Mårten Lagergren

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

Background and aims: A large, national, long-term, longitudinal, multi-purpose study has been launched in Sweden — the Swedish National study on Aging and Care (SNAC). The study involves four research centers collecting data in four different areas of Sweden. Methods: The study consists of two parts: the population part and the care and services part. In the population part, a large, representative panel of elders in different age cohorts is followed over time to record and describe the aging process from different aspects. In the care and services part, a systematic, longitudinal, individually-based collection of data is performed concerning provision of care and services together with functional ability, specific health care problems, and living conditions of the recipients living in the area. Results: The data collection in the population part of the SNAC is not yet completed. In the present article, some preliminary results are reported from the care and services part. These pertain to comparisons between the participating areas with respect to the prevalence of disability among those receiving care and social services in their ordinary homes and those receiving care in special accommodation. A comparison is also presented with regard to the amount of home help provided to subjects with a given disability. Conclusions: This project has several advantages. It is expected to generate a rich data base relevant for future research on aging and care and to have a direct impact on the future Swedish system of care and services for the elderly.

The systems of care for frail elderly persons: The case of Sweden

Sweden has a well-developed welfare system following the Nordic model and it maintains —even though there have been some reductions in the last decade — good economic security and comprehensive services for the elderly. The national policy for the elderly aims at enabling older persons to live independently with a high quality of life. A great majority of the elderly in Sweden live in ordinary homes — very few live with their grownup children. The municipalities are responsible for providing long-term social services and care for the frail elderly in the form of home help services for those that live in ordinary housing, and special housing accommodation for those with extensive needs. The county councils are responsible for health care and provide home nursing care and rehabilitation. Sweden used to have the oldest population in the world. The proportion of 80+ years old in the population increased from 3% to over 5% between 1980 and 2000. Due to financial restrictions as a result of the economic recession in the last decade, the health and social services for the elderly have not been able to keep up with the population development. The previous generous allocation of care has been replaced by a more restrictive approach. This has mainly affected persons with lesser needs for help, younger elderly, and married persons. The number of elderly persons is expected to increase rapidly in the coming decades. However, due to improved health among the elderly, this will lead to a relatively limited increase of needs. Depending on assumptions concerning the health development, the required increase in volume of health and social services is expected to fall somewhere between 10–30% during the coming 30- year period.

Population ageing in Sweden: the effect of change in educational composition on the future number of older people suffering severe ill-health

We investigate how expected changes in the educational level composition of the older population may affect future prevalence of severe ill-health among older people in Sweden. Previous research has indicated that the number of older people, given educational differentials in mortality and expected changes in educational composition during the next decades, may increase more than expected following official population projections in Sweden. Eight alternative scenario projections for the possible development in the number of people with severe ill-health in Sweden between 2000 and 2035 are presented. Scenario projections, where both morbidity and mortality inequalities by educational level are taken into account, are compared with scenarios in which only age and gender are modelled. The projections are made with both constant and decreasing mortality. The calculations show that the expected increases in severe ill-health as a result from the ageing of the population in the period 2000–2035 might, to a large extent, be counteracted by the increase in the educational level of the Swedish population. We recommend therefore that in projections of the prevalence of ill-health, in addition to the ageing of the population, also changes in educational level should be taken into account.

Moving in and out of public old age care among the very old in Sweden

In this paper, we present empirical results for the very old (75+) concerning transitions between independent living in ordinary home without public support, independent living in ordinary home or special accommodations with home help and home health care, and living in around the clock care. We investigate the role of age and gender, dependency in activities of daily living (ADL) and the informal support from a partner. We also study mortality conditional on the above-mentioned variables and on the mode of old age care. The results show that the propensity to move to a more intensive mode of care is less for males, higher with more limitations in personal ADL and increasing with age. There is also a stabilizing effect of the availability of informal care support, as measured by marriage or cohabitation, as it makes it less likely to move from the current care mode. In the case of mortality, the observed relations pointed in the expected directions—mortality increasing with increasing PADL-limitations and age and being higher for men than for women. The age relation, however, does not hold in the same way in around the clock care. The estimated relationships are used as input in a micro-simulation model intended for analysis of the effect of population aging on the needs and resource requirements for old age care in Sweden.

Impact of living alone on institutionalization and mortality: a population-based longitudinal study

BACKGROUND Living alone is common among elderly people in Western countries, and studies on its relationship with institutionalization and all-cause mortality have shown inconsistent results. We investigated that the impact of living alone on institutionalization and mortality in a population-based cohort of elderly people. METHODS Data originate from the Swedish National study on Aging and Care-Kungsholmen. Participants aged ≥66 years and living at home (n = 2404) at baseline underwent interviews and clinical examination. Data on living arrangements were collected in interviews. All participants were followed for 6 years; survival status and admission into institutions were tracked continuously through administrative registers from 2001 to 2007. Data were analysed using Cox proportional hazard models, competing risk regressions and Laplace regressions with adjustment for potential confounders. RESULTS Of the 2404 participants, 1464 (60.9%) lived alone at baseline. During the follow-up, 711 (29.6%) participants died, and 185 (15.0%) were institutionalized. In the multi-adjusted Cox model, the hazard ratio (HR) of mortality in those living alone was 1.35 (95% confidence interval [CI] 1.18 to 1.54), especially among men (HR = 1.44, 95% CI 1.18 to 1.76). Living alone shortened survival by 0.6 years and was associated with the risk of institutionalization (HR = 1.74, 95% CI 1.10 to 2.77) after taking death into account as a competing risk. CONCLUSIONS Living alone is associated with elevated mortality, especially among men and an increased risk of institutionalization. Over a 6-year period, living alone was related to a half year reduction in survival among elderly people in Sweden.

