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Received 15 September 2009; accepted in revised form
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© The Author 2010. Published by Oxford University Press on behalf of the British Geriatrics Society.
All rights reserved. For Permissions, please email: [email protected]
Trends in disability prevalence over 10 years in
older people living in Gloucestershire
IAN P. DONALD1, CHRIS FOY2, CAROL JAGGER3
1
Gloucestershire Royal Hospital, Great Western Road, Gloucester GL1 3NN, UK
Research and Development Support Unit, Gloucestershire Royal Hospital, Great Western Road, Gloucester GL1 3NN, UK
3
Department of Health Sciences, University of Leicester, Leicester, UK
2
Address correspondence to: I. P. Donald. Tel: (+44) 8454 226112; Fax: (+44) 8454 226979. Email: [email protected]
Abstract
Introduction: life expectancy in the UK appears to be growing faster than healthy life expectancy, which may imply that
there are increasing years of disability. There are few sequential studies examining changes in disability amongst older people
within a defined locality.
Methods: the population aged 75 and over of 10 general practices in Gloucestershire was surveyed using a validated postal
questionnaire for disability called the Elderly At Risk Rating Scale. Surveys were carried out in 1998 and 2008. Age-adjusted
disability prevalences were measured. Care home residents were under-represented in the 1998 survey, and missing data was
supplied from a countywide census of care home residents in 2000.
Results: response rates of 81 and 74% were achieved. Reductions in disability prevalence were found for mobility, vision and
self-care, but there was no significant change in a measure of self-rated health. Higher rates of independence were found in
both genders and across the age range in 2008. The improvements suggested that the latter sample was equivalent to subjects
being 3.8 years ‘younger’ than 10 years before and entering dependency on care 2.1 years later.
Discussion: the prevalence of disability affecting activities of daily living appears to have reduced over 10 years in older
people in Gloucestershire. If generalisable, these results provide some optimism for current trends in ageing in England.
Keywords: cohorts, disability, older people, self-rated health
Introduction
In the UK, as in many other developed nations, the population aged over 80 years is growing rapidly: in the last
10 years, there has been a growth of around 20%, and further dramatic rises are expected in the coming decade. Life
expectancy has increased by almost 3.2 years for men and
2.2 years for women during this decade, but estimated
337
I. P. Donald et al.
healthy life expectancy has probably increased by around
half of this [1].
Trends in the prevalence of age-standardised disability
worldwide are variable [2] with five out of 12 countries
showing clear evidence of a decline in severe disability and
three showing an increase. Furthermore, in two countries
(France and the UK) the trends differed depending on the
data source. Within the UK there have been only two previous studies comparing health and disability in comparable
cohorts over a period of time [3, 4] but both pertain to previous decades. Neither study showed a clear picture of
declining disability.
There is anxiety about a potential increasing burden of
disability in old age requiring support by health and social
care services. Yet some observations appear to be to the
contrary: the number of long-term care places is stable or
decreasing; there is no marked increase in expenditure on
domiciliary care; and the average 80 year old in the UK
today seems fitter than a decade ago. The Rowntree foundation has shown that between 1991 and 2001, the care
home population in England fell by 50,000 places or 13%
of the provision [5]. The proportion of the 75–84 population in care homes in England fell from 5.3 to 3.3%, and for
those over 85 from 20 to 16% [5]. Of course there may be
considerable numbers of older people with disability who are
not accessing long-term care with an iceberg of unmet need.
More information regarding trends in the disability of older
people is required to disentangle what is happening.
The present study comprises information from two large
postal surveys of the population aged 75 and over in
Gloucestershire in 1998 and 2008. The samples included
all patients registered with the same 10 general practices
and represented about 10% of the county’s population.
The population is very stable, with 94% of the 2008 survey
having lived in the county for over 10 years. This stability
made it feasible to compare the prevalence of disability in
the two samples.
Methods
The 10 practices included in the surveys represented a range
of location, but with a predominance of rural towns reflecting the population of Gloucestershire: four were in rural
towns, two of which were the sole practice for the locality;
three were suburban practices and three urban practices.
