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Epidemiology of ageing:

Healthy old age only for the

socially well-off? well off?

Prof. Dorly J.H. Deeg, PhD

Department of Psychiatry and

Institute for Research in Extramural Medicine

VU University Medical Centre, Amsterdam, The Netherlands


Population ageing

Chronic diseases

Themes

Consequences: functional limitations and

disability

Use of health care services and equipment

Shifts (trends) in functional limitations and in

care services supply


Population ageing

Chronic diseases

Themes

Consequences: functional limitations and

disability

Use of health care services and equipment

Shifts (trends) in functional limitations and in

care services supply


%

Survival to age 1, birth cohorts 1900-1937

Males and females, The Netherlands

100

90

80

70

60

50

1900 '10 '20 '30

Year of birth

Source: Nethderlands Interdisciplinary Demographic Institute

Men

Women


%

100

Survival to age 50, birth cohorts 1907-1937

Males and females, The Netherlands

90

80

70

60

50

1910 1925

Year of birth

Source: Netherlands Interdisciplinary Demographic Institute

Men

Women


Remaining years of life

25

20

15

10

5

0

Bron: CBS Statline 2003

Development of the life expectancy

from age 65 and 80 years

'50 '60 '70 '80 '90 '00

Jaar

Men 65

Women 65

Men 80

Women 80


Change over time

Population trends: compression of mortality across time

Before/after 1950: reduction mortality ~ social/medical


Population ageing

Chronic diseases

Themes

Consequences: functional limitations and selfperceived

health

Use of health care services

Shifts (trends) in functional limitations and in

care services supply


Longitudinal Aging Study Amsterdam

Random sample

3107 men and women

Ages 55-85

Start 1992

3-year intervals

North Sea

Amsterdam

Belgium

Oss

Zwolle

Germany


Independent

variables

Coping

The LASA-model

Objective

functioning

Standards / aspirations

Subjective

functioning

Contributions /

needs:

- participation

- use of care

General

well-being

Mortality


Development of health problems

Disability

Limitation

Impairment

Disease


Chronic physical diseases and Age

80

70

60

50

40

30

20

10

0

% no chronic

diseases

% > 1 chronic

diseases

55-64 65-74 75-84 85-94

Source: Longitudinal Aging Study Amsterdam, 2002


Main chronic conditions

Heart diseases (Myocardial Infarction,

Angina Pectoris, Heart Failure,

Atherosclerosis)

Diabetes (type II)

Lung Diseases (Asthma, COPD)

Cancer

Joint disorders (Osteo-arthritis)

Psychiatric complaints (Depression,

Anxiety, Dementia)


%

60

50

40

30

20

10

0

*

Heart

Chronic diseases 65+

*

Diabetes

*

Lung

Cancer

Joints

Psych

2001

Source: Longitudinal Aging Study Amsterdam * expected increase >10% to 2020 (NPHP)

?


Female/male difference in disaease prevalence 65+

f / m

Heart 0,6

Diabetes 1,5

Lung 1,0

Cancer 1,0

Joints 2,4

Psychiatric 1,7


35

30

25

20

15

10

5

0

Life expectancy at age 65, 1993

Average

Lung/Cancer

Heart diseases

Joint disorders

Source: Longitudinal Aging Study Amsterdam

Healthy

Men

Women


Why sex differences?

Biological differences: genetic, hormonal

(estrogens)

Risks during the life course

(labour, smoking)

Use of health care

Coping with disease (disease behaviour)

Reporting behaviour


Population ageing

Chronic diseases

Themes

Consequences: functional limitations and

disability

Use of health care services and equipment

Shifts (trends) in functional limitations and in

care services supply


• Definition:

Disability

√ Inability to carry out the usual tasks of daily living

√ Gap between capacity of individual and demands of

environment

• Powerful measure of health in older age

√ Associated with most chronic conditions (e.g., stroke,

arthritis, diabetes)

