Geriatrics in Latin America

Fernando Gomez, Carmen-Lucia Curcio

Most older people live in less developed countries, and these countries will experience the most rapid aging compared with other countries. For example, in Latin American and Caribbean (LAC) countries, population aging will be the most significant demographic trend of the coming decades. From the mid-twentieth century to the present, the region has shown an accelerated aging of its population: from the 561 million people living in this region, about 5.7% are 65 years or older. The proportion of the population aged 60 years or older increased from 6% in 1950 to 10% in 2010. It is expected to reach 21% in 2040 and nearly 36% by 2100.¹ LAC populations are aging at a faster rate than the population in North American and European countries. Most developed nations have had decades to adjust to their changing age structures. For example, it took more than 100 years for the share of France’s population aged 65 years or older to rise from 7% to 14%, whereas in Latin America the same percentage increase took only 50 years.² Furthermore, many countries of the region are experiencing a rapid increase in the number and percentage of older people, often within a single generation. By 2025, the number of people older than 60 years in LAC countries will be increased twofold to threefold, from 43 million to 100 million. Fertility and mortality decline have occurred in less than half the time observed in industrialized countries. In Latin America, older persons are predicted to outnumber children for the first time by around 2036, and their numbers will continue to grow until 2080.²

In conclusion, by the mid-twenty-first century, the region may be at the same stage of the aging process as the developed countries now are, with 1 in 5 people aged 60 years or older.

As a consequence, the demographic transition has taken place rapidly, although there is still some diversity among countries. Within these countries, at the regional level, two major changes have taken place: a reduction in demographic dependency and population aging.¹ For example, in countries with old and very old populations (Cuba, Barbados, Argentina, and Uruguay), a drastic situation is expected to arise during the second half of the twenty-first century, comparable with that of Europe in terms of the age structure of the population.³ Thanks to medical and health care advances, life expectancy indices are at levels that were unimaginable just a few decades ago. Over the past 25 years, the life expectancy in LAC countries has increased: 79% of the population will reach old age and at least 40% will live until 80 years. Life expectancy at 60 years varies across the region: it is 19 years for men and 22 years for women.² However, this phenomenon of rapid aging has not been accompanied by social and health policy reforms that appropriately address the needs of an aging country.⁴

The Economic Commission for Latin America and the Caribbean (ECLAC) has classified LAC countries into four stages of demographic transition according to life expectancy and fertility rates.³ Cuba and Barbados have been classified as being at a very advanced stage of demographic transition; both countries have seen the mortality rate decline more slowly than the fertility rate. Among the countries at an advanced stage of demographic transition are Argentina, Uruguay, and Chile; all three countries saw an early drop in their vital rates with growth rates lower than 1%. Unlike other countries at an advanced stage of transition, Brazil, Colombia, Costa Rica, and Mexico have growth rates between 1.3% and 1.4%. Brazil and Colombia have achieved the least in terms of increasing life expectancy (72.4 years and 72.8 years, respectively). In full demographic transition are Venezuela, Dominican Republic, Ecuador, El Salvador, Panama, and Peru; their fertility rates had declined considerably in the past two decades. Finally, the countries at a moderate stage of demographic transition are Bolivia, Guatemala, and Haiti.³

With respect to epidemiologic transition, LAC countries are characterized as a “prolonged polarized model,” with high incidence of communicable and noncommunicable diseases. High death rates from infectious diseases are commonly associated with poverty, poor diets, and limited infrastructure found in the region. Most LAC countries have passed the epidemiologic transition, and the main causes of mortality and morbidity in these countries have shifted from infectious diseases to degenerative diseases, including disability-causing disorders such as osteoarthritis. However, the characteristic of LAC countries is heterogeneity in the epidemiologic transition between social groups and geographic areas within each country and among the countries. For example, death caused by communicable diseases has a rate of less than 10% in Uruguay, Costa Rica, Cuba, and Chile, whereas it is higher than 30% in Peru, Bolivia, Guatemala, and Haiti. Behind apparent uniformity, LAC countries are extremely diverse, reflecting a long history of human settlement.⁵