Townsend score [6] is a measure of deprivation based upon
four items extracted from Office of Population Censuses and
Surveys (OPCS); here Townsend scores were derived from
the postal codes of each patient on the practice register in
1998. The Townsend scores were all in a narrow band: five
of these practices had slightly negative Townsend scores
(range −1.99 to −0.16) and five slightly positive scores (range
0.11 to 0.88). The average Townsend score for the included
practices was −0.4 and −0.2 for Gloucestershire (Standard
Deviation (SD) 1.05, range 3.62 to −1.99). The standardised
mortality ratio for Gloucestershire is currently 94.
338
All patients aged 75 years or over on the 1 May 1998 and
1 May 2008 in the 10 practices were sent the postal version
of the Elderly At Risk Rating Scale (EARRS), a previously
validated scale for assessing older people [7]. Brief postal
questionnaires have been shown to be a reliable source of
disability information with older people [8]. This tool consists of 20 domains, each with five hierarchical, categorical
responses, which cover activity and mobility, personal activities of daily living (ADL), mental health and support at
home. It was designed to satisfy the requirements of the
over 75 health check as defined by the 1990 General Practitioner (GP) contract. In 2008, some additional questions
were included to enable cross-referencing to the national
census and to establish the stability of the population. The
method of the 1998 survey has been described previously
[9]. No reminders were sent in either survey.
‘No dependency’ was defined as having no memory
problem and being independent in all four following questions: outdoor mobility at least able to go outside for short
walks, managing to wash or shower independently, managing to dress easily on own and able to cook or reheat a
whole meal. ‘High dependency’ was defined as either having
a memory problem (‘You are forgetful, and this interferes
with your everyday life’) or physical dependency, derived
from all three of the following questions—unable to walk
inside without a walking aid, plus needing help for washing
plus having great difficulty in dressing. ‘Limited dependency’
were individuals falling between these groups.
The 2008 sample included a representative sample of
care home subjects, but care home residents were under-represented in the 1998 sample. The data presented here is
mainly a comparison of those living at home. To enable
some estimate of the changing burden of disability in the
whole population, missing data was taken from the census
of care home residents undertaken in Gloucestershire in
October 2000 [10]. The methodology was based on that
used in a previous census in Trent [11]. Care Home staff
completed the census forms on each resident. A response
rate of 73% was achieved. The census included similarly
phrased questions on mobility, memory, washing and dressing, allowing residents’ dependency to be defined as
above. A random sampling of the cases within the census
was taken to represent the proportion of the population believed to be in care at the time.
Population sizes for the county were obtained from
Nomis [12]. Comparison populations were derived from
the Health Survey for England [13], which in 2000 and
2005 included larger samples of people over the age of
75 (3,000 in 2000 and almost 2,000 in 2005).
Statistical analysis
Data has been analysed using SPSS version 14.0. Disability
rates in the 1998 survey were standardised to the age quintiles and sex distribution of the 2008 sample. Logistic
regression adjusted for age, gender and Townsend was used
to examine outdoor mobility and dependency. The effective
Trends in disability prevalence in Gloucestershire
Table 1. Demography of two sample populations
1998
n
2008
Mean age
n
Mean age
............................................................
Overall
Responders
Non-responders
Response rate
Non-response♀
Non-response♂
5,117
4,159
958
81%
20.2%
17.7%
80.8
82.4
7,154
5,266
1,888
74%
27.5%
24.6%
82.1
82.6
age difference for independence and high dependence was
estimated as the ratio of the unstandardised beta coefficients, for sample and age, of a logistic regression for the
outcome, using age and sample as predictors. The 95% confidence interval (95% CI) was estimated using a formula for
the variance of a ratio [14].
Ethical issues
Consent was obtained from all participating general practitioners, but was not explicitly sought from individuals.
The 1998 study was approved by the West Gloucestershire
Research Ethics Committee, and the 2008 study by the Wiltshire Research Ethics Committee. Computerised data did
not contain any personal identifiers, using only gender and
year of birth.
Results
The samples were derived from two postal surveys (in 1998
and 2008) of those aged 75 years and over belonging to 10
general practices, these practices representing 9.2% of the
population of Gloucestershire.
