Temporal trends in impairments of physical function among older adults during 2001-16 in Sweden: towards a healthier ageing.

Background: a trend towards decline in disability has been reported in older adults, but less is known about corresponding temporal trends in measured physical functions. Objective: to verify these trends during 2001-16 in an older Swedish population. Methods: functional status was assessed at three occasions: 2001-04 (n = 2,266), 2007-10 (n = 2,033) and 2013-16 (n = 1,476), using objectively measured balance, chair stands and walking speed. Point prevalence was calculated and trajectories of change in impairment/vital status were assessed and were sex-adjusted and age-stratified: 66; 72; 78; 81 and 84; 87 and 90. Results: point prevalence of impairment was significantly lower at the 2013-16 assessment than the 2001-04 in chair stand amongst age cohorts 78-90 years, and in walking speed amongst age cohorts 72-84 years (P < 0.05), but not significantly different for balance. The prevalence remained stable between 2001-04 and 2007-10, while the decrease in chair stands and walking speed primarily occurred between 2007-10 and 2013-16. Among persons unimpaired in 2007-10, the proportion of persons who remained unimpaired in 2013-16 tended to be higher, and both the proportion of persons who became impaired and the proportion of persons who died within 6 years tended to be lower, relative to corresponding proportions for persons unimpaired in 2001-04. Overall, there were no corresponding changes for those starting with impairment. Conclusions: our results suggest a trend towards less functional impairment in older adults in recent years. The improvements appear to be driven by improved prognosis amongst those without impairments rather than substantial changes in prognosis for those with impairments.

Towards a postponement of activities of daily living dependence and mobility limitations: Trends in healthy life years in old age in Sweden.

AIMS: To investigate the development of healthy life expectancy from 65 years (HLE65) in Sweden in the period 1980-2011 using the health indicators activities of daily living (ADL) and mobility limitations within the framework of the postponement, compression and expansion theories. METHODS: Sources of data for the HLE computations were Swedish national mortality statistics and the nationwide Swedish Surveys of Living Conditions, conducted biennially by Statistics Sweden since 1974. We used the Sullivan method for calculations of HLE and a decomposition into mortality and disability effects was made. RESULTS: Life expectancy at age 65 (LE65) increased by 3.1 years for women and 4.0 years for men from 1980-1985 to 2006-2011. HLE65 calculated according to ADL and mobility limitations increased more rapidly than LE65 for both men and women ( p<0.05). CONCLUSIONS: Our results for trends in the Swedish LE65 and HLE65, computed on the basis of ADL and mobility limitations and using the Swedish Surveys of Living Conditions study, are in line with the postponement hypothesis and there is also a tendency for compression. Thus the years with ADL dependence and mobility limitations are postponed to a higher age and the numbers of these years have decreased.

Living alone and unplanned hospitalizations among older adults: a population-based longitudinal study.

Background: The association of living alone with hospitalization among the general elderly population has been rarely investigated, and the influence of common disorders on this association remains unknown. Methods: We used data on participants in the Swedish National study on Aging and Care in Kungsholmen ( n = 3130). Risk and number of unplanned hospitalizations and length of hospital stays were studied over a period of 2 years. We used Cox proportional hazard models to estimate hazard ratios (HRs) of incident hospitalization and zero-inflated negative binomial regression models adjusted for potential confounders to estimate incident rate ratios (IRR) of the number of hospitalizations and total length of stay associated with living alone. Results: A total of 1768 participants (56.5%) lived alone. Five hundred and sixty-one (31.7%) of those who lived alone had at least one unplanned hospitalization. In the multivariate analyses, living alone was significantly associated with the risk of unplanned hospitalization (HR = 1.21, 95% confidence interval [CI] 1.01-1.45) and the number of hospitalizations (IRR = 1.35, 95% CI 1.04-1.76) but not with the length of hospital stays. In stratified analyses, the association between living alone and unplanned hospitalizations remained statistically significant only among men (HR = 1.52, 95% CI 1.17-1.99). Conclusions: Living alone is associated with higher risks of unplanned hospitalization in elderly, especially for men.

Healthy life years in old age: Swedish development 1980-2010 according to different health indicators.

