Abstracts

INTRODUCTION

The population of Catalonia (Spain) has one of the world’s highest life expectancies. Due to the increase in longevity, the percentage of older population in Catalonia is higher than that in many other countries.²⁰20. Spijker J, Blanes A. Mortality in Catalonia in the context of the third, fourth and future phases of the epidemiological transition theory. Demogr Res. 2009;20(8):129-68. DOI:10.4054/DemRes.2009.20.8 Catalonia had a population of almost 7.6 million people in 2011, of which 17.0% were aged ≥ 65 years, and 2.5% were aged ≥ 85 years.^a Improvements in longevity should be accompained by an increase in the quality of life of older adults. However, the number of individuals suffering from chronic diseases, disabilities, and functional limitations, resulting in dependence, has increased in absolute terms in recent decades.¹1. Abellán A, Esparza C, Castejón P, Pérez J. Epidemiology of disability and dependency in old age in Spain. Gac Sanit. 2011;25(Suppl 2):5-11. DOI:10.1016/j.gaceta.2011.07.010 ^{, 18}18. Solé-Auró A, Alcañiz M. Are we living longer but less healthy? Trends in mortality and morbidity in Catalonia (Spain), 1994-2011. Eur J Ageing. 2014 in press. In addition, an increase in life expectancy²²22. Vidiella-Anguera A, Guillén M. Forecasting Spanish natural life expectancy. Risk Anal. 2005;25(5):1161-70. DOI:10.1111/j.1539-6924.2005.00671.x significantly impacts the planning of health services and contributes to socioeconomic costs, because of the need of long-term care.⁹9. de Meijer C, Koopmanschap M, d’Uva TB, van Doorslaer E. Determinants of long-term care spending: Age, time to death or disability? J Health Econ. 2011;30(2):425-38. DOI:10.1016/j.jhealeco.2010.12.010 ^{, 19}19. Solé-Auró A, Guillén M, Crimmins EM. Health care usage among immigrants and native-born elderly populations in eleven European countries: results from SHARE. Eur J Health Econ. 2012;13(6)741-54. DOI:10.1007/s10198-011-0327-x An in-depth analysis of the situation may reveal the trends that present a highly complex phenomenon such as aging and its relationship with the health. However, there is scant information available regarding the connection between the disorders that affect personal autonomy with health status, use of healthcare services, and different lifestyles. This knowledge is essential to anticipate and plan optimal social and health responses to allow an increase in the quality of life along with longevity.

This study aims to analyze the prevalence of individuals at risk of dependence and its associated factors.

The number of dependent individuals in the resident population of Catalonia in the 2010-2011 period was described, and the variables associated with the lack of personal autonomy were identified. Individuals with a high probability of having their abilities reduced to the point of needing help and support from others to carry out their daily routine were also identified. Using logistic regression models, some variables were determined to distinguish dependent individuals from those who are at risk of dependence. Such variables are predictive and modifiable indicators that can be changed by social and healthcare intervention and preventive actions. Their control can delay or prevent the need of receiving support and care.

METHODS

The data used in this study is from the 2010-2011 Catalan Health Survey (ESCA).^ba Instituto de Estadística de Cataluña. Indicadores demográficos. Población según sexo y edad quinquenal. Barcelona (ES); 2011 [cited 2014 Apr 2]. Available from: http://www.idescat.cat/es/poblacio/poblestructura.html This is an official semi-annual survey which is included in the current Catalan Statistical Plan^cb Departamento de Salud, Generalitat de Catalunya. Encuesta de Salud de Cataluña, 2010-2014. Ficha técnica. Barcelona (ES); 2014 [cited 2014 Apr 5]. Available from: http://www20.gencat.cat/docs/salut/Home/El%20Departament/Indicadors%20de%20salut/Enquestes/02_enquesta_catalunya_continua/fitxatecnica_esca.pdf and satisfies all principles of the European Code of Good Practices in Statistics.^dc Parlamento de Cataluña (ES). Ley 13/2010, de 21 de mayo, del Plan Estadístico de Cataluña 2011-2014. DOGC. 28 Mayo 2010. In each sampling round, we selected aproximately 2,500 individuals who resided in Catalonia and were not institutionalized. They were interviewed using a computer-assisted structured questionnaire. Interviews were personal; if the person was unable to answer because of age or disability, an indirect informer gave the answers.

