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

Trends in Positive Life Orientation Among 70-Year-Olds: A Comparison of Two Finnish Cohorts Born 20 Years Apart

OBJECTIVES

We assessed if positive life orientation (PLO) has increased among older individuals and explored gender disparities in PLO changes.

METHODS

Two cohorts of 70-year-olds from Turku, Finland were included: the 1920 birth cohort (examined in 1991; n = 1,032) and the 1940 birth cohort (examined in 2011; n = 956). Participants completed an identical questionnaire assessing life satisfaction, feeling needed, future plans, zest for life, depression, and loneliness. A composite PLO score (range 0-1) was computed.

RESULTS

The 2011 cohort had a higher mean PLO score than the 1991 cohort (.87 vs. .83, p < .001). The 2011 cohort reported higher sense of being needed, more future plans, and reduced loneliness (all p < .001). No significant differences were found in life satisfaction, zest for life, or depression. Gender disparities in PLO persisted across both cohorts, with men scoring slightly higher but following similar trends as women.

DISCUSSION

PLO appears to have increased among older individuals.

CLINICAL IMPLICATIONS

Recognizing the rising trend of PLO in recent decades may influence the development of societal and healthcare policies to further improve overall well-being among older individuals.

Secular trends in functional abilities, health and psychological well-being among community-dwelling 75- to 95-year-old cohorts over three decades in Helsinki, Finland

Background: Life expectancy has increased markedly in the past decades. Thus, it is of great importance to understand how people are ageing and if the trajectories of health and disability are changing over time. This study aimed to examine trends in functional abilities and health in independent cohorts of people aged 75–95 over three decades. Methods: This Helsinki Ageing Study consists of repeated cross-sectional postal surveys examining independent cohorts of old people (75, 80, 85 and 90+ years old). This study combined data from four waves (1989, 1999, 2009 and 2019). Results: In the most recent wave, there was an increase in the portion of participants who were able to walk outdoors easily (75-year-olds p=0.03, 80-year-olds p=0.002, 85-year-olds p<0.001; p for linearity for the study year effect, all adjusted for sex). Fewer people in the youngest age group (75-year-olds) needed daily help from another person in 2019 compared to the earlier waves (p=0.02 for linearity for the study year). Over the past three decades, the proportions of self-reported good mobility have risen 8.7% (95% confidence interval (CI) 2.3–15.1) in 75-year-olds, 11.7% (95% CI 3.9–19.6) in 80-year-olds and 20.1% (95% CI 10.7–29.4) in 85-year-olds, after adjusting for sex. Furthermore, in 2019, more people rated their health as good and scored better in psychological well-being than in the previous waves among 75-, 80- and 85-year-olds. However, no improvements were found among 90+-year-olds in any of these variables. Conclusions: People between 75 and 85 years old are presently feeling and functioning better than their predecessors. This may be an important objective for both economics and health policy.

Changes in disability, self-rated health, comorbidities and psychological wellbeing in community-dwelling 75-95-year-old cohorts over two decades in Helsinki

OBJECTIVE

To explore changes in self-reported disabilities, health, comorbidities and psychological wellbeing (PWB) in aged cohorts over two decades.

DESIGN, SETTING AND SUBJECTS

Cross-sectional cohort studies with postal surveys were conducted among community-dwelling people aged 75, 80, 85, 90 and 95 years in 1989 (n = 660), 1999 (n = 2598) and 2009 (n = 1637) in Helsinki, Finland.

MAIN OUTCOME MEASURES

Self-reported items on disability, self-rated health (SRH), diagnoses and PWB were compared between cohorts of the same age. Standardized mortality ratios (SMRs) were calculated for each study year to explore the representativeness of the samples compared to general population of same age.

RESULTS

A significantly lower proportion of the 75-85-year-olds of the later study years reported going outdoors daily, although this group had improvements in both SRH and PWB scores. The number of comorbidities increased over time among 75-85-year-olds. The only significant change that could be verified among 90- and 95-year-olds between 1999 and 2009, was the lower proportion of participants going outdoors daily. The trend of leveling-off in disabilities was not explained by the SMRs (0.90, 0.71 and 0.60 for 1989, 1999 and 2009).

