Vital and

Health Statistics

Proceedings of

1988 International

Symposium on

Data on Aging

Series 5:

Comparative International Vital and

Health Statistics Report

Not 6

The International Symposium was convened from December 7 to 9, 1988, in

Bethesda, Maryland, to develop proposals for research in measuring the health and

health care of the aging, The Proceedings include papers from the plenary sessions,

where measurement issues were identified, and the workshops, where specific

proposals for research were outlined, Speakers and participants were distinguished

International experts from a dozen different countries and a variety of organizations,

They were selected for their expertise in the six topics addressed by the International

Symposium: Common chronic diseases, health promotion, vitality, functioning,

mortallty statistics, and outcomes of nursing home care.

Manning Feinleib, M. D., Dr. P.H., Editor

US, DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Centersfor Disease Control

National Center for Health Statistics

Hyaftsville, Ma@and

August 1991

DHHS Publication No, (PHS) 91-1482
Copyright Information

Permission has been obtained from the copyright hoiders to reproduce certain

quoted materiai in this report. Further reproduction of this material is prohibited

without specific permission of the copyright holders, Ali other materiai

contained in the report is in the public domain and may be used and reprinted

without special permission; citation as to source, however, is appreciated.

Suggested Citation

Feinleib MF, ed. Proceedings of 1988 International Symposium on Data on

Aging. National Center for Health Statistics. Vital Health Stat 5(6). 1991.

Library of Congress Cataloging-in-Publication Data

International Symposium on Data on Aging (1988 : Bethesda, Md.)

Proceedings of 1988 International Symposium on Data on Aging /

Manning Feinleib, editor.

p. cm. – (Vital and Health statistics. Series 5, Comparative international

vital and health statistics report ; no. 6) (DHHS publication ; no. (PHS)

91–1482)

“Symposium was convened from December 7-9, 1988, in Bethesda,

Maryiand.”

inciudes bibliographical references.

iSBN 0-8406-0450-5

1. Aged – Health and hygiene – Statistics – Congresses. 2. Health

surveys -Congresses.3. Health statistics -Congresses. 4. Aging–

Research– Methodology –Congresses. LFeinleib, Manning. li. Titie. lil. Series.

iV. Series: DHHS publication ; no. (PHS) 91-1482. [DNLM: 1.

Aged – congresses. 2. Aging-congresses, 3. Heaith Status – congresses.

4. Health Suweys-United States -congresses. 5, Research-United

States - congresses. W2 A NI 48ve no. 6]

RA408.A3158 1988

362.1 ‘9897 –dc20 91–10087

ciP
National Center for Health Statistics Acknowledgment

Manning Feinleib, M.D., Dr.P.H., Director

Robert A. Israel, Deputy Director

Jacob J. Feldman, Ph.D., Associate Director for

Analysis and Epidemiolo~

Gail F, Fisher, Ph.D., Associate Director for

Planning and Extramural Programs

Peter L. Hurley, Associate Director for Wal and

Health Statistics Systems

Robert A. Israel, Acting Associate Director for

International Statistics

Stephen E. Nieberding, Associate Director for

Management

Charles J. Rothwell, Associate Director for Data

Processing and Services

Monroe G. Sirken, Ph.D., Associate Director for

Research and Methodology

David L, Larson, Assistant Director, Atlanta

Office of Vital and Health Statistics

Systems

Peter L. Hurley, Associate Director

Joan F. Van Nostrand, NCHS Coordinator of

Data on Aging

Mary Grace Kovar, Dr.P.H., Special Assistant

for Data Policy and Analysis

Support for preparation of this report was

provided by the Federal Interagency Forum on

Aging-Related Statistics.

Note

The affiliations shown in the papers in this

report are those in effect at the time of the

International Symposium on Data on Aging.

The opinions expressed are those of the authors,

not of the organizations for which they work,

John S. Gardenier, Ph.D., Manage~

Computer/Laptop Assisted Survey Information

Collection
Contents

Part L Introduction

Chapter 1. Measuring the health and health care of the aging by Manning Feinleib. . . . . . . . . . . . . . . . . . 3

Chapter 2. My grandmother said, “If you have your health, you have everything.” What did she mean?

by Harvey Jay Cohen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Part U. Comparing cardiovascular and cancer statistics

Introduction by Harry M. Rosenberg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Chapter3. Morbidity andmortality information on old age: Comments on availability, validity, and

comparability by Thomas Strasser . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Chapter 4. Validity ofdiagnosis ofcancer intheelderlyby C.S.Muir . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Chapter5. Causes ofdeath among the elderly: Information from the death certificate by Harry i14.

Rosenberg, Frances Chevarley,Eve Powell-Griner, KennethKochanek, andManning Feinleib . . . . . . 35

Chapter 6. Diagnosisofcardiovascular diseaseinelderlypopulationsbyMillicent W. Higgins . . . . . . . . 59

Part [11. Health promotion and disease prevention among the aged

Introduction by Gerry E. Hendershot. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Chapter 7. Statistics onhedthpromotion md&seaseprevention in The Netierlmds by Henk Swinkels. . 69

Chapter 8. Health promotion among the aged in the United States by Gerry E. Hendershot . . . . . . . . . . . 77

Chapter 9. Optimal survey research methods for studying health-related behaviors of older people

by John B. McKinlay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Part IV. Functional disability

Introduction by Mary Grace Kovar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Chapter 10. Functional ability and the need for care: Issues for measurement research by Mary

GraceKovar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Chapter ll. Surveys ofthesituation oftheelderlyinHungarybyAndrds Klinger . . . . . . . . . . . . . . . . . . 105

Chapter 12. A comparison of demographic, health, and housing variables in studies of elderly

populationsin Canada andtheUnited States by W.F. Forbes, L.M.Hayward, andB.D.McPherson . . . 113

Chapter 13. Functioning old age: Measurement, comparability, and service planning by A. Michael

Davies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

Chapter 14. Functionaldisabilityissues byMaryGraceKovar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Part V. International health care research

IntroductionbyJacobJ.Feldman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

Chapter 15. Cross-nationalresearch inhealth care by GaryRobertAndrews . . . . . . . . . . . . . . . . . . . . . . . 135

...

Ill
Part VI. Comparative analysis of health statistics for selected diseases common in older

persons in the United States

Introduction by Tamara Harris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

Chapter 16. Opportunities for international collaboration: Comparisons of morbidity and mortality for

chronic diseases inolderpersons byJacobA.Brody . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

Chapter 17. Epidemiology of aging in Hong Kong: Health status of the Hong Kong Chinese elderly

bySuzanne C. Ho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

Chapter 18. The utility ofcross-national comparisonsofdiseasesofolderpersons byTamaraHarris ... 163

Chapter 19. Utility of cross-national comparisons of diseases of older persons: Osteoporosis as an

example byJenniferL.KeLwy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

Part VII. Measuring risk factors and outcomes of institutional long-term care

IntroductionbyJoanF. VanNostrand. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

Chapter20. Research oninstitutional long-terrncareinAustraliabyAnnaL. Howe . . . . . . . . . . . . . . . . . 175

Chapter 21. Long-term care in the United States: Issues in measuring nursing home outcomes

byJoanF. VanNostrand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189

Chapter 22. Measuring outcomes of institutional long-term care: The problem of both the dependent

andindependent variables byl?osalie A.Kane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195

Chapter23. Outcomes ofcommunity andinstitutionallong-termcarebyBetty Havens . . . . . . . . . . . . . . 199

Part Vlll. Assessment of vitality and aging

Introduction by RichardJ. Havlik . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209

Chapter24. Quality oflifeamongtheelderly inVeneto,Italy:A cross-sectional study byStefaniaA4aggi,

TrudyL. Bush, Giuliano Enzi,andGaetano Crepaldi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

Chapter 25. Physical, social, and mental vitality by RichardJ. Havlik. . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

Chapter 26. Measmement ofvitatity inthe Ameticms' Chm~ng Lives study by A. Regula Herzog . . . . 223

Part IX. Special activities related tomeasuring health and health care

Chapter 27. Contribution of the World Health Organization Program for Research on Aging to

activities related tomeasuting hedthmdhealti cweby Jorge Liwak . . . . . . . . . . . . . . . . . . . . . . . . . . . 235

Chapter 28. Hedthforthe elderly bytheyem2MO: Statistical needs by Ronald G. Blankenbaker . . . . . . 239

Part X. Summary

Chapter 29. Overview by Manning Feinleib . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245

Chapter 30. Comptingcmdiovasculm ~dcmcer statistics by Har~M. Rosenberg . . . . . . . . . . . . . . . . 247

Chapter 31. Hedthpromotion and&seaseprevention among theagdby Ger~E. Hendershot, ,., ,,, , 253

Chapter 32. Functional disability by Mary Grace Kovar. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257

Chapter 33. Comparative analysis of health statistics for selected diseases common in older persons in

the United States by Tamara Harris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,, ... 261

Chapter 34. International collaboration in measuring outcomes of nursing home care by Joan F,

Van Nostrand . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263

Chapter 35. Assessment of vitality and aging by RichardJ. Havlik . . . . . . . . . . . . . . . . . . . . ... . . . . . . . 267
Symbols

... Data not available

. . . Category not applicable

Quantity zero

0.0 Quantity more than zero but less than

0.05

z Quantity more than zero but less than

500 where numbers are rounded to

thousands

* Figure does not meet standard of

reliability or precision

# Figure suppressed to camply with

confidentiality requirements
Part I

Introduction
Chapter 1

Measuring the health and

health care of the aging

by Manning Feinleib, M.D., Dr.P.H., Director,

National Center for Health Statistics

As Director of the National Center for Health

Statistics (NCHS),I ampleasedto welcome you to this

International Symposium on Data on Aging. I would

like to thank Joan Van Nostrand, Robert Hartford,

SamNotzon, andalltheothermembersof theplanning

committee for the hard work they have done in organizing the Symposium.

This Symposium marks the beginning of NCHS’s

International Collaborative Effort on Measuring the

Health and Health Care of the Aging. We abbreviate

this to the ICE on Aging: Some even abbreviate it to

the ICE Age. Like its predecessor, the International

Collaborative Effort on Infant andPerinatal Mortality,

the ICE on Aging is designed to help NCHS meet its

mandate to provide reliable and timely data to assess

the health of the population and to track progress in

promoting the Nation’s health. We feel it is important

to share our experience with others and, in turn, to

learn from our colleagues in other countries how they

are responding to their nations’ requirements for highquality data.

The aging of the population is an unprecedented

worldwide phenomenon with major social and economic consequences. One important consequence is

the need for increased efforts and resources to maintain the health of older people and to provide them

with adequate health care.

Questions raised by researchers, cme providers,

andpolicymakersreflect the complexity of these health

issues:

s Are the final years of life ones of quality?

“ How can disability from chronic conditions be

delayed or even prevented entirely?

s How can outcomes of care be improved?

These and many simikw questions challenge us to

improve our ability to measure the health of the aging.

In response to this challenge, NCHS has launched

a major program on measuring the health and health

care of the aging, of which this International Collaborative Effort on Aging is an essential component. The

ultimate goal of the ICE on Aging is to strengthen the

measurement of health and health care of the aging in

both NCHS programs and international applications.

The emphasis on international collaboration provides

increased opportunity forcomparinghealth data among

nations and for sharing our accumulated knowledge

and experience.

The focus of the ICE on Aging is on the health and

wellness of older persons and, in particular, on several

measurement issues that arise in assessing the many

aspects of health and illness in this population. To

make our task manageable, we have selected three

themes for consideration within the scope of the

International Collaborative Effort:

“ Comparing diagnostic statistics.

● Measuring vitality.

● Assessing outcomes of health care.

Within these three overarching themes, a set of specificmeasurement issues has been selected forpriority

attention.

For the task of comparing diagnostic statistics, the

two measurement topics selected are:

“ Mortality statistics for cardiovascular disease and

cancer.

‘ Morbidity measures forchronicdiseases common

in older persons.

For the task of measuring vitality, the three measurement issues are:

● Assessment of vitality and aging.

● Defining and measuring functional disability.

s Appropriate measures relevant to health

promotion and disease prevention among

the aging.

3
In assessing outcomes of health care, a single area was

selected, namely, measuring risk factors and outcomes of institutional long-term care.

Joan Van Nostrand has aptly summarized the

interrelation of these topics in the form of a diagram

(see figure 1) with vitality and health promotion at the

core, indicating the focus on wellness and quality of

life. Surrounding these two essential elements are

three critical aspects of health for older personsdisability, variation in disease patterns, and long-term

care. Each is connected to the others by two-way

arrows, indicating the plasticity of aging: Older persons can shift from able to disabled and back again;

disability can lead to a need for long-term care; good

care can return one to improved vitality. Finally,

surrounding all of these topics are the underlying

issues on which the ICE on Aging concentrates-the

measurement issues relating to health and use of care,

and comparability issues for international studies.

To assist us in developing an agenda for further

research in the six targeted areas, NCHS has organized

this Symposium and has invited a group of distinguished international experts from a dozen different

countries and a variety of organizations, including

governmental offices, universities, foundations, and

SOURCE: National Center for Health Statistics.

Figure 1. Interrelationship of International

Collaborative Effort on Aging topics

4

international agencies. They have been asked to participate in this Symposium as experts on particular

research topics and as knowledgeable consultants on

international research activities and data sets in the

field of aging. They have not been asked to serve as

formal or official representatives of their countries or

organizations.

This brings us to the specific objective of the

International Symposium, and that is to develop a

research agenda for each of the six targeted measurement topics. To do this, the Symposium has been

organized into two types of activities-a plenary session for each topic, at which the international and

domestic experts will raise pertinent research issues,

and then workshops to discuss these issues and develop specific research p~oposals. The draft research

proposals are presented in Part X.

In developing the research proposals, I ask you to

concentrate on using existing data sets. Our experience from the first ICE on Infant and Perinatal Mortality has demonstrated that existing data, viewed from

an international perspective, are a rich and relatively

untapped source of valuable information. Furthermore,

using existing data sets will facilitate the completion

of the projects within a relatively short timeframe of

about 3 to 4 years, so that the results can be incorporated into the programs of NCHS and other groups by

the mid- 1990’s.

In the weeks following this Symposium, the research proposals will be reviewed for feasibility. Consideration will be given to technical, scheduling, and

resource aspects. We hope to initiate the research

projects in spring 1989. If this schedule is achieved,

we hope to hold a second Symposium at which interim

research results can be pmented. Depending on the

progress of the research, the Symposium is tentatively

planned for summer 1991.We hope that the final mults

and mcornrnendationsfrom the selected projects will be

presented at a third International Symposium in 1993.

In concluding, I would like to repeat my welcome

to you andreaffm my belief that conducting internationalcollaborative research will allow us to build on

existing knowledge and experience in measuring the

health of the aging. Strengthening the measurement of

health and health care of older persons will assist us all

in meeting the diverse challenges that an aging world

presents.
Chapter 2

My grandmother said,

“If you have your health,

you have everything.”

What did she mean?

by Harvey Jay Cohen, M.D., Director, Center

for the Study of Aging and Human Development, Duke University Medical Center, and

Geriatric Research Education and Clinical

Center, Veterans Administration Medical

Center, Durham, North Carolina

I am quite honored to have been asked to keynote

this Symposium and, reflecting on it, I was a little

puzzled as to why I was selected. I have tried to figure

this out and have come up with a few possible answers.

Ordinarily, I would have thought that you would

have selected an expert in some of the measurement

issues that are to be discussed at length here today. I

do not consider myself an expert in any of these issues.

This is confirmed by the definition of an expert which

I have heard proposed, that is, a person who comes

from more than 50 miles away and shows slides. I do

come from more than 50 miles away. However, heretical as it may be to admit at a symposium so steeped in

data and statistics, I will show no slides and present no

data.

So I am not an expert. In fact, I once defined a talk

without slides or a paper without data as a philosophical discussion. I have never considered myself much

of a philosopher either, but in a sense, I guess this will

be a philosophical discussion.

Actually, I suspect that my presence has to do with

a couple of things that are pertinent. I come from a

clinical background and thus face the problems which

we are going to discuss and see them acted out on an

everyday, practical basis. So I see the actual clinical

impact of topics which we are going to discuss for the

next few days in terms of measurement issues. Finally,

I have assumed that I arn here, in a sense, as a

representative of the history and tradition that are

present at the Duke Center for the Study of Aging and

Human Development and more recently in the

Veterans Administration Geriatric Research Education and Clinical Center (GRECC) regarding a number of issues. I think that these issues are quite pertinent, and I consider them essential to the enterprise

that is to be embarked upon in the next couple of days.

First, the Duke Center has a long history in data

collection on health and longitudinal changesin health.

The Duke longitudinal studies, the Duke Older

Americans Resources and Services (OARS) methodologies, and more recently our studies of geriatric and

functional assessment speak to some of those issues

(l-5). Second, many of those aspects of data collection have involved targeted, specific measurements

geared to provide information in the areas which we

wish to understand better. Third, we have had a history

of international collaboration, acting as one of the two

World Health Organization collaborating centers on

aging in the United States.

Investigators in the Duke Aging Center have a

long history of purposive archiving and a long history

of secondary data analysis through our survey data

laboratory. Perhaps most important in this area, we

have a multidisciplinary team of people available to

help in the interpretation of data being collected and

assessed, to know what questions can and cannot be

answered with a particular data set, the purposes for

which it was elicited, the alternative uses to which it

can be put; and-of almost too obvious importance—

the quality of the data.

I think such a team needs to contain people knowledgeable not only in data collection and analysis but in

5
thesubstantivecontent issues of aging. If I can deliver

any exhortation, it is that many of these sorts of

principles will govern the interpretation and organization of the data to be collected and, in this context, to

be interpreted, since we will largely be dealing with

secondary data analysis.

This conference will delve heavily into measurement issues in health and health care in a number of

important areas. Since I have already said I am not an

expert in these, I will not address them specifically,

even though some, such as the cancer statistics, are of

particular interest to me.

Instead, Iwouldliketoaddress some of the general

issues behind the conference—the overall aim of the

International Collaborative Effort on Aging which

you have already heard articulated, that is, the focus on

the health and wellness of the elderly. Those words

flow trippingly from the tongue—health and wellness

of the elderly. They are almost as cute as the phrase

that the geriatric education coordinator at Duke used

the other day when I mentioned to her that I was

speaking at this conference. She said, “Oh! You are

going to talk about hippy dippy.”1 looked at her, a little

confused, and said, “Hippy dippy? What’s that?” She

said, “Oh, that is what we call health promotion and

disease prevention” (HPDP).

Those are catchy words, catchy phrases, almost as

though we know what we are talking about. The

question I would ask is, Do we? I would like to start

and perhaps spend most of the time on the basics,

really the basics.

We are planning to measure health. My grandmother said, “If you have it, you have everything.”

What did she mean? What is “it”? It seems as if this

should be really easy, one of those things we seem to

know when we see it. In ourmind’s eye, each of us has

a picture of what it is and what those “healthy” older

people look like.

But it seems much more difficult to get a handle on

what health is when we start to characterize it, and

especially when we start to quantify it. This may be

complicated somewhat by different pictures of health

carried around in our mind’s eye and conditioned in

different countries by different cultures. I am sure in

the next few days, as we address some of these issues

from the international perspective, some of these

images will become clear. At least they may become

obvious. Whether they will become clear is another

issue.

How, then, do we define some of these concepts?

I thought it would be fun to get really basic, so I

consulted one of my favorite medical textbooks,

Webster’s Dictionary, and looked up some of the

definitions. The dictionary defines “health” as a conditionof being sound in body, mind, orspirit,especially

freedom from physical disease or pain. It defined

“healthy” as implying full strength and vigor, as well

as freedom from signs of disease. The dictionary also

provided some synonyms in that same definition. One

of them was “well.” Being well, as opposed to healthy,

was said to imply merely (my emphasis) freedom from

disease or illness.

Other interesting terms were provided. One was

“robust,” which was defined interestingly asthe opposite of delicate and sickly. I love terms that are defined

asthe opposite of something, because then you have to

go figure out what those other things were defined as

in the first place. Another interesting term was “hale,”

which was defined particularly as robustness in old

age.

So we have a spectrum of that mind’s-eye picture

of the healthy older individual. I think there are some

problems with some of these definitions, especially

the one of “healthy” as full strength. It reminds one of

the story about the man walking along the street and

meeting an old friend who came up to him and asked,

“How are you andhowis your wife?’’Themanreplied,

“Compared to what?” Full strength compared to

what? For elderly people, if by full strength we mean

compared to a 20-year-old’s full strength, that is

probably not what my grandmother meant.

For purposes of argument, I would like to propose

that health of the elderly, by and large, is the absence of

chronic illness.Note thatI have used the term illness,not

disease, and I will comeback to that in a moment.

Many have noted the reciprocal relationship of

health and disease. As far back as 500 B.C. Aeschylus

wrote, “Of a truly lusty health, rest us not content with

its due bounds, for disease ever presseth close against

it, its neighbor with a common wall.”

More recently, Ed Bierman and Bill Hazzard, in

promoting preventive gerontology, have focused on

6
prevention or attenuation of the chronic diseases of

aging as a major goal of medical practice. Others, on

the other hand, have claimed that the disease focus is

too narrow and have set up aconfrontational situation,

a confrontation between a biomedical model and a

social model. I believe that broadening the focus to

illness—that is, both disease and its manifestations

and functional effects on the individual-makes this

moot, at least for the elderly. An old Russian proverb

says,“Onecanalwaysbe healthy aslong asoneis notill.”

Clearly, economic, social, and many other factors

play important roles. These same factors must be dealt

with by people of any age. It is my view that a healthy,

well older person—that is, one in the absence of

chronic illness, which inch.idesdisease anddisability—

can do fine even in a setting of fairly limited resources.

The crisis occurs when health fails, that is, illness

occurs. I believe that this is what my grandmother

wanted, to be free of chronic disabling illness.

Could we do more? Perhaps. We could strive for

that full strength of youth. I suspect that this is probably not what we wish to do. However, perhaps once

we have finished defining vitality, during these next 2

days and over the next few years, we might wish to

strive for vitality as elderly individuals.

I would remind you, though, of the caution of the

French writer of the 1600’s who said, “To preserve

one’s health by too strict a regimen is, in itself, a

tedious malady.” As a confirmed nonjogger, I would

have to agree with that.

Regarding measurement issues, I would like to

stress a couple of points. First, as I have already

indicated, I believe we must account for both disease

and function. This is not an either-or situation, and

these two concepts are not to be placed in conflict.

These are complementary, noncompetitive concepts.

Recently in geriatric circles the talk of functional

assessment has become so great and so dominant that

I fear we sometimes tend to forget the importance that

specific diagnostic information can provide. Previous

studies, recently confiied by analyses of national

long-term care surveys done by investigators at Duke,

have noted the additive importance played by diagnostic and functional information. Thus, although

functional measures in these studies determined the

level of services needed by the elderly population,

diagnostic information-information about specitilc

disease processes--often determined the duration of

need of these services. For example, women with the

same degree of functional impairment as men lived

considerably longer with this degree of functional

impairment, because the functional impairment in

women was caused by different medical conditions,

those with lower force of mortality. As a result, the

women actually exhibited much greater resource need

than did the men (6).

Some of our current studies of geriatric consultation team assessment at the Durham Veterans

Administration Medical Center GRECC (5) noted, in

following a cohort of elderly individuals, that despite

the excellent overall functional status of many of these

individuals, there was an extremely high mortality

over the next 2 years. At first, we were surprised,

because functional status has been said to be everything. We should not have been surprised. It is clear

that we are looking at the same issue, the force of

mortality of specific diagnoses: That is, we had a

population, a hospitalized population, with a number

of severe and high-mortality illnesses, such as cancer

and late-stage cardiac disease, and these dominated

the mortality picture.

This relates to the concept of health, the duality of

function and disease. For example, is the elderly

individual who presents with no functional impairment, perfect performance status, high level of activity, but with widely metastatic oat cell carcinoma of

the lung, healthy? I think not. That person will likely

be dead within 9 months as well.

We cannot ignore either facet of this complex

issue of function and disease. It is my hope, in looking

at the organization of this conference, that both of

these areas will be addressed specifically.

Likewise, in the medical context, sometimes the

best way to improve functional status is by addressing

a specific diagnostic entity. There has been a lot of

writing in recent years in geriatric circles on maintenance of functional status, as if this were some separable magic process.

It is clearly true that for many individuals with

multiple chronic, irremediable medical problems, maintaining functional status by a variety of symptomatic

measures is the appropriate way to go. However, it is

probably best not to treat patients with aches and pains

in their bones by symptomatic measures alone, if the

7
origin of these aches and pains is, for example, multiple myeloma, which could be treated quite specii%

tally with excellent relief of symptoms and rather

dramatic functional status improvement. Again, I

would emphasize that functional status, as determined

by functional assessment, and disease-specific and

diagnostic information are complementary and dually

useful pieces of information.

Why, then, are we so eager to look at all these data

and to collaborate and to analyze them so thoroughly?

I suggest that it is precisely because health will be

created if we can prevent or attenuate the chronic

illnesses of aging, but that we have a very poor handle

on what the predictors for many of these illnesses are

and what the risk factors for them are. We clearly need

to learn more about those aspects of health in the

elderly if we are to achieve the goal.

If we learn more, can we do anything about it? Are

health promotion and disease prevention for the elderly contradictions in terms? I do not believe so.

However, I believe we must avoid being too “hippy

dippy” about this. We have to avoid espousingpopular

and trendy causes too quickly in the absence of data.

We have to watch out for the cereal manufacturers

who like to pick up on every announcement of a

potential dietary manipulation to avoid a chronic

illness of aging and flash it across their cereal

advertisements.

However, if we learn more, I believe there is some

precedent for hopeful outcomes even in situations

where one might not have thought them probable.

I will give you two examples. Recent studies have

,demonstrated that even for older smokers, at least over

&eageof65, smokingcessation candecreasemorbidity

~ and, translating that term, improve health (7,8).

.” An interesting study a few years ago in patients

‘ with lung cancer also demonstrated that even for

patients undergoing treatment for lung cancer, smoking cessation was able to increase response to treatment, and survival. Even when it would seem that the

horse is out of the barn, sometimes we have been

premature in making that conclusion. Isuggest that we

need to continue to look at the information that will tell

us where the appropriate emphasis is to be placed on

health promotion and disease prevention.

If we can truly identify the risk factors for these

chronic illnesses, perhaps we maybe able to begin to

8

modify them and create a more healthy elderly population. In a sense, this is the same concept as that of

“successful aging,” which in 1974, adecade prior to its

more recent popularization as a phrase and as aproject

of the MacArthur Foundation, was a title of a monograph and conference at the Duke Aging Center (9).

In that conference a number of speakers-George

Maddox, Bernice Neugarten, and many others—

wrestled with some of these same concepts: What is

success in aging to be? One of the conclusions wasthat

success in this context is largely in the eye of the

beholder, that everything is relative.

My grandmother provided some insight for me in

this area as well a number of years ago. I had talked

with her while she was living in Miami Beach when

she was 78, and I asked her if she went out on the

boardwalk much. She replied, “Nab. Who wants to sit

around with those old people?” Her concept of a

healthy older age was clearly a little different from the

“old” people out on the boardwalk.

I look forward to hearing how many of you propose to measure avarietyof aspects of health. Isuspect

that there will be some lively discussions, but hope

that we will all learn a great deal from each other and

that we can help set an agenda for this most worthwhile

goal of seeking ways to help our elderly, as the U.S.

Army recruiting posters would suggest, “Be all that

they and we can be.”

References

1.

2.

3.

4.

5.

BusseEW, MaddoxGL.The Dukelongitudinalstudies of normal aging, 1955–1980.New York:Springer

Publishing. 1985.

FillenbaumGG.Multidimensionalassessmentofolder

adults, Hillsdale, New Jersey: Erlbaum Associates.

1988.

BeckerPM,CohenHJ.The fictional approachto the

care of the elderly. A conceptual framework.J Am

Geriatr Soc 32(12):923-9. 1984,

Becker PM, McVey LJ, Saltz CC, et al, Hospitalacquired complications in a randomized controlled

clinical trial of a geriatric consultation team. JAMA

257:2313-7.1987.

McVey LJ, Becker PM, Sakz, CC, et al. Effect of a

geriatric consultation team on functional status of

elderlyhospitalizedpatients. Ann InternMed 110(1):

79-84.1989.
6. Manton K. Planning long-term care for heterogeneous older men and women with coronary artery disease.

older populations, Annu Rev Gerontol Geriatr 8(8): N Engl J Med 319(21):1365–9. 1988.

217-55.1988. 9. PfeifferE, ed. Successful aging. Durham, North Caro7, PathakDR, Samet JM, HumbelCG, SkipperBJ. Deter- lina: Center for the Study of Aging and Human Develminants oflung cancerriskincigarette smokers inNew opment. 1974.

Mexico, J Natl Cancer Inst 76:597–604. 1986,

8. Hermanson B, Omenn G, Kronmal R, Gersh B.

Beneficial six-year outcome of smoking cessation in
Part II

Comparing

cardiovascular and

cancer statistics
Introduction

by Harry M. Rosenberg, Ph.D., Chief, Mortality

Statistics Branch, National Center for Health

Statistics

It is a great pleasure and honor to be at this

Symposium on Aging. The topic that Iamdealing with

is the international comparability of diagnostic statistics, with emphasis on cardiovascular disease and

cancer. I would like to acknowledge my collaboration

on this topic with Dr. Tamara Harris, who is also one

of the organizers of the Symposium. Dr. Harris is a

Medical Officer in the Office of Analysis and Epidemiology at the National Center for Health Statistics.

We are going to concern ourselves in our workshop sessions with an overarching issue that touches

the substantive focuses of the Symposium overall:

That is, the comparability of diagnostic statistics, with

a particular emphasis on comparing diagnoses for the

elderly population. Issues affecting the comparability

of diagnoses area problem not only for information on

causes of death but also for medical conditions representing the morbidity of the population.

Proper interpretation of international differences

in both morbidity and mortality patterns requires understanding the comparability of health data among

countries. For example, reported differences in life

expectancy among countries may be real, or they may

be artifacts reflecting differences in definition or in

vital registration practices. Again, reported differences among countries in the age curve of death from

cancer may be real or may instead reflect differences

in the way in which physicians report neoplasms on

the death certificate or differences in processing the

information on the death certificate, such as the application of international rules in selecting the underlying cause of death. Again, international differences in

the prevalence of chronic respiratory problems such as

emphysema, bronchitis, chronic obstructive pulmonary disease, or coronary heart disease may represent

true and important geographic variation or they may

reflect, in large measure, differences in patterns in

health services utilization, diagnostic techniques,

definitions, terminologies, or data processing.

Clearly, a variety of terminologies and measurement issues bear importantly on international

comparisons of the health status of the elderly population. Considerable work has been done and continues to be done on the comparability of medical coding

of the cause of death, led by the World Health Organization (WHO) and implemented in WHO and in

many individual countries. Additional work is needed

that focuses more attention on comparative data and

measurement techniques. A number of initiatives are

under way.

This International Collaborative Effort on Aging,

the ICE Age, provides a forum in which information

on comparability of diagnostic information can be

investigated by identifying various aspects of the

area, including measurement techniques for establishing diagnoses, cause-of-death validation studies,

and possibly use of autopsy, clinical, and survey

information to establish the reliability and validity of

cause-of-death information on the death certificate.

Our long-term goal is to develop a research proposal that can explore some of these issues, using

existing data bases and knowledge. The specific diagnoses for which comparability will be explored will

dovetail to some extent with other ICE projects, with

particular emphasis on cardiovascular diseases and

cancer. Initial research efforts may focus on a specific

age group, such as the population 65–74 years of age,

with a view to ascertaining if the problems of the old

old are but an extension of those in the younger

population or if, instead, they represent an entirely

different set of issues.

13
Chapter 3

Morbidity and mortality

information on old age:

Comments on availability,

validity, and comparability

by Thomas Strasser, M.D., Ph.D., World

Hypertension League and Department of

Social and Preventive Medicine, University of

Geneva

Introduction

Although the title of the present session refers to

comparisons of statistics, I would prefer to comment

in more general terms on both available and desirable

information on cardiovascular morbidity and mortality in the elderly from the international point of view.

Available information on international validity and

comparability, referring specflcally to this topic, is

scarce (1), However, by taking a wider look at the

problem, by reviewing the various possible sources

that may yield data on the elderly, we may arrive at a

composite and perhaps consistent picture, and eventually come to certain conclusions that might be of some

use to the present International Collaborative Effort

on Aging.

There are three main sources of such information:

(a) cause- and age-specific mortality statistics; (b)

epidemiological studies-moreprecisely, cornmunityorpopulation-based surveys anddiseaseregisters; and

(c) anatomo-clinical comparisons.

Mortality statistics

It can be assumed apriori that the validity of nonmedically certified causes of death is too limited to

take such information into account. In 1989, out of

more than 150 member countries of the World Health

Organization (WHO), 35 countries reported that 96-

100percent of deaths were medically certified (2).

Thisexcludesfmm ourconsiderationsmost, although

not all, developing countries: For example, medically

certified mortality information has become available

from parts of China recently, covering about 10 percent of the total population of the country (2).

The question is, how valid, and thus how comparable, are statistics derived from medically certified

death records in various countries. More precisely,

how well is the validity of mortality statistics established in general, and what information is available on

the validity of cause-of-death statistics in the older as

compared with the younger age groups.

The Unit for Global Epidemiological Surveillance and Health Situation Assessment of WHO recently started a Cause of Death Validation Program

(3). This program consists of four parts: Consistency

checks, surveilhmce, coverage and quality checks,

and time-series checks. The program is geared neither

toward cardiovascular diseases nor toward older age

groups but could easily beexpandedtothese problems.

Consistency warnings could be issued for highly improbable conditions in the elderly, such as death coded

as due to acute rheumatic fever or, for that matter, to

congenital heart disease in the oldest age groups.

While surveillance concerns infectious diseases, coverage checks could be introduced specifically with

regard to old age, such as too low rates for pulmonary

embolism, known to be a major cause of death in the

elderly. By the same token, time-series checks could

be useful for producing warnings on deviations from

established trends in changing age-related mortality

patterns.

WHO’s International Classification of Diseases

and Causes of Death promulgates worldwide uniform

coding of the causes of death (4). Yetin the field much

depends on how coders interpret the rules. Moriyama,

one of the most prominent experts in this field, recently

15
commented on the complexities of measurement of

accuracy of cause-of-death statistics: “Although the

notion of the underlying cause of death appears to be

fairly simple and straightforward, the actual determination of the underlying cause-sequence may be

difficult in practice where a number of diseases and

conditions are involved in the death”(5). This applies

most pertinently to old age, with its well-known

polypathology.

So, how do we assess validity? One way is to have

a panel “blindly” recode a sample of death certificates

on the basis of all available clinical information and to

compare the thus-established “reference causes of

death” with those recorded on the death certMcates. In

this way a “detection rate” and a “confmation rate”

can be calculated. The f~st gives information on

missed diagnoses or false negatives, as in the corresponding epidemiological concept of sensitivity. The

second provides information on the proportion of false

positives, an analogy to the notion of specificity in

epidemiology.

As an example, a recent study from Spain (6)

gives insight into the degree of concordance of underlying causes of death as recorded on the certificates

and as assessed by a panel of internists. On a total of

1,454 cases, there was an overall concordance of

around 80 percent of the certificates. For cardiovascular diseases, the detection rate was 88 percen~ the

confutation rate, 80 percent. These figures are

within the ranges observed earlier in some other

countries (Sweden, United Kingdom, United States)

and indicate an acceptable level of validity and of

international comparability. It may be of interest to

mention that the greatest proportions of miscodings

pertained to respiratory and circulatory diseases,

both for false positives and for false negatives; circulatory diseases were often coded as respiratory

disease and vice versa.

How relevant are such findings to statistics for

the elderly? Because the majority of cardiovascular

deaths occur in elderly people, even in the absence of

age-specific information, it should be surmised that

such findings largely reflect the situation of the

elderly (provided that, in developed countries, no age

limits for review of death certificates are set). The absolute numbers of autopsies are greatest in the elderly,

even if the proportion of autopsies of persons over

65 years of age is low in most countries. It can be

assumed that validity checks on general mortality,

and on cardiovascular deaths in particular, reflect

mortality over 60 or 65 years of age reasonably well

within the limits of the methods applied.

Epidemiological studies

The second possible source of information on

morbidity is epidemiological studies, both population

surveys and population-based registries. Population

surveys could yield valuable information on cardiovascular health variables in the elderly, such as blood

pressure distributions; they could but frequently do

not, because many epidemiological studies stop at

age 64, e.g., (7–9). Since the beginnings of cardiovascular epidemiology, older age groups were “orphan

categories.” The historical reasons of this fact can be

understood. However, it cannot be justified if epidemiological surveys started recently still ignore the

need for more and better information on the elderly.

Demographers showed decades ago that the problem

is with us. Omitting the elderly from epidemiological

surveys is ostrich policy.

This applies particularly to international comparative epidemiological projects, such as the Multinational Monitoring of Trends and Determinants in

Cardiovascular Diseases (MONICA) Study (9),

in which an upper age limit of 64 years was established—as if the bulk of cardiovascular morbidity

and mortality were not occurring past that age.

The opportunity of obtaining comparable cardiovascular information on the elderly of some 40

populations has thus been missed. The lesson for

epidemiological surveys to come is clear: The elderly

must not be ignored.

Similar considerations apply to a number of community-based disease registers. The European Myocardial Infarction Registration Project, which in the

1970’s yielded valuable comparative data on incidence rates of myocardial infarction in some 20 European centers, also stopped at age 64. Nevertheless,

this study showed a good correlation between registered incidence rates of myocardial infarction in the

studied communities and nationwide myocardial infarction mortality rates, thus validating indirectly the

16
information on this disease obtained from the ofilcial

vital statistics,atleastforthe age group 55-64 years(10).

Acooperative,multicenterstrokeregistration study

coordinated by WHO (11),on the other hand, included

men and women of all ages from 17communities in 13

countries in Europe, Africa, and Asia. A common

operating protocol was strictly observed, and the results were comparable. Geographical differences in

the incidence of stroke were moderate. In the ongoing

MOMCA Study (9), stroke is being registered in 21

centers out of a total of51, the others registering only

myocardial infarction. However, in only 12 centers is

the age limit over 64 years-in most of the 12 it is 74

years and in only 3 centers is there no upper age limit

to registration. In view of the considerable qualitycontrol efforts in this project, the information will be

comparable.

Anatomo-clinical comparisons

In the hospital setting, systematical autopsies are

the classical, and still best, means of validating clinical diagnosis. One should not, of course, extrapolate

from selected hospital populations to deaths and death

certification in the field. Still, the information from

hospital-based autopsy studies can be useful, because

the validity of cause-of-death information is unlikely

to be better in the field than in the hospital.

Autopsy rates have been declining steadily over

the past decades (12). In the elderly population of the

United States, for instance, the average rate of autopsy

is less than 8 percent (13). The most accurately diagnosed condition was found to be cerebrovascular

accident, with a 92-percent ante mortem accuracy

rate; the highest error rate was due to underdiagnosis

of pulmonary embolism, with a 39-percent ante

mortem accuracy rate. In data similar to these from

U.S. hospitals, findings from Belgrade, Yugoslavia,

indicate the highest diagnostic accuracy for cases of

stroke (87 percent). For myocardial infarction, the

accuracy rate was 76 percent, but again many cases of

pulmonary embolism were misdiagnosed as myocardial infarction (14).

On what does the validity of clinical diagnoses

depend? Battle et al. (15) analyzed factors influencing

discrepancies between ante mortem and post mortem

diagnoses in a study of 2,067 autopsies collected from

32 university and community hospitals of various

sizes located throughout the United States. Age was

such a factor. In adolescents and young adults, the

discrepancy rates were around 20percent. At ages 50-

59 years, the rate was 35 percenq it was nearly 40

percent in the group ages 60-69 years and rose to 50

percent for those 90 years of age and over. Incidentally, pulmonary embolism, among all causes, had the

highest discrepancy rate in this study, 47 percent. In

myocardial infarction, the discrepancy rate was 28

percent. There was little uncertainty about stroke.

Thus, the second factor influencing diagnosis validity

was the disease category itself.

The third factor was the type and size of hospital.

University hospitals had better results than community hospitals; bigger hospitals were better than smaller

ones. In all likelihood, the higher the level of services,

the better the diagnoses. Better medicine obviously

yields better diagnoses.

Discussion

Vital statistics from countries where deaths are

medically certified are useful, despite their moderate

general reliability. Validation procedures could, and

should, be complemented with special considerations

targeted at deaths in old age. Validation procedures of

samples of death certificates play a useful role, too. It

is conceivable to apply the type of exercise described

in the example of Valencia, Spain, in an international

effort by sampling cases from multiple countries and

having the death certificates reexamined by an international board of experts.

Another, more innovative approach is automation

of the coding process. As a matter of fact, a system of

Automated Classit3cationof MedicalEntities (ACME)

was introduced in the United States in 1968, applied to

the International Classification of Diseases, Eighth

Revision (ICD-8). The system was used to process

almost 2 million records per year during the currency

of ICD–8 and was converted to ICD–9 for the coding

of death records as of 1979 (16). The performance of

ACME was remarkable: Only 3 percent of cases were

referred for nosological review, and coding achieved

an accuracy of 99.5 percent.

17
More recently, the MICAR system (Mortality

Medical Indexing, Classification and Retrieval) was

introduced. This automated system internally performs ICD multiple-cause coding from basic information. MICAR is not yet operative, but ACME is being

used in the United States and Brazil. (It has been tried

also in the United Kingdom but has been abandoned.)