Disability transitions in an area-based system of long-term care for the elderly and disabled

OBJECTIVE To describe patterns of individual disability development and mortality in an area-based system for long-term care of the elderly and disabled. DATA SOURCES AND STUDY SETTING Yearly surveys according to the ASIM system from 1985 to 1991 of all citizens of Solna, Sweden, receiving long-term care services from the municipality and/or the county council. STUDY DESIGN Linkage of individual assessments concerning disability and level of care from one survey to the next, using national registration numbers. DATA COLLECTION Registrations according to the ASIM system concerning services actually provided, assessed need of services, social environment and disability were collected by the staff responsible for the services provided. PRINCIPAL FINDINGS Mortality was shown to be strongly connected to disability. Disability transitions occurred in both directions for all age groups, but the average rate of disability increase rose with advancing age. Rapid disability development was shown in a multivariate analysis to be connected to institutional care and change in the level of care between surveys. CONCLUSIONS Data describing disability development can be used for planning purposes, either directly or with the help of a simulation model. More research seems to be needed with regard to the influence of the level of care and of transfers on disability development.

Allocation of Care and Services in an Area-Based System for Long-Term Care of Elderly and Disabled People

In order to analyse the allocation of public care services in the city of Solna, Sweden, and how they changed in response to a rapid growth of the number of elderly people, a comparison was made between two surveys, 1985 and 1991. The surveys comprised all citizens of Solna who, on the day of the survey, were receiving long-term public medical and/or social care services. Living arrangements and services received were registered together with assessments of social support and disability/dependency. The latter was measured according to a special scale (the ASIM index) and – for 1991 – the Katz index of ADL. The assessments were made by the ordinary staff. The analysis showed that older and non-married persons were more likely to become clients of the public care system. Institutionalisation was also more common among the non-married – especially for men. Connected to the rapid increase in the number of the very old in the context of limited resources was a sharp decline during the period 1985–1991 in the proportion of the Solna population that received public care services in some form. This decline concerned all age-groups of both sexes, married as well as non-married, but the married were more affected than the non-married – especially among the women. The reductions in the proportion of the population that received care in the home affected mostly married persons in the oldest age group. Reductions in institutionalisation had most impact on very old, non-married men – partly counteracted by increases in the provision of home help. Multivariate analysis showed functional disability – in 1991 dependency in ADL according to Katz - and living arrangements to be the most important variables in explaining the allocation of home help in domiciliary care and sheltered housing.

Healthy life years in old age: Swedish development 1980-2010 according to different health indicators.

Aims: To investigate the development of healthy life expectancy from 65 years (HLE65) in Sweden in the period 1980 and 2010 by using two different health indicators: self-rated health and the global activity limitation indicator (GALI). Methods: Sources of data for the HLE computations were Swedish national mortality statistics and the nationwide Swedish Survey of Living Conditions (SSLC), which have been conducted biennially by Statistics Sweden since 1974. We used the Sullivan method for calculations of HLE. A decomposition into mortality and disability effect has been made in accordance with the method devised by Nusselder. Results: Life expectancy at age 65 (LE65) increased by 3.1 years for women and 4.0 years for men from 1980/85 to 2006/11. Regardless of which health measure investigated – self-rated health or GALI – HLE65 increased between the periods 1980/85 to 2006/2011 more rapidly than LE65 and as a consequence the years with bad self-rated health and years with activity limitations decreased. These increases as well as the decreases were significant (p<0.05). Conclusions: The Swedish LE65 and HLE65 development, as judged by the SSLC study, are compatible with the postponement hypothesis and there is even a clear tendency for compression. Thus, the years with bad self-rated health and years with activity limitations are postponed to a higher age and the number of those years have decreased. From this respect, the Swedish development looks positive. The need of old age care in 2010 would have been much higher if it had been expansion – not postponement – of bad self-rated health and years with activity limitations during the time period.

Horizontal and vertical target efficiency - a comparison between users and non-users of public long-term care in Sweden

ABSTRACT The extent to which a system of services is in tune with the needs of the population can be expressed in terms of target efficiency, which includes horizontal target efficiency – the extent to which those deemed to need a service receive it – and vertical target efficiency – the corresponding extent to which those who receive a service actually need it. Vertical efficiency can be measured by looking only at those receiving services. To measure horizontal target efficiency in a population, one must have access to population surveys. Data were taken from the baseline survey of the Swedish National Study on Ageing and Care (SNAC study). The results show that more than 80 per cent of those dependent in personal activities of daily living in the studied geographic areas were users of public long-term care (LTC). Dependency in instrumental activities of daily living was identified as the most important predictor of using LTC. Vertical target efficiency was 83–95 per cent depending on age, gender and type of household, if need was defined as dependency in instrumental activities of daily living. It was considerably lower, 35–61 per cent when defined as dependency in personal daily activities. Overall, long-term target efficiency in Sweden must be regarded as high. Few persons who need public LTC services fail to receive them.

Comparing Long-Term Care Recipients in Urban and Rural Municipalities in Japan and Sweden

Japan and Sweden both have national systems of long-term care (LTC) and face similar challenges. This study compared various indicators of disability in LTC recipients in nine large urban, midsize urban, and rural municipalities in both countries. The aim was to establish whether urban-rural differences exist and whether they follow similar patterns in Japan and Sweden. It was found that LTC recipients in large urban municipalities in both countries were on average significantly less disabled than those from the other types of municipalities, regardless of the indicator for disability. Fewer persons in large urban municipalities live in extended families, which may increase the propensity to apply for LTC. The number of older people living alone in Japan is increasing, which means that the formal LTC system will come under increased pressure.