Can someone simply die of 'old age'?

[Guest guest]

By Brown

Washington Post Staff Writer

Sunday, September 19, 2010

You know the cartoon where a character is driving an old car that suddenly falls apart, every bolt sprung, with the last hubcap rattling in a circle until it comes to rest?

Some people die like that, too. The trouble is there's not a good name for it.

Is there a single problem that gets the final chain of events going? Or should " old age " under some circumstances be considered an actual cause of death, equal to lung cancer, leukemia and diabetes?

Those questions are becoming increasingly important as more and more people die at very advanced ages without an obvious cause that can be confidently entered on the death certificate.

The difficulty of naming a cause of death in the very old is becoming enough of a problem in the industrialized world that the World Health Organization is likely to address it head-on it in the next year.

" If we can't find a way of dealing with this, then I think mortality statistics will lose much of their value, " said Lars Age Johansson, who chairs the WHO's Mortality Reference Group and is a biostatistician with Sweden's National Board of Health and Welfare. " I see this as very, very important. "

Mortality statistics are the backbone of public health.

Without knowing how the members of a population die, and at what ages, epidemiologists can only guess how many deaths are potentially preventable.

On the other hand, good mortality data can identify overlooked problems and help public health agencies decide where to direct effort and money.

The issue is especially topical because experts from around the world next year will start updating the International Classification of Diseases, medicine's official list of more than 14,000 diagnoses.

" Each revision of the ICD is the right moment to reconsider this question, " said Gerard Pavillon, a French biostatistician who will co-lead the mortality statistics committee.

The official list of causes

Some places began recording all deaths and their causes in the early 1800s. The original list, called the International List of Causes of Death, was adopted in 1893. It had 161 headings, with more specific causes falling under some of them. It was probably easier for a physician to choose a cause of death then than it is now, though far more is known about the complicated physiology of dying.

Today, doctors are expected to list both " immediate " and " underlying " causes of death and how long diseases had been present. They are also asked to list " significant conditions contributing to death " but not causing it directly. But picking the " underlying cause " - the most important one - when a patient has several chronic illnesses, such as hypertension, dementia and coronary heart disease, is often difficult.

Many physicians find the task even harder when a very old person declines over a few weeks or months and then dies.

The steps of that process often include muscular weakness that leads to inactivity and increased susceptibility to infection, or poor intake of food and fluid that leads to dehydration and electrolyte imbalances in the blood and a final fatal heart rhythm. The " underlying cause " is hard to find even with an autopsy.

What's certain is that the number of these older people is growing.

Consider a hypothetical group of 100,000 people born in 1901. If they experienced the mortality rates in all age groups present at the turn of the 20th century, then only 31 would be expected to reach age 100. On the other hand, in a group of 100,000 people born in 2006 and experiencing our era's mortality rates, 1,737 would live to 100.

However, giving " old age " greater legitimacy in the lexicon of 21st-century medicine has risks, especially beyond the industrialized world.

A 2005 study found that " death registration " is complete in only 64 of 115 countries reporting data to the WHO. Only one-third of the 57 million deaths that will occur this year around the world will be assigned a cause and reported to a government bureau of vital statistics.

Furthermore, the fraction of deaths ascribed to ill-defined causes that provide little useful medical information - " cardiac arrest, " " failure to thrive " or " multi-organ failure " - is high in a surprising variety of countries. Such vague causes appear on 26 percent of death certificates in Greece, 37 percent in South Africa, 40 percent in Egypt, 49 percent in Thailand.

The potential drawbacks

Giving old age greater credibility could make mortality data in much of the world even more muddy. It might also provide a reason for overlooking the health problems of very old people, some experts believe.

" It's kind of a tricky issue, " said N. , chief of mortality statistics at the National Center for Health Statistics.

" If someone is over 100, I wouldn't quibble with old age as a cause of death, " said. " But I certainly wouldn't like to see 'old age' as a cause of death in someone who is 75. Even 85 would be pushing it. "

In fact, terms such as " senescence, " " debility " and " old age " are already in the ICD catalogue, and physicians sometimes enter them on death certificates. But in many states the terms aren't accepted. The vital-statistics office kicks such certificates back to the doctor with a request for a more precise cause of death.

How often that happens differs greatly from state to state.

In the period 1999 through 2006, the rate at which " senility " or one of its subcategories appeared on death certificates in Florida was 100 times the rate in California. In Virginia it was used at a rate below the national average. It was essentially never used in land and the District.

If senility is accepted more widely, it will probably be under very specific circumstances. A person will have to be beyond a certain age and have no serious chronic illness, for example. But few people doubt that old age is sometimes a cause of death.

" We as human organisms sometimes just run out of energy and shut down, " said Cheryl , a San Francisco doctor and chairman of the American Geriatrics Society.

Johansson, the Swedish expert in mortality statistics, said that is what happened to his grandmother, a farm wife who died several years ago at age 107.

" She just withered away. Nobody could find anything wrong with her, " he said. " There was nothing wrong with her except her age. "