Data for the ESCA survey was collected beginning from the second half of 2010. The interviews conducted during that period, as well as those made in the first half of 2011, resulted in a sample of 4,873 individuals. This sample included 3,842 individuals (1,918 men and 1,924 women) aged ≥ 15 years, of whom 913 were aged over 65 years. A total of 2.9% of the answers came by means of an indirect informer. The basic set of questions were regarding health status, use of healthcare services, medication, healthy habits, and activity limitations, while also establishing the population’s sociodemographic profile. In the complementary modules used in the two aforementioned semesters, particular attention was given to issues associated with older individuals, their personal autonomy, and the social support they receive.

In recent years, there has been an effort in Europe to unify health-related vocabulary and to precisely define concepts related to health and personal autonomy. The definitions used in this study were based on the recommendations from the Council of Europe^ee Consejo de Europa. Recomendación 98 de 9 del Comité de Ministros a los Estados miembros relativa a la dependencia, 1998 [cited 2014 Apr 6]. Available from: http://sid.usal.es/idocs/F3/LYN10476/3-10476.pdf and the World Health Organization.^ff Organización Mundial de la Salud. Clasificación Internacional del Funcionamiento, de la Discapacidad y de la Salud, 2001. Geneva; 2001 [cited 2014 Apr 6]. Available from: http://www.imserso.es/InterPresent2/groups /imserso/documents/binario/435cif.pdf

Dependence is the permanent state of individuals who, due to age, illness, or disability, associated with the lack or loss of physical, mental, intellectual, or sensorial autonomy, need attention or significant help and support from others to perform activities of daily living. Autonomy is the ability to control, cope, and take voluntary personal decisions about how to live according to one’s own norms and preferences, as well as to perform the basic activities of daily living. An accidental lesion may cause one to suddenly lose their personal autonomy, although that loss is normally gradual. Here, we treat “dependent population” and “population with loss of personal autonomy” as synonyms.

ESCA evaluates the lack of personal autonomy based on the individual’s perception (or that of the indirect informer) about the severity of his or her limitations or the amount of help required. The survey asks whether “because of a health problem, the individual needs the help or company of others to perform the usual activities of daily living”, either regularly or occasionally. The person is considered dependent if the answer is positive. Epidemiological and clinical studies use similar subjective dependence ratings,¹³13. Hoogendijk EO, Muntinga ME, van Leeuwen KM, van der Horst HE, Deeg DJH, Hermsen LAH, et al. Self-perceived met and unmet care needs of frail older adults in primary care. Arch Gerontol Geriat. 2014;58(1):37-42. DOI:10.1016/j.archger.2013.09.001 as large discrepancies do not seem to exist between one’s self-perception of the need for care and the objective situation.¹⁴14. Merrill SS, Seeman TE, Kasl SV, Berkman LF. Gender differences in the comparison of self-reported disability and performance measures. J Gerontol A Biol Sci Med Sci. 1997;52(1):M19-26. DOI:10.1093/gerona/52A.1.M19