√ Independent predictor of mortality


80

60

40

20

Change in functional limitations with aging

0

70-74 75-59 80-84 85-89

Source: Longitudinal Aging Study Amsterdam

Men

Women


3-year changes in functional limitations

55-64 65-74 75-85 yrs

Worse 18% 30% 50%

Better 12% 9% 7%

Source: Longitudinal Aging Study Amsterdam


Chronic conditions: consequences

0,2

0,15

0,1

0,05

0

Heart

Diabetes

Lung

Cancer

Joints

Psych

Physical Limitations Mortality in 1,5 years

Source: Longitudinal Aging Study Amsterdam


Special groups

• Low education/low income

• Living alone

• Urban areas


• Higher mortality

• More health problems


20

18

16

14

12

10

8

Life expectancy at 65 years

Elementary

by level of education

Lower-middle

Source: TNO-PG (ERGO, GLOBE, LASA)

Higher-middle

Higher

Men

Women


100

90

80

70

60

50

% disability-free life expectancy

at 65 years, by level of education

Elementary

Lower-middle

Source: TNO-PG (ERGO, GLOBE, LASA)

Higher-middle

Higher

Men

Women


Social determinants

Associated with lower risk of disability:

• Higher education: life-long asset;

knowledge, living standard

• Having a partner: life-long asset but can be lost;

support, self-esteem, living standard, information

… independent of age, gender, chronic conditions


Cluster analysis

Trajectories of disability

In surviving subjects (n=1988):

limitation scores T 1 , T 2 , T 3 --> 5 course types

In subjects who died between T 2 , T 3 (n=325):

limitation scores T 1 , T 2 --> 2 course types

In subjects who survived between T 1 , T 2 (n=417):

limitation score T 1 --> 1 course type


Summary of trajectories

Compression of disability

‘So far so good’

Stable no disability 53%

‘Terminal drop’

No limitations, died 18%

Late increase in disability 5%

Expansion of disability

All others 24%


70

60

50

40

30

20

10

0

%

Education

high

Social determinants

Stable no disability Terminal drop Expansion

* *

Education

low

Partner No partner

* Distribution of trajectories significantly different (p < 0.05); adjusted for age, sex and other factor


70

60

50

40

30

20

10

0

Interaction of social determinants

Education

high

Stable no disability Terminal drop Expansion

Partner No partner

* *

Education

low

* Distribution of trajectories significantly different (p < 0.05)

Education

high

Education

low


Conclusions (1)

• Increase in life expectancy since 1950 largely due to

medical advances

• Multimorbidity is rule more than exception in older age

• Joint disorders most prevalent, especially in women

• Psychiatric disorders second in prevalence, first in

disabling consequences

• Gender- and educational differences in (healthy) life

expectancy

• Most unfavourable trajectories of disability among

lower educated persons without partner


Population ageing

Chronic diseases

Themes

Consequences: functional limitations and

disability

Use of health care services and equipment

Shifts (trends) in functional limitations and in

care services supply


Change over time

• Population trends: compression versus expansion of

disability across time:

√ Compression: disability decreases faster than mortality or

disability increases slower than mortality

√ Expansion: disability decreases slower than mortality or

disability increases faster than mortality


Health status in 1993 compared to 1956

1956 (reference year)

Mortality

>2 diseases

Physical limitations

Fair/poor self-rated ealth

Men Women

1.00

0.80

1.63

1.23

2.25

1.00

0.40

1.42

0.78

1.46

Sources:

Dutch Longitudinal Study among the Elderly, Longitudinal Aging Study Amsterdam

(Deeg et al 1994)


1992/93

1995/96

1998/99

LASA time schedule (1)

Baseline cycle T 1

Second cycle T 2

Third cycle T 3

n=3107

n=2545

n=2076

2001/02 Fourth cycle T4 n=1691

Longitudinal change


1992/93

1995/96

1998/99

LASA time schedule (2)

Baseline cycle T 1

Second cycle T 2

Third cycle T 3

n=3107

n=2545

n=2076

2001/02 Fourth cycle T4 n=1691

Trend shift


Number

2,5

2

1,5

1

0,5

0

Chronic diseases 65+, 1993-2002

Source: Longitudinal Aging Study Amsterdam

65-74 75-85

1993

1996

1999

2002


%

25

20

15

10

5

0

National Long Term Care Survey (Spillman 2004)

