Trends in Life Expectancy in Residential Long-Term Care by Sociodemographic Position in 1999-2018: A Multistate Life Table Study of Finnish Older Adults

OBJECTIVES

Residential long-term care (LTC) use has declined in many countries over the past years. This study quantifies how changing rates of entry, exit, and mortality have contributed to trends in life expectancy in LTC (i.e., average time spent in LTC after age 65) across sociodemographic groups.

METHODS

We analyzed population-register data of all Finns aged ≥65 during 1999-2018 (n = 2,016,987) with dates of LTC and death and sociodemographic characteristics. We estimated transition rates between home, LTC, and death using Poisson generalized additive models, and calculated multistate life tables across 1999-2003, 2004-2008, 2009-2013, and 2014-2018.

RESULTS

Between 1999-2003 and 2004-2008, life expectancy in LTC increased from 0.75 (95% CI: 0.74-0.76) to 0.89 (95% CI: 0.88-0.90) years among men and from 1.61 (95% CI: 1.59-1.62) to 1.83 (95% CI: 1.81-1.85) years among women, mainly due to declining exit rates from LTC. Thereafter, life expectancy in LTC decreased, reaching 0.80 (95% CI: 0.79-0.81) and 1.51 (95% CI: 1.50-1.53) years among men and women, respectively, in 2014-2018. Especially among women and nonmarried men, the decline was largely due to increasing death rates in LTC. Admission rates declined throughout the study period, which offset the increase in life expectancy in LTC attributable to declining mortality in the community. Marital status differences in life expectancy in LTC narrowed over time.

DISCUSSION

Recent declines in LTC use were driven by postponed LTC admission closer to death. The results suggest that across sociodemographic strata older adults enter LTC in even worse health and spend a shorter time in care than before.

Estimating the Sex Gap in Depression-Free Life Expectancy Among Widowed Americans Aged 50 and Older: An Application Using the Interpolated Markov Chain Approach

OBJECTIVES

Using Interpolated Markov Chain software, we compare the length of life with and without depression among married individuals and widowers, and the related sex differences.

METHODS

We applied a multi-state life table approach to estimate depression-free life expectancy among recent cohorts of older married and widowed women and men in the United States, using data from the Health and Retirement Study over a 7-year period (2012-2018).

RESULTS

The study revealed that the difference in life expectancy between sexes widens in the context of widowhood. At age 50, the sex gap in depression-free life expectancy is 0.8 years among married people, whereas the gap almost doubles to 1.7 years among widowed people.

DISCUSSION

By quantifying disparities in the duration of life affected by depression between married and widowed women and men, policymakers could properly allocate resources specifically to address the mental health needs of these groups.

Gender Disparity and the Association Between Socioeconomic Status, Mental Health, and the Need for Long-Term Services and Support Among the Older Koreans

Background

Population aging-the inevitable increase in the percentage of older adults-is occurring all around the world as the fertility rate declines and life expectancy rises. This study examined the relationship between socioeconomic status (SES), mental health, and the need for long-term services and support (LTSS) among Korean older adults. It also aimed to provide evidence-based information for South Korea's long-term support services and programs.

Methods

This study used the data on older adults aged over 60 years from the 2018 Korean Longitudinal Study of Aging (KLoSA). Ultimately, 5,527 older adults were included in the database (42.6% men, 57.4% women). To clarify the association between SES, mental health, and the need for LTSS among older Korean men and women, chi-squared test, t-test, and structural equation modeling (SEM) were performed.

Results

The SEM analysis showed that a significant, negative association was observed between SES and the need for LTSS among these older adults-the higher SES groups would generally have less need for LTSS. Mental health had a strong, negative impact on the need for LTSS-better mental health status of the older individuals would indicate a lower need for LTSS, and the effect was stronger among older men. Meanwhile, the positive relationship between SES and mental health was verified-the higher the SES of these older adults the better their mental health.

Conclusions

Gender- and social class-sensitive impacts of mental health on the need for LTSS were observed in this study. These findings could provide an evidence-based reference for interventions targeting different genders and social classes in Korea's long-term care system, such as the enhancement of social welfare and mental health status of the older adults.

Estimation of Life Expectancy for Dependent Population in a Multi-State Context

Population statistics show that there was an increase in life expectancy during the last century. However, this fact hides that this increase was not equal for all groups of the population. One of the most problematic cases for measuring this increase is that of the dependent population because of the absence of specific statistics. This paper describes a methodology for calculating life expectancy using multistate models that take into account the diversity of situations considered by Spanish legislation. For this purpose, statistical information contained in the national survey on disability and dependency (EDAD 2008) is used. The results suggest that life expectancies are lower than those of the general population and that they differ according to gender and intensity of suffering from this contingency. The calculations were made considering the legal framework currently existing in Spain. This fact conditions the definition of dependent person and, therefore, the set of individuals, their characteristics, and therefore, their final results.

