Living longer but doing worse: assessing health status in elderly persons at two points in time in Manitoba, Canada, 1971 and 1983

Strengthening the Call for Intentional Intergenerational Programmes towards Sustainable Futures for Children and Families

As a response to the call for reimagining early childhood education for social sustainability in the future, this conceptual paper aims to suggest revisiting and strengthening the case to include intentional intergenerational engagements and programmes in kindergartens as approaches towards sustainable futures for children. In this paper, we argue that we must talk about intergenerational solidarity on all levels, including in early childhood education and care settings, and that it must be deliberate and by design. Learning from cultural–historical concepts and the UN Convention on the Rights of the Child, intergenerational programmes in early years settings are to be presented as intentional initiatives and opportunities for interrelated and collaborating actors and institutions to bring younger children and older adults together. We present a conceptual framework that features conflicts and opportunities within overlapping and congruent spaces to understand conditions for various intergenerational practices and activities in different places, and to promote intergenerational dialogues, collaborations and shared knowledge, contributing to a relational and socially sustainable future for which we aim.

Addressing Myths about End-of-Life Care: Research into the Use of Acute Care Hospitals over the Last Five Years of Life

Despite very little confirming evidence, one of the most pervasive beliefs about dying is that terminally ill people receive a great deal of health care in the last few days, weeks, or months of life. A secondary analysis of 1992/93 through 1996/97 Alberta inpatient hospital abstracts data was undertaken to explore and describe hospital use over the five years before death by all Albertans who died in acute care hospital beds during the 1996/97 year (n=7,429). There were four key findings: (1) hospital use varied, but was most often low, (2) the last hospital stay was infrequently resource intensive, (3) age, gender, and illness did not distinguish use, and (4) most ultra-high users were rural residents, with the majority of care episodes taking place in small, rural hospitals.

Client-centred coaching in the paediatric health professions: a critical scoping review

PURPOSE

Coaching is mainstream in business and is expanding into paediatric health care. With the focus on evidence-informed health practice, it is imperative to identify the key active components of interventions. Coaching is by definition a complex intervention with numerous components. The purpose of this critical review is to determine how coaching is currently defined, its prevalence in paediatric health care services and the frequency of the active components of coaching and to consider the findings of research to date.

METHOD

A critical review of the literature was conducted. Inclusion/exclusion criteria were based on the International Coach Federation, which stipulates that coaching is a collaborative process that involves client-centred goal setting, facilitation, self-discovery and capacity building. Seventeen studies were selected for thorough review.

RESULTS

Throughout the literature, there was inconsistency in how coaching was defined. Studies included various components, but overall the literature lacked cohesion.

CONCLUSION

To advance the field, a list of components that foster client engagement was developed along with a comprehensive definition of coaching involving affective, behavioural and cognitive components and a path of research necessary to evaluate this complex intervention. Implications for Rehabilitation A comprehensive approach to coaching involves consideration of multiple components. A coaching approach can enhance engagement in rehabilitation interventions. The operationalization of holistic ABC coaching that encapsulates the important components, which are affective, behavioural and cognitive in nature.

Epidemiologic-Ecological Models of Aging

Model building in epidemiological-ecologic research on aging is hampered by the prevailing paradigm of standard empiricism, lack of knowledge about the biological origins and causes of aging and problems in differentiating the aging process from age-related diseases and disabilities. Consequently, the identification of associations or causal relations between risk factors, aging, diseases and disabilities suffers from a number of conceptual and methodological problems which sometimes can lead to research results which are absurd in the context of real life despite their formal correctness. The benefit of building theoretical models arises out of the necessity to construct an empirically sensible order of events which renders the research object intelligible. It is suggested that in the multifactorial epidemiological-ecologic aging research it might be useful to adopt and empirically test the concept of the “effective causal complex” instead of continuing, in many cases fruitless, attempts to define the effects of single risk factors on the associations between aging, physiological damage and disease and disability outcomes.

