Heta Moustgaard

Gender, Living Arrangements, and Social Circumstances as Determinants of Entry Into and Exit From Long-Term Institutional Care at Older Ages: A 6-Year Follow-Up Study of Older Finns

PURPOSE Due to population aging, the need for long-term institutional care is increasing. We study the potentially modifiable sociodemographic factors that affect the rate of entry into and exit from long-term care. DESIGN AND METHODS A 40% sample from the population registration data of Finns aged 65 and older living in private households at the end of 1997 (n = 280,722) was followed for first entry into (n = 35,926) and subsequent exit -- due to death or return to the community -- from long-term institutional care until the end of 2003. RESULTS Being female, old, living alone, and of low socioeconomic status increased the risk for entering long-term care. Exit was affected by the same factors, but the associations were weaker and, with the exception of age, in the opposite direction. Womens higher risk for entry was due to older age and greater likelihood of living alone. The effects of living arrangements and socioeconomic factors on entry were stronger among men and were attenuated after adjustment for each other and for health status. The mean duration of care was 1,064 days among women and 686 among men. IMPLICATIONS Gender, age, living arrangements, and socioeconomic status are major determinants of institutional residence. Women and certain other population groups, e.g., those living alone, are likely to spend a longer time in institutional care because of higher rates of entry and lower rates of exit. These results have implications for the financing of long-term care and for targeting of interventions aimed at delaying it.

The effects of individual taxable income, household taxable income, and household disposable income on mortality in Finland, 1998–2004

To improve our understanding of the association between income and mortality, we analysed prospective record linkage data on Finns aged 30 and over in 1997. The results show a weaker association of mortality with household disposable income—the measure that best captures consumption potential—than with individual income, particularly above age 65 when the ability to work does not bias the associations. The association between income and mortality is greatly weakened by adjustment for socio-economic status and economic activity, and there is also weak evidence of curvature in the relationship with household disposable income. Among younger participants, social characteristics of the family of origin and early career incomes have a very limited effect on the association between adult income and mortality. The causal effects of income on mortality remain difficult to establish with certainty, and may easily be overestimated. Causal explanations based solely on material factors should be treated with scepticism.

Nonmarital Cohabitation Among Older Finnish Men and Women: Socioeconomic Characteristics and Forms of Union Dissolution

OBJECTIVES Nonmarital cohabitation has increased substantially among older adults. Our objective was to enhance understanding of cohabitation by comparing elderly cohabiters with the married according to socioeconomic status and union dissolution. METHODS We used population registration data on Finns aged 65 years and older living with a cohabiting partner or a married spouse in 1997 (n = 140,902). The participants were characterized according to various socioeconomic indicators and followed for separation, institutionalization, bereavement, and death until 2002. RESULTS Elderly cohabitation almost doubled between 1990 and 2003, with 3.4% of men and 2.1% of women currently cohabiting. Low educational attainment, low occupational social class, and living in rented housing were associated with cohabiting rather than being married. Low income among men but high income among women predicted cohabitation. Cohabiting unions were more likely than marriages to end through separation, institutionalization, bereavement, and death, with the highest excess risk being for separation. These effects were mostly independent of socioeconomic factors. DISCUSSION In socioeconomic terms, elderly cohabiters are mostly less privileged than the married. Nonmarital unions seem somewhat less protective than marriages against institutionalization and death. The substantially higher risk of separation also puts cohabiters at higher risk of losing potential care and support provided by coresident partners.

Seven-year hospital and nursing home care use according to age and proximity to death: variations by cause of death and socio-demographic position

Background Provision of hospital and long-term care services for the growing number of older people is a major policy concern. The authors estimate hospital and nursing home care use by age and proximity to death for selected causes and by gender, education and marital status. Methods A 40% random sample of the Finnish population aged 65+ years alive at the end of 1997 was followed to death in 1998–2002. Use of hospital and nursing home care was assessed up to 7 years prior to death for those who died and prior to the end of 2002 for survivors. Results In the 7-year period, before death total average care days were 294 (95% CI 286 to 301) for men and 430 (95% CI 423 to 438) for women. For surviving men and women, the corresponding figures were 89 (95% CI 86 to 92) and 136 (95% CI 130 to 141) days. Use of hospital and particularly nursing home care increased rapidly with age, while proximity to death was more important for hospital care. The married used less care than the non-married. Care use of those dying from dementia was approximately twice that for all causes combined and was substantial for an extended period before death. Conclusions The effects of age are more substantial for nursing home than for hospital care use, and both are larger the older the age at death. Care use will be considerably higher among the non-married. Increasing longevity coupled with a rising trend of dementia is likely to mean a major shift towards higher nursing home care use in the future.