Representativeness of Gloucestershire population
The population aged 75 and over in Gloucestershire is
7.6% of the total population, which compares with 7.1%
in England [12]. This population in England grew by
10% in the last 10 years, but by 13% in Gloucestershire,
which has experienced net immigration of around 2,000
people aged 75 and over in the last 10 years. The over
75 population within the 10 practices in this study grew
by 19% as three practices experienced larger growth
through expansion of their business. A little less than a
third of the growth may be accounted for by the net immigration, and only 6.2% of the 2008 sample had lived in
the county for <10 years. Much <1% of the county’s older
population is non-Caucasian.
Study population
Adequate questionnaires were returned by 4,159 subjects in
1998 and 5,266 subjects in 2008. This represented response
rates of 81% in 1998 and 74% in 2008 (Table 1). The responders were younger than non-responders (80.8 years vs
82.4 in 1998; 82.1 vs 82.6 in 2008), and males had a higher
response rate than females in both surveys.
Representativeness of the responders compared to
the Gloucestershire and English population
Comparisons of the two samples with the county population
estimates from Nomis [12] and the 2001 census in England
are shown in Supplementary Table 1 (Supplementary data
are available in Age and Ageing online). The age distribution
closely resembled the county populations at the time.
Self-rated health in the 2008 survey was similar to
figures in the 2000 and 2005 Health Survey of England
[13] (Supplementary Table 2 is available in Age and Ageing
online).
Demographic changes
The proportion of the older population living alone fell from
31 to 26% for men and from 59 to 57% for women. This
compares with data from the 2000 and 2005 Health Surveys
for England, where the figure for men has fallen from 35 to
Table 2. Prevalence of disabilities in each sample for those outside care (shown as %) (n = 4,224 in 1998; 5,002 in 2008)
Disability/problem
Crude prevalence 1998
Standardised prevalence 1998 (95% CI)
Prevalence 2008 (95% CI)
.............................................................................................................................
Unable to walk beyond gate
Unable to walk inside without aid
Fall in last 3months
Difficulty/inability washing
Difficulty/inability dressing
Unable to prepare a meal
Requires hearing aid
Regarding vision, unable to read
Regular joint pain
Requires help with nails
Memory impaired
Frequently sad or low
Limited energy
16.7
19.1
20.7
40.0
8.1
13.9
24.6
7.7
52.1
49.4
6.9
14.1
45.3
19.5
21.8
22.4
43.7
8.8
15.6
26.7
9.1
53.1
53.0
7.6
14.9
48.4
(18.3, 20.8)
(20.5, 23.1)
(21.0, 23.7)
(42.2, 45.2)
(7.9, 9.7)
(14.4, 16.7)
(25.3, 28.1)
(8.1, 10.0)
(51.5, 54.6)
(51.5, 54.5)
(6.7, 8.4)
(13.8, 16.1)
(46.9, 50.0)
16.1
22.4
23.8
29.2
7.6
12.3
25.9
5.2
47.9
44.7
6.1
12.8
47.2
(15.1, 17.1)
(21.4, 23.6)
(22.7, 25.0)
(28.1, 30.6)
(6.9, 8.4)
(11.4, 13.2)
(24.7, 27.0)
(4.6, 5.8)
(46.5, 49.3)
(43.4, 46.1)
(5.5, 6.7)
(11.9, 13.7)
(45.9, 48.6)
The rates in 1998 were standardised to the age and sex profile of the 2008 population.
339
I. P. Donald et al.
Table 3. Prevalence of no dependency, limited dependency and high dependency (shown as %)a (n = 4,482 in 1998; 5,290 in
2008)
1998
2008
No dependency
Limited dependency
High dependency
No dependency
Limited dependency
High dependency
69.5
57.4
41.0
20.8
63.3
44.4
26.3
10.9
22.4
29.0
35.7
47.6
28.7
43.4
49.8
48.2
8.1
13.6
23.3
31.6
8.0
12.2
23.9
40.9
75.9
65.9
52.6
35.5
73.5
60.4
43.6
23.1
16.5
23.6
34.0
40.1
20.9
29.0
35.5
39.8
7.6
10.5
13.4
24.4
5.6
10.6
20.9
37.1
.............................................................................................................................
Men
Women
a
75–79
80–84
85–89
90+
75–79
80–84
85–89
90+
1998 data includes Care Home data from 2000.