AIMS: To investigate the development of healthy life expectancy from 65 years (HLE65) in Sweden in the period 1980 and 2010 by using two different health indicators: self-rated health and the global activity limitation indicator (GALI). METHODS: Sources of data for the HLE computations were Swedish national mortality statistics and the nationwide Swedish Survey of Living Conditions (SSLC), which have been conducted biennially by Statistics Sweden since 1974. We used the Sullivan method for calculations of HLE. A decomposition into mortality and disability effect has been made in accordance with the method devised by Nusselder. RESULTS: Life expectancy at age 65 (LE65) increased by 3.1 years for women and 4.0 years for men from 1980/85 to 2006/11. Regardless of which health measure investigated - self-rated health or GALI - HLE65 increased between the periods 1980/85 to 2006/2011 more rapidly than LE65 and as a consequence the years with bad self-rated health and years with activity limitations decreased. These increases as well as the decreases were significant (p<0.05). CONCLUSIONS: The Swedish LE65 and HLE65 development, as judged by the SSLC study, are compatible with the postponement hypothesis and there is even a clear tendency for compression. Thus, the years with bad self-rated health and years with activity limitations are postponed to a higher age and the number of those years have decreased. From this respect, the Swedish development looks positive. The need of old age care in 2010 would have been much higher if it had been expansion - not postponement - of bad self-rated health and years with activity limitations during the time period.

Impact of living alone on institutionalization and mortality: a population-based longitudinal study.

BACKGROUND: Living alone is common among elderly people in Western countries, and studies on its relationship with institutionalization and all-cause mortality have shown inconsistent results. We investigated that the impact of living alone on institutionalization and mortality in a population-based cohort of elderly people. METHODS: Data originate from the Swedish National study on Aging and Care-Kungsholmen. Participants aged ≥66 years and living at home (n = 2404) at baseline underwent interviews and clinical examination. Data on living arrangements were collected in interviews. All participants were followed for 6 years; survival status and admission into institutions were tracked continuously through administrative registers from 2001 to 2007. Data were analysed using Cox proportional hazard models, competing risk regressions and Laplace regressions with adjustment for potential confounders. RESULTS: Of the 2404 participants, 1464 (60.9%) lived alone at baseline. During the follow-up, 711 (29.6%) participants died, and 185 (15.0%) were institutionalized. In the multi-adjusted Cox model, the hazard ratio (HR) of mortality in those living alone was 1.35 (95% confidence interval [CI] 1.18 to 1.54), especially among men (HR = 1.44, 95% CI 1.18 to 1.76). Living alone shortened survival by 0.6 years and was associated with the risk of institutionalization (HR = 1.74, 95% CI 1.10 to 2.77) after taking death into account as a competing risk. CONCLUSIONS: Living alone is associated with elevated mortality, especially among men and an increased risk of institutionalization. Over a 6-year period, living alone was related to a half year reduction in survival among elderly people in Sweden.

Horizontal and vertical targeting: a population-based comparison of public eldercare services in urban and rural areas of Sweden.

The concepts of target efficiency can be used to assess the extent to which service provision is in line with the needs of the population. Horizontal target efficiency denotes the extent to which those deemed to need a service receive it and vertical target efficiency is the corresponding extent to which those who receive services actually need them. The aim of this study was to assess the target efficiency of the Swedish eldercare system and to establish whether target efficiencies differ in different geographical areas such as large urban, midsize urban and rural areas. Vertical efficiency was measured by studying those people who received eldercare services and was expressed as a percentage of those who received services who were functionally dependent. To measure horizontal target efficiency, data collected at baseline in the longitudinal population study SNAC (Swedish National study on Aging and Care) during the years 2001-2004 were used. The horizontal efficiency was calculated as the percentage of functionally dependent persons who received services. Functional dependency was measured as having difficulty with instrumental activities of daily living (IADL) and/or personal activities of daily living (PADL). Services included long-term municipal eldercare services (LTC). Horizontal target efficiency for the public LTC system was reasonably high in all three geographical areas, when using dependency in PADL as the measure of need (70-90 %), but efficiency was lower when the less restrictive measure of IADL dependency was used (40-50 %). In both cases, the target efficiency was markedly higher in the large urban and the rural areas than in the midsize urban areas. Vertical target efficiency showed the same pattern-it was almost 100 % in all areas for IADL dependency, but only 50-60 % for PADL dependency. Household composition differed in the areas studied as did the way public long-term care was provided to people living alone as compared to those co-habiting.