Using Existing Data Sets to Study Aging and the Elderly: An Introduction

Le dévéloppement des systèmes d'information a permis la création de vastes banques de données informatisées détaillées, dont bon nombre contiennent des renseignements pertinents à la recherche sur les personnes âgées et le vieillissement. Cet article cite plusieurs types de banques de données exhaustives et fournit des exemples de chacun. Il présente ensuite les points forts et les points faibles des études menées à l'aide de données déjà existantes, puis souligne des stratégies pour l'analyse de données secondaires. Les banques de données déjà en place exigent beaucoup d'efforts dans la compilation de données individuelles et offrent d'immenses possibilités pour répondre aux questions importantes en matière de recherche sur le vieillissement.

Avalanche or Glacier?: Health Care and the Demographic Rhetoric

Claims that the health care system is about to be engulfed in a “wave of grey” have become commonplace. Recent cost escalation is commonly attributed to the aging of the population, and there is no shortage of dire warnings about the cost implications of the even more dramatic aging, and costs, still to come. These claims have been largely unsubstantiated. Yet they persist for a number of reasons. First, over long periods of time, the effects of demographic trends can be (and probably will be) quite substantial. But these effects move like glaciers, not avalanches. Second, the effects of aging populations on some types of services which cater differentially to seniors will be much more dramatic; observers of those sub-sectors (such as long-term care) tend to extrapolate that sector-specific experience to health care generally. Third, at the “coal-face,” health care providers are seeing their practices become ever more dominated by seniors. They mistake this increased “presence” of patients aged 65 and over in their practices as evidence of the effects of demographic changes. In this paper we discuss each of these sources of error about the effects of aging population on health care costs. We focus primarily on the confusion between changes in patterns of care for particular age groups, and changes in overall levels of care. Quite extensive empirical evidence has been collected over the past decade from analyses of British Columbia data bases, and these findings are not unique, in Canada, or beyond. The common finding of this body of research is that population aging has accounted for very little of the increase in health care costs over the past three decades, in Canada or elsewhere. Health care utilization has increased dramatically among seniors. But this has had less to do with the fact that there are more of them, than with the fact that the health care system is doing much more to (and for) them than was the case even a decade ago. This suggests that the appropriate care of elderly people should be a central issue for health care policy and management, but that demographic issues are, in the short run at least, largely a red herring.

Method and Description of the Aging in Manitoba Project: A 20-Year Longitudinal Study

The Aging in Manitoba (AIM) project includes nearly 9,000 seniors who have been interviewed. Three independent cross-sectional samples (i.e. 1971, 1976, 1983) were subsequently followed (1983–1984, 1990), producing cross-sectional and longitudinal data. A major goal of this paper was to examine non-response over time and representativeness of the panel of AIM survivors. This involved analysis of non-response, calculations of completion/response rates, and comparisons of demographic variables across the AIM sample and the broader Manitoba and Canadian populations. Non-response was very low (4.6% in 1983–1984, 5.0% in 1990) and did not appear to be dependent on such factors as location, gender, education level, or nationality descent. The 95.0 per cent completion rate compares favourably with other longitudinal studies, demonstrating the value of employing rigorous tracking procedures. These findings suggest that attempts to minimize bias and selective attrition in the AIM study have been successful.

Rising Use of Physician Services by the Elderly: The Contribution of Morbidity

Use of medical services by the elderly population is increasing. While rising numbers of elderly persons account for much of the overall increase, per capita increases in use of medical services within this group have been substantial. This phenomenon is commonly attributed to greater need due to the “aging” of the elderly population (i.e. an increased proportion of those 85 years of age and over) and to changing patterns of morbidity or to changing patterns of servicing the old and sick. Research to date suggests that the impact of the aging of the elderly population has been small. However, because the relationship between morbidity and rising utilization has not yet been studied, there is considerable debate about the extent to which increased “need” for care contributes to patterns of rising utilization. This research studied the impact of changes in numbers, demographics, and morbidity patterns of the elderly on per capita and aggregate consumption of ambulatory physician services at two points in time. Linked survey and physician claims data for representative samples of the elderly in 1971 and 1983 were used to study patterns of utilization of total ambulatory, consultative and non-consultative care by age and health status. The research found that per capita utilization of both consult and non-consult visits rose across all categories, with older individuals and those in poor health experiencing greater increases in utilization than younger and healthier individuals. At the aggregate level, a large percentage of the increase in utilization of medical services was related to increased numbers of elderly. Changes in ‘need’ attributable to aging of the elderly population and increased morbidity had only minor effects. At least 35 per cent of the increase in non-consult visits and 50 per cent of the increase in consult visits were not specifically related to changes in need of the elderly population and remain as unexplained changes in patterns of servicing individuals. While some of this increase was directed to individuals in poor health, the majority of increased servicing (32% of the increase in non-consultative visits and 58% of the increase in consultation visits) was directed to individuals in good health. Policy implications are discussed.