Any statistical analysis based on primary ESCA data must consider its complex sampling design. This implies the need of the following: (i) using sampling weights that assign to each individual the appropriate weight in the population, according to their sex, age group, and health district and (ii) considering the combination of strata and clusters when calculating the standard deviations of the estimators.²2. Alcañiz-Zanón M, Mompart-Penina A, Guillén-Estany M, Medina-Bustos A, Aragay-Barbany JM, Brugulat-Guiteras P, et al. Nuevo diseño de la Encuesta de Salud de Cataluña (2010-2014): un paso adelante en planificación y evaluación sanitaria. Gac Sanit. 2014;28(4):338-340. DOI:10.1016/j.gaceta.2013.12.004 ^{, 8}8. Da Silva NN, Roncalli AG. Sampling plan, weighting process and design effects of the Brazilian Oral Health Survey. Rev Saude Publica. 2013;47(Suppl 3):3-11. DOI:10.1590/S0034-8910.2013047004362 The SURVEYFREQ procedure of SAS 9.2. (SAS Institute Inc., 2009) was used.

The population at risk of dependence was detected and characterized (Figure). After analyzing the prevalence of dependence for the variables included in the study (Table 1), a binary logistic regression model was proposed for each sex (Figure, Model 1). That model explains the presence or absence of dependence in the Catalan population which was aged ≥ 15 years. The included explanatory variables were as follows: age group (15 to 44 years, 45 to 64 years, 65 to 74 years, 75 to 84 years, and ≥ 85 years), education level (elementary or none, secondary school, and higher education), visit to emergency services (having been treated at an emergency department up to a year before the interview), hospitalization (having been hospitalized at least once in the 12 months prior to the interview), and use of medication (having taken any medication in the days immediately before the interview).

Model 1 allows the classification of individuals according to the probability of them losing personal autonomy. If that probability is greater than a certain threshold, the model establishes that the individual is dependent. In order to obtain the correct classification, the cut-off point that maximized the Youden index was established, i.e., the sum of the model’s sensitivity and specificity, minus one unit.¹⁶16. Perkins NJ, Schisterman EF. The Youden index and the optimal cut-point corrected for measurement error. Biom J. 2005;47(4):428-41. DOI:10.1002/bimj.200410133 This value minimizes the number of both false positives and false negatives, while also maximizing the area under the ROC curve.²⁵25. Youden WJ. An index for rating diagnostic tests. Cancer. 1950;3(1):32-5. DOI:10.1002/1097-0142(1950)3:1<32::AID-CNCR2820030106>3.0.CO;2-3
https://doi.org/10.1002/1097-0142(1950)3... This ensures the greatest possible number of well-classified individuals. An individual is at risk if the model assigns them a probability of dependence which is > 9.0% for men and > 13.0% for women. Using this classification, one can conservatively quantify the population which shares relevant characteristics with dependent individuals while still retaining personal autonomy (Figure), and therefore, is at risk of reaching a situation of dependence.

In order to identify which modifiable factors protect non-dependent individuals from the impairment of their functions, we applied a second logistic regression model in which the response variables do not reflect whether the individual is actually dependent or not, but if they are at risk of becoming so (Figure, Model 2). We distinguished two age groups for individuals aged under and over 65 years, which is the usual age of retirement from work in Spain. Aspects related to health status, social support, and lifestyle were incorporated as explanatory variables in Model 2: presence of problems during walking, washing or dressing oneself, or performing activities of daily living; feeling pain or discomfort or being anxious or depressed (dimensions from EQ-5D, a multidimensional standardized tool that measures quality of life relative to health using the five variables mentioned above);¹⁰10. EuroQol Group. EuroQol - A new facility for the measurement of health-related quality of life. Health Policy. 1990;16(3):199-208. DOI:10.1016/0168-8510(90)90421-9 ^{, 17}17. Rabin R, de Charro F. EQ-5D: a measure of health status from the EuroQol Group. Ann Med. 2001;33(5):337-43. DOI:10.3109/07853890109002087 self-perception of any chronic disorder from a list of 33 possible ones; receiving affective social support – that is, being the object of expressions of love and empathy (score of a total of four variables from the Duke-UNC-11 questionnaire); receiving confidential social support, meaning having others to communicate with, receiving information and advice from, or share concerns with (seven variables);⁵5. Broadhead WE, Gelhbach SH, Degruy FV, Kaplan BH. The Duke-UNC Functional Social Support Questionnaire - Measurement of social support in family medicine patients. Med Care. 1988;26(7):709-23. DOI:10.1097/00005650-198807000-00006 receiving support in activities of daily living; alcohol consumption (risk-level drinker versus non-drinker or moderate drinker);⁷7. Colom J, Contel M, Segura L, Gual A. Intervención en poblaciones de riesgo (2): los bebedores de riesgo. Adicciones. 2002;14(Suppl 1):375-85. tobacco consumption (smoker versus ex-smoker or non-smoker); and sedentary lifestyle (sitting down most of the day, compared with having a minimum level of physical activity).

