Revisiting unstable disability and the fluctuations of frailty: a measurement burst approach.

BACKGROUND: It has been hypothesised that frailty is the root cause of clinically observed but rarely systematically measured unstable disability among older adults. In this study, we measure the extent of short-term disability fluctuations and estimate their association with frailty using intensive longitudinal data. METHODS: Repeated measurements of disability were collected under a measurement burst design in the FRequent health Assessment In Later life (FRAIL70+) study. A total of 426 community-dwelling older adults (70+) in Austria were interviewed about difficulties with basic, instrumental and mobility-related activities of daily living biweekly up to a total of 14 times in two measurement bursts (2891 and 2192 observations). Baseline frailty was assessed with both physical frailty (FP) and the frailty index (FI). Disability fluctuations were measured with the intra-individual interquartile range (iIQR) and estimated with a two-step generalised mixed regression procedure. RESULTS: Fewer participants were frail at baseline according to FP (11%) than FI (32%). Frail study participants reported not only more severe disability but also had more short-term disability fluctuations (iIQR = 1.0-1.5) compared with their robust counterparts (iIQR = 0). Regression models indicated that baseline frailty was associated with 2-3 times larger short-term disability fluctuations, which were also more prevalent among women, and increased with age and disability severity. CONCLUSION: Compared with those who were robust, frail older adults were characterised by not only more severe but also more unstable disability. Short-term disability fluctuations are closely tied to disability severity. Future studies should assess both stressors that may cause disability fluctuations among frail older adults as well as their potential consequences to inform frailty-centred care.

Short-term dynamics of loneliness and depressive symptoms: Gender differences in older adults.

BACKGROUND: Previous research examining the relationship between loneliness and depressive symptoms often treated these constructs as static traits rather than dynamic states. The current study focused on the short-term, prospective link between loneliness and depressive symptoms, while also analyzing potential gender differences. METHODS: We modeled panel data from seven bi-weekly assessments gathered in the FRequent health Assessment In Later life (FRAIL70+) study. At baseline, the sample size amounted to N = 426 community-dwelling older adults aged 70 years or older in Austria. The relationship between loneliness and depressive symptoms was analyzed using a latent change score modeling framework. RESULTS: As regards depressive symptoms, women showed higher initial levels and more change across the three months than men. Loneliness did not considerably change across time for both sexes. Moreover, greater levels of loneliness at a given point in time were associated with an accelerated increase in depressive symptoms two weeks later in women but not in men. CONCLUSION: Loneliness appeared to be a potential determinant of future increases in depressive symptoms. The varying effects observed between men and women suggest potential gender differences in short-term fluctuations of depressive symptoms and their underlying mechanisms.

Frailty predicts all-cause and cause-specific mortality among older adults in Austria: 8-year mortality follow-up of the Austrian Health Interview Survey (ATHIS 2014).

BACKGROUND: The frailty index (FI) is an established predictor of all-cause mortality among older adults, but less is known with regard to cause-specific mortality, and whether the predictive power of the FI varies between men and women and by socio-economic position. METHODS: We assessed all-cause and cause-specific mortality during 8 years of follow-up (median = 7 years) among the population-representative sample of older adults (65 + , n = 2,561) from the European Health Interview Survey in Austria (ATHIS 2014). A FI at baseline was constructed from 41 health deficits. Official cause of death information from Statistics Austria was linked with the survey data by the Austrian Micro Data Center (AMDC). Next to all-cause mortality, we differentiated between mortality from cardiovascular diseases (CVD), cancer, and other causes. Cox proportional hazard models adjusted for socio-demographic variables and causes of death as competing risks were used to assess mortality prediction. RESULTS: Among the participants, 43.5% were robust (FI < 0.10), 37.7% pre-frail (FI = 0.10-0.21), and 18.7% were frail (FI > 0.21). 405 (15.8%) participants died during follow-up. Among the deceased, 148 (36.5%) died from CVD, 127 (31.4%) died from cancer, and 130 (32.1%) died from other causes of death. The FI predicted all-cause (hazard ratio, HR = 1.33 per 0.1 FI and HR = 2.4 for frail compared to robust older adults) and cause-specific mortality risk (HRCVD = 1.25/2.46, HRcancer = 1.19/1.47, HRother = 1.49/3.59). Area under the curve (AUC) values were acceptable for CVD mortality (0.78) and other causes of death (0.74), and poor for cancer mortality (0.64). CONCLUSIONS: The FI predicts all-cause and cause-specific mortality (CVD, other causes) well, which points to its relevance as a potential screening tool for risk stratification among community-dwelling older adults.