Research Note: Describing Canada's Residential Continuing Care Population through an Analysis of a National Mortality Dataset and a Provincial Hospital Dataset

While there are 157,000 designated continuing care (CC) beds in Canada – beds that are only used by a rather distinct group of individuals – no comprehensive description of the CC resident population exists. An analysis of 1974–1997 Statistics Canada mortality data and 1992/93–1996/97 Alberta hospital utilization data was undertaken to provide a description of one segment of this population, those at the end of life. Statistics Canada data indicate that only a small (<3%) proportion of deaths take place each year in CC facilities, with these persons 84.5 years of age on average, and most often female (62.5%), widowed (61.9%), and Canadian born (61.8%). The primary cause of death/diagnosis varied considerably, as it did for CC residents in Alberta who were transferred to acute care hospitals before dying there. The average hospital stay for transferred persons was 14.0 days in length, with these hospitalizations normally characterized by few diagnostic tests or treatments (mean=0.9).

What do we know about the agricultural demographic transition?

The Agricultural Revolution accompanied, either as a cause or as an effect, important changes in human demographic systems. The consensus model is that fertility and mortality increased and health declined with the adoption of agriculture, compared to those for hunter-gatherers. Analysis of the agricultural transition relies primarily on archaeological and paleodemographic data and is thus subject to the errors associated with such data. The assumptions needed to use these data can profoundly affect the inferences that are drawn. While it is clear that, in general, population growth accompanied the agricultural transition, it is not as clear exactly how fertility and mortality changed or whether the transition caused a decline in health. Although the model of the agricultural demographic transition as outlined here may be correct, researchers should remain aware of the underlying assumptions and be open to future empirical evidence.

A health profile of community-living nonagenarians in Canada

Due to increasing life expectancy over time, persons who live into their ninety, known as nonagenarians, are an important and growing segment of the Canadian population. In 2001, there were 130,325 nonagenarians (compared to 3,795 centenarians), and it is estimated that they will top 400,000 by 2026. This paper provides a health profile and an exploratory analysis of selected social determinants of health for community-living nonagenarians, using the 2001 Canadian Community Health Survey (Statistics Canada, 2003). Perceived health, selection of prevalent chronic illnesses, and several health behaviours are examined. One dominant pattern is the tendency for male nonagenarians to be in better health than their female counterparts. This finding is consistent with research on centenarians and is discussed in terms of a mortality selection effect. Other key findings include the strength of sense of belonging, income, and physical activity as potential social determinants of health, connected to particular dimensions of health status.

Health Trends in the Elderly Population: Getting Better and Getting Worse

Health trends in the fastest growing sector of the population, the oldest old, have received much attention during the past decade because of the rising costs of medical and long-term care. Many studies have suggested a compression of morbidity in this sector, implying that the future care needs of elderly people will not follow the demographic prognoses. Most of these studies have used health indicators based on disability, a concept that is contextually embedded. We have taken a closer look at health-trend surveys with a focus on the health indicator used. Our findings reveal that although disability measures often show improvement, there is a simultaneous increase in chronic disease and functional impairments-health components that require care resources. That is, an expansion of other health problems may accompany a compression of disability. Therefore, a concept of general morbidity is not sufficient when discussing health trends and the need for care services in the elderly population. Because different indicators do not show the same trends over time, we suggest a more refined discussion that distinguishes between different health components. In addition, different components have different implications for the amount and kind of care resources needed. If the current positive trends in disability continue, future need for social services and long-term care may not parallel demographic projections. Trends in disease and functional limitations seem to have taken a different direction, suggesting a parallel or increased need for resources in medical care, rehabilitation, and compensatory interventions such as assistive technology.