CONCLUSIONS

The latest older people's cohorts showed an end to previously reported improvements in disabilities, despite having favorable trends in SRH and PWB. Primary care may be faced with increasing need of appropriate services for their senior members.

Loneliness of older people aged 70: a comparison of two Finnish cohorts born 20 years apart

OBJECTIVE

This study aimed to examine loneliness among two birth cohorts, born 20 years apart, when they were 70 years of age, and to identify factors explaining loneliness.

METHODS

The cohorts consisted of older home-dwelling residents of Turku, Finland, from the birth cohort 1920 in 1991 (N=1530) and the birth cohort 1940 in 2011 (N=1307). Suffering from loneliness was assessed with the question: 'Do you suffer from loneliness?' Cross-tabulations with chi-square test, general linear model (GLM) and multiple regression analysis were used in statistical testing and modeling.

RESULTS

In the 1940 cohort, around one-fifth (18%) of the respondents suffered from loneliness at least sometimes, while the corresponding figure in the 1920 cohort was around one-fourth (26%). Our analyses indicated that the effect of cohort was not a statistically significant explanatory factor of loneliness. Living status, self-rated health and memory compared to age peers were statistically significant explanatory factors for suffering from loneliness. When we controlled the effect of depressiveness on the experience of loneliness, it was shown that the effects of living status and self-rated health remained statistically significant, whereas memory compared to age peers did not. Depressiveness itself was highly important. The combined effect of living status and self-rated health emerged as the most significant explanatory factor for loneliness. Older people with poor self-rated health who lived alone were most likely to suffer from loneliness.

CONCLUSION

The findings give healthcare professionals an opportunity to plan for interventions aimed at combating loneliness among home-dwelling older people.

Factors connected with positive life orientation at age 70, 80, 85 and 90 - The Turku Elderly Study

BACKGROUND

A positive life orientation (PLO) is important for staying healthy physically, mentally and functionally. However, little is known about the factors connected with PLO in home-dwelling older people, even though it is an important topic.

AIM

The aim of this study was to identify factors connected with positive life orientation among home-dwelling older people.

STUDY DESIGN

An explorative, population-based cross-sectional study of the age cohort of 70-year-olds living at home at the age of 70, 80, 85 and 90.

METHODS

The data were collected in 1991 among all residents of Turku, Finland, born in 1920 (N = 1530). Follow-ups were conducted in 2001 (n = 656), 2006 (n = 304) and 2011 (n = 156). A multiple regression analysis was conducted to estimate a model of factors that connected with PLO.

RESULTS

Several factors were significantly connected with PLO at ages 70, 80, 85 and 90. For example, if 70-year-old respondents perceived themselves as being in better health than others of the same age, it improved their PLO. We also observed that PLO was improved by good self-rated health during the past 12 months at 80, good self-rated health at 85 and good self-rated health compared to others of the same age at 90. The various explanatory models explained between 24 and 36% of the variance in outcomes.

CONCLUSION

Overall, our results showed that the respondents' own subjective views were significant independent factors of PLO in all four analyses (70, 80, 85 and 90 years). These subjective experiences remained significant even when objective indicators such as medication use, the presence of diseases and functional capacity were taken into account.

Functional disability and ability 75-year-olds: a comparison of two Swedish cohorts born 30 years apart

OBJECTIVE

to compare the level of functional disability and involvement in leisure activities between two birth cohorts of Swedish 75-year-olds examined in 1976-77 and 2005-06.

DESIGN

cohort comparison.

SETTING AND PARTICIPANTS

representative data from the general population in Gothenburg, Sweden, examined at the age of 75 in 1976-77 (n = 744), and in 2005-06 (n = 731) with comprehensive somatic and psychiatric examinations.

MEASUREMENTS

activities of daily living (ADL); instrumental activities of daily living (IADL); a battery of self-report measures, including involvement in leisure activities, satisfaction with home-environment, social networks and self-rated health.

RESULTS

functional disability in ADL decreased between the cohorts (13.9 versus 5.6%, P < 0.001). Functional disability in IADL also decreased between the cohorts (33.4 versus 13.0%, P < 0.001). Combining ADL and IADL resulted in an overall decreased dependency, with the largest decrease seen in women (42.3 versus 15.1%, P < 0.001). Involvement in leisure activities increased between the cohorts. For example, the proportion going on international and domestic holiday travels increased (6.3 versus 16.2%, P < 0.001), and the proportion who independently drove their own car also increased (10.0 versus 53.0%, P < 0.001).