Although the demographic peculiarity described in this chapter makes the aging process in developing countries unique, it is by no means the only one that stands out. Indeed, the demographic process takes place within the boundaries of institutional arrangements, political organization, and cultural superstructure that are, to say the least, in contrast to those that hosted the aging process in Europe and North America. The blend of unique demography with contrasting economic, institutional, political, and cultural contexts can result in very large diversity of aging processes, diversity that, if identified and suitably taken into account, can go a long way toward explaining observed regularities.⁶

Health of Older Adults in Latin America and the Caribbean

The major study on the health of older adults in LAC countries is the Salud, Bienestar y Envejecimiento en América Latina y Caribe (SABE) study (Survey on Health, Well-being and Aging in Latin America and the Caribbean), a multicentric project conducted by the Pan-American Health Organization (PAHO).⁶^–⁹ It included 10,891 people aged 60 years and older, living in seven big cities of the region (Bridgetown, Buenos Aires, Havana, Mexico City, Montevideo, Santiago, and Sao Paulo). SABE was based on a probabilistic, stratified, multistage, cluster-sampling design of the noninstitutionalized older adult population of the seven participating cities. The SABE study represented a milestone in the field of population aging in the region and could provide enough information to study the phenomena of aging in detail. Results of SABE increased understanding of the aging process and the formulation of public policy toward the well-being of LAC populations and provided a solid base for a second generation of studies in the region.⁷

Data from the SABE study showed that a high percentage of old people have a poor self-perception of their health. The cities with the highest proportions of individuals in bad self-reported health were found in Santiago (21%), Mexico City (20%), and Havana (13%), whereas those with the lowest were found in Buenos Aires, Bridgetown, and Montevideo (5% to 7%). The poor self-reported health was higher in women and old age groups. The mean number of self-reported chronic conditions increased with age and is higher for females than it is for males. Of all chronic conditions highlighted in the SABE survey, arthritis, heart disease, obesity, and diabetes are the most salient across all LAC regions.⁸ The prevalence of self-reported diabetes in this study ranged from 12.9% (Santiago) to 21.6% (Mexico City); diabetes is directly related to diet and obesity and has a strong association with disability. This study also documented that the prevalence of difficulties in activities of daily living (ADLs) fluctuated between 14% in Bridgetown and 23% in Santiago (the mean for the LAC region was 19%). Difficulties with instrumental activities of daily living (IADLs) ranged from 12% in Montevideo to 40.3% in Sao Paulo. There are strong age gradients and important gender differences in self-reported limitations in ADLs and IADLs. The SABE study also focused on basic problems, such as falls and mental health. The prevalence of falls varied from 21.6% in Bridgetown to 34.0% in Santiago. The prevalence of cognitive decline evaluated by the Mini Mental State Examination (MMSE) was 1.1% in Montevideo and 12% in Sao Paulo, and depression oscillated between 21.5% and 33.2%.⁴

In conclusion, the most important findings of SABE include all LAC countries differ in self-reported health but exhibit much less difference in terms of functional limitations. The number of chronic conditions increases with age and is higher among females than among males. On average, SABE countries display levels of self-reported diabetes (and obesity) that are as high as if not higher than those found in the United States. Furthermore, there is evidence suggesting deteriorated health and functional status in the region, and there is important evidence pointing toward rather strong inequalities (by education and income) in selected health-related outcomes.⁴

At least 40 papers from the SABE study have been published in the past decade on topics such as gender,¹⁰ chronic conditions,¹¹^,¹² hypertension,¹³ diabetes mellitus,¹⁴^,¹⁵ obesity,¹⁶ cancer,¹⁷ anthropometric measures,¹⁸ mobility,¹⁹ frailty and sarcopenia,²⁰^–²³ disability,²⁴^–²⁸ falls,²⁹ depression,³⁰^,³¹ cognitive function,³² and caregivers.³³