Psychiatric comorbidity in couples: a longitudinal study of 202,959 married and cohabiting individuals

PurposeTo examine whether partner’s psychiatric and somatic disorders are risk factors for incidence of psychiatric disorders among non-psychiatric individuals at baseline.MethodsRegister-based 6-year follow-up on Finns (106,935 men and 96,024 women aged 40 and over), living with a married or cohabiting partner at the end of 1997. The outcome measures included non-psychotic major depressive disorder (MDD), substance use disorder (SUD), and severe psychiatric disorder, evaluated using information on reimbursement for drug costs, purchases of prescription medication, and principal causes of hospitalization.ResultsAmong persons whose partner had any psychiatric disorder, the incidence rate ratio (IRR) for own MDD, controlling for own age at baseline, was 1.58 (95% confidence interval 1.48–1.69) in men, and 1.58 (1.48–1.69) in women. Among persons whose partner had somatic hospitalization, the IRR for own MDD was 1.14 (1.08–1.20) in men and 1.20 (1.15–1.25) in women. Among both men and women, the highest risk for incidence of own MDD was among persons whose partner had both MDD and SUD (IRR 2.65, 1.67–4.21 and IRR 2.13, 1.62–2.80, respectively). Further adjustment for sociodemographic and union characteristics had little effect on the associations.ConclusionsIn married and cohabiting couples, partner’s somatic and particularly psychiatric morbidity associate with psychiatric disorders in non-psychiatric subjects, independent of sociodemographic and union characteristics. The healthy spouse’s care burden is a potential point of intervention in order to prevent new psychiatric morbidity, but also to provide the mentally ill first partner a chance to recover in a supportive family environment.

Alcohol-related deaths and social factors in depression mortality: a register-based follow-up of depressed in-patients and antidepressant users in Finland.

BACKGROUND Excess mortality of depression is established for various causes of death, but evidence is scarce on alcohol-related causes. It also remains unclear whether the magnitude of the excess varies by social factors. This study aimed to quantify the contribution of alcohol-related causes of death and to assess modifying effects of socioeconomic position, employment status, and living arrangements in the excess mortality of depression. METHODS A 14% sample of community-dwelling Finns aged 40-64 at the end of 1997 was assessed for depression, using register data on psychiatric hospital care and antidepressant use in 1996-1997. Depressed in-patients (n=897), out-patients using antidepressants (n=13,658), and non-depressed individuals (n=217,140) were followed up for cause-specific mortality in 1998-2007, distinguishing between alcohol- and non-alcohol-related deaths, and testing for variation in the excess mortality according to baseline social factors. RESULTS Depressed in- and out-patients had significant excess mortality for suicide (age-adjusted rate ratios RR=3.77 for men and RR=6.35 for women), all accidental and violent causes (RR=3.47 and RR=4.43), and diseases (RR=1.67 and RR=1.41). Of the excess, alcohol-related causes accounted for 50% among depressed men and 30% among women. Excess mortality varied little by social factors, particularly in non-alcohol-related causes. Where variation was significant, the relative excess was larger among those with higher socioeconomic position and the employed. Absolute excess was, however, larger among those with lower socioeconomic position, the unemployed, and the unpartnered. LIMITATIONS Depression was measured indirectly by hospital and antidepressant use. CONCLUSIONS The results highlight the major role of alcohol in depression mortality.

Life Expectancy in Long-Term Institutional Care by Marital Status: Multistate Life Table Estimates for Older Finnish Men and Women

OBJECTIVES We estimate (a) probabilities of moving to and from long-term institutional care and probabilities of death and (b) life expectancy in the community and in care by gender and marital status. METHOD A 40% random sample of Finns aged 65+ at the end of 1997 (n = 301,263) drawn from the population register was linked with register-based information on sociodemographic characteristics, entry and exit dates for long-term institutional care, and dates of death in 1998-2003. Probabilities and life expectancies were estimated using multistate life tables. RESULTS At age 65, women are expected to spend more of their remaining lifetime in institutions than men (1.6 and 0.7 years, respectively). These care expectancies remain similar even for survivors to very advanced ages. Gender differences are driven by womens higher chances of entering institutions at ages above 80 years and lower chances of exit. At age 65, 59% of women and 36% of men will ever enter long-term institutions. The married spend less of their longer life expectancy in institutions than the non-married. The large gender difference in care use exists within each marital status group. DISCUSSION The resources that are needed to provide long-term care services will increase as age of death increases. We demonstrate significantly longer care expectancy among women and among the unmarried.

