Aripiprazole lauroxil 2-month formulation with 1-day initiation in patients hospitalized for an acute exacerbation of schizophrenia: exploratory efficacy and patient-reported outcomes in the randomized controlled ALPINE study.

BACKGROUND: A randomized, controlled, phase 3b study (ALPINE) evaluated efficacy and safety of a 2-month formulation of aripiprazole lauroxil (AL) using a 1-day initiation regimen in patients hospitalized for an acute exacerbation of schizophrenia. Paliperidone palmitate (PP) was used as an active control. Exploratory endpoint assessments included severity of illness, positive and negative symptoms, quality of life, caregiver burden, and satisfaction with medication. METHODS: Adults were randomly assigned to AL 1064 mg q8wk or PP 156 mg q4wk as inpatients, discharged after 2 weeks, and followed through week 25. Exploratory efficacy measures included the 3 original PANSS subscales, Clinical Global Impression-Severity (CGI-S) subscale, and caregiver Burden Assessment Scale. Exploratory patient-reported outcomes (PROs) included the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q-SF) and the Medication Satisfaction Questionnaire. Within-group changes from baseline through week 25 were analyzed for AL and PP separately. PROs were summarized based on observed data. RESULTS: Of 200 patients randomized (AL, n = 99; PP, n = 101), 99 completed the study (AL, n = 56; PP, n = 43). For AL, PANSS subscale and CGI-S scores improved from baseline through week 25 (mean [SE] change from baseline at week 25: Positive, -7.5 [0.70]; Negative, -3.9 [0.46]; General, -11.8 [0.83]; CGI-S, -1.3 [0.12]). Caregiver burden also improved (mean [SD] changes from baseline at week 9: -8.4 [10.15]; week 25: -8.9 [12.36]). Most AL patients were somewhat/very satisfied with treatment at each timepoint (70.8%-74.7%); mean Q-LES-Q-SF total scores were stable in the outpatient period. For PP, results were similar: PANSS Positive, -7.3 (0.67); Negative, -3.6 (0.69); General, -10.9 (1.22); CGI-S, -1.4 (0.16); caregiver burden, week 9: -8.8 (11.89) and week 25: -9.2 (14.55); satisfaction with treatment, 64.7%-69.3%; and stable Q-LES-Q-SF scores. CONCLUSIONS: ALPINE patients initiating the 2-month AL formulation using the 1-day initiation regimen as inpatients and continuing outpatient care experienced schizophrenia symptom improvement, sustained patient satisfaction with medication, stable quality of life, and reduced caregiver burden. A similar benefit pattern was observed for PP. These results support the feasibility of starting either long-acting injectable in the hospital and transitioning to outpatient treatment. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03345979 [trial registration date: 15/11/2017].

Assistance provided in daily tasks and difficulty experienced by caregivers for people living with dementia.

INTRODUCTION: There is a growing body of research that addresses caregivers for people living with dementia. However, there is limited research looking at the perceptions of caregivers in specific daily tasks. To address this gap, this study investigated the assistance caregivers provided and the difficulty they faced when completing daily tasks for people with dementia and, additionally, how these experiences might relate to their perceived burden. METHODS: Sixty-two caregivers for people living with dementia completed the study. Data were collected, through a survey, on the level of assistance caregivers provided, and the difficulties they experienced. The Zarit Burden Scale was used to measure the level of perceived burden. Descriptive statistics and Spearman's correlation coefficient were used to report the results and the relationship between the perceived burden, the level of assistance provided, and the difficulty experienced. RESULTS: The activities of daily living that caregivers provided the most assistance for was dressing and showering. Most instrumental activities of daily living required maximal to total assistance. Overall, the caregivers did not experience a high level of difficulty with assisting with these daily tasks in comparison to the level of assistance provided. The caregiver burden was associated significantly with the difficulties experienced in dressing, toileting, and showering (rho = 0.30-0.75), most instrumental activities of daily living (rho = 0.29-0.47), but not with the level of assistance provided. CONCLUSION: Caregivers are assisting in many daily tasks. Their level of difficulty is relatively low in comparison to the level of assistance they provide. Significant correlations were found between the difficulties experienced and the burden scale. There is a need for occupational therapists to address the specific daily tasks and the concerns experienced by caregivers and to provide them with adequate support to improve the quality of care for people with dementia.