Despite the logistic difficulties, it maybe possible to

apply this system more generally. This would solve

the problem of uniformity in interpreting underlying

causes of death. Naturally, good-quality grassroots

information remains a prerequisite.

From the epidemiologist’s point of view, it becomesimperative to include old people in health surveys

and disease registers, provided that classical registers

still have a future. It is conceivable that in the not-toodistant future comprehensive morbidity information

systemscould be established by an electronic, computerto-computer mailing system. Again, innovative approaches are needed if long-term efforts are being

planned By the same token, and much more easily,

collection of autopsy versus clinical information could

be processed by establishing nationwide electronic

mailing networks in technically advanced countries.

How does all this relate to the validity and comparability of cardiovascular statistics in old age? Itis my

fm conviction that, in order to assess and upgrade

cardiovascular statistics in the elderly, a systemic

approach will yield, in the long run, better results than

partial, fragmented action aimed specifically at the

cardiovascular system of elderly persons. Better and

more valid health statistics at all ages will result in

more reliable information on the elderly as well.

Prerequisites are good-quality medicine and comprehensive epidemiology.

Conclusions

Valid and comparable information on cardiovascular morbidity and mortality in old age is scarce. The

main sources of such information are national vital

statistics, epidemiological surveys and registers, and

comparisons between clinical diagnoses and autopsies. The uses of these sources could be improved by

paying more attention to older age groups, for example, by the introduction of consistency checks of

mortality statistics relevant to old age and the inclusion of elderly subjects in epiderniological studies.

In general, there is need for innovative approaches,

Though fraught with special problems, information on

cardiovascular morbidity and mortality in the elderly

is only part of the problem of quality of health information in general. Overall efforts to upgrade health

information also should improve knowledge about the

elderly population, provided due attention is paid to

them.

References

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

World Health Organization. The uses of epidemiology

in the study of the elderly. Technical reportseriesno

706. Geneva: World Health Organization. 19i39.

World Health Organization. World health statistics

annual 1989. Geneva: World Health Organization.

1990.

Lopez AD. World Health Organization. Personal

communication.

World Health Organization. Manual of the International Statistical Classification of Diseases, Injuries,

and Causes of Death, based on the recommendations

of the Ninth Revision Conference, 1975. Geneva:

World HealthOrganization. 1977.

Moriyama IM. Problems in measurement of accuracy

of cause-of-death statistics. Am J Public Health

79:1349–50. 1989.

Benavides FG, Boh.unar F, Pens R, Quality of death

certificates in Valencia, Spain. Am J Public Health

79:13524.1989.

Shaper AG, Pocock SJ, Walker M, et al. British

regional heart study: Cardiovascular risk factors in

middle-aged men in 24 towns. Br Med J 283:179-86.

1981.

National Heart Foundation of Australia. Risk factor

prevalence study. Report no 2, 1983.

Multinational Monitoring of Trends and Determinants

in Cardiovascular Diseases (MONICA) project principal investigators, prepared by Pedoe HT. The World

Health Organization MONICA ProjecE A major international collaboration, J ClinEpidemio141 (2): 105-

14.1988.

World Health Organization. Myocardial Infarction

Community Registers, Public health in Europe, 5,

Copenhagen Regional OfticeforEurope, World Health

Organization. 1977.

18
110

12.

13.

14.

Aho K, Harmien P, Hatano S, et al. Cerebrovascular disease in the community: Results of a

WHO Collaborative Study. Bull WHO 58(l):

113-30.1980.

Scottolini A, Weinstein SR. The autopsy in clinical

control. JAMA 250:1192-4.1983.

Gross JS. Neufeld RR, Libow LS, et al. Autopsy study

of the elderly institutionalized patient, Arch Intern

Med 148:173-6.1988.

Stevanovic G, Tucakovic G, Dotlic R, Kanjuh V.

Correlation of clinical diagnoses with autopsy findings: A retrospective studyof2145 consecutive autopsies. Hum Pathol 12:1225–30. 1986.

15. Battle RM, Pathar D, Humble CG, et al. Factors influencing discrepancies between premortem and postmortem diagnoses. JAMA 258:33%14. 1987.

16. L’Hours ACP. Encoding of health problems expressed

in natural language: Some experiences, using the International Classification of Diseases, Im ScherrerJR,

C&&RA,Mandil SH, eds. Computerized natural medical language processing for knowledge representation.

Amsterdam: North-Holland. 1989.

19
Chapter 4

Validity of diagnosis

cancer in the elderly

by C.S. Muir, M.B., Ph.D., Deputy Director,

International Agency for Research on Cancer

Introduction

In simplistic termstheconquestofinfectious disease

in much of the world has resulted in a fall in infant

mortality, an increase in the average age ofpopulations,

and hence an increasing proportion of elderly persons.

As the strongest risk factor for malignant disease is

age, it is axiomatic that, other things being equal, the

numbers of people with cancer to be diagnosed and

treated will grow.

Rationalplanningof health services demands sound

statistics of the impact of cancer on the elderly, here

defined as persons over the age of 65 years. Sound

statistics require that cancer be accurately diagnosed

and recorded. This paper examines the validity of the

diagnosis of cancer in older persons.

Data available

The two main sources of information on cancer in

a population are mortality (derived from death certificates) and incidence (collectedly cancerregistries).

Although mortality information is more widely

available (figure 1), this source is generally acknowledged to be less precise than incidence, practically never indicating the basis on which cancer was

diagnosed. (In some countries, the death certificate

may indicate whether an autopsy was performed.)

Further, given thevaryinglethalityof different cancers,

death rates give an incomplete picture of the cancer

burden. This paper thus deals with incidencedataonly.

The editors of successive volumes of CancerIncidence in Five Continents (1) have requested contributing cancer registries to provide data on (a) the

proportion of diagnoses reported to the registry with

histological verification of diagnosis (HV), (b) the

proportion of cases registered for which the existence

of a cancer was known from a statement on a death

certificate only (DCO), (c) the proportion ofregistered

cases whose age was not known, and (d) the ratio of

mortality to incidence. Volume V of Cancer Incidence inFive Continents(1) presents such data for all

ages, O-34 years, 35-64 years, 65–74 years, and 75

years and over. For Volume V, many contributors

provided this information by5-year age group up to 95

years of age and over. These unpublished data have

been further analyzed and are presented below for

selectedtyperegisrnes, being supplemented bymaterial

from the Surveillance, Epidemiology, andEndResults

(SEER) registries of the United States, the collection

of which is coordinated by the National Cancer Institute (2) of the National Institutes of Health.

When examining these indexes (3), it should be

borne in mind that the proportion of diagnoses with

histological verification (W percent) may vary by

site as other reliable methods of diagnosis exist, e.g.,

radiology for cancer of the esophagus and serum

alpha-fetoprotein for hepatocellular cancer. DCO

percent, i.e., the proportion of all notifications for

which the only underlying information available to the

cancer registry was a statement on a death certificate

that a deceased person had cancer, is usually less than

1 in 20 notifications in most registries for all ages

combined. Higher values indicate that the registration

process is incomplete or that the quality of death

certification is poor. By definition, a person with

cancer diagnosed microscopically cannot be in the

DCO category (but see below). The relationship between mortality and incidence (M-I) for a given cancer

in the registration area at a particular time varies

substantially from site to site, being close to unity for

rapidly fatal forms of malignancy such as those of the

stomach, lung, and esophagus and very low for

21
World (4,453)

Developed countries (1,134)

Developing countries (3,317)

fn

c

o Africa (476) .-

-

E

.-c

C Latin America (362)

.-o

3

~

0

Q. North America (252)

m

c

m

~

Asia (2,591)

a

Europe (484)

Oceania (23)

Union of Soviet Socialist

Republics (265)

o 20 40 60 80 10C

Percent

—

Figure 1. Percent of cancer mortality and incidence data available, by United Nations area and

population: Circa 1980

nonmelanoma skin cancer. For a given cancer site, the

ratio is likely to vary from center to center according

to results of treatment and possibly the definition of

what constitutes a cancer. The proportion of notifications of unknown age is usually very low other than for

nonmelanoma skin cancer.

Results

Table A contains data for selected sites of cancer by

age and sex for the SEER registries. Although the

proportion of histological verification at ages 65-69

years and 70-74 years is much the same for the sites

listed, after 75 years there is a gradual diminution in

the proportion with HV, a rise in the proportion

22

. . . . . . . . . .

diagnosed on clinical grounds, and an increasem the

proportion registered on the basis of a death certificate

only.

Table B compares HV percent, DCOpercent, and

the M-I ratios for males in Connecticut and in Miyagi

Prefecture in Japan for gastric cancer. The proportion

with HV is substantially higher at any age in Connecticut and the proportion registered on the basis of

DCO very low, whereas in the age group 85years and

over, over half of the cases in the Miyagi cancer

registry had not been reported to the registry before

death. As noted above, a DCO case cannot, by definition, have histological verification of diagnosis.

Nonetheless, when the M-I ratios are compared up to

the age of 79 years, these ratios are remarkably similar
Table A. Percent distribution of cancer diagnoses by mode of diagnosis, according to age, cancer site, and

sex, as reported in Surveiiiance, Epidemiology, and End Resuits (SEER) registries: United States, 1983-86

Site of

cancer 65-69 years 70-74 years 75-79 years 80-84 years 85 years and over

and sex HV A C DCO HV A C DCO HV A C DCO HV A C DCO HV A C DCO

Totai Percent distribution

Maie , . ..95.5 0.9 2.6 0.9 94.0 1.0 1.9 0.8 91.6 1.2 5.6 1.1 87.4 1.3 8.8 1.9 79.2 1.7 14.5 3.7

Female . . 96.6 0.3 2.2 0.6 94.6 0.4 3.7 1.0 92.3 0.6 5.3 1.4 87.2 0.7 9.4 2.2 76.6 0.7 16.7 4.9

Esophagus

Male . . . . 97.5 0.2 1.6 0.2 93.9 0.5 4.3 0.5 92.5 1.6 4.0 2.0 91.8 0.8 5.2 1.5 80.6 1.0 15.3 3.1

Female .. 98.8 --- --- 0.6 95.6 0.6 1.9 1.2 92.7 0.7 2.9 3.7 93.0 --- 7.5 3.5 79.1 --- 16.3 4.7

Stomach

Male .,.. 97.6 0.4 0.9 0.9 96.5 1.0 1.0 1.0 94.5 0.6 3.9 0.5 92.8 1.2 4.0 1.4 84.6 1.3 11.2 2.4

Female .. 98.5 --- --- 0.5 94.4 0.4 3.3 2.0 92.8 0.6 4.2 2.0 90.0 1.6 7.5 0.7 70.9 1.8 20.4 5.7

Liver

Male . . . . 73.9 5.1 17.1 2.3 72.5 8.213.0 4.8 71.5 7.816.8 3.4 69.0 6.0 18.1 6.9 58.6 8.6 20.710.3

Femaie . . 81.1 2.1 12.6 4.2 76.7 1.913.6 4.9 71.1 4.418.9 5.6 72.6 5.5 19.2 2.7 52.9 2.9 25.711.4

Pancreas

Male . . . . 80.5 1.714.3 2.2 77.8 1.717.7 1.8 69.9 2.023.6 3.3 54.6 1.2 39.8 3.6 43.1 1.5 45.2 7.5

Femaie . . 83.4 1.1 13.8 1.1 77.3 0.919.2 1.9 69.7 1.024.5 4.1 57.7 1.1 36.7 3.9 34.7 1.7 55.5 6.8

Lung

Male . . . . 93.8 0.9 3.8 1.0 91.3 1.0 6.2 1.1 86.8 1.4 9.4 1.9 77.1 1.0 18.1 3.1 58.5 2.0 31.8 6.8

Female . . 93.3 0.7 4.3 1.1 90.8 0.8 6.2 1.7 85.6 1.1 10.6 2.0 70.3 2.0 23.7 3.5 54.8 1.3 32.9 4.1

Breast

Femaie .. 99.3 --- 0.4 0.2 98.3 0.1 1.0 0.5 97.5 0.1 1.5 0.7 94.7 0.2 3.6 1.5 85.8 0.1 9.4 8.9

Prostate

Male ... , 97.5 1.4 0.9 0.2 97.1 1.4 1.2 0.2 95.2 1.4 2.5 0.5 92.2 1.8 4.6 0.9 83.6 2.6 10.6 2.4

Brain

Male . . . . 90.2 0.3 8,3 009 82.1 --- 14.9 3,1 69.9 2.928.3 1,7 56.1 --- 36.6 6.1 42.9 --- 47.6 7.1

Female .. 83.3 --- 15,7 0.4 80.5 --- 17.5 1.6 71.4 0.522.9 3.7 44.1 2.5 46.9 5.9 35.3 --- 52.9 5.9

NOTE: Totals are less than 100 percent due to small numbers of cases diagnosed in hospital for which the record did not indicate

whether diagnosis was histologically confirmed. HV is histological verification, A is diagnosed at autopsy, C is clinical diagnosis only,

DCO is known from death certificate oniy.

SOURCE: Basic data were provided by V, Van Hoiten and C. Percy of the U.S. National Cancer Institute.

in both areas, suggesting that despite the high level of

DCO, most cases in Japan were in fact recognized

although not reported to the cancer registry before

death. Fujimoto and Hanai (4) discuss the reasons for

thevery highproportion of DCO cases inregistries in

Japan and demonstrate that in Osaka Prefecture, when

a special effort was made to follow up DCO cases, the

diagnosis proved to be highly reliable. Of 345 such

DCO notifications, 7.2 percent had been diagnosed at

autopsy, 37,1 percent had HV of diagnosis, 10.4

percent cytology, 19.4 percent radiology, and 10.2

percent ultrasound or other tests.

Comparison in the same table of similar data for

males in the German Democratic Republic reveals a

very low percentage of DCO and a somewhat greater

proportion with HV of diagnosis than in Japan, which

should indicate more reliable data than in Japan. Yet

in the older age groups in the German Democratic

Republic, more deaths were stated to be due to gastric

cancer than there were incident cases, reflecting either

underregistration or poor death certification.

The overall proportions of HV in male Japanese in

Miyagi and’in Los Angeles were 67 percent and 95

percent, respechvely. The overall M-Iratios were 0.67

23
Table B. Percent of males diagnosed with gastric cancer, by age, mode of diagnosis, and ratio of mortality to

incidence: Connecticut, Miyagi, Japan, and German Democratic Republic, 1978-82

Area and o-34 35-64 65-69 70-74 75–79 80-84 85 years

item All ages years years years years years years and over

Connecticutt

HV percent . . . . 93

DCO percent ., . 1

M-l ratio . . . . . . 66

Miyagi, Japan

HV percent . . . . 75

DCO percent . . . 14

M-l ratio . . . . . . 59

German Democratic

Republic

HV percent . . . . 77

DCO percent . . . 1

M-l ratio . . . . . . 91

100.00

0.8;

89.90

5.10

0.46

97.90

0.7;

98.30

1.10

0.59

85.30

6.80

0.47

89.00

0.10

0.80

94.30

1.70

0.66

78.60

11.00

0.62

82.30

0.30

0.88

96.20

0.65

69.20

18.40

0.70

75.80

0.70

0.92

92.20

1.50

0.80

50.00

29.90

0.82

68.10

1.00

1.01

88.80

2.00

0.70

30.80

41.40

0.91

58.70

2.10

1.05

70.20

4.80

0.75

217.30

259.70

20,98

255,10

20,80

21.40

IData are for white males.

2Data available for age groups up to 95 years of age and over.

NOTE: HV percent is percent histologically verified, DCO percent is percent known from death certificate only, M-1ratio is ratio of

mortality to incidence.

SOURCE: Muir CS, Waterhouse J, Mack T, et al., eds. Cancer incidence in five czmtinents, VOIV. International Agency for Research

on Cancer scientific publications no 88. Lyon, France: International Agency for Research on Cancer. 1987.

and 0.60, nxpectivel~ i.e., survival appeared to be

slightly better in Japanese living in Los Angeles. Comparison of these indicators of data quality by sex

showed that females in Miyagi also had a much lower

proportion of HV, 69 percent compared with 96 percent in Los Angeles; a much higher proportion of

DCO only, 15 percent compared with 2 percent and

somewhat poorer survival, the M-I ratios being 0.60

and 0.43. Comparing male lung cancer and female

breast cancer in Connecticut and Miyagi (table C),

survival at any age tendsto be slightly ktterin Connecticut than Miyagi for lung cancer, the M-I ratios being

0.78 and 0.83, respectively. For breast cancer, the

M-Iratios were 0.34 and 0.25, findings in consonance

with observed survival for white persons and Japanese

in the SEER program (5). The consistency of these

data suggests that, despite the lower proportion with

HV in Japan, the diagnosis was reasonably reliable.

Table C. Ratio of mortality to incidence for male lung cancer and female breast cancer, by age: Connecticut

and Miyagi, Japan, 1978-82

Site of cancer o-34 35-64 6569 70-74 75-79 80-84 85 years

and area All ages years years years years years years and over

Lungl Ratio

Connecticut . . . . . 0.78 0.65 0.72 0.76 0.83 0.84 0.92 0.92

Miyagi, Japan . . . 0.83 0.86 0.72 0.86 0.82 0.92 0.99 31.00

Breast2

Connecticut . . . . . 0.34 0.15 0.31 0.36 0.36 0.38 0.44 0.50

Miyagi, Japan . . . 0.25 0.17 0.24 0.28 0.28 0.63 0.41 30.50

‘Data are for males.

‘Data are for females.

3Data available for age groups up to 95 years of age and over.

SOURCE: Muir CS, Waterhouse J, Mack T, et al., eds. Cancer incidence in five continents, VOIV. International Agency for

Research on Cancer scientific publications no 88. Lyon, France: International Agency for Research on Cancer. 1987.

24
Discussion

Indexes of reliability

While the indexes ofreliability are useful guides to

data quality, they cannot be used without some knowledge of local circumstances. A high proportion of HV

may reflect complete reporting by pathologists and

lesser degrees of reporting by other sources. A low

proportion of HV may reflect inadequate provision of

pathologists, a high proportion of cancer that can be

diagnosed by othermeans, failure to notify the registry

that biopsy and/or autopsy were performed, or an

unwillingness to investigate elderly persons exhaustively. A high proportion of DCO may, asin Japan, reflect the inability of cancer registration systems to link

hospital records with death certificates. The M-I ratio

maybedistortedbypoororimprecisedeath certification;

for example, there are usually more deaths attributed

to unspecified leukemias than there are incident cases,

as the more precise data on cell type available to the

clinician and cancer registry do not appear on the

death certificate. Similarly, a neoplasm reported to a

cancer registry as arising in the rectum may appear as

cancer of the large bowel on a death certificate and,

following current coding rules, be classified with

cancer of the colon (see also (6)). The mechanical

application of these indexes can be misleading—all

available information has to be taken into account.

Use of cumulative rate

Believing that the detection and diagnosis of cancer were optimal for ages 35-64 years, Doll and Cook

(7)introducedtheTruncatedStandardizedRate (TSR)

for the comparison of international incidence and

mortality data. Yet in many populations the cumulativerate (8)forcancerforages 65–74 years is about the

same as that for ages birth to 64 years (table D and

figures 2-6), and that for ages 75–84 years is likely to

be substantially larger, although based on smaller

numbers of persons. The TSR, in effect, “writes off”

older persons.

Treatment of cancer in elderly persons

The precision of cancer diagnosis may depend on

the attitude of physicians toward treatment of older

persons. If treatment is not contemplated, investigation is likely to be less thorough. While there is no

reason why the elderly person with cancer should not

be treated as energetically as those who are younger

(and indeed, astheneoplasmsoften growmoreslowly,

with success), physicians are often reluctant to submit

elderly patients to the discomfort of invasive diagnostic procedures and aggressive therapy. It is probable

that in several cultures permission to do so would be

refused. Such considerations may be at least in part

responsible for the large differences among selected

areas seen around 1980 in the indexes of data reliability

Table D.Cumulative incidence rate for severai common cancers, by site of cancer, age, and area: Seiected

areas, circa 1980

Site of cancer

Stomach 1 Colon’ Lung 1 Breast 2 Prostate’

o-64 0-74 0-64 0-74 0-64 0-74 0-64 0-74 0-64 0-74

Area years years years years years years years years years years

Rate

Cal . . . . . . . . . . . . . . . 2.4 5.2 1.3 1.5 1.2 3.1 2.4 3.8 0.8 3.5

Detroit:

Black, ,,, . . . . . . . . . 0.9 2.0 1.3 3.5 7.4 14.0 4.5 3.0 11.1

White . . . . . . . . . . . . . 0.5 1.2 1.3 3.2 5.0 10.7 5.4 ::: 1.3 5.9

Shanghai . . . . . . . . . . . 3.0 7.4 0.5 1.0 2.7 7.3 1.5 2.1 0.0 0.2

Osaka . . . . . . . . . . . . . 3.4 9.1 0.6 1.4 4.5 1.6 2.1 0.1 0.5

Denmark . . . . . . . . . . . 0.6 1.6 2.2 ;:; 7.5 4.6 6.9 3.1

Warsaw . . . . . . . . . . . . 1.1 2.8 ?I:: 1.3 3.4 7.0 2.5 3.7 u 1.3

‘Data are for males.

‘Data are for females.

SOURCE: Muir CS, Waterhouse J, Mack T, et al., eds. Cancer incidence in five continents, VOIV. International Agency for

Research on Cancer scientific publications no 88. Lyon, France: International Agency for Research on Cancer. 1987.

25
Cali

Detroit:

Black

White

Shanghai

Osaka

Denmark

Warsaw , I 1

❑ O-64 years

m O-74 years

I

o 5 10 15 20

Percent

igure 2. Cumulative incidence rate for stomach cancer among males, by age: Selected areas, circa 1980

Detroit:

Black

White

❑ O-64 years

= O-74 years

Shanghai

Osaka

Denmark

Warsaw I I

o 5 10

Percent

‘igure 3. Cumulative incidence rate for colon cancer among males, by age: Selected areas, circa 1980

for persons 80-84 years (table E). The substantially

lower M-I ratios in North America (the United States

and Canada only) demand further study, as it is unlikely that standards of medical care are higher than in,

say, Geneva. For a proportion of the elderly, the

presence of concomitant cardiovascular, cardiorespiratory, or other disease may in effect rule out therapy

for the cancer. Nonetheless, results are often better

than might be imagined, although not as favorable as

in younger patients. This type of information is rarely

available but was published in 1980 by the Norwegian

Cancer Registry (9). Table F gives 5-year relative

survival for colon cancer by stage, sex, and age group.

26

Breast cancer survival data from the same source are

presented in table G. Given the accessibility of this

site, the quality of diagnosis, including staging, is

likely to be fairly uniform across ages. At any stage,

survival is poorer in the age group 75 years and ove~

at any age, stage at diagnosis is a more important

prognostic factor than age per se. The use of the

relative survival rate takes the effect of the weight of

other causes of death into account.

Unfortunately, in many countries it is not possible

to estimate cancer survival for the population as a

whole, as to do so requires three items of information:

Knowledge of all persons Withnewly diagnosed cancer,
Cali

Detroit:

Black

White

❑ O-64 years

M O-74 years

Shanghai

Osaka

DenmaA

Warsaw

o 5 10 15 20

Percent

Figure4. Cumulative incidence rate forlung cancer among males, byage: Selected areas, circa 1980

Cali

Detroit:

Black

White

Shanghai

Osaka

Denmark

Warsaw

❑ O-64 years

m O-74 years

o 5 10 15

Percent

Figure 5. Cumulative incidence rate for breast cancer among females, by age: Selected areas, circa 1980

their date of diagnosis, and their date of death. This

implies either national cancerregistration or, ifregistration covers only part of the country, the ability to

determinewhetherregisteredcancerpatients are alive

or dead, no matter where they happen to reside at the

time of death. Unfortunately,in severalWesternEuropean countries, considerations of so-called confidentiality prevent such matches being made. (The

WesternEuropean countriesreferred to in this paper

are Austria,Belgium,France, theFederalRepublicof

Germany,Luxembourg,The Netherlands, and Switzerland.) It must be stressed that the survival figures

emerging from controlled clinical trials are in no way

representative of the cancer survival of a given population, in that patients entered in these trials rightly are

highly selected so that valid comparisons can be made

between treatment regimens.

While there have been very substantial improvements in survival for Hodgkin’s disease, acute lymphocytic leukemia in childhood, choriocarcinoma,

and testis cancer, these rather uncommon forms of

malignancy are unusual in older persons. Survival for

.

27
Cali

Detroit:

Black

White

❑ O-64 years

= O-74 years

Shanghai ]

Osaka y

Denmark

Warsaw

I 1 I I I

I

o 5 10 15 20 25 30

Percent

‘igure 6. Cumulative incidence rate for prostate cancer among males, by age: Selected areas, circa 1980

Table E. Percent of persons 80-84 years of age with cancer, by mode of diagnosis, ratio of mortality to

incidence, and sex: Selected areas, circa 1980

Percent histologically Percent known from

verified death certificate only Mortality-incidence ratio

Area Male Female Male Female Male Female

North Americal . . . . . . . . . 80+ 80-1- 0.70 0.60

Shanghai . . . . . . . . . . . . . 20 15 5: 6; 0.96 0.57

Japan . . . . . . . . . . . . . . . . 40 30 40 45 0.93 0.93

Geneva . . . . . . . . . . . . . . 90 90 2 4 0.88 0,91

Scotland . . . . . . . . . . . . . . 60 11 14 0.81 0.78

Victoria, Australia . . . . . . . 70 % 8 9 0.84 0.93

‘United States and Canada only.

Table F. Rate of 5-year relative survival for persons

with colon cancer, by age, stage, and sex: Norway,

1968-75

0-54 55-74 75 years

Stage and sex years years and over

Localized Rate

Male . . . . . . . . . . . . .. O.77 0.69 0.60

Female . . . . . . . . . ...0.79 0.71 0.56

Regionai spread

Male . . . . . . . . . . . . .. O.48 0.42 0.35

Female . . . . . . . . . ...0.45 0.42 0.36

Distant spread

Male . . . . . . . . . . . ...0.05 0.04 0.08

Female . . . . . . . . . ...0.08 0.06 0.05

SOURCE: The Cancer Registry of Norway. Survival of cancer

patients: Cases diagnosed in Norway, 1968-1975. Oslo:

Norwegian Cancer Registry. 1980.

28

stomach, lung, and large bowel cancer has improved

very little over the past decades (10).

The world cancer burden

Parkin et al. (11) estimated the global cancer

burden around 1980 in terms of numbers of cases of

cancer. These estimates were based on incidence and

mortality data, when available, and on relative frequency, usually based on series of histologically

diagnosed cancers, for the very large parts of the

world without such data (figure 1). The top 10

ranking cancers are given in table H. It will be seen

from figures 7–10 that the cancer patterns are

quite different for the 4 of the 24 demographic

regions recognized by the United Nations (U.N.) that

are presented.

Not only are patterns different, but the degree of
Table G. Rate of 5-year relative survivai for persons with breast cancer, by stage and age: Norway, 1968-75

Age All cases Stage I Stage II Stage Ill Stage W

Number

Total cases, . . . . . . . . . . . . . . . ..l O.59l 4,743 3,305 772 912

Rate

Alleges . . . . . . . . . . . . . . . . . . . . . 0.67 0.86 0.58 0.46 0.12

O-44years . . . . . . . . . . . . . . . . . . 0.72 0.90 0.60 0.48 0.14

45-54 years . . . . . . . . . . . . . . . . . 0.71 0.89 0.62 0.47 0.16

55-74year8 . . . . . . . . . . . . . . . . . 0.65 0.86 0.56 0.48 0.12

75 years andover . . . . . . . . . . . . . 0.58 0.76 0.48 0.40 0.09

SOURCE:TheCancer RegistryofNorway. Survivalofcancer Patients:Casesdiagnosedin NorwaY,1968-1975. Oslo: Norwegian

CancerRegistry.1980.

Table H. Number and percent of the 10 most

frequent cancers woridwide, by sex and site

of cancer: 1980

Sex and site Number in

of cancer thousands Percent

Maie

1, Lung . . . . . . . . . . . . . . . . .

2. Stomach . . . . . . . . . . . . . .

3. Colon/rectum . . . . . . . . . .

4. Mouth/pharynx . . . . . . . . .

5. Prostate . . . . . . . . . . . . . .

6. Esophagus . . . . . . . . . . . .

7. Liver . . . . . . . . . . . . . . . . .

8. Bladder . . . . . . . . . . . . . . .

9. Lymphoma . . . . . . . . . . . .

10. Leukemia . . . . . . . . . . . . .

Female

1, Breast . . . . . . . . . . . . . . . .

2. Cervix . . . . . . . . . . . . . . . .

3. Coion/rectum . . . . . . . . . .

4. Stomach . . . . . . . . . . . . . .

5. Corpus uteri . . . . . . . . . . .

6. Lung . . . . . . . . . . . . . . . . .

7, Ova~ . . . . . . . . . . . . . . . .

8. Mouth/pharynx . . . . . . . . .

9. Esophagus . . . . . . . . . . . .

10. Lymphoma . . . . . . . . . . . .

513.6

408.8

286.2

257.3

235.8

202.1

171.7

167.7

139.9

106.9

572.1

465.6

285.9

260.6

148.8

146.9

137.6

121.2

108.2

98.0

15.8

12.6

8.8

7.9

7.3

H

5.2

4.3

3.3

18,4

15.0

9.2

8.4

4.8

4.7

4.4

U

3.2

SOURCE:Parkin DM, Laara E, Muir CS. Estimates of the

worldwide frequency of sixteen major cancers in 1980. Int J

Cancer 41:184-97.1988.

sophistication of medical services required to

diagnose these cancers varies considerably. Cancers

of the mouth andpharynx can be readily diagnosed

with fairly simple apparatus, as can those of the cervix;

cancers of the breast are also readily accessible. The

detection of prostate and ovary cancer and the accurate

diagnosis of lymphoma demand another level of

complexity and expertise, afurtherfactorto be considered when comparing data from different parts of the

world.

The effect of aging populations: The future

While somewhat outside the scope of this paper, it

is nonetheless sobering to examine what is likely to

happen in the future. The increasing average age of the

many populations means that, should present cancer

patterns and levels of risk be “frozen,” the total cancer

burden would nonetheless substantially increase. The

U.N. in 1986 (12) calculated that there would be a 15-

percentincreasein total population in southern Europe

between 1975and the year2000. Further, theproportion

of the male population over 60 years of age would

increase by 24 percen~ the female, by 27 percent, in

contrast to northern Europe, where population size

and age structure were considered to be virtually

stable. The ratio of the cancer burden in the year 2000

compared with that in 1975, assuming that the projected population rises and change in age structure

take place and taking into account likely secular trends

in cancer risk, has been assessed (13). While the

numbers of northern Europe wouId show little change,

there would be increases of 60-80 percent in eastern

and southern Europe, these increases being smaller,

although stillsubstantial (10-30 percent), in thewestern

part of that continent.

The World Health Organization (14) has recently

examined the impact of demographic trends on health,

publishing the median age for the world as awhole and

formajordemographic areas for the years 1950,1975,

and 1985, with projections for 2000 and 2025. This

29
All sites 100 percent

Male

Lung

Prostate

Colon and rectum

Bladder

Lymphatic

All sites

Breast

Colon and rectum

Lung

Corpus uteri

Lymphatic

00 percent

I I I I I I

o 100 200 300 400 500

Number in thousands

NOTE: North America includes the United States and Canada only.

Figure 7. Number and percent of cases of the 5 most frequent cancers, by sex and cancer site:

North America, 1980

figure is perhaps not asinformative as the dependency

ratio (defined as the number of persons under 15years

and of those 65 years and over, divided by the number

of persons aged 15-64 years and multiplied by 100),

which provides an indicator of the relative sizes of the

non-working-age and working-agepopulations. Noting

that at present two out of five persons in the world are

urban residents, the proportion of those living in cities

is projected to exceed 50 percent sometime during the

f~stdecadeof the21stcentwy. While this concentration

of the population should, in theory, make it easier for

the elderly in the population to have access to goodquality medical care, this is currently not so for many

megacities.

Changes in cancer risk

Changes in the risk of cancer in either direction are

often fust observed in younger age groups, as change

in exposures is frequently a reflection of changes in

the habits of a particular generation or birth cohort

(15,16). As most cancers are the result of lifelong

30

exposures, the risk of developing malignant disease

after the age of 65 (and it will be recalled that there are

normally as many cancers at ages 65–74 as there are

fi-ombirthto64) isprobablylargely already determined

on reaching the age of 65 and is frequently characteristic for a given birth cohort. Thus, successive birth

cohorts, on reaching, say, the age of 65 in many fairskinned populations, have higher age-specific incidence rates for malignant melanoma than those born

previously, rates that in turn are lower at the same age

in those born subsequently. While it would currently

appear very difficult to undo or reverse the cellular

damage already sustained on reaching older ages,

nonetheless, for the initiated cells to be transformed, it

is believed that prolonged exposure to promoting

agents is needed. If exposure to promoters can be

avoided orreduced (and, indeed, antipromoters given),

then the malignant transformation may not take place

or may be delayed. Although Berenblum (17) stated

that “interference with the promoting phase of

carcinogenesis would seem to offer the best prospects
Male

All sites 100

percent

Lung

Colon and rectum

Prostate

Stomach

Bladder

All sites ercent

Breast

Colon and rectum

Stomach

Corpus uteri

Cervix

1

0 100 200 300

Number in thousands

NOTE: Western Europe includes Austria, Belgium, France, the Federal Republic of Germany, Luxembourg, The Netherlands,

and Switzerland.

Figure 8. Number and percent of cases of the !5most frequent cancers, by sex and cancer site:

W&tern Europe, 1980-

for cancer prevention, if only because the promoting

phase covers most of the latent period ofcarcinogenesis

(which, in humans, maybe 30 years or more),” it is

only recently that extensive work, including search for

short-term tests of promoting activity, has begun on

this topic. It is currently believed that fresh fi-uitsand

vegetables may contain antipromoters, and their use

by elderly persons should be encouraged. Unfortunately, dietary habits are often set at a much younger

age, and it may not be easy to persuade older persons

of the need to change. In terms of lung cancer risk, it

is probable that ceasing to smoke would be helpful at

any age. The beneficial effect of small quantities of

alcohol need not be abandoned.

Comment

Even in the absence of change in cancer risk,

increasing longevity will result in many more cancers

in elderly persons to be diagnosed and treated. The

results of therapy for common cancers, such as large

bowel, lung, and stomach, show little improvement.

The burden of medical care budgets, with an everdecreasing productive population base, is likely to be

such that no nation, however prosperous, will be able

to cope. Prevention is surely to be preferred. Tobacco

is responsible for at least 10 percent of the global

cancer burden and viruses (liver and cervix uteri) for

another 10 percent (18). The major enigma remains

the etiology of cancers of breast, large bowel, and

prostate: It is here that research effort should be concentrated.Rational prevention iseasierwhencauseisknown.

References

1. Muir CS, Waterhouse J, Mack T, et al., eds. Cancer

incidenee in five continents, VOIV. International Agency

for Research on Cancer scientific publications no 88.

31
All sites

Stomach

Lung

Colon and rectum

Liver

Esophagus

All sites

Stomach

Breast

Colon and rectum

Cervix

Lung

o 50 100 150 200

Number in thousands

-. . . . — . . .. . ----

t-lgure Y. NumDer and percent of cases of the 5 most frequent cancers, Dy sex ana cancer site: Japan, 1980

2.

3.

4.

5.

Lyon, France: International Agency for Research on

Cancer. 1987.

NationalCancerInstitute. 1987annualcancerstatistics

reviewincluding cancer trends, 1950-1985. National

InstitutesofHealthpublicationno 88-2789.Bethesda,

Maryland. 1988.

Muir C, Waterhouse J. Comparability and quality of

data: Reliability of registration. In: Muir CS,

WaterhouseJ, MackT, et al., eds.Cancerincidencein

five continents, vol V. International Agency for Researchon Cancerscientificpublicationsno 88.Lyon,

France:InternationalAgencyforResearchon Cancer,

45–169. 1987.

FujimotoI,HanaiA.Japan,OsakaPmfecture.In:Muir

CS, Waterhouse J, Mack T, et al., eds. Cancer incidence in five continents,VOIV. InternationalAgency

for Research on Cancerscientific publicationsno 88.

Lyon, France: International Agency for Research on

Cancer. 1987.

Baquet CR, Ringen K, Pollack ES, et al. Cancer

among blacks and other minorities: Statistical

profiles. National Institutes of Health publication

6.

7.

8.

9.

no 86-2785. Bethesda, Maryland: National Cancer

Institute. 1986.

Percy C, Muir C. The international comparabilityof

cancermortalitydata.AmJEpidemiol 129(5):934-46.

1989.

DollR, CookP. Summarizingindicesfor comparison

of cancerincidencedata.IntJ Cancer2:269–79.1967,

Day NE. Cumulative rate and cumulative risk.

In: Waterhouse J, Muir C, Shanmugaratnam K,

Powell J, eds. Cancer incidence in five continents,

VOIIV. International Agency for Research on

Cancer scientific publications no 42. Lyon,

France: International Agency for Research on

Cancer, 668-70.1982.

The Cancer Registry of Norway. Survival of cancer

patients: Cases diagnosed in Norway, 1968-1975,

Oslo:NorwegianCancerRegistry. 1980.

10. Sondik EJ, Young JL, Horm JW, et al. 1985 annual

cancer statisticsreview.National Institutes of Health

publication no 86–2789, Bethesda, Maryland:

NationalCancerInstitute. 1986.

32
All sites 100

percent

Stomach

Esophagus

Liver

Lung

Colon and rectum

All sites 100

percent

Cervix

Stomach

Esophagus

Colon and rectum

I I I 1 I 1

0 100 200 300 400 500 600 700

Number in thousands

Figure 10. Number and percent of cases of the 5 most frequent cancers, by sex and cancer site: China, 1980

11,

12.

13.

14.

Parkin DM, LMra E, Muir CS. Estimates of the world- 15.

wide frequency of sixteen major cancers in 1980. Int J

Cancer 41:184-97. 1988.

United Nations Organization. Demographic indicators

of countries: Estimates and projections as assessed in 16.

1984. New York: United Nations Organization. 1986.

Muir CS. Changing international patterns of cancer

incidence. In: Fortner JG, Rhoads JE, eds. Accom- 17.

plishments in cancer research 1988, Philadelphia: J.B.

Lippincott Company, 126-46.1989.

World Health Organization. The impact of demographic trends on health. World Health Stat Q 40(1). 18.

1987.

MuirCS, ChoiNW, SchifflersE. Time trends in cancer

mortality in some countries: Their possible causes and

significance. In: Proceedings of the Skania InternationalSymposium. Stockholm, 269–309. 1980.

Doll R. Epidemiology and the prevention of cance~

Some recent developments. J Cancer Res Clin Oncol

114:447–58. 1988.

Berenblum I. Cancer prevention as a realizable goal.

In: Fortner JG, Rhoads JE, eds. Accomplishments in

cancer research 1980. Philadelphia: J.B. Llppincott

Company, 101-5.1980.

Muir CS, Parkin DM. The world cancer burden: Prevent or ~-. Derish. – -. Br Med J 290:5-6.1985. -.

33
Chapter 5

Causes of death among

the elderly: Information

from the death certificate

by Harry M. Rosenberg, Ph.D., Chief, Mortality

Statistics Branch; Frances Chevarley, Ph.D.,

Eve Powell-Griner, Ph.D., and Kenneth

Kochanek, M.A.; and Manning Feinleib, M.D.,

Dr,P.H., Director, National Center for Health

Statistics

The leading causes of death among the elderly in

the United States are heart disease, cancer, and stroke.

In 1986, these three conditions accounted for 41.6,

20.7, and 8.7percent of deaths, respectively, topersons

65 years of age andover, based on the causes of death

reported by physicians on death certificates and collected through the national vital statistics system (1)

(table A).

Such a health profile of the elderly, based on

cause-of-death information from the death certificate, reflects the ready availability of mortality

dataffom thenationalvital statistics system, as well as

its uniqueness as a health data source that is comparable at the national, State, and local levels (2). Causeof-death data from the death certificate are a key

statistical resource for describing the health problems of the general population as weI1as the health of

the elderly (3).

Two questions arise in using these data for describing and studying the health of older persons. The

first, not limited to the elderly population, is the

persistent issue of the validity of cause of death reported on the death certificate. This has been examined

over the years in numerous studies, which are summarized in an annotated bibliography prepared by the

National Center for Health Statistics (NCHS) (4) and

in other studies (5,6). It was also the focus of a recent

workshop convened under the auspices of the U.S.

National CornmitteeonVital andHealth Statistics (7).

Arelatedquestion, noted by others (8,9), is the ability

of the medical certification on the death certificate to

capture the complexity of the morbid process leading

to death in eIderly persons, who often have several

concurrent chronic conditions, any or a combination

of which could lead to death.

Table A. Number and percent distribution of deaths

for the 10 leading causes of death for persons 65

years of age and over in rank order:

United States, 1986

Rank Percent

order Cause of death’ Number distribution

Allcauses . . . . . . . . . . . . . . . . . .