Life expectancy and active life expectancy by marital status among older U.S. adults: Results from the U.S. Medicare Health Outcome Survey (HOS)

Background

Previous investigations of the relationship between marital status and life expectancy and healthy life expectancy rely on the assumption that participants will remain in a given marital status until death. This study estimated total life expectancy (TLE) and active life expectancy (ALE) for respondents by their baseline marital status using a large longitudinal sample of the U.S. community-dwelling elderly population.

Methods

Data were from the Medicare Health Outcomes Survey Cohort 15 (2012 baseline, 2014 follow-up). We included respondents aged ≥65 years (n = 164,597). Multi-state models estimated TLE and ALE by marital status to allow participants’ marital status to change during the remaining lifetime.

Results

Between 65 and 85 years, married men and women had a longer TLE and ALE than unmarried men and women. For example, at 65 years, TLE for married men was 18.6 years, 2.2 years longer than unmarried men, and ALE for married men was 12.3 years, 2.4 years longer than unmarried men. Similarly, at 65 years, TLE for married women was 21.1 years, 1.5 years longer than unmarried women, and ALE for married women was 13.0 years, 2.0 years longer than unmarried women. Such marriage protection effects decreased with age. In subgroups of unmarried persons, never married persons had the shortest TLE and ALE among men, and never married, divorced, and widowed persons had a similar, and shorter, TLE and ALE among women. The difference in TLE between married and unmarried persons was smaller after adjusting for baseline activity limitation status.

Conclusions

This study provides additional evidence for marriage's protective effect, with the magnitude of protection being greater for younger as compared to older persons. Selection bias was a large contributor to longer life expectancy among married persons.

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Married persons are known to have lower mortality and longer life expectancy (LE) than unmarried.

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We estimated total and active life expectancy by marital status for community-dwelling elderly.

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Constructing multi-state models in large, longitudinal data set allowed marital status to change.

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Married men and women had longer total and active LE than unmarried; protection decreased with age.

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Selection bias was a large contributor to longer life expectancy among married persons.

Death Anxiety and Life Expectancy among Older Adults in Iran

Purpose: Life expectancy is one of the indices used to analyze health status. This index changes during aging as a result of a variety of incidents, diseases, stress, and anxiety. Death anxiety is one of the problems that can turn into a deadly fear. This study was aimed to determine the association between life expectancy and death anxiety among older adults in Tehran, Iran.

Methods: In this correlational descriptive study, 208 older adults aged ≥60 years, who had referred to adult daycare centers in Tehran, were chosen by cluster random sampling. Data were collected using a demographic questionnaire, Temper’s death anxiety scale and Snyder’s life expectancy scale. Data analysis was completed through SPSS ver. 22.

Results: The mean age of the older adults was 66.60 (6.58) years. The results showed a mean death anxiety of 12.21 mean life expectancy of 24.94. Furthermore, Pearson’s correlation coefficient indicated a negative correlation between death anxiety and life expectancy. The results of multiple regression analysis revealed that the major predictor of life expectancy decline were death anxiety, age, and residential status.

Conclusion: It can be concluded from the results that the negative correlation between death anxiety and life expectancy requires teaching coping methods for anxiety and using appropriate methods to improve life expectancy among older adults.

Trajectories of Long-Term Residential Care Needs Among Older Australian Women: A Cohort Study Using Linked Data

OBJECTIVE

Older women are more likely than men to enter residential aged care (RAC) and generally stay longer. We aimed to identify and examine their trajectories of care needs over time in RAC across 3 fundamental care needs domains, including activities of daily living (ADL), behavior, and complex health care.

DESIGN

Population-based longitudinal cohort study.

SETTING

RAC facilities in Australia.

PARTICIPANTS

A total of 3519 participants from the 1921-1926 birth cohort of the Australian Longitudinal Study on Women's Health (ALSWH), who used permanent RAC between 2008 and 2014.

METHODS

We used data from the Aged Care Funding Instrument, National Death Index, and linked ALSWH survey. Participants' care needs in the 3 domains were followed every 6 months up to 60 months from the date of admission to RAC. Trajectories of care needs over time were identified using group-based multitrajectory modeling.

RESULTS

Five distinct trajectory groups were identified, with large variation in the combinations of levels of care needs over time. Approximately 28% of residents belonged to the "high dependent-behavioral and complex need" group, which had high care needs in all 3 domains over time, whereas around one-third of residents (31%) were included in 2 trajectory groups ("less dependent-low need" and "less dependent-increasing need"), which had low or low to medium care needs over time. More than two-fifths of residents (41%) comprised 2 trajectory groups ("high dependent-complex need" and "high dependent-behavioral need"), which had medium to high care needs in 2 domains. Higher age at admission to RAC and multiple morbidities were associated with increased odds of being a member of the high dependent-complex need group than the less dependent-increasing need group.