Effectiveness of interventions for co-residing family caregivers of people with dementia: Systematic review and meta-analysis.

BACKGROUND/AIM: Occupational therapists and health practitioners commonly provide interventions to family caregivers of people with dementia with the aim of relieving burden, depression, and disruptions in health and social support. To date, the effects of multicomponent interventions specifically targeting these four important outcomes has not been established. The aim of this study was to evaluate the effectiveness of multicomponent interventions on four outcomes for co-residing family caregivers of people with dementia. METHODS: A comprehensive database search of the literature was performed using CINAHL, MEDLINE, PubMed, PsycINFO, OTseeker, EMBASE and the Cochrane library. Randomised control trials (RCTs) that included multicomponent interventions for co-residing family caregivers addressing burden, depression, health and social support were selected. Relevant articles were critically reviewed and study results were synthesised. Meta-analysis was conducted separately. RESULTS: Twenty-two of 358 retrieved studies were selected, with 15 studies being included in the meta-analyses. The multicomponent interventions identified were comprised of a range of different individual strategies. Significant effective results were found for all four specified outcomes. CONCLUSIONS: Many types of multicomponent interventions appear beneficial on all of the four specified outcomes. The literature presents a trend that multicomponent interventions consisting of a combination of counselling, support groups, education, stress and mood management or telephone support are important strategies within an effective multicomponent intervention.

A cost of living longer: Projections of the effects of prospective mortality improvement on economic support ratios for 14 advanced economies.

The economic implications of increasing life expectancy are important concerns for governments in developed countries. The aims of this study were as follows: (i) to forecast mortality for 14 developed countries from 2010 to 2050, using the Poisson Common Factor Model; (ii) to project the effects of the forecast mortality patterns on support ratios; and (iii) to calculate labour force participation increases which could offset these effects. The forecast gains in life expectancy correlate negatively with current fertility. Pre-2050 support ratios are projected to fall most in Japan and east-central and southern Europe, and least in Sweden and Australia. A post-2050 recovery is projected for most east-central and southern European countries. The increases in labour force participation needed to counterbalance the effects of mortality improvement are greatest for Japan, Poland, and the Czech Republic, and least for the USA, Canada, Netherlands, and Sweden. The policy implications are discussed.

The Impact of Dependency Burden on Urban Household Health Expenditure and Its Regional Heterogeneity in China: Based on Quantile Regression Method.

Background: The aging population has led to a growing health expenditure burden. According to the National Bureau of Statistics of China, the old-age dependency ratio rose from 10.7% in 2003 to 17.8% in 2019, and health expenditure increased from 658.410 billion yuan in 2003 to 5812.191 billion yuan in 2019 in China. Methods: This paper utilizes the quantile regression method to discuss the influencing factors of health expenditure in urban China based on the China Household Finance Survey (CHFS), especially dependency burden. Moreover, its regional heterogeneity is also compared. Results: The old-age dependency ratio, age, family size, self-rated health status, and income significantly impact the health expenditure of urban families in the quantile regression of the national sample. Dependency burden and other variables on urban household health expenditure have great regional heterogeneity. The relationship between urban health expenditure and residential areas in western China is more stable than that in eastern and central China. Discussion: Government should improve the healthcare system suitable for the older adult population as soon as possible. The government of western China should pay more attention to the introduction of professional medical talents and the configuration of precision medical equipment to improve the health system in western China.

[Caregiver burden in patients with moderate-severe cerebral palsy. The influence of nutritional status]. / Carga del cuidador del paciente con parálisis cerebral moderada-grave: ¿influye el estado nutricional?

INTRODUCTION: Patients with moderate-severe cerebral palsy require the support of their caregivers to carry out the activities of daily living (ADLs). OBJECTIVES: To describe the comorbidities, need for care in children with cerebral palsy and to analyse the influence of the degree of motor involvement, nutritional status and other neurological disorders. METHODS: Cross-sectional and observational study. Patients with cerebral palsy degrees III-IV-V according to the Gross Motor Function Classification System (GMFCS) have been studied. A record of comorbidities has been made and body composition has been studied using anthropometry and bioimpedance. In addition, a caregiver burden survey on ADLs has been carried out (10 items on the different actions: hygiene, clothing, transfers, sleeping and feeding). Which variables have the greatest influence on the perception of difficulty in performing ADLs have been studied. RESULTS: A total of 69 patients (50.7% women, mean age 10.46 ± 0.4 years) were analysed, with GMFCS grades: grade III 36.2% (N=25), grade IV 29.0% (N=20), grade V 34.8% (N=24). A relationship was found between the caregiver burden score and GMFCS grade (P=0.003) and intellectual disability (P<0.001). However, regardless of the degree of GMFCS and intellectual disability, there is greater difficulty in performing ADLs in relation to lower values in weight (Z-score) (P=0.028), fat mass (kg) (P=0.035), fat mass (%) (P=0.094), body mass index (Z-score) (P=0.086). CONCLUSIONS: In addition to the degree of clinical impairment, nutritional status is a factor that influences the caregiver's difficulty in performing the ADLs in cerebral palsy patients on which we can act to improve this problem.