Comparing long-term care recipients in urban and rural municipalities in Japan and Sweden.

Japan and Sweden both have national systems of long-term care (LTC) and face similar challenges. This study compared various indicators of disability in LTC recipients in nine large urban, midsize urban, and rural municipalities in both countries. The aim was to establish whether urban-rural differences exist and whether they follow similar patterns in Japan and Sweden. It was found that LTC recipients in large urban municipalities in both countries were on average significantly less disabled than those from the other types of municipalities, regardless of the indicator for disability. Fewer persons in large urban municipalities live in extended families, which may increase the propensity to apply for LTC. The number of older people living alone in Japan is increasing, which means that the formal LTC system will come under increased pressure.

Future Costs of Long-term Care in Japan and Sweden.

Population aging is expected to increase long-term care (LTC) costs in both Japan and Sweden. This study projected LTC costs for 2010 through 2040 for different assumptions of population change, LTC need by age group and gender, and LTC provided per level of need and cost in Japan and Sweden. Population data were taken from the official national forecasts. Needs projections were based on epidemiological data from the Nihon University Japanese Longitudinal Study of Aging and the Swedish Survey of Living Conditions. Data on LTC provision by need and cost were taken from nine Japanese municipalities collected by assessments in the LTC insurance system and from surveys in eight Swedish municipalities. Total initial costs were calibrated to official national figures. Two projections based on two different scenarios were made for each country from 2010 to 2040. The first scenario assumed a constant level of need for LTC by age group and gender, and the other assumed a continuation of the present LTC need trends until 2025. For Japan, this resulted in a projected cost increase of 93% for the one and 80% for the other; for Sweden it was 52% and 24%, respectively. The results reflected differences in population aging and health development.

Rapid decrease in length of stay in institutional care for older people in Sweden between 2006 and 2012: results from a population-based study.

There is limited knowledge about older people's length of stay (time until death) in institutional care and how it has changed over time. The aim of this study was to analyse changes in the length of stay for older people in institutional care between 2006 and 2012. All persons 65+ living in Kungsholmen (an urban area of Stockholm), who moved to an institution between 2006 and 2012, were included (N = 1103). The data source was the care system part of a longitudinal database, the Swedish National Study on Aging and Care. The average length of stay was analysed using Laplace regression for the 10th to the 50th percentile for the years 2006-2012. The regressions showed that in 2006, it took an average of 764 days before 50% of those who had moved into institutional care had died. The corresponding figure for 2012 was 595 days, which amounts to a 22.1% decrease over the period studied (P = 0.078). For the lower percentiles, the decrease was even more rapid, for example for the 30th percentile, the length of stay reduced from 335 days in 2006 to 119 days in 2012, a decrease of 64.3% (P < 0.001). The most rapid increase was found in the proportion that moved to an institution and died within a short time period. In 2006, the first 10% had on average died after 85 days, in 2012 after only 8 days; a decrease in the length of stay of 90.5% (P = 0.002). In general, there was a significant decrease in the length of stay in institutional care between 2006 and 2012. The most dramatic change over the period studied was an increase in the proportion of people who moved into an institution and died shortly afterwards.

Influence of Incipient Dementia on Hospitalization for Primary Care Sensitive Conditions: A Population-Based Cohort Study.

BACKGROUND: Studies have reported that moderate/severe stages of dementia are linked to increased hospitalization rates, but little is known about the influence of incipient dementia on hospitalizations for primary care sensitive conditions (PCSCs). OBJECTIVE: To examine the associations between incipient dementia and hospitalization outcomes, including all-cause and PCSC hospitalization. METHODS: A total of 2,268 dementia-free participants in the Swedish National study on Aging and Care-Kungsholmen were interviewed and clinically examined at baseline. Participants aged ≥78 years were followed for 3 years, and those aged 60-72 years, for 6 years. Number of hospitalizations was retrieved from the National Patient Register. Dementia was diagnosed in accordance with Diagnostic and Statistical Manual of Mental Disorders-IV criteria. Hospitalization outcomes were compared in participants who did and did not develop dementia. Zero-inflated Poisson regressions and logistic regressions were used in data analysis. RESULTS: During the follow-up, 175 participants developed dementia. The unadjusted PCSC admission rate was 88.2 per 1000 person-years in those who developed dementia and 25.6 per 1000 person-years in those who did not. In the fully adjusted logistic regression model, incipient dementia was associated with an increased risk of hospitalization for PCSCs (OR = 2.3, 95% CI 1.3-3.9) but not with the number of hospitalizations or with all-cause hospitalization. Risks for hospitalization for diabetes, congestive heart failure, and pyelonephritis were higher in those who developed dementia than in those who did not. About 10% participants had a PCSC hospitalization attributable to incipient dementia. CONCLUSION: People with incipient dementia are more prone to hospitalization for PCSCs but not to all-cause hospitalization.