RESULTS

A total of 7.7% of men and 14.1% of women aged ≥ 15 years were declared to be dependent, because they needed help in their activities of daily living (Table 1). The percentage of dependent individuals increased rapidly with age, and the prevalence of dependent women was significantly higher than dependent men in the 65 to 84 years age range. Greater percentages of dependence were found in groups with less education, particularly women, except in the group with university education. Dependent individuals, especially women, needed emergency services more often than the non-dependent population. More than 27.0% of the hospitalized population was dependent, with no significant differences between sexes. Use of medication, limited mobility, pain, anxiety or depression, and the self-perception of having a chronic disorder were associated with dependence, particularly in women. When social support was low or when help was received for activities of daily living, propensity for dependence was higher in both sexes. Sedentary lifestyle was also associated with dependence (18.2% and 29.0% for men and women, respectively). The percentages of smokers and drinkers at risk levels among dependent individuals were lower than those in the general population.

Dependent individuals were older compared with non-dependent ones (odds ratio [OR] = 2.9 / OR = 12.7 and OR = 13.1 / OR = 55.4, respectively for men and women aged 75 to 84 years/≥ 85 years), had less education (OR = 0.5 for secondary and university level studies), had been hospitalized in the previous 12 months (OR = 3.5 for men and OR = 2.3 for women), and had taken medication in the previous two days (OR = 2.2 for men and OR = 3.5 for women) (Model 1; Table 2). The use of emergency services was significant only for women (OR = 2.2).

About 702,000 individuals aged ≥ 15 years in Catalonia were declared to be dependent in the 2010 to 2011 biennium (11.0% of the total population) (Table 3). Individuals who did not have loss of autonomy in spite of having been assigned a significant risk by the model, totaling almost 1.2 million (18.6% of the population), were those who were in danger of having their abilities impaired until losing personal autonomy, since they shared characteristics with the population that already needed help (Figure). On the other hand, more than 4.5 million individuals were neither dependent nor at risk for eing dependent.

The risk of dependence was greater for individuals aged > 65 years and those who had ended their professional life. A total of 55.7% of them shared characteristics with individuals who were already dependent. Differences between sexes were significant above 65 years of age: 40.0% of women and a little more than 20.0% of men declared to need help; 2.2% of women aged ≥ 65 years had no risk, versus 25.7% of men. The situation was more favorable for individuals aged < 65 years: 9.5% were at risk for dependence, whereas 5.8% declared to suffer from a lack of personal autonomy, without significant differences between men and women.

The variables from the EQ-5D questionnaire were associated with physical and mental deterioration. The presence of problems in walking was a distinguishing feature between individuals with established dependence and those who were at risk of becoming dependent. Such mobility problems appeared earlier in males (OR = 3.7; in males aged 15 to 64 years) than in females (OR = 2.9; starting at age 65). Men who declared to be dependent exhibited more problems washing and dressing themselves (OR = 5.1; at age ≥ 65); there was no correlation for women.

Difficulties in performing activities of daily living significantly increased the probability of declaring themselves dependent (OR = 2.7 and OR = 3.2 for men and women, respectively), with a particularly high value for women aged between 15 and 64 years (OR = 6.9). The younger dependent population suffered more from pain or discomfort than the corresponding at-risk population (OR = 2.0 for men and OR = 2.4 for women), with no difference observed for older individuals. Only after age 65 did dependent women suffer more from anxiety or depression than the corresponding at-risk population (OR = 2.0).