Informal caregivers' burden and stress in caring for stroke survivors with spatial neglect: an exploratory mixed-method study.

BACKGROUND: Spatial neglect prolongs stroke survivors' recovery to independence. However, little is known about the impact of spatial neglect on caregivers of stroke survivors. OBJECTIVE: To explore the factors associated with burden and stress among informal caregivers of stroke survivors with spatial neglect. METHODS: Following the previous study of 108 stroke survivors, we reached 24 stroke survivors' caregivers, and 20 caregivers (age: M±SD=56.9±12.7 years; 12 females) completed the study. 10 survivors had symptoms of spatial neglect, and 10 did not (i.e., SN+ or SN-, respectively) at the time when discharged from inpatient rehabilitation, which was 9.3±6.2 months before the present study. Via a semi-structured telephone interview, we assessed caregivers' burden and stress qualitatively and quantitatively. RESULTS: No difference was observed across caregiver groups in cognitive function, depressive mood, or community mobility. In comparison, caregivers of the SN+ group allocated more time to care, controlling for survivors' disability (adjusted effective size d = 1.80). Their self-perceived burden and stress were more severe than the other group (adjusted d = .99). Qualitative analysis indicated caregivers of the SN+ group were more likely to describe economic stressors and undesirable changes in career and vacation planning. While 80% of participants preferred their care recipients to receive additional motor or mobility therapy, caregivers of the SN+ group were more likely to suggest additional therapy for cognitive impairment. CONCLUSIONS: This exploratory study suggests that spatial neglect may heighten caregivers' burden and stress levels. Future studies with a large sample size are required.

[Depression and caregiving burden in families of patients with amyotrophic lateral sclerosis].

PURPOSE: The purpose of this study was to describe depression, caregiving burden and the correlation of the two variables in the families of patients with amyotrophic lateral sclerosis (ALS) and to clarify factors predicting caregiving burden. METHODS: A descriptive and cross-sectional study was conducted with 139 family members who provided care to patients with ALS. The characteristics of patients and families, Korean-Beck Depression Inventory (K-BDI), Korean version of Zarit Burden Interview (K-ZBI) and Korean-Amyotrophic Lateral Sclerosis Functional Rating Scale - Revised (K-ALSFRS-R) were used as study measures. RESULTS: The mean score for K-BDI was 19.39 out of 63 suggesting sub-clinical depression and 38.2% of the family members exhibited depression. The mean score for K-ZBI was 66.03 out of 88. The predictors for K-ZBI were K-BDI, age of family member, length of time spent per day in caring, relationship to patient and K-ALSFRS-R. CONCLUSION: The results of this study suggest that levels of depression and caregiving burden are high among family members caring for patients with ALS. As depression is associated with caregiving burden, screening and emotional supports should be provided to reduce the burden of care for these family. Support programs to alleviate the care burden are also needed, considering family demographics, time per day in caring giving and K-ALSFRS-R.

Social impacts of the HIV epidemic.

PIP: Since there is no sociological literature on AIDS, this paper is an introduction to the concepts of culture, social structure, population and human ecology, with hypothetical applications of AIDS information to these ideas. As C. W. Mills set forth, basic questions of social reality applicable to AIDS research might include: what is the social structure of the society; where does the society stand in economic development; and how will the pandemic affect the varieties of people in the society? A culture is the set of ideas and material products that a society uses in interpreting their world. AIDS will renew attention to regulation of sexuality and research on sexual behavior. Social structures are patterns of relationships that give predictability to social life. Patterns of discrimination against minorities and drug users will be affected by AIDS. The dependency ratio of some populations, if not the size of the population itself, may be affected by AIDS. Human ecology is the study of how societies adapt to physical environments, organization and technology. How society uses human and monetary resources will be markedly affected by AIDS, considering the high social costs of education, condoms, treatment, death and burial. A list of positive changes that AIDS may evoke is given: new effectiveness of WHO, and of indigenous health personnel in developing countries, universal health insurance in the U.S., medical rather than criminal treatment of drug users, attention to poor minorities and elimination of racial and ethnic prejudices.^ieng

The influence of different sexual-contact patterns between age classes on the predicted demographic impact of AIDS in developing countries.