What happened to the care of older persons in Sweden? A retrospective analysis based upon simulation model calculations, 1985-2000.

There is in Sweden a lack of national data connecting public care services to needs in various sub-groups. As result of these statistical deficiencies there has been a severe lack of solid facts to guide the public debate in Sweden concerning the developments of the old age care system. Also connected to this are the similar problems of predicting future needs development in order to estimate future burdens on the systems of care. A computer model has been developed that, by combining different national and local data sources, describes the development of the Swedish public system of care for older persons in terms of service provision and costs per needs group according to age, gender, marital status and degree of disability or ill-health. The model works in 5-year steps and has a retrospective part covering the period 1985-2000 and a prospective part for the period 2005-2030. In this article is described the structure of the model, assumptions, data sources and results for the retrospective part of the model. The model calculations show that despite of a large increase in the number of older persons there has not been a very substantial increase of needs. The number of persons with severe ill-health is basically unchanged, even if there appears to have been some shift in the composition of the group towards more heavy disability. The reductions in provided services, that the municipalities have been forced to do depending on the harsher economic conditions in Sweden since the beginning of the 1990s, have almost exclusively been targeted on persons with lesser needs. Those most in need have largely been shielded.

Whither care of older persons in Sweden?--A prospective analysis based upon simulation model calculations, 2000-2030.

The increasing number of older persons to be expected in the coming decades raises serious questions concerning the resources that will be demanded for provision of long-term care of the frail elderly. Clearly there is a need for increased resources. However, simplistic calculations based upon the assumption that future needs of care will be proportional to the number of old persons per age group seem to lead to substantially exaggerated results by failing to take into account the positive health development of the older persons. In fact a simple model earlier co-developed by the author showed that the expected increase in the period 2000-2030 was reduced from 60% to around 20%, assuming that prevailing health trends should continue. In an effort to corroborate these results and make possible further analysis of different factors pertaining to the estimation of future needs of publicly financed long-term care of frail older persons, a new model has been developed. The model also contains a retrospective part described in another paper. Data for the model are derived from different sources--longitudinal studies, local surveys of recipients of care, etc. Four different scenarios are explored. The model calculations show that the results are highly sensitive to the assumptions you make concerning the health development of older persons. In the most pessimistic scenario D the projected cost increase in fixed prices during the period amounts to 69%--in the most optimistic scenario 0 the cost increase stays at 25%. This shows the great importance of policy measures directed at improving the health of the elderly--involving among others conditions that stimulate to increased physical and mental activity and also different medical interventions.

According to need? Predicting the amount of municipal home help allocated to elderly recipients in an urban area of Sweden.

Given the cutbacks which have been carried out in the Swedish welfare state despite the unchanged official policy of allocation of home help services according to needs, it is essential to evaluate the factors which guide the allocation of home help today. Whereas numerous studies have identified factors which predict entry into the home help system, the present paper concentrates on predictors of the amount of home help amongst those allocated assistance. Data were obtained from the population-based care and services section of the 2002 Swedish National Study of Aging and Care-Kungsholmen (SNAC-K). All home help recipients (> or = 65 years of age) living in an inner city district of Stockholm (Kungsholmen) were analysed with ordinary least squares regressions to identify predictors of the number of hours of home help (n = 943). Need indicators, i.e. dependency in activities of daily living (ADLs) and instrumental ADLs (IADLs), and cognitive impairment (Berger scale) were the strongest predictors of more hours of home help. The addition of sociodemographic (i.e. age, gender and income), environmental (i.e. informal care, housing adaptations and housing accessibility) and structural (i.e. variations in allocation decisions between one care manager and another) factors contributed only marginally to the explained variance. Hours of help entitlement increased slightly with greater age. Co-residing individuals were allocated significantly fewer home help hours than those living alone. Income and regular access to informal care were not significant predictors. The fact that services are provided according to need criteria does not necessarily mean that the provided services are adequate to meet needs. On the macro level, social policy decisions and available economic and manpower resources determine the allotment of municipal home help. However, this study in an urban sample suggests that, within the available resources, the amount of home help allocated is guided mainly by need indicators amongst those given assistance.