Reliability of the Frailty Index Among Community-Dwelling Older Adults.

BACKGROUND: Consistent and reproducible estimates of the underlying true level of frailty are essential for risk stratification and monitoring of health changes. The purpose of this study is to examine the reliability of the frailty index (FI). METHODS: A total of 426 community-dwelling older adults from the FRequent health Assessment In Later life (FRAIL70+) study in Austria were interviewed biweekly up to 7 times. Two versions of the FI, one with 49 deficits (baseline), and another with 44 (follow-up) were created. Internal consistency was assessed using confirmatory factor analysis and coefficient omega. Test-retest reliability was assessed with Pearson correlation coefficients and the intraclass correlation coefficient. Measurement error was assessed with the standard error of measurement, limits of agreement, and smallest detectable change. RESULTS: Participants (64.6% women) were on average 77.2 (±5.4) years old with mean FI49 at a baseline of 0.19 (±0.14). Internal consistency (coefficient omega) was 0.81. Correlations between biweekly FI44 assessments ranged between 0.86 and 0.94 and reliability (intraclass correlation coefficient) was 0.88. The standard error of measurement was 0.05, and the smallest detectable change and upper limits of agreement were 0.13; the latter is larger than previously reported minimal clinically meaningful changes. CONCLUSIONS: Both internal consistency and reliability of the FI were good, that is, the FI differentiates well between community-dwelling older adults, which is an important requirement for risk stratification for both group-level oriented research and patient-level clinical purposes. Measurement error, however, was large, suggesting that individual health deteriorations or improvements, cannot be reliably detected for FI changes smaller than 0.13.

Terminal Decline in Physical Function in Older Adults.

BACKGROUND: It is currently unclear whether (and when) physical function exhibits a terminal decline phase, that is, a substantial acceleration of decline in the very last years before death. METHODS: 702 deceased adults aged 70 years and older from the Yale PEP Study provided 4 133 measurements of physical function (Short Physical Performance Battery, SPPB) up to 20 years before death. In addition, continuous gait and chair rise subtest scores (in seconds) were assessed. Generalized mixed regression models with random change points were used to estimate the onset and the steepness of terminal decline in physical function. RESULTS: Decline accelerated in the last years of life in all 3 measures of physical function. The onset of terminal decline occurred 1 year before death for the SPPB, and at 2.5 and 2.6 years before death for chair rise and gait speed test scores, respectively. Terminal declines in physical function were 6-8 times steeper than pre-terminal declines. Relative to those whose condition leading to death was frailty, participants who died from dementia and cancer had an up to 6 months earlier and 3 months later onset of terminal decline in SPPB, respectively. CONCLUSIONS: Terminal decline in physical function among older adults is comparable to the more established terminal decline phenomenon in cognition. Our results provide additional evidence of late-life rapid decline in physical function due to impending death.

Facilitators and barriers in general practitioners' choice to work in primary care units in Austria: a qualitative study.

BACKGROUND: Recent reforms in Austria have focused on establishing team-based care within multiprofessional primary care units, to enhance amongst others, the work attractiveness of general practice. Nearly 75% of qualified general practitioners are not working as contracted physicians with the social health insurance. This study aims to explore the facilitators of and barriers to non-contracted general practitioners to work in a primary care unit. METHODS: We conducted twelve semi-structured, problem-centered interviews among purposively sampled non-contracted general practitioners. To extract categories of facilitators and barriers for working in a primary care unit, transcribed interviews were inductively coded using qualitative content analysis. Subcategories were grouped into factors (facilitators and barriers) of thematic criteria and mapped on the macro-, meso-, micro-, and individual levels. RESULTS: We identified 41 categories, including 21 facilitators and 20 barriers. Most facilitators were located at the micro-level, while most barriers were located at the macro-level. Teamwork and associated conditions made primary care units attractive as workplaces and corresponded with individual demands. In contrast, system factors tended to reduce the attractiveness of working as a general practitioner. CONCLUSIONS: Multifaceted efforts are needed to address relevant factors at all of the levels mentioned above. These need to be carried out and consistently communicated by all stakeholders. Efforts to strengthen the holistic approach in primary care, like modern remuneration and patient steering mechanisms, are essential. Financial support, consulting services as well as training on entrepreneurship, management, leadership, and team-based care may help to reduce the risk and burden of founding and running a primary care unit.

Lonely and depressed in older age: prospective associations and common vulnerabilities.