Trend in disability 65+,

United States, 1984-1999

1984 1989 1994 1999

Total

limitations

Severe

limitations


%

40

35

30

25

20

15

10

5

0

Trend in disability 65+,

The Netherlands, 1993-2002

1992-93 1995-96 1998-99 2001-02

Longitudinal Aging Study Amsterdam (Portrait 2003)

Total

limitations

Severe

limitations


1992/93

1995/96

1998/99

LASA time schedule (3)

Baseline cycle T 1

Second cycle T 2

Third cycle T 3

n=3107

n=2545

n=2076

2001/02 Fourth cycle T4 n=1691

2002/03 Baseline new n=1002

Trend shift


12

10

8

6

4

2

0

Trends in lung diseases, 55-64-years

Men

1992/93

* adjusted for age

Brinkkemper 2005

Men

2002/03

Women

1992/93

Women

2002/03

Men 1992/93

Men 2002/03

Women 1992/93

Women 2002/03


12

10

8

6

4

2

0

Men

1992/93

* adjusted for age

Brinkkemper 2005

Trends in diabetes, 55-64-years

Men

2002/03

Women

1992/93

Women

2002/03

Men 1992/93

Men 2002/03

Women 1992/93

Women 2002/03


100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Trends in body weight, 55-64-years

Men

1992/93

* adjusted for age, education

Visser et al. 2005

Men

2002/03

Women

1992/93

Women

2002/03

Normal weight

Overweight

Obesity


Mi

nu

te

n

pe

r

da

Trends in physical activity, 55-64-years

250

200

150

100

50

0

61

45

17

* adjusted for age, education

Visser et al. 2005

58

33

176

42

138

29

9 12 11

23 18 18 15

Mannen

1992/93

Mannen

2002/03

*

*

*

Vrouwen

1992/93

Vrouwen

2002/03

*

*

sports

biking

walking

household

activities


Ages: 65-84

Trends 1992-2002: Education

Education:

Low Middle High

Year: * * *

. 1992-3 50 39 11

. 1995-6 44 44 12

. 1998-9 40 47 14

. 2001-2 36 48 15

Note: Prevalences are weighted to the general population

* Significant trend


Trends 1992-2002: Education

Ages: 55-64

Education:

Low Middle High

Year: * * *

. 1992-3 32 51 17

. 2002-3 21 55 24

Note: Prevalences are weighted to the general population

* Significant trend


Explanations

Increasing level of education =>

Healthier cohorts


Explanations for mixed changes over time

• Earlier diagnosis of chronic conditions

• Better disease management

• Increase in mild, decrease in severe

limitations

• Higher expectations of medical science

• Higher norms of good health

• Poorer life style


Conclusions (2)

• Cohort explanation unlikely to account for full

trends in prevalence of diseases and

limitations

• Period effects seem larger part of explanation

• Either explanation leads to very different

projections


Population ageing

Chronic diseases

Themes

Consequences: functional limitations and

disability

Use of health care services and equipment

Shifts (trends) in functional limitations and in

care services supply


Source: CBS

Hospital admission by age


Distribution of diseases in persons 65+ without (red)

and with (blue) recent hospital admission

45

40

35

30

25

20

15

10

5

0

%

0 1 2 >2 diseases 0 1 2 >2 diseases

number of diseases

Source: Deeg & Broese van Groenou 2007


Longitudinal Aging Study Amsterdam

Hospital admission: reasons

Most important reasons for admission:

Cardiovascular diseases 25% L+

Musculoskeletal disorders 17% L+

Eye disorders 13%

Genital organs (men) 10%

Malignancies 7% L+

Accidents 7% L+

Digestive organs 6%

* in past 6 months

L+: relatively severely limiting


%

70

60

50

40

30

20

10

0

1992-93

Longitudinal Aging Study Amsterdam

Post-hospital disability

1995-96

1998-99

2001-02

Total

limitations

Severe

limitations


%

Trend in care services supply, Netherlands

20

18

16

14

12

10

8

6

4

2

0

1992 1993 1995 1996 1998 1999

Statistics Netherlands (Portrait 2003)

