon before death and were under frequent medical care are most likely to have had lung cancer. Amount of smoking is tied to variations in cause-of-death patterns. Differences by age and gender are not substantial, although other cancers appear frequently for both smokers and non-smokers among women. The distribution of medical causes of death for ever smokers is not radically different from that of never smokers. However, differences in cause patterns are seen when smoking statuses are detailed by amount of smoking and timing of quitting. These similarities and differences in cause patterns must be related to the fundamental fact that the average smoker will die earlier than the average nonsmoker. Such findings should especially influence programs for diseases whose links to smoking have been underestimated.     

How Long Do We Live?

Period life expectancy is calculated from age‐specific death rates using life table methods that are among the oldest and most widely employed tools of demography. These methods are rarely questioned, much less criticized. Yet changing age patterns of adult mortality in countries with high life expectancy provide a basis for questioning the conventional use of life tables. This article argues that when the mean age at death is rising, period life expectancy at birth as conventionally calculated overestimates life expectancy. Estimates of this upward bias, ranging from 1.6 years for the United States and Sweden to 3.3 years for Japan for 1980–95, are presented. A similar bias in the opposite direction occurs when mean age at death is falling. These biases can also distort trends in life expectancy as conventionally calculated and may affect projected future trends in period life expectation, particularly in the short run.     

Geographic Divergence in Mortality in the United States

The United States trails other developed countries in adult mortality, a process that has become more pronounced over the past several decades. However, comparisons are complicated by substantial geographic variations in mortality within the United States. The second half of the twentieth century was characterized by a substantial divergence in adult mortality between the South and the rest of the United States. The article examines trends in US geographic variation in mortality between 1965 and 2004, in particular the aggregate divergence in mortality between the southern states and states with more favorable mortality experience. Relatively high smoking‐attributable mortality in the South explains 50–100 percent of the divergence for men between 1965 and 1985 and up to 50 percent for women between 1985 and 2004. There is also a geographic correspondence between the contribution of smoking and other factors, suggesting that smoking may be one piece of a more complex health‐related puzzle.     

Population Variation in Cause of Death: Level,Gender, and Period Effects

The trends in 13 cause of death categories are examined with respect to expectation of life, sex differences, and period effects while misclassification of cause of death is controlled. The results suggest that as mortality declines, 1) the increasingly U-shaped age pattern of mortality is a period effect associated with the infectious diseases, 2) the risks of both overall infectious and degenerative causes of death decline, and 3) infectious disease mortality declines more in males, while degenerative disease mortality declines more in females. Finally, the model shows that some contemporary populations are approaching the .limits of reduction in mortality during infancy, childhood, and young adulthood. Past declines in the degenerative diseases, however, suggest that mortality may continue to decline.     

Trends in senescent life expectancy

The distinction between senescent and non-senescent mortality proves to be very valuable for describing and analysing age patterns of death rates. Unfortunately, standard methods for estimating these mortality components are lacking. The first part of this paper discusses alternative methods for estimating background and senescent mortality among adults and proposes a simple approach based on death rates by causes of death. The second part examines trends in senescent life expectancy (i.e., the life expectancy implied by senescent mortality) and compares them with trends in conventional longevity indicators between 1960 and 2000 in a group of 17 developed countries with low mortality. Senescent life expectancy for females rises at an average rate of 1.54 years per decade between 1960 and 2000 in these countries. The shape of the distribution of senescent deaths by age remains relatively invariant while the entire distribution shifts over time to higher ages as longevity rises.     

Projecting the Effect of Changes in Smoking and Obesity on Future Life Expectancy in the United States

We estimate the effects of declining smoking and increasing obesity on mortality in the United States over the period 2010–2040. Data on cohort behavioral histories are integrated into these estimates. Future distributions of body mass indices are projected using transition matrices applied to the initial distribution in 2010. In addition to projections of current obesity, we project distributions of obesity when cohorts are age 25. To these distributions, we apply death rates by current and age-25 obesity status observed in the National Health and Nutrition Examination Survey, 1988–2006. Estimates of the effects of smoking changes are based on observed relations between cohort smoking patterns and cohort death rates from lung cancer. We find that changes in both smoking and obesity are expected to have large effects on U.S. mortality. For males, the reductions in smoking have larger effects than the rise in obesity throughout the projection period. By 2040, male life expectancy at age 40 is expected to have gained 0.83 years from the combined effects. Among women, however, the two sets of effects largely offset one another throughout the projection period, with a small gain of 0.09 years expected by 2040.     

Mortality in England and Wales from 1848 to 1947

This is a survey of the changing causes of death in England and Wales during the past 100 years. Based on the published mortality statistics of the General Register Office the framework of the survey is a series of specially prepared tables of death rates by sex, age and cause of death for the periods 1848–72, 1901–10, 1921, 1931, 1939 and 1947. Adjustments were made wherever necessary to compensate for changes in medical nomenclature and in the statistical classification of disease.

