Preparing for an Aging World The Case for Cross-National Research (2001) / Chapter Skim
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6. The Health of Aging Populations
6. The Health of Aging Populations
Pages 200-249
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From page 200... ...
However, while all modern societies are committed to providing health and social services to their citizens, these systems are always in flux, guided by diverse and evolving national and regional policy formulations. Health, social, and economic policies for older persons vary substantially among industrialized nations.
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Should more resources be directed toward behavioral change and other health promotion and disease prevention programs, including health enhancement in early life, or should more be dedicated to the treatment of patients with advanced diseases? How much should be invested in the development of new health care technologies, service delivery enhancements, and professional training?
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Public Health · Creation of prevention and health promotion programs that affect older persons. Education · Training of all levels of health professionals and ancillary workers in special skills related to the problems of older persons.
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How has the changing health status of older persons altered the productivity and economic status of families and households? How do families make economic provisions to care for unhealthy parents, and what are the effects on labor force participation?
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And comparative work can improve our understanding of how particular diseases and conditions are expressed as disability in a variety of work, social, policy, and living environments, thus providing insight into which adjustments in those environments may be most cost-effective. CONCEPTUAL MODEL OF THE DETERMINANTS OF HEALTH STATUS As noted above, the determinants of health are complex and comprise multiple policy domains.
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MEASURING HEALTH STATUS During the 20th century there were great changes in patterns of population health status and survivorship in both the industrialized and developing worlds. Among industrialized nations, the early part of the century saw the greatest improvement in mortality among infants, children, and pregnant women.
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From page 206... ...
Population surveys have also indicated that the age-specific prevalence of physical disability has declined in some countries (lacobzone et al., 1998~. Developing countries have lagged behind their more industrialized counterparts in terms of mortality decline and the overall epidemiological transition from a preponderance of infectious and parasitic diseases to one of chronic and degenerative diseases.
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Annex 6-2 describes in detail the health status measures most commonly used for survey and administrative data collection in the categories of clinical signs, symptoms, and syndromes; morbidity (i.e., discretely defined medical conditions) ; self-rated health; functional status and disability; physiological and pathological measures; mortality data and derived measures; and aging and mental illness.
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From page 208... ...
Coordination of public and clinical policies relevant to health promotion and disease prevention among the various sectors involved is essential if these policies are to have the desired positive effects on the health status of older persons. International comparisons of preventive service delivery programs may help identify those with the most desired outcomes and indicate which individual programs may be applied usefully in many nations.
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A broad range of health system typologies is reviewed by Mechanic and Rochefort (1996~; these typologies variously emphasize such dimensions as political organization and control, economics and fiscal management, population demands and utilization, the role of market forces, universality of coverage, cultural influences on professional practice, the degree of professional dominance, and adherence to various social movements and principles. Because of the higher rates of morbidity and disability that occur with increasing age, older people make substantial use of formal health services.
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210 Netherlands Luxembourg Canada Finland New Zealand Norway Japan Australia Germany Denmark Sweden United States Belgium United Kingdom France Ireland Austria Spain Portugal Turkey PREPARING FOR AN AGING WORLD 6.7 6.5 6.4 5.4 5.2 5.3 5.2 5.2 5.0 5.0 4.6 2.0 0.2 7.0 FIGURE 6-2 Percent of elderly population in residential care: Circa 1991. SOURCE: Organization for Economic Co-Operation and Development (1996~.
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Regardless of how sophisticated, modern, and comprehensive health services may be in a nation, utilization of those services is often uneven and may vary by socioeconomic status, ethnicity, geographic location,
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· Older persons have many clinical signs, symptoms, and functional impairments that need to be given special attention since they are not included within traditional administrative data systems that focus on morbidity. · Since older persons commonly have multiple medical conditions and functional impairments, there is a need to develop summary measures of comorbidity and health status in order to deal efficiently with the available health and administrative data.
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The remainder of this section reviews the various sources of health data on the elderly, along with ways in which these data could be made more useful for cross-national research and policy formulation. Sources of National Health Data A broad range of data on health and health status is available in most developed nations and increasingly in developing nations as well.
