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LETTER TO THE EDITOR |
St. Mary's/Duluth Clinic Duluth, Minnesota
To the Editor:
In their study of causes of death in France, Horiuchi and colleagues conclude that the disease processes that lead to death may be "fundamentally different" in middle age and old age (1). We reached similar conclusions in our study of cause of death in Minnesota (2), albeit in a somewhat older population that included centenarians.
Horiuchi's principal conclusion is that mortality increase in old age differs from the patterns in younger decedents in that it is "dominated by senescent processes." He also documents that death rates from several acute conditions—such as respiratory infections and accidents—increase steeply with advancing age in the older age group. We believe that this finding is entirely consistent with his overall thesis, since most of the acute conditions in question would not ordinarily cause death in younger, more robust individuals. As Horiuchi notes, "physiologic stresses that were not serious at younger ages become life threatening at old ages." That is, while the proximate or acute cause of death may be influenza or a fall, the underlying cause of death is age-related frailty.
The differences between causes of death in midlife and causes of death in old age cannot be elucidated fully using data from death certificates. Many deaths in middle age are caused by a single, readily identifiable condition, severe enough to overwhelm physiologic defenses and homeostasis; such causes of death are usually recorded on death certificates (3). Conversely, in old age, death is more likely to result from the combined effects of several chronic conditions; inevitably some of these conditions are omitted from death certificates. This leads to the systematic underreporting of common chronic conditions of aging on death certificates. An illustrative example is provided by osteoporosis, which may contribute directly to fractures and fatal sequelae, but rarely appears on death certificates. Goldacre (3) found that the conditions most likely to be omitted from death certificates included some that are common in very old age, such as fractured neck of femur and neurological conditions.
Aging has been defined as "the accumulation of random damage to the building blocks of life—especially to DNA, certain proteins, carbohydrates and lipids (fats)—that begins early in life and eventually exceeds the body's self-repair capabilities" (4). Conversely, diseases and injuries may be seen as nonrandom damage to the building blocks of life. Work such as that reported by Horiuchi suggests that this conceptual difference may be reflected in epidemiological data.
Ultimately, it may not ever be possible—or desirable—to make an unambiguous distinction between conditions of aging and diseases. However, the issue has significant policy implications and is not about to disappear. While scholars may have difficulty agreeing on a definition of "premature" death, the lay public and the policymakers who respond to the public generally do not share this dilemma. To the public, premature death is that which robs an individual of potential life. As such, causes of premature death attract health resources. Senescent death, on the other hand, is understood to be part of the natural order, and there is little consensus on how vigorously it should be combated.
Acknowledgments
Address correspondence to Charles E. Gessert, MD, MPH, St. Mary's/Duluth Clinic, 400 East 3rd St., Duluth, MN 55812-1852. E-mail: cgessert{at}smdc.org
References
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