1 Diseases of heart . . ...390-

398,402,404-429

2 Malignant neoplasms, including neoplasms of lymphatic

and hematopoietic

tissues . . . . . . . ..140-208

3 Cerebrovascular

diseases . . . . . ...430-438

4 Chronic obstructive pulmonary

diseases and allied

conditions . . . . ...490-496

5 Pneumonia and

influenza . . . . . . ..480-487

6 Diabetes mellitus . . . ...250

7 Accidents and adverse

effects . . . . . . .E800-E949

Motor vehicle

accidents . . . .E81O-E825

All other accidents and adverse effects . . . . .E800-

E-807, E826-E949

8 Atherosclerosis . . . . . ...440

9 Nephritis, nephrotic syndrome,

and nephrosis . ...580-589

10 Septicemia . . . . . . . . ...038

11 All other causes . . .Residual

1,488,161

619,009

308,184

129,357

62,649

60,801

27,256

25,134

6,410

18,724

21,555

17,851

14,821

201,544

100.0

41.6

20.7

8.7

4.2

4.1

1.8

1.7

0.4

1.3

1.4

1.2

1.0

13.5

‘Includes code numbersof Ninth RevisionInternational

Classification of Diseases.

SOURCE: NationalCenterfor Health Statistics. National Vital

Statistics System. 1986.

35
The second question is the extent to which causeof-death patterns really reflect patterns of illness and

serious disability in the population; in other words,

how good a proxy mortality is for morbidity. This

issue, which has been raised by others (10), accounts

in part for the creation of the national health surveys

conducted by NCHS.

The studies that examine these broad questions do

so by comparing information from the death certificate with another source. In the case of studies of

“validity” of cause of death reported on the death

certificate, the comparisons are between the report on

the death certificate and a report of clinical findings,

autopsy, or correlation of clinical and pathological findings.To make such comparisons, a variety of methodologies have been used, including using a panel

of physicians to construct a hypothetical death certificate from available diagnostic information and

then comparing the hypothetical certificate with the

death certificate that was actually filed for the

same decedent. The feasibility of adapting such a

methodology for national evaluations of cause of

death on the death certilcate is currently being explored byNCHS(11).

Inthispaper, a somewhat similarapproachis used.

Data on cause of death from the death certificate are

compared with those from another source of information to enhance our understanding of what cause-ofdeath statistics, particularly those for the elderly

population, really mean.

The independent source is a survey of informants

who were asked to respond to questions about the

health history of the decedent. By correlating the

responses from the survey with the reported cause of

death, the study provides information on both the

extent to which the death certificate reflects aspects of

themedical history ofthedecedent and,further, whether

this correlation is stronger for some age groups than

others. Because the independent source of information is not clinical or autopsy information or physicians’ independent assessment of cause of death,

results of thisstudy should not be construed asmeasures

of the validity of cause of death on the death certificate

in the classical sense, but rather as indicators of how

well cause of death on the death certificate reflects

prior medical history and whether this association

changes with age of the decedent.

The paper also addresses two related questions

beating on the nature of the cause of death reported on

the death certMcate. It examines statistical evidence

for the association between quality and completeness

of reporting cause of death and age of decedent, using

a cause-of-death classification category that can represent the adequacy of the medical certification on the

death certificate. The paper also uses multiple causeof-death data to ascertain whether medical certifiers

report more medical conditions at the time of death for

elderly decedents than for younger decedents. Such a

finding would be consistent with Kohn’s description

of death in the elderly as “an increasing collection of

diseases” (9), and it would suggest that medical certifiers of cause of death are attempting to record some

of the increasing complexity of the morbid process

leading to death with increasing age of decedent.

Methods

Death certificates and survey comparisons

To compare cause of death and medical history for

decedents, two sources of NCHS data were used: (a)

underlying cause-of-death data for U.S. deaths in

1986 compiled from the Current Mortality Sample, a

10-percent systematic sample of death certificates

received each month in the vital statistics offices in the

50 States, the District of Columbia, and the independent registration area of New York City and coded by

NCHS (12) and (b) medical data from the 1986 National Mortality Followback Survey (NMFS), a survey

used to augment information from a large sample of

U.S. death certificates for 1986 (13). Comparisons

were made between underlying cause of death reported

on death certificates and selected information on the

health history of the same decedents from the NMFS.

Below are described the sources of the data—mortality data from the national vital statistics registration

system and medical history information from the 1986

NMFS-and the principal analytical procedure, contingency table analysis.

Cause of death---Mortality data in comparisons

between the underlying cause on the death certificate

and medical history from the 1986 NMFS are based on

underlying cause-of-death coding procedures used by

36
NCHS for the Current Mortality Sample (12). The

single underlying cause of death is from the medical

conditions reported on the death certificate by the

attending physician, medical examiner, or coroner

as contributing to death (figure 1). The underlying

cause is selected using a set of medical coding

rules specified by the World Health Organization

(WHO) in the Ninth Revision International Classification of Diseases (ICD–9) (14), which ensure consistency in coding, particularly when medical cmtifications are reported incompletely, incorrectly, or

ambiguously.

The underlying cause is defined as “(a) the disease

or injury which initiated the train of morbid events

leading directly to death, or (b) the circumstances of

the accident or violence which produced the fatal

injury” (14). The sequence of conditions can be etioIogical as well, as when there is no direct causation but

an antecedent condition is believed to have prepared

the way for the direct cause by damage to tissues or

impairment of function even after a long interval.

The use of a single underlying cause of death to

characterize each death is an obvious oversimplification of the morbid process that culminated in death,

particularly deaths resulting from natural causes and

at advanced ages. The widespread and institutionalized

use of underlying cause-of-death information represents adoption of the WHO procedures for mortality

{pHYSICIAN. MEDICAL EXAMINER OR CORONER) Form Approved

U.S. STANDARD OMB No. 68R 1901

LOCAL FILE NUMBER CERTIFICATE OF DEATH

WPE STATE FILE NUMBER

OFI PRINT DECEDENT-N&ME F,RST M,DDLE LAST

,.,

SEX DATE OF DEATH i.w... DW, Y,.,

,,.

PEW;ENT

FoR

lNSTR&TIONS

HANDBOOK

IF 13EATH

CIC!XI1417CD IN

tN511TUT10N

LKC HAN DE!O13K

R[13ABCI, NG

cOM!~L~TtON OF

M?!,, L)l NCE ,TCMS

1, 2. 3.

RACE-le g,,Whlte<OISk, Ame,lcan AGE-L,,t Birthday UNDER 1 YEAR I UNDER 1 DAY DATE OF BIRTH (hf.., Do,. i%., COUNTY OF DEATH

Inulan. etc.1 lSPC.NYJ (Y,’.) MOS. DAVS

4

I

HoURS ; MINS,

5a. 5b. 5C. I 6, la.

CITY. TOWN OR LOCATION OF DEATH HOSPITAL OR OTHER lNSTITUTlON-Nmn, ,lf not i“ c,th<r. i-t”. street and number, IF HOSP. OR INST. Indicate 00A,

OPfEme,, Rm., I!watient lSF%.NYJ

7b. k 7d.

sTA7E of BIRTH or .et,. U,S. A, CITIZEN OF WHAT COUNTRY MARRIED. NEVER MARRIED. SURVIVING SPOUSE (If tulle, zfw nmlds” “am,,

11.nl. country) WIDOWED. DIVORCED ,SP.CNY,

wAS DECEDENT EVER IN U.S.

ARMED FORCES?

8. 9. 10. 11.

~2/eclf> Y.’ or NO)

SOCIAL SECURITY NUM8ER USUAL OCCUPATION (c)he hind ofu.a?k done dur{nc “m,, of KIND OF BUSINESS OR INDuSTRY

!uork,,w 11,..,“.” ,f ,. ,,,ed,

13, 14a. 14b,

RESIDENCE–STATE COUNTY CITY. TOWN OR LOCATION STREET AND NUMBER INSIDE CITY LIMITS

(S.nm,(, Y., or No)

15d, 158.

FATHER-NAME FIRST Ml DDI-E LAST MOTH ER-MAI DEN NAME FIRST MIODLE LAST

INFORMANT-NAME (Type m Prfnt) MAILING ADDRESS STREET 0. R.F. O. NO. C!TV 0. TOWN STATE ZIP

SURIAL. cREMATION, REMOVAL. OTHER (S...10, CEMETERY OR CREMATORY-NAME LOCATION CITY OR ToWN STATE

19a. 19b. 19C.

FUNERAL SERVICE LICENSEE 0, PersonAc,l,g A, Such NAME OF FACILITY

,Si,”.futc,

ADDRESS OF FACILITY

20b. 20C.

218. To lho ba%tof my knov+lodge,death occurred at the time, date and place and due 10 lhe 22a. 0. the bask.1 ewninad.a. and!., mvestwtion, in mv +mn!c.ndeath occ.r.ed at the urn%

causo[d stated. a date and Dlaceand due to the cawe(d stated.

DATE SIGNED 01., D.,, w I ~~ : DATE SIGNED ,Mo.. D.!,. Yr., HOUR OF DEATH

~w~

21C. M 8 <ix 22b. 22C. M

NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (TYP< o?P.tnt, : = ~ PRONCI” NCEII DEAO (.MO,,D.,, V,.,

g~ ~:;

PRONOUNCED DEAO ,H,w,,

I

8 21d.

2

22d. ON 22e. AT M

NAME AND ADDRESS OF CERTIFt ER {PHYSICIAN. MEDICAL EXAMINER OR CORONER) (TYD, or Print)

DATE RECEIVED BY REGISTRAR 131... Do?. Y,)

CONDITIONS

,F AN”

24b.

WH!CH i3AvE IMMEDIATE CAUSE [ENTER ONLY oNE CAUSE PER LINE FOR LoI. lb), AND fC)./ , 1mend t%twee” Q“S-Xand death

4

RISE ,0

th3h3[DlATC PART ,,, I

cAUSE I

STATING THE DuE TO, DR AS A COnSeqUenCe OF

UNOLULVING P

I“,wwI between onset and death

CAUSE LAST

,,

1.

{

[b)

I

DUE TO. OR AS A CDNSEOUENCE OF lntww! betwae” 0“ss1and desth

(c) I

PART OTHER SIGNIFICANT Conditions-Co”d,t,ons C-a”tr,butlngto death but “o, related to causeg,.,. I. PART 1[d AUTOPSY ,S,<<,f, Ye,

‘w No,

WAS CASE REFERRED TO MEDICAL

n

EXAMINER OR CORONER

26.

(s,..1{, Ye, or ‘v.,

27.

AcC . SUICIDE, HOM., UNDET.. DATE DF INJURY ,.$1., D.,, Y,, HOUR OF INJURY

OR PENDING INVEST, ,Smvtf?)

DESCRIBE MOW INJURY OCCURRED

2sa. 28b. 28c. M 28d.

INJURY AT WORK l~Nfl~ Y,’ PLACE OF INJURY-A% home. Iann. stmat, Imlow. office budding. LOCATION STREET OR .Q.F.O. No. .,,” OR TOWN 6TATE

etc. L9.eclr,)

;:vA~~7#

28e. ] 28f. I 28g.

Figure 1. U.S. Standard Certificate of Death (1989 version)

37
data collection and tabulation, especially at the international level—procedures that at once embody simplicity, logic, and recognition of the inherent limitations of the medical certification of cause of death on

the death certificate. The limitations, in turn, reflect

the dual nature of the death certificate, which is, on the

one hand, a concise legal document required fordisposition of a body and settlement of legal and financial

matters attendant to death and, on the other hand, a

statistical document that in limited space summarizes

the facts of death. The procedures assume that, for

public health purposes, a single cause of death for each

death may be a sufficient and possibly the only available descriptor of the medical conditions responsible

for death.

To some degree thedualpurposes of the document

result in a competition in which pressures for expeditious disposal of the body tend to outweigh those for

detailed, multifactorial, and well-substantiated diagnostic information on cause of death. Further limiting

the information on cause of death is the known difficulty of ascribing a natural death to a single cause,

particularly for persons at advanced ages (8). Some of

the limitations of underlying cause-of-death data can

be addressed by using multiple cause-of-death data,

that is, data on all of the conditions reported on death

certificates (15). Multiple-cause data are not a panacea, however. They are subject to, and may be more

seriously affected by, the limitations of the present

WHO form used to certify causes of death, which is

designed to elicit a single underlying cause of death,

not multiple causes.

National Mortality Followback Survey-The

other major source of information in this study is the

1986 NMFS (13). The NMFS is designed to fill a key

research gap by supplementing the information obtained from death records in the vital statistics mortality file with information on important characteristics

of the decedent that may have affected mortality.

These characteristics include patterns of lifetime behavior, health services experienced prior to death,

socioeconomic status, and many other aspects of life

that affect when and how death occurs.

TheNMFS is a l-percent stratified random sample

nationally representative of adults 25 years of age and

over who died in the United States during 1986. The

sample, which was selected from the Current Mortality Sample of NCHS, consists of data for 18,753

decedents. The Current Mortality Sample is the basis

for provisional estimates of mortality by underlying

cause of death and selected demographic characteristics for the United States published monthly and

annually (12). The survey data on social, demographic,

and behavioral characteristics of decedents were obtained from a mailed questionnaire or interview with

the person identified on the death certificate as the

informant. The response rate for the 1986 NMFS was

89 percent.

Information on the decedents’ age, race, sex, and

underlying cause of death was obtained from statistical records of the Cument Mortality Sample. The

survey data were weighted to produce unbiased estimates. The weight for each sample certificate is the

product of the reciprocal of the probability of sample

selection andan adjustment fornonresponse. Weighted

data are used in this study. While all 50 States and the

District of Columbia granted approval for use of a

sample of their death certificates in the NMFS, the

State of Oregon was not included because of respondent consent requirements. Thus, the data in this study

are representative of deaths in the United States,

excluding Oregon.

Twelve items pertaining to the health conditions

and history of the decedent were available for this

study. These items, shown in appendix I, concerned

whether the decedent had ever had hypertension; a

heart attack; angina pectoris; stroke; Alzheimer’s disease or other chronic brain syndrome; other mental,

nervous, or emotional problems; diabetes; cance~

asthma; other lung conditions; or cirrhosis of the liver.

The analysis was limited to six conditions-hypertension, heart attack, stroke, cancer, diabetes, and

asthma—for which sample numbers in the survey

were sufficiently large.

Comparisonofsurvey and death certificateinformation—The presence of each of these conditions in

the health history of the decedent according to survey

data was compared with selected underlying causes of

death from the death certificate. The categories of

cause of death were selected on the basis of their

similarity to the survey condition or because of a

known etiological relationship, as follows:

38
●

●

●

●

●

●

Hypertension on survey was compared separately

with two different broad cause-of-death categories: Diseases of heart and Major cardiovascular

diseases.

Heart attack was compared with three categories:

Deaths related to heart attacks (a specially constructed category comprising International Classification of Diseases (ICD) codes that include such

terms as “heart attack~’ “heart attack, 8 weeks or

more, “ “healed or old heart attack;’ “coronary

failure,” “cardiac arrest;’ and’’cardiovascular disease, unspecified”); Diseases of beam, and Major

cardiovascular diseases.

Stroke was compared with two categories: Cerebrovascular diseases and Major cardiovascukir

diseases.

Diabetes was compared with two categories:

Diseases of heart and Major cardiovascular

diseases.

Cancer was compared with two categories of

Malignant neoplasms.

Asthma was compared with Chronic obstructive

pulmonary disease (COPD) and allied conditions.

The questions on the NMFS related to these medical

conditions and the names of the compared causes of

death with ICD-9 category names and code numbers

are shown in appendix II.

Because older individuals generally have more

morbid conditions present from which to select the

underlying cause of death for the death certificate, it

was hypothesized that the associations between causeof-de~th categories would diminish by age. Therefore,

each association was examined by age, as it was

conjectured that the underlying cause-of-death information is less informative for older persons than for

younger persons.

The degree of association between the medical

history obtained in the NMFS and the cause of death

on the death certificate is measured using the “odds

ratio” applied to data arrayed as contingency tables

(16,17). In table B is shown the construction of an

odds ratio for cardiovascular disease (CVD) as

an underlying cause of death on the death certificate and a reported history of hypertension from

the NMFS, by age of decedent. Thus, for the age

group 25-64 years, 46.8 percent of persons dyingiiom

CVD were reported as having a history of hypertension, compared with 53.2 percent of persons dying

from other causes who also were reported as having a

history of CVD.

The ratio of these percents46.8 to 53.2, or

0.88—represents the “odds” of dying from CVD

rather than another disease for decedents in this age

group reported as having a history of hypertension.

This ratio of 0.88 can be compared with the ratio of

the percent dying of CVD (23.7 percent) or other

causes (76.3 percent) when there was no reported

history of hypertension, which is 23.7/76.3, or 0.31,

The odds ratio is the ratio of the first odds quantity,

0.88, to the second odds quantity, 0.31—that is, 0.88/

0.31, or 2.83. This odds ratio means that a history

of hypertension increased the odds about three

times that a person aged 25-64 years died of CVD

rather than another cause of death in 1986. Data from

which odds ratios were constructed are shown in

appendix III.

Diagnostic completeness

Data on diagnostic completeness are based on

final mortality data for all deaths occurring to residents of the United States in 1985, as published in

Vital Statistics of the United States, 1985, Volume 11,

Part A (18). Final data for 1986 were not readily

available for this analysis. Diagnostic completeness

was measured using the number of deaths assigned to

ICD–9 category Nos. 780-799, Symptoms, signs,

and ill-defined conditions. To this category are assigned deaths whose underlying cause is characterized

by such terms as “natural causes,” “stopped breathing,” or “old age.” More generally, the category

includes a range of medical terms and conditions that

cannot be classified to other parts of the ICD that are

more precise with respect to anatomical characterization or disease.

Multiple cause-of-death analysis

The multiple cause-of-death analysis is also based

on final mortality data for all U.S. resident deaths

occurring in 1985 (18). Multiple causes of death

represent all conditions reported by the medical certifier as contributing to death, regardless of whether

they were selected as the underlying cause (19). The

source of the multiple-cause data are the multiple

39
Table B. Number and percent of deaths and odds and odds ratio of dying from Cardiovascular disease (death

certificate compared with survey reports of Hypertension), by age: United States, 1986

Age and cause of death on death certificate

25-64 years 6S74 years 75+4 years 85 years and over

History of Cardio- Cardio- Cardio- Cardiohypertension vascular vascular vascular vascular

on survev diseases Other diseases Other diseases Other diseases Other

Yes . . . . . . . . . 93,150 105,990

No . . . . . . . . . . 68,590 221,060

Unknown . . . . . 6,990 16,920

Yes . . . . . . . . . 46.8 53.2

No . . . . . . . . . . 23.7 76.3

Unknown . . . . . 29.2 70.8

Yes . . . . . . . . . 0.88

No . . . . . . . . . . 0.31

Unknown . . . . . 0.41

Odds ratio . . . . 2.83

Number

128,060 109,030 159,460 112,780

80,140 135,340 122,600 136,560

11,920 11,640 16,690 15,160

Percent

54.0 46.0 58.6 41.4

37.2 62.8 47.3 52.7

50.6 49.4 52.4 47.6

Odds

1.17 1.41

0.59 0.90

1.02 1.10

1.98 1.57

118,800 58,540

128,190 88,030

17,410 10,560

67,0 33.0

59.3 40.7

62.2 37.8

2,03

1.46

1.65

1.39

NOTE: Calculation of odds ratio:

With Without

specified specified

cause of cause of

death death

With mention

of condition A

Without mention

B

odds ratio _ & AD

CID ‘E

of condition c D

SOURCE: National Center for Health Statistics. National Mortality Followback Survey. 1986.

cause-of-death public use data tapes for 1985 (20).

Multiple-cause data for 1986 were not available for

the analysis. In this analysis each medical condition

reported on the death certificate was counted oncq for

example, if for the same death, Coronary atherosclerosis and Aneurysm of heart were reported, each

would be counted once. If a physician reported three

nonredundant conditions in Part I and two conditions

in Part II of the certificate, this death would be tabulated as having a total of five reported conditions.

Excluded from the analysis were external causes, that

is, conditions coded to trauma such as accidents,

homicides, and suicides; however, for these deaths the

nature of trauma, such as fracture, was counted as a

condition.

40

Results

Death certificate and survey comparisons

Comparison of cause of death on the death certificate with medical history information from the NMFS

can shed light on the degree to which cause of death is

associated retrospectively with reported medical history of the decedent. One can also see if the correlation

between diagnostic information from the death certificate and from the survey changes with the age of the

decedent. For only one cause of death in the NMFS—

cancer—was the informant actually asked the main

cause of death of the decedent. The reply can be used

as a rough indicator of the validity of the cause of death

reported on the death certificate. However, the
respondent’s answer cannot be viewed as a rigorous

standard for assessing the reported cause of death on

the death certificate; for that, a clinicill or pathological

determination assessed by a physician is required.

Comparison between survey and death certificate

information is shown for selected causes of death in

tables C-F and figures 2–8 and is discussed below for

major cardiovascular diseases, heart attacks, cancer,

stroke, and COPD, conditions for which the NMFS

reported medical history and for which the sample size

was sufficient to ensure statistically reliable measures.

Major cardiovascular diseases—In table C is

shown the relationship between CVD reported on the

death certificate and related medical history reported

from the NMFS. Within the broad category CVD isthe

subcategory Diseases of heart and a more specific

component called Heart attack related in this study.

Compared with CVD on the death certificate are the

medical items on the survey for hypertension, heart

attack, diabetes, and stroke.

CVD accounts for a large share of the deaths

annually in the United States; of the 2,105,361 deaths

in the United States in 1986, a total of 968,240 were

due to these conditions. In 1986, CVD was selected as

the underlying cause of death for 48.2 percent of the

decedents who were 25 years of age andover. In 1986,

CVD’S prevalence as an underlying cause of death

increased gradually with age, from about one-third

(32.9 percent) of deaths at ages 25-64 years to twothirds (62.7 percent) at ages 85 and over (table C). The

fiist association examined is between the CVD as the

underlying cause of death and a reported history of

high blood pressure, or hypertension. Hypertension,

according to the NMFS, is a highly prevalent condition: 44.9 percent of the decedents 25 years of age and

over in 1986 had this condition at some point in their

life, while 49.7 percent were reported as never having

had high blood pressure; fortheremaining 5.4percent,

information about hypertension was not available

(table B).

The data in table C show that the percent dying of

CVD increases gradually with age for decedents both

with and without a reported history of hypertension.

For those with reported hypertension, the percent

dying of CVD increased fiom46.8 percent at ages 25–

64 years to 67.0 percent at ages 85 years and over

(figure 2); for those without, from23.7 to 59.3 percent.

The odds of dying from cardiovascular disease compared with other causes also increased with age for

decedents regardless of their history of hypertension.

For those with such a history, the odds increased from

0.88 at 25-64 years to 2.03 at 85 years and over (table

C). For those without a history of hypertension, the

odds increased more slowly, fkom 0.31 to 1.46. As a

consequence of the differential rate of increase in the

odds, the odds ratio-the measure chosen to represent

Table C. Percent of deaths and odds and odds ratios of dying from Cardiovascular disease (death certificate

compared with survey reports of seiected conditions), by age: United States, 1986

Underlyingcause of

death on death

certificate withor

Percent dying of Cardiovascukr

withouthisiory of disease on death certificate Odds and odds ratios

specified condition 25-64 65-74 75-84 85 years 25-64 65–74 75-84 85 years

reported on survey years years years and over years years years and over

Cardiovasculardisease . . 32.9 46.2 53.0 62.7 Odds ratio .. 2.83 1.98 1.57 1.39

With Hypertension . . . . . 46.8 54.0 58.6 67.0 Odds . . . ...0.88 1.17 1.41 2.03

Without Hypertension . . 23.7 37.2 47.3 59.3 0.31 0.59 0.90 1.46

Cardiovascular disease: Odds ratio .. 7.58 4.65 3.37 1.67

With Heart attack . . . . . . 66.2 69.4 72.4 71.4 Odds . . . ...1.95 2.27 2.62 2.50

Without Heart attack . . . 20.5 32.8 43.7 59.9 0.26 0.49 0.78 1.50

Cardiovascular disease: Odds ratio .. 1.90 1.61 1.61 0,84

With Diabetes . . . . . . . . 45.4 55.7 62.7 59.3 Odds . . . ...0.83 1.26 1.68 1.46

Without Diabetes ., . . . . 30.5 43.8 51.1 63.4 0.44 0.78 1.04 1.73

Cardiovascular disease: Odds ratio .. 2.12 1.61 2.00 1.82

With Stroke . . . . . . . . . . 47.8 54.8 64.8 71.7 Odds . . . ...0.91 1.21 1.84 2.53

Without Stroke . . . . . . . . 30.2 43.0 47.9 58.1 0.43 0.75 0.92 1.39

SOURCE:National Center for Health Statistics. National Mortality Followback Survey. 1986.

41
----- CVD with Hypertensionreport

— Total CVD

80

[

‘--- .----’ (2VD without Hypertension report

60 -

E

g 40

r$

20 -

0 -[ I I I

25-64 65–74 75-84 85 years

years years years and over

Age

NOTE: CVD is cardiovasculardisease.

SOURCE: NationalCenterfor Health Statistics. National

Mortality Followback Survey. 1986.

Figure 2. Percent of deaths from Cardiovascular

disease, survey reportsof Hypertensionand age:

UnitedStates, 1986

the association between CVD reported on the death

certificateanda history of hypertension on theNMFS—

diminishes from 2.83 to 1.39 with increasing age

(table C and figure 3).

The relatively large odds ratio for the youngest age

group represents a statistical association between a

reported history of hypertension on the survey and the

report of CVD as the underlying cause of death on the

death certificate for this broad age group. However,

for the oldest old—those aged 85 years and over—the

odds ratio of close to 1.0 indicates essentially no

relationship between CVD cause of death and a history of hypertension.

The association between CVD as a cause of death

and a history of heart attack on the NMFS is even

stronger than the association of CVD with a history of

hypertension. C)fpersons aged 25-64 years who died

in 1986, more than two of three with a history of heart

42

10 : — Odds ratio

----- (XD with Hypertension

‘--------- CVD without Hypertension

: ~

(n ●.=

~~

-e ●*..

%1 *~0- ●.

-..

0

●.. **..

●..***=

.* ●,* ,.*

.“”” ●.*

0.1 I r I I

25-64 65-74 75-84 85 years

years years years and over

Age

NOTE: CVD is Cardiovascular disease.

SOURCE: National Center for Health Statistics. National

Mortality Followback Survey. 1986.

Figure3. Oddsand odds ratioof dyingfrom

Cardiovasculardisease (deathcertificate

comparedwith survey reportsof Hypertension),by

age: UnitedStates, 1986

attack died of CVD, while only one of five who had not

had a heart attack died of CVD rather than from

another underlying cause of death (table C). For that

broad age group, a reported history of heart attack was

associated with odds of dying from CVD of 1.95, as

compared with odds for other causes of 0.26, resulting

in an odds ratio of 7.58. The odds ratio for dying of

CVD in relation to a history of heart attack decreased

rapidly with increasing age to 1.67 for the oldest age

group (table C).

Another condition expected to be associated with

deaths from CVD is diabetes, A total of 17.2 percent

of persons 25 years of age and over who died in 1986

had a reported medical history of diabetes. By broad

age group, the percent did not vary greatly. For the

youngest age group of decedents, 25--64 years, the

percent was 15.7; for those aged 65–74 years, 75-84

years, and 85 years and over, the percents were 20.6,

18.6, and 13.4, respectively.

A history of diabetes increased the probability of
dying from CVD compared with other causes for

every age group. The odds ratio was 1.9 at ages 25-64

years, indicating that persons in this age group who

died in 1986 were twice as likely to die from CVD as

from other causes if they had a reported prior history

of diabetes (table C). By 85 years and over, the odds

ratio was about 1.0, indicating essentially no association between these conditions at that age.

The association between CVD as an underlying

cause and stroke reported on the NMFS for 1986 is

also shown in table C. As with the previously discussed medical conditions reported on the survey, the

odds of dying from CVD as an underlying cause on the

death certificate increased for those both with and

without a reported history of stroke. The rate of

increase in the odds for the two groups remained about

the same throughout the age span, with odds of persons

with stroke being about twice those of persons without

stroke. Thus, stroke as a risk factor contrasts with

hypertension and heart attack, for which the odds ratio

diminished sharply with increasing agq for stroke the

ratio remained relatively constant.

In sum, the likelihood of CVD as an underlying

cause increased if the decedent had a medical history

of one of the reported conditions—hypertension, heart

attack, diabetes, or stroke. The strongest association

was with a reported history of heart attack, which

increased the odds of dying from this cause rather than

another cause by an average factor of 4.31 for aIl ages

combined (the simple average of the odds ratios at

each age). In order of strength of association, this was

followed by the impact of stroke, with an average odds

ratio of 1.89, then by hypertension (1.94) and diabetes

(1.49).

For each of these conditions, the effect of the prior

history of disease decreased with increasing age. The

sharpest reduction was for heart attack, for which the

odds ratio diminished by an average of 0.099 points

per year of age between ages 25 and 85 years and over,

compared with 0.024 for hypertension, 0.018 for diabetes, and 0.005 for stroke-differentials that are

illustrated in figure 4.

lYeartdisease-Heartdisease, orDiseasesof heart,

is a subcategory of Major cardiovascular diseases,

accounting for 765,490 deaths, or 79 percent of all

CVD deaths in the United States in 1986. Table D

Heart-attack-relateddkease

----- Hypertension

‘“-0 -”-”-’ Stroke

.......... Diabetes

8r2

1

c)~

25-64 65-74 75-84 85 years

years years years and over

Age

SOURCE: NationalCenterfor Health Statistics. National

Mortality Followback Survey. 1986.

Figure4. Odds ratio of dying from Cardiovascular

di~ease for survey repo& of Hypertension,Heartattack-relateddisease, Diabetes,and Stroke, by age:

UnitedStates, 1986

shows the association between death due to heart

disease andahistory of hypertension andheartdisease

reported in the NMFS.

Deaths from heart disease as an underlying cause

increased from 27.8 percent at ages 25-64 years to

46.5 percent at ages 85 years andover. For ages 25-64

years, a history of hypertension raised the percent

dying of heart disease by a factor of 2.45 compared

with persons without a history of hypertension. By 85

years and over, the odds ratio decreased to 1.15.

A history of heart attack was strongly associated

with death fi-omheart disease, as it was for CVD. The

odds ratio was 9.63 for the youngest age group, decreasing to 2.17 for decedents in the oldest age group.

The pattern of association between heart disease

and CVD as underlying causes of death on the death

certificate in relation to a reported history of hypertension or heart attack in the NMFS was, not surprisingly,

similar in terms of both order of magnitude and rate

of change with increasing age of decedent (table G).

43
Table D. Percent of deaths and odds and odds ratios of dying from Heart-attack=related diseases or Heart

disease (death certificate compared with survey reports of seiected conditions), by age: United States, 1986

Underlying cause of

death on death Percentdying of specified

certificatewithor uncfer/yingcause of

withouthistoryof death on death certificate Oddsand odds ratios

specified condition 25=64 65-74 7S84 85 years 25-64 65-74 75-64 85 years

reported on survey years years years and over years years years and over

Heart-attack-reiated

diseases . . . . . . . . . . . . . 22.7 32.2 35.4 39.7 Odds ratio .. 8.63 5.59 3.61 1.92

With Heartattack . . . . . . 53.0 56.1 55.4 51.7 Odds . . . ...1.13 1.28 1.24 1.07

WithoutHeari attack . . . 11.6 18.6 25.6 35.8 0.13 0.23 0.34 0.56

Heartdisease . . . . . . . . . . 27.8 38.4 41.3 46.5 Odds ratio .. 2.45 1.59 1.29 1.15

With Hypertension . . . . . 38.6 43.2 44.4 48.4 Odds . . . ...0.63 0.76 0.80 0.94

Without Hypertension . . 20.4 32.4 38.2 44.9 0.26 0.48 0.62 0.81

Heartdisease: Odds ratio .. 9.63 5.71 3.73 2.17

With Heart attack . . . . . . 62.6 63.8 62.6 61.0 Odds . . . ...1.67 1.76 1.67 1.57

WithoutHeart attack . . . 14.8 23.6 31.0 41.9 0.17 0.31 0.45 0.72

SOURCE:National Center for Health Statistics. National Mortality Followback Survey. 1986.

Heart attack has a greater impact on the underlying

cause of death than a history of hypertension, as well

as a much more rapidly declining ratio with increasing

age of decedent.

Heart attack—According to the 1986 NMFS, an

estimated 29.2 percent of decedents in 1986 had had a

heart attack prior to death. The percent varied by age

as follows: For decedents aged 25-64 years, 26.2

percent had had a heart attack for those aged 65–74

years, 35.5 percent; for 75–84, 31.9 percent; and for

those aged 85 years and over, 22.1 percent.

The percent of deaths attributed to the underlying

cause-of-death category Heart attack related (see appendix II) increased from 22.7 percent at ages 25-64

years to 39.7 percent at ages 85 years and over (table

D). The percent was affected by a reported history of

heart attack such that the odds ratio for the youngest

age group was 8.63. The odds ratio declined to 1.92for

the oldest group, apattern similar to the impact ofprior

heart attack on death due to CVD and heart disease, as

shown in figure 5 and table H.

The analysis of the association between heart

attack reported on the NMFS and heart attack reported

as an underlying cause on death certificates was carried out in three different ways, once for the broad

category CVD; then for its subcomponent Diseases of

heart; and finally, within that category, for the speciallyconstructedcategory Heart-attack-related deaths.

For each of these, the relationship was similar (tables

44

C and D, and figure 5). For (ND and heart attack, the

odds ratios ranged with increasing age from 7.58 to

1.67; for Diseases of heart, from 9.63 to 2. 17; and for

Heart-attack-related deaths, from 8.63 to 1.92. Generally, the associations are stronger for the more specific

categories of cause of death than for the broader

categories.

Cancer—In the NMFS, the question about medical history related to cancer differed from that for the

other conditions. For the other conditions, the question on medical history was couched in terms of, “At

any time during theperson’s life did he orshehave [the

condition],” thus providing information on the medical history of the decedent regarding the specified

condition. In contrast, the question for cancer—’’Was

cancer the main condition leading to death? ’’—is

directed more at confirming the diagnosis reported on

the death certificate or, conversely, determining the

knowledge of the informant regarding the cause of

death reported by the physician. The analysis was

carried out using alternative sets of ICD categories for

Malignant neoplasms, one including ICD Nos. 140-

209, the other including a broader range of ICD Nos.

140-239. Results were about the same for the two

definitions.

Cancer is the second leading cause of death in the

United States. In 1986, it accounted for a total of

469,376 deaths, or 22.3 percent of all deaths. The

proportion of deaths due to cancer decreased with
— Heart-attack-related disease

----- Heart disease

--=------- Cardiovascular disease

10“

9 -

8 “

7 -

.9 6 -

~

rn5 -

%

04 -

3 -

2 “

(—j~

25-64 65-74 75-84 85 years

years years years and over

Age

SOURCE:National Center for Health Statistics. National

MortalityFollowbackSurvey. 1986.

Figure 5. odds ratioof dyingfrom Cardiovascular

disease,Heart disease, and Heart-attack-related

diseasefor survey reportsof Heartattack, by age:

United States, 1986

increasing age of the decedent, from about31 percent

at ages 25-64 years to about 11 percent at ages 85

years and over (table E). For a very high percent of

decedents for whom cancer was reported as the underlyingcause on the death certificate, cancer was also

reported on the NMFS as the condition leading to

detith. Of those aged 25-64 years, the NMFS figure

was close to 90 percent; it decreased gradually to 72

percent by ages 85 years and over. Conversely, of

those not reported on the death certificate as dying of

cancer, the percent reported on the NMFS as dying of

cancer was only 1.6percent for the youngest age group

and increased to 2.3 percent for the oIdest group (table

E). As a consequence, the odds ratios for cancer were

very high—about 400 at ages 25-64 years, declining

to zbout 100 at ages 85 years and over (table E and

figure 6).

S’tm&-—Cerebrovascular disease, or stroke, is the

third leading cause of death in the United States,

— Odds ratio

1000 -----

[

With Cancer

‘--------- Without Cancer

k’

I ........................

O*, ~

25-64 65-74 75-84 85 years

years years years and over

Age

SOURCE: National Center for Health Statistics. National

Mortality Followback Survey. 1986.

Figure 6. Odds and odds ratio of dying from Cancer

(death certificate compared with survey report of

Cancer as main condition leading to death), by age:

United States, 1986

accounting for 149,643 deaths, or 7.1 percent of the

total in 1986. For decedents aged 25 years and over,

stroke was selected as the underlying cause of death

for 7.5 percent of the deaths in 1986. The proportion

of deaths due to stroke increased rapidly with age,

from about 4 percent at ages 25-64 years to 12percent

at ages 85 years and over (table F).

According to the NMFS, 25.4 percent of the decedents in 1986 had a stroke during their lifetime; 70.9

percent had not had a stroke; and information regarding stroke was not available for 3.6 percent of the

decedents. The percent who hadhada stroke increased

with age of the decedent from 14.2 percent for persons

45
Table E. Percent of deaths and odds and odds ratios of dying from Cancer (death certificate compared with

survey reports of seiected conditions), by age: United States, 1986

Underlying cause ot

death on death

certificate with or Percent dying of specified

without Cancer as Cancer on death certificate

main cause of death 25-64 65-74 75-84 85 years

reported on survey years years years and over

Cancer (iCD-9 Nos. 140-

208) . . . . . . . . . . . . . . . . 30.9 29.7 20.3 10.5

With Cancer . . . . . . . . . . 87.6 84.9 81.6 71.8

Without Cancer . . . . . . . 1.6 1.8 1.7 2.3

Cancer (ICD-9 Nos. 140–

239) . . . . . . . . . . . . . . . . 31.3 30.1 20.5 10.8

With Cancer . . . . . . . . . . 88.2 85.4 82.4 72.7

Without Cancer . . . . . . . 1.9 2.0 1.8 2.5

Odds and odds ratios

25-64 65-74 75-84 85 years

vears vears vears and over

Odds ratio ..421 .26 304.71 252.99 106,79

Odds . . . . . . 7.07 5.60 4.43 2,54

0.02 0.02 0.02 0.02

Odds ratio ..381 .15 280.09 251.52 102.85

Odds . . . . . . 7.49 5.86 4.67 2.67

0.02 0.02 0.02 0.03

NOTE: iCD-9 is Ninth Revision international Classification of Diseases.

SOURCE: National Center for Health Statistics. National Mortality Followback Survey. 1986.

Tabie F. Percent of deaths and odds and odds ratios of dying from Cerebrovascuiar disease or Chronic obstructive Duimonary disease (death certificate compared with survey reports of selected conditions), by age:

United States, 1986

Underlying cause of

death on death Percent dying of specified

certificate with or underlying cause of

without history of death on death certificate

specified condition 25-64 65-74 75-84 85 years

reported on survey years years years and over

Cerebrovascuiar disease . . 3.9 5.6 9.1 12.0

With Stroke , . . . . . . . ...16.2 15.7 22.3 22.9

Without Stroke . . . . . . . . . 1.8 2.1 3.2 6.0

Chronic obstructive

puimonary disease . . . . . . 2.1 5.2 5.1 2.3

With Asthma . . . . . . . . . . . 9.8 19.2 16.1 5.0

WithoutAsthma . . . . . . . . 1.5 4.1 4.1 2.2

Odds and odds ratios

25-64 65–74 75-84 85 years

vears vears vears and over

Odds ratio ..10.52 8.55 8.72 4.64

Odds . . . . . . 0.19 0.19 0.29 0.30

0.02 0.02 0.03 0.06

Odds ratio . . 7.20 5.52 4.49 2,35

Odds . . . . .. O.ll 0.24 0.19 0,05

0.02 0.04 0.04 0.02

SOURCE: National Center for Health Statistics. National Mortality Followback Survey.1986.

aged 25-64 years to 33.3 percent for those aged 85

years and over.

For each age group, the percent of decedents for

whom stroke rather than another cause was selected as

the underlying cause of death was higher if they had a

history of stroke than if they did not (table F). As with

reported cancer, report of a stroke in the survey is

strongly associated with stroke as an underlying cause

of death; that is, the odds of dying from stroke are

much larger forthosereporting a history of stroke than

for those who did not, resulting in large odds ratios.

The odds ratio is almost 11for the youngest age group,

decreasing to 4.6 at ages 85 years and over (figure 7).

The high odds ratio for even the oldest old indicates a

46

strong association between a history of stroke and

death from stroke throughout the age range.

Chronic obstructive pulmonary disease—COPD

was the fifth leading cause of death in the United

States in 1986, accounting for 76,559 deaths, 3.6

percent of deaths from all causes combined. The

category COPD includes bronchitis, emphysema,

asthma, and other chronic respiratory diseases that are

difficult to differentiate from one another in the elderly population. In the NMFS, information was collected not on COPD but on asthma (appendix I). The

percent of deaths due to COPD in 1986 ranged among

the age groups from 2 to 5 percent (table F).

Asthma was not reported as a highly prevalent
— Odds ratio

----- Cerebrovascular disease with Stroke

‘ --------- Cerebrovascular disease without Stroke

#-------

## d“

------ +

0.1

!

●-.

-*..*”

..

/

● ... .

.*----

. . . . . . . . . . . . -*-

0,0, ~

25-64 65-74 75-84 85 years

years years years and over

Age

;OURCE: National Center for Health Statistics. National

dortality Followback Survey. 1986.

Figure7. Odds and odds ratioof dyingfrom

Cerebrovasculardisease (deathcertificate

comparedwith survey reportof Strokeas main

conditionleadingto death),by age: UnitedStates,

1986

medical condition for persons who died in 1986. Only

6.3 percent of all decedents 25 years or older in 1986

were reported to have ever had a history of this

respiratory condition. The percent was about the same

throughout the age span, except for the oldest age

group, for whom the percent declined to about 4.