OBJECTIVES: Research demonstrated a close relationship between loneliness and depressive symptoms, but it remains unclear whether these constructs reciprocally influence each other or whether the association is due to common causes. This study aimed at examining how loneliness and depressive symptoms jointly unfold across time and how the relationship varies both within and between individuals. METHODS: We used survey data of N = 8472 older adults gathered in the English Longitudinal Study of Ageing, which included eight waves over a time period of up to 15 years. The relationship was analyzed using a latent curve model, allowing us to separate within-person processes from between-person differences in long-term growth. RESULTS: Results showed no prospective effects of loneliness on depressive symptoms (or vice versa) at the within-person level. Yet, within-person increases in loneliness were related to within-person increases in depressive symptoms at the same point in time. As regards the between-person effects, greater long-term growth in loneliness went along with greater long-term growth in depressive symptoms. CONCLUSION: Our findings did not support the assumption that loneliness and depressive symptoms influence each other over time, but rather suggest that the short- and long-term associations may be due to a common vulnerability to the same causes.Supplemental data for this article is available online at https://doi.org/10.1080/13607863.2022.2056138 .

The impact of COVID-19 restrictions on older adults' loneliness: Evidence from high-frequency panel data in Austria (2020-2022).

BACKGROUND: It is unclear how strong and long lasting the effects of recurring COVID-19 pandemic restrictions are on older adults' loneliness. METHODS: 457 retired older Austrians (60+) provided 9,489 repeated observations of loneliness across 30 survey waves of the Austrian Corona Panel Project between March 2020 and March 2022. Ordinal mixed regression models were used to estimate the effect of time-varying country-level strictness of COVID-19 restrictions (stringency index, range=0-100) on older adult's loneliness. RESULTS: The proportion of older adults who reported to be often lonely correlated (r = 0.45) with the stringency index over time: both peaked during lock-downs (stringency index = 82, often lonely = 10%-13%) and were lowest during the summer of 2020 (stringency index = 36, often lonely = 4%-6%). Results from regression models adjusted for the number of new COVID-19 cases and deaths indicate, that when the stringency index increased by one point, the odds for loneliness increased by 2%. Older adults who lived alone were more likely lonely during the pandemic and were more affected by COVID-19 restriction measures compared to those living with others. CONCLUSIONS: More stringent COVID-19 restrictions were associated with an increase in (situational) loneliness among older adults in Austria, and this effect was stronger among those who lived alone. Efforts should be made to enable older adults, in particular those who live alone, to allow for save in-person contact in case of (future) periods of strict pandemic restriction measures.

Frailty in the oldest old: is the current level or the rate of change more predictive of mortality?

BACKGROUND: It is unclear whether frailty index (FI) change captures mortality risk better than and independently of the current FI level, i.e. whether a regular FI assessment among older adults provides additional insights for mortality risk stratification or not. METHODS: We used data from the LASA 75-PLUS-study, which monitored health among 508 older adults (75+) between 2016 and 2019 every 9 months. Joint models for longitudinal and time-to-event data were used to assess the impact of both current FI and within-person FI change during the last year on mortality risk. RESULTS: Twenty percent of the participants died during 4.5 years of follow-up. Adding within-person FI change to the current FI model improved model fit and it showed that FI increases during the last year were associated with an increase in mortality risk. Consequently, the effect of the current FI decreased considerably and became statistically non-significant. CONCLUSIONS: The rate of FI change was more important than the current FI level for short-term mortality prediction among the oldest old, which highlights the benefits of regular frailty assessments.

Intrinsic Capacity Predicts Negative Health Outcomes in Older Adults.

BACKGROUND: Monitoring trajectories of intrinsic capacity (IC) in older adults has been suggested by the World Health Organization as a means to inform prevention to avoid or delay negative health outcomes. Due to a lack of longitudinal studies, it is currently unclear how IC changes over time and whether repeatedly measured IC predicts negative health outcomes. METHODS: Based on 4 751 repeated observations of IC (range = 0-100) during 21 years of follow-up among 754 older adults 70 and older, we assessed longitudinal trajectories of IC, and whether time-varying IC predicted the risk of chronic activities of daily living disability, long-term nursing home stay, and mortality using joint models. RESULTS: Average IC declined progressively from 77 to 11 points during follow-up, with substantial heterogeneity between older adults. Adjusted for sociodemographics and chronic diseases, a 1-point lower IC value was associated with a 7% increase in the risk of activities of daily living disability, a 6% increase in the risk of a nursing home stay, and a 5% increase in mortality. Accuracy for 5- and 10-year predictions based on up to 3 repeated measurements of IC ranged between moderate and good (area under the receiver operating characteristic curve = 0.76-0.82). CONCLUSIONS: Our study indicates that IC declines progressively and that it predicts negative health outcomes among older adults. Therefore, regular monitoring of IC could work as an early warning system informing preventive efforts.