29% and for women from 63 to 62% over 5 years. Comparable increases in the proportion living with a partner or
spouse have been observed. Mean age at time of death in
the county increased from 74.2 to 76.3 years for men and
from 80 to 81.2 for women between 1998 and 2008.
Changes in disability prevalence
For those living at home, crude disability rates fell for seven
domains of physical disability and increased for three
(Table 2). The rates in 1998 were standardised to the age
and sex profile of the 2008 population. There were significant reductions in adjusted disability rates for the seven
domains: outdoor mobility, washing and dressing difficulty,
ability to prepare a meal, sight, joint pain and requiring help
with nailcare. The remaining domains were unchanged. Outdoor mobility was further examined using multinomial
regression with short walks as the reference category: the
2008 sample was less likely to take exercise (Odds Ratio
(OR) 0.63, 0.57–0.71, P < 0.001) and less likely to be housebound (OR 0.56, 0.47–0.66, P < 0.001) or walk only to the
gate (OR 0.78, 0.65–0.93, P < 0.01). There was no difference in walking daily.
Changes in mental health problems
There are difficulties in gathering information about memory problems from a self-administered postal survey.
However, 21% in 1998 and 15% in 2008 received help in
completing the survey, and of these, 21% in 1998 and
36% in 2008 registered a memory problem. Small reductions
in the prevalence of memory impairment and sadness were
found, with no change in energy, Table 2.
Dependency
An estimate of the overall population’s dependency has
been achieved through using the additional data on care
home residents from the 2000 Care Home census combined with the 1998 survey. Independence rates improved
in both genders and for each age group over 10 years,
Table 3. Logistic regression for likelihood of independence
340
adjusted for age, gender and Townsend score gave beta
coefficients of 0.484 for survey difference and 0.128 per
year of age. This can be expressed as the 2008 sample being
the equivalent of 3.8 years (95% CI 3.04, 4.54) more independent or ‘younger’ than the earlier sample. No
interactions between sample and age, gender or Townsend
score were found.
Rates of high dependency also improved in both genders
and for each age group, Table 3. Logistic regression for high
dependency adjusted for age and gender gave beta coefficients of 0.234 for survey difference and 0.112 per year of
age, or the equivalent of the 2008 sample being 1.9 years less
dependent (95% CI 0.76, 3.12). The rates of high dependency for care home residents alone increased for men
(51.2% in 2000 and 70.6% in 2008 (P = 0.053)) and women
(69.9 and 79.8%, respectively (P = 0.025)).
Discussion
As the timing and methodology of the surveys were identical,
the robustness of the conclusions from the comparison of
these two surveys depends largely on the representativeness
of those samples. Drawing the samples from the same general
practices increases the comparability of the surveys, and they
represent around 10% of the county’s population. The age
and sex profile of the samples was similar to the county’s
overall elderly population. The net immigration of older
people into the county could have imported relatively fitter
individuals. The response rates to each survey were high,
and the age profile of the non-responders was similar in each
survey. Previous work in Gloucestershire has demonstrated
that non-responders to the EARRS survey have a similar
3-year mortality to responders [15]. Disabled subjects might
contribute disproportionately to the reduced response rate
in 2008, causing bias, but a recent US postal survey did
not find this [8]. Our conclusions cannot be extended to
more deprived populations or to non-Caucasian populations. The substitution of the missing data from care
home residents in 1998 with data from a census 2 years later
clearly can only provide an approximation to the true picture in 1998.
Trends in disability prevalence in Gloucestershire
The improvements in ADL were significant in the majority of domains and remarkably consistent in magnitude
across each of the 10 practices, with their range of
deprivation levels. The improvements were generally seen
in both genders and across the age spectrum. An 84 year
old today appears like an 80 year old 10 years ago, while serious disability may be delayed by 2 years. Mortality data
showed lengthening lifespan of about 2 years over the decade, and so disability duration may have been stable.
The improvements may be in keeping with the observed
stable care home population numbers (residents over 75
have fallen from 7.8% (3,800 residents) in 2000 census to
7.1% (3,700) in 2008 (survey by Gloucestershire Care Home
Support Team, unpublished)). There has also been a fall in
numbers supported by homecare in Gloucestershire, falling
from 60 households per 1,000 people over 75 in 2001 to 52
households in 2008 [16], which reflects national trends with
the number of households receiving a service falling by 8%
in recent years [17]. Of course both of these services reflect
supply rather than need, and thresholds for care have almost
certainly increased.