The odds of dying from COPD as an underlying

cause were greatly affected by the reported presence

— Odds ratio

----- COPD with Asthma

‘--------- COPD without Asthma

.“------,

,0. \

.N \

\

\

\

\

\

-----------------

--. ..**

. .

..*” ----

. .

=.O

00, L__L_L—

25-64 65-74 75-84 85 years

years years years and over

Age

NOTE: COPD is chronic obstructive pulmonary disease.

;OURCE: National Center for Health Statistics. National

Jortality Followback Survey. 1986.

Figure8. Oddsand odds ratio of dyingfrom Chronic

obstructivepulmonarydisease (deathcertificate

comparedwith survey reportof Asthmaas main

conditionieadingto death),by age:

UnitedStates, 1986

of asthma during the decedent’s lifetime. For the

youngest group, the percent dying of COPD who had

a reported history of asthma was almost 10 percent,

compared with on]y 1.5 percent for those without a

history of the condition-a fivefold difference that

diminished only slightly with increasing age. The

odds ratio, which was over 7 at ages 25-64 years,

declined to slow ofjust over 2forpersons 85 years and

over (figure 8).

Summary-A comparison of underlying cause on

the death certificate with reported medical history on

the NMFS for the same decedents in 1986 shows

significant associations, although the strength and

variation by age differ among the selected conditions.

Excluding cancer, for which the item on the NMFS

differed from the other conditions, the strongest association was for stroke. The odds ratio was close to

47
Table G. Odds ratio of dying from Cardiovascular

disease or Heart disease (death certificates compared with survey reports of Hypertension and Heart

attack) and average change in odds ratio per year of

age: United States, 1986

Underlying cause of death

on death certificate

Cardiovascular Heart

Survev historv disease disease

Hypertension

Average odds ratio . . . . . . . . 1.94 1.62

Average change in odds ratio

peryearof age . . . . . . . . . . -0.024 -0.022

Heart attack

Average odds ratio . . . . . . . . 4.31 5.31

Average change in odds ratio

peryearof age . . . . . . . . . . -0.099 -0.124

SOURCE: National Center for Health Statistics. National

Mortality Foliowback Survey. 1986.

8.0 for all ages combined for this condition. In terms

of strength of association between the two sources of

information, stroke was followed by heart attack.

Heart attack listed on the NMFS was related to death

from heart attack, heart disease, and CVD reported on

the death certificate; the odds ratios were in the range

of 4--5, as was the association between asthma on the

survey and COPD reported on the death certificate.

The odds ratio was about 2,0 for the association

between stroke on the survey and CVD on the death

certificate.

The odds ratio diminished with increasing age for

all of the combinations of conditions from the two

sources. The sharpest declines were for a history of

heart attack in combination with any of the causes of

death with which it was paired. The smallest change

was for stroke as a factor associated with death from

CVD.

Diagnostic completeness

It has been suggested that theprecisionof diagnostic information on the death certificate may decline

with increasing age of decedent; that is, as the age of

the decedent increases, the medical certifier is more

likely to characterize the cause of death on the death

certificate with imprecise and vague terms such as

“natural causes” or “old age” (9). This can be examined by determining the proportion of deaths at an age

Table H. Odds ratio of dying from Cardiovascular

disease, Heart disease, and Heart attack (death

certificates compared with survey reports of Heart

attack) and average change in odds ratio per year of

age: United States, 1986

Average

change in

odds ratio

Underlying cause of Average odds per year

death on death certificate ratio of age

Cardiovascular disease . . . . 4.31 -0.099

Heart disease . . . . . . . . . . . . 5.31 -0.124

Heafi attack . . . . . . . . . . . . . 4.94 -0.112

SOURCE: National Center for Health Statistics. National

Mortality Followback Survey. 1986.

assigned to the category Symptoms, signs, and illdefined conditions, ICD–9 Nos. 780-799.

Table J shows the number and percent of deaths in

1985 to persons 25 years of age and over classified to

this category, by age, race, and sex. The percents are

about the same for males as for females and slightly

higher for black decedents than for white decedents.

By age, the percent is highest for the age group 25-34

years (3.19 percent), but it declines rapidly to 0.98

percent at ages 75–84 years and increases only slightly

thereafter (figure 9). Using this as an index of the

quality and completeness of reporting cause of death,

there is no indication of a decline in the quality of

reporting with increasing age. However, the index

represents the physician’s use of medical terms that

are codable to informative diagnostic categories in the

ICD, not the reliability or validity of these terms in

relation to the actual diagnosis of cause of death.

Multiple causes of death

Death among the oldest old appears to have a

somewhat opportunistic character, with many chronic

conditions competing to be the precipitating cause.

The particular cause of death is less the result of a

clearly defined etiological path than the random result

of a more generalized deterioration of the capacity for

life. Data on the reported number of chronic conditions contributing to death, by age of decedent, are

available from multiple cause-of-death data from

NCHS.

TableK a.ndfigure 10 show the average number of

conditions reported on death certificates in the United

States in 1985 for persons 25 years and over, by age,

48
TableJ. Numberof deaths and numberand percentof deathsdue to Symptoms, signs, and ill-defined condit10n!3,by sex, race,and age: UnitedStates,1985

Both sexes Male Female

Total Ill-defined Total Ill-defined Total Ill-defined

Race and age deaths deaths Percent deaths deaths Percent deaths deaths Percent

All races Number Number Number

25-34 years . . . .

35-44 years . . . .

45-54 years . . . .

55-64 years . . . .

65-74 years ,.. .

75-84 years . . . .

85 years and

over . . . . . . . . . .

Not stated . . . . . .

White

25-34 years . . . .

35-44 years . . . .

45-54 years . . . .

55-64 years . . . .

65-74 years . . . .

75-84 years .,. .

85 years and

over . . . . . . . . . .

Not stated . . . . . .

Black

25-34 years ,., .

35-44 years . . . .

45-54 years . . . .

55-64 years . . . .

65-74 years . . . .

75-84 years .,. .

85 years and

over . . . . . . . . . .

Not stated . . . . . .

51,852

65,815

116,634

286,480

482,646

568,848

1,655

1,490

1,731

3,331

4,832

5,581

5,160

92

1,113

1,017

1,219

2,553

3,849

4,592

4,481

76

512

442

492

747

940

942

633

16

3.19

2.26

1.48

1.16

1.00

0.98

37,354 1,133

1,041

1,154

2,245

2,957

2,821

1,710

63

791

712

804

1,723

2,385

2,319

1,428

53

320

307

337

502

546

473

257

10

3.03

2.39

1.57

1.26

1.04

1.01

14,498

22,321

43,314

108,769

199,629

288,976

522

449

577

1,086

1,875

2,760

3,450

29

322

305

415

830

1,464

2,273

3,053

23

192

135

155

245

394

469

376

6

3.60

2.01

1.33

1.00

0.94

0.96

1.24

. . .

3.11

1.83

1.23

0.92

0.85

0.87

1.18

. . .

5.15

2.67

1.79

1.43

1.59

1.79

2.23

. . .

43;494

73,320

177;711

283,017

279,872

419,051

877

1.23 141,653

491

1.21

. . .

277,398

. . . 386

38,463

49,608

92,204

241,237

422,956

513,954

2,89

2.05

1.32

1.06

0.91

0.89

28,102

32,907

58,347

151,038

249,919

253,056

2.81

2.16

1.38

1.14

0.95

0.92

10,361

16,701

33,857

90,199

173,037

260,898

389,513

702

1.15

. . .

130,583

377

1.09

. . .

258,930

325

12,144

14,779

22,486

41,836

55,032

50,000

4.22

2.99

2.19

1.79

1.71

1.88

8,415

9,724

13,821

24,657

30,310

23,804

3.80

3.16

2.44

2.04

1.80

1.99

3,729

5,055

8,665

17,179

24,722

26,196

26,675

158

2.37

. . .

9,780

106

2.63

. . .

16,895

52

SOURCE:NationalCenterfor Health Statistics. National Vital Statistics System. 1985.

race, and sex of the decedent. Excluded from these

counts are “external” causes, that is, accidents, suicides, and homicides, because these causes are also

represented by the “nature of the injury,” that is,

whether the injury was a fracture, cut, abrasion, etc.

The average number of reported conditions was fairly

constant at about 2.5 for the age groups 25–34 years to

45-54 years, then increased steadily to 2.89 for persons aged 75-84 years old and over. The number of

conditions by age was about the same for males and

females and for white and black decedents.

The increasing number of conditions reported

with increasing age presented as a percent distribution

is shown in table L and figure 11. For each broad age

group-25-64 years, 65–84 years, and 85 years and

over—the number and percent of death certificates on

which one, two, three, or four or more conditions were

reported in 1985 is shown in table L. The percent with

one condition decreases from about 24 percent for

decedents 25-64 years to about 14 percent for deaths

at ages 85 years and over. The percent with four or

more conditions increases between these ages fi-om22

to 28 percent.

Discussion

Several sources were usedtoexamine the nature of

cause-of-death data from the death certificate with

respect to the health of the elderly population. One of

these was the 1986 National Mortality Followback

49
3.5–

3.0–

2.5–

E 2.0–

g

E 1.5-

1.0-

0.5-

25-34 35-44 45-54 55-64 65-74 75-84 85 years

years years years years years years and over

Age

SOURCE:NationalCenterfor Health Statistics. National Vial Statistics System. 1985.

Figure 9. Percent of deaths due to Symptoms, signs, and ill-defined conditions, by age: United States, 1985

Survey. Survey responses on the medical history of

decedents were correlated with their reported underlying cause of death on the death certificate. Another

approach was examining whether statistical indicators of imprecise diagnosis of cause of death on the

death certificate as classified under the ICD changed

systematically with increasing age of decedent. Finally,

multiple cause-of-death data were examined to determine whether more contributing conditions were reported for the older population than for the younger

population.

The study shows an association between medical

history on the survey and underlying cause of death

from the death certificate for each of the conditions

selected from the NMFS. A medical history of conditions hypothesized to be associated with the fatal

outcome did increase the risk of death for the selected

cause, as measured by the odds ratio. The degree to

Table K. Average number of medical conditions reported on death certificates, by race, sex, and age:

United States, 1985

.. All races White Black All other

Age Total Male Female Total Male Female Total Male Female Total Male Female

25-34 years . . . . . . . 2.52 2.52 2.53 2.51 2.51 2.52 2.54 2.53 2.54 2.59 2.58 2.60

35-44 years . . . . . . . 2.51 2.50 2.52 2.48 2.48 2.50 2.57 2.56 2.58 2.59 2.64 2.52

45–54 years . . . . . . . 2.52 2.50 2.56 2.50 2.49 2.52 2.58 2.52 2.67 2,69 2.65 2.73

55-64 years . . . . . . . 2.63 2.62 2.66 2.63 2.62 2.65 2.66 2.61 2.73 2.76 2.74 2.80

65-74years . . . . . . . 2.78 2.77 2.80 2.79 2.78 2.80 2.75 2.70 2.81 2.96 2.95 2.97

75-64 years . . . . . . . 2.89 2.88 2.89 2.89 2.89 2.89 2.82 2.78 2.85 3.02 3,02 3.03

85 years and

over . . . . . . . . . . . . 2.89 2.91 2,88 2,89 2,92 2.88 2.81 2.79 2.82 3.03 3.04 3,03

NOTE: Excludes external “E” codes listed as underlying cause.

SOURCE: National Center for Health Statistics, National Vital Statistics System, 1985.

50
3.0 r

2.2

t

25-34 35-44 45-54 55-64 65-74 75-84 85 years

years years years years years years and over

Age

NOTE:Excludesexternal“E” codes listedas underlyingcause.

SOURCE: National Center for Health Statistics. National Vital Statistioe System. 1985.

Figure 10. Average number of medical conditions reported on death certificates, by age: United States, 1985

which the history raised the likelihood of death from to the antecedent condition, except for stroke. A large

a particular cause compared with all other causes proportion of deaths at each age were due to cardlocombined varied considerably. vascular diseases. However, this proportion was only

While the presence of the antecedent condition weakly associated with the conditions reported on the

increased the likelihood of dying from this or a closely survey, especially among the elderly, suggesting that

related condition, the relationship was far from per- deaths from heart disease among the oldest old do not

fec~ thatis,proportions increase at each age,sometimes reflect the antecedent prevalence of serious chronic

severalfold, but are never close to 100 percent (except illness from this or related conditions.

for cancer, which is not comparable with other condi- In summary, with increasing age of decedent, the

tions on the survey). With increasing age, the associa- relationship between the reported medical history in

tion for every condition weakens. At the very oldest the NMFS and the physician’s report of underlying

ages, the underlying cause of death wasfairly invariant cause of death diminished considerably. Several

Table L. Number and percent distribution of deaths by number of conditions reported on death certificate,

according to age: United States, 1985

25–64 years 65-84 years 85 years and over

Number of conditions Percent Percent Percent

reported per certificate Number distribution Number distribution Number distribution

Total . . . . . . . . . . . . . . . . 446,558 100.00 1,026,737 100.00 411,486 100,00

1 ................... 106,348 23.82 175,573 17.10 59,005 14.34

2 ................... 133,235 29.84 285,770 27.83 117,997 28.68

3 ................. 108,423 24.28 280,924 27.36 118,936 28.90

40; more . . . . . . . . . . . . 98,552 22.07 284,470 27.71 115,548 28.08

NOTE:Excludes external “E” codes listed as underlying cause.

SOURCE: National Center for Health Statistics. National Vial Statistics System. 1985.

51
■ 25-64 years

❑ 65-84 years

35

r

❑ 85 years and over

30 -

25 -

g 20

Q

g 15 -

10 -

5 -

0 -

1 2 3 4 or more

Number of conditions reported

SOURCE:NationalCenterfor HealthStatistics. National

Vital StatisticsSystem.1985.

Figure 11. Percent distribution of deaths by number

of conditions reported on death certificate, according to age: United States, 1985

factors may account for this. One is that, for younger

persons, antecedent medical conditions may be more

acute and directly associated with the death. Thus, a

history of hypertension may indicate a much more

intensive disease process for a younger person dying

of CVD than for an elderly person dying of CVD. This

interpretation could be tested by introducing another

variable into the analysis, namely, duration of the

condition; this is because persons dying at a younger

age usually had the reported medical conditions for a

shorter period than persons dying at more advanced

ages.

Another possible reason for the weakening association with increasing age of decedent is poorer

diagnoses of cause of death for the elderly population

as compared with younger decedents. For the elderly,

particularly those dying in long-term care institutions,

medical certification of cause of death maybe handled

with less precision, with less knowledge about the

decedent’s medical history, and with less diagnostic

information from laboratory tests and autopsy than for

younger decedents. Another possible factor account52

ing for the change in association with increasing age is

that the informant on the NMFS was simply less

knowledgeable about the health history of older decedents compared with younger decedents.

With respect to completeness of medical certification, underlying cause-of-death data show little deterioration with increasing age. The percent of deaths

assigned to the category Symptoms and ill-defined

conditions as an underlying cause of death was very

small and increased little with advancing age. This

suggests that certifying physicians are about equally

likely to provide an unambiguous, specific, and codable cause of death at any age. However, the comparisons with survey data suggest that the reported causes

are more informative with respect to medical history

for younger decedents than for older decedents.

Multiple cause-of-death data show that the reported number of medical conditions increases with

age, apattern consistent with deaths of elderly persons

being multifactorial and more difficult to capture with

a single underlying cause of death than deaths of

younger decedents are. For 1985, the average number

ofreportedconditions onthedeath certificate increased

systematically with age, from 2.51 at ages 35-44 years

to 2.89 for persons 85 years and over.

The results of the study all support the usefulness

of underlying cause-of-death data at younger ages;

however, the results do lend credence to concerns

about its validity as an indicator of the health status of

the very old, whose health may be compromised by

more than one serious chronic condition. Verbrugge

questionedthecorrespondence between cause of death

and major illness or disability proximate to death for

the elderly (10). Moriyama was concerned about the

loss of useful information on current diseases and

conditions because of the emphasis in the medical

certification on a single underlying cause of death (8).

Kohn, taking the most extremeposition, recommended

that the cause of death for the elderly be reported as

“senescence” when “deaths in debilitated members of

the aged population cannot be ascribed to a disease

process that would cause death in a middle-aged

person” (9). While Kohn’s recommendation is impractical as well as at odds with the need for more care

and specificity in medical certification of death rather

than less, it nevertheless serves as a caution with
respect to interpreting cause-of-death data for the

elderly population. As such, it is consistent with the

concerns of Moriyama, Verbrugge, and others and

with the findings of this study.

One approach to more effective use of cause-ofdeath data from the death certificate for studying the

health of elderly people is increased reliance on multiple cause-of-death data, a statistical resource available in theUnitedStates but notin many other countries

on a routine basis (15). Most death certificates have

more than one reported medical condition cited as

contributing to death; this study shows that the average number of causes reported for deaths in the United

States is now close to 3.0 and that thenumberincreases

systematically with increasing age of decedent. Were

the present study to be repeated using multiple-cause

data, greater concordance might be found between

reported medical history from the NMFS and reported

causes of death from the death certificate. Such results

would strengthen the use of cause-of-death data for

studying the health of the elderly.

Further, duration of the medical condition reported in the survey may also affect the association

between cause of death on the death certificate and a

history of a related medical condition, on the assumption that death at an earlier age might reflect a

more severe condition. In a future study, duration

since onset of the major medical condition could be

used as a control for severity of illness. This, too, may

result in a more consistently strong association between cause of death and prior medical history with

increasing age.

While the results of this study pose questions

about the validity of underlying cause of death as an

indicator of health status of the elderly, additional

research taking into account multiple causes of death

and duration of illness is needed to further clarify the

way in which death certificates reflect the prior health

status of decedents and how well mortality data measure the health of our older population.

References

1. NationalCenterfor Health Statistics.Advancereport,

finalmortalitystatistics, 1986.Monthlyvitalstatistics

repom, vol 37 no 6, suppl. Hyattsville, Maryland:

Public Health Service. 1988.

2. Zemach R. What the vital statistics system can and

cannot do. Am J Public Health 74(8):756-8. 1984.

3. National Research Council. The aging population in

the twenty-first century: Statistics for health policy.

Washington: National Academy Press. 1988.

4. Gittelsohn A, Royston PN. Annotated bibliography of

cause-of-death validation studies, 1958-80. National

Center for Health Statistics. Vital Health Stat 2(89).

1982.

5. Kircher L. Validity of cause-of-death reported on the

death certificate: Issues for the present and future. In:

Proceedings of the biennial conference on records and

statistics. Hyattsville, Maryland: National Center for

Health Statistics. 188–93. 1987.

6. Stehbens WE. An appraisal of the epidemic rise of

coronary hezxtdiseaseanditsdecline.Lancet 8533:606-

11.1987.

7. Report on the workshop on improving cause-of-death

statistics, Virginia Beach, Virginia, October 15–17,

1989.Hyattsville, Maryland: National CenterforHealth

Statistics. 1990. To be published.

8. Monyama IM. Evaluation of medical certification of

causes of death: Review and critique of alternative

approaches for a national program. Contract No. 233-

79-2103. National Center for Health Statistics. 1980.

9. Kohn RR. Cause of death in very old people. JAMA

247(70):2793-7. 1981.

10. Verbrugge LM. Recent, present, and future health of

American adults. In: Breslow L, Fielding JE, LaveLB,

eds. Amual review of public health. Palo Alto, California Annual Reviews, Inc. 1989.

11. Edmonds FC, CurtinLR, RoystonP. NCHSpilot study

for a national cause-of-death validation study. Proceedings of the section on survey research methods.

American Statistical Association. 405–10. 1984.

12. National Center for Health Statistics. Annual summary

of births, marriages, divorces, and deaths, 1986.

Monthly vital statistics repo~ vo135no 13.Hyattsville,

Maryland: Public Health Service. 1987.

13. Kapantais G, Powell-Griner EP. characteristics of

persons dying of diseases of heart: Preliminary data

from the 1986 National Mortality Followback Survey.

Advance data from vital and health statistics; no 172.

Hyattsville, Maryland: National Center for Health Statistics. 1989.

14. World Health Organization. Manual of the International Statistical Classification of Diseases, Injuries,

and Causes of Death, based on the recommendations of

the NMh Revision Conference, 1975. Geneva World

Health Organization. 1977.

53
15.

16.

17.

18.

19.

20.

Israel RA, Rosenberg HM, Curtin LR. Analytical potentialformukiplecause-of-deathdata. Am JEpidemiol

124:161–79. 1986.

Feinberg SE. The analysis of cross-classified categorical data. Cambridge, Massachusetts: MIT Press. 1977.

Fleiss, JL. Statistical methods for rates and proportions. New York: John Wiley and Sons. 1973.

National Center for Health Statistics. Vital statistics of

the United States, 1985, vol II, mortality, part A,

technical appendix. Washington: Public Health Service. 1988.

National Center for Health Statistics. Multiple causes

of death in the United States. Monthly vital statistics

reporc vol 32 no 10, suppl 2. Hyattsville, Maryland:

Public Health Service. 1984.

National Center for Health Statistics. Catalog of public

use data tapes. Hyattsville, Maryland: Pubjic Health

Service. 1988.

Appendix I

Questions from the National

Mortality Followback Survey

The following questions from the National Mortality Followback Survey provided information used

in the study. The respondent was asked to check boxes

for “yes” or “no” for each item.

●

●

●

●

●

●

●

●

●

●

●

●

At anytime in the person’s life, did he or she ever

have high blood pressure (hypertension)?

At anytime in the person’s life, did he or she ever

have a heart attack?

At anytime in the person’s life, did he or she ever

have angina pectoris?

At any time in his or her life, did the person have

a stroke in which any resulting conditions (such as

paralysis, loss of vision or speech) lasted AT

LEAST ONE DAY OR LONGER?

At any time in the person’s life, did a doctor say

that the person had Alzheimer’s disease, chronic

brain syndrome, dementia, senility, or any other

serious memory impairment?

At anytime in the person’s life, did he or she have

OTHER mental, nervous, or emotional problems?

At any time during the person’s life, did he or she

have diabetes?

Was cancer the main condition leading to death?

At anytime during the person’s life, did he or she

have cancer of any kind, except skin cancer?

At anytime during the person’s life, did he or she

have asthma?

At anytime during the person’s life, did he or she

have anyotherlungcondition, such as emphysema

or bronchitis, lasting 3 months or longer?

At anytime in the person’s life, did he or she have

cirrhosis of the liver?

54
Appendix II

Selected underlying causes of death that were compared with specified conditions identified in the National Mortality Followback Study

(NMFS)

NMFS question Underlying cause of death

Hypertension— At anytime in theperson’s life, did he 1. Diseases of heart (ICD–9 Nos. 390-398,402,404-

or she have high blood pressure (hypertension)? 429)

2. Major cardiovascular diseases (ICD–9 Nos. 390-

448)

Heart attack—At any time in the person’s life, did he 1. Heart attack related (ICD–9 Nos. 410-414,427.5,

or she ever have a heart attack? 429.2)

2. Diseases of heart (ICD-9 Nos. 390-398,402,404-

429)

3. Major cardiovascular diseases (ICD–9 Nos. 390-

448)

Stroke-At any time in his or her life, did the person 1. Cerebrovascular diseases (ICD–9 Nos. 430A$38)

have a stroke in which any resulting conditions (such 2. Major cardiovascular diseases (ICD–9 Nos. 390–

as paralysis, loss of vision or speech) lasted AT 448)

LEAST ONE DAY OR LONGER?

Diabetes—At any time during the person’s life, did he 1. Diseases of heart (ICD–9 Nos. 390-398,402,404-

or she have diabetes? 429)

2. Major cardiovascular diseases (ICD–9 Nos. 390–

448)

Cancer—Was cancer the main condition leading to 1. Malignant neoplasms, including neoplasms of

death? lymphatic and hematopoietic tissues (ICD-9 Nos.

140-208)

2. Neoplasms (ICD-9 Nos. 140-239)

Asthma-At any time during the person’s life, did he 1. Chronic obstructive pulmonary diseases and allied

or she have asthma? conditions (ICD–9 Nos. 490-496)

NOTE:ICD-9 is NWh Revision InternationalClassificationof Diseases.

55
Appendix HI

National Mortality Followback Survey and death certificate

comparisons

Table 1.Number of deaths with underlying cause of cardiovascular disease and other causes, by age and

survey response: United States, 1986

Survey

response

Hypertension

Yes . . . . . . . . . . .

No . . . . . . . . . . . .

Unknown . . . . . . .

Heart attack

Yes . . . . . . . . . . .

No . . . . . . . . . . . .

Unknown . . . . . . .

Diabetes

Yes . . . . . . . . . . .

No . . . . . . . . . . . .

Unknown . . . . . . .

Stroke

Yes . . . . . . . . . . .

No . . . . . . . . . . . .

Unknown . . . . . . .

Age and underlying cause of death on death certificate

25-64 years 65–74 years 75-84 years 85 years and over

Cardio- Cardio-, Cardio- Cardiovascular vascular vascular vascular

disease Other disease Other disease Other disease Other

Number

93,150 105,990 128,060 109,030 159,460 112,780 118,800 58,540

68,590 221,060 80,140 135,340 122,600 136,560 128,190 88,030

6,990 16,920 11,920 11,640 16,690 15,160 17,410 10,560

88,930 45,490 117,380 51,780 129,970 49,640 66,680 26,670

74,990 290,670 96,640 198,240 159,630 205,540 188,020 125,620

4,810 7,800 6,090 6,000 9,150 9,310 9,690 4,850

36,680 44,060 54,550 43,400 65,720 39,180 33,530 22,970

127,530 290,810 159,940 205,000 226,380 217,000 223,120 128,650

4,520 9,100 5,620 7,620 6,650 8,310 7,750 5,520

34,780 38,020 66,450 54,700 109,060 59,300 100,750 39,810

127,910 296,290 145,280 192,690 179,900 195,540 151,990 109,430

6,050 9,640 8,380 8,620 9,800 9,650 11,650 7,910

Table Il. Number of deaths with underlying cause of heart-attack-related diseases and other causes, by age

and survey response: United States, 1986

Age and underlying cause of death on death certificate

25-64 years 65-74 years 75-84 years 85 years and over

Heart- Heart- Heart- Heartattack- attackSurvey

attack- attackrelated related related related

response diseases Other diseases Other diseases Other diseases Other

Heart attack Number

Yes . . . . . . . . . . . 71,290 63,130 94,900 74,260 99,510 80,100 48,240 45,110

No . . . . . . . . . . . . 42,330 323,330 54,880 240,000 93,520 271,650 112,250 201,390

Unknown ..,.... 2,910 9,700 3,750 8,340 6,160 12,300 6,650 7,890

56
Table Ill. Number of deaths with underlying cause of heart disease and other causes, by age and survey

response: United States, 1986

Age and underlying cause of death on death certificate

25-64 years 65-74 years 75-84 years 85 years and over

Survey Heart Heart Heart Heart

res~onse disease Other disease Other disease Other disease Other

Hypertension Number

Yes . . . . . . . . . . . 76,840 122,300 102,350 134,740 120,960 151,280 85,840 91,500

No . . . . . . . . . . . . 59,200 230,450 69,760 145,720 99,070 160,090 97,010 119,210

Unknown, . . . . . . 6,470 17,440 10,780 12,780 12,320 19,530 13,250 14,720

Heart attack

Yes . . . . . . . . . . . 84,080 50,340 107,960 61,200 112,450 67,160 56,970 36,380

No ...,,....,.. 54,070 311,590 69,610 225,270 113,150 252,020 131,420 182,220

Unknown, .,.,.. 4,360 8,250 5,330 6,760 6,750 11,710 7,710 6,830

Table IV. Number of deaths with underlying cause of cancer—international Classification of Diseases (lCD)

Nos. 140-208-and other causes, by age and survey response: United States, 1986

Age and underlying cause of death on death cetfificate

25-64 years 65–74 years 75-84 years 85 years and over

Cancer Cancer Cancer Cancer

Suwey (ICD NOS. (ICD NoS. (ICD Nos. (ICD NOS.

remonse 140-208) Other 140–208) Other 140–208) Other 140-208) Other

Cancer Number

Yes . . . . . . . . . . . 152,120 21,530 134,140 23,950 104,710 23,650 35,260 13,860

No . . . . . . . . . . . . 5,420 323,150 5,550 301,940 7,230 413,120 8,400 352,610

Unknown . . . . . . . 910 9,550 1,910 8,630 2,140 12,390 570 10,830

Table V. Number of deaths with underlying cause of cancer—international Classification of Diseases (lCD)

Nos. 140-239-and other causes, by age and survey response: United States, 1986

Age and underlying cause of death on death certificate

25-64 years 65-74 years 75-84 years 85 years andover

Cancer Cancer Cancer Cancer

Survey (ICD hfos. (ICD NOS. (ICD NOS. (ICD NOS.

response 140-239) Other 140–239) Other 140–239) Other 140-239) Other

Cancer Number

Yes . . . . . . . . . . . 153,190 20,460 135,040 23,050 105,740 22,620 35,720 13,400

No . . . . . . . . . . . . 6,330 322,240 6,300 301,190 7,670 412,680 9,120 351,890

Unknown . . . . . . . 910 9,550 1,910 8,630 2,190 12,340 570 10,830

57
Table V1.Number of deaths with underlying cause of cerebrovascular disease and other causes, by age and

survey response: United States, 1986

Age and underlying cause of death on death certificate

25-64 years 65-74 years 75-84 years 85 years and over

Cerebro- Cerebro- Cerebro- CerebroSurvey vascular vascular vascular vascular

response disease Other disease Other disease Other disease Other

Stroke Number

Yes . . . . . . . . . . . i 1,760 61,040 18,970 102,180 37,590 130,770 32,120 108,440

No . . . . . . . . . . . . 7,630 416,570 7,180 330,790 11,980 363,460 15,690 245,730

Unknown . . . . . . . 400 15,290 690 16,310 1,910 17,540 2,980 16,580

Table W. Number of deaths with underlying cause of chronic obstructive pulmonary disease and other

causes, by age and survey response: United States, 1986

Age and underlying cause of death on death certificate

25-64 years 65–74 years 75-84 years 85 years and over

Chronic Chronic Chronic Chronic

obstructive obstructive obstructive

Survey

obstructive

pulmonary p::::a~ery pulmonary pu/monary

response disease Other “ Other disease Other disease Other

Asthma Number

Yes . . . . . . . . . . . 3,460 31,840 6,320 26,660 6,350 33,170 810 15,510

No . . . . . . . . . . . . 6,870 455,030 17,530 408,500 20,620 483,520 8,510 382,510

Unknown . . . . . . . 400 15,090 980 16,140 1,680 17,900 220 13,970

58
Chapter 6

Diagnosis of

cardiovascular disease

in elderly populations

by Millicent W. Higgins, M.D., Associate

Director for Epidemiology and Biometry

Program, National Heart, Lung and Blood

Institute, National Institutes of Health

This paper provides a brief overview of studies of

cardiovascular disease (CVD) in the elderly sponsored

by the National Heart, Lung and Blood Institute. I will

emphasize international collaborative studies but will

present information about themagnitudeof theproblem

in the United States as background.

The prevalence of cardiovascular diseases and the

numbers of physician’s office visits, hospitalizations,

and deaths from cardiovascular disease among people

ages 65 and over are shown in table A (l-6). The

elderly make up only 12 percent of the population but

account for a disproportionately large amount of

prevalent illness, use of medical services, and expenditures for cardiovascular disease.

Mortality rates for cardiovascular disease rise

steeply with increasing age in men and women (figure

1), but rates provide an incomplete estimate of the

magnitude of the problem of cardiovascular disease in

the elderly. Morbidity data are also available and

provide (a) additional information about the frequency

and distribution of these conditions by age and (b) help

to measure the burden of illness in the elderly.

The FraminghamHeart Study initially began with

a cohort of middle-aged men and women (30-62

years). For over 40 years, this study has provided

unique information about the incidence of different

kinds of fatal and nonfatal cardiovascular disease by

age and sex for the white population. In both sexes,

incidence of cardiovascular disease rises dramatically

with increasing age. The most frequent condition is

coronary heart disease followed by stroke and congestive hemt failure, all of which increase steeply with

increasing age.Intermittent claudication islessfrequent

and does not increase with age after about age 60

(figure 2) (7).

Table A. Selected measures of impact of cardiovascular disease among persons 65 years of age and

over: United States, 1980’s

Item Number Percent

With hypertension . . . . . . . . .

With heart disease . . . . . . . . .

With cerebrovascular

disease . . . . . . . . . . . . . . . . .

Annual hospitalizations . . . . . .

Physician’s office visits . . . . . .

Annual deaths . . . . . . . . . . . .

Health care expenditures

in 1980 . . . . . . . . . . . . . . . . .

Population . . . . . . . . . . . . . . .

18,500,000

8,900,000

1,400,000

3,200,000

27,000,000

800,000

$20 billion

30 million

32

40

60

12

‘Blood pressure > 140/90 mmHg or on antihypertensive

medication.

SOURCES: Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension

prevalence and the status of awareness, treatment, and control

in the United States. January 11, 1984.

Adams PF, Hardy AM. Current estimates from the National

Health Interview Survey, 1988. National Center for Health

Statistics. Vital Health Stat 10(173). 1989.

Graves EJ. 1988 Summary: National Hospital Discharge

Survey. Advance data from vital and health statistics; no 185.

Hyattsville, Maryland: National Center for Health Statistics.

1990.

National Center for Health Statistics. Unpublished tabulations

from the 1985 National Ambulatory Medical Care Survey.

Personal communication. June 1988.

National Center for Health Statistics. Vital statistics of the

United States, 1987, VOI11,mortality, part B. Washington:

Public Health Service. 1990.

Hodgson TA, Kopstein AN. Health care expenditures for major

diseases in 1980. Health Care Financ Rev 5(4):1-12. 1984.

At ages over 65, many individuals have more than

one of these conditions, and having one cardiovascular condition increases the risk of developing another.

Coronary heart disease, congestive heart failure, and

atrial fibrillation are strong predictors of stroke

59
5,000

4,000

3,000

2,000

1,000

0

— Black men

--—-- White men

.—. — .— -

35-44 45-54 55-64 65-74 75-84

years years years years years

Age

NOTE:Includes Ninth Revision International Classification of Diseases codes 390-459.

Figure 1. Death rates for cardiovascular disease for persons 35-84 years of age, by age, race, and sex:

United States, 1987

occurring at a later age (8). Recently, attention has

been drawn to the substantial proportion of myocardial infarctions that are not recognized at the time but

are detected when routine electrocardiograms are obtained later. Rates of unrecognized myocardial infarction are higher in women than in men and occur

with increasing frequency at older ages in both sexes

(9). In the Framingham experience, more than 40

percent of fiist myocardial infarctions were unrecognized in women, and about 33 percent were unrecognized in men. In interview surveys such as the

National Health Interview Survey, information can be

obtained only on events that have been diagnosed

clinically and are reported by the respondents or their

family members. Thus, this measure of the prevalence

of coronary heart disease is incomplete.

The Framingham Heart Study was the model for a

number of other studies that were added later. These

include the Honolulu and Puerto Rico Heart Studies

and the Yugoslavia Heart Study. These studies have

participated in domestic and international compari60

sons, as well as in comparisons with U.S. mainland

populations, whose experience of cardiovascular

disease is substantially different. Similar methods

were used in these studies so that comparisons could

be made with populations whose mortality rates were

lower and whose risk factor levels and distributions

provided a broader range of experiences than was

available in the United States.

One of the earliest international studies of cardiovascular disease wasthe Seven Countries Study, which

has been reported extensively in the literature (10).

The Ni-Hon San Study can be used to illustrate some

of the methodologic issues that are important in studies of the elderly. The study of Atherosclerosis Risk in

Communities (ARIC), which shares some features in

common with the Multinational Monitoring of Trends

and Determinants in Cardiovascular Diseases

(MONICA) Study, promises to provide new opportunities for international collaboration (11, 12). Intersalt

is a recent collaborative effort to evaluate blood pressure and its relationship with obesity, sodium and
c

.=o

Jg

a!

a.

Cardiovascular disease

60 -

“-—--— Coronary heart disease

----------- Stroke and transient ischemic

--—-— Congestive heart failure

..................... Intermittent claudication

50 -

40 -

Men Women

30 -

20 -

10 -

............................

o !

35-44 45-!54 55-64 65-74 75-84 35-44 45-54 55-64 65-74 75=84

years years years years years years years years years years

Age

SOURCE: National Institutes of Health. The Framingham Study: an epidemiological investigation of

cardiovascular disease, section 34. NIH publication no. 87-2703.1987.

Figure 2. Average annual incidence of cardiovascular disease for persons 35-64 years of age, by age and sex:

Friimingham Heart Study 30-year foiiowup

potassium, and other electrolytes. This study also

encompasses a broad range of prevalence rates of

hypertension, obesity, and electrolyte intake and

excretion (13).

In 1950 mortality statistics indicated that there

were substantial differences in death rates for atherosclerotic heart disease and stroke for Japanese men

in Japan, Hawaii, and California, as shown in table B

(14,15). (For the white population intheUnitedStates,

rates for coronary heart disease, not shown, were even

higher.) Across the Japanese populations, we see that

the pattern for stroke is in the reverse direction; death

rates were highest for those in Japan, intermediate for

those in Hawaii, and lower for Japanese in the United

States. Some of the questions that have already been

raised about the validity of differences in death certitlcate enties led to the design of studies that would

provide more accurate information about relationships

between mortality and morbidity rates and risk factor

levels. A major emphasis of the study of coronary

heart disease and stroke in Japanese men in Japan,

Honolulu, and San Francisco was an attempt to use

comparable methods. Although this effort has not

been entirely successful, some valid comparisonshave

made use of information on autopsy findings, morbidity, mortality, and risk factors.

Comparison of electrocardiogram evidence of

myocardial infarction showed no significant differences in prevalence between the Japanese in Japan and

Honolulu, but there is a substantial difference between

these populations and those on the U.S. mainland. The

pattern of angina pectoris is similar to that for

61
Table B. Rate of mortality, incidence, and prevalence

of corona~ heart disease and stroke for Japanese

men ages 55-64 years: Japan, Hawaii, and California

Item Ja~an Hawaii Ca/ifomia

Mortalityi

Coronaryheart disease . . . 160

Stroke . . . . . . . . . . . . . . ...525

lncidence2

Fatal coronary heart

disease . . . . . . . . . . . . . . . 1.0

Hemorrhagic stroke . . . . . . 1.7

Thromboembolic stroke . . . 3.0

Prevalence

Myocardial infarction

confirmed by electrocardiogram . . . . . . . . . . . . 5.3

Angina pectoris . . . . . . ...11.2

Stroke . . . . . . . . . . . . . . ...35.4

Rate

300

300

5.2

14.3

10.7

464

230

...

..-

---

10.8

25.3

10.4

‘Mortality per 100,000 in 1950.

2Average annual incidence per 1,000.

3Prevalence per 1,000.

in Honolulu than in Japan, which was not expected.

However, small cerebral artery disease is more frequent

in Japan. Investigations are continuing in Japan and

Hawaii in thehopethatthedifferencescanbeexplained.

Clearly, comparable methods inexaminingpeople

and specimens are an important advance. However, it

is also important to consider the participation rates and

the frequency with which examinations are done,

since these aspects of a study can have a marked

impact on ability to detect disease, to generalize the

results to the populations horn which the study subjects come, and to make comparisons between populations living in different areas.

The ARIC Study was established as a collaborative study in the United States to investigate the

epidemiology and natural history of atherosclerosis

and clinical atherosclerotic diseases in cohorts using

new methods of measurement and detection of atherosclerosis by a noninvasive method. New risk factors as well as the established risk factors are being

SOURCES: Yano K, MacLean CJ, Reed DM, et al. A comparison of the 12-year mortality and predictive factors of coronary

measured (11). Preliminary information is available

heart disease among Japanese men in Japan and Hawaii. Am about variation in cardiovascular disease risk factors,

J Epidemiol 127:478-87.1988. medical care, and disease, by race, sex, and place and

Takeya Y, Popper JS, Shimizu Y, et al. Epidemiologic studies

of coronary heart disease and stroke in Japanese men living in

Japan, Hawaii and California: Incidence of stroke in Japan and

Hawaii. Stroke 15:15-23.1984.

coronary heart disease. Stroke prevalence rates were

similar for the Japanese populations in Honolulu and

California, contrary to expectations; however, there is

a major discrepancy between these populations and

the Japanese in Japan, who have stroke prevalence

rates more than three times as high. Over the course of

time, as this originally middle-aged population has

advanced in years, we have gained information on

incidence in the elderly. The comparisons must be

restricted to fatal coronary heart disease and hemorrhagic and thromboembolic stroke, because these

conditions could be detected using comparable criteriain the two populations. Again, there are differences

in stroke rates between the Japanese residents and the

other two cohorts and between coronary heart disease

in U.S. mainland residents and the other two cohorts

(14). More atherosclerosis was found in the coronary

arteries of men in Honolulu than in Japan, but ak.o

there was more atherosclerosis in the circle of Willis

over time. The important contribution that ~hisstudy

can make to our understanding of disease in populations is that information about cohorts undergoing

detailed examination to detect all manifestations of

cardiovascular disease can be related to information

from surveillance of the populations from which the

cohorts come. Approximately 10times asmany people

are included in the community surveillance as in the

cohort examinations. Thus, the number of new events

is much larger for the community, but the completeness and accuracy of this information may not be as

good as information resulting from repeated examinations of the cohort. The goal for surveillance is more

circumscribed and is restricted to the investigation of

hospitalizedmyocardial infarctions and fatal coronary

heart disease. Approaches to community surveillance

for the fatal events include identification of possible

coronary heart disease deaths from vital statistics

records supplemented by information from the next of

kin or other informants and from hospital and physicians’ records. Standardized criteria are used to classify the events. Both cohort and surveillance data will

be related to national vital statistics information to

62
compare the more detailed information with

routinely available for the U.S. population.

what is

A pilot study known as the Cardiovascular Community Surveillance Project (CCSP) investigated the

ability to use readily available mortality and hospital

statistics to identify cases of coronary heart disease

and stroke. Potential cases were identified through an

initial screening, and variable sampling rates were

developed for International Classification of Diseases

(ICD) codes. In ARIC sampling, rates are highest

for codes with the highest probability of identifying

coronary heart disease or stroke events. The sampling fraction for death certificates is 100 percent for

ICD codes 410-414 and429.2, but only 25 percent for

codes where ischemic heart disease is less likely to be

present (11). Hospital records are abstracted according to primary or secondary discharge diagnoses. The

sampling fractions are 100 percent for acute myocardial infarction (ICD–9 code 410); 50 percent for other

acute and subacute ischemic heart disease (ICD–9

code 411); 25 percent for old myocardial infarction,

angina pectoris, and other forms of chronic ischemic

heart disease (codes 412-414); and 10 percent for

conditions less likely to yield cases of acute myocardial infarction (ICD-9 codes402,427,428, and518.4).