Physical functioning in elderly Europeans: 10 year changes in the north and south: the HALE project

OBJECTIVES

To examine age related changes in physical functioning in elderly men and women.

DESIGN

Prospective, population based study.

SETTING

Population of 15 rural and urban centres in 10 European countries.

PARTICIPANTS

Altogether 3496 men and women born between 1900 and 1920 who participated in the baseline survey of the HALE project in 1988-1991. The study population was examined again about five (in 1993-1995) and 10 (in 1999-2001) years after the baseline examination.

MAIN OUTCOME MEASURES

Physical functioning was measured by means of a self administered questionnaire of activities of daily living (ADL). Dichotomised prevalence of disability and need for help in self care and mobility ADL were used as dependent variables in the analyses.

RESULTS

Prevalence of disability and need for help tended to be higher in women than in men and in mobility abilities than in self care activities. Disability and need for help increased with advancing age but ameliorated over time from one birth cohort to another. In longitudinal analyses this beneficial time trend was independent of the effect of age, study, and region in self care disability in men and women (OR 0.85, 95% CI 0.75 to 0.97 and OR 0.64, 95% CI 0.43 to 0.97, respectively) and self care need for help in men (OR 0.83, 95% CI 0.70 to 0.96). Mobility disability among men and self care disability among women decreased more in the south than in the north.

CONCLUSION

While European populations are aging, the proportions of elderly people with disability are decreasing. These results suggest that dynamics of functioning may differ across cultures. Future studies are needed to clarify which potentially modifiable and culturally determined factors protect against functional decline.

A follow-up study found that cardiovascular risk in middle age predicted mortality and quality of life in old age

OBJECTIVE

Cardiovascular risk reduction, while saving lives, may prolong the time with disability and impair the quality of life in survivors. We compared the consequences of middle age cardiovascular risk in old age.

STUDY DESIGN AND SETTING

In 1974, risk was low in 593 (low-risk group) and high in 610 men (high-risk group). At baseline, all were healthy with similar age and socioeconomic status. Lifestyle and clinical factors, including quality of life (RAND-36), were surveyed with a questionnaire in 2000, and mortality was determined up to 2002.

RESULTS

During the follow-up, 303 men died, with mortality 54% higher in the high-risk group (P=.001). In the 2000 survey, high-risk men still had significantly greater BMI, higher blood glucose, higher prevalence of smoking, and more sedentary lifestyle, and they reported more both cardiovascular and noncardiovascular diseases. All the RAND-36 scales were worse in the high-risk group; of the two component summary scores, physical (PCS), but not mental (MCS) score, was significantly lower in the high-risk group.

CONCLUSION

Low cardiovascular risk in middle age was associated with lower mortality, morbidity, and better quality of life in old age 26 years later. The results may support the theory of compression of morbidity.

A longitudinal study integrating population, care and social services data. The Swedish National study on Aging and Care (SNAC)

BACKGROUND AND AIMS

A large, national, long-term, longitudinal, multi-purpose study has been launched in Sweden--the Swedish National study on Aging and Care (SNAC). The study involves four research centers collecting data in four different areas of Sweden.

METHODS

The study consists of two parts: the population part and the care and services part. In the population part, a large, representative panel of elders in different age cohorts is followed over time to record and describe the aging process from different aspects. In the care and services part, a systematic, longitudinal, individually-based collection of data is performed concerning provision of care and services together with functional ability, specific health care problems, and living conditions of the recipients living in the area.

RESULTS

The data collection in the population part of the SNAC is not yet completed. In the present article, some preliminary results are reported from the care and services part. These pertain to comparisons between the participating areas with respect to the prevalence of disability among those receiving care and social services in their ordinary homes and those receiving care in special accommodation. A comparison is also presented with regard to the amount of home help provided to subjects with a given disability.