CONCLUSION

later born cohorts of 75-year-olds are less dependent in ADL and more engaged in leisure activities compared with earlier cohorts. Later born cohorts of 75-year-olds are thus better equipped to maintain a non-age-related identity compared with earlier cohorts. Our findings might serve as a reason to adopt a more positive view to ageing in a world with an increasing number of older people.

Positive life orientation in old age: a 15-year follow-up

BACKGROUND

Positive life orientation (PLO) is considered an important dimension of successful aging.

AIM

To investigate how self-reported PLO changed among home-dwelling people from age 70 to 80 and 85 years.

STUDY DESIGN

A prospective, population-based 15-year follow-up study of the age cohort of 70-year-olds living in the city of Turku, Finland.

SUBJECTS AND METHODS

The data were collected in 1991 by a postal questionnaire that was sent to all residents of Turku, Finland, born in 1920 (N=1530). Follow-ups using the same procedure were conducted in 2001 and 2006. PLO was assessed with the following items: life satisfaction, feeling needed, having plans for the future, having zest for life, feeling depressed, and suffering from loneliness. We created a PLO score from the answers to these questions, where 1 represented the best PLO and 0 the poorest.

RESULTS

At baseline, the participants showed rather high levels of positive life orientation (PLO total score 0.83). PLO declined markedly after the 70-year-old participants reached the age of 80 and 85 years (p<.001). However, depressive feelings remained quite stable. The decrease was similar among men and women except for the items suffering from loneliness and feeling needed. At age 70 and 80 years women suffered more from loneliness than men, while men experienced feeling needed more than women.

CONCLUSIONS

Positive life orientation declines during old age, especially from age 70 to 80 years. Thereafter the decline is less steep except for changes in future plans and feeling needed.

Older adults' own reasoning for their alcohol consumption

OBJECTIVE

The aim of the study was to investigate what the older adults themselves consider to be the reasons for their alcohol consumption.

METHODS

The data were collected with a postal questionnaire from a random sample of 2100 elderly people (≥65 years) living in the medium-sized city of Espoo, Finland. The response rate was 71.6% from the community-dwelling sample. Altogether 868 persons responded that they use alcohol. Of them, 831 gave reasons for their drinking. We defined "at-risk users" as consuming >7 drinks per week, or ≥5 drinks on a typical drinking day, or using ≥3 drinks several times per week.

RESULTS

Main reasons given for alcohol consumption were "having fun or celebration" (58.7%), "for social reasons" (54.2%), "using alcohol for medicinal purposes" (20.1%), and "with meals" (13.8%). Younger age groups reported more often than the older age groups that they use alcohol for "having fun or celebration" and "for social reasons." The older age groups used more often "alcohol for medicinal purposes". Men used alcohol more often than women "as pastime" or "as sauna drink". Those defined as "at-risk users" reported using alcohol because of "meaningless life," for "relieving depression," "relieving anxiety," and "relieving loneliness."

CONCLUSIONS

Older adults have diverse alcohol consumption habits like people in other age groups. The oldest olds reported that they use alcohol for medicinal purposes. The "at-risk users" admit they use alcohol because of meaningless life, and relieving depression, anxiety, and loneliness.

Prevalence of at-risk drinking among older adults and associated sociodemographic and health-related factors

OBJECTIVES

Recognition of alcohol-related health problems in the elderly is challenging. Alcohol use also tends to be a hidden issue. The aim of this study was to examine the prevalence and at-risk drinking patterns in community-dwelling older adults and their associations with socio-demographic and health-related factors.

DESIGN

The data were collected with a postal questionnaire from a random sample of 2100 elderly people (≥ 65 years) living in the medium-sized city of Espoo, Finland. The response rate was 71.6% from the community-dwelling sample. We defined the amount of at-risk drinking as 1) consuming >7 drinks per week or 2) >5 drinks on a typical drinking day or 3) using >3 drinks several times per week.