Diagnostic criteria are based on information about

chest pain, cardiac enzymes, and electrocardiograms,

which are classified according to the Minnesota code.

This strategy is designed as a cost-efficient approach

to monitoring cardiovascular events in defined

communities.

The National Heart, Lung and Blood Institute

qualifies as an associate member of the “MOMCA

Study, sponsored by the World Health Organization,

through its ARIC Study. MONICA’s objectives are to

monitor trends and determinants in cardiovascular mortality, coronary heart disease, and cerebrovascular disease morbidity in participating countries and to relate the trends to changes in risk

factors, living habits, health care, and socioeconomic

characteristics (12). This study includes 26 countries,

many of which are European. There are two sites

in North America: One in Canada and one in the

United States. There are also centers in New Zealand,

Australia, Japan, and China, but developing countries, unfortunately, are not represented adequately.

Opportunities certainly exist for extending internationalcollaborative studies of cardiovascular disease

to include participants from developing as well as

developed countries.

Collaborative studies have provided data not previously available. In addition, these studies have led to

the development and use of standardized methods that

other researchers can adopt. Greater attention has been

paid to quality control and to the training of personnel

who can participate in epidemiologic studies. Analyses

of performance at different sites overtime have shown

that agreement was not very good initially, but training and practice and circulation of case histories to all

MONICA participants led to improved agreement on

classifying events (16).

In conclusion, I would like to comment on trends

in cardiovascular disease in the United States, where

the elderly population is increasing disproportionately. Despite declining death rates, these diseases

continue to be the leading cause of death and a major

cause of morbidity. The percentage of various cardiovascular andnoncardiovascular diseases that occur

among the elderly has increased especially at ages 75

and over (table C). While these trends are favorable,

they indicate that cardiovascular diseases will continue

to be a major health problem in the older members of

the U.S. population. Opportunities for international

studies are probably better now than they have ever

been. We are aware of opportunities and pitfalls, and

we can focus oureffortson collaborative investigations

in elderly populations to take advantage of knowledge

gained from previous studies of middle-aged populations and to take advantage of new technologies to

address unanswered questions.

Table C. Percent of deaths occurring after age 75, by

year and cause of death: United States, 1950 and

1988

Cause of death 1950 1988

‘Heartdkease . . . . . . . . . . .

Coronary heart disease . . .

Stroke . . . . . . . . . . . . . . . . .

Cancer . . . . . . . . . . . . . . . .

Chronic obstructive

pulmonary disease . . . . . .

Diabetes . . . . . . . . . . . . . . .

Pneumonia . . . . . . . . . . . . .

Allcauses . . . . . . . . . . . . . .

36

33

42

22

26

26

32

29

Percent

59

59

68

36

49

46

74

49

63
References

1.

2.

3.

4.

5.

6.

7.

8.

Joint National Committee on Detection, Evaluation,

andTreatment of HighBlood Pressure.Hypertension

prevalenceandthe statusof awareness,treatment,and

control in the United States.January 11, 1984.

Adams PF, Hardy AM. Current estimates from the

National Health Interview Survey, 1988. National

CenterforHealthStatistics.VitalHealthStat 10(173).

1989.

Graves EJ. 1988 summary: National Hospital Discharge Survey. Advance data from vital and health

statistic no 185. Hyattsville, Maryland: National

Centerfor Health Statistics. 1990.

National Center for Health Statistics. Unpublished

tabulations from the National Ambulatory Medical

Care Survey.Personal communication. 1985.

NationalCenterforHealthStatistics.Vitalstatisticsof

the United States, 1987, vol II, mortality, part B.

Washington:Public Health Service. 1990.

HodgsonTA, KopsteinAN. Health care expenditures

for major diseases in 1980. Health Care Financ Rev

5(4):1–12. 1984.

NationalInstitutesof Health.The FraminghamStudy:

An epidemiological investigation of cardiovascular

disease,section 34. NationalInstitutesof Health publication no 87–2703. 1987.

Kannel WB, Wolf PA, Verter J. Manifestations of

coronary disease predisposing to stroke. JAMA

250:2942-6.1983.

9.

10.

11.

12,

13.

14,

15.

16.

Kannell WB, CupplesLA. Silent myocardial infarction.In:SinghBN,ed. Silentmyocardialischemiaand

angina.New York: PergamonPress. 1988.

KeysA, ed. Sevencountries-A muhivariate analysis

of death and coronary heart disease. Cambridge,

Massachusetts:Harvard UniversityPress. 1980.

The ARIC investigators.The AtherosclerosisRisk in

Communities (ARIC) study Design and objectives.

Am J Epidemiol 129:687–702.1989.

MultinationalMonitoringofTnmdsandDeterminants

in CardiovascularDiseases(MONICA)project principalinvestigators,preparedby PedoeHT.The World

HealthOrganizationMONICAProject:Amajorinternational collaboration. J Clin Epidemiol 41(2):105–

14.1988.

Intersalt Cooperative Research Group. Intersak An

internationalstudy of electrolyte exc~tion and blood

pressure: Results for 24 hour urinary sodium and

potassiumexc~tion. Br Med J 297:319-28.1988.

Yano K, MacLeanCJ,Reed DM, et al. A comparison

of the 12-year mortality and predictive factors of

coronaryheart disease among Japanesemen in Japan

and Hawaii.Am J Epidemiol 127:476-87.1988.

TakeyaY,PopperJS, ShimizuY, et al.Epidemiologic

studiesofcoronaryheartdiseaseandstmkeinJapanese

menlivinginJapan,Hawaii,andCalifornia:Incidence

ofstrokeinJapanandHawaii.Stroke 15:15–23,1984.

Tunstall-PedoeH. Diagnosis, measu~ment and surveillanceof coronaryevents.IntJEpidemiol 18(suppl

1):S169–73. 1989.

64
Part !11

Health promotion and disease prevention

among the aged
Introduction

by Gerry E. Hendershot, Ph.D., Chief, Illness

and Disability Statistics Branch, National

Center for Health Statistics

In this international collaborative effort on aging

for health promotion and disease prevention statistics,

our goal is to improve measures of health-related

behaviors and use of preventive services among the

aged population, and to standardize measures across

nations so that comparative analyses can beundertalcen.

We hope these analyses will reveal some important

determinants of the success and failure of health

promotion and disease prevention programs.

The countries that are prospectively involved are

The Netherlands and the United States. The Netherlands was particularly interesting to us in the U.S.

National Health Interview Survey because The Netherlands conducts a national health interview survey

that is very similar in important respects to ours. There

are also some important similarities and differences in

the population characteristics of the two nations that

make potential comparisons interesting.

We would like to add other countries to this

collaborative effort on health promotion and disease

prevention statistics whenever they are available and

interested.

67
Chapter 7

Statistics on health

promotion and disease

prevention in The

Netherlands

by Henk Swinkels, Ph.D., Netherlands Central

Bureau of Statistics, Department for Health

Statistics

Introduction

Since World War II, the costs of medical care in

The Netherlands have increased sharply. The costs of

care for different kinds of patients and for the prevention of diseases increased from 1 billion guilders in

1953to 37 billion guilders in 1987 (table A).

Recent health statistics and epidemiological research have shown that in the last 15–20 years there

has been hmdly any change in the perceived health

status of the population (table B) and that social (table

C) and geographic differences still remain.

In 1982, the World Health Organization (WHO)

predicted that if the current European development of

physical, economic, and social environmental factors

continued and people did not behave in a healthier

way, there would be a dangerous situation by the year

TableA. Cost of health care as a percent of net

national Income at market prices: The Netherlands,

1953-87

Percent of

net rMtiona/

Guilders product at

Year in billions market prices

1953, . . . . . . . . . . . . . . . . . . 0.8

1958 . . . . . . . . . . . . . . . . . . . 1.4

1963 . . . . . . . . . . . . . . . . . . . 2.2

1968, . . . . . . . . . . . . . . . . . . 4.8

1973, . . . . . . . . . . . . . . . . . . 12.3

1978 . . . . . . . . . . . . . . . . . . . 23.4

1983, ,, ., . . . . . . . . . . . . . . 33.0

1987 .,...,,.,. ..,...... 36.8

3.5

4.2

4.7

5.8

7.9

8.7

9.7

9.6

SOURCE: Netherlands Central Bureau of Health Statistics.

Historical series of The Netherlands, 1899-1989. The Hague.

1989,

2000 (l). Health status would decrease absolutely

despite the continuing high level of the use of health

services. Therefore, Dutch Government policy up to

the year 2000 will aim at the promotion of health,

given limited provisions. Policy objectives will be

expressed as much as possible in terms of the desired

improvement in health of the Dutch population. Attention will k-edrawntoinfluencingphysical, economic,

and social environmental factors in order to promote

healthier lifestyles. In connection with these objectives,

it is necessary to measure relations existing between

cultural, social, and other environmental factors, on

the one hand, and health, diseases, and the quality of

people’s lives, on the other.

Health can be seen as a state of balance determined

by the circumstances people are in and the power they

have, or can get with the aid of others, to defend

themselves from disturbances (1, p. 10), An important

aspect of this definition of health isitsrelative meaning

with regard to different age groups. Every phase in life

has its own threats to health and ways of coping with

them. This relative meaning of health is one of the

reasons why in The Netherlands a special policy for

the elderly exists. Another reason is the increasing

number of elderly people. Asin many other developed

countries, the percentage of elderly people in The

Netherlands is increasing rapidly. At the moment the

population of The Netherlands amounts to 14.7 million people, among whom there are 1.8million persons

aged 65 years and over (table D). This is 12.4 percent

of the total population. Population forecasts of the

Netherlands Central Bureau of Statistics predict that

persons 65 years and over will constitute about 14

percent in the year 2000 and about 25 percent in the

69
Table B. Percentdistributionof all adultsand elderlyadults by perceptionof generalstate of health,according

to age: The Netherlands,1970 and 1987

18years and over 65 years and over

Perception of general Standard Standard

state of health and vear Percent error Percent error

Very good

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Good

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Fair

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Notverygood

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Bad

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28.1

27.7

50.6

52.1

12,9

12.1

1.2

2.5

1.3

0.6

0.8

0.2

0.7

0.3

0.3

0.2

18.9

15.5

42.4

46.7

21.7

22.9

12.9

9.2

4.1

5.7

2.7

1.1

3.4

1.5

2,8

1.3

2.3

0.9

1.3

0.7

SOURCES:SwinkeLs H. Trends in gezondheidsindicatoren, 1970-1984(Trends of health indicators, 1970-1984). Monthly Bull

Health Stat(7):5-15. 1986. (ln Dut&h with English summary.)

Swinkels H. Trendcyfers G6zondheidsenquite, 1981-1987 (Trendfigures, Netherlands Health lnterviewSurvey, l 981-1987).

MonthlyBull Health Stat(8-9):14-20. 1988.

TableC. Percentof personswith healthstatusof

fair, notverygood, andbad,bylevel ofeducation:

The Netherlands,1983-85

TableD. Numberand percentdistributionofmedlum

variant ofpopulation forecastforThe Netherlands

byage: The Netherlands,1988,2000,and2035

Level of Acjustedfor Standard

education lJnacJusted age and sex error

Primary school . . . . . 35.2 29.0 0.6

Junior (vocational)

training . . . . . . . . . . 17.9 20.1 0.5

Secondary (vocational)

training . . . . . . . . . . 13.9 16.7 0.4

Vocational college . . . 11.9 12.7 0.7

University . . . . . . . . . 12.5 13.2 1.3

SOURCE: Netherlands Central Bureau of Statistics. Netherlands Health Interview Survey, 1981-1985. The Hague. 1988.

Aae 1988 2000 2035

Number in millions

Allages . . . . . . . . . . . . . . 14.7 15.6 14.6

Percent distribution

0-19years . . . . . . . . . . . . 26.9 24.4 20.5

20-64 years . . . . . . . . . . . 60.7 61.5 54.8

65 years and over . . . . . . 12.4 13.5 24.7

SOURCE: Cruijsen H. Bevolkingsprognose voor Nederiand,

1986-2035 (Population forecasts for The Netherlands,1986-

2035). Monthly Bull Popul Stat 2:15-21.1987. (In Dutch with

English summary.)

70
year 2035. This means that the percentage of persons

aged 65 and over is expected to double by the year

2035.

National objectives

In 1984, the Dutch Government accepted the 38

targets developed by WHO (2, p. 5). In The Netherlands these targets are of great importance for national

health policy: In fact, they are regarded as identical to

health policy. A selection of targets of relevance to the

elderly is listed in appendix I. A number of these

targets deal with health status, lifestyle, and environmental factors.

The national objectives for health promotion and

diseasepreventionto bepresentedinthispaper and the

statistics concerning these objectives arederivedmostly

from The Netherlands 1988 report, “Health for All by

the Year 2000” (2). This report was produced by the

Ministry of Welfare, Health and Cultural Affairs in

cooperation with the Netherlands Central Bureau of

Statistics. The majority of the data in this report are

derived from the Netherlands Central Bureau of Statistics and in particular fi-om its Health Interview

Survey. The report describes progress toward the

targets developed by WHO.

During recent years there has been a shift of

emphasis in policy in The Netherlands, which calls for

closer observation of the effects of policy on general

standards of health (3, p. 132). Increasingly, this is

being done in accordance with the methods advocated

by WHO. These methods are:

● Setting up health and policy goals.

● Determining indicators against which developments relating to these goals can be measured.

● Monitoring these developments (2, p. 107).

In The Netherlands the Health 2000 memorandum, the national Health for All document, pays close

attention to factors outside the bounds of health care,

such as physical and social environment and lifestyle.

These factors are being taken into account, and the

Government has announced its intention to set up

preventive measures and intersectional policy. The

position of the elderly in Dutch society has been an

important area of concern in Government policy for

many years now. One of the ways in which this

concern is manifested is the Government’s interest in

the financial problems of those sectors most affected

by the aging of the population.

An important topic in health promotion and disease prevention in The Netherlands is the laws, regulations, and programs aimed at protecting the public

against the promotion, production, distribution, and

use of potentially harmful consumer goods. Dutch

policy in this respect is based on the principle that

every citizen has the right to health and safety, The

Ministry of Welfare, Health and Cultural Affairs has

a general responsibility for safety in the home and is

specifically responsible for safety with respect to

sports and leisure activities, pesticides, and consumer

products. In its health policy this Ministry places

considerable emphasis on the promotion of healthy,

safe lifestyles and on avoiding unnecessary hazards to

health.

A second topic dealing with the policy on health

promotion and disease prevention is the existence of

laws, regulations, and practices integrating representative public participation in bodies responsible for

health promotion at all levels. Public involvement in

health education and the promotion of healthy living

has grown in importance during recent years. Efforts

are being made, through supplementary legislation,

planning, and funding, to arouse greater public interest in the factors that may positively or adversely

affect health, thus enabling the public to make more

conscious decisions regarding their health.

A third topic deals with education programs to

increasepeople’s knowledge, motivation, and skills to

stay healthy. In The Netherlands the following education programs and information campaigns have been

initiated:

Q The current intensive alcohol information campaign was started in 1987. It is being conducted in

the mass media, schools, and health service and

constitutes a serious drive to reduce alcohol consumption.

● A multiyear information plan aimed at promoting

discussion on tobacco use was completed early in

1988. It focused on preventing young people from

starting to smoke, helping smokers to give up

smoking, and protecting nonsmokers.

71
s An important item of the national objectives is the

promotion of healthy habits such as maintaining

good nutrition, not smoking, getting enough exercise, and coping with stress. With respect to

good nutrition, the following should be mentioned:

In April 1986 the Nutrition Council issued an

advisory report titled “Guidelines on Good Nutrition” (4), which sets out the components of a

healthy diet. Over the last few years the Nutrition

Council and the Health Council have issued a

number of different advisory reports dealing with

the link between diet and health, such as “Diet and

Cardiovascular Disease” and “Diet and Cancer.”

The Nutrition Council recommends that people

make efforts to reach an appropriate weight and sums

up

●

●

●

●

●

●

the following guidelines:

Make sure your diet is varied.

Eat fats (particularly saturated ones) in moderation and make sure that you have adequate intake

of polyunsaturated fats.

Eat cholesterol in moderation.

Make sure that you have an adequate intake of

complex carbohydrates and dietary fiber, and avoid

eating sugars too frequently and in excessively

large quantities.

Drink alcohol in moderation.

Use cooking salt in moderation.

As indicated in the Progress Report on Nutrition

Policy, which was forwarded to the Parliament in

September 1987, these guidelines will serve as a basis

for the promotion of sensible eating habits over the

next few years.

Statistics measuring progress

toward national objectives

A joint working group of WHO (Regional Office

for Europe) and the Netherlands Central Bureau of

Statistics convenedin Voorburg on June 21-23,1988,

todiscusscornmon methods and instruments for health

interview surveys. The general experience and progress

in countries monitoring health in the framework of

“Health for All by the Year 2000” by way of health

interview surveys was reviewed. Common instruments and methodological issues such as the use,

72

coverage, and precision of indicators were discussed,

and special survey topics were submitted. On the last

dayrecommendations andinstruments were discussed,

and a draft plan for future action was drawn up.

Participants came from eight European countries and

Japan.

A number of the national objectives data are available now. Some examples follow. According to target

16 of WHO, there should be significant increases by

1995 in positive health behavior, such as nonsmoking,

balanced nutrition, appropriate physical activity, and

good stress management. “It has been estimated that

up to 10million people in the European Region are at

risk of death from illnesses related to smoking between

1980 and the year 2000” (5, p. 66). With respect to

nonsmoking, the situation in The Netherlands has

already changed positively, as is shown by results of

various surveys. Figure 1, based on several surveysin

the period 1958-87, shows a decline in thepercentage of

smokersfrom 90 to 41 among men but no drastic change

among women (6, p. 23).

Figure 2 shows the proportion of smokers among

persons in the age group 65 years and over from 1967

through 1987.Thepercentageof smokersin this group

declinedfiom 83 to 39 among men and shows apattern

similar to that of the total population. Again, as in the

total population, the percentage among elderly women

did not change significantly during the period. However, the level of smokers among elderly women is

remarkably lower than among the total population of

women.

Target 17 of WHO deals with alcohol consumption. The measurement of alcohol consumption by

means of population surveys has proven to underestimate consumption levels: A substantial proportion of

heavy drinkers are not reached by surveys

(nonresponse), and many moderate drinkers seem to

underreport their use of alcohol. Nevertheless, itshould

be realized that population-based surveys are practically the only source on the distribution of alcohol use

among the general population. The distribution figures are not perfect, but as a rule are sufficient for

many purposes, such as the measurement of trends.

Table E shows a decrease in the percentage of

nondrinkers from 1983 to 1986, among men from 17

percent to 16 percent and among women from 43
100

90

80

70

60

50

40

30

20

10

0

Women

-“ ------- ---------- -

--- -------- -------- -

--- *.- ‘.

---

---- --- ----------------

—---------

-------

.

I I I I 1 I I I

1958 1960 1965 1970 1975 fl980 1985 1990

SOURCE: Stichting Volksgezondheid en Roken (Foundation on Smoking and Health). Jaarverslag (Annual report), 1987. The

Hague. 1988.

Figure 1. Percent of persons 15 years of age and over who smoke, by sex: The Netherlands, 1958-87

30

20

[

Women

------- ------- ------- ------- ------- ------- -- ~~z----- -------- ----------

10

-.

01 I I I I I I

1967 1970 1975 1980 1985 1990

SOURCE: Stichting Volksgezondheid en Roken (Foundation on Smoking and Health). Jaarverslag (Annual report), 1987. The

Hague. 1988. I

Figure 2. Percent of persons 65 years of age and over who smoke, by sex: The Netherlands, 1967-87

73
Table E. Percent of persons who are nondrinkers, by

sex and age: The Netherlands, 1983 and 1986

Men Women

Age 1983 1986 1983 1986

Total . . . . . . . . . . . . . . . . . 17

18-24 years . . . . . . . . . . . 16

25-34 years . . . . . . . . . . . 9

35-44 years . . . . . . . . . . . 9

45-54 years . . . . . . . . . . . 14

55-64 years . . . . . . . . . . . 27

65-74 years . . . . . . . . . . . 33

75yearsandover . . . . . . 42

Sample size . . . . . . . . . ..l.952

Percent

16 43

14 42

12 27

11 31

12 43

22 56

25 60

38 75

Number

1,982 2,039

38

33

28

:

50

54

63

2,065

SOURCE:Ministry of Welfare, Health and Public Affairs.

Health for all by the year 2000, Rapportage Nederland 1988

(Report of The Netherlands, 1988). Rijswijk. 1988. “

percent to 38 percent. In both groups the decrease is

mainly in the elderly population.

Given the present state of Dutch eating habits,

high fat consumption is the main problem. The nature

and quantity of the fats in the diet and their cholesterol

content have been linked with cardiovascular disease.

There is also thought to be a correlation between the

amount of fat in the diet and cancer, particularly breast

cancer and cancer of the large intestine. In The

Netherlands, fats account for approximately 40 percent of total energy intake. According to the Nutrition

Council’s report, fat consumption should be reduced

to 30-35 percent of the daily energy intake. This

should preferably be achieved by cutting down the

intake of saturated fats. In view of this, the emphasis

of nutrition policy for the next few years is placed on

reducing the consumption of fats, especially saturated

fats. A large-scale survey of the dietary habits of the

Dutch public was started in 1987.This survey involves

a representative sample of 2,000 households. Over a 2-

day period, the members of each household note their

food and drink intake, including quantities. The data

are being collected over a whole year so as to take

account of seasonal fluctuations. The dietary intake

will be calculated with the help of the Netherlands

Nutrients Database. This large-scale diet survey is

planned to be repeated in a few years’ time, so it will

be possible to calculate whether fat consumption has

been reduced. Data on overweight are available from

Table F. Percent of persons who are overweight, by

age: The Netherlands, 1981-87

18years and over 65 years and over

Standard Standard

Year Per. ‘t error Percent error

1981 . . . . . . . 15.9 0.4 27.1 1.3

1982 . . . . . . . 15.1 23.1

1983 . . . . . . . 15.7 ::: 25.5 ;::

1984 . . . . . . . 16.1 0.4 27.4 1.3

1985 . . . . . . . 16.0 0.4 26.0 1.3

1986 . . . . . . . 16.2 0.4 25.3 1.3

1987 . . . . . . . 16.4 0.4 28.3 1.3

NOTE: Overweight persons are those with a body-mass index

>27.0.

SOURCE: Verweij GCG. Developments in underweight and

overweight, 1901-1989. Monthly Bull Health Stat 11:5-10.

1989. (In Dutch with English summary.)

the Netherlands Health Interview Survey. These data

showno signiilcant changesfrom 1981to 1987(tableF).

The Netherlands continuous Health Interview

Survey has yielded invaluable data for health management, planning, and evaluation. Hitherto, many

new data contributed to government decisions. Existing

statistics have been complemented with extra data

from theHealth Interview Survey, which hasincreased

their usefulness substantially (3, p. 129).

The Netherlands Health Interview Survey contains

a supplementary part whose contents vary from year to

year. This part is reserved for items that do not require

continuous measurement but for which only periodic

information is needed. In addition, supplements are

also suited to evaluate political decisions within a

reasonable timespan. In the 1989 survey, this part will

contain anumberof questions about smoking, drinking,

and eating habits. The integration of the supplementary part into the continuous part makes it possible to

relate these questions about smoking, drinking, and

eating habits to characteristics from the continuous

part of the survey, such assoeiodemographic variables,

health indicators, and data on medical consumption.

In future Health Interview Surveys, it will be

possible to include these (and other) questions again in

order to measure trends. Some general information

about the Netherlands Health Interview Survey can be

found in appendix II.

74
Acknowledgment

meviews expressed in this paper are those of the

author and do not necessarily reflect the position or

policies of the Netherlands Central Bureau of Statistics.

References

1.

2.

3.

4.

5.

6.

Ministry of Welfare, Health and Public Affairs.Nota

2000 (Health2000 memorandum).The Hague. 1986.

MinistryofWelfare,HealthandPublicAffairs.Health

for all by the year 2000, RapportageNederland 1988

(Reportof The Netherlands, 1988).Rijswijk. 1988.

BonteJ,vanSonP. HealthstatisticsinTheNetherlands

for health policy and evaluation Experience and developments.StatJ UnitedNations ECE 5.1988.

Voedingsraad(NutritionCouncil).RichtlijnenGoede

Voeding (Guidelineson good nutrition).The Hague.

1986,

World HeaIth Organization, Regional Office for

Europe.Targetsforhea.lthfor all. Copenhagen.1985.

StichtingVolksgezondheiden Roken (Foundationon

Smokin~ and Health). Jaarverslag (P&ml report),

1987.The Hague. 1988.

Appendix I

Health promotion and disease

prevention targets for the elderly

In 1984 the 33 Member States of the European

Region accepted the 38 targets for Health for AHdeveloped by WHO (2). A tentative selection of these targets of relevance to the elderly with respect to health

promotion and disease prevention is listed below.

Target 1. Reduction of the dijlerermes-lily the year

2000 the actual differences in health status among

countries and among groups within countries should

be reduced by at Ieast 25 percent by improving the

level of health of disadvantaged nations and groups.

Target 13. Healthy public policy--By 1990 national

policies in all Member States should ensure that legislative, administrative, and economic mechanisms

provide broad intersectoral support and resources for

the promotion of healthy lifestyles and effective participation of the people at all levels of such

policymaking.

Target 14. Social support systems-By 1990 all

Member States should have specific programs that

enhance the major roles of the family and other social

groupsindeveloping andsupportinghealthy lifestyles.

Target 15. Knowledge and motivation for healthy

behavior—B y 1990 educational programs in all

Member States should enhance the knowledge, motivation, and skills of people to acquire and maintain

health.

Target 16. Positive health behavior-By 1995 in all

Member States there should be significant increasesin

positive health behavior, such as balanced nutrition,

nonsmoking, appropriate physical activity, and good

stress management.

Target 17. Health-damaging behavior-By 1995 in

allMember Statesthere should be significant decreases

in health-damaging behavior, such asoveruse of alcohol

and pharmaceutical products, use of illicit drugs and

dangerous chemical substances, and dangerous driving and violent social behavior.

Target 18. Multisectoralpolicies—By 1990 Member

States should have multisectoral policies that effectively protect the environment from health hazards,

ensure community awareness and involvement, and

support international efforts to curb hazards affecting

more than one country.

Target 19. Monitoring and control mechanisms—By

1990 aIl Member States should have adequate machinery for monitoring, assessing, and controlling

environmental hazards that pose a threat to human

health, including potentially toxic chemicals, radiation, harmful consumer goods, and biological agents.

Target 20. Control of water pollution—By 1990 aIl

peopIe of the Region should have adequate supplies of

safe drinking water, and by the year 1995 pollution of

rivers, lakes, and seas should no longer pose a threat to

human health.

Target 21. Control of air pollution-By 1995 all

people of the Region should be effectively protected

against recognized health risks from air pollution.

Target 22. Food safety-By 1990 all Member States

should have signiilcantly reduced health risks from

food contamination and implemented measures to

protect consumers from harmful additives.

Target 23. Control of hazardous wastes—By 1995 all

Member States should have eliminated major known

75
health risks associated with the disposal of hazardous

wastes.

Target 24. Human settlements and housing—By the

year2000allpeople of the Region should have abetter

opportunity to live in houses and settlements that

provide a healthy and safe environment.

Appendix II

The continuous Netherlands

Health Interview Survey

Since January 1, 1981, the Netherlands Central

Bureau of Statistics (CBS) has been conducting a

continuous Health Interview Survey. The aim of the

survey is to give a picture of the trends in health and

medical consumption of the Dutch population that is

as complete as possible. To this end, respondents are

interviewed about, among other subjects, their state of

health; restricted activity; sick leave; consultations

with general practitioners, specialists, and dentists;

hospital admittance; and use of medication. At the

same time, questions about various personal and

background characteristics are also asked.

The survey is conducted among a random sample

of residential addresses (excluding homes for aged

and institutions). The survey is divided into 26

subsamples evenly spread over the year, i.e., one for

each 2-week period. In principle, all residents at the

selected addresses are interviewed (except in the case

of refusals); since 1983, however, a maximum of four

persons are interviewed. If a household consists of

more than four persons, the head of the household and

(where applicable) his or her partner are interviewed,

followed by two other members of the household who

are chosen based on whose birthday comes soonest

after the date of the interview. The figures are corrected for the underrepresentation resulting from this

method.

Nonresponse amounts to about 35 percent. For

this reason, the results may be slightly distorted,

although it is difficult to establish to what extent. The

response group (approximately 10,000 persons a year)

corresponds fairly well with the Dutch population. As

a rule, a weighting scheme is applied for differences

that might arise between the composition of the sample

and that of the overall population.

The 1984 version of the Health Interview Survey

questionnaire has been translated into English.

Questionnaire A is completed for every responding

household; questionnaire B, for household members

aged 16 years and over. Questionnaire C (for children

under 16years of age) is an abbreviated form of B and

has not been printed in English. Finally, D is a selfadministered questionnaire for those who already have

replied to B. The English versions of the 1984 questionnaires give a good impression of the content of the

survey from 1981 until now, although there have been

some changes. The major part of questionnaire D was

used only in the period 1983–85. During 1986-88, a

substantial part of the survey will deal with the measurement of impairment and disability. This part has

been developed along the lines of the International

Classification of Impairments, Disabilities and

Handicaps. In 1989, additional information will be

gathered on tobacco use, drinking, and eating habits.

The total number of questions amounts to about 50;

they have not been translated yet.

The results of the Health Interview Survey are

published in the Monthly Bulletin of Health Statistics

through quarterly and annual figures on medical

consumption and restricted activity as well as articles

that examine certain subjects in closer detail. In addition, figures are included in other CBS publications,

such as the Compendium of Health Statistics, The

CBS Pocket Yearbook, The Statistical Yearbook, and

Vademecum of Health Statistics.

76
Chapter 8

Health promotion among

the aged in the United

States

by Gerry E. Hendershot, Ph.D., Chief, Illness

and Disability Statistics Branch, National

Centerfor Health Statistics

As used in the United States, the term “health

promotion and disease prevention” refers to a wide

range of programs and activities that elude any simple

definition. For purposes of this presentation, however,

I mean to include programs that intervene to increase

the early use of preventive services in the population,

and programs that intervene to improve the healthrelated habits of individuals in the population.

In 1980 the United States established national

objectives for health promotion in this Nation to be

achieved by 1990.As the Federal agency responsible

for providing health statistics for the Nation, the

National Center for Health Statistics (NCHS)—and

especially its National Health Interview Survey

(NHIS)-has had a major role in tracking progress

toward the national objectives. Because the focus of

most health promotion activities has been on young

and middle-aged persons, the NHIS data have not

been especially well suited to describing the status and

progress of health promotion among the elderly. The

participation of NCHS in this International Collaborative Effort (ICE) is intended to correct that shortcoming by developing better measures of health promotion

and disease prevention among the aged.

The purpose of this paper is to review in greater

detail the national objectives forhealthpromotion, the

use of NHIS for tracking those objectives, the need for

objectives and tracking specific to the aged population,

some international comparisons already undertaken

using NHIS, and the objectives of the ICE on health

promotion.

National objectives for health

promotion

In 1980 the Surgeon General of the United States

published a set of health objectives for the Nation to be

achieved by 1990. The objectives were developed by

groups of subject matter experts from government

and nongovernment organizations. There were 256

specific objectives grouped in 15 priority areas, and

each objective specified a goal that could be measured quantitatively. For instance, one objective was

to reduce the proportion of adults who smoke to

25 percent. A new set of Objectives for the Year 2000

is being prepared and will be announced in 1990.

By all accounts, the national objectives have had

substantial effects on research, policy, and programs.

Theirexistence andauthorityhaveprovided guidelines

for decisions at every level of government-Federal,

State, and local-and in the private sector as well.

One aspect of the objectives, and one reason for

their success, was a system to track progress toward

their achievement. Because the objectives were stated

quantitatively, they could be measured by a variety of

statistical data systems. Our interest in this report is in

using NHIS for tracking progress toward the national

objectives.

NHIS represents the civilian noninstitutionalized

population of the United States. The survey is basedon

a multistage, area probability sample of 50,000

households, a population of 125,000 persons. NHIS is

cross-sectional in design, although it includes a capability to do followup longitudinal studies as well.

The survey is in the field throughout the year, with

each week’s interviewing assignment constituting a

nationally representative sample. The data arecollected

by means of face-to-face, standardized interviews in

the homes of the sample families. The questionnaire

has two parts: An unchanging set of basic questions

about health status, health care, and demographic

characteristics (the core questionnaire); and one or

more sets of questionnaires on special health topics

that change each year (supplements).

77
Both core and supplement data from NHIS have

been used to track progress toward the 1990 Objectives, but the focus in this paper will be on NHIS

supplements used for that purpose. In 1985 NHIS

included a special supplement on Health Promotion

and Disease Prevention that was designed to measure

progress toward many of the 1990 Objectives, includingreducing smoking, encouraging exercise, practicing

good nutrition, and controlling hypertension. For that

survey one adult was randomly selected from each

NHIS sample family, for a total of 32,000 completed

interviews. (The NIUS sample was only three-fourths

of its full size that year because of budget limitations.)

The 1985 survey will be repeated in 1990 using

essentially the same questionnaire, with minor modifications to correct problems in the earlier questionnaire. Again, one adult will be randomly selected in

each NHIS sample family, for an expected 47,000

completed questionnaires. (The 1990 NHIS sample

will be full size.)

To provide baseline data for the new Year 2000

Objectives fortheNation, scheduled forpublicationin

1990, the 1991 NHIS will include a special questionnaire on health promotion. Plans beyond that are less

certain, of course, but it seems probable that the 1991

survey will be repeated at the midpoint and endpoint

for the objectives, 1995 and 2000.

These several surveys demonstrate that NHIS has

a major and continuing involvement in measuring

behaviors related to health promotion and disease

prevention in the United States.

Aging and health promotion

In the Proceedings of the Surgeon General’s

Workshop on Health Promotion and Aging (1) the

following statement is found:

The 1990 Objectives did not adequately

address this population .... This time we know

more about the effectiveness of health promotion for this age group .... One national

strategy must be to balance curative medicine

with preventing disease and promoting

health .... Leading chronic conditions afflicting older people...respond to health promotion

interventions such as exercise, healthy diet,

and early care.

The statement reflects the growing recognition

between the formulation of the 1990 Objectives and

the preparation of the Year 2000 Objectives that it is

important to consider the older population when setting objectives for health. That growing interest has

affected the drafting of the Year2000 Objectives: One

of the 21 priority areas in the draft objectives is to

“maintainthehealth and quality oflife of older people.”

That priority area will include numerous specific,

quantitative goals related to the older population.

With the elevation of health promotion for the aged to

the level of anationalpriority, it has become imperative

that improvements bemadein the data systems used to

track progress toward this objective.

The need for better data on health promotion

among the aged was recognized by a panel of experts

convened by the U.S. National Academy of Sciences,

whose report (2) included these recommendations:

● That modules of health promotion items be developed that are appropriate for the elderly.

● That these survey modules be tested on the elderly.

● That successful modules be incorporated in surveys such as NHIS.

Implicit in these recommendations (and explicit in the

report itself) isthat the health promotion modules now

in use in NHIS are not fully appropriate to the aged

population, nor have they been fully tested on the aged

population.

NHIS measures of health

promotion variables

While it is not possible in this brief presentation to

review the many NHIS measures of health-related

behavior, two will be considered here—smoking and

physical exercise—to illustrate the kinds of data colIected and some problems with these measures for the

aged population.

One of the 1990 Objectives was to reduce the

prevalence of cigarette smoking. The 1985 NHIS

showed that among persons 65–74 years of age, the

prevalence of smoking was about 22 percent for men

78
and 18percent for women; among persons 75 years of

age and over, the corresponding rates were 15 and

7percent. Amongpersons 65–74 whohadeversmoked,

71 percent of men and 57 percent of women had

stopped smoking by 1985; the corresponding figures

for persons 75 years of age and over were 77 and

72 percent.

While these findingsindicate that the prevalence

ofsmokingamongolder personsisrelatively low and

large proportions have quit smoking, there are problems with interpreting this as a success in terms of the

objectives. For instance, because smoking increases

the risk of mortality from several causes, the older

persons who survived to be included in NHIS would

disproportionately includepersons who never smoked

and persons who stopped smoking early in life. For an

adequate understanding of the risk in the older population from smoking, information about the duration

of smoking and duration since quitting is also needed.

Another of the objectives was to increase the

proportions of people who get regular exercise. To

measure physical activity, the 1985 NHIS asked

questions about 22 Ieisuretime activities, such as

jogging, playing volleyball, and playing baseball. If

any of the activities were reported tohave been engaged

in during the 2 weeks before the interview, information was obtained about the fkequency, duration, and

intensity of the activity. The information was used to

estimate the number of kilocalories (kcal) expended

per kilogram (kg) of body weight per day, and that

measure was used to classify the population in categories of physical activity.

Among persons 65-74 years of age, the percent

“very active” (3 kcal/kg/day) was 29 for men and 15

for women; for persons 75 years of age and over, the

corresponding percents were 14 and 7. The meaning

of these figures in terms of health objectives for older

persons is not clear, because many of the questions

asked were about activities not often engaged in by

elders, and perhaps not even appropriate for them.

Conversely, many physical activities that are appropriate for elders were not on the list of questions asked.

Furthermore, the standardfor’’very active” was applied

to all age groups, whereas the standard probably

should vary across age groups to account for changes

in physical condition associated with age.

International comparisons

These problems of measurement in NHIS will be

compounded by issues of comparability when efforts

are made to make international comparisons, the goal

ofthe ICE. Some comptu-isonshave been made between

the 1985 NHIS on health promotion and a health

promotion survey done in Canada in the same year.

While the comparisons did not focus on the elderly

populations of the two nations, they do illustrate some

of the opportunities and problems in international

comparisons.

Considering two types of health-related behavior,

smoking and exercise, comparison of the United States

andCanada showed that smoking was equally prevalent

among men in the two countries but lower for women

in the United States than in Canada. With respect to the

important measure used ea.dier-quitting smoking—

no comparison could be made between the two

countries because those data were not available in the

Canadian survey.

There was no measure of kcal/kg/day in the Canadian sumey, but both it and the U.S. survey asked a

more general question about the level of physical

activity. According to that less precise measure, both

men and women in Canada were more likely than their

U.S. counterparts to be “regularly active.”

These two brief examples of comparisons between

two neighboring countries with many culturaI similarities underscore the problems likely to be encountered in international comparisons of data from health

promotion surveys.

Objectives for the ICE

The U.S. Health Objectives for the Year 2000

probably will make health promotion for the aged

population a priority topic. NHIS will bean important

data source for setting objectives for the aged and for

tracking progress toward them. As pointed out by

experts in the aging field, NH.ISdoes not currently use

health promotion questions designed for and tested on

the aged population. Other nations, such as Canada

and The Netherlands, have conducted surveys on

health promotion and are facing some of the same data

demands and survey problems experienced in NH.IS.

By sharing the experiences of those nations, it may be

79
possible to improve and standardize some health aging, March 20-23, 1988.Washington:U.S. Public

promotion data items for the elderly, and that will Health Service.No publication date.

make it possible to make international comparisons. 2. Committee on National Statistics.The aging population in the twenty-first century: Statistics for health

References policy. Washington:National AcademyPress. 1988.

1. Abdellah FG, Moore SR, eds. Proceedings of the

SurgeonGeneral’sworkshoponhealthpromotion and

. .

80
Chapter 9

Opt[mal survey research

methods for studying

health-related behaviors

of older people

by John B. McKinlay, Ph.D., Vice President

and Director, New England Research Institute;

Professor of Sociology and Research and

Professor of Medicine, Boston University

I wasinvited to focus on optimal research methods

for studying health-related behaviors of older people

in household surveys. Given the well-documented

aging of our population and the need for valid and

reliable data on which to base sound social policy, the

issue of research methods appropriate to older people

is becoming increasingly important. Obviously, with

limited time and space available, my discussion must

be highly selective: In fact, I amgoingtoconsideronly

four issues. First, and by way of background, we shall

review some of the social and health characteristics of

older people that can influence the success of any field

approach. Second, mixed or multimode data gathering

and its particular advantages with older populations is

discussed. Third, the promise and appropriateness of

inhome physical measurement protocols, especially

in studies of older people, are reviewed. Finally, the

much neglected issue of interviewer and fieldworker

training for studies of older people is highlighted.