CONCLUSIONS

This project has several advantages. It is expected to generate a rich data base relevant for future research on aging and care and to have a direct impact on the future Swedish system of care and services for the elderly.

The impact of ageing on hospital care and long-term care--the example of Germany

BACKGROUND

In the next few decades the population in all EU-countries will age rapidly. This could have a major impact on the health care sector. This study analyses the effect of population ageing on utilisation in two key sectors of the health care system, namely hospital care and long-term care in Germany, up to 2020 with an outlook to 2050.

METHODS

Two population scenarios, one with constant, one with increasing life expectancy, were combined with constant age and gender specific utilisation rates of hospital and long-term care. In the case of hospital care two projection methods were used: Method A differentiates between age-groups, gender and main diagnosis. Method B differentiates between age-groups, survivors and decedents.

RESULTS

Population ageing was found to cause a moderate increase in hospital days, but was associated with substantial changes in the disease and age structure. In the case of increasing life expectancy, method B lead to a lower growth in hospital days than method A. The number of persons receiving long-term care will increase strongly, associated with a shift to more severe disability and institutional care. Changes in the composition of private households and the increasing labour participation of women will lead to additional demand for professional caregivers at home and in institutions.

CONCLUSIONS

Changes in the number and disease structure of hospital days due to population ageing will require reorganisation and restructuring of hospital departments. In the case of long-term care a high increase in professional home care and institutional care will be required. Health policy has to take into account these developments in order to adequately deal with future demand for these services.

The compression of morbidity debate in aging: an empirical test using the gerontological and geriatric population studies in Göteborg, Sweden (H70)

The H70 longitudinal study of aging, Göteborg, Sweden is used to empirically test the compression of morbidity theory advanced by. We reconceptualize compression as postponement of morbidity in the sense of decreasing amounts of illness for increasingly long life spans. Operationally, morbidity is defined as the average number of hospital days in the last year of life. The date of death and the date of 1-year prior to death define the risk period. The linear regression model with age at death, age at death squared, year of birth, and sex are statistically significant with the oldest having the fewest hospital days. The findings offer partial support for the compression of morbidity theory.

Functional ability in the elderly Finnish population: time period differences and associations, 1985-99

AIMS

The aim of this study was to determine whether functional ability among 65- to 79-year-old Finnish men and women changed at population level from the 1980s to 1990s and how gender, age, previous occupation, and marital status are associated with functional ability and whether these associations have changed over time.

METHODS

Biennial surveys on health behaviour among Finnish elderly people were used to study 10,309 men and women from 1985 to 1999. Age, gender, previous occupation, and marital status were the demographic variables. Logistic regression was used to determine differences.

RESULTS

Functional ability deteriorated clearly with age, but was slightly better in the 1990s than 1980s. Gender differences of functional ability were small. Retired office employees had the best functional ability. Moreover, time changes of functional ability between occupational groups were a little more positive among men than among women. Functional ability of divorced and widowed elderly emerged as slightly worse than among married persons.

CONCLUSIONS

Young age and non-manual occupation prior to retirement were associated with better functional ability. The overall improvement of self-reported functional ability among elderly people suggests that the onset of disabilities could be postponed, especially if health-related circumstances were more evenly distributed at the start of or even before retirement age.

Improved functional status in 16 years of follow up of middle aged and elderly men and women in north eastern Finland

STUDY OBJECTIVE

To investigate age, period, and cohort effects on functional status.

DESIGN

A prospective cohort study with measurements in 1981, 1990, and 1996.

SETTING

Three municipalities in north east Finland.

PARTICIPANTS

A regionally representative sample of 19 to 63 year old men and women was drawn from the census data in 1979, of which 758 men and 1033 women initially aged 39-63 years entered the study in 1980 and completed the follow up in 1996 (90.9% of the alive cohort).