Inpatient/outpatient health care costs and remaining years of life--effect of decreasing mortality on future acute health care demand.

The article introduces a method that may be used to estimate how demographic changes may affect future demand for inpatient/outpatient health care. The method is useful in order to refine estimation of demographic influence on demand in the process of health human resources planning. Empirical evidence focuses on the connection between health care costs and remaining years of life. We estimate the demographically determined rise in inpatient/outpatient health care demand in Sweden in the period 2000-2030. The increase arrived at, by means of our method, is circa 37% lower than estimates done with a simple demographical extrapolation, which does not take the decreasing mortality pattern into account.

Provision of long-term care in relation to needs in urban and rural municipalities in Japan and Sweden.

AIM: The aim of the study was to establish whether there are differences in long-term care (LTC) provision with regard to needs between rural and urban municipalities in Japan and Sweden, and we propose possible causes for these differences. METHODS: Using comparable datasets from Japan (n = 20 699) and Sweden (n = 17 576), the care systems have been compared on an individual level. The datasets each contain information from nine large urban, midsize urban and rural municipalities regarding disability levels and the LTC services provided. RESULTS: LTC users in the large urban municipalities in both countries are, on average, less disabled than users in the midsize urban and rural municipalities. In both countries, per capita costs for LTC were lower in the large urban municipalities than in the rural municipalities (10% and 14%, respectively). However, when standardized for the level of disability, the per capita costs were higher in the large urban municipalities (4% in both cases). Multivariate analysis showed that there were significant per capita cost differences between the large urban and the rural municipalities in Japan. In Sweden, there were no significant per capita cost differences between the different types of municipality when age, sex and disability differences were accounted for. CONCLUSION: The findings seem to reflect the effect of differences in household structure, which in the large urban municipalities result in less access to informal LTC, thereby influencing the propensity to apply for formal, public LTC - especially for those with lesser needs. In Japan, where the number of extended family households is decreasing, this gives an idea of the future challenges facing LTC provision.

The rise and fall of women's advantage: a comparison of national trends in life expectancy at age 65 years.

The female advantage in life expectancy (LE) is found worldwide, despite differences in living conditions, the status of women and other factors. However, this advantage has decreased in recent years in low-mortality countries. Few researchers have looked at the gender gap in LE in old age (age 65) in a longer historical perspective. Have women always had an advantage in LE at old age and do different countries share the same trends? Life expectancy data for 17 countries were assessed from Human Mortality Database from 1751 to 2007. Since most of the changes in LE taking place today are driven by reductions of old age mortality the gender difference in LE was calculated at age 65. Most low-mortality countries show the same historical trend, a rise and fall of women's advantage in LE at age 65. Three phases that all but two countries passed through were discerned. After a long phase with a female advantage in LE at 65 of <1 year, the gender gap increased significantly during the twentieth century. The increase occurred in all countries but at different time points. Some countries such as England and France had an early rise in female advantage (1900-1919), while it occurred 50 years later in Sweden, Norway and in the Netherlands. The rise was followed by a more simultaneous fall in female advantage in the studied countries towards the end of the century, with exceptions of Japan and Spain. The different timing regarding the increase of women's advantage indicates that country-specific factors may have driven the rise in female advantage, while factors shared by all countries may underlie the simultaneous fall. More comprehensive, multi-disciplinary study of the evolution of the gender gap in old age could provide new hypotheses concerning the determinants of gendered differences in mortality.

Moving in and out of public old age care among the very old in Sweden.