Wherever possible, key points will be illustrated from

ongoing field research work with older people being

conducted by staff at the New England Research

Institute (NERI).

Social characteristics and health

status

Field studies of older people living independently

in the community present a great challenge to researchers because the social and physical characteristics of older people obviously influence their willingness and/or ability to participate in research studies.

Consider, for example, the social situation of the

oldest old (persons 75 years of age and over). People

in this age group are more likely than younger people

to be women (71percent), to be widowed (72 percent),

to live alone (45 percent), and to have little formal

education (48 percent have 8 years or less). Such

characteristics influence therelative success ofdifferent

field approaches. Forexarnple, the proportion of older

people living alone (which is the situation of one of

two women 85 years of age and over) may affect the

success of in-person interviewing in the community.

There me numerous reports from community leaders

and media sources that older people living in large

cities are fearful for their persorral safety and therefore

are likely to exhibit reluctance to permit stiangers (i.e.,

research workers) to enter their homes to ask personal

questions. In the United States, widespread fear of

drug-related violence and mugging, especially among

inner-city elderly, probably influences the success of

in-person interviewing. Recognizing these risks, many

community groups attended by older people advise

their members not to answer personal questions on the

telephone or to let strangers into their homes.

Having perhaps even greater impact on participation in research are the health and functional status of

the oldest old. Without appreciation of the physical

limitations and social circumstances of older people

and appropriate adjustment of traditional field methodsin order to accornrnodateolderpeople and facilitate

participation, both response rates and data quality are

compromised.

In the context of these limitations common among

older people, the use of proxies is attracting considerable attention: It offers the promise of obtaining at

least some (otherwise lost) information on people who

81
are unable to participate in a study (l–3). Several

studies reveal that responses by proxies correlate

highly with self-reportsin areas such asfunctional and

mental health, life satisfaction, and depression (4).

But there are limitations: Proxies apparently rate mental health and depression as worse than do respondents

themselves. NERI researchers are conducting a study

to determine the validity of data obtained from primary informal caregivers and different categories of

institutional staff concerning older people in nursing

homes (5).

Rather than reflecting an unwillingness to respond, nonresponse may result from an inability to

respond to an inappropriate field approach. Table A

summarizes some health statistics for the elderly that

determine which field approaches are feasible. Among

people 75 years of age and over, about 4 out of 10have

hearing impairments, with about 40-60 percent experiencing difficulty even with a hearing aid (6-8). One

out of every four people 85 years of age and over

reports trouble with vision, with around 50 percent

experiencing difficulty seeing even with glasses.

Difficulty getting out of bed or a chair (regarded as a

good indicator of severe limitation of activity) is a

common experience among people75 years of age and

over, with marked differences between men and

women. For example, 12 percent of men 85 years and

over, compared with 22 percent of women the same

age, experience such difficulties. Difilculty grasping

small objects (such as a pen) ranges from 8 percent in

men 65–74 years to 16percent among women 85 years

and over.

The recognition that some aspects of cognition

decline in older age is the source of major concern

about survey data quality with older people (9,10).

Excellent work, principally by Herzog and her colleagues at Michigan, has been undertaken on the

quality of older adults’ survey responses, by comparing

the responses to external records or by using a

multimethod-multitrait approach and then contrasting

the validities obtained with those of middle-aged and

younger adults. No substantial differences have been

detected. Although survey questions often produce

errors in response, generally these are little different

among older and younger respondents (11–16).

Researchers focusing on older populations must

weigh the advantages and disadvantages of thedifferent

approaches to obtaining quality data and the appropriateness of these approaches given the physical

limitations and social characteristics discussed above.

For a long time, the face-to-face, or in-person, interview was thought to be the only way to obtain valid

and reliable information; it has become the “gold

standard’’forfieldmethodsin social and epidemiologic

research. Even today, there are some who still regard

it as the only approach, but that situation seems to be

Table A. Percentof persons65 years of age and over, by age, sex, physical limitations,and social

characteristics:UnitedStates,January-June 1984

Tots/ 65 years 65-74 years 75-84 years 85 years and over

Respondent characteristic and over Male Female Male Female Male Female

Physical limitation

Hearing . . . . . . . . . . . . . . . . . . . . .

Difficulty even with hearing aid 1..

Vision . . . . . . . . . . . . . . . . . . . . . . .

Difficulty even with glasses 2. . . . .

Difficulty getting out of bed or chair

Difficulty grasping small objects. . .

Social characteristic

Lives alone . . . . . . . . . . . . . . . . . . .

Lacks telephone . . . . . . . . . . . . . . .

. . . . . . 27.8 30.0 17.5

. . . . . . 38.9 40.8 27.2

. . . . . . 12.8 9.7 9.4

. . . . . . 31.1 23.3 25.8

. . . . . . 8.0 4.8 7.0

. . . . . . 10.7 8.1 10.5

. . . . . . 31.8 13.6 35.5

. . . . . . 3.1 3.9 2.3

Percent

39.9

52.3

16.7

38.0

5.9

9.6

19.0

4.4

28.2 58.3 44.3

40.6 66.1 60.9

15.6 25.0 27.5

40.0 45.0 55,9

11.2 12.7 22.2

14.1 10.3 16.4

52.9 28.3 52,9

2.5 5.4 3.7

Less than 5 years at current address. . . . . 17.2 18.3 18.0 13.9 15.9 14:1 20.1

lAmOngindividualswho wear hearingaids.

2Among individuals who wear glasses.

SOURCE:National Center for Health Statistics. Supplement on Aging, National Health Interview Survey. 1984.

82
changing for a number of reasons: (a) there has been

a temporal decline in response rates in face-to-face

surveys; (b) in-person interviewing of large numbers

in the community isprohibitively expensive, especially

because of the labor costs for fieldworkers; (c) unlike

the situation in the 1940’s and 1950’s, when in-person

interviewing became well established, there is public

concern about strangers and issues of security (which

sometimes make it difficult for fieldworkers to obtain

access to respondents’ homes); and (d) there appears

to be aperceiveddangerto fieldworkers today, although

we have yet to uncover evidence of any harm experienced by workers in the field.

Table B summarizes some of the well-known

advantages and limitations of the major field approaches: In-person interviews, telephone interviews,

and mail questionnaires. (See also (9,17-24).) Clearly

the mail questionnaire has distinct cost advantages

over telephone and in-person interviewing, which are

the more expensive field approaches. Larger sample

sizes can be obtained cost efficiently with mail questionnaires and telephone interviews, while in-person

interviews generally permit only a relatively small

group to be reached. For the cost of 25 cents, one can

mail a questionnaire anywhere in the United States,

including Alaska and Hawaii. Telephone interviews

Table B. Advantages and limitations of 3 major field

approaches to surveys

In-person Mail

Survey (face-to-face) Telephone questioncharacteristic interview interview naire

cost . . . . . . . . . . . . . I A H

Sampie size . . . . . . . I A H

Geographic

dispersion . . . . . . . I A H

Response rate . . . . . H A i

Duration of study . . . i H A

Length of interview. .

Type of information. . : t /

Data quality:

Correct respondent

questioned, . . . . . H H I

Questions

comprehended . . . H H I

Minimization of item

nonresponse . . . . H H I

NOTE: H = highly appropriate; A = appropriate;

I = inappropriate.

are more expensive than mail questionnaires (mainly

because of interviewer labor), while in-person interviews, especially across a broad geographic area, are

by far the most expensive. Mail questionnaires have

well-known disadvantages, however. Their response

rates are usually quite low (around 50 percent),

questionnaires must be very brief, and only limited

and quite superJ3cial information can be obtained.

Data quality clearly varies by mode. For the mail

questionnaire, for example, one is never sure that the

correct respondent completed the instrument or that

the questions were comprehended, and nothing can be

done about item nonresponse, which can occur at high

rates. With in-person and telephone interviews,

however, one can check that the correct respondent is

being addressed, there can be confidence that the

question is comprehended, and when appropriate,

prompts and some explanation of the question can be

provided. Well-trained interviewers, with appropriate

monitoring, can significantly minimize item

nonresponse, The subject of interviewer training is

addressed again below.

Generally speaking, the telephone interview is the

most cost-efficient approach, and it is certainly feasible in many areas of research with older people. (See

especially (24,25 ).) While both the mail questionnaire

and the in-person interview have advantages (indicated

by A orHin table B), they also have obvious disadvantages (indicated by an I) that are not shared by the

telephone interview. In our experience, there isvirtually

no self-report information that cannot be reliably

obtained over the telephone with a well-designed

instrument and appropriately trained interviewers.

Unless physiologic values are required, the in-person

interview appears to constitute a suboptimal approach

in studies of older populations and a costly luxury

from which researchers must be weaned, especially

during these economically stringent times for

sociomedical research.

When in-person interviewing became well established in the 1950’s, only about 40-50 percent of the

American public had telephones, and therefore inperson interviewing was the optimal approach. Today,

however, almost all older people have telephones,

making this avery attractive mode of data gathering (26).

Even for the 20-30 percent of potential respondents who

83
mayhaveunlistedtelephonenurnbws (oftenolderwomen Table C. Advantages and limitations of 3 major fieid

who are fearful for their safety), random-digit-dialing

techniques are well developed and permit easy contact

with otherwise unreachable respondents (27).

Mail questionnaires have also become more feasible and attractive as a result of the improved and

well-tested techniques developed by, for example,

Dillman (28,29). Such work ensures acceptable responserates through use of awell-developed sequence

of tested steps and attention to the formatting of

questions, the length of the instrument, the weight and

color of the paper, the way inserts should be folded, the

days on which mailings should occur, and so forth.

Additionally, technological improvements in microcomputing and memory typewriting make it possible

to implement and monitor larger and more complex

field designs. We need a Dillman total design method

of mail and telephone surveys developed specifically

for use with older populations.

The promise of mixed-mode field

approaches

Given the common impairments of the oldest old,

choosing an appropriate field approach requires discrimination. From table C it is clear that, even within

a single study, what maybe appropriate and acceptable

to some older respondents maybe quite inappropriate

and disagreeable to others. For example, it is appropriate to distribute mail questionnaires to people who

are hard of hearing, but unrealistic to undertake telephone interviews. It may be possible, depending on

the skill of the interviewer, to conduct an in-person

interview in this situation. Conversely, the sight impairedcancomplete in-person and telephone interviews

but cannot be expected to complete a mail questionnaire. Homeless people are, of course, also site impaired, somailquestionnaires andtelephoneinterviews

are out of the question. People with major speech or

language pathology (as a result of stroke, for example)

cannot easily undertake a telephone interview but may

be able to complete a mail questionnaire and, depending

on the skill of the interviewer, maybe able to complete

an in-person interview. Fear of strangers and concern

for personal safety may rule out in-person interviews

with some respondents but make mail questionnaires

approaches to surveys of persons 75 years of age

and over, by respondent characteristics

In-person Mail

Respondent (face-to-face) Telephone questioncharacteristic interview interview naire

Hard of hearing

(deaf) . . . . . . . . . . . ? i A

Sight impaired

(blind) . . . . . . . . . . . A A I

Speech or ianguage

pathology . . . . . . . . ? i A

Arthritis, tremors, or

paraplegia . . . . . . . A A I

Fear of

strangers . . . . . . . . i A A

NOTE: A = appropriate; I = inappropriate; ‘?= possible.

and telephone interviews quite acceptable (if sufficient preparatory work is done with community groups

and leaders to establish the legitimacy of the study).

The need to combine different field approaches in

studies of older people is illustrated by experience in

the Established Populations for Epidemiologic Studies of the Elderly, supported by the National Institute

on Aging. This project at different locations involves

a baseline inhome interview survey, followed by annual interviews, conducted mainly by telephone (30).

In Iowa, 3,673 subjects aged 65 and over responded at

baseline to an inhome interview (response rate: 80

percent). A total of 3,497 were reinterviewed, primarily by telephone, at the first followup. Among the

remaining 176,128 had died, 47 refused a reinterview,

and one was not interviewed because he was incorrectly coded as dead. At the first followup, 5.3 percent

of the subjects required an inhome interview rather

than a telephone interview because of hearing problems. Another 8.2 percent of the interviews were

conducted with proxy respondents (telephone or

inhome) because subjects were too ill, mentally incompetent, or out working on their farm. In New

Haven, Connecticut, 2,811 subjects aged 65 and over

responded in person at baseline (response rate: 82

percent). A total of 2,562 were reinterviewed at the

fiist followup. Among the remaining 249, 145 had

died, 91 refused a reinterview, and 13are unaccounted

for at present. At the f~st followup, 11.6 percent of the

interviews were done face to face in the subject’s

84
home because of hearing problems orlanguageproblems. (The subject spoke Italian or Russian, rather

than English, fluently.) Another 6.1 percent were done

by proxy (telephone or inhome) because the respondent was too ill or was mentally incompetent. Note the

substantial variation between locations in the reasons

for doing something other than interviewing the chosen subject on the telephone.

Perhaps among the elderly, more than any other

demographic category, there is a need for flexibility in

research methods and a clear case for mixed or multimode surveys (i.e., studies that attempt to obtain the

same information fromanidentified population through

different field approaches). For example, one may

start with amail questionnaire, follow up with attempts

to reach nonrespondents by telephone, and, where

unsuccessful, approach subjects for an in-person interview. Mixed-mode surveys are usually viewed

simply as a means of achieving higher response rates

bygettingresponses frompeople who otherwise would

not respond (31). But mixed-mode surveys may be

particularly useful in studies of older people who

experience the types of impairments and limitations

described. In other words, these types of surveys may

be a means of getting responses from people who

simply cannot respond. Mixed-mode approaches are

not only a desirable method for improving response

rates, therefore, but in community-based studies of the

oldest old, in particular, the approaches may be essential

to obtain reliable data (25).

Most mixed-mode surveys start with either mail

questionnaires ortelephoneinterviews (19,20,31, 32).

Followup ofnonrespondents usually involves the other

of these two methods, face-to-face interviews, or a

combination of approaches. The sequence usually

ranges from the less expensive (mail questionnaires)

to the more expensive (in-person interviews), enabling

resources to be devoted to the subjects who are the

hardest to reach. Obviously, it is not cost efficient to

employ costly in-person interviewing when the same

data and quality can be obtained through a cheaper

mode. There are quantum leaps in costs from mail

questionnaires to telephone interviews to in-person interviews.While cost is usually the major determinant of

mode sequence, other considerations, such astime constraint and study content, can also be important factors.

Generally speaking, which approach is adopted

and whether mixed modes are employed are determined by cost considerations. With older populations,

the cost efficiency of an approach appears less important than the appropriateness and feasibility of that

approach. Clearly, based on the dataalreadydescribed,

no one mode is appropriate for all elders. Different

modes are appropriate for different groups of older

people, depending on different types of physical

limitations and social circumstances. In studies of

younger groups, onecanprobably getaway with using

only one mode. (People do that all the time.) With the

elderly, however, one has to be prepared to use two or

three different approaches. This has obvious implications for interviewer training and protocol development (instrumentation).

While mixed-mode surveys offer considerable

promise, particularly in studies of older populations,

not surprisingly, mixed-mode surveys have their disl

advantages and limitations. This discussion will focus

on three concerns: Cost, missing data, and response

validity.

Followup often constitutes work in excess of effort normally expended in single-mode mail or telephone surveys, so mixed-mode surveys are always

more expensive than surveys using the initial mode

alone but less expensive than using the followup mode

alone (19,20).

Aside from a few well-known items (e.g., household income), item nonresponse is most frequent on

mail questionnaires (19,33,34). Thus, mixed-mode

surveys that include this mode may produce somewhat

higher levels of missing data. Apparently, part of the

problem is caused by inadvertent respondent error,

which can be reduced through careful instrument

design. Data missing for other reasons are of greater

concern. The propensity for item nonresponse can

vary with respondent characteristics, especially on

mail questionnaires (34,35). These data clearly are not

missing at random and can bias survey results (36).

We have found in health-related surveys that item

nonresponseisrelatedto healthstatus(34).Unfortunately,

estimates of bias are not yet available; more work is

needed in this area and is under way.

The issue of validity arises from the frequently

observed variation among modes in responses to some

85
items in mixed-mode surveys (21,31,37). Telephone

and face-to-face interviews may be more likely than

mail questionnaires to suffer from biased recall of, for

example, a recent visit with a physician (22), or biased

responses to questions that are personally sensitive or

have socially desirable answers (38). Mode-dependent

response variation can be minimized through sensitive

interviewing and careful question design (39). Finally,

some of this variation is actually caused by factors that

are confounded with mode, such as characteristics of

early versus late respondents, rather than by the modes

themselves (31). This implies that responses to the

initial mode are from a biased sample of the population, rather than indicative of mode-dependent variation in the validity of survey responses.

The development of innovative

inhome collection of physiologic

measures

In the past, even the oldest old have been requested

to attend some central clinic or hospital location

whenever physiologic measurements were required.

Doing research at the investigator’s convenience may

be acceptable in studies of younger populations, but

with older people (especially the oldest old), studies

ought to be done at the respondent’s or subject’s

convenience (usually the home or workplace). For

poor health and other reasons unrelated to health,

older people are often unlikely or unable to respond to

requests to come to a clinic. As the Framingham Heart

Study cohort has aged, homevisitshavebeen instituted

to compensate for the problem of increasing

nonresponse—primarily because of ill health among

men, but not among women, in that study. Agoraphobia

(the fear of public places or new experiences) appears,

from some of our ongoing work at NERI, to be an

important source of nonresponse among older women.

In contrast, nonresponse among older men appearsto be

primarily caused by illness or functional limitations.

For some health researchers the familiar clinicbased physiologic measurements are being replaced

with inhome protocols. Technologic improvements

(especially microcircuitry and portable compact

equipment) are opening new horizons. Permit a personal aside: Irecall in work with Dr. Ian Prior some 30

years ago in New Zealand that electrocardiograms

(EKG’s) presented a real challenge in field studies of

Maoris and Tokelau Islanders. In those days, EKG

machines were very delicate and required stable power

supplies (not always available in rural areas and on

some islands). Today, in order to identify silent

myocardial infarctions in the community, NERI field

staff are successfully conducting 12-lead EKG’s on

black persons in their homes in high-risk, violenceridden, inner-city neighborhoods of Boston. We are

using the Burdick EK1O,which weighs only 8 pounds

and is about the size of a telephone directoxy. Staff at

the Minnesota Heart program, where our EKG strips

are being read, have informed us that they are among

the best (cleanest) they have seen. At NERI, easily

transportable equipment is being used by specially

trained field technicians, withnopriormedical training

or experience, to measure blood pressure, body-mass

index, urine, and saliva (for cotinine); forvenipuncture,

EKG, and fitness testing; and to assist with a full oral

health examination.

Inhome physical examinations are safe, reliable,

and (except for blood pressure) equivalent in results to

clinic-based protocols that use fixed standard equipment with more costly staff, facilities, and overhead.

Based on experience in the Pawtucket Heart Health

Program, inhome protocols produce at least a 10-

percent increase in response rates, and do so at onethird less cost, mainly labor savings (40). In sum,

inhome protocols not only are cost efficient but also

produce higher quality data, particularly in terms of

response rate.

The inhome approach is especially promising and

perhaps even essential when studying the biomedical

and physiologic status of older, less mobile populations. There are at least three reasons for this. First,

it is the only way to gain the participation of some

elders, especially the oldest old. They simply will

not come in to (if they are women) or are unable to

attend (ifthey are men) an often strange medical facility

(e.g., a clinic, health center, hospital, or laborato~).

Usually, the research setting to which they are invited

is not the institution providing their ongoing primary

care. One NERI study prospectively examining lipids,

hormones, and bone density in an aging cohort of

women living in the community obtains response rates

86
of around 90percent when respondents are interviewed

at home, where the venipuncture is conducted, but

experiences about a 20-percent drop in participation

when the same women are requested to attend a

hospital to undergo dual-photon absorptiometry to

measure bone density.

Second, inhome protocols are often the only way

to obtain certain types of information of importance to

elders’ health. Polypharmacy is recognized as an

increasingly important problem for older people (both

prescribed and over-the-counter medications). It is

difficult to obtain detailed and accurate drug usage

data in a clinic or hospital visit. “Black and yellow

pills” may be the only information some older people

are able to provide concerning their medication.

Moreover, the most common medications may be

overlooked precisely because they are so much a part

of the respondent’s everyday world. Asking older

people to bring all their medicines with them to a clinic

or hospital produces uncertain results. When asked by

anNERI fieldworker what pills she took, one respondent replied that her doctor gave her “pills for her

memory.” In response to a supplementary question

concerning how often she took them, the respondent

replied, “Only when I remember”!

Endocrine functioning is of increasing interest to

gerontology researchers because of the possible relationship of hormones to osteoporosis, coronary heart

disease, and depression, among other outcomes. Work

in this area presents special challenges. These challenges are illustrated by an NERI study of hormone

profiles and sexual functioning across the lifespan

(1,700 men aged 40-70 years were examined). An

inhome protocol was required because: (a) we wanted

to study normal aging in a representative population

(not in convenience samples of patients-the usual

source); (b)werequired arandom sample of community

residents who lived independently; (c) two blood

samples over a short interval were required (to control

for pulsatile emissions); (d) these samples had to be

obtained within 2 hours of awakening to obtain basal

levels and to permit control of diurnal variability; and

(e) information was required on medications, blood

pressure, nutritionalbehavior (willett’sfoodfiequency

questionnaire), etc.

Our recent meta-analysis of the magnitude of

research method effects on the age-testosterone relationshipprovides strong support for an inhomeprotocol

when studying endocrine functioning in older people

(41). Wefoundmarkeddifferencesinresultsproduced

by sampling characteristic, targetpopulation (whether

patients, geriatric residents, or volunteers), and health

status (whether people taking prescribed medications

were included). We found a significant effect of time

of blood sampling on the testosterone-age relation,

with groups where no relevant information was given

showing steep slopes and groups with afternoon

sampling having a nonsignificant positive relation.

We also uncovered differences in testosterone between

subjects who were supposedly “healthy volunteers”

(not the same as a random sample) and those who were

selected from patient groups.

Third, and of equal significance, is the fact that

there are large differences in some important measurements performed at home compared with a clinic

or hospital setting. For example, data from the

Pawtucket Heart Health Program show how the difference in blood pressure readings at the two sites

increases with age. Figure 1presents data for systolic

and diastolic pressures separately and reveals clear

age increases, especially for women (who are the

majority of the oldest old).

These data call into question many of our traditional

epidemiologic approaches to physiologic measures

and suggest that, for example, in any epidemiologic

observational study involving blood pressure (e.g.,

coronary heart disease, diabetes, and stroke) the inhome

protocol is the preferred approach. With an inhome

protocol you not only get a higher response rate at a

lowercost,but you can getmoreaccurate measurements

(e.g.,forcortisol,prolactin, personality trait, and stress)

under natural circumstances.

The matter of interviewer

training

Fowler and Mangione ( 17) observe that consideration of interviewers and quality of interviewing in a

survey, although crucial to any study’s success, is

typically ignored. Groves and Kahn (23) have shown

that one-fourth to one-third of survey items are subject

to significant interviewer effects (42,43). Interviewers

87
lo8 —

6 — 6

r

g

$4 –

(nWI a)

&2

u

j

‘o

(2) –

(4) —

Females Systolic

m

~~ Diastolic

4.6

-2.1

4.3 3.8 4.0

8.1

18-19 years 20-29 years 30-39 years 40-49 years 50-59 years 60-64 years

Age

Males Systolic

(2, L- -0.1

18-19 years 20-29 years 30-39 years 40-49 years 50-59 years 60-64 years

Age

SOURCE:Unpublisheddatafrom the PawtucketHeart HealthProgram,The MemorialHospital,Pawtucket,RhodeIsland,

Figure 1. Mean differences in systolic and diastolic blood pressure (clinic minus inhome) for 553 subjects

ages 18-64 years completing both protocols, by age and sex

88
can affect quality in two principal ways. First, if

interviewers are not consistently standardized, surveybased estimates are less precise, thereby increasing

the amountofrandomerroraroundthe survey estimates

“ and decreasing the extent to which the differences

among respondents are detectable in the answers.

Second, interviewers can systematically bias data and

render them invalid. In a recent study at NERI of

middle-aged women, around 30 percent of the variation in some key outcome variables (e.g., social support networks and symptom reporting) was explained

by interviewer differences!

The pace at which an interview is conducted, the

kind of respondent behaviors interviewers elicit and

reinforce, and the goals interviewers communicate to

respondents have been shown to relate to data accuracy (44,45). Fowler and Mangione examined the

potential of various training and supervisory programs

to affect the performance of health survey interviewers and the quality of datatheycollect (17).Interviewers

receiving less than 1 day of basic training generally

displayed inadequate interviewing skills. A program

of tape recordings, as part of the supervision of

household interviewers, was associated with more

precise and less biased data if interviewers were more

than minimally trained. Training and supervision were

found to be related to data quality. Attention to aspects

ofinterviewermanagement-training and supervision,

design of questions to reduce the need for probing,

procedures to be used, and the size of assignments—

is a cost-effective way to improve the quality of

survey-based estimates. I concur with Fowler and

Mangione (17), who suggest that standards for the

way interviewers are trained and managed have been

too long absent, despite a history of research showing

that interviewers matter.

Field research with older populations requires

special training for interviewers (46-50). It is not

sufficient to expose potential interviewers to the

usual brief, canned training course that is often

provided by inexperienced research organizations

and university-based researchers not routinely

conducting surveys of older people. Two issues

illustrate this need for additiomd training for fieldwork with older populations.

First, many older respondents have difficulty

processing and giving clear responses to apparently

straightforward questions. For example, it may take

up to 5 minutes to establish whether a respondent has

arthritis-a seemingly straightforward question. With

older populations, such a question will often elicit

prolonged descriptions of disabilities, medications,

and utilization behavior associated with the condition

ofinterest. This hasimportant implications for the cost

offieldwork. Interviewers must be trained to sensitively

keep therespondentfocused and to elicitclearresponses

in an economical fashion.

Second, in studies of older populations, particular

attention must be devoted to concluding an interview.

In our experience, respondents frequently enjoy discussing their problems and lives with the interviewer.

Often the challenge is not respondent fatigue but

interviewer fatigue. A telephone call from an interviewer may be the only call the respondents have

received in sometime. Respondents often perceive the

interviewer as someone who is interested in their

situation and circumstances. A problem frequently

encountered is how to sensitively and respectfully, but

not abruptly, terminate interviews with obviously

interested, talkative olderrespondents. Prolonging the

interview after the required data have been obtained

has obvious cost implications. As in all types of

research, one wants to close the interview as gently as

possible, so that the next researcher who calls will

encounter an interested respondent and one who will

be inclined to participate again.

The issue of staff burnout is particularly important for in-person and telephone interviews of older

people because the interviewer may need to almost

shout (requiring separate rooms, not cords), frequently

repeat questions, and listen with great concentration.

With older populations, fieldwork can, without exaggeration, be physically and emotionally demanding.

Herzog and Rodgers(4) observe that interviewers find

interviews with older people taxing because of the

requirement for greater attention to procedures and

because of the often distressing personal situations

of many elderly respondents. On average, interviews

with older adults take about 10 percent longer than

interviews with other adult age groups. NERI has

instituted regular office-wide meetings of interviewing staff to respond to the emotional burden and

89
personal drain associated with regular interviewing of

older people.

There are many other issues concerning research

methods and data gathering with older populations

that could be the subject of lengthy discussion. The

four highlighted in this paper are only a beginning and

emerge as a result of recent NERI experience with

field studies of older populations.

With the widely discussed aging of Western

populations, particularly theincreasein the oldest old,

there is an urgent need for valid and reliable data with

which to inform health and social policy concerning

this demographic category. Researchers are not well

prepared to meet the challenges. Research methods

derived from and useful in studies of younger populations or convenience samples maybe inappropriate

and require modification for use with older people

whose health status and social circumstances preclude

their use.

It is not my intention to argue for one ideal way of

conducting social research with older populations.

Rather, the essential message in this paper isthat there

is a need for flexibility. While all field approaches are

useful, some appear to be more useful than others,

depending on the topic and objective of the study and

characteristics of the population under investigation.

Mixed-mode surveys am viewed as particularly promisingwith olderpopulations, although theirlimitations are

well recognized. Certainly, in-person interviews can

no longer be considered the “gold standard” and may

indeed be a luxury from which social researchers must

be weaned, especially during economically stringent

times for sociomedical research. Based on recent

successful experience with several different observational and experimental studies of older people in the

northeastern United States, some suggestions are offered, which I hope will assist other researchers embarking on studies of older people.

Acknowledgments

This paper draws on recent experience with several sociomedical field studies of primarily older

populationsconductedby NERIstaffi Specifically,

“An Epidemiological Investigation of Menopause”

(Grant AG031 11), “Health and Effective Functioning

in the Normally Aging” (Grant AG04673), “Hypertension in the Elderly” (Grant HL183 18–11), “Pathways to Provision of Care for Frail Older Persons”

(Grant AG07182), “Validation and Field Tests for

Risk Appraisal Instruments” (Grant HL3214), “Oral

Health of Older Adults” (Grant 5R01 AG07139--O2),

and “Follow-Up Tracking on the Framingham Heart

Study” (Grant HL38038). These studies were supported by the National Institute on Aging and the

NationalHeart,Lung andBloodInstitute oftheNational

Institutes of Health, Washington, DC.

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92
Part IV

Functional disability
Introduction

by Mary Grace Kovar, Dr.P.H., Special

Assistant for Data Policy and Analysis,

National Center for Health Statistics

The ultimate goal of measuring functional disabil- increase in the size of the older population will require

ity isto contribute to the prevention and postponement a tremendous number of people to provide care if

of functional disability. Reducing the prevalence of current disability rates prevail. Reducing the number

disability would improve the quality of life of older of disabled people would in turn lead to a reduction in

people, which is a worthwhile goal in itself. The the burden of providing care.

reduction may also be critical to society. The projected

95
Functional ability and the

need for care: Issues for

measurement research

by Mary Grace Kovar, Dr.P.H., Special

Assistant for Data Policy and Analysis,

National Center for Health Statistics

I would like to begin by giving you a scenario of

what could happen in the United States. In the mid1980’s, about 12 percent of the population of the

United States (28.6 million people) was age 65 and

over.

There were 1.5 million residents of nursing homes

(l). The proportion of the people who were in nursing

homes was higher at older than at younger ages and

higher for women than for men. Most of the residents

were functionally disabled. Nine out of 10 required

assistance in bathing; three-quarters required assistance in dressing; half had difficulty with bowel or

bladder control.

However, the vast majority of older people were

not in nursing homes. There were more people receiving help with one or more of six activities of daily

living (ADL’s) in the community (2.5 million people)

than there were residents of nursing homes. Again, the

prevalence was much higher among people 85 years of

age and over than among people ages 65–74 years or

75-84 years (table A).

The very high prevalence of institutionalization

and functional disability in old age is critically important. The proportion of the population 85 years of age

and over has grown, and it is projected to continue

growing rapidly. According to population projections

made by the U.S. Bureau of the Census, what was still

a population pyramid in 1990 will essentially be a

lopsided rectangle by 2025 (figures 1 and 2). The

Census midlevel projection is that there will be 58.8

million people 65 years of age and over by 2025—

20 percent of the population of the United States (2).

Projections, based on the prevalence rates of the

1980’s and the Census Bureau population projections,

show what an increasingly large older population,

especially an increasingly large population of the

oldest old, could be like.

If there is no change in the current age-specific

disability rates, postponing mortality will increase the

burden of providing care to older people because of

the great increase in the number of people in nursing

homes or living in the community with functional

Table A. Number and percent of persons 65 years of age and over living in the community,by help received

with activities of daily living or instrumental activities of daily living and age: United States, 1984

Help with ADL’s 1 Help with IADL’s 2

Population Number Number

Age in thousands in thousands Percent in thousands Percent

All ages 65 years and over . . . . . . . 26,433 2,549 9.6 3,710 14.0

65-74 years . . . . . . . . . . . . . . . . . . 16,288 973 6.0 1,822 11.2

75-84 years . . . . . . . . . . . . . . . . . . 8,249 986 12.0 1,437 17.4

85years andover . . . . . . . . . . . . . . 1,897 589 31.1 451 23.8

‘ Activities of daily living.

2Instrumental activities of daily living.

SOURCE: National Center for Health Statistics. Supplement on Aging, National Health Interview Survey. 1984.

97
80

Age

years and over

70-79 years

60-69 years

50-59 years

40-49 years

30-39 years

20-29 years

10-19 years

O-9 years

Females

25 20 15 10 5 0 0 5 10 15 20 25

Population in millions

SOURCE: U.S. Bureauof the Census. Projections of the population of States by age, sex, and race. Population estimates and

projections. Current population reports; series P-25, no 1018. Washington: U.S. Department of Commerce. 1989.

Figure 1. U.S. population, by age: 1990

disability. Assuming thatthereis nochangein the agesex specific rates:

● There will be 3.1 million residents of nursing

homes in 2025. There will be fewer if mortality

rates are higher than projected and more if they are

lower.

+ There will be 6.5 million people receiving help

with one or more ADL’s in 2025. Again, if death

rates are higher, there will be fewe~ if death rates

are lower, there will be more.

Conversely, postponing disability greatly decreases

the burden of providing care to older people even if

mortality rates decline and the expectation of life

increases.

If disability can be prevented or postponed so that

the prevalence of people receiving help declines at the

relatively slow rate of 1percent per year, there will be

2.1 million fewer people receiving help with an ADL

in 2025 than there would be if a constant rate continued. Even if mortality is lower than projected, there

will be 1.5 million fewer people receiving care than

there would be with the rnidlevel projection and no

reduction in theprevalence ofdisabled people receiving

help.

The prevention and postponement of disability is

an effective policy for reducing the burden of disability to both individuals and society. This is a goal worth

aiming for.

The projected worldwide increase in the population of older people is from 286million in 1985to410

million in the year 2000 (3). The number of older

people is expected to continue growing rapidly far into

the 21st century. As a consequence, the number of

people with disabilities, the number needing help, and

the number needing long-term care can be expected to

98
I

Males Age Females

I

I 1 I I 1

80 years and over

70-79 years

60-69 years

50-59 years

40-49 years

30-39 years

20-29 years

10-19 years

O-9 years

25 20 15 10 5 0 0 5 10 15 20

Population in millions

SOURCE:US. Bureauof the Census. Projections of the population of States by age, sex, and race. Population estimates and

projections. Current population reports; series P–25, no 1018. Washington: U.S. Department of Commerce. 1989.

J

25

Figure 2. U.S. population, by age: 2025

increase unless we can prevent or postpone disability

and decrease the age-specific rates.

Measurement issues

It is difficult to forecast the future for even one

country. It isfar more difficult to forecast the future for

the world when we know little about the prevalence of

disability in many counties andevenless about differences among populations.

The first step is to develop conceptually similar

questions on functional disability and the need for care

that can be used in cross-cultural and cross-national

population studies.

There is an approach to measurement based on a

functional ability model (4-6) used to assess the health

of older people primarily in terms of functional adequacy. This approach is based on asocial definition

of health, and it views health as a state of optimum

capacity to perform the roles and tasks for which a

person has been socialized. The functional adequacy

model acknowledges the relationship between level of

expectation and health status. The focus is on the

complex pattern of interaction between individuals

and their ecological and cultural contexts.

This approach recognizes the importance of behavioral capability and the personal and social nature

of disability. Using this model, disability is a function

of the culture and the expectations for people in that

culture. Disability is a condition or state that results in

partial or complete limitation of one’s “normal” activities.

There are further distinctions between disability

and impairment (a physical or psychological abnormality that does not interfere with normal activities)

and between disability and handicap (a socially,

99
environmentally, and/or personally specified limitation) (7). Those distinctions are important for measurement. Although it is critical to measure the entire

range of functioning-from fully functional to completely dependent, including impairments and handicaps as well as disabilities-disability is distinguished

by including the context in which an individual lives.

Given the complexity of the concept, measurement is difficult. Differences in prevalence estimates

may be due to differences in the measurement instrument instead of differences in the true prevalence.

They may also be due to differences in perception or

the cultural context. The fact that functional disability,

at least in its less extreme forms, is so intertwined with

the cultural and physical environment makes themeasurement problem more difficult to solve.

Measuring need for care, unless the need is extreme and obvious, is just as complex, although less

has been written about it forpopulation studies. In this

context, care is usually defined as care by another

person. The need may be modified by characteristics

of the housing and the outside environmen~ availability of aids, such as canes and walkers; availability of

community services, whether formal or informal; the

perception of the older person or the perception of

others; the ability to pay for care, including health

insurance; and the mode of providing care. Again,

differences in prevalence estimates may be due to

differences in the questions used for measurement.

The variation in questions about the need for care is

enormous.

Some understanding of the etiology of disability is

also needed to reduce the risks of disability, to interfere with its progression, and to assess the need for

care. The path to functional disability is usually through

disease, although it maybe through injury. Much is

known about the risk of some diseases but less about

the risk of others. Little is known about the risk of

disability given the presence of disease, and little is

known about the progression of disability. Itispossible

that there are many paths depending on the nature of

the underlying disease and the disability itself. International studies with comparable measures will help

disentangle the influence of culture, disease, and

genetics.

People who are in academic Western environments must also recognize that the vast majority of

people in this world do not live in the same social,

cultural, or even physical world that they do. They

must be careful not to measure disability according to

Western standards. Where there is no perception of a

need for the ability, there can be no perception of

disability. In fact, if in real life there is no need for that

particular ability, there is no disability if one is unable

to perform it.

Even in one country, perceptions differ. The

Supplement on Aging (SOA) to the 1984 National

Health Interview Survey included questions on both

ADL’s and instrumental activities of daily living

(IADL’s) (8). Responses to the questions show that in

the United States there is no perception of need for

some of the activities. Some older men report no

difficulty in preparing meals they say that they do not

cook. In the same way, some older women report no

difficulty managing money; they say that they do not

do it.

Some measures are extremely dependent on culture. The SOA included a question on whether the

individual had difficulty dressing. Some people volunteered that they had no difficulty dressing because

they wore clothes without zippers in the back and

without small buttons. The introduction of Velcro,

which has simplified fastening clothing and eliminated tying shoes, probably means that data from that

question are not comparable over time even in one

country. Data from that question would certainly not

be comparable over cultures. In Southeast Asia and in

parts of Africa, many people do not wear shoes that tie,

and many women wear saris or other wraparound

clothing that does not require the wearer to have the

same abilities as needed for clothing worn in the

United States and Europe.

Nevertheless, a question on dressing could still

have meaning—the person who cannot dress appropriately for the culture will still be unable to participate without help in the activities usual for the culture.

However, responses to the question should not be

interpreted as an ability to perform a specific activity—using small hand motions to fasten buttons,

reaching around to zip a zipper, bending down to tie

shoes—because the activities involved in dressing

would be different.

100
The differences are important to understand, to

appreciate, and to use. If the purpose is to determine

how well an older individual can function within his or

her own cultural environment, it is possible to develop

questions that can be used internationally. If the purpose is to develop measures that ascertain how well an

individual can perform certain physical motions, it is

also possible to develop questions that can be used

internationally, but they will be different questions. It

is important to realize that the means of postponing or

preventing the disability will probably not be the

same. The means of reducing the impact will differ, as

will the kind of care needed.

Inability to function in one’s environment maybe

due to mental or emotional disease, to lack of cognitive ability, or to physical disease or impairment.

Functional disabilities that appear to be similar may

have very different etiologies. The means of preventing disability from depression are not the same as the

means for preventing disability from heart disease.

The care needed by an Alzheimer patient is different

from the care needed by a person who cannot walk

because of arthritis.

Survey estimates of the prevalence of people with

functional disability are important because they are

used to form local and national health policy. However, the prevalence estimates can differ greatly according to the way in which the questions are worded

and the way in which the answers are tabulated.

Estimates can also differaccordingto who is permitted

torespondto the questions. Study design, measurement,

and tabulation have an enormous influence on the

estimates.

If the SOA had relied only on self-respondents or

if the questions had been asked differently, the prevalence of functional disability could have been vastly

different. Even controlling for study design and

wording of the questions, tabulations can yield different estimates.

On the SOA, people (or proxies) were asked

whether they had difficulty with each ADL and L4DL.

For each activity people had any difficulty doing, they

or their proxy were asked the degree of difficulty and

whether they received help. Most of the people responded for themselves. People who were 85 years of

age and over and people with difficulty or receiving

help with ADL’s were less likely than others to respond for themselves (8).

If proxy respondents had been declared out of

scope and only people who answered for themselves

had been the basis fornationalestimates, the estimated

number of people receiving help with two or more

ADL’s would have been 600,000 people lower than it

was. Since the data from this study are being used by

the U.S. Congress to design legislation for long-term

care, that would have been adangerous underestimate.

People may ask, “Where is the truth? Isn’t it

possible that self-respondents denied disability and

that proxy respondents overemphasized it?’ It is

possible, but death is an objective measure, and 29

percent of the people with proxy respondents died

within 2 years, in contrast to 9.5 percent of those who

responded for themselves (9).

The most prevalent ADLreportedon the SOA was

difficulty walking. It is worth examining that estimate

in more detail to show how the data could be tabulated

in different ways. Among people 65–74 years of age

(the example is restricted t’oone age group to avoid

confounding), the prevalence of difficulty walking is

higher among women than among men, but the proportions of men and women receiving help are virtually identical (table B). That is, women with difficulty

walking are less likely to receive help than men.