A model is developed to describe the spread of HIV within heterosexual communities and the demographic impact of AIDS. The model combines epidemiologic and demographic processes and is designed to mirror the impact of AIDS in sub-Saharan Africa. Refinements on past work in this area include unequal probabilities for transmission from females to males and from males to females, the inclusion of an age- and sex-dependent sexual-partner choice function and distributed incubation plus infectious periods. Numerical studies suggest that unequal transmission probabilities (weighted to a greater probability from males to females than vice versa), and the tendency of males to choose sexual partners of the opposite sex younger than themselves, both act to increase the demographic impact of AIDS over that predicted with equal transmission between the sexes and partner choice restricted within given age classes. Analyses support the conclusions of past work that the epidemic will only have a small detrimental impact on the dependency ratio of a population (the ratio of dependents to working adults) even when a weighting is added to take account of the extra burden imposed by the care of adult AIDS patients. However, a small increase in the ratio can imply a significant rise in the number of dependents within the population. Stimulation studies of the impact of changes in behavior to reduce transmission highlight to the need to induce such changes as early as possible in the course of the epidemic in order to minimize its impact. Directions for future research are discussed emphasizing the need to acquire quantitative data on sexual habits and to construct models to represent heterogeneity in sexual behavior.

PIP: A mathematical model of the likely demographic impact of acquired immunodeficiency syndrome (AIDS) suggest that, in the countries of sub- Saharan Africa, this impact can be expected to increase in the years ahead as a result of unequal transmission probabilities (weighted toward a greater probability from males to females) and the tendency of men to select female sexual partners from a younger class. The model refines earlier work in its consideration of predicted influence of human immunodeficiency virus (HIV) infection on the age structure and dependency ratio of the population, the significance of patterns of sexual contact between the age classes of the 2 sexes, and the impact of control measures such as health education and condom use. The assumptions of a doubling time of 1.5 years in the early stages of the epidemic and a 3 times greater probability of transmission from infected males to susceptible females rather than vice versa produce the observation that net population growth rate will change from positive to negative 25 years after introduction of the AIDS virus. The dependency ration is not significantly affected by AIDS due to the counterbalancing effects of deaths from vertical and horizontal transmission. On the other hand, if dependency ratio is defined to encompass the burden created by the care of AIDS patients, the disease-related ratio will increase over time. The most significant social factor in terms of the impact of AIDS on net fertility is the tendency of African men to choose female sexual partners at least 5 years younger than themselves. Finally, the numerical analyses indicate that the introduction of AIDS control measures 10 years after the onset of the epidemic will slow the progression of the epidemic and prevent a change in the population growth rate from positive to negative over a 100-year period.

A multistate analysis of active life expectancy.

With today's lower mortality rates, longer expectations of life, and new medical technologies, the nation's health policy focus has shifted from emphasis on individual survival to emphasis on personal health and independent living. Using longitudinal data sets and new methodological techniques, researchers have begun to assess active life expectancies, estimating not only how long a subpopulation can expect to live beyond each age, but what fractions of the expected remaining lifetime will be lived as independent, dependent, or institutionalized. New ideas are addressed, applying recently developed multistate life table methods to Waves One and Two of the Massachusetts Health Care Panel Study. Expectations of active life are presented for those 65 and older who initially are in one of two functional states of well-being. Included are expectations of life, for those, for example, who were independent and remained so, or those who were dependent and became independent. Although public health officials are concerned about the number of elderly who cease being independent, preliminary analysis shows that a significant number of the dependent elderly regain their independence, a situation which needs to be addressed in health care planning.

Ageing in India--an overview.