There are comparatively few similar studies on sequential
samples of older people in the UK. A similar study from Melton Mowbray in Leicestershire reported changes from 1981 to
1988 [3]. In that study, significant increases in independence
levels were found over the time period for getting in and out
of a chair and bed, dressing, bathing and getting to and from
the toilet, while no differences were found for mobility
around the home and feeding. The Health Survey for England
in 2000 and 2005 [13] altered the phrasing of questions, making comparisons difficult. The General Household Surveys
have more consistent questioning, and no convincing change
in disability or self-reported health for older people over the
period 1980–2001 has been found [18]. A study comparing
65 year olds in the UK between 1991 and 1996 showed
no significant changes in disability [4]. International studies have shown conflicting evidence with some reporting
positive changes in disability [2, 19], while most report
increasing prevalence of disease [2, 20].
The improvements in disability were not reflected in improvements in energy, a measure of self-rated health, across
gender and age groups. The earlier study from Leicestershire
found a deterioration in self-rated health in the second sample while disability improved [21]. Trends in self-rated health
may therefore not reflect trends in disability.
In the face of society’s anxiety about the burden of an
ageing population, this study provides some encouragement
that older people today are fitter than a decade ago and may
remain independent for longer. The onset of significant disability in ADL may be delayed by 4 years, and it remains
possible that the years requiring support are stable.
Key points
• Prevalence of disability affecting ADL showed reductions over 10 years.
• Findings were consistent across all age groups of older
people and both genders.
• Dependency rates in care homes have increased.
• Self-rated health has been stable and does not reflect the
improvements in disability.
Acknowledgements
I am grateful to Dr Anita Wood for her assistance with the
2008 survey. We are extremely grateful to the general
practices — doctors, nurses and administrative staff —
who made these surveys possible. The practices were
Hucclecote Surgery, Gloucester; Heathville Road Surgery,
Gloucester; Forest Health Care, Cinderford; Coleford Health
Centre; Beeches Green Health Centre, Stroud; Hadwen
Practice, Gloucester; Painswick Surgery; Frithwood Surgery,
Bussage; Abbotswood Surgery, Brockworth; and Barnwood
Medical Practice, Gloucester.
Conflicts of interest
None.
Funding
The work in 1998 was funded by a grant from the Edith
Mackay bequest. The 2000 Care Home census was funded
by the Whole System Group, Gloucestershire Health Authority. The survey in 2008 was funded by an SpR start-up
grant from the British Geriatrics Society.
Supplementary data
Supplementary data mentioned in the text is available to subscribers in Age and Ageing online.
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© The Author 2010. Published by Oxford University Press on behalf of the British Geriatrics Society.
All rights reserved. For Permissions, please email: [email protected]
Health, social and lifestyle factors in entry to
residential aged care: an Australian longitudinal
analysis
HAL KENDIG1, COLETTE BROWNING2, ROBERT PEDLOW3, YVONNE WELLS4, SHANE THOMAS5
1
Ageing, Work, and Health Research Unit, The University of Sydney, Sydney, New South Wales, Australia
Medicine, Monash University, Melbourne, Victoria, Australia
3
Safe Work Australia, Canberra, Australian Capital Territory, Australia
4
Lincoln Centre for Research on Ageing, La Trobe University, Melbourne, Victoria, Australia
5
School of Primary Health Care, Monash University, Melbourne, Victoria, Australia
2
Address correspondence to: H. Kendig. Tel: +61 2 9351 9049; Fax: +61 2 9351 9566. E-mail: [email protected]
Abstract
Background: strategies to enable older people to remain in their own homes require information on potential intervention
areas and target groups for health promotion and healthcare services.
Objective: this study aimed to identify socioeconomic, health and lifestyle factors in entry to residential aged care facilities.
Design: a prospective cohort study was conducted from 1994 to 2005.
Setting: the information source was the Melbourne Longitudinal Studies on Healthy Ageing Program.
Subjects: one thousand Australians aged 65 years and over living in the community were used as baseline sample.
342