Table B. Number and percent of persons 65-74

years of age living in the community who have

difficulty walking, by sex and amount of difficulty:

United States, 1984

Difficulty

walking Both sexes Men Women

Number in thousands

Total . . . . . . . . . . ...16.288 7,075 9,213

Percent

Any difficulty

Total . . . . . . . . . . . . . 14.2 12.9 15.1

With help . . . . . . . . . . 2.9 2.8 2.9

Amount of clifficuity

Some . . . . . . . . . . . . 7.8 6.7 8.7

A lit . . . . . . . . . . . . . . 4.7 4.7 4.6

Unableto walk . . . . . 1.6 1.4 1.8

SOURCE: National Center for Health Statistics. Supplement on

Aging, National Health Interview Survey. 1984.

101
However, the data also show that the difference in the

prevalence of difficulty is almost entirely due to the

higher percentage of women with some difficulty.

Women appear to report difficulty with less severe

manifestations than do men; the percentages with a lot

of difficulty or unable to walk are virtually identical.

As one might expect, people with more difficulty are

more likely to receive help, which explains why the

percentage of women receiving help is about the same

as the percentage of men.

Using different combinations of these data, it is

possible to make many different estimates of the

prevalence of difficulty walking and the need for help

(table C). The preva.lencecould be the 19percent with

any difficulty or the 9 percent who either have a lot of

difficulty or are unable to walk. The prevalence of

need could be that same 9 percent or the 6.5 percent

with a lot of difficulty or the 5 percent currently

receiving help.

Those examples are an illustration of the possibility of different respondents, questions, or tabulations

leading to different estimates. They illustrate the possibilities for misinterpretation of the data. However, the

Table C. Number and percent of persons 65 years of

age and over living In the community, by amount of

difficulty walking: United States, 1984

Amount of Number

difficulty waking in thousands Percent

Total(with and without

difficulty) . . . . . . . . . . . . . .

With and without help

Any difficulty walking . . . . . .

Some difficulty walking ., .

A lot of difficulty or

unable to walk . . . . . . . .

A lot of difficulty

walking . ., ..,,.....

Unable to walk . . . . . . .

With help

Any difficulty walking . . . . . .

Some difficulty walking . . .

A lot of difficulty or

unable towalk . . . . . . . .

A lot of difficulty

walking . . . . . . . . . . . .

Unable to walk . . . . . . .

26,433

4,947

2,534

2,385

1,717

668

1,228

362

863

495

368

100.0

18.7

9.6

9.0

6.5

2.5

4.6

1.4

3.3

1.9

1.4

SOURCE:NationalCenterfor Health Statistics. Supplement on

Aging, National Health Interview Survey, 1984.

102

examples should not be interpreted to mean that the

data are not useful. They are, and they are being widely

used, but using them well requires knowledge of the

study design, the wording of questions, and the items

selected for tabulation.

Longitudinal studies

Until recently there have been very few longitudinal studies of older men and women. There is a need

for more such studies, for they yield information that

cannot be obtained from cross-sectional, even repeated cross-sectional, surveys.

In the United States, there are now several such

studies. One, the prospective Longitudinal Study of

Aging (LSOA), which is based on the SOA, is beginning to yield information about transitions that older

people make as they grow older. This study is designed to assess change in functional ability and in

living arrangements.

Receiving help with an ADL is highly predictive

of death or institutionalization within 2 years ( 10).

Those people who were receiving help with an IADL

only or who had difficulty but were not receiving help

were at less risk. People without difficulty were least

likely to die orenternursing homes. Even among these

people, who were all age 70 and over when they

entered the study, there was some reversal. Some

people who had been receiving help with one or more

ADL’s in 1984 reported no difficulty 2 years later.

Other analyses have investigated correlates of

“successfulaging” (11). While these analyses may be

of less importance to issues of functional disability,

they do demonstrate the importance of longitudinal

data.

Data from the LSOA also show that living alone

was not highly predictive of either entering a nursing

home or dying. One reason is that relatively few

people living alone were receiving help. The numbers

are small and the period of followup is short, but if the

analysis isrestricted to people receiving help with one

or more ADL’s, people living alone were more likely

to become institutionalized than people who were

living with others, but they were not more likely to die

within 2 years.
The remarkable thing is the stability of the population. Most of the people were in much the same

condition and living in the same households 2 years

after they were first interviewed.

Summary

Measuring the prevalence of functional disability

among older people is extremely important. The number of older people is projected to increase in both the

developed and the developing countries. The incidence and prevalence of functional disability are high

among older people, and they are higher at older ages.

Many countries plan to care for their impaired older

populations. They need good information to plan for

their care.

The available data are soft. They are often fragmentary and based on research done 20 or 30 years ago

when conditions were different. Data may not take

into account the differences among people living in

widely varying cultures.

Nevertheless, the available data, including data

from longitudinal studies, have started to yield useful

information. Cross-national studies can only increase

the value of the information that many people have

devoted enormous resources to obtain.

People should devote their time to cross-national

comparisons, with the respect for the careful study of

survey design, question wording, and tabulation that

has been addressedin this paper. Researchersshould

also devote time to considering whether questions

appropriate in one culture are equally appropriate in

another. Investigating such issues is one of the purposes of this conference.

References

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11,

HingE. Nursinghomeutilizationby currentresidents,

United States, 1985.National Center for Health Statistics. Vital Health Stat 13 (102). 1989.

U.S.Bureau of the Census.Projectionsof the populationoftheUnitedStates,by age,sex, andrace: 1988to

2080.Currentpopulationreports;seriesP-25,no 1018.

Washington:U.S. Departmentof Commerce. 1989.

U.S. Bureau of the Census. An aging world.Internationalpopulation repmt.s;seriesP-95,no78.Washington U.S. Departmentof Commerce. 1987.

Lawton MT. The functional assessment of elderly

people.J Am Geriatr Soc 19:465–81.1971.

ShanasE, Maddox GL. Aging,health and the organizationof health resources.In:BinstockRH, ShanasE,

eds. Handbook of the aging and the social sciences.

New York: D. Van Nostrand,592–618. 1976.

Kane R, Kane R. Assessing the elderly. Lexington,

Massachusetts:LexingtonBooks. 1981.

Office of Technology Assessment.Technology and

handicapped people. Draft monograph. Washington

1981.

Fitti JE, KovarMG. The Supplementon Agingto the

1984NationalHealthIntemiewSurvey.NationalCenter

for Health Statistics.Vital Health Stat 1(21). 1987.

Kovar MG. Collecting health data from and about

older people: The Longitudinal Study of Aging. In

Conference proceedings: Health survey research

methods.Washington:NationalCenterforHealthServices Research and Health Care Technology Assessment, 115–20.1989.

Kovar MG. The Longitudinal Study of Aging: Some

estimates of change among older Americans.In Proceedings of the 1987 Public Health Conference on

Records and Statistics. Washington:National Center

for Health Statistics,397–8. 1987.

Harris T, Kovar MG, Suzman R, et al. Longitudinal

studyof physicalabilityin the oldest-old.AmJPublic

Health 79 (6):698–702.1989.

103
Chapter 11

Surveys of the situation of

the elderly in Hungary

by Andras Klinger, Ph.D., Chief, Population

Statistics Department, Hungarian Central

Statistical Office

The aging of the population and the increase in the

proportion of the elderly have provided more and

more grounds for studying the situation of the elderly

in Hungary.

For a very long time, members of the elderly

population were not investigated separately. The only

exception was a very specific group that we called the

“very old.” This group initially included all persons

99 years of age and over, but later its scope was

extended to include all those 90 years of age and over

and, in other cases in the later 1970’s and 1980’s, 95

years of age and over.

The methodology used for the investigation of the

very old varied from time to time, but the investigation

was always based on the population census reports.

We visited the households of the very old and asked

them specific questions. Before the 1990 population

census, the last such investigation was carried out in

1987.

In the 1980’s the Hungarian Central Statistical

Office carried out a number of surveys that increased

the knowledge of the situation of the elderly. Many

surveys were carried out with the express intention of

getting better acquainted with the life and health

conditions of elderly Hungarians and gaining insight

into the circumstances of only one group of them—the

most aged.

1984 microcensus

The first general investigation of the elderly

population was performed in 1984, when a so-called

microcensus (a term we use for a sample census) was

organized by the Hungarian Central Statistical Office.

The sample included 2 percent of the total population

of Hungary-elderly and nonelderly—i.e., more than

200,000 persons. The microcensus included general

questions about the population, such as number of

persons, housing, and family situations. At the same

time, however, it was a specific investigation into the

lives of elderly persons.

By the definition used in the 1984 microcensus—

one of the most important sources of data of this

period-the elderly are persons who have reached

pensionable age (males 60 years of age and over or

females 55 years and over), irrespective of their economic activity. The term also includes persons younger

than the legal pensionable age who receive, by their

own right, a pension (on the grounds of age exemption) or a disability pension.

The primary difference between the grouping

applied in the microcensus and that used in other

surveys is that the former also covers younger persons. The basis for the inclusion of different groups

was the nearly identical way of life and the relatively

uniform source of subsistence. This made it possible to perform a comprehensive study of the housing, life, and health conditions of a population corresponding to the applied system of criteria.

The grouping of the elderly as defined above,

although it differs from the categories used undomestic

and international practice (which in turn generally

also differ from one another), makes it possible—by

also taking into consideration other grouping criteria—

to compare the results of the microcensus with the

findings from other surveys.

The persons who fit into this grouping first answered a basic questionnaire regarding their housing

conditions (39 questions), family-household relations

(4 questions), and personal characteristics (36 questions). They also filled out an additional 4-page

questionnaire containing 29 questions divided into 3

105
sections. The fwst section consisted of 10 questions

regarding general personal characteristics. The section had questions about the elderly person’s marriage

history, cohabiting partnership, and number of children. In the case of active earners it contained questions about theexpecteddate ofretirement and whether

the person had plans to undertake work afterretirement.

Pensioners had to answer questions regarding the date

when they started receiving pensions, whether they

had since undertaken work, and whether they had

plans to work in the future.

Data on occupational history are available about

the dependent elderly and those elderly who were

receiving pensions by the “widowed’s right.” (The

widowed have the right to a certain proportion of the

pension their deceased spouses would have receive~

the size of the pension depends on the living spouse’s

age and occupational status.) Finally—also within the

first section-the number of days of work performed

in the household and auxiliary (farming) plots was

reported.

The second section contained health-related

questions regarding diseases of more than 3 months’

duration, handicaps, use of spectacles or dental prostheses, and accidents that had occurred during the

year preceding the survey. This section also included

a question regarding the person who took care of

the ataxic elderly person. The last three questions,

asked only about persons 70 years of age and over,

concerned their motility.

The third section served to render the study of the

housing and life conditions more profound and to

make it more complete by bringing in new points of

view. With respect to housing conditions, questions

were asked about the elderly person’s title to the

housing (the basic questionnaire concerned the title of

the whole household) and the number of places used

by the elderly exclusively, as well as the characteristics of the place where they slept.

With respect to life conditions, the questionnaire

asked about contracting for “support for life,” relationships with kin, eating habits, and other circumstances. (InHungary, “supportforlife’’entails a contract

between an elderly person and someone who moves

into the older person’s apartment and provides care. If

the death of the older person occurs after completion

of the contract, the caretaker legally becomes an

occupant of the apartment. This institution was necessitated by the grave housing shortage in Hungary.)

The questionnaire also included questions regarding the form of social support (from fiends or

family) as well as the use of day care centers. Finally,

14 subquestions were aimed at eliciting information

about elderly persons’ habits of amusing themselves

and leisure activities.

The microcensus covered 2 percent of the population and of the total available housing, and the

survey included 52,055 elderly persons. Nearly 90

percent of the latter, 46,724 persons, were of pensionable age (males and femaIes 60 yearsof age and

over and 55 years of age and over, respectively). Ofthe

population 60 years of age and over, 39,240 persons

were included in the 2-percent sample of the

microcensus (table A).

1987 survey

The next investigation, the survey of the most aged

in 1987, was not a sample survey but one which tried

to be full scope. Earlier surveys pursuing similar aims

had been carried out on the basis of addresses used for

the population censuses, usually in the year following

the population censuses. The first such survey took

place in 1935 and was repeated in 1943, 1960, and

1970. Addresses for the 1987 survey were provided by

the State Population Registration Office. On the basis

of the data in the population register, a list of names of

persons born in 1887 and earlier was prepared.

Table A. Number of the elderly surveyed in the

microcensus, by sex and age group: Hungary, 1984

Age group Both sexes Male Female

Total . . . . . . . . . . . . ...52.055 19,815 32,240

l-54years . . . . . . . . . . 3,470 1,806 1,664

55-59 years . . . . . . . . . 9,345 1,861 7,484

60 years and over . . . . 39,240 16,148 23,092

Pensioners under

pensionable age . . . . 5,331 3,667 1,664

Persons of pensionable

age . . . . . . . . . . . ...46.724 16,148 30,576

106
The population register had the names of 275

persons born in 1887 and earlier. The survey had to be

carried out in two steps, First, the data in the population register had to be checked, and the statistical

questionnaire had to be filled ouc in the second step,

the elderly subjects were examined by a medicogerontological team.

Of the 275 persons, 7 were younger than 99 years;

10 were not known at the indicated addresses; 20 had

died in 1986 or earlier, and 10 had died in 1987; 10

refused to answer questions or were in a state in which

it was impossible to receive answers from them.

Statistical questionnaires were filled out for 218 persons.

The 10 sections of the statistical questionnaire

included 80 questions. Among questions regarding

general characteristics, one concerned documents

certifying the date of birth. The same section included

questions about the present and earlier residences of

the person surveyed.

The aim of the questions regarding grandparents,

parents, brothers, and sisters was to discover whether

there had been other family members who reached an

equally high age, and from what diseases and at what

age the grandparents, parents, brothers, and sisters had

died.

The third section concerned the marriage history,

spouses, and descendants of persons born in 1887 and

earlier, This section included a question regarding

keeping up relationships with relatives, which had

also been asked in the microcensus.

The scope of inquiry regarding educational attainment and occupational history was completed by

questions about the financial situation—the type and

sum of pensions, the form ofsocial support. (The latter

question had also been used in the additional questionnaire of the microcensus, while questions regarding educational attainment and the type of pension

were included in the basic questionnaire of the

microcensus. Further, the sum of the pension was also

known, asthe microcensus was based on data from the

National Pensions Office.)

The questions regarding households, housing, and

life conditions were somewhat broader in scope than

the questions in the microcensus had been. However,

this is because the basic unit of sampling in the

microcensus—and consequently also in the survey—

had been the dwelling, so separate questionnaires

were filled out about the dwelling and about each

individual living there. This survey included only the

population 99 years of age and over.

The scope of inquiry regarding the state of health

also included questions formerly asked in the

microcensus (for example, subjective judgment about

the state of health, bodily deficiency, motility). Also

asked were questions regarding those states of health

that gain in importance as age increases.

The scope of inquiry regarding daily eating habits

was completed by questions regarding food consumed

for breakfast and supper, as well as by questions

regarding dietary habits as a child, an adult, and at

present. To establish the level of nourishment and

indicators of body proportions, the lowest and the

highest adult-age body weights, as well as the height

in adulthood, also figured among the questions. Asfor

health-damaging practices, questions regarding the

consumption of alcoholic beverages and kinds of

tobacco concerned habits both as an adult and at

present. The scope of questions regarding amusement

and pastime activities was narrower than it had been in

the microcensus, which is in accordance with agespecific characteristics.

There were four questions regarding the impact of

changes in the economic-political situation on the life

of the persons surveyed. Those surveyed had the

opportunity to answer two questions regarding their

opinion about the secret of longevity and what they

would still like to achieve in life. Finally, the surveyor

could register a personal opinion about the intellectual

agility of the person surveyed and about the way the

person was being taken care of.

The survey of the most aged covered 218 persons.

Naturally, their number is decreasing rapidly with

advancing age. Of them, those 99 years of age were the

greatest number (96). The oldest two citizens were

both females 107 years of age. The sex ratio is characterized by an overwhelming female predominance:

Less than a quarter of those surveyed were males (50

persons) (table B).

The study of the situation of the elderly in the 1980’s

inHungary isrenderedpossible by these two surveys and

by the data of surveys carried out with other aims.

107
Table B. Number of persons 99 years of age and

over, by sex, year of birth, and age: Hungary, 1987

Year of birth

and age Both sexes Male Female

Total . . . . . . . . . . . . . . . 218

1887 (99 years) . . . . . . 96

1886 (100 years) . . . . .

1885 (101years) . . . . . ::

1884 (102years) . . . . . 11

1883 (103years) . . . . .

1882 (104years) . . . . . :

1881 (105years) . . . . . 4

1879 (107years) . . . . . 2

50 168

24

8 %

11 22

3 8

2 6

1 2

1 3

2

Comprehensive analyses anddatacollections have

already been published on the basis of these and other

surveys. The volume containing the data from the

surveys of the elderly that appeared in the series of

micrccensuspublications includes, besides a relatively

narrow analysis, significant tabular material. For the

purpose of analyzing the results, besides the tables

published in the volume, other issues can be examined

through computer processing of the raw data. By

combining the information stored on various magnetic

tapes, further statistical tables can also be prepared. In

the future, it will be possible to look for a way to

expand the stored information about the elderly,

possibly bydataabout these samepeopletobcollected

in future surveys.

One extraordinarily interesting aspect of the

analyses in the population census programs from the

beginning of this century until 1949 is the study of the

handicapped. The 1949census was the first conducted

after the Second World War. The Government was

greatly interested unknowing which kinds of handicaps

were caused by the war and which were not.

Of the 52,055 elderly surveyed in the 1984

rnicrocensus, 7,198 (14percent) suffered from at least

one handicap. The number of handicaps was 7,908,

i.e., on the average there was 1.1 handicap for 1

handicapped person.

Of the handicaps, the most frequently encountered

were those of the sensory organs (62 percent of the

handicaps belonged to this group). In accordance with

age-specific

elderly with

characteristics, the proportions of the

impaired hearing (the sample included

2,024 elderly with impaired hearing, and impaired

hearing accounted for 41 percent of the sensory organ

handicaps) and with poor eyesight (1,909 persons, 39

percent) were the highest. The proportion of those

elderly with damaged motility was 3 percent; one-fifth

of the handicaps and 22 percent of handicapped persons belonged in this group (table C).

The proportion of the handicapped within the agegrouped data on the elderly—with the exception of

those 54 years of age and under receiving pensions in

their own right-gradually increased with age. Consequently, the handicaps of the elderly are primarily

due to age, to natural wear and tear. This was also

indicated by the especially high proportions of those

with impaired hearing and poor eyesight.

Among males, the proportion of the handicapped

was highe~ 16 percent versus 12 percent among

females. This higherproportion wasfound everywhere

except among the group ages 75–79 years. Because

the proportion of males constantly decreases as age

progresses, the difference between the two sexes becomes more and more striking (table D).

The 1987 survey of the most aged registered

significantlyfewerhandicappedamongthepopulation

99 years of age than would have been expected on the

basis of the rising proportion of the handicapped as

age progresses.

TableC.Numberof handicaps among the eideriy

and number of elderly persons with handicaps, by

sex and type and number of handicaps: Hunga~,

1984

Type and number

of handicaps Both sexes Male Female

Type Number of handicaps

Total . . . . . . . . . . . . . . . 7,908 3,496 4,412

Physical handicap . . . . 538 325 213

Damaged motility . . . . . 1,594 745 849

Mental handicap . . . . . 571 228 343

Sense organ

handicap . . . . . . . . . . 4,883 2,018 2,865

Other . . . . . . . . . . . . . . 322 180 142

Number Number of handicapped persons

Total . . . . . . . . . . . . . . . 7,198 3,198 4,000

I handicap . . . . . . . . . . 6,543 2,920 3,623

2 handicaps . . . . . . . . . 600 258 342

3 or more handicaps . . 55 20 35

108
Table D. Percent of the handicapped elderly, by sex

and age group: Hungary, 1984

Age group Both sexes Male Female

Total ..,...,.....,.. 13.8

l-54years . . . . . . . . . . 24.5

55-59 years . . . . . . . . . 8.0

60-64 years ...,..... 8.5

65-69 years.,.,..,.. 10.9

70-74 years . . . . . . . . . 14.1

75-79 years . . . . . . . . . 20.0

80-84 years . . . . . . . . . 24.7

85-89 years .,....... 32.4

90 years and over . . . . 44.4

16.1

28.5

15.4

10.1

11.8

14.9

19.5

26.1

37.7

50.5

12.4

20.2

6.2

7.3

10.3

13.6

20.3

24.0

30.1

41.5

Naturally, this is due to the fact that the increase in

the proportion of the handicapped as age progresses

doesnot,originatefrom anyincreasedsurvival chances

of the handicapped but is the result of their increasing

tendency to develop handicaps owing to the natural

wear and tear of aging. We must look at other reasons

to explain such a conspicuous difference between the

proportion of the handicapped at the time of the two

surveys.

It would be erroneous to conclude that only a

person without a physical, mental, or sensory organ

handicap has the chance to reach the age of 100 years.

Of the218 most aged persons, 38 had some handicap,

and one of them was handicapped (deaf and mute)

since birth. (According to the survey, she had been

dropped on her head as an infant and isthought to have

become deaf andmuteas a consequence.) The majority

became handicapped after the age of 80 years; 8, at the

age of 80-89 years and22, at the age of 90 years andover.

Among the most aged, one handicap was characteristic. Of the 38 handicapped, 5 had 2 handicaps.

Three or more handicaps together were not found. The

deficiency of the deaf and mute person described

above was regarded as one handicap.

Among the persons 99 years of age and over,

blindness in one or both eyes was encountered most

often (table E). Fifteen persons (39 percent of the

handicapped) were completely blind, and four of

them, besides being blind, were also deaf. In each

case, blindness developed after the age of 80 years.

Twelve of them went blind after the age of 90. Fourteen persons were blind in one eye. Other handicaps

were encountered less frequently. It is characteristic

that the other handicaps-with the exception of the

case of the deaf and mute person—began to develop at

adult age, mainly at old age.

A sex-specific analysis was prevented by the fact

that three-quarters of the most aged were females. The

sex ratio of the 38 handicapped was 29 females and 9

males. The most frequently encountered handicapTable E. Number of handicaps among the most aged and number with handicaps, by age became handicapped

and type and number of handicaps: Hungary, 1987

Age became handicapped

Type and number All 49 years 50–69 70–79 80-89 90 years

of handicaps ages Birth and under years years years and over

Type

Total . . . . . . . . . . . . . . . . . . . . 43

Blind in botheyes, .,...,... 15

Blind inone eye . . . . . . . . . . . 14

Deaf and mute . . . . . . . . . . . . 1

Completely deaf . . . . . . . . . . . 6

Lame, amputated hand . . . . . . 1

Lame, amputated foot . . . . . . 3

Other . . . . . . . . . . . . . . . . . . . 3

Number

Total . . . . . . . . . . . . . . . . . . . . 38

lhandicap . . . . . . . . . . . . . . . 33

2handicaps . . . . . . . . . . . . . . 5

1

1

1

1

Number of handicaps

3 2 3

2 3

2

1

Number of handicapped persons

2 2 3

1 2 3

1

10

:

1

1

1

1

8

7

1

24

12

6

.

5

.

1

22

19

3

109
blindness—was characteristic of females: Of the 15

blind, there was only one male.

It was not always possible to form a judgment as

to whether a handicap existed. There were some cases

in which the physical and mental condition of the person surveyed made it impossible to fill out the questionnaire completely. Establishing the existence of

handicaps was rendered more difficult by the need to

treat a significant portion of the physiological symptoms originating from old age as natural conditions that

characterize the age. Thus, poor eyesight does not figure

among the handicaps. However, itistobementioned that

theeyesightof111 persons was-in their opinion or that

of others in their environment—poor. While 15 were

blind according to the answers to the question about

handicaps, based on the answers to the question regarding eyesight, 16 persons were completely incapable of seeing. With two people it was impossible to

establish whether they could see. Similar problems

also arose in connection with hearing. One hundred

twenty-five persons had impaired hearing, and seven

could not hear at all. (The number of completely deaf

persons and deafandmutepersons being the same, the

results of the two questions coincided in this respect.)

However, in the case of one person it was impossible

to establish whether she could hear.

Among the handicapped, one could also mention

the 47 persons who, as a consequence of old-age

mental decline, were capable of only reduced mental

activity or who were mentally deficient. Taking all the

above into account, it can be established that the

contradiction between the results of the survey of the

elderly in the microcensus, on the one hand, and the

results regarding the handicapped within the survey of

the most aged, on the other, only seem to exist,

originating from the differences in categorization

between the two surveys.

Surveying the handicapped also will figure in the

survey program of the 1990 population census. An

additional questionnaire to be addressed to 20 percent

of the total population includes five questions regarding

bodily, mental, or sensory defects: “What kind of

defectdoyouhave?”,’TVhatisthecauseof yourdefect?”,

“When did it begin?”,’ ‘Do you have any limitation in

working?”, “Ifyou donotwork, doyou intend to work?”

Taking into consideration both the age group and the

combination of age group and kind of economic activity, it will be possible to compare the data on

handicaps from the 1984 microcensus, the 1987 survey of the most aged, and the 1990 population census.

Among the most aged, active support and care by

the residential community is needed not only by the

handicapped but also by those 180 persons who,

according to the survey, had not developed handicaps.

Increased care by persons in the immediate environment is also needed by those whose limited motility is

not a handicap in the sense used here but the consequence of a natural condition. A question regarding

motility was included both in the program of the

microcensus and in that of the survey of the most aged.

The data from the rnicrocensus concerned the population born in 1914 and earlier, i.e., 70 years of age and

over at the time of the survey.

In the case of both surveys, three questions concerned motility: The frequency of leaving the dwelling, the difficulties in walking upstairs and downstairs;

and walking within the dwelling. Comparison of the

data seems to be appropriate in connection with the

last problem, walking within the dwelling.

Of the 19,583persons 70 years of age and over surveyed, 469 (2 percent) could not walk within their

dwellings. An additional 342 persons could walk within

the dwelling only with the help of another person.

Thus, 4 percent of the population 70 years of age and

over had problems walking within their own dwellings.

Within their dwellings, 24 of the most aged could

not walk at all and 19could walk only with the help of

another person. In spite of their advanced age, a

relatively high number could walk independently at

least within their dwellings. Of them, 105 could walk

leaning on something (a stick or a walking frame) or

holding onto pieces of furniture, while 68 could walk

without any assistance (table F).

Naturally, the possibilities of analyzing the data

on the elderly and the most aged have not been

exhausted. The distribution by types of settlement,

housing conditions, household-family relations, income situation, health status, and type and number of

chronic diseases are all viewpoints that—when studied with the already published analyses—present the

situation of the population from different aspects and

call the attention of society to what needs to be done.

110
Table F. Number and percent distribution of t~e eideriy population by manner of waiking within a fiat dweiiing,

according to age: Hungary, 1984 and 1987

Manner of walking 70 years of age and over 1 99 years of age and over2

within a f/at dwe//ing Number Percent distribution Number Percent distribution

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Without anydifficulty . . . . . . . . . . . . . . . . . . .

Cautiously but without assistance . . . . . . . . .

Holding onto pieces of furniture . . . . . . . . . .

Leaning on a stick . . . . . . . . . . . . . . . . . . . . .

Usinga walkingframe or some other

device . . . . . . . . . ., ..0,... . . . . . . . . . . . .

Withthe assistanceof another person . . . . . .

Cannotwaikat all.......,...........,..

Cannot be established,no answer . . . . . . . . .

19,583

14,209

1,990

2,256

162

342

469

155

100.0

72,6

10.2

11.5

0.8

1.7

2.4

0.8

218

39

3

66

2

19

24

2

100.0

17.9

13.2

17.0

30.3

0.9

8.7

11.0

0.9

‘ Datafrom the 1984microcensus.

2Datafrom the 1987surveyofthe mostaged.

NOTE:A flat dwelling is one without stairs.

111
Chapter 12

A comparison of

demographic, health, and

housing variables in

studies of elderly

populations in Canada

and the United States

by W. F. Forbes, Ph.D., D.SC., L. M. Hayward,

M.A., and B. D. McPherson, Ph.D., University

of Waterloo, Ontario, Canada

Introduction

With the aging of the population, scientists and

policymakers are constantly searching for current

valid data. However, the collection of population data

can be both expensive and time consuming. As a

result, policy decisions may be made on the basis of

outdated or limited data. One possible solution to

overcome this difficulty is to employ recent and valid

data collected in similar jurisdictions. Questions then

arise as to whether data collected in the United States

can be generalized to Canada, or to parts of Canada

such as Ontario; or whether data collected from New

York or Ohio can be generalized to Ontario, or data

from Oregon or Washington to British Columbia.

Given the political, economic, andculturaldifferences

between Canada and the United States, most investigators would argue that the use of data collected in one

jurisdiction forpolicydecisions in anotherjurisdiction

would have limited validity and usefulness.

To consider a specific example, in recent years a

number of data sets describing the elderly population

in the United States and Canada have become available, and itis ofinterest to compare the results obtained

from these data. If similar measures are used and if the

results are found to be similar, this would enhance the

credibility of the results’ reliability for interpretive or

policy use in otherjurisdictions. This conclusion would

also suggest that, with respect to some factors, the two

populations are essentially similar, implying that inferences derived from U.S. data could be assumed to

be generally valid for Canada. However, if the results

differ appreciably, this would suggest that for cultural

and methodological reasons the data should not be

usedin otherjurisdictions. Regional differences within

Canada are also of interest because they may indicate

greater similarities to some regions of the United

States because of economic and/or cultural factors, in

particular if the data for the largest province, Ontario,

are compared with data for the rest of Canada. In

addition, if longitudinal data are available in some

areas, interpretations might be made across a period of

time involving a greater part of the adult years.

Methodology

Description of the surveys used

The Canadian General Social Survey (GSS) was

designed to monitor social trends and to obtain information on specific policy issues of current interest

(l). The f~st cycle of this annual survey, conducted in

the fall of 1985, includes variables concerning health

and well-being, with an additional focus on social

support for those 55 years of age and over. The target

population was noninstitutionalized residents of

Canada 15 years of age and over, excluding residents

of the Yukon and Northwest Territories. The elderly

respondents (65 years of age and over) were selected

from households that had recently rotated out of the

Labor Force Survey, and they were interviewed in

person. The resulting sample size for persons 65 years

113
of age and over was 3,130. The data presented in this

paper have been weighted to adjust for sampling

variation and response bias.

The data for the United States (2) were derived

from the Supplement on Aging (SOA) to the 1984

National Health Interview Survey (NHIS) (3). The

NHIS is an ongoing weekly survey that also examines

health and well-being, and in 1984 the supplement

focused on issues associated with aging. The target

population for this survey is the civilian noninstitutionalized population of the United States. The SOA

sample of respondents 65 years of age and over included all eligible people in the surveyed households,

each interviewed in person. This sample of elderly

persons (65 years of age and over) totaled 5,982 (2).

The Ontario Long-Term Study of Aging (Ontario

LSA), 1959–78, was a longitudinal survey conducted

to examine the process of aging, particularly during

the preretirement period. A stratified quota sample of

2,000 men 45 years of age in the labor force in 1959

was selected to be interviewed annually over a period

of20 years. With attrition, 1,039participants completed

the study in 1978. (For details of the Ontario LSA, see

(4).) The Ontario LSA data permit some comparisons

to be made with the GSS; for example, the percentage

of Ontario males ages 65–74 years in 1985 who report

O-8 years of education afforded similar values for the

two studies, 32.4 percent and 32.6 percent, thus supporting the validity of both studies.

Measurement

Unfortunately, the various survey data are based

on different questions, as is often the case. For this

reason it was not possible to produce comparable

Canadian measures for all of theU.S. data (2). Specific

variables from the SOA that were not available from

the Canadian data setsincluded race; the interval since

last doctor contac~ place of residence (urban or rural);

and the questions, “How good ajob do you feel you are

doing in taking care of your health?”, “How much

control do you think you have over yourfuturehealth?”,

“During the past year, has your overall health caused

you a great deal of worry, some worry, hardly any

worry, or no worry at all?”, “Compared to your own

level of physical activity 1 year ago, would you say

you are now more active, less active, or about the same

as you were then?”, and “How often do you walk a

mile or more at a time without resting?” In addition,

some questions—such as, “Do you feel that you get as

much exercise as you need or less than you need?”-

were asked in a different way in Canada. The question

concerning bed days in a year was estimated for only

the last 14days in Canada, and the question in Canada

concerning hospitalization during the year asked about

the number of nights spent in a hospital. Further, the

question on regular exercise routine was not asked

explicitly in Canada, where the question concerned

only how regularly specific activities were carried out.

Also, in a few instances the responses to similar

questions were grouped differently in the two studies,

for example, the time since last residential move and

the number of activity limitations.

However, a number of questions are identical or

almost identical in the surveys carried out in the two

countries, and it is therefore possible to compare the

responses to these questions. The variables described

below, which were selected for this comparison, are

based on similar questions.

Marital status in the Canadian GSS was collected

as part of the household chart, which listed the basic

demographic characteristics of all household members

and their relationships to the respondent. In the NHIS

SOA, marital status was asked as part of the interview,

as it was for the Ontario LSA surveys.

Family size is computed from the household charts

for both the Canadian GSS and the NHIS.

The questions concerning the education of the

respondent are worded differently in the three surveys.

However, the differences are minor and are unlikely to

affect the conclusions. The GSS has the most complex

series of questions. Respondents were asked, “How

many years of elementary/secondary education have

you completed?”, followed by, “Have you graduated

from secondary school?” and “What is the highest

level?” To make Ontario grade 13 graduates comparable to graduates in the other Provinces and the

United States, they were considered to have 12 years

of secondary schooling. Those with college, university, or other postsecondary education were coded in

the category 13years or more, while those who did not

complete high school but had some other further

education had 1 year added to their total.

114
In the NHIS the respondents were asked, “What is

the highest grade or year of regular school

has ever attended?” This was coded as the number of

years at the highest level of education: Elementary,

high school, and college. Similarly, the Ontario LSA

asked’’What is your education?” andcodedthe number

of years at each level.

Housing was also measured differently in the

various surveys. The GSS asked the respondent, “In

what type of dwelling are you now living?”, whereas

the NHIS instructed the interviewer to classify the

living quarters. Again, this different manner of asking

the question is unlikely to affect the conclusions

concerning the influence of type of housing.

The measurement of major daily activity of the

respondents was also slightly different in the three

studies. The GSS survey asked, “During those 2 weeks,

was your main activity working, going to school,

keeping house, or something else?”, plus a series of

questions designed to assess the labor force status of

the respondents. The NHIS questionnaire, on the other

hand, asked, “What was doing most of the

past 12months: Working at ajob or business, keeping

house, going to school, or something else?” In an

attempt to make the two surveys comparable, the

GSS-derived labor force status was used as the main

indicator of usual activity, using the question quoted

above to separate respondents not in the labor force

into those keeping house and those going to school.

The questions concerning perceived health status

are fairly similar, except that the GSS asked the

respondents to compare themselves to people of their

own age. This could lead to a possible positive bias

when compared with the other surveys. In addition,

because of coding differences it was necessary to

combine the “good” to “excellent” categories.

The last variable chosen for comparison was the

number of doctor contacts in a year. In the GSS, the

two relevant questions were: “During the last 12

months, how many times did you see or talk to a

general practitioner about your health?” and “During

the last 12months, how many times did you see or talk

to a medical specialist about your health?” The results

of these two questions were summed to arrive at a total

number of doctor contacts.

In the NHIS, respondents were asked, “During the

past 12 months, about how many times did

see or talk to a medical doctor or assistant (about

)? (Do not count doctors seen while an overnight patient in a hospital.)” The exclusion of contacts

while in the hospital may cause a negative bias in the

number of contacts when compared with the other

studies, especially for those with frequent contact who

are more likely to have been hospitalized.

Two measures in the Ontario LSA concerning

doctor contacts were used, one from the initial 1959

survey, which is similar to that in the GSS, and a later

one based on two questions asked in 1975: “Have you

visited or been examined by an M.D. since last interview?” and “If yes, number of visits.” Since the latter

does not explicitly include talking to a doctor without

a visit, this may also lead to slightly lower values for

the Ontario LSA when comparing these results with

those of the other two studies.

Data presentation

The data are presented for the population 65 years

and over, subdivided for the population ages 65–74

years and for the population 75 years of age and over,

given as percentages. Because the numbers surveyed

are relatively large, most of the differences, both

between different jurisdictions and between males

and females, are significant at the p < 0.05 level.

Specifically, all the standard errors were less than

0.075 percent, hence a difference of 0.5 percent is

highly significant. This shows that the differences are

not due to the expected difference that would arise if

another similar sample were selected. However, a

significant difference may not indicate areal difference,

since the wording of the questions was not always

identical. Also, differences in responses to many of the

questions, such asthose pertaining toperceivedhealth

status, might arise because of a different perception of

what a different health status signifies; for example, a

more positive outlook on life might give rise to a

relatively larger proportion of individuals reporting

their health as excellent.

Results

The results comparing Canada and the United

States are shown in table A.

115
w Table A. Percent distribution of persons 65 years and over by selected characteristics, according to age: United States and Canada

.

&

65-74 years 75years and over

65 years and over Both sexes Men Women Both sexes Men Women

United Unjted United United Unjted United United

Characteristic Canada States Canada States Canada States Canada States Canada States Canada States Canada States

Marital status

Married . . . . . . . . . . . . .

Widowed . . . . . . . . . . .

Divorced

or separated . . . . . .

Never married . . . . . . .

Family size

I person . . . . . . . . . . . .

Alone . . . . . . . . . . . .

With a nonrelative . .

2persons . .. m.......

Spouse . . . . . . . . . .

Other relative . . . . . .

3 or more persons . . . .

3persons . . . . . . . . .

4 or more persons . .

Education

0-8years . . . . . . . . . . .

9-n years . . . . . . . . . .

12years7 . . . . . . . . . . .

13years or more . . . . .

Housing

House or apartment. . .

Other . . . . . . . . . . . . . .

Usual activity

Working . . . . . . . . . . . .

Keeping house. . . . . . .

Other . . . . . . . . . . . . .

Perceived health status

Good to excellent. . . . .

Fair . . . . . . . . . . . . . . .

Poor . . . . . . . . . . . . . . .

57.1

31.4

3.9

7.5

31.0

28.2

5:::

45.1

6.9

17.0

9.8

7.1

46.9

22.4

9.9

19.5

95.5

3.3

9.0

53.0

35.4

62.0

28.9

8.9

54.7

34.1

6.3

4.4

32.2

30.5

5:::

46.0

7.1

14.8

8.9

5.9

34.6

16.8

28.1

18.6

93.5

6.5

10.7

42.8

46.6

66.7

21.4

11.5

64.0

24.1

4.1

7.8

26.1

23.6

5;:;

49.5

5.7

18.6

11.3

7.3

41.7

24.1

11.1

21.9

95.9

3.4

12.7

50.8

34.1

66.9

27.4

7.4

63.3

25.0

6.9

4.4

26.4

24.8

1.6

58.1

52.2

5.8

15.5

9.6

6.0

29.7

17.6

31.7

19.6

93.5

6.5

14.8

42.1

43.1

67.6

21.4

10.6

80.4

8.5

3.3

7.8

15.7

14.8

0.9

62.1

59.8

2.4

22.1

13.4

8.7

43.8

21.9

10.0

23.0

95.9

2.8

19.6

15.3

61.9

66.9

24.7

8.1

Percent distribution

80.3

8.3

6.2

4.8

13.9

12.3

1.7

67.0

63.8

3.2

19.1

12.1

6.9

32.1

16.8

26.9

22.8

94.5

5.4

20.8

4.0

75.2

66.7

20.6

12.5

50.0

37.3

4.8

7.9

34.9

31.1

3.8

49.4

40.9

8.6

15.7

9.5

6.2

39.8

25.9

12.1

21.0

94.3

3.9

6.8

80.9

10.6

63.3

29.7

6.8

50.3

37.8

7.4

4.0

36.0

34.4

1.6

51.2

43.3

7.8

12.8

7.6

5.2

27.9

18.2

35.4

17.2

92.8

7.3

10.2

71.4

18.4

68.3

22.1

9.2

45.1

44.2

3.7

7.0

39.7

36.2

3.5

46.2

37.3

8.9

14.1

7.3

6.8

56.1

19.6

7.7

15.4

96.3

3.2

2.6

56.8

37.5

56.9

31.5

11.6

40.9

48.8

5.4

4.4

41.4

39.7

1.8

44.9

35.8

9.1

13.6

7.7

5.9

42.5

15.6

22.4

17.0

93.3

6.7

3.9

43.9

52.2

65.2

21.3

13.0

67.1

23.2

4.6

5.1

23.5

20.7

2.8

62.3

54.3

8.0

14.2

8.7

5.4

62.8

16.6

7.0

12.8

96.5

2.4

5.6

17.0

71.3

60.3

29.2

10.5

70.4

21.6

4.4

3.1

21.3

20.6

0.7

65.9

62.0

3.9

12.9

8.4

4.4

45.1

15.5

19.7

17.3

92.3

7.7

6.8

5.2

88.0

64.2

21.3

13.8

31.5

57.2

3.2

8.2

49.7

45.8

3.9

36.3

26.8

9.5

14.0

6.4

7.6

52.0

21.5

8.1

17.0

96.2

3.8

0.8

81.4

16.6

54.8

32.9

12.3

23.8

64.5

::;

53.1

50.7

2.4

32.9

20.8

12.1

14.1

7.3

6.8

41.0

15.7

23.9

16.9

94.0

6.1

2.3

66.2

31.5

65.6

21.2

12.5
Number of doctor

corrtaotsin year

Ocontacts . . . . . . . . . . 11.7 18.6 12.8 19.7 14.4 21.2 11.5 18.5 9.7 17.0 12.9 17.7 7.7 16.5

l-2corttaots . . . . . . . . 27.5 27.8 30.7 28.9 32.4 28.8 29.2 29.0 21.9 26.1 25.5 28.7 19.7 24.6

3-6contacts . . . . . . . . 30.1 31.7 29.1 30.3 28.8 30.2 29.3 30.4 31.8 34.0 30.4 33.6 32.6 34.3

7-12contaots . . . . . . . 16.9 13.2 16.2 13.0 14.1 12.7 17.9 13.3 18.2 13.4 16.3 11.8 19.4 14.4

13-24 oontacts . . . . . . 9.5 4.9 7.8 4.9 6.7 4.3 ~.~ 5.3 12.4 4.8 9.4 3.4 14.3 5.6

25 oontactsor more. . . 2.9 3.3 2.4 2.9 2.8 2.6 . 3.2 3.8 3.8 3.7 4.2 3.9 3.6

Number

Estimatedpopulation

inthousands . . . . . . 2,472 26,299 1,573 16,227 722 7,046 851 9,178 900 10,063 344 3,665 556 6,378

Sample size . . . . . . . . . 3,130 5,982 1,898 3,731 953 1,625 954 2,106 1,232 2,251 511 822 721 1,429

‘Includes grade 13; see text.