RESULTS

Of the respondents, 8.2% (N=114) were at-risk drinkers. At-risk drinking was associated with younger age and male sex, higher level of education, good income, living with a spouse, and current smoking. In addition, good functioning was associated with at-risk drinking. Although frequency and quantity of alcohol consumption declined with age, of our respondents nearly one-fifth of men aged 71-80 years and one-tenth of men aged 81-90 years could be classified as at-risk drinkers. At-risk drinkers had comorbidities and multiple medications as often as non-risk group. A significantly larger proportion of the at-risk drinking group relative to the non-risk group admitted falling or injuring themselves (5.3% vs. 0.7%) or forgotten to take their medications because of the use of alcohol.

CONCLUSIONS

At-risk drinking is prevalent among older adults, particularly among males, despite prevalent comorbidities and multiple medications. At-risk drinking is associated with adverse events such as a tendency for injuries.

Perceptions of the psychological well-being and care of older home care clients: clients and their carers

AIM

To explore and compare older home care clients' (65+) and their professionals' perceptions of the clients' psychological well-being and care and to identify possible differences in these perceptions.

BACKGROUND

Psychological well-being is considered an important dimension of quality of life. With advancing age, older people require home care support to be able to remain in their own home. The main goal of care is to maximise their independence and quality of life.

DESIGN

Descriptive, survey design with questionnaire.

METHODS

A postal questionnaire was distributed to 200 older home care clients and 570 social and health care professionals in 2007. The total response rate was 63%. The questionnaire consisted of questions about clients' psychological well-being and the provision of care by home care professionals. The differences in responses between clients and professionals were analysed using cross-tabulations, the Pearson Chi-Square Test and Fisher's Exact Tests.

RESULTS

The professional group believed that their clients did not have plans for the future. They believed that their clients felt themselves depressed and suffering from loneliness significantly more often than the client group did. The client group were also significantly more critical of the care (motivating independent actions, physical, psychological and social care) they got from the professional group than how the professionals evaluated the care they gave.

CONCLUSIONS

To be able to support older clients to continue living at home, professionals need to provide a service that meets client's own perceptions and complex social and health care needs as well as personal sense of well-being.

RELEVANCE TO CLINICAL PRACTICE

The findings offer useful insights for the professional in planning and delivering appropriate home care services. A better understanding of differences between clients' and professionals' perceptions could lead to a better individualised care outcome.

Trends in health status and the use of services among the 80-84-year-old Finnish war veterans during 1992 and 2004

AIM

The aim of this study was to compare the differences in health state, functional capacity and the use of social and health services among the 80-84-year-old Finnish Second World War veterans in 1992 and 2004 and to describe the possible effects of the improvements made based on the results after 1992.

METHODS

The Veteran Projects were conducted among the veterans using a postal questionnaire. In 1992, the questionnaire was sent to all veterans (n = 242,720) living in Finland, and in 2004 to 5750 veterans who had participated in the study in 1992. The comparable age groups of veterans aged 80-84 years were used. The data were analysed by descriptive statistics and binary logistic regression analysis. Analyses were conducted separately for men with and without disability and for all women.

RESULTS

The proportion of men with good self-reported health, painlessness, normal memory and vision and who were able to walk 500 m without difficulties, significantly increased, as did the proportion of women with normal memory and vision. The prevalence of many diseases increased, but diseases appeared to be less disabling in 2004 than 1992. The need for hospital care decreased and the use of rehabilitation services increased, but the increased use of rehabilitation services was not indicative of the ability to walk 500 m.

CONCLUSIONS

Self-rated health and functional capacity improved and the need for hospital care decreased among veterans, although the prevalence of many diseases increased during the follow-up. Rehabilitation was not associated with the ability to walk 500 m without difficulties.

Health and disease in 85 year olds: baseline findings from the Newcastle 85+ cohort study

OBJECTIVES

The Newcastle 85+ Study aims to systematically study the clinical, biological, and psychosocial attributes of an unselected cohort of 85 year olds and to examine subsequent health trajectories as the cohort ages; health at baseline is reported.

DESIGN

Cross sectional analysis of baseline data from a cohort study.

SETTING

Newcastle upon Tyne and North Tyneside primary care trusts, United Kingdom.

PARTICIPANTS

1042 people born in 1921 and registered with the participating general practices.

MAIN OUTCOME MEASURES

Detailed health assessment and review of general practice records (disease, medication, and use of general practice services); participants could decline elements of the protocol.