After allowance has been made for the changing age structure of the population, the male death rate at all ages in 1947 was 42% of the rate in 1846–50, and the female rate 35 %. Maximum improvement was among girls aged 5–9 years, whose death rate in 1947 was 9% of the rate 100 years before.

In 1848–72 the group to which were allocated the largest proportion of the deaths at all ages were the infectious diseases with one-third of the total; and these were followed by the respiratory, nervous and digestive diseases. In 1947, on the other hand, diseases of the circulatory system came first with rather more than one-third of the total at all ages, and these were followed by cancer.

Changes in proportionate mortality rates from various causes have been examined at successive ages from infancy to old age. There was a decline in proportionate mortality from the infectious diseases other than tuberculosis, but increased mortality from tuberculosis in the younger age groups and from violence, circulatory diseases and cancer.

The trends of absolute mortality from the various causes were also studied. The reduction in total mortality was such that whereas there were half a million deaths of civilians registered in England and Wales in 1947, the total would have been over a million had the death rates of 1848–72 still prevailed.

The article concludes with a brief review of the factors responsible for the changes that have taken place.     

A Comparison of US and Canadian Mortality in 1998

On average, Americans die earlier than Canadians. An estimate based on comparing the number of actual US deaths with the number that would have obtained had Canadian age‐ and sex‐specific death rates applied to the US population shows an excess number of US deaths in 1998 amounting approximately to 253,000. Excess US deaths were especially numerous among older women, middle‐aged men, and nonwhites. Circulatory diseases were the major cause of excess deaths. Prevalences of two of the major risk factors for circulatory deaths—smoking and hypertension—were higher in Canada than in the US. But obesity was higher in the US, suggesting a likely important role that obesity plays in higher mortality in the US relative to Canada. Comparisons of the level, age pattern, and causes of US and Canadian mortality, however, raise more questions than currently available data can answer.     

Lifespan Dispersion in Times of Life Expectancy Fluctuation: The Case of Central and Eastern Europe

Central and Eastern Europe (CEE) have experienced considerable instability in mortality since the 1960s. Long periods of stagnating life expectancy were followed by rapid increases in life expectancy and, in some cases, even more rapid declines, before more recent periods of improvement. These trends have been well documented, but to date, no study has comprehensively explored trends in lifespan variation. We improved such analyses by incorporating life disparity as a health indicator alongside life expectancy, examining trends since the 1960s for 12 countries from the region. Generally, life disparity was high and fluctuated strongly over the period. For nearly 30 of these years, life expectancy and life disparity varied independently of each other, largely because mortality trends ran in opposite directions over different ages. Furthermore, we quantified the impact of large classes of diseases on life disparity trends since 1994 using a newly harmonized cause-of-death time series for eight countries in the region. Mortality patterns in CEE countries were heterogeneous and ran counter to the common patterns observed in most developed countries. They contribute to the discussion about life expectancy disparity by showing that expansion/compression levels do not necessarily mean lower/higher life expectancy or mortality deterioration/improvements.     

On the Determinants of Mortality Reductions in the Developing World

This article presents and critically discusses evidence on the determinants of mortality reductions in developing countries. It argues that increases in life expectancy between 1960 and 2000 were largely independent of improvements in income. The author characterizes the age and cause‐of‐death profile of changes in mortality and assesses what can be learned about the determinants of these changes from the international evidence and from country‐specific studies. Public health infrastructure, immunization, targeted programs, and the spread of less palpable forms of knowledge all seem to have been important factors. Finally, the article suggests that the evolution of health inequality across and within countries is intrinsically related to the process of diffusion of new technologies and to the nature of these new technologies, public or private.     

Age-Specific Variation in Adult Mortality Rates in Developed Countries

This paper investigates historical changes in both single-year-of-age adult mortality rates and variation of the single-year mortality rates around expected values within age intervals over the past two centuries in 15 developed countries. We apply an integrated hierarchical age-period-cohort—variance function regression model to data from the human mortality database. We find increasing variation of the single-year rates within broader age intervals over the life course for all countries, but the increasing variation slows down at age 90 and then increases again after age 100 for some countries; the variation significantly declined across cohorts born after the early 20th century; and the variation continuously declined over much of the last two centuries but has substantially increased since 1980. Our further analysis finds the recent increases in mortality variation are not due to increasing proportions of older adults in the population, trends in mortality rates, or disproportionate delays in deaths from degenerative and man-made diseases, but rather due to increasing variations in young and middle-age adults.     

