When a very old and apparently healthy person dies it is often said that he is “dead of old age”, with an implicit reference to old age as the only cause of death. This was also recently said in the case of Queen Elizabeth II of the United Kingdom, on whose death at the age of 96 the British monarchy has not provided any details. Death of old age is understandably the aspiration of many, but it is not strictly part of the death statistics, even if in some countries with a very long-lived population, such as Japan, discussions are starting about the possibility of introducing it as a possible definition of the main cause. of death.
Usually, after the death of a person, a doctor completes a death certificate, in which he provides information on the health conditions before the death and the probable causes of death. In many cases these are evident, for example if the death occurred as a result of an accident or a disease already diagnosed as a tumor, in others they are more difficult to recognize and often linked to health problems that had not been detected.
The ultimate cause of death is always the same: a cardiac arrest which consequently prevents organs and tissues from receiving oxygen and other substances through the bloodstream. A brain death, with which the ability to breathe and maintain other vital functions is lost, can anticipate the end of cardiac activity, but it is still the latter that is considered in most cases the point of arrival of a existence.
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In general, the health problems that cause death in very old people are not very different from those that can occur in younger people, who are however able to react better. In fact, with aging increases the risk that complications arise with a disease or trauma, which can last for a long time making the development of chronic diseases more likely. Aging processes can also mask the symptoms of some diseases, making it difficult to diagnose them and initiate treatments to control them. It often happens that an elderly person dies due to one or more health problems that they did not know they had and characterized by a slow evolution, due to the slowing of the metabolism compared to the young age.
Precisely because of these circumstances, the indication on death of old age was once frequently used by doctors, because there were not many possibilities to trace the actual causes of death. The fewer chances of diagnosis meant that these remained rather confusing, prompting them to point mostly to cardiac arrest. Today the main health institutions advise against giving such vague indications, because important information of an epidemiological and public health nature can be derived from more precise reports on the causes of death.
In Italy, death certificates are compiled starting from the initial cause and ending with the terminal one, often linked to cardiac arrest. In the international arena, instead, an inverse system is applied, with the presentation of the ultimate cause and a tracing of the previous ones.
During the coronavirus pandemic, which has become a major cause of death in the last two and a half years in many areas of the world, there was discussion on whether to indicate the deaths of patients “for” or “with” COVID-19. In the sense of establishing if a person had died directly from the coronavirus, or if she had died from other causes while she was infected, or because the infection had worsened other health problems that had then directly caused death. Beyond the controversies and exploitation, the comparison had highlighted how difficult it can be to identify the cause and effect processes that lead to death, especially among the elderly.
However, the pandemic has led health institutions to explore the issue of deaths of old age better. The World Health Organization (WHO), for example, at the beginning of the year published the new version of the International Classification of Diseases, Accidents and Causes of Death (ICD-11), including for the first time the item “Aging associated with a decline of the intrinsic abilities “of patients. The wording initially referred to advanced age, but was later changed following some criticism of the use of terms that could have led to think that a person was ill because they were simply old.
The appropriateness of indicating old age as the main cause of death is however discussed in the health sector, considering that age is a very significant risk factor associated with the progressive loss of some functions of the tissues of our body. Japan, the country with the highest percentage of people over 65, includes age as a cause of death in its statistics. In recent years, death from old age is third, preceded by that from cardiovascular problems and cancer. Of every ten deaths in the country, one is reported as death from old age.
The indication is accepted in the country, but raises some perplexity because it seems to indicate an inevitable condition, recognizing that nothing could be done to prolong the life of the person who later died. On the other hand, the indication of a disease in the death certificate of a very elderly person does not always add much, considering that not all treatments can be performed on elderly and frail subjects, especially if invasive and such as to compromise the quality of the life in the last period of their existence.
In the indications of Japanese health institutions, the indication of death of old age must be used as a last resort, only in the case in which it is not possible to specify other causes. If a person due to senile dementia and other health problems no longer regularly takes certain medications and develops complications, such as pneumonia, the death certificate should be indicated along with an indication of death due to old age. .
The aim is to find the right balance between the information to be included in the certificates for the statistics and for the relatives of the deceased person, without adding details on other health conditions that could suggest poor medical care before the death. With this approach we can put things in an acceptable perspective, making it clear how what is defined as “death of old age” is actually the result of a more complex process, which cannot always be reconstructed in every detail.