Acceleration of health deficit accumulation in late-life: evidence of terminal decline in frailty index three years before death in the US Health and Retirement Study.

BACKGROUND: Little is known about within-person frailty index (FI) changes during the last years of life. In this study, we assess whether there is a phase of accelerated health deficit accumulation (terminal health decline) in late-life. MATERIAL AND METHODS: A total of 23,393 observations from up to the last 21 years of life of 5713 deceased participants of the AHEAD cohort in the Health and Retirement Study were assessed. A FI with 32 health deficits was calculated for up to 10 successive biannual, self- and proxy-reported assessments (1995-2014), and FI changes according to time-to-death were analyzed with a piecewise linear mixed model with random change points. RESULTS: The average normal (preterminal) health deficit accumulation rate was 0.01 per year, which increased to 0.05 per year at approximately 3 years before death. Terminal decline began earlier in women and was steeper among men. The accelerated (terminal) rate of health deficit accumulation began at a FI-value of 0.29 in the total sample, 0.27 for men, and 0.30 for women. CONCLUSION: We found evidence for an observable terminal health decline in the FI following declining physiological reserves and failing repair mechanisms. Our results suggest a conceptually meaningful cut-off value for the continuous FI around 0.30.

Within- and between-person effects in the relationship between effort-reward imbalance and depressive symptoms.

Theory suggests that a stressful working environment negatively affects workers' health. However, methodological limitations in observational studies often restrict conclusions about observed relationships. In this study, we examined cross-lagged effects of effort-reward imbalance (ERI; i.e., an indicator of work stress) and mental health (i.e., depressive symptoms) at the within-person level, while accounting for between-person variability. We used data from five panel waves gathered in the Survey of Health, Ageing and Retirement in Europe (SHARE), comprising N = 5,778 (self-)employed individuals aged 50 years or older. Repeated measures for both ERI and depressive symptoms were modeled using random intercept cross-lagged panel modeling. The results showed no cross-lagged effects of ERI and depressive symptoms at the within-person level, but the intra-individual variations in ERI were positively related to the intra-individual variations in depressive symptoms at the same point in time. At the between-person level, it showed that individuals with generally higher levels of ERI tend to demonstrate generally higher levels of depressive symptoms. The findings question the notion that ERI and depressive symptoms influence each other over the course of time, but rather indicate that third variable effects account for observed relationships between these constructs.

The impact of COVID-19 restriction measures on loneliness among older adults in Austria.

BACKGROUND: To halt the spread of COVID-19, Austria implemented a 7-week 'lockdown' in March/April 2020. We assess whether the ensuing reduction in social contacts led to increased loneliness among older adults (60+). METHODS: Three analyses were conducted: (i) a comparison between pre-pandemic (SHARE: 2013-17) and pandemic (May 2020) levels of loneliness (UCLA-3 scale), (ii) an assessment of the cross-sectional correlation between being affected by COVID-19 restriction measures and loneliness (May 2020) and (iii) a longitudinal analysis of weekly changes (March-June 2020) in loneliness (Corona panel). RESULTS: We found (i) increased loneliness in 2020 compared with previous years, (ii) a moderate positive association between the number of restriction measures older adults were affected from and their loneliness and (iii) that loneliness was higher during 'lockdown' compared to the subsequent re-opening phase, particularly among those who live alone. CONCLUSIONS: We found evidence that COVID-19 restriction measures in Austria have indeed resulted in increased levels of loneliness among older adults. However, these effects seem to be short-lived, and thus no strong negative consequences for older adults' mental health are expected. Nonetheless, the effects on loneliness, and subsequent mental health issues, could be both more long-lasting and severe if future restriction measures are enacted repeatedly and/or over longer time periods.

Frailty Changes Predict Mortality in 4 Longitudinal Studies of Aging.