NOTE:Fwures may not add to 100.0 because of missing data.
Marital status

More individuals in Canada than in the United

States reported their marital status as never married

(7.5 percent versus 4.4 percent). This difference is

observed in both age groups and for both sexes in the

two samples. This consistency suggests that being

never married is indeed more common in Canada than

in the United States for the population 65 years of age

and over. The reason for this difference is not known,

but it may have occurred because of higher Canadian

death rates during World War I or because of differences in immigration policies. At the same time, there

are appreciable variations within Canada, with percentages ranging from 3.5 percent to 13.2 percent

(data not shown). For example, in Ontario the percentage of never-married persons is 4.8 percent, close to

the U.S. figure (table B). Ontario is more prosperous

than the rest of Canada, as can be seen from table C;

this suggests that a low never-married proportion is

related to prosperity. In this connection, it may be

noted that there is a reasonably strong correlation in

Canada between annual marriages permillionpopulation (1926-55) and the gross national product (GNP)

per capita in 1985 dollars (r= 0.658; p < 0.01) and

income per capita in 1985 (r = 0.621; p < 0.01). At the

same time, prosperity is not the complete explanation

because cultural or religious factors, which may affect

practices, beliefs, or attitudes (particularly of women

toward careers) also play a role, as illustrated by the

relatively high never-married rate for the Quebec

region (13.2 percent). It should also be noted that the

relatively high correlation coefficients arise because

groups are considered the correlations might be lower

if individuals were considered (the ecological fallacy).

With respect to the elderly who report their status

as divorced or separated, the percentage is higher in

the United States than in Canada, except for males in

the age group 75 years and over (table A). One reason

for this finding maybe that, until recently, it was easier

to divorce in the United States than in Canada. However, within the Canadian regions, again there are

pronounced differences, and these percentages range

from 0.5 percent to 10.0 percent. It may be that

a greater percentage of never-married persons is

inversely related to a greater percentage of divorced

Table B. Percentof persons reportingnever-marriedstatus, by age: UnitedStates, Canada,and Ontario

Ontario Rest of

Age United States Canada Cross-sectional Longitudinal 1 Canada

Percent

65 years andover . . . . . . . . . . . . . . . . . . . 4.4 7.5 4.8 --- 9.1

75 years and over

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4 7.0 3.4 --- 9.3

Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1 1.4 --- 7.3

Women . . . . . . . . . . . . . . . . . . . . . . . . . . . ::4 8,2 4.6 ..- 10.6

65-74 years

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4 7,8 5.7 --- 9.0

Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.8 7.8 6.6 8.4

Women . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.0

---

7.9 5.0 --- 9.5

Menaged 65years . . . . . . . . . . . . . . . . . . --- --- ---

Menaged 45years . . . . . . . . . . . . . . . . . . ---

...

... ...

::: ...

‘The percentages for the Ontario Long-Term Study of Aging (LSA) are relatively low compared with the relevant Canadian General

Social Survey (GSS) data (6.6 percent for Ontario males ages 65-74 years). Presumably never-married males participate infrequently in longitudinal studies. They also drop out from a long-term study more frequently for all reasons, including death. (See

Forbes WF, McPherson BD, Shacfbolt-Forbes MA. The validation of longitudinal studies: The case of the Ontario Longitudinal Study

of Aging. Can J Aging 8(1):51-67. 1989.) This suggestion is suppotted by examining the data for the men in the Ontario LSA at age

45; if only men who completed the study are considered, this percentage is 2.9 percent, considerably lower than the value of 4.4

percent for males at the beginning of the Ontario LSA,

118
Table C. Income per capita, gross nationai product per capita, and numberof marriagesper miiiion population:

Canada, Ontario. and United States, seiected vears 1926-85

Marriagesper

Income per capita Gross national product million population

United United

Year Canada Ontario States Canada States Canada Ontario

1926 . . . . . .

1930 .$....

1935 .,,..,

1940 . . . . . .

1945 ..,...

1950 . . . . . .

1955 . . . . . .

1985 .,....

1985 doilars’

$2,935 $3,359 .-. $3,730 ..-

2,965 3,669 $3,983 3,870 $4,762

2,714 3,442 3,686 3,449 4,430

3,454 4,339 4,546 4,683 5,841

5,331 6,446 7,341 6,788 9,122

5,249 6,364 6,679 6,627 8,384

6,045 7,223 --- 7,711 9,649

15,708 17,186 13,902 17,891 16,757

Number

588 622

585 630

592 626

904 917

747 711

760 815

680 706

--- ---

1Monetary statistics are reported in the currency of the relevant country adjusted by the respective consumer price index; the

average rate of exchange for the U.S. dollar in Canada in 1985 was 1.366.

SOURCES: Department of Finance. Annual reference tables. Quarterly economic review. Ottawa: Ministry of Supply and Services

Canada. 1987.

Department of Finance. Annual reference tables. Quarterly economic review. Ottawa: Ministry of Supply and Services Canada.

1988.

Dominion Bureau of Statistics, Canadian statistical review, 1953 supplement. Ottawa: The Queen’s Printer. 1953.

Dominion Bureau of Statistics. Canadian statistical review, 1959 supplement. Ottawa: The Queen’s Printer. 1960.

Statistics Canada. Canadian statistical review 61(3). Ottawa: Ministry of Supply and Sewices Canada. 1986.

Statistics Canada, National income and expenditure accounts 1926–1972. Ottawa: Statistics Canada computer tabulations.

US, Bureau of the Census. Statistical abstract of the United States, 1988; 108th ed. Washington: U.S. Department of Commerce.

1989,

or separated persons, because a larger proportion

of married persons may lead to more divorces or

separations. In fact, if data for the Canadian Provinces

are compared, a relatively high negative correlation is

observed for the age group 60-64 years (r = -0.72).

However, this correlation is much less for the other

age groups, possibly because of the greater mortality

of the never-married orbecauseboth these groups may

tend to migrate to other regions in Canada.

A major difference between the sexes is observed

in widowhood; for example, in the age group 65–74

years, thepercentageof widowed women in the United

States is 37.8 percent, while the percentage of widowed

men is 8.3 percenq for Canada the corresponding

percentages are 37.3 percent for women and 8.5 percent for men (table A). These sex differences presumably occur mainly because of the higher death rate of

widowed males than widowed females. Similar differences have been notedin other countries. For example,

for Australia the percentage of widowed males in the

age group 70 years and over for 1981 has been reported as 20.8 percent, whereas for females it was 60.2

percent (5). These data confii the importance of

subdividing data on marital status by both age and sex,

since both variables affect marital status.

Family size and living arrangement

It appears to be slightly more common in the

United States than in Canada for elderly persons to

live alone; however, again there are appreciable differences within regions in Canada (data not shown),

and the differences are not consistent for all age-sex

groups (table A). In both counties, as is well known,

women live alone more often than men, and these

differences arepronounced and consistent. Arelathvely

small number of elderly women live with a nonrelative,

and this figure is generally slightly higher for Canada

than for the United States (table A).

Considering two-person families, specifically the

elderly living with a spouse, there do not appear to be

119
pronounceddifferences betweenCanadaand theUnited

States (table A) except in the age group 75 years and

over. There are substantial differences between the

sexes, particularly at the higher ages. The percentage

of men in Canada who live with their spouse is 54.3

percent, whereas for women it is only 26.8 percent. In

the United States, the corresponding figures are 62.0

percent and 20.8 percent. These sex differences presumably arise because of the higher male mortality in

both countries.

The percentage of elderly who live in a household

offour ormorerelatedpeople is consistently greater in

Canada than in the United States (table A), perhaps

because of smaller families in the United States.

Consistent with this explanation, the figures for Ontario are slightly smaller than figures for the rest of

Canada (6.8 percent and 7.1 percent, respectively).

The role of prosperity is also indicated by considering

the Atlantic region in Canada, a poorer region with

more outward migration, where the percentage is

11.2 percent. If the proportion of households of four

or more people is plotted against gross domestic

product per capita in 1985 or against personal income

per capita in 1985 for the 10 Canadian provinces,

correlation coefficients of-0.63 (p <0.03) and-0.71

(p e 0.01), respectively, are obtained. Again, this

suggests an association between lack ofprosperity and

relatively large families.

Education

There are appreciable differences between Canada

and the United States in levels of educational attainment. Specifically, a larger percentage of individuals

in Canada than in the United States report O-8 years of

education (table D). Thepercentagefor Ontario is 42.4

percent, somewhat closer to the U.S. percentage. In

the British Columbia region, the percentage (31.4

percent) is lower than the U.S. figure, but in the

Atlantic region it is 49.5 percent and in the Quebec

region it is as high as 60.2 percent. This difference

between Canada and the United States appears to be

similar for the age groups 65–74 years and 75 years

and over. A cohort effect is evident in both countries

because the percentages are consistently higher at the

older ages. Incidentally, the Ontario LSA percentages

for 45-year-old males who were about 70 years old in

1985, the time of the GSS Survey (32.4 percent), are

similar to the GSS percentages for Ontario for the age

group 65–74 years (32.6 percen~ tableD). Reasons for

the differences between the United States and most

parts of Canada may include the smaller number of

colleges and universities in Canada at the time these

cohorts were of high school age and/or the more rural

values prevalent in Canada at that time.

Somewhat surprisingly, since these cohorts of

Canadians appear more often to have little formal

education, the proportion of individuals reporting 13

Table D. Percent of persons reporting O-8 years of education, by age: United States, Canada, and Ontario

Ontario Rest of

Age United States Canada Cross-sectional Longitudinal Canada

Percent

65years andover . . . . . . . . . . . . . . . . . . . 34.6 46.9 42.4 ... 49.6

75 years and over

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42.5 56.1 56.7 ... 55,8

Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.1 62.8 68.5 59.5

Women . . . . . . . . . . . . . . . . . . . . . . . . . . .

-..

41.0 52.0 50.1 ... 53.3

65-74 years

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29.7 41.7 33.5 --- 46.2

Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.1 43.8 32.6 50.3

Women . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.9

---

39.8 34.3 --- 42,8

Menaged45 years . . . . . . . . . . . . . . . . . . --- --- ..- ‘32.4 ---

‘The percentage for males who completed the Ontario Long-Term Study of Aging is 30.5 percent.

120
years or more of education is similar for Canada and

the United States (table A). The largest difference

between the two countries appears to be for individuals reporting 12 years of education (9.9 percent for

Canada versus 28.1 percent for the United States

table A); the value for Ontario (11. 1percent) is again

slightly closer to the value for the United States (data

not shown). However, the questions were worded

slightly differently (see the section on measurement).

Also, there arerelativelylargedifferencesbetweenthe

Canadian provinces (data not shown). Again, the

differences may be related, at least in part, to greater

prosperity in the United States or to cultural norms

pertaining to the pursuit of higher education, as well as

the greater availability of institutions of higher education in the United States.

With respect to sex differences, more males than

females report O-8 years of education in both Canada

and the United States, and this effect is noted in both

age groups (table A). At the same time, there are also

more males than females reporting 13years or more of

education for the age group 65–74 years; for the age

group 75 years and over, the male and female values

for the United States are 17.3 percent versus 16.9

percent, respectively, but for Canada the reverse effect

is observed (12.8 percent for men versus 17.0 percent

for women). This latter figure is surprising possibly

upper class older women were overrepresented in the

sample.

Table E. Percent of persons reporting iiving in a

house or apartment, by age: United States, Canada,

and Ontario

United Rest of

Age States Canada Ontario Canada

65 years and over . . . 93.5

75 years and over

Total , ...,........93.3

Men . . . . . . . . . . . ...92.3

Women . . . . . . . . ...94.0

65-74 years

Total, . . . . . . . . . . . . 93.5

Men . . . . . . . . . . . . . . 94.5

Women . . . . . . . . . . . 92.8

Percent

95.5 97.7 94.2

96.3 98.6 94.9

96.5 97.4 96,0

96.2 99.3 94.1

95.0 97.1 93,8

95.9 96.8 95.4

94.3 97.4 92.5

Type of housing

The percentage of individuals who report living in

a house or apartment is slightly higher in Canada than

in the United States (table A), although in the Quebec

region the percentage (91.9 percent) is lower than in

the United States (data not shown). For Ontario, the

percentage is even higher (table E). This suggests that

prosperity is one of the factors influencing type of

housing selected early and late in life. Incidentally, for

the 10Canadian Provinces the correlation between the

1985 unemployment rate and the proportion living in

a house or apartment is negative (r= -0.32), but it is not

significant. Another reason for the difference between

Canada and the United States may be that Canada

represents a more stable, or less mobile, population.

That is, Canadians may be slightly more likely to live

in a house or apartment. Another possibility is that the

difference may be related to climate, with the harsher

Canadian climate making temporary accommodation,

such as trailers, less suitable.

Major daily activity

The percentage of elderly persons who report they

are working is slightiy higher in the United States than

for all of Canada (table A), but the range of values

within the Canadian regions is relatively large and

includes the value for the United States (data not

shown). Reasons for the differences may include

variations in climate andin the amount and availability

of public and private pension plans. The difference

between Canada and the United States is consistent

across the two age groups and for both maIes and

females (table A). As expected, the percentage who

work is appreciably lower in the higher age groups

(table A). Also, as expected, the percentage who

report that keeping house is the major activity is

considerably larger for females than for males. Elderly

Canadian males also seem more often to be keeping

house than their U.S. counterparts.

Perceived health status

The percentage of elderly persons who report their

health as being good to excellent is slightly higher in

the United States than in Canada. Similar differences

are observed in both age groups (tables A and F). At

the same time, the proportion reporting poor health is

consistently greater in the United States (table A).

121
This is one of the few examples in which all five

regions of Canada (4.5 percent to 11 percent) fall

below the U.S. value (11.5 percent). One reason for

this greater rate of individuals reporting poor health in

the United States maybe the greater rate of institutionalization in Canadzq both samples included only the

noninstitutionalized populations. Another reason may

be the slightly different wording of the question (see

the section on measurement). With age, as expected,

the percentage reporting good or excellent health

decreases; the data for Ontario, both cross-sectional

and longitudinal, also show this trend (table F).

Number of doctor contacts

Another estimate of health status is provided by

the reported number of doctor contacts during 1 year.

The percentage of individuals who reported no doctor

contacts is larger in the United States than in Canada

(table G). This is another example in which the range

within the five Canadian regions (10.3 percent to 15.1

percent) does not include the U.S. percentage. Presumably these differences are, at least in part, related

to the more ready access to health services and the

lowerpersonalcosts foreachvisit, formost individuals,

in Canada than the United States. The Ontario figures

tend to be relatively low, except for males 75 years of

age and over (table G). However, for one to six doctor

contacts, the Ontario percentages are lower than those

for the other four Canadian regions (data not shown).

The Ontario LSA data are somewhat higher (table G),

but this may be because of a selection bias whereby

Ontario LSA subjects were relatively healthier.

The percentage of individuals reporting 25 or

more doctor contacts is also greater in the United

States than in Canada (3.3 percent versus 2.9 percent),

and is even higher in Ontario (table H). The percentages from the longitudinal data are relatively low,

possibly because only visits to doctors were recorded;

calls were excluded (see the section on measurement).

Also, when the OntarioLSA subjects were 45 years of

age, access to health services in Ontario may have

been more limited since the Ontario health insurance

plan was not then in force. Although some individuals

who report this number of contacts probably have

health problems that require them to visit a physician

on a regular basis, this percentage would be expected

to be similar in the three jurisdictions, unless survival

or institutionalization of frail persons varies appreciably. Incidentally, the percentage of individuals who

report 13–24 contacts is consistently greater in Canada

than in the United States (table A).

Concluding remarks

In spite of numerous difficulties that arise when

comparing the various characteristics of elderly

Table F. Percent of persons reportinggoodto excellent healthstatus, by age: UnitedStates, Canada,and

Ontario

Ontario Rest of

Age United States Canada Cross-sections/ Longitudinal Canada

65years andover . . . . . . . . . . . . . . . . . . .

.

75 years and over

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Women ., . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Women . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Menaged62 years . . . . . . . . . . . . . . . . . .

Menaged45 years . . . . . . . . . . . . . . . . . .

66.7

65.2

64.2

65.6

67.6

66.7

68.3

---

..-

62.0

56.9

60.3

54.8

64.9

66.9

63.3

---

-..

63.7

52.2

57.5

49.2

70.8

72,4

69.5

---

--- 61.0

--- 59.9

--- 61.9

--- 58.5

--- 61.6

... 63.8

--- 59.9

‘69.8 ---

‘85.1 ---

‘The percentages for individuals who completed the Ontario Long-Term Study of Aging are slightly higher: 86.1 percent for men 45

years of age and 72.4 percent for men 62 years of age.

122
Table G. Percent of persons reporting no doctor contacts during 1 year, by age: United States, Canada, and

Ontario

Ontario Restof

Age United States Canada Cross-sections/ Longitudinal Canada

Percent

65years andover . . . . . . . . . . . . . . . . . . . 18.6 11.7 10.4 --- 12.4

75 years and over

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.o 9.7 9.4 ---- 9.9

Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.7 12.9 18.4 9.6

Women . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.5

---

7.7 4.3 ---- 10.1

65-74years

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.7 12.8 11.1 ... 13.8

Men”::::::::::::::::::::::: ::::::: 21.2 14.4 14.0 14.6

Women

---

,. .,,,.. . . . . . . . . . . . . . . . . . . . 18.5 11.5 8.5 --- 13.1

Menaged62years . . . . . . . . . . . . . . . . . . --- ---- --- ‘24.6

Menaged45years . . . . . . . . . . . . . . . . . . ---

-..

--- --- ‘35.0 ---

‘The percentages for maleswho completed the Ontario Long-Term StudyofAgingwere 25.2percentat 62yearsofage and34.3

percentat45years ofage.

Table H. Percent ofpersons reporting 25 doctor contacts ormoreduring Iyear, byage: United States,

Canada, and Ontario

Ontario Rest of

Age United States Canada Cross-sectional Longitudinal Canada

65years andover . . . . . . . . . . . . . . . . . . .

75 years and over

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Women . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years

Total, , ... ,, . . . . . . . . . . . . . . . . . . . . . . .

Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Women . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Menaged62years . . . . . . . . . . . . . . . . . .

Menaged45years ,. .,..,. . . . . . . . . . .

3.3

3.8

4.2

3.6

2.9

2.6

3.2

2.9

3.8

3.7

3.9

2.4

2.8

2.1

---

...

Percent

3.5

4.8

6.5

3.9

2.6

3.6

1.8

---

---

---

---

---

..-

---

---

‘2.2

‘0.6

2,6

3.2

2.0

4,0

2.3

2.3

2.3

‘The percentages for males who completed the Ontario Long-Term StudyofAging were l.7percent at62years ofage andO.9

percentat45years ofage.

123
populations in Canada and the United States, some

comparisons are possible. For example, never-married

status is more common among the elderly in Canada

than it is in the United States. Also, being divorced or

separated appears to be more common in the United

States than in Canada. In addition, it seems slightly

more common for elderly persons to live alone in the

United States than in Canada, and less common for a

family to be comprised of four or more people in the

United States.

With respect coeducation, it appears that, compared

with elderly persons in the United States, a greater

percentage of elderly persons in Canada report O-8

years of education. On the other hand, the proportion

of elderly reporting 13 years or more of education is

similar. The largest differences are for individuals

reporting 12 years of education; this proportion is

considerably greater in the United States.

There are only slight differences with respect to

type of housing. Specifically, more elderly people in

Canada than in the United States report living in a

house or an apartment. There are also only slight

differences in the percentage of elderly persons who

report being employed, which again is slightly higher

in the United States than in Canada.

With respect to health status, the questions asked

were not identical, but it seems that the percentage of

elderly persons who report their health as being good

to excellent is slightly higher in the United States than

in Canada. A greater percentage of the elderly in the

United States than in Canada report having no doctor

contacts. At the same time, thepercentageof individuals

reporting 25 or more doctor contacts is also greater in

the United States than in Canada.

It should be noted that the variations within the

Canadian regions are generally larger than the differences between the United States and Canada. Two

exceptions were the differences between Canada and

the United States in the proportion of individuals who

report poor health and the proportion of individuals

who report having no doctor contacts. It is tempting to

ascribe these differences to variations in the two health

care systems.

In summary, it is difficult to answer the questions

posed at the beginning of this paper. If the questions

are worded in an identical manner, one’s confidence in

the similarities and differences noted increases. For

example, the observed differences in education were

relatively large, suggesting that this variable should be

statistically controlled if data from the United States

are to be generalized to Canada. It should also be noted

that many of the variables are related, and this may

account for some of the observed differences. For

example, the level of education might well be related

to a number of variables, including health and housing

variables, and it is therefore not clear which of these

variables account for the observed differences unless

education is controlleci in the analyses.

Acknowledgment

This study was supported by an SSHRC Population Aging Grant (#492-85-OO04).

References

1.

2.

3.

4.

5.

Statistics Canada. General Social Survey of Canada,

healthandsocialsupport-1985. Publicusemicm data

filedocumentationanduser’sguide.Ottawa:Statistics

Canada. 1986.

Kovar, MG. Aging in the eighties: Preliminary data

fromthe Supplementon Agingto the NationalHealth

Interview Survey,United States,January-June 1984.

Advancedata fromvital and health statistics;no 115.

Hyattsville, Maryland: National Center for Health

Statistics. 1986.

Fitti JE, KovarMG. The Supplementon Agingto the

1984NationalHealthInterviewSurvey.NationalCenter

for Health Statistics.Vital Health Stat 1(21). 1987,

Forbes WF, McPherson BD, Shadbolt-Forbes MA.

The validationoflongitudinalstudies: The caseofthe

OntarioLongitudinalStudy of Aging (L.S.A.). CanJ

Aging 8(1):51-67. 1989.

Leeds M. Dependent wives defined. Aust J Ageing

3(4):17–25. 1984.

124
Chapter 13

Function in old age:

Measurement,

comparability, and service

planning

by A. Michael Davies, M.D., Jerrold Michael

Professor of Public Health, Hebrew University

of Jerusalem

In the interest of time, I will skip my theoretical

introduction, except to say that while we would really

like to measure health, we know how to measure only

disease. At least we think we know but we are not sure,

so we must measure several aspects-of morbidity, of

mortality, of health behavior, and so on—to obtain a

rounded picture. The titles of the different sessions of

this conference come from these aspects of disease. In

this session, we are looking at functional disability.

Assessment of function, according to the recent

World Health Organization (WHO) Expert Committee on the Health of the Elderly, should include the

following seven areas, of which the first four items are

intrinsic and the last three are extrinsic:

● Activities of daily living (ADL’s).

● Mental health functioning.

● Psychosocial functioning.

● Physical health functioning.

● Social resources.

● Economic resources.

● Environmental resources.

TheADL scalesincludemobility, instrumental ADL’s,

andphysical ADL’s. Thementalhealth section includes

psychiatric symptomatology as well as cognitive

function, while the psychosocial functioning is the

personal assessment of well-being. Physical health

functioning includes a range of measures, from selfperceived health status through symptoms, diagnosed

conditions, utilization of health services, and activity

levels and measures of incapacity such as bed days.

Now the expression of these functional abilities

and thus the results of surveys are of course greatly

modified, as Dr. Kovar reminded us, by the availability

of family, friends, and neighborhood resources the

adequacy of incom% and the quality of housing and

availability of transportation, shopping, and public

services, listed here under the general rubric of environmental resources.

Multiphasic assessment, comprising all these

variables, is necessary for the treatment and support of

the individual and for the rational planning of services

for the community. But how nice it would be to have

a single simple question to measure health status, and

I will come back to that in a minute.

Cross-national studies

Information on extrinsic factors in aging and the

effects of different patterns of social support and

health care can come from comparative and crossnational studies (table A). As we have already heard,

the methodological pitfalls are considerable: There

are many problems of measurement that have to be

resolved on the road to such studies.

Table A. Percent of respondents 70-74 years of age

who rate their health as worse than that of others their

own age, by sex: Selected communities, 1980-81

Community sampled Men Women

Percent

Upper Normandy . . . . . . . . . . . 13 16

Florence . . . . . . . . . . . . . . . . . . 18 12

Belgrade . . . . . . . . . . . . . . . . . . 20

Bucharest . . . . . . . . . . . . . . . . . 24 %

Bialystok . . . . . . . . . . . . . . . . . . 26 34

Kiev . . . . . . . . . . . . . . . . . . . . . . 22 33

SOURCE: World Health Organization surveys, 1980-81.

125
To return to our simple question and to generalize

a point made by Dr. Forbes, the WHO survey of the

elderly in 11 countries used the same questionnaire,

suitably translated, in 16 different populations ages

60-100 years. The response to a general question on a

self-appraisal of health showed wide variations in

different populations, with urban-rural, sex, and EastWest differences.

The more sophisticated version of this question,

“If you compare your health with that of other persons

you know of your own age, is your health better, about

the same, worse, don’t know?”, gives the results

illustrated in table A for the age group 70-74 years, for

which the numbers were adequate and the response

rates relatively high. The same East-West trend is seen

in each 5-year age and sex group.

Are these differences real? Are these answers

culturally driven? Or are there explanations perhaps

linked to faults in the survey methodology? We really

do not have all the answers.

Inmost surveys, assessment ofhealthanddisability

is on firmer ground; many multiphasic survey instruments have been proposed, and not a few have been

evaluated. Nearly all of them, however, are limited in

that they are based on responses to questions asked by

an interviewer under conditions open to a number of

confounding factors.

A major confounding factor is education. In one

national study in Israel in 1984, three-quarters of

persons 75 years of age and over with little or no

schooling rated their health as poor or bad. Of persons

the same age who had had 9 years ormore ofschooling,

less than half gave that answer. Was this due to

education alone? Or the differences in socioeconomic

level or ethnicity of those with higher and lower

education? Or a combination of these and other factors?

These are differences that are obviously affected

by the methodology and need to be teased out. Several

studies, including our own, have shown that the

uneducated do poorly on cognitive function screening

tests, and the universal validity of these tests has been

questioned, spec~lcally in the United States.

In the course of development of a new screening

test for our own heterogeneous and often uneducated

population, wetesteda second instrument inparallel—

with questions on health, ADL’s, and instrumental

ADL’s--on a small subsetof200ind.ividuals, Performances in the cognitive screening test and in the ADL’s

were significantly correlated.

Elderly subjects who reported one or more deficiencies in the Katz ADL scale showed a significantly

higher score on the Brookdale Cognitive Screening

Test—that is, increased disability—as did those with

two or more instrumental ADL deficiencies. These

associations were stronger at higher levels of education, and similar results were reported last month

(November 1988) in theAmerican Journal of Epidemiology (1) on a far larger sample from East Boston.

Even aside fi-omthe confounding effects of education, however, do some people perform badly on all

questionnaires or are there more subtle relationships

between mental and physical disabilities?

Subjective and objective health

Our basic problem is that we do not have objective

definitions, let alone objective measures, of health in

old age. We need more progress in geriatric clinical

assessment to differentiate between the decrements of

old age and disease pathology. The correlations between defined diseases and limitations of mobility to

be reported by Harris and Kovar are an important

advance in this direction.

Svanborg reported from the Swedish Gothenburg

Study that half of those70 years of age who were being

treated for heart failure were, in fact, showing a mild

dyspnea on exertion, some cardiac enlargement, and a

little swelling of the ankles, which could reconsidered

physiologically normal at their age. Of course, the

other half of the group did indeed have heart failure.

Difficultyin climbing stairscouldbedueto arthritis

of the knees in one person, emphysema of the lungs in

an”other,and cardiac failure in a third. The outcome on

a disability scale might be similar, as Dr. Cohen

reminded us, but the possibilities for prevention and

amelioration by treatment are quite different. A full

medical evaluation of a disabled person is always

necessary, and an estimate of prognosis is important

in formulating care plans.

There is not necessarily a correlation between

ADL dependency and the number of conditions or

126
diseases reported. Figure 1 illustrates the results of a

survey of all the elderly in one Israeli community (2).

There was a direct correlation between the number of

conditions reported and the feeling of ill health, but

not, as you see, between number of conditions and

ADL dependency.

It is well known that there is, in fact, little or no

correlation between measures of different aspects of

health and disability that have been designed in various questionnaires. Figure 2 illustrates data derived

from a sample of elderly people in a neighborhood of

Jerusalem asreportedbyDr. RosaGofin (3). Igavethe

title to this figure some 6 years ago when I believed

that “objective” assessments had been made in

population studies. Today I would call them’’doctors’

guesses” and suggest that we actually compare two

subjective assessments of health, one by the subject

herself othimselfandone by theprofessional observer.

Proxy reporting

The last methodological point that I would like to

make adumbrates a point, made by Dr. Kovar and

particularly by Dr. Forbes, on the effect of type of

respondent on the answer to questions. We know that

many disabled elderly persons could be kept in the

80 -

60 -

E

g 4(-J.

●

$

e“

20 -

.“

8

o~

Conditions

or more

SOURCE: Barell V, Kaplan G. Reported health of the elderly:

The Kkyat Ono census. Isr J Med Sci 21:254-9.1985.

Figure 1. Percent of eldMy persons, by prevalent

conditions reported, bad heaith, and dependency

in activities of daily living (ADL’s): Kiryat Onoj

israei, 1984

50

k

Limited in major activities

40 Moderately to

/k --

/

-<~erely ill’

g 30 /

/ ,A

~ / .O..A

/

2 20 {

“’”<

~’”<””Poor subjective .....7’”

...

.,.<..

. ........ ................*.-.. health

10 ./. * Dependency in

/. /-/

./. activities of daily living

o

65-69 years 7C-74 years 75 years and over

Age

‘Doctor assessment.

NOTE: 217 men were assessed.

SOURCE: Gofin R. The health status of elderly men:

A community study. J Public Health 96:345-54.1982.

Figure 2. Indexes of subjective and objective health

in men 65 years of age and over: Jerusalem, 1969-71

community if appropriate social and health support

were available. In a study by Factor and colleagues in

Israel (figure 3), elderly persons on waiting lists for

admission to the different types of long-term care

institutions were reassessed (4). Forty-threepercent of

the elderly who were moderately disabled in performing ADL’s said that they could remain in the community, given adequate support. The informal

caregivers were conservative. They thought only 37

percent could remain. But the multidisciplinary assessment team of public health nurse and social worker

felt that 82 percent could remain in the community.

The influence of experience, beliefs, availability of

services, and attitudes of assessor on such a decision

are critical.

Unfortunately, such soft data are all that we have.

When age-specific disability rates of those requiring

admission to long-term care institutions are applied to

future population predictions, we derive forecasts of

future needs for long-term care. It will be necessary to

refine our measurement techniques considerably before we can put confidence limits on those estimates.

As Dr. Kovar said in the introduction, the goal of

measuring functional disability is to contribute to its

postponement or prevention. I would add that the goal

should also be to contribute to its amelioration. We

shall need adequate, cost-effective services to do so.

127
n

n

-l Multidisciplinary team

~~ Formal caregiver

- Elderly person

_ Informal caregiver

n

Semi-independent Moderately disabled in Mentally fraill Severely disabled in

activities of daily living activities of daily living 1

Condition

‘Elder’s opinion not presented as many could not be interviewed.

SOURCE: Factor H. Brookdale Institute for Gerontology, Jerusalem. Personal communication. 1987.

Figure 3. Percent of elderly on approved waiting lists for institutionalization who could remain in the

community, by condition of elderly and type of informant: Israel, 1987

Conclusions

It is a characteristic of epidemiologists that they

rarely provide final answers to questions but usually

produce anew hypothesis for test in yet further studies

that some agency will fund. Therefore, the moral of

these arguments really is festina lente or, in a free

translation, “Let us progress systematically,” For collaborative studies in disability and indeed, as we have

heard, for studies in one country, we need a research

program that will include at least the following four

elements. I offer these as topics for discussion in the

workshop.

1.

2.

128

We will need checks of the validity of each survey

instrument in each population tested and the consistency of the findings in repeat interviews.

We will need to develop more longitudinal studies

toprovidedataon theincidenceof defined disability

and the changes in prevalence, i.e., how many

people improve in time, even if only a little.

3.

4.

We will have to combine the hitherto separate

approaches of epidemiology, social survey, and

clinical medicine and relate dysfunction to pathology and disease.

Finally, repeating a suggestion of Dr. Forbes, we

must undertake clinical trials to establish the effects

of changing risk factors and the value of different

regimes of intervention.

References

1.

2.

3.

4.

ScherrPA, AlbertMS, FrankensteinHH,et al. Correlates of cognitive function in an elderly community

population.Am J Epidemiol 128:1084-1101.1988.

Barcll V, Kaplan G. Reported health of the elderly:

The KiryatOnocensus.IsrJ Med Sci21:254-9.1985.

Gofin R. The health status of elderly men: A community study. J Public Health 96:345–54. 1982.

FactorH, BrookdaleInstituteforGerontology,Jemsalem. Personal communication. 1987.
Chapter 14

Functional disability

issues

by Mary Grace Kovar, Dr.P.H., Special

Assistant for Data Policy and Analysis,

National Center for Health Statistics

Dr. Davies has laid out our work better than I can

and, with his usual farsightedness, has seen to it that

we shall all be busy well into the next century. The

proposed international collaborative effort is only one

of many that will be needed if we are to reach the

ultimate goal.

We have to take the first small steps now. We need

to plan collaborative research that can be carried out

during the next few years. I hope that the research is

designed to begin the development of a manageable

set of questions that can be used in interview surveys

to measure the prevalence of functional disability and

the need for care fkom another person. If possible, the

measures will include duration and frequency of both

disability and need.

I think that we agree that dissimilar questions can

measure similar concepts and that similar questions

can measure dissimilar concepts. Therefore, we need

to develop conceptually similar questions on functional disability and the need for care that can be used

in cross-cultural and cross-national population studies. Doing so will take the kind of research that Dr.

Davies has outlined.

Some of this research should be done in conjunction with other projects. In particular, since the path to

disability is usually through disease, the research

projects should be coordinated with those on chronic

disease morbidity. That is especially important if our

goal is to prevent or postpone disability.

While that is going on, we can use the data that we

have and design tabulations to make comparisons that

we can trust across cultures and nations. I think that

Dr. Forbes has shown the way, and we are ready to

begin.

129
Part V

International health

care research
Introduction

by Jacob J. Feldman, Ph. D., Associate Director

for Analysis and Epidemiology, National Center

for Health Statistics

Dr. Feinleib, yesterday morning, indicated that the

major focus of this conference is essentially methodological: The primary reason that we are interested in

these current comparative analyses is that the National

Center for Health Statistics intends to apply what we

learn through these projects to the improvement of our

measurement methods.

We hope the same thing will also happen in all of

your countries, and perhaps at that point comparative

analysis for more substantive purposes may be possible. Certainly, the current major goal isfor each of us

to be able to improve the way in which we measure the

various health variables that are being discussed here.

However, it is clear that in order to improve

measurements, you have to know why you are trying

to measure what you are trying to measure. A writer,

presumably an ecclesiastical writer, once indicated

that we measure but we know not what we measure. To

the extent to which that is the case, of course, it is very

difficult to arrive at protocolsfor these projects.

I do want to commend to you a volume by the

Committee on National Statistics. The Center and

other parts of the Public Health Service and the Department of Health and Human Services in general

formed a committee for the purpose of exploring the

issues of statistical needs in the future. The volume

that came out of that project is The Aging Population

in the 21st Century: Statistics for Health Policy (1).

This volume attempts to deal with the uses ofstatistics.

In other words, it is set up in a framework of deciding

(a) what the policy issues would beat that time and

then (b) what statistics might be needed in order to

inform those policy discussions. Therefore, as background to the activity we are currently undertaking, I

would recommend that you review the data needs that

are explicated in that volume.

Reference

1. Committee on National Statistics.The aging population in the 21st century: statistics for health policy.

Washington:National AcademyPress. 1988.

133
Chapter 15

Cross-national research

in health care

by Gary Robert Andrews, M. B., Director,

Centre for Ageing Studies, Flinders University

of South Australia

Introduction

In 1983 the United Nations (CJ.N.)called a World

Assembly on Aging, which drew attention to the

dramatic phenomenon of the graying of the world(l).

The scale on which population aging is now occurring

worldwide is beyond ordinary human conception.

Further, the experience of population aging on such a

scale is an entirely new event: The world has faced

nothing like it in times past.

In 1980 the global population could be characterized as “young”: Thirty-five percent of all persons

were ages 0-14, and 8.5 percent were 60 years of age

and over, according to U.N. estimates (2). At that

time, significant aging in population terms was already evident in the more developed regions, with

some 15 percent of their population in the age

group 60 years and over. The less developed regions

were by contrast exceedingly youthful, with 39 percent

of their aggregate population in the age group 0-14

years, and only 6 pement in the age group 60 years and

over.

This pattern of relative youthfulness reflects past

high fertility and reduction of mortality, particularly

among infants and young children. As a result,

policymakers have tended to focus attention on such

issues as birth control and provision of health care,

education,andotherservices to growing cohorts of the

young. Relatively little attention has been given to the

longer term consequences of successful birth control

programs andimprovedlife expectancy at birth, which

result in an increasing relative weight of the elderly in

the population and growing numbers of persons surviving to old age.

The profile of the world’s population will change

dramatically, however, during the next four decades.

Mainly as a result of current and anticipated changes

in fertility, the world will become markedly older.

U.N. projections forecast that by 2025 only 25 percent

of the world’s population will be in the age group

0-14 years, and nearly 14 percent will be in the age

group 60 years and over. There will be a significant

shift toward aging in developing countries. By the

year 2000, roughly two out of three of the world’s 600

million people 60 years of age and over will be living

in developing countries, compared with 50 percent in

1980. The growth of the elderly population will be

particularly marked in Asia, owing primarily to the

growth expected in the number of aged in China and

India. Between now and the year 2020, the population

60 years of age and over will increase in China and

India by over 100 million, and in Indonesia by more

than 20 million. In the developing world overall, while

the total population will increase by 95 percent from

1980 to 2000, the population 60 ~ears of age and over

will rise by almost 240 percent(3).

The impact of aging of the population will be felt

in many key policy areas, including economic, social,

and health arenas. Decisionmakers must be persuaded

to anticipate aging and its influence upon needs and

priorities for government policies and services. This is

especially true for health services, given the association between morbidity and aging and the associated

increase in needs for health care.

China, with over90 million people 60 years of age

and over, now has the world’s largest population of

older persons. In the 21st century, as a result of the

implementation of the official policy of one child per

married couple, it could be the most rapidly aging of

all of the world’s countries. The successful nationwide implementation of the policy according to current projections would result in 40 percent of the total

population being 65 years of age and over by the

middle of the next century (4).

135
There is an urgent need for relevant, sound, and

timely information on the health impacts of aging in

all of the countries and regions of the world. Much of

the work that has previously been done in this area

relates to the situation in Western developed countries. In Asia and other developing regions of the

world, the geophysical, socioeconomic, and cultural

settings are very different from those of Europe or

North America, and it is essential to undertake resemch now to provide data that will underpin policy

directions and programs aimed at maintaining and

restoring health of the elderly in the future in these

settings. The different historical, current, and projected

demographic experience of various parts of the world

provides an extraordintuy potential range of natural

experiments. In these diverse settings there are significant variations in terms of the trajectories of demographic and epidemiologic transitions and the

consequent social, economic, and health impacts.

Cross-national comparative

research—the challenge

The idea of cross-national comparisons of health

and well-being clearly implies an ability to measure

health and well-being and to define accurately the

presence or absence of disabdity among individuals

and populations. Further, it suggests that this can be

done reliably and validly across nations and between

cultures. There are, however, several factors that lead

us to raise questions about the quality of much of the

effortsto go beyond thereportingofresults ofindividual

studies in this critical area of human inquiry.

Thus, in terms of international comparative effort,

we can ask the following questions:

● Are our conceptual ideas of health and disability

sufficiently refined that it is possible to effectively

operationalize them in very different settings with

some confidence?

● Are the definitionsthatmight then be applied tothese

concepts of health and