MEASUREMENTS AND MAIN RESULTS

Functional status was determined based on self estimated disabilities (difficulties or not able) to walk 2 km, climb several flights of stairs, and run 100 m. The age adjusted odds of disability in stair climbing and running were lower among the men and the women in 1990 and 1996 than among the men and the women in 1981. There was a declining trend in the odds of disability with succeeding birth cohorts among both the men (odds ratios (OR) 0.79 and 95% confidence intervals (CI) 0.70 to 0.88 for stair climbing and OR 0.88 and 95% CI 0.78 to 0.98 for running) and the women (OR 0.85 and 95% CI 0.77 to 0.93 for stair climbing and OR 0.85 and 95% CI 0.76 to 0.94 for running). No statistically significant differences in walking disability were found between the study periods or the study cohorts.

CONCLUSIONS

The findings depict an improved time trend in functional status in the study population, with implications for future health and social care planning.

Mortality in three different cohorts of 70-year olds: the impact of social factors and health

BACKGROUND AND AIMS

Little is known about changes in mortality among elderly over time, especially in subgroups differing in social and other background factors. The aim of this study was to analyze differences in mortality in three different cohorts of 70-year olds regarding social factors, social network, self-assessed health and number of diseases.

METHODS

We used data from 3 random samples of 70-year olds born in 1901/02 (N=973), 1906/07 (N=1036) and 1911/12 (N=619). At age 70 all participants were given medical examinations and interviewed regarding social background, social network, self-assessed health, need of care and number of diseases. Death records were obtained up to and including 1998.

RESULTS

The youngest cohorts had significantly decreased mortality compared to the oldest cohort (RR 0.86; CI 0.78-0.95 and RR 0.88; CI 0.78-0.995 respectively). There were no differences between the two youngest cohorts. Decrease in mortality in the younger cohorts was found among those who lived in their own home, did not feel tired, were non- or ex-smokers and had one or more diseases.

CONCLUSIONS

There was a small difference in total mortality between these cohorts of 70-year olds. There were differences in development of mortality in subgroups distributed by health and social factors, indicating more years of life, partly due to life-style factors such as non-smoking.

A 3-year follow-up study of social, lifestyle and health predictors of cognitive impairment in a Chinese older cohort

BACKGROUND

Longitudinal data on the older population in the Asian setting are limited. This paper reports the factors associated with the development of cognitive impairment (CI) in a cohort of Chinese elderly aged > or =70 years.

METHODS

The study cohort comprising 2030 subjects aged > or =70 years was assembled in 1991-1992 and followed for 36 months. Baseline information on cognitive function, as well as a number of social and health variables were obtained through face-to-face interview at the respondent's place of residence. The outcome variable was the development of CI among 988 cohort members who were initially free from CI, and who could be contacted at the 36-month follow-up. The instrument used to assess CI was based on the information/orientation part of the Clifton Assessment Procedure for the elderly (CAPE), using a cut-off point of 7.

RESULTS

Of the men, 6.7%, but 22.2% of women had CI at 3-year follow-up. The age-adjusted annual incidence of CI was 1.52% in men, and 6.37% in women. Multivariate logistic regression analysis showed that women had a 2.5-fold increased risk of having CI, compared with men. The risk increased by about 1.5-fold with every 5-year increase in age. Slow gait time, as assessed by the 16-foot walk, was a predictor of CI in both sexes (odds ratio [OR] = 1.03 per second increase, 95% CI : 1.0-1.07). Men residing in institutions had a 4.4-fold increased risk of having CI (95% CI : 1.7-11.1) compared with those residing in community, while the OR among women was 2.5 (95% CI : 1.3-4.9). Among women, no formal education increased the risk of having CI by 3.2-fold (95% CI : 1.8-5.5). Income dependency also increased the risk of CI by about fourfold, and no exercise at baseline was associated with a twofold increased risk of CI. Incident stroke during follow-up also increased the risk of CI (OR = 8.4, 95% CI : 1.2-59.4).

CONCLUSIONS

Older age and female sex were independent factors associated with CI. No formal education, slow gait time and institutionalization increased the risk of CI in both sexes. While education had a stronger effect in women, institutionalization had a stronger effect in men. Financial dependency, lack of exercise and incident stroke played a significant role in women.

Secular trends in self-reported functioning, need for assistance and attitudes towards life: 10-year differences of three older cohorts

OBJECTIVES

To compare the self-reported functional status of cohorts, born 10 years apart, when they were at equivalent ages: 75, 80, or 85.