The Epidemiologic Transition Revisited: Compositional Models for Causes of Death by Age and Sex

For decades, researchers have noted systematic shifts in cause‐of‐death patterns as mortality levels change. The notion of the “epidemiologic transition” has influenced thinking about the evolution of health in different societies and the response of the health system to these changes. This article re‐examines the epidemiologic transition in terms of empirical regularities in the cause composition of mortality by age and sex since 1950, and considers whether the theory of epidemiologic transition presents a durable framework for understanding more recent patterns. Age‐sex‐specific mortality rates from three broad cause groups are analyzed: Group 1 (communicable diseases, maternal and perinatal causes, and nutritional deficiencies); Group 2 (noncommunicable diseases); and Group 3 (injuries), using the most extensive international database on mortality by cause, including 1,576 country‐years of observation, and new statistical models for compositional data. The analyses relate changes in cause‐of‐death patterns to changing levels of all‐cause mortality and income per capita. The results confirm that declines in overall mortality are accompanied by systematic changes in the composition of causes in many age groups. These changes are most pronounced among children, for whom Group 1 causes decline as overall mortality falls, and in younger adults, where strikingly different patterns are found for men (shift from Group 3 to Group 2) compared to women (shift toward Group 2 then Group 3). The underlying patterns that emerge from this analysis offer insights into the epidemiologic transition from high‐mortality to low‐mortality settings.     

Three measures of longevity: Time trends and record values

This article examines the trend over time in the measures of “typical” longevity experienced by members of a population: life expectancy at birth, and the median and modal ages at death. The article also analyzes trends in record values observed for all three measures. The record life expectancy at birth increased from a level of 44 years in Sweden in 1840 to 82 years in Japan in 2005. The record median age at death shows increasing patterns similar to those observed in life expectancy at birth. However, the record modal age at death changes very little until the second half of the twentieth century: it moved from a plateau level, around age 80, to having a similar pace of increase as that observed for the mean and the median in most recent years. These findings explain the previously observed uninterrupted increase in the record life expectancy. The cause of this increase has changed over time from a dominance of child mortality reductions to a dominance of adult mortality reductions, which became evident by studying trends in the record modal age at death.     

Structure and change in causes of death: An international summary

Abstract Model patterns of the cause structure of mortality at different levels were established for males and females, based on data for 165 national populations. These patterns suggest that the cause of death most responsible for mortality variation is influenza/bronchitis, followed by 'other infectious and parasitic diseases', respiratory tuberculosis, and diarrhoeal disease. Together, these causes typically account for about 60 per cent of the change in level of mortality from all causes combined. Their respective contributions have not depended in an important way on the initial level of mortality. These results - especially tbe importance of the respiratory and diarrhoeal diseases - imply that past accounts may have over-emphasized the role in mortality decline of specific and well-defined infectious diseases and their corresponding methods of control. There is strong statistical support for the suggestion that most of the remainder of mortality variation should be ascribed to changes in cardio-vascular diseases, but that methods of cause-of-death assignment in high-mortality populations have often obscured the importance of these diseases. When death rates from 'other and unknown' causes are held constant, changes in cardio-vascular disease account for about one-quarter of the decline in mortality from 'all causes'.Although the causal factors are poorly established, corroborative results have been demonstrated cross-sectionally in the United States. The composition of the group of populations most deviant from the structural norms is apparently dominated by differentials in the mode of assigning deaths to cardio-vascular disease. However, when broad groups of regions or periods are distinguished, more subtle differences emerge. Controlling mortality level for all causes combined, diarrhoeal diseases are significantly higher in non-Western populations and southern/eastern Europe than in overseas Europe or northern/western Europe. These differences are probably related to standards of nutrition and personal hygiene, but may also reflect climatic factors. Much higher cardio-vascular mortality in overseas European populations than in non-Western populations at similar overall levels probably reflects variation in habits of life. Regional differences in death rates from violence, maternal mortality, respiratory tuberculosis and influenza/pneumonia/bronchitis are briefly noted and commented upon. Cause-of-death structures at a particular level of mortality display some important changes over time. Respiratory tuberculosis and 'other infectious and parasitic diseases' have tended to contribute less and less to a certain level of mortality. They have in part been 'replaced' by diarrhoeal disease, specifically in non-Western populations. These developments reflect an accelerating rate of medical and public health progress against the specific infectious diseases, and a disappointing rate of progress against diarrhoeal disease. Western and non-western populations have shared to approximately the same extent in the accelerating progress against infectious diseases, and developments during the post-war period are more appropriately viewed as an extension of prior trends rather than as radical departures therefrom. For males, cardio-vascular disease and cancer have significantly increased their contribution to a particular level of mortality, while no such tendency is apparent for females. These developments may be related to changes in personal behaviour and in environmental influences whose differential impact on the sexes has been demonstrated in epidemiological studies. Although we have avoided an explicit treatment of age by having recourse at the outset to standardization, certain of the results are apparently reflected in studies of age patterns of mortality. The joint occurrence in non-Western populations and Southern/Eastern populations of exceptionally high death rates from diarrhoeal disease may explain why the 'South' age-pattern, with it high death rates between ages one and five, is often the most accurate referent for use in Latin America and Asia. The fact that the list of populations with the least deviation cause structure is almost exclusively confined to members of the 'West' group of Coale and Demeny may account for the lack of persistent deviation in this group's age patterns. Finally, tbe increasing importance of cardio-vascular disease and neoplasms in cause-of-death structures for males but not females is probably associated with the changing age patterns of male mortality noted by Coale and Demeny.