After the SABE study was conducted in Latin America, several cross-sectional studies were carried out in the region. Between 2009 and 2010 in Ecuador, a similar study with emphasis on the aborigine population (10.4% of total population), SABE Ecuador, was conducted.³⁴ As expected, ethnicity was found to be a critical factor in poverty, inequity, and social exclusion for aborigines in the region. Data from this study showed that at least half of the aborigine older people live in extreme poverty situation, with no access to health services and high vulnerability status due to socioeconomic conditions and ethnicity.³⁵ Recently, with a similar methodology of SABE study, a cross-sectional survey including 2044 people of 60 years and older, living in the urban zone of Bogota (Colombia), was conducted.³⁶ A SABE Colombia study with a similar methodology of original study is in progress.

Longitudinal Studies

In the past decade, several population longitudinal studies in aging have been conducted in the LAC region.

The Costa Rican Study on Longevity and Healthy Aging, known by its Spanish language acronym CRELES, is a longitudinal study of a nationally representative sample of adults born before 1945 (aged 60 years and older in 2005), a total 2900 respondents, residing in Costa Rica, with oversampling of the oldest old.³⁷ One of the most important findings of this study is that organ-specific functional reserve biomarkers (hand grip strength, walking speed, and pulmonary peak flow), along with C-reactive protein, hemoglobin A_1c, and DHEAS, have been found to be suitable biomarkers for improving the identification of vulnerable individuals in an older adult population of the developing world.³⁸ Several papers of this study have been published with emphasis on cardiovascular risk factors,³⁹ hypertension,⁴⁰ socioeconomic status,³⁷^,⁴¹ and neuroendocrine system dysfunction.⁴²

Another longitudinal study in the region is REDE FIBRA (Frailty in the Brazilian Elderly Study). The REDE FIBRA study was carried out in 17 Brazilian cities, designed to identify conditions of frailty in relation to social, demographic, health, cognitive, functional, and psychosocial variables in community-dwelling older adults.⁴³ The aim of this study was to determine the traits, prevalence, and associated biologic, psychological, and environmental factors related to the frailty syndrome. At this time, the study continues with only the Rio de Janeiro sample (FIBRA-SJ) with 847 individuals aged 65 years or older. This study has three phases, the first related with frailty and risk factors,⁴⁴ the second with cognitive impairment,⁴⁵ and the third (ongoing) with sarcopenia. Results of this longitudinal study have revealed identifying characteristics of Brazil’s older people with respect to frailty, cognitive impairment, and sarcopenia.

A Mexican population-based cohort study, the Mexican Study of Nutritional and Psychosocial Markers of Frailty (also referred to as the “Coyoacan cohort”), was designed to assess the nutritional and psychosocial determinants of frailty and its consequences on the health of Mexican older adults living in Coyoacan, one of the 16 districts of Mexico City. A total of 1124 noninstitutionalized men and women aged 70 years and older participated.⁴⁶ Papers based on results from the Coyoacan cohort study cover topics such as normative data for the MMSE and Isaacs Set Test to use in the Mexican older population,⁴⁷ the close relationship between self-perception of oral health and the probability of being frail,⁴⁸ the importance of urinary incontinence as a factor in decreased health-related quality of life,⁴⁹ and the influence of writing and reading skills of older people with no formal education on their cognitive performance.⁵⁰

The Mexican Health and Aging Study (MHAS or Estudio Nacional sobre Salud y Envejecimiento en México) is a prospective two-wave panel study of health and aging in Mexico with 7000 older adults who represent 8 million subjects nationally; with a representative cohort of Mexicans born before 1951 (aged 50 years and older). The survey has national and urban/rural representation. The study was designed with a field protocol and content similar to the Health and Retirement Survey conducted in the United States.⁷ MHAS recorded detailed information on individual health, migration history, socioeconomic status, family transfers, kin availability and attributes, and household composition of Mexicans. The most important findings of this longitudinal study included explaining the unique health dynamics of Mexico within a wide socioeconomic context with a life-course perspective approach⁵¹ and how the epidemiologic transition in LAC countries adds to the mortality health burden experienced by older people in Mexico and how the inequalities based on socioeconomic status are important mortality risk factors.⁵²