The self-perception of chronic disorders was associated with dependence (OR = 2.7). Available affective social support correlated with dependence for both sexes. While dependent men received less expressions of love and empathy than men at risk (OR = 0.9), women received more (OR = 1.1), with no difference between age groups except for males aged 15 to 64 years (OR = 0.8). Confidential social support was a significant influence in older women, who received less support than the corresponding risk population (OR = 0.9). Receiving help in activities of daily living was strongly associated with consolidated situations of lack of personal autonomy in all age groups (OR = 11.7 for men and OR = 11.3 for women) (Model 2; Table 4).

The three risk factors considered – alcohol, tobacco, and sedentary lifestyle – were differential factors between the dependent population and the at-risk population, especially for females (OR = 2.2 for the smoking habit, OR = 12.2 for drinkers at risk, and OR = 3.4 for sedentary lifestyle). Women aged between 15 and 64 years showed an intense association between dependence and excessive alcohol consumption (OR = 24.4). No significant differences were observed regarding tobacco or alcohol consumption among men. Dependent individuals were more often sedentary than the at-risk population aged between 15 and 64 years (OR = 1.9).

DISCUSSION

A significant percentage of the Catalan population aged ≥ 15 years is at risk for dependence, even if the need for help has not yet been manifested. This condition affects almost one-fifth of the population, whereas after the age of 65, 25.7% of men and 2.2% of women can be considered to be at a low risk of becoming dependent. Women are the group most vulnerable to aging, while also living longer, according to other studies.²⁴24. Yong V, Saito Y, Chan A. Gender differences in health and health expectancies of older adults in Singapore: an examination of diseases, impairments, and functional disabilities. J Cross Cult Gerontol. 2011;26(2):189-203. DOI:10.1007/s10823-011-9143-0

The condition of dependence is strongly associated with an increased use of healthcare services – visits to emergency services and hospitalizations – and to a high consumption of medication in both sexes, especially in women. Healthcare is public in Spain. In 2014, the Ministry of Health, Social Services, and Equality assigned 61.0% of its credit to the Program for Personal Autonomy and Care for Dependency.^gg Gobierno de España. Ley 22/2013, de 23 de diciembre, de Presupuestos Generales del Estado para el año 2014. BOE. 26 dic 2013. Thus, the costs generated by healthcare, including those related to long-term care, represent a significant part of the Ministry’s budget.

In men, dependence starts with problems in walking, pain or discomfort, low affective social support, and sedentary lifestyle. If this conjunction of factors is not detected and not changed in time, the individual at risk will undergo a progressive decline until losing their autonomy after the age of 65. The clinical evolution could include a greater difficulty in taking care of their personal hygiene and performing activities of daily living, a limitation that has been associated with a severe state of dependence.¹¹11. Gispert R, Clot-Razquin G, Rivero A, Freitas A, Ruiz-Ramos M, Ruiz C, et al. Dependence profile in Spain: an analysis from the disability survey of 1999. Rev Esp Salud Publica. 2008;82(6):653-65. DOI:10.1590/S1135-57272008000600006 In addition, they are expected to suffer from more chronic illnesses and to need help from caregivers to perform their routine. Health professionals must carefully observe for symptoms that precede the onset of dependence. Improving the patient’s mobility will be particularly important for them to be able to have a more active lifestyle. The possibility of moving without pain will also allow them to increase social interactions, seeking the affective support needed to feel well.