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No single central repository now exists for health information from population surveys or health system administrative data relevant to older persons. Important catalogues are being compiled, however, by such organizations as the United Nations (Agree and Myers, 1998)
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In the United States, the National Center for Health Statistics, working with other agencies in the Department of Health and Human Services and with the advice of the National Committee on Vital and Health Statistics, establishes minimum datasets, data elements, and data definitions used uniformly throughout the Department of Health and Human Services. While these activities contribute importantly to common nomenclatures and data standards, special data repositories are needed for information thus collected in developed and, where possible, developing countries.
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The concept of the graduated minimum dataset could be applied to facilitate health research and policy analysis relevant to aging by providing basic descriptive data on individuals, disease and disability measures, long-term care programs and facilities, health service utilization, and related data elements. Since all nations cannot be expected to invest the same level of resources in data collection, a hierarchy of data collection modules, ranging from easily collected basic data elements to increasingly elaborate datasets, would be an appropriate universal approach.
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For example, underlying population health status may vary across nations; this variation may lead to different outcomes of the same health policy or intervention. There may also be differences in the nature, selection, representativeness, or completeness of population samples and health administration databases, possibly leading to spurious analytic findings.
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important acute and chronic medical conditions and their major manifestations; (3) measures of important self-reported health status; (4)
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To provide basic descriptive data on individuals, disease and disability measures, long-term care programs and facilities, and health service utilization, countries should adopt systematic data collection procedures. All nations cannot invest the same level of resources in data collection; thus a hierarchy of data collection modules ranging from easily collected basic data elements to increasingly elaborate datasets would be an appropriate universal approach.
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The implication for monitoring and for policy is that this is not a clear case of poor health among those who are materially deprived and better health for everyone else; the social gradient in health runs the social gamut from top to bottom. While Annex Figure 6-1 is confined to mortality, social inequalities in morbidity loom large among the elderly, and the implications for policy are perhaps even more challenging here.
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In such cases there are clear social inequalities in health among people who are not materially deprived. Other concepts must therefore come into play.
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Close attention must be paid to the most appropriate measures that will allow comparison of social inequalities in health within and between genders.
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These may be thought of as falling under social exclusion, but, as with health itself, their quality is likely to follow a social gradient. A fuller understanding of the appropriate determinants of socioeconomic differences in health and functioning generally requires longitudinal, representative population surveys.
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ANNEX 6-2 COMMONLY USED MEASURES OF HEALTH STATUS The measures of health status commonly used for survey questionnaires and administrative data collection can be grouped into seven categories: clinical symptoms, signs, and syndromes; morbidity, or discretely defined medical conditions; self-rated health; functional status and disability; physiological and pathological measures; mortality data and derived measures; and aging and mental illness. The measures used in each of these categories are reviewed in turn below.
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Morbidity, or Discretely Defined Medical Conditions The term "morbidity" in the present context refers to the named medical conditions that health professionals, administrators, and patients and their families use to define and communicate health information. Most morbid conditions, such as diabetes mellitus, stroke, lung cancer, and myocardial infarction (heart attack)
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, and generally alter health outcomes after hospitalization (Elixhauser et al., 1998~. Comorbidity scales can be applied both to population survey data and to health care administrative datasets (Katz et al., 1996~.
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· Some types of clinical information are not available in disease names, such as individual functional status (see below) or the physiological severity of a condition.
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Second, self-rated health can be used as a screening tool to identify high-risk groups and risk factors; poor self-rated health is consistently associated with low socioeconomic status and high levels of other illness risk factors in both national and international studies. Third, selfrated health can be used as an outcome in the evaluation of medical interventions as an important addition to the usual mortality and morbidity outcomes; treatments with similar effects on length of life may have different implications with respect to the quality of those years.
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Age-related increases in physical and cognitive disability are often a direct result of chronic medical conditions such as heart disease, stroke, vascular disease, arthritis, Parkinson's disease, cancers, and dementia. Yet they are also related to social and environmental factors.
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Disability and dependency rates among older adults, as well as use of long-term care, vary substantially among regions and cultures and by socioeconomic status and social structure. Understanding rates of disability within and among countries and regions, as well as the health, health care, social, and economic factors that may affect these rates, helps provide a basis for planning for future chronic care needs.