In this paper, we present empirical results for the very old (75+) concerning transitions between independent living in ordinary home without public support, independent living in ordinary home or special accommodations with home help and home health care, and living in around the clock care. We investigate the role of age and gender, dependency in activities of daily living (ADL) and the informal support from a partner. We also study mortality conditional on the above-mentioned variables and on the mode of old age care. The results show that the propensity to move to a more intensive mode of care is less for males, higher with more limitations in personal ADL and increasing with age. There is also a stabilizing effect of the availability of informal care support, as measured by marriage or cohabitation, as it makes it less likely to move from the current care mode. In the case of mortality, the observed relations pointed in the expected directions-mortality increasing with increasing PADL-limitations and age and being higher for men than for women. The age relation, however, does not hold in the same way in around the clock care. The estimated relationships are used as input in a micro-simulation model intended for analysis of the effect of population aging on the needs and resource requirements for old age care in Sweden.

Population ageing in Sweden: the effect of change in educational composition on the future number of older people suffering severe ill-health.

We investigate how expected changes in the educational level composition of the older population may affect future prevalence of severe ill-health among older people in Sweden. Previous research has indicated that the number of older people, given educational differentials in mortality and expected changes in educational composition during the next decades, may increase more than expected following official population projections in Sweden. Eight alternative scenario projections for the possible development in the number of people with severe ill-health in Sweden between 2000 and 2035 are presented. Scenario projections, where both morbidity and mortality inequalities by educational level are taken into account, are compared with scenarios in which only age and gender are modelled. The projections are made with both constant and decreasing mortality. The calculations show that the expected increases in severe ill-health as a result from the ageing of the population in the period 2000-2035 might, to a large extent, be counteracted by the increase in the educational level of the Swedish population. We recommend therefore that in projections of the prevalence of ill-health, in addition to the ageing of the population, also changes in educational level should be taken into account.

Functional ability in the elderly Swedish population from 1980 to 2005.

Statistics Sweden has interviewed representative samples of the population annually since 1980. This study looks at ages 65-84 (n ≈ 3,000 per year) and presents prevalence rates for functional ability (walking and running ability, vision and hearing, and disability) for different age groups and for men and women. Prevalence rates of functional problems increase with age, for all indicators and for men and women. With the exception of hearing, women have poorer function than men. Different function indicators showed different trends over time. For example, vision (reading text) improved over the studied time period, while hearing (a conversation between two or more people) showed a clear worsening over the time period. Seen over the entire time period 1980-2005, mobility items (running, walking) and disability indicators showed improvement. However, figures suggested that most of this improvement occurred during the 1980s and early 1990s. Regression analyses of the estimated trends up until 1996 show for the most part significant improvement, but this positive development seems to cease after 1996 and in some cases there seems to be a significant upswing in problems. On other hand, for hearing, the negative trend of increased problems seems to have been broken after 1996. Results emphasize the necessity to follow population trends over long periods of time with multiple waves and multiple indicators.

Time use and costs of institutionalised elderly persons with or without dementia: results from the Nordanstig cohort in the Kungsholmen Project--a population based study in Sweden.

BACKGROUND: The aging of the population has become a worldwide phenomenon. This leads to increased demand for services and with limited resources it is important to find a way to estimate how resources can be match to those with greatest need. AIMS: To analyse time use and costs in institutional care in relation to different levels of cognitive and functional capacity for elderly persons. METHODS: The population consisted of all institutionalised inhabitants, 75 + years, living in a rural community (n = 176). They were clinically examined by physicians and interviewed by nurses. Staff and informal care-giving time was examined with the RUD (Resource Utilization in Dementia) instrument. RESULTS: Tobit regression analyses showed that having dementia increased the amount of ADL care time with 0.9 h when compared to those not having dementia, whereas each loss of an ADL function (0-6) added 0.6 h of ADL care time. Analysing the total care time use, the presence of dementia added more than 9 h, while each loss of one ADL function added 2.9 h. There were some informal care contributions, however with no correlation to severity in dependency. The estimated cost for institutional care increased with more than 85% for people being dependent in 5-6 ADL activities compared to persons with no functional dependency, and with 30% for persons with dementia compared to the non-demented. CONCLUSION: There is a variation in time use in institutional settings due to differences in ADL dependency but also whether dementia is present or not. This variation has implications for costs of institutional care.