BACKGROUND: Baseline frailty index (FI) values have been shown to predict mortality among older adults, but little is known about the effects of changes in FI on mortality. METHODS: In a coordinated approach, we analyzed data from 4 population-based cohorts: the Health and Retirement Study (HRS), the Survey of Health, Ageing and Retirement in Europe (SHARE), the English Longitudinal Survey of Ageing (ELSA), and the Longitudinal Aging Study Amsterdam (LASA), comprising a total of 24 961 respondents (65+), 95 897 observations, up to 9 repeated FI assessments, and up to 23 years of mortality follow-up. The effect of time-varying FI on mortality was modeled with joint regression models for longitudinal and time-to-event data. RESULTS: Differences (of 0.01) in current FI levels (hazard ratio [HR] = 1.04, 95% credible interval [CI] = 1.03-1.05) and baseline FI levels (HR = 1.03, 95% CI = 1.03-1.05) were consistently associated with mortality across studies. Importantly, individuals with steeper FI growth also had a higher mortality risk: An increase in annual FI growth by 0.01 was associated with an increased mortality risk of HR = 1.56 (95% CI = 1.49-1.63) in HRS, HR = 1.24 (95% CI = 1.13-1.35) in SHARE, HR = 1.40 (95% CI = 1.25-1.52) in ELSA, and HR = 1.71 (95% CI = 1.46-2.01) in LASA. CONCLUSIONS: FI changes predicted mortality independently of baseline FI differences. Repeated assessment of frailty and individual's frailty trajectory could provide a means to anticipate further health deterioration and mortality and could thus support clinical decision making.

Trajectories of Late-Life Disability Vary by the Condition Leading to Death.

BACKGROUND: Previous research suggested that there might be distinct patterns of functional decline in the last years of life depending on the condition leading to death, but the validity of these results and hence the explanatory value of the condition leading to death for late-life disability are uncertain. METHODS: A total of 636 decedents from a cohort of 754 community-living persons, 70+ years of age (Yale PEP Study) provided 33 700 monthly observations of self-/proxy-reported disability during the last 5 years of life. Nonlinear trajectories and short-term fluctuations of late-life disability by condition leading to death (cancer, organ failure, frailty, severe dementia, sudden death, other) were estimated with flexible mixed spline regression models. RESULTS: Disability trajectories at the end of life varied distinctively by the condition leading to death. Estimated disability trajectories among cancer deaths increased gradually up until about 6 months before death, after which a steep terminal decline set in. Among those with organ failure, frailty, and dementia, in contrast, disability was higher, increased more gradually, and there was no clear-cut terminal phase. Adding the condition leading to death to other known risk factors increased the amount of explained between-person variation in late-life disability from R2 = 0.35 to 0.49. Short-term fluctuations in disability were not specific for decedents with organ failure. CONCLUSIONS: The condition leading to death is an important determinant of trajectories of late-life disability. These trajectories follow distinct patterns partially resembling a previously outlined theoretical typology.

Frailty and depression: Reciprocal influences or common causes?

BACKGROUND: Previous research demonstrated substantial associations between frailty and depression in late life, but it remains unclear whether this relationship is best explained by reciprocal influences of these variables or by common causes. This study investigated the interdependencies between frailty and depression across time by examining cross-lagged effects within individuals, while accounting for variability in baseline levels and long-term development between individuals. METHODS: We modeled longitudinal data from six panel waves gathered in the Survey of Health, Ageing and Retirement in Europe, covering a time period of up to 14 years. The total sample size was N = 58,152 individuals aged 50 years or older. Frailty was based on a deficit accumulation frailty index and depressive symptoms were measured with the EURO-D scale. We used a latent curve model with structured residuals for statistical analysis. RESULTS: The results did not demonstrate relevant cross-lagged effects of frailty and depression at the within-person level. However, within-person increases in frailty were accompanied by within-person increases in depression at the same point in time. At the between-person level, it showed that individuals with higher levels and steeper trajectories in frailty also tend to show higher levels and steeper trajectories in depression. CONCLUSION: These findings question the notion that frailty and depression reciprocally influence each other over the course of time, but rather indicate that frailty and depression might be both affected by common causes, in both the short and the long term.

[Survey of Relatives' Perspective on Dying In The Hospital: A Comparison Between Departments of Internal Medicine and Palliative Care In Styria (Austria)]. / Angehörigenbefragung zum Sterben im Krankenhaus: Ein Vergleich zwischen Abteilungen für innere Medizin und Palliativstationen in der Steiermark (Österreich).

