Functioning and Disability in Ageing Population in Europe: What Policy for which Interventions?

3. Disability and Ageing: The Results of Ageing Studies in Europe

As stated by C.T. Römer and H.J. von Kondratowitz. “…The current state of comparative ageing research seems to be characterized by little theorizing as to whether (and why) there should be differences (or similarities) in ageing processes across countries, societies, or cultures”. In the first issue of the European Journal of Ageing (December 2004), results from a variety of European projects have been published, and most of them have used the method of cross-cultural surveys (e.g. CLESA, ENABLE AGE, ESAW, EURODEP, FAMSUP, MOBILATE, OASIS, and SHARE). Although all of these projects involved four to eleven European countries, explicit a priori hypotheses about differences (or similarities) across societies and cultures are hardly to be found. More often, a posteriori reasoning is presented. (Römer and von Kondratowitz 2006). A brief analysis of some relevant ageing studies is presented below, focussing on methodology of analysis of health and disability information and on the effects of different definitions of disability in ageing.

3.1 OECD Health Working Paper

In 2007, the OECD released a Health Working Paper on trends in severe disability among the elderly in 12 OECD countries (including Belgium, Denmark, Finland, France, Italy, the Netherlands, and Sweden). The Paper operationalized ‘severe disability’ in terms of dependency and presence of one or more limitations in ADLs (activities of daily living). Prevalence data were acquired from national data sources, where possible keeping to the definition of severe disability based on the self-report of one or more ADL limitations. The major finding was that, though there is clear evidence of a decline in disability among elderly people in five of the 12 countries, three other countries reported an increase, while two countries reported a stable rate. Additional data on chronic diseases (arthritis, heart problems, diabetes, hypertension and obesity) and risk factors among the elderly were consulted to see whether disability trends in different countries could be associated with reductions or increases in the prevalence of these chronic conditions. Although prevalence in most of these conditions and risk factors has increased in most countries, no clear judgment could be made about the linkages between chronic conditions and severe disabilities. The OECD Working Paper concludes that ‘it would not seem prudent for policy-makers to count on future reductions in the prevalence of severe disability among the elderly, but rather to expand national capacity in long-term care and programs to prevent or postpone chronic conditions. It would not be wholly unfair to characterize this policy implication as ‘erring on the side of caution’ given the unreliable data (Lafortune, et al., 2007).
It is important to notice that the OECD study relied on a proxy definition of ‘severe disability’, namely one that a) was most clearly consistent with the available national, self-report, survey data, and b) was intuitively linked to long-term care needs. Although this methodology was the product of expert consultation, it was constrained by the nature of the data sources available, and in particular by the various data collection instruments that were used. It took an a priori approach to data collection, in the sense that the policy question (‘What will be our long-term care needs in the future?’) is used to define the phenomena (‘severe disability’) under investigation. The authors were forced to this approach primarily because of the diversity of definitions and measures of ‘severe disability’ across OECD countries and the fact that the consistent conceptual framework provided by the WHO-ICF Classification has not as yet been adopted in survey practice across the OECD. This is scientifically inadequate. To give evidence of trends in needs, it is obviously preferable to define the phenomena that generate these needs independently of the needs themselves. The state-of-art represented by the OECD study makes it clear that rather than manipulating existing disability data from different countries, and thereby relying on an uncoordinated and non-comparably diverse collection of instruments for data collection, it makes far more sense scientifically, to develop a single measure and to perfect and test a single methodology that can be used by all countries to determine the population’s health and actual disability trends. In this way, relevant and useful data for whatever policy question can be derived.