RESULTS

Of the 1453 eligible people, 851 (58.6%) were recruited to health assessment plus record review, 188 (12.9%) to record review only, and 3 (0.2%) to health assessment only. Data from record review are reported on a maximum of 1030 and from health assessment on a maximum of 853; individual denominators differ owing to withdrawal and missing values. Of the health assessment sample (n=853), 62.1% (n=530) were women and 10.4% (n=89) were in institutional care. The most prevalent diseases were hypertension (57.5%, 592/1030) and osteoarthritis (51.8%, 534/1030). Moderate or severe cognitive impairment was present in 11.7% (96/824) of participants, severe or profound urinary incontinence in 21.3% (173/813), hearing impairment in 59.6% (505/848), and visual impairment in 37.2% (309/831). Health assessment identified participants with possible disease but without a previous diagnosis in their medical record for hypertension (25.1%, 206/821), ischaemic heart disease (12.6%, 99/788), depression (6.9%, 53/772), dementia (6.7%, 56/840), and atrial fibrillation (3.8%, 30/788). Undiagnosed diabetes mellitus and thyroid disease were rare (1%, 7/717 and 6/762, respectively). A median of 3 (interquartile range 1-8) activities of daily living were undertaken with difficulty. Overall, 77.6% (646/832) of participants rated their health compared with others of the same age as good, very good, or excellent. High contact rates in the previous year with general practitioners (93.8%, 960/1024) were recorded. Women had significantly higher disease counts (medians: women 5, men 4; P=0.033) and disability scores (medians: women 4, men 2; P=0.0006) than men, but were less likely to have attended outpatient clinics in the previous three months (women 29% (150/524), men 37% (118/320), odds ratio 0.7, 95% confidence interval 0.5 to 0.9).

CONCLUSIONS

This large cohort of 85 year olds showed good levels of both self rated health and functional ability despite significant levels of disease and impairment. Hypertension, ischaemic heart disease, atrial fibrillation, depression, and dementia may be underdiagnosed. Notable differences were found between the sexes: women outnumbered men and had more disease and disability.

Cohort changes in cognitive function among Danish centenarians. A comparative study of 2 birth cohorts born in 1895 and 1905

BACKGROUND/AIM

The objective was to examine cohort changes in cognitive function in 2 cohorts of centenarians born 10 years apart.

METHODS

The Longitudinal Study of Danish Centenarians comprises all Danes reaching the age of 100 in the period April 1, 1995 through May 31, 1996. A total of 207 out of 276 persons participated (75%). The Danish 1905 Cohort Survey includes all individuals born in 1905. In total, 225 out of 364 persons who reached the age of 100 in the cohort participated in the most recent 2005 follow-up (62%). In both cohorts, cognitive function was assessed using the Mini-Mental State Examination.

RESULTS

There were no significant differences in cognitive score between the two centenarian birth cohorts. However, modest tendencies were seen towards better cognitive functioning for the centenarians in the 1905 cohort living at home compared to the home-dwelling ones in the 1895 cohort and worse cognitive performance for the centenarians in the 1905 group living in nursing homes compared to the nursing home dwellers in the 1895 cohort.

CONCLUSION

The increasing number of centenarians may not entail larger proportions of cognitively impaired individuals in this extreme age group.

How do officially organized services meet the needs of elderly caregivers and their spouses with Alzheimer's disease?

The caregiving situation among caregivers and their spouses with Alzheimer's disease, the support and services received, the unmet needs, and the caregivers' satisfaction with the services are examined. The study included a survey of a random sample of 1943 caregivers of persons with Alzheimer's disease in Finland. Mean age of the caregivers was 78.2 years, and 35% had poor subjective health. Disabilities and behavioral symptoms were common among the spouses with Alzheimer's disease. The services most often offered were financial support (36%), technical devices (33%), physiotherapy (32%), and respite care in nursing homes (31%). Most often needed services were physiotherapy for the spouse with dementia (56%), financial support (50%), house-cleaning (41%), and home respite (40%). Only 39% of the caregivers were satisfied with the services, and 69% felt they did not have any influence on what services were offered. It was concluded that official services poorly meet the needs of these caregivers.