Home care

workers /

1000

Hospital

days / 1000


%

50

40

30

20

10

0

Longitudinal Aging Study Amsterdam

*

1992-93

Post-hospital use of care (1)

*

1995-96

*

1998-99

*

*

2001-02

Care by partner

if partner

Care by partner

total

Subsidised

home care

* significant difference with non-hospital admissions


Longitudinal Aging Study Amsterdam

Post-hospital use of care (2)

No change in:

• Informal care by others, stayed 13%

• Private care, stayed 18%

Change in:

• Subsidised home care: 23% – 14%

• Care by partner: 37% – 47%

• Dissatisfaction about care received

increased: 16% – 27%


Conclusions (3)

• At population level, increase in mild (not severe)

limitations

• Happens at the same time as decrease in care supply

• Most expensive care service, hospital days,

decreased

• Less subsidised home care; more care by partner

after hospital admission

• Older couples are group at risk


Population ageing

Chronic diseases

Themes

Consequences: functional limitations and

disability

Use of health care services and equipment

Shifts (trends) in functional limitations and in

care services supply


Background

• United States a.o.: Decreasing trends in

disability rates in older age

• Decreases in disability partly attributed to

increases in use of assistive devices

• The Netherlands: Contradictory evidence on

trends in disability rates at older ages

• LASA: increasing disability rates, despite

increases in use of assistive devices


Research question

Seemingly contradictory trends -

explanation?

Different trends for disability and device

use across subpopulations?


1992/93

1995/96

1998/99

LASA time schedule (3)

Baseline cycle T 1

Second cycle T 2

Third cycle T 3

n=3107

n=2545

n=2076

2001/02 Fourth cycle T4 n=1691

2002/03 Baseline new n=1002

Trend shift


For each disability item if:

Assistance

no difficulty / difficulty / only with help

Assistive device use: no - yes

Human assistance: no / seldom / sometimes - often / always


% Device use in 1992 and 2002, ages 55-64

1992 2002

No disability 2.6 2.8

Mild disability 19.3 27.5

Severe disability 24.1* 33.5*

Men 5.5 8.3

Women 6.2 12.6*

Low education 8.5* 13.8*

High education 2.8 8.2

Partner 5.3 9.3

No partner 8.4 16.8*

Longitudinal Aging Study Amsterdam ; sample 2002 weighted to 1992; * association with covariate p < 0.05

age and chronic diseases not independently associated


Compative analysis

Logistic regression analysis -> OR

• Dummy for Cohort: 0 = 1992, 1 = 2002

test of OR(Cohort) -> trend

• Adjustment for covariates

• Interaction Cohort*Covariate one by one

test of Interaction -> differential trend


Trend in disability & device use 1992-02,

adjusted OR

Mild Severe Device

Total 1.85 1.71 1.71

Men 1.36 1.05

Women 2.39 2.48

Partner 2.38 1.21

No partner 0.84 2.53

Low education 1.02

High education 2.57

Longitudinal Aging Study Amsterdam; bold italic: trend significant; bold italic: interaction significant


Conclusion on trends

• Increase in disability, mild more than severe

• Increase in assistive device use

• Increase in disability in women and partnered

• Increase in device use in higher educated and

partnerless


Explanations (?)

Education/gender discrepancy in device use:

• Higher educated better manage their disability

- if disabled

• Higher educated have higher norms of good

health

• Lower educated and women have less money

to spend than higher educated and men


Policy on ageing

A valid policy on ageing should be based

on:

•a correct understanding of the various

groups of older persons at risk in our society,

and

•a correct understanding of the macroinfluences

on the chain from disease to care

utilisation


Hendrikje Van Andel,

died 115 years old

Two oldest ladies

Jeanne Calment,

died 122 years old

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