CONCLUSIONS AND IMPLICATIONS

Identification of the differential trajectories of care needs among older women in RAC will help to better understand the circumstances of their changing care needs over time. This will facilitate appropriate care planning and service delivery for RAC residents, who are mostly older women.

Predictors of long-term care among nonagenarians: the Vitality 90 + Study with linked data of the care registers

BACKGROUND

The need for long-term care services increases with age. However, little is known about the predictors of long-term care (LTC) entry among the oldest old.

AIMS

Aim of this study was to assess predictors of LTC entry in a sample of men and women aged 90 years and older.

METHODS

This study was based on the Vitality 90 + Study, a population-based study of nonagenarians in the city of Tampere, Finland. Baseline information about health, functioning and living conditions were collected by mailed questionnaires. Information about LTC was drawn from care registers during the follow-up period extending up to 11 years. Cox regression models were used for the analyses, taking into account the competing risk of mortality.

RESULTS

During the mean follow-up period of 2.3 years, 844 (43%) subjects entered first time into LTC. Female gender (HR 1.39, 95% CI 1.14-1.69), having at least two chronic conditions (HR 1.24, 95% CI 1.07-1.44), living alone (HR 1.37, 95% CI 1.15-1.63) and help received sometimes (HR 1.23, 95% CI 1.02-1.49) or daily (HR 1.68, 95% CI 1.38-2.04) were independent predictors of LTC entry.

CONCLUSION

Risk of entering into LTC was increased among women, subjects with at least two chronic conditions, those living alone and with higher level of received help. Since number of nonagenarians will increase and the need of care thereby, it is essential to understand predictors of LTC entry to offer appropriate care for the oldest old in future.

Cumulative incidence of admission to permanent residential aged care for Australian women - A competing risk analysis

OBJECTIVE

To provide a direct estimate of the risk of admission to permanent residential aged care among older women while accounting for death, according to housing type and other variables.

METHODS

A competing risk analysis from 8,867 Australian women born 1921-26, using linked data from the Australian Longitudinal Study on Women's Health (ALSWH), Residential Aged Care (RAC), and the Australian National Death Index.

RESULTS

After accounting for deaths, around 35% of women will be admitted to RAC between ages 73 and 90. The conditional cumulative incidence of admission to RAC was 26.9% if living in a house, compared to 36.0% from an apartment, 43.6% within a retirement village, and 37.1% if living in a mobile home. Each one-year increase in age was associated with a relative 17% increased risk of RAC.

CONCLUSIONS

Around one-third of women will enter RAC between age 73 and 90. Living in a house had the lowest risk of entering residential aged care over time. Implications for public health: These findings have important implications for planning for aged care services, including the role of housing in delaying admission to residential aged care, and the need for residential care by a high proportion of women towards the end of life.

Transitions to and from long-term care facilities and length of completed stay: Reuse of population-based survey data

OBJECTIVE

This article estimates length of completed stay and resident transitions for RAC residents over 12 months in Auckland.

METHODS

Data from a census-type survey of nursing home residents (n = 6816) were linked with national mortality data. Transitions described include entry to residential aged care (RAC), movement between RAC facilities and deaths.

RESULTS

When reweighted for missing data and adjusted for length bias, an estimated 9676 residents (95% CI 8368-10 985) used care over a 12-month period. Half of new residents entered RAC via an acute hospital. Median survival was 2.0 years; 17% died within 3 months, and 23% survived over 5 years.

CONCLUSION

Cross-sectional survey data, when appropriately adjusted for length-biased sampling, enable estimates of period prevalence and transition probabilities that are useful for simulation studies. Given population ageing and the costs of ongoing care, these results can inform policy and planning for long-term care needs of older people.

"When I Said I Wanted to Die at Home I Didn't Mean a Nursing Home": Care Trajectories at the End of Life

Background and Objectives

Little is known regarding the care trajectories older adults experience at the end of life (EOL). We drew on a structural/institutional life course perspective to examine the trajectories evident among older adults transitioning through the Canadian formal long-term care system. The sequence of care transitions as well as the impact of social location, social and economic resources, and health-related factors on these trajectories were examined.

Research Design and Methods

To identify EOL care trajectories, we used administrative data collected on older adults (aged 65+) who received publicly subsidized long-term care services (e.g., nursing home and home and community-based care) in one health region in British Columbia, Canada from January 1, 2008 through December 31, 2011 and who died by March 31, 2012 (n = 11,816). Multinomial logistic regression analyses assessed the impact of selected covariates on these trajectories.

Results

The majority of those studied (65.4%) died outside of acute hospital settings. The most common trajectories involved transitions from home care to nursing home/residential care to non-hospital death (39.5%) and transitions from in-home care to hospital death (22.4%). These and other trajectories were shaped by social structural factors, access to social and economic resources, as well as health status and prior hospitalizations.