Accelerated population ageing experienced in the last few decades is an unprecedented phenomenon. Currently, this is more in the developing countries. Soon three-fourths of the elderly will be in the developing world. From 1990 to 2025, the elderly population in Asia will rise from 50 per cent of the world's elderly to 58 per cent, in Africa and Latin America from 5 to 7 per cent, but in Europe the figure will drop from 19 to 12 per cent of the world's elderly. The life span has increased in India from 32 yr in 1947 to more than 62 yr now. From the morbidity point of view, almost 50 per cent of the Indian elderly have chronic diseases and 5 per cent suffer from immobility. There are several vulnerable groups and a big disadvantaged lot are elderly females who are one of the fastest growing segments, which will increase to become 4 times the current figure, by 2025. In spite of professional disinterest in the speciality, recent trends indicate the beginning of sensitization of medical teachers, advancing speciality of psychosocial gerontology and availability of some research funds. Importance of training of health professionals and priorities in gerontological research are also under consideration. Infections still take a heavy toll of our elderly population apart from well known degenerative disorders. Limitations of a developing country further influence the morbidity pattern in various ways. Nutritional deficiencies are common and often subclinical thus escaping the desired interventions. Coronary heart disease, hypertension, mental and many other disorders in the elderly have been reported as isolated observations highlighting differences from those made in the Western countries. Socio-economically, the traditional support of extended families is rapidly undergoing erosion making the elderly further vulnerable. This causes more emotional and psychological problems while the State finds itself helpless in providing a comprehensive care to its large chunk of elderly population. It will be important to surmise and predetermine the future factors that are going to modify the diverse patterns of morbidity, disability and mortality in regional context.

PIP: The author discusses aging trends in India, with a focus on ways of dealing with the resulting dependency burden. Sections are included on various dimensions of aging, the health status of the elderly, mortality and morbidity, and psychosocial status and support for the aged.

America's elderly: policy implications.

Senior citizens, particularly those aged 75 or older, are the fastest growing group in the US today. 25 million strong, the elderly make up 11% of the total population, the proportion ranging from 18.1% in Florida to 2.6% in Alaska. 1/4 of the federal budget, $155 billion in 1980, now goes to their support yet many face difficulty in gaining access to the programs designed to benefit them. The elderly, especially those who rely solely on Social Security, comprise a disproportionate share of all poor households. The retirement system itself is facing financing challenges that promise to grow as the baby boom generation swells the number of senior citizens to 55 million in 2030. Plans to coordinate government programs and improve the method of financing the retirement system are receiving increasing attention. Financing Social Security from revenue funds, or with actuarial reserves, are 2 alternatives to the present pay-as-you-go system. Another area of concern to policymakers is America's health care system, which is now crisis oriented and heavily biased toward institutionalization. Health care must be made more responsive to the long-term needs of the oldest segment of the population, many of whom suffer from chronic illnesses. Impaired elderly receive most of their care from family or friends, and private organizations, but this natural support network largely has been ignored by government. New program initiatives might emphasize homemaker services, geriatric day care, compensation for families that provide for the needs of an elderly relative, and the strengthening of the informal partnership between the elderly themselves, their families and friends, community groups, private organizations, and government at the state and local as well as the federal level.

The demographic face of America's elderly.

PIP: Based on a 1996 U.S. census report on aging, the author discusses possible future trends in the aging of the U.S. population, with a focus on the consequences of significant changes in the number and proportion of elderly. The need to understand these trends in order to plan effectively for the future is emphasized.^ieng

Stochastic demographic forecasting.

"This paper describes a particular approach to stochastic population forecasting, which is implemented for the U.S.A. through 2065. Statistical time series methods are combined with demographic models to produce plausible long run forecasts of vital rates, with probability distributions. The resulting mortality forecasts imply gains in future life expectancy that are roughly twice as large as those forecast by the Office of the Social Security Actuary.... Resulting stochastic forecasts of the elderly population, elderly dependency ratios, and payroll tax rates for health, education and pensions are presented."

Changing household composition, labor patterns, and fertility in a highland New Guinea population.