Cohort differences in disease and disability in the young-old: findings from the MRC Cognitive Function and Ageing Study (MRC-CFAS)

Background

Projections of health and social care need are highly sensitive to assumptions about cohort trends in health and disability. We use a repeated population-based cross-sectional study from the Cambridgeshire centre of the UK Medical Research Council Cognitive Function and Ageing Study to investigate trends in the health of the young-old UK population

Methods

Non-overlapping cohorts of men and women aged 65–69 years in 1991/2 (n = 689) and 1996/7 (n = 687) were compared on: self-reported diseases and conditions; self-rated health; mobility limitation; disability by logistic regression and four-year survival by Cox Proportional Hazards Regression models, with adjustments for differences in socio-economic and lifestyle factors.

Results

Survival was similar between cohorts (HR: 0.91, 95% CI: 0.62 to 1.32). There was a significant increase in the number of conditions reported between cohorts, with more participants reporting 3 or more conditions in the new cohort (14.2% vs. 10.1%). When individual conditions were considered, there was a 10% increase in the reporting of arthritis and a significant increase in the reporting of chronic airways obstruction (OR: 1.36, 95% CI: 1.04 to 1.78).

Conclusion

This study provides evidence of rising levels of ill-health, as measured by the prevalence of self-reported chronic conditions, in the newer cohorts of the young-old. Though changes in diagnosis or reporting of disease cannot, as yet, be excluded, to better understand whether our findings reflect real increases in ill-health, investment should be made into improved population-based databases, linking self-report and objective measures of health and function, and including those in long-term care.

Decreasing prevalence of disability in activities of daily living, functional limitations and poor self-rated health: a 6-year follow-up study in Spain

BACKGROUND AND AIMS

Forecasting functional status in elderly populations is uncertain. Our aim is to provide evidence of population trends of Activities of Daily Living (ADL) disability, functional limitations and self-rated health.

METHODS

Data come from a longitudinal study of aging in Leganés (Spain), collected in 1993, 1995, 1997 and 1999, on a representative sample of 1560 community dwelling people over 65. Response rate at baseline was 82%. ADL disability was defined as needing help in at least one of the following: walking across a small room, taking a shower, toileting, getting out of bed, getting up from a chair, using the toilet, dressing and eating. Functional limitations were based on questions of difficulty with upper and lower limbs. Self-rated health was assessed with a single question. ADL disability, functional limitations and self-rated health were regressed on age, survey year, sex and education.

RESULTS

There are significant declines in ADL disability, functional limitations and poor self-rated health at every age and up to very advanced ages. Over 90, the ADL disability trend may be reversed, with the emergence of a very old and disabled population. Women and people with little education have a higher prevalence of disability, functional limitations and poor health, when compared with men and those with higher education.

CONCLUSIONS

Results suggest the postponement of severe disability onset in this Spanish population, leading to longer healthy life expectancy, and support the emergence of a very disabled population over 90 years of age.

Ten-year change in disability prevalence and related factors in two generations of French elderly community dwellers: data from the PAQUID study

BACKGROUND AND AIMS

Some studies have reported a decline in disability prevalence in older people, but few data were available for Europe, especially for France. Our aim was to study the 10-year evolution of disability prevalence in elderly community dwellers and related factors.

METHODS

Two generations of subjects aged 75 to 84, participants in the PAQUID (Personnes Agées QUID) cohort were compared. The first generation included 1496 subjects (born between 1903 and 1912) and the second 910 subjects (born between 1913 and 1922). Three domains of disability were assessed: mobility, Activities of Daily Living (ADL) and Instrumental ADL (IADL). Logistic regressions were used to explain the effect of generation on disability, controlling for sociodemographic characteristics, impairment, life-style, medical care, and social support.

RESULTS

The percentage of subjects fully independent increased from 13.5 to 23.3% (p < 0.001). A large decline in disability prevalence independent of the controlled factors was observed for mobility in both genders [Odds Ratio for the second generation (OR(G2)) = 0.48, 95% CI 0.38-0.60]. When adjusting for age and education, the risk of IADL disability was significantly lower in women in the second generation (ORG2 0.61, 95% CI 0.49-0.77), and the generation effect was strengthened when adjusting for the other covariates, but unchanged in men (ORG2 1.09, 95% CI 0.81-1.48). There was no significant change for ADL.