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Other measures can be used to describe the cumulative impact on an individual of one or more chronic conditions, cognitive impairments, and physiological changes associated with aging, as well as social, environmental, and psychological modifiers of these conditions. Thus, functional status and disability measures serve both to assess the net impact of disease and aging on the individual and to express the ability of the individual to care for him- or herself and to manage a household.
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An increasing number of population surveys with health and economic goals contain functional status measures, often in longitudinal perspective, and offer considerable analytical potential for policy applications. Some recent examples from various countries are shown in Annex Box 6-1.
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An example of the application of this approach is shown in schematic form in Annex Figure 6-2. Age-specific prevalence rates provide important information and have been determined for representative population samples in many countries.
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Mortality "` \ `% "` \ ~ "` \ ~ " \ _ ' ~ \ "I 1 1 1 1 1 1 1 1 <` ' ~ 1 0 10 20 30 40 50 60 70 80 90 100 1 10 Age ANNEX FIGURE 6-2 A general model of health status and change (observed mortality and hypothetical morbidity and disability survival curves for U.S. females in 1980~.
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+ 1986 data -- -- -- 1995 data _,~ 0% 1 65-70 70-75 75-80 80-85 85-90 90+ Age Group 20% 5% _ 0% 1 1 1 1 65-70 70-75 75-80 80-85 85-90 90+ + 1986 data -- _ -- 100-S Strata Age Group ANNEX FIGURE 6-3 Trends in the prevalence of severe disability among the elderly in four countries. NOTES: Australia: severe handicap, households and institutions; Canada: HALS survey, households and institutions, severe disability; France: households, confined to bed; Germany: households, microcensus, severe disability.
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.2 It may be noted that new testing procedures for population health assessments are continually being evaluated and should always be considered. Mortality Data and Derived Measures Mortality data, despite certain weaknesses in accuracy and as measures of population health, have been widely applied to guide health policy, in part because of their universal availability from industrialized countries.
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These potential changes argue for the collection of data needed to estimate trends in future total mortality and specific diseases. Despite generally decreasing mortality rates, there are disparities among various groups within industrialized countries; mortality rates are lower among women, married persons, and those of higher social class.
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Kannisto (1994) has constructed a database that comprises a mortality series for persons aged 80 and over for a set of industrialized countries that publish such data annually.
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Amalgamation of data on life expectancy, diseases, and disabilities will make it possible to derive measures that incorporate healthy and disabled life expectancy. Quality of Vital Records It is well known that mortality estimates at old ages may be hampered by various problems (Coale and Kisker, 1986, 1990; Kannisto, 1994, 1996; Thatcher et al., 1998~.
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Individual Data and Mortality Differentials The study of mortality differentials has provided a number of explanatory hypotheses and offered the possibility of moving from description of the differences observed to identification of their root causes. Many studies have involved analyzing mortality differences according to socioeconomic status, usually encompassing cross-sectional analyses of older populations (e.g., Mare, 1990; Martelin, 1995~.
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\ \ \ .. 1 1 1982 1992 Year ANNEX FIGURE 6-4 Probability of death at ages 80-99 in five countries: 1952 to 1994.
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Aging and Mental Illness Psychiatric disorders are significant contributors to physical, social, and emotional dysfunction and disability among the elderly, but it is only recently that such problems have drawn significant attention (Wells et al., 1989~. All of the important mental conditions of young adulthood and middle age, including depression, mania, schizophrenia, personality disorders, addictions (including alcoholism)
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Thus, population rates of mental illness may not be attainable from clinical or administrative records, and the use of population surveys for this purpose should be considered. It is ironic that surveying for mental illness requires a substantial participant burden, as the instruments are often long and detailed.
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Ahmed, and J Thompson 2000 Tracking clinical preventive service use: A comparison of the health plan employer data and information set with the behavioral risk factor surveillance system.
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Stallard 1993 Estimates in the change in chronic disability and institutional incidence and prevalence rates in the U.S. elderly population from the 1982, 1984 and 1989 National Long Term Care Survey.
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Mechanic, D., and D.D. McAlpine 2000 Use of nursing homes in the care of persons with severe mental illness: 1985 to 1995.
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United States Agency for International Development (USAID) 2000 Biological and Clinical Data Collection in Population Surveys in Less Developed Countries.
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1980 Unloving Care: The Nursing Home Tragedy. New York: Basic Books.
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