DESIGN

Cross-sectional mailed survey of three birth cohorts in 1989 and 1999.

PARTICIPANTS

Random samples of older home-dwelling residents from birth cohorts 1904, 1909, and 1914 in 1989 ( N = 685) and the birth cohorts 1914, 1919, and 1924 in 1999 ( N = 2,047) were asked the same questions.

MEASUREMENTS

Self-reported physical functioning, need for assistance in daily living, and attitudes toward life.

RESULTS

Among 85-year-olds born in 1914 there was a significantly larger proportion able to go outdoors compared with 85-year-olds born in 1904 (72.9% vs 60.6% in women (P <.01) and 84.6% vs 63.6 % in men (P <.01), respectively). Similar trends were observed between the oldest cohorts concerning the need for assistance. The amount of publicly funded domestic help had reduced in the two oldest cohorts in 1999 compared with 1989 (20.3% vs 29.8% in 85-year-old women born in 1914 vs 1904 (P <.05); and 10.2 % vs 25.0% in 85-year-old men born 1914 vs 1904 (P <.05), but at the same time 75-year-old women born in 1924 had increased the use of private domestic help compared with 75-year-old women born in 1914. Significantly larger proportions of both men and women had plans for the future in all the cohorts in 1999 than in 1989.

CONCLUSIONS

Consistent yet small differences between the corresponding cohorts suggest that physical functioning and more-optimistic attitude toward life have increased and need for assistance has decreased over 10 years in the older population up to the age of 85.

Health, function and survival of a cohort of very old Canadians: results from the second wave of the Canadian Study of Health and Aging

Seniors 85 years of age and older (85+) make up the fastest-growing segment of the Canadian population. There is a need for longitudinal data on the health status of this group. We used data collected as part of the Canadian Study of Health and Aging to examine how health status changed over five years in a large (n = 1799) cohort of Canadians 85+. By the time of the follow-up assessment, 60.1% had died and 33.9% of those who had been residing in the community when the cohort was initially formed had been institutionalized. Most (79.2%) of the community survivors felt that their health had stayed the same or improved, even though over two thirds (67.9%) reported a decline in their functional abilities. Potential predictors of both good and adverse outcomes were explored. While disease prevention, health promotion and environmental modifications may decrease the personal and societal impacts of these age-associated findings, health care planning for the very old should take these data into account.

Aging-related clinical and health services research in Canada

Research by Canadian geriatricians has grown significantly since the Canadian Society of Geriatric Medicine was founded in 1981. Most research has been clinical or related to health service use. More recently, the Canadian Study of Health and Aging (CSHA) has proved an important focus for population-based research, and research on dementia. An increasing number of Canadian geriatricians have undertaken formal research training, and the CSHA study team and other groups are providing opportunities for multicentre, multidisciplinary, collaborative studies. These developments point to continued growth in research by Canadian geriatricians, most likely research with a clinical and population focus and employing multicenter designs.

Not-So-New Public Management and the Denial of Geography: Ontario Health-Care Reform in the 1990s

New public management (NPM) has become the mantra for public sector restructuring in OECD nations. We critically examine NPM in the context of recent public sector restructuring initiatives in the province of Ontario, Canada. Two NPM-inspired reform mechanisms employed by the Ontario government—the benchmarking of hospital-utilization indicators and the offloading of a greater share of patient-care responsibilities to the private sector—are examined as they impact on the economically disadvantaged city of Thunder Bay in the province's remote Northwestern region. We argue that the health reforms pursued by the Ontario government are focused on a one-dimensional notion of efficiency which denies important socioeconomic and health-service-environment dimensions that account for local differences in health-services utilization. Although this type of reform approach achieves short-term cost savings, we question whether the longer term effects on health and social services are efficient and equitable from a systemwide perspective. Ultimately, we question whether NPM will solve the problems inherent in publicly supported health and social services or will generate a new set of problems linked to the belief in the primacy of market mechanisms.