Intergenerational transmission of depressive symptoms – The role of gender, socioeconomic circumstances, and the accumulation of parental symptoms

BACKGROUND The relationship between parental and offspring depression is well established. Evidence regarding the significance of gender, socioeconomic circumstances, and the accumulation of parental symptoms in intergenerational transmission is, however, mixed and scarce. METHODS Using a 20% random sample of Finns born between 1986 and 1996 (n=138,559), we performed a Cox proportional hazards regression to analyze the incidence of depressive symptoms between ages 15-20 by exposure to maternal and paternal depressive symptoms earlier in life. Depressive symptoms were inferred from antidepressant purchases and/or a diagnosis of depression at outpatient or inpatient health services. RESULTS Exposure to maternal depressive symptoms posed an equal risk for girls and boys (hazard ratio, HR, 2.09 vs. 2.28 respectively, p=0.077), whereas the effect of paternal depressive symptoms was weaker for girls (HR 1.77 vs. 2.22, p<0.001). Parental socioeconomic status neither confounded nor moderated these effects. Dual exposure to both maternal and paternal depressive symptoms posed a larger risk than single exposure, and children exposed recurrently at ages 0-5 and 9-14 faced an elevated risk compared with those exposed at only one period. LIMITATIONS Since depressive symptoms were inferred from prescription purchases and treatment records, we were unable to observe untreated depression or to determine the underlying condition the antidepressants were prescribed for. CONCLUSIONS Our results support the idea that maternal depression affects both genders equally, whereas paternal depression affects girls less than boys. We show that parental depression and low socioeconomic status are mainly independent risk factors of adolescent depressive symptoms and do not cause an interactive effect.

Antidepressant Sales and the Risk for Alcohol-Related and Non-Alcohol-Related Suicide in Finland-An Individual-Level Population Study

Objectives A marked decline in suicide rates has co-occurred with increased antidepressant sales in several countries but the causal connection between the trends remains debated. Most previous studies have focused on overall suicide rates and neglected differential effects in population subgroups. Our objective was to investigate whether increasing sales of non-tricyclic antidepressants have reduced alcohol- and non-alcohol-related suicide risk in different population subgroups. Methods We followed a nationally representative sample of 950,158 Finnish adults in 1995–2007 for alcohol-related (n = 2,859) and non-alcohol-related (n = 8,632) suicides. We assessed suicide risk by gender and social group according to regional sales of non-tricyclic antidepressants, measured by sold doses per capita, prevalence of antidepressant users, and proportion of antidepressant users with doses reflecting minimally adequate treatment. Fixed-effects Poisson regression models controlled for regional differences and time trends that may influence suicide risk irrespective of antidepressant sales. Results The number of sold antidepressant doses per capita and the prevalence of antidepressant users were unrelated to male suicide risk. However, one percentage point increase in the proportion of antidepressant users receiving minimally adequate treatment reduced non-alcohol-related male suicide risk by one percent (relative risk 0.987, 95% confidence interval 0.976–0.998). This beneficial effect only emerged among men with high education, high income, and employment, among men without a partner, and men not owning their home. Alcohol-related suicides and female suicides were unrelated to all measures of antidepressant sales. Conclusion We found little evidence that increase in overall sales or in the prevalence of non-tricyclic antidepressant users would have caused the fall in suicide rates in Finland in 1995–2007. However, the rise in the proportion of antidepressant users receiving minimally adequate treatment, possibly due to enhanced treatment compliance, may have prevented non-alcohol-related suicides among men.

Changing associations between partnership history and risk of accidents, violence and suicides

Background Lower mortality has been systematically found in married when compared with non-married, especially in men, but little is known about marital status differences in mortality from external causes. Furthermore, the role of cohabitation and partnership history in the formation of these differences and how they have been changed over time are poorly understood. Methods The incidence of fatal and non-fatal cases of accidents, violence and suicides by partnership history was analysed during 1991–1997 and 2001–2007 in a representative sample of the Finnish population aged 26–59 years. HRs were calculated using Cox proportional hazards models. Results Incidence rates in accidents, violence and suicides were generally lower in men and women living with a partner than those living alone. Current cohabitation and previous divorce increased the risk of all of these outcomes when compared with married without previous divorce. Higher incidence rates were found in men who had divorced 3 years ago or earlier when compared with those who had divorced later. Generally, these differences were larger in fatal than in non-fatal cases and significantly larger in men. There was little change in these differences between 1991–1997 and 2001–2007. These differences were partly explained by socioeconomic factors but remained statistically significant also after these adjustments. Conclusions Currently living without a partner and cohabitation and previous divorce increased the risk of accidents, violence and suicides. This indicates that also other mechanisms than immediate support from a partner are important in the formation of marital status differences in mortality.