BACKGROUND: Currently, 49% of deaths in Austria occur in a hospital which makes in-patient quality of care as well as quality of death and dying a highly relevant topic. In this article, we compare the quality of care and death and dying in departments of internal medicine and palliative care in hospitals from the perspective of relatives. METHODS: In a pilot study, 210 relatives of patients who died on 4 departments of internal medicine and 2 departments of palliative care in the state of Styria (Austria) were interviewed in 2015-2017 by means of a postal survey with regard to communication by hospital personnel, quality of care, and time of dying. RESULTS: Compared to the departments of internal medicine, the 2 departments of palliative care were perceived to provide better quality of care and better service with regard to the time of death and dying, that is, timely communication of critical health deterioration of the patient, enabling relatives' attendance at the time of death, preparing relatives, and the quality of death of the patient. CONCLUSION: Against the background of the large proportion of individuals who die in hospitals in Austria, this exploratory study showed that relatives perceived both better quality of care and better quality of death and dying in the assessed departments of palliative care compared to the departments of internal medicine. Thus, a more comprehensive and systematic evaluation of the potential added value of palliative care teams in Austrian hospitals is recommended.

Short-Term Disability Fluctuations in Late Life.

OBJECTIVES: Late-life disability is highly dynamic but within-person short-term fluctuations have not been assessed previously. We analyze how substantial such late-life disability fluctuations are and whether they are associated with time-to-death, long-term disability trajectories, frailty, and sociodemographics. METHODS: Monthly survey data (Precipitating Events Project Study) on activities of daily living/instrumental activities of daily living (ADL/IADL) disability (0-9) in the last years of life from 642 deceased respondents providing 56,308 observations were analyzed with a two-step approach. Observation-level residuals extracted from a Poisson mixed regression model (first step), which depict vertical short-term fluctuations from individual long-term trajectories, were analyzed with a linear mixed regression model (second step). RESULTS: Short-term disability fluctuations amounted to about one ADL/IADL limitation, increased in the last 4 years of life, and were closely associated with disability increases. Associations with frailty or sociodemographics characteristics were absent except for living alone. DISCUSSION: Short-term disability fluctuations in late life were substantial, were linked to mortality-related processes, and represent a concomitant feature of disability increases in late life.

Fluctuations in frailty among older adults.

BACKGROUND: frailty fluctuations, that is, within-person up and down deviations from individual long-term frailty index trajectories represent a hitherto both conceptually and empirically untapped facet of frailty among older adults. OBJECTIVE: to assess the size of frailty fluctuations in old age and their association with frailty levels, frailty growth as well as sex and socio-economic position. METHODS: a total of 18,704 biannual observations from 4,514 community-dwelling older adults (65+) in 10 European countries over 12 years from the Survey of Health, Ageing and Retirement in Europe (SHARE) were analysed. A frailty index was constructed based on 50 items. Long-term frailty trajectories and fluctuations were modelled simultaneously using Bayesian mixed-effects location-scale regression models. RESULTS: frailty index fluctuations were non-negligible among older adults, amounting to 0.04/0.05 FI or 2.0/2.5 health deficits on average. 30% of fluctuations were between 0.04 and 0.1 FI (2 and 5 health deficits) and 8% were larger than 0.1 FI (5 health deficits). Fluctuations increased with age and frailty levels, and were higher among women, those with low socio-economic position (education) and individuals who died during follow-up. CONCLUSIONS: frailty index fluctuations refer to instabilities in an older person's health status and represent a hitherto untapped but relevant aspect of vulnerability in old age. Future analysis of frailty fluctuations should be based on a larger number of repeated observations with shorter time intervals.

Individual and country-level determinants of nursing home admission in the last year of life in Europe.

BACKGROUND: Previous research has focussed on individual-level determinants of nursing home admission (NHA), although substantial variation in the prevalence of NHA between European countries suggests a substantial impact of country of residence. The aim of this analysis was to assess individual-level determinants and the role of country of residence and specifically a country`s public institutional long-term care infrastructure on proxy-reported NHA in the last year of life. METHODS: We analysed data from 7,018 deceased respondents (65+) of the Survey of Health, Ageing and Retirement in Europe (2004-2015, 16 countries) using Bayesian hierarchical logistic regression analysis in order to model proxy-reported NHA. RESULTS: In total, 14% of the general older population utilised nursing home care in the last year of life but there was substantial variation across countries (range = 2-30%). On the individual-level, need factors such as functional and cognitive impairment were the strongest predictors of NHA. In total, 18% of the variance of NHA was located at the country-level; public expenditure on institutional care strongly affected the chance of NHA in the last year of life. CONCLUSION: On the individual-level, the strong impact of need factors indicated equitable access to NHA, whereas differences in public spending for institutional care indicated inequitable access across European countries.