Another longitudinal study, the Sao Paulo Aging and Health Study (SPAH), conducted between 2005 and 2007, involved 1025 participants aged 65 years or older who lived in sectors with the lowest human development index in the borough, including numerous shantytowns.⁵³ This study showed a high incidence of vertebral fracture in older Latin Americans⁵⁴ and a high prevalence of 25-hydroxyvitamin D insufficiency in Brazilian community-dwelling older adults.⁵⁵ With respect to the prevalence of dementia, one survey of this study showed how nearly 50% of this prevalence could be potentially attributed to the combination of two or three of the socioeconomic adversities during the life span: illiteracy, nonskilled occupations, and lower income.⁵⁶

One of the most recent ongoing longitudinal cross-cultural studies in the region is the International Mobility in Aging Study (IMIAS), which aims at understanding the mobility differences between men and women by comparing mobility disability in populations that differ widely in gender norms and values. The primary objective of IMIAS is to measure the magnitude of the sex/gender gap in mobility and to increase the understanding of sex/gender differences in life course exposures related to mobility. IMIAS is ongoing at five sites: Tirana (Albania), Natal (Brazil), Manizales (Colombia), Kingston (Ontario, Canada), and Saint-Hyacinthe (Quebec, Canada). The study population is composed of community-dwelling older people between 65 and 74 years of age. The sample was stratified by sex with an aim to recruit 200 men and 200 women at each site. The total sample size of the study at the five research sites is 1995.⁵⁷

In conclusion, Latin American nations have begun to develop appropriate data systems and research capacity to monitor and understand aging accompanied by a longer period of good health, a sustained sense of well-being, and extended periods of social engagement and productivity, specifically with longitudinal studies that incorporate measures of health, economic status, family, and well-being. As a consequence, in addition to demographic information, more detailed information about the aging process in LAC countries is becoming increasingly available in English-language journals.

Self-Rated Health

As a powerful predictor of mortality, disability, and health care utilization, self-rated health (SRH) has been regarded as a key indicator of health status.⁵⁸^,⁵⁹ Information from the SABE study showed high percentages of poor SRH in the region. Environmental factors related to poor SRH have been explored in the region. For example, in a cross-sectional study to determine the association between urban and environmental characteristics in the city of Bogota (Colombia) with SRH and quality of life related to health, a positive association was found between the perception of neighborhood safety with good SRH and quality of life related to health. Likewise, the availability of recreational spaces such as safe parks that promote social interaction and recreational activities was associated with good SRH and quality of life in the mental health domain. On the contrary, zones with high levels of noise were associated with bad SRH and poor quality of life.⁶⁰ Other studies based on Brazil SABE data determined the relationship between SRH and demographic, social, and economic factors along with the presence of chronic diseases and functional ability. It was found that the presence of a chronic disease in relation to gender had the greatest association with SRH; males presenting four or more chronic illnesses had 10.53 times greater opportunity for bad SRH; similarly, for females, it was 8.31 times. Likewise, educational level, income, and functional capacity were related to SRH.⁶¹ For older people, an LAC religiosity is associated with SRH; in other studies with data from SABE study, it was found that most (90%) participants reported having some religious affiliation and that those who considered religion very important in their lives had better SRH compared with those who considered religion less important.⁶² Another recent paper from the Coyoacan cohort insisted that poor SRH shares common correlates and adverse health-related outcomes with frailty syndrome and remains associated with it even when possible confounders are taken into account. They concluded that SRH as an option for frailty syndrome screening could be further explored.⁶³