Do disease specific characteristics add to the explanation of mobility limitations in patients with different chronic diseases? A study in The Netherlands

STUDY OBJECTIVES

To determine whether disease specific characteristics, reflecting clinical disease severity, add to the explanation of mobility limitations in patients with specific chronic diseases.

DESIGN AND SETTING

Cross sectional study of survey data from community dwelling elderly people, aged 55-85 years, in the Netherlands.

PARTICIPANTS AND METHODS

The additional explanation of mobility limitations by disease specific characteristics was examined by logistic regression analyses on data from 2830 community dwelling elderly people.

MAIN RESULTS

In the total sample, chronic non-specific lung disease, cardiac disease, peripheral atherosclerosis, diabetes mellitus, stroke, arthritis and cancer (the index diseases), were all independently associated with mobility limitations. Adjusted for age, sex, comorbidity, and medical treatment disease specific characteristics that explain the association between disease and mobility mostly reflect decreased endurance capacity (shortness of breath and disturbed night rest in chronic non-specific lung disease, angina pectoris and congestive heart failure in cardiac disease), or are directly related to mobility function (stiffness and lower body complaints in arthritis). For atherosclerosis and diabetes mellitus, disease specific characteristics did not add to the explanation of mobility limitations.

CONCLUSIONS

The results provide evidence that, to obtain more detailed information about the differential impact of chronic diseases on mobility, disease specific characteristics are important to take into account.

Age-specific education and income gradients in morbidity and mortality in a Canadian province

While important age-related trends in the use of health care services over the past two decades in Canada have been well described, a comprehensive description of socioeconomic gradients in morbidity and mortality across age cohorts for a representative population has not been accomplished to date in Canada. The objective of this study was to describe age-specific socioeconomic differentials in mortality and morbidity for a representative sample of a single Canadian province. The study sample was formed from the linkage of individual respondent records in the 1986 census to vital statistics records and comprehensive records of health care utilization for a 5% sample of residents of the province of Manitoba. Using two measures of socioeconomic status derived from census responses, attained education and household income, individuals were stratified into age-specific quartile ranks. Based on diagnostic information contained on health care utilization records, the proportion of the sample in treatment during a 12-month observation period was calculated for 15 broadly defined categories of morbidity and tested for differences across socioeconomic quartiles. Mortality was inversely associated with both income and education quartile rank. In the analysis of morbidity, no association between socioeconomic status and treatment prevalence was observed in the majority, no association between socioeconomic status and treatment prevalence was observed in the majority of the 122 age- and disorder-specific strata tested. Of the observed associations, however, negative relationships were dominant, indicating a higher treatment prevalence among individuals of lower attained education or lower household income. Across the age course, negative relationships were most frequently present among young and middle aged adults, those aged 30-64, and were more consistently found for income than for education. The general findings of this study of a representative Canadian population support observations from other developed country settings that socioeconomic differences in relative rates of mortality and morbidity over the life course are greatest in the adult years.

Intensive use of mental health care

OBJECTIVE

To describe the profile of the intensive use of mental health services over a 4-year period in a population of 1.1 million people.

METHODS

Data obtained from computerized hospital separation records and physician reimbursement claims were combined to form patient-based histories of mental health care utilization. Users of mental health services in a 24-month period were hierarchically classified as having a psychotic disorder (ICD-9-CM 295-299) or a nonpsychotic disorder (ICD-9-CM 300-301, 306-309, 311). Intensive use was defined as 12 or more contact months or a minimum of 2 episodes of therapy in the 24-month period. The cohort of intensive users were followed over the subsequent 24-month interval to describe the persistence of intensive use.

RESULTS

In the initial observation periods, intensive users constituted 27.4% of individuals in treatment for psychotic disorder and 4.4% of persons in treatment for nonpsychotic disorder. These 2 groups, which represent 7.4% of all users of mental health care, were responsible for 53% of physician services, 72.7% of contacts with psychiatrists, and 64.4% of acute psychiatric bed days in the initial period. In the follow-up period, intensive use status was replicated by 44.6% of the cohort.

CONCLUSIONS

The diagnostic and therapeutic characteristics of intensive users of mental health services are heterogeneous. There is substantial persistence of intensive mental health service use over time.