3.2 Survey of Health, Ageing and Retirement in Europe- SHARE project

Of the available ageing studies that have been conducted in Europe, undoubtedly the most comprehensive has been the Survey of Health, Ageing and Retirement in Europe (SHARE) (Borsch-Supan et al. 2005 a, b). The first round of field work for SHARE was carried out in eleven European countries in 2004. The second round of field work is scheduled to be completed in 2007 with two countries added to the original eleven. SHARE built on the U.S. Health and Retirement Study (HRS), as well as the English Longitudinal Study on Ageing (ELSA) and other European surveys such as the Italian Longitudinal Survey on Ageing (ILSA), the European Community Household Panel (EHCP), the Survey of Income and Living Conditions (SILC), and the European Social Survey (ESS). The three main research areas covered by SHARE are economics, sociology, and health. SHARE instruments ask questions about overall subjective ratings of health, diagnosed medical conditions, symptoms that have bothered the individual, ratings of vision and hearing, and difficulties in carrying out activities of daily living and instrumental activities of daily living. In addition, the instruments ask self-reported height, weight and symptoms of depression. Respondents (but only those over 75) also perform tests of grip strength, walking speed, verbal fluency, immediate and delayed word recall. Questions about smoking and alcohol use, global questions on physical activity, and health care utilization are included too. SHARE measures quality of life using the CASP 12 item version, which is derived from the original 19 item version (Hyde, et al. 2003). In a separate ‘drop and collect’ survey, SHARE asked more detailed questions about health states, relying on anchoring vignettes to adjust for reporting biases. Initial analyses of the SHARE data (Borsch-Supan 2005a) show that while 50% of the Danish respondents reported being in very good or excellent health, less than 20% of Spanish respondents reported the same. When data were combined into a single index for health (which included health conditions, symptoms and limitations), with 0 being worst health and 1 perfect health, Spain had a mean score of 0.7 while Denmark’s mean score was more than 0.75. More generally, SHARE data show a consistent North-South gradient. By contrast data from the WHO on Healthy Life Expectancies (HALE) study, which combines fatal and non-fatal health outcomes into a single measure, show clearly that at age 50 the Spanish population overall is in better health than the Danish. The primary reason for this substantial discrepancy lies in SHARE instruments. Its conceptualization of health as a combination of diagnosis, symptoms, ADLs and IADLs (and a limited selection of functioning domains) fails to separate clearly individual health (an objective phenomenon) from the subjective phenomena of quality of life and well-being.

3.3 ELSA English Longitudinal Study on Ageing

The second major European ageing study, the English Longitudinal Study on Ageing (ELSA), has completed two waves of data collection on health, disability and healthy life expectancy, as well as a range of issues linking economic status and ageing. On the health side, ELSA has so far provided interesting data, including the fact that the older population in the UK has fewer chronic conditions than those in the US, despite health care expenditures in the US being two-and-a-half times higher than in the UK (Banks, et al. 2006). Nonetheless, the instrument used by ELSA involves self-reported health measures that focus on chronic illness and symptoms. The ELSA instrument therefore suffers from the same limitations as SHARE.

3.4 Cross-National Determinants of Quality of Life and Health Services for the Elderly Project (CLESA)

Another major effort in Europe funded by FP5 is the Cross-national determinants of quality of life and health services for the elderly project (CLESA), which harmonizes and analyses data from Finland (Tampere), Israel, Italy, The Netherlands, Spain (Leganes) and Sweden. CLESA is a longitudinal study but used different instruments to produce a common database, with a four item ADL measure to compare disability across countries. Data from CLESA show that while 22.1% of Spanish elderly men were classified as disabled, only 9.8% of males in Finland were so classified (for females the percentages were 33.3 vs. 14.2 respectively). The corresponding mortality data from the same study, however, indicated that mortality for men was highest in Finland and lowest in Spain (Minicucci et al. 2003, Noale et al. 2005). This discrepancy resulted from the instruments used, which asked questions only about impairments and presupposed an inadequately limited conception of disability.
This is only a brief overview of some relevant studies, however the results of these studies on ageing show how it is crucial to spotlight the need of collecting data on health and disability using a clear and shared parameter of functioning. Data based on unclear definitions of disabled population or on prevalence alone, give poor information on persons’ and populations’ health and, alone, cannot provide useful information for policy planning.

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