Discussion and Implications

Despite calls for minimizing hospital-based deaths and maximizing home-based deaths, older LTC recipients often experience EOL care trajectories that end in death in a nursing home care setting. Our findings point to the value of a structural/institutional life course perspective in informing an understanding of who experiences this and other major EOL care trajectories. In doing so, they also provide direction for policy and practice designed to address inequalities and enhance the quality of EOL care.

Years of life lost due to lower extremity injury in association with dementia, and care need: a 6-year follow-up population-based study using a multi-state approach among German elderly

BACKGROUND

Dementia and care need are challenging aging populations worldwide. Lower extremity injury (LEI) in the elderly makes matters worse. Using a multi-state approach, we express the effect of LEI on dementia, care need, and mortality in terms of remaining life expectancy at age 75 (rLE) and years of life lost (YLL).

METHODS

A population-based random sample of beneficiaries aged 75-95 years was drawn from the largest public health insurer in Germany in 2004 and followed until 2010 (N 62,103; Mean Age ± SD 81.5 ± 4.8 years; Female 71.2%). We defined a five-state model (Healthy, Dementia, Care, Dementia & Care, Dead), and calculated transition-specific hazard ratios of LEI using Cox regression. The transition probabilities as well as the YLL due to LEI were estimated.

RESULTS

LEI significantly increased the risk for each transition, with a maximum risk for the transition from Healthy to Care (HR: 1.70, 95% CI: 1.63-1.77) and a minimum risk for the transition from Care to Dead (HR: 1.16, 95% CI: 1.10-1.22). If the elderly had LEI-history, their age-specific mortality was generally higher and their probabilities of transient states peaked at younger ages. At age 75, initially dementia-free and care-independent elderly experiencing LEI lost about 2 years of life, of which more than 90% were life years free of dementia or care need. Dementia patients lost about one and a half year, more than 60% were free of long-term care need.

CONCLUSIONS

LEI not only casts a large health burden on care need, but is also associated with cognitive decline and shortened rLE. LEI plus dementia extend the relative life time in need of care, despite generally shortening rLE. Using the composite measure YLL may help to better convey these results to the elderly, families, and health professionals. This may strengthen preventive measures as well as improve timely and rehabilitative treatment of LEI, not only in cognitive and physically intact elderly.

Living arrangements and marital status: a register-based study of survival of older adults in Belgium at the beginning of the 21st century

Being married reduces the mortality risk of older persons. More generally, living arrangements that include co-residence with a source of support and a close care-giver are associated with a lower mortality risk. We build a detailed typology of private and collective living arrangements, including marital status, and check its association with mortality risks, controlling for health status. Using administrative data from the population register, we identify the living arrangement of all individuals aged 65 years and over living in Belgium as at 1 January 2002, and their survival during the year 2002. Data on health status are extracted from the 2001 census. We use binary logistic regression with the probability to die as outcome and living arrangement, health, age and gender as covariates. Our results show that mortality is more closely associated with actual living arrangements than with marital status. This association is age and gender-specific and remains even at very old ages. Living with a spouse is confirmed to be beneficial for survival but in older age living alone becomes more favourable. Of all living arrangements, older persons living in religious communities experience the lowest mortality risk whereas those living in nursing homes experience the highest risk.

Gender disparities in German home-care arrangements

An ageing population correlates with rising needs for long-term care (LTC). Support programmes should consider the specific needs of the various subgroups of care dependents and family caregivers. The objective of this study was to analyse the gender-specific disparities in home-care arrangements in Germany, and for this purpose, survey and insurance claims data were used. A survey of 2545 insured care recipients with high-level care needs was conducted in 2012 with the Barmer GEK, a major German statutory healthcare insurance. Insurance claims data were provided for a follow-up, focussing on the group aged 60 years and older. For statistical comparison, chi-squared test and t-tests were used, and a p-value < 0.05 was considered statistically significant. Most care recipients are female, and they are on average 2 years older than males. Men receive family care mostly from their wives, whereas widows frequently live alone and receive care from daughters, sons, other relatives, neighbours and friends, as well as from professional nursing services. Furthermore, women more often anticipate the need for (further) professional assistance and move in with a relative or to an assisted living facility or a nursing home in good time. The desired rate for relocation to a nursing home was higher than the anticipated, and during the 6-month follow-up, the actual rate of relocations was in between both. In summary, the caring situation of men and women is different. Care-receiving men are most often cared for by their wives. Widowed women need a social network and their children in order to remain in their own home. To provide better home-care arrangements for women in this situation, the family and social networks need a stronger focus in politics and research. To stabilise the home-care situation of men with high-level care needs, their wives need more support.