Geriatrics Conditions

Dementia

The major study on dementia in older adults in LAC countries is the 10/66 population-based study.⁶⁴ It investigated the prevalence and severity of dementia in sites in low-income and middle-income countries according to two definitions of dementia diagnosis. This cross-sectional study had a target sample size of 2000 to 3000 participants for every country, in total more than 12,800 individuals. It included five countries: Cuba, Dominican Republic, Venezuela, Mexico, and Peru. The main finding was that the prevalence of dementia (as defined in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition [DSM-IV]) in urban Latin America is similar to that previously recorded in Europe and other developed country settings. However, the prevalence of DSM-IV dementia in rural Latin America was very low, a quarter or less than that typically seen in Europe. The researchers concluded that the DSM-IV dementia criteria might substantially underestimate the true prevalence of dementia, especially in the least developed regions, because of difficulties in defining and ascertaining decline in intellectual function and its consequences.⁶⁵ However, other studies in the region have shown higher prevalence of cognitive impairment than that found by population-based studies, for example, in Brazil (16.1%)⁴⁵ and Mexico (28.7%).⁶⁶

In another cohort survey of the 10/66 study, the independent effects of age, sex, socioeconomic position, and indicators of cognitive reserve (educational level, occupational attainment, literacy, and executive function) on dementia incidence were investigated. Results provided supportive evidence for the cognitive reserve hypothesis for dementia in LAC older people.⁶⁷ Other related findings were about awareness of dementia being lower than in high-income countries, probably because in the region, older adults are routinely supported in many basic and instrumental activities of daily living.⁶⁷

In the Coyoacan cohort referred to earlier, cognitive impairment is suggested as a very important component of frailty because of its strong association with prevalent disability in the Mexican population. This study showed that, as in other regions of the world, the life course socioeconomic indicators and current wealth are important predictors of cognitive impairment.⁶⁸ In the SABE study, respondents who experienced disadvantaged conditions (lived in rural areas during childhood, perception of poor health during childhood, illiteracy, unskilled occupation or being a farmer or housewife, and reporting insufficient income) presented the highest prevalence of cognitive impairment.³²

Frailty

A few studies on frailty in older adults have been conducted in Latin America. The first epidemiologic study on the prevalence of frailty in the region was the SABE.²⁰ In this study, the prevalence of frailty ranged from 30% to 48% in women and from 21% to 35% in men, rates that were much higher than those of their American and European counterparts. In 2009, a frailty index using 34 variables was developed, which allows stratifying older Mexicans into several groups according to the degree of the risk of mortality.⁶⁹ The prevalence of frailty using modified Fried criteria has been reported in several studies in the region: Peru, 7.7%⁷⁰; Mexico, ranging from 13.9% to 37%⁶⁸; Colombia, 12.1% frail and 53% prefrail⁷¹; and Brazil, ranging from 9.1% to 17.1% frail and 47.3% to 60.1% prefrail.⁴⁴^,⁷²^,⁷³ In these studies, multiple factors were identified with frailty, including advanced age, lower education, presence of comorbidity, poor SRH status, dependence in basic and instrumental activities of daily living (ADLs and IADLs, respectively), depression, and cognitive impairment. Data from SABE showed that age, schooling, sedentary lifestyle, and screening positive for depression were associated similarly with more than one component of frailty in Brazilian older men and women. These associations were more similar between the following components of frailty: weakness and slowness (MMSE ≤ 18 points in men and schooling in women); weakness, slowness, and low physical activity level (LPAL) (age in both genders and stroke in men) or weakness, slowness, and exhaustion (schooling in men and sedentary lifestyle in both genders).²¹ Furthermore, another Mexican study determined that phenotype of frailty was a predictor for adverse health-related outcomes (including mobility, ADL, and IADL disability).⁷³ Finally, several studies in the region also support the idea that cognitive functioning must be considered as part of the phenotype of frailty and can contribute to a more accurate profile of frailty in older adults.⁶⁸^,⁷²

Sarcopenia is considered as a key component of frailty and has also been evaluated in the region. Based on the European Working Group on Sarcopenia in Older People (EWGSOP) with data from the second wave of the SABE study in Brazil, sarcopenia prevalence was established. Sarcopenia was present in 16.1% of women and 14.4% of men. Advanced age, cognitive impairment, lower income, smoking, undernutrition, and risk for undernutrition were factors associated with sarcopenia.²²

Fewer studies have been carried out in the region related with other geriatric conditions and syndromes.

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