CONCLUSIONS

A significant decline in disability prevalence was observed over 10 years, which was not explained by the selected covariates. These aggregate changes differed by gender, education, and the domain of disability considered.

Living Will, Resuscitation Preferences, and Attitudes towards Life in an Aged Population

BACKGROUND

The growth of life-sustaining medical technology and greater attention to medical care at the end of life have provoked interest in issues related to advance care planning.

OBJECTIVE

To investigate how having a living will (LW), resuscitation preferences, health condition, and life attitudes are related in home-dwelling elderly people.

METHODS

In a cross-sectional descriptive study, detailed assessments were made of 378 home-dwelling elderly individuals participating in a cardiovascular prevention study (DEBATE Study). The participants were inquired about a preexistence of a written document (LW) concerning life-sustaining care, preferences of cardiopulmonary resuscitation (CPR) in their current situation, and attitudes towards life. General health, physical and cognitive functioning, the presence of depression, and quality of life were also assessed.

RESULTS

Forty-four of the 378 participants (12%) had a LW. As compared with those without one (n = 334), there were more women [82% (36/44) vs. 63% (210/334)] and widows [57% (25/44) vs. 41% (135/334)] among those with a LW. They were also more educated and considered their health to be better. Despite having a LW, 46% (20/44) of them preferred CPR in their current condition, a proportion not statistically different from the 58% (194/334) of the individuals without a LW. In the whole sample, 39% (149/378) of the individuals preferred to forgo CPR. As compared with those preferring CPR, they were older, more often women, and widowed. Participants preferring to forgo CPR had a poorer quality of life, were more lonely, and showed signs of depression more often than those preferring CPR. The preference to forgo CPR was related to attitudes towards life regardless of physical or cognitive functioning.

CONCLUSIONS

Having a LW does not reduce the reported preference of CPR which is related more to current mental status and life attitudes. In-depth assessment of the patient's preferences should be performed in any comprehensive care plan.

Cost of pharmacological care of the elderly: implications for healthcare resources

Expenditures on prescribed medicines are significantly higher among those aged 65 years and over than among younger people. As populations in developed countries age so the cost of pharmacological care associated with the older population can be expected to increase. While pharmacological care represents only one component of healthcare, its costs are increasing rapidly because of advances in technology and increasing use. However, such costs should be considered within a context of decreasing disability in the elderly population, improving economic conditions among seniors and the relationship of these costs with those in other aspects of healthcare. Where medications have been demonstrated to be cost-effective, attempts to curtail expenditure growth may prove a false economy resulting in significantly higher growth elsewhere such as in the hospital and long-term care sectors. Policy responses to this issue should encompass the inclusion of elderly patients in clinical trials, the use of evidence-based principles of practice and strategies to ensure that this population obtain maximum benefit from medication through education and counselling.

Pharmaceutical care programmes for the elderly: economic issues

Pharmaceutical care is defined as the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life. It describes the process through which a pharmacist collaborates with a patient and with healthcare professionals in designing, implementing and monitoring a therapeutic plan that will produce specific, desirable therapeutic outcomes for the patient. The elderly are a patient population who could particularly benefit from pharmaceutical care provision as they are at greater risk of experiencing significant drug-related problems such as inappropriate prescribing, noncompliance with prescribed medication and adverse drug reactions/interactions leading to a decrease in health-related quality of life. The extent of economic benefit of pharmaceutical care reported in the literature is variable and its generalisability is suspect due to the lack of trials which have utilised a robust research design. The few studies which have undertaken a rigourous economic evaluation have used a range of data collection methods that is reflective of the difficulty of capturing essential data. Furthermore, even in well-designed studies, the generalisability of economic evaluations to other countries is questionable because of unique national data collection systems and an inability to pool international data because of disparities between different healthcare systems. The use of a suitable measure for health-related quality of life is also problematic in a very diverse and heterogeneous population such as the elderly and, therefore, adds to the difficulties of inclusion of such measures in economic analyses of pharmaceutical care programmes. A more standardised approach to data collection is required to facilitate economic analyses as an essential element in the evaluation of any pharmaceutical care programme for the elderly. Suggestions on such approaches, together with a critical appraisal of studies performed to date, are the focus of this review.