Likewise, problems in performing activities of daily living, like working or housekeeping, and pain or discomfort are factors for the early detection of risk for dependence in the female population. A very revealing item that is not observed in men is excessive alcohol consumption. Although moderate alcohol ingestion is beneficial for the cardiovascular system and cognitive functions in older individuals,¹²12. Hogenkamp PS, Benedict C, Sjogren P, Kilander L, Lind L, Schioth HB. Late-life alcohol consumption and cognitive function in elderly men. Age. 2014;36(1):243-9. DOI:10.1007/s11357-013-9538-7 its consumption at risk levels is strongly associated with dependence among women aged between 15 to 64 years. Moderation in the consumption of alcoholic beverages may be a relevant factor to slow down the loss of personal autonomy. If the latter ends up manifesting itself, a dependent woman will show a significant impairment in her quality of life regarding health factors starting at age 65. She will also take up a sedentary lifestyle, which leads to muscular weakness in the legs and an increased risk of falls,²³23. Volkers KM, de Kieviet JF, Wittingen HP, Scherder EJ. Lower limb muscle strength (LLMS): Why sedentary life should never start? A review. Arch Gerontol Geriat. 2012;54(3):399-414. DOI:10.1016/j.archger.2011.04.018 as well as a reduction in her mobility.¹⁵15. Peeters G, Lips P, Brown WJ. Changes in physical functioning over 6 years in older women: effects of sitting time and physical activity. Eur J Ageing. 2014;11(3):205-12. DOI:10.1007/s10433-013-0300-x She will suffer from anxiety or depression. She will have a low frequency of social contacts and will need help from other people for attention and care.

No recent data are available about institutionalized individuals. This is an extremely vulnerable group, whose inclusion in the study would increase the prevalence of the studied disorders, particularly in older ages, as shown in the 2006 Catalan Survey of the Institutionalized Population (ESPI).^hh Departament de Salut, Generalitat de Catalunya. Enquesta de Salut a la població institucionalitzada de Catalunya, 2006. Residències i centres de llarga estada. Barcelona (ES); 2006 [cited 2014 Apr 15]. Available from: http://www20.gencat.cat/docs/canalsalut/Home%20Canal%20Salut/Professionals/Temes_de_salut/Gent_gran/documents/espi_cat_65.pdf On the other hand, since no information about the severity of dependence is provided by the ESCA, this has not been taken into consideration, contrary to what has been undertaken by other authors,³3. Alegre A, Ayuso M, Guillén M, Monteverde M, Pociello E. Tasa de dependencia de la población española no institucionalizada y criterios de valoración de la severidad. Rev Esp Salud Publica. 2005;79(3):351-63. DOI:10.1590/S1135-57272005000300004 based on more specific disabilities.

Despite these limitations, this study demonstrates the parameters that help identify risk factors to observe in order to delay the onset of dependence. Identifying these early indications for each sex is essential to delay the functional decline⁴4. Alexandre TS, Corona LP, Nunes DP, Ferreira JL, Oliveira YA, Lebrao ML. Gender differences in incidence and determinants of disability in activities of daily living among elderly individuals: SABE study. Arch Gerontol Geriat. 2012;55(2):431-7. DOI:10.1016/j.archger.2012.04.001 and the social deprivation suffered by individuals at risk.²¹21. Stuck AE, Walthert JM, Nikolaus T, Bula CJ, Hohmann C, Beck JC. Risk factors for functional status decline in community living elderly people: a systematic literature review. Soc Sci Med. 1999;48(4):445-69. DOI:10.1016/S0277-9536(98)00370-0 Adequate planning of preventive strategies is an effective approach to preserve the health and autonomy of older adults,⁶6. Clark F, Jackson J, Carlson M, Chou CP, Cherry BJ, Jordan-Marsh M, et al. Effectiveness of a lifestyle intervention in promoting the well-being of independently living older people: results of the Well Elderly 2 Randomised Controlled Trial. J Epidemiol Community Health. 2012;66(9):782-90. DOI:10.1136/jech.2009.099754 without incurring socio-health costs that would be difficult to overcome. Healthcare policies should be used as protective tools to facilitate and promote healthy aging with more years of enhanced quality of life for all population groups.

REFERENCES

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