PIP: A multidisciplinary team of researchers have studied the Gainj population in Papua New Guinea's central highlands since the late 1960s. Even though they do not use effective contraception nor practice induced abortion, the total fertility rate (TFR) is very low (4.3). In fact, it is one of the lowest TFRs for a noncontracepting population in the world. Further sexually transmitted diseases are rare thus the Gainj have a low primary sterility rate (1.1%). Moreover premarital pregnancy does not occur. A late median age at 1st birth and long median interbirth intervals contribute to low fertility (25.7 years and 36.5 months). Besides a sizable lag between median age at marriage (21.2 years) and 1st birth exists (4.5 years). In addition, median age at menarche is quite high (18.4 years). Median age at weaning is 38 months. Median lactational anovulation lasts for 20.4 months. These data have inspired the team to determine what effect continuing economic development (Gainj women now grow and market coffee) will have on age at 1st birth, lactational anovulation, and TFR. In 1983, the team surveyed 86 households in 10 Gainj parishes. They consisted of a male head of household and at least 1 wife (conjugal family). It is the cultural and statistical norm and the basic unit of production and consumption among the Gainj. The largest and most significant positive effects on coffee growing success were the number of nonwives, who were the producers, (t=7.4; p.001) and wives (t=2.35; p.05) in the household. In fact, 54% of the nonwives were of marriageable age. Between 1978-1983, the more successful households decreased their dependency ratios while the less successful households increased them. The team surmised that the demands of coffee growing may result in a decrease in the weaning age resulting in a higher TFR. In conclusion, the demographic transition model does not apply to the Gainj.^ieng

Population growth and development in the Third World: the neocolonial context.

PIP: Less developed countries (LDCs) that were colonies of other nations continued operating under the same social and political structures set up by the former ruling nations. The small minority of elites in the LDCs held on to the power acquired during colonial times. In order to preserve their political and financial status after independence, they maintained their close linkages to the capitalist nations and their multinational corporations (MNCs). The elites did not generally have popular support, however. These capitalist nations and their commercial interests continue to dictate most LDCs development process which supports the financial interests of the MNCs and the local elites and not those of the majority, the poor. The poor realize that they are trapped and unable to break away from the economic and political structures, therefore, to assure some form of security, they have many children which exacerbates their poverty. Yet population control policies based on Malthusian theory and those that rely on such undimensional, technical approaches as family planning alone cannot cure the multidimensional social problems of high population growth and poverty. Neither the Malthusian nor Marxist theories totally explain the situation in the LDCs or even provide workable solutions. Research on population and development in LDCs needs to address both the Malthusian concern for the problems posed by high growth rates and the Marxist critique of class struggle in development trends. To eliminate the trap of poverty and dependent economies, each country must design its own remedies based on its history, culture, and geography and alter the prevailing social, economic, and political power structures in favor of the poor. 6 propositions that must be modified to each nation's particular problems and needs are presented to guide LDCs in formulating or reformulating policies to alleviate the problems of population and poverty.^ieng

Population age structure and the size of social security.

"This paper uses a general overlapping generations model to analyze social security. Rather than focusing on intertemporal price and income considerations, however, the paper focuses on the effect of contemporaneous (same period) prices and income. The analysis shows that the old-age dependency ratio acts as a shadow price for old-age benefits. With this new shadow price, the equilibrium price and quantity of social security benefits and the level of the payroll tax rate are determined in a demand-supply framework with individual utility maximization. Three explicit demand functions (intergenerational contracts) are analyzed. The model is tested using [U.S.] time series data for the social security Old-Age and Survivors (OASI) program."

Simulating alternative social security responses to the demographic transition.

"This paper uses a perfect foresight life cycle simulation model to examine the dynamic economic effects of baby 'booms' and baby 'busts' as well as the interaction of such demographic changes with social security policy. Demographic change can have sizeable short and long-run effects on saving rates and factors returns." The geographic focus is on the United States. "The model predicts long-run improvement in welfare associated with a prolonged baby bust. This improvement holds even in the absence of accommodating social security policy. It reflects a long-run decline in the dependency ratio, with the reduction in dependent children per worker more than offsetting the increase in retirees per worker."

When the baby boom grows old: impacts on Canada's public sector.

The authors discuss the dependency burden that is expected to result from demographic aging in Canada. "The estimated size of the burden depends on projections of demographic change, economic growth, and structural aspects of the major age-sensitive public-sector programmes. The burdens are analysed for 2016 and 2036, the period when demographic aging may be expected to have its most adverse impacts on old-age dependency ratios and public-sector programme costs. Contrary to many popularly expressed concerns, demographic aging is not the most important factor in determining future public-sector costs and revenues. Rather, aspects of the design and management of public-sector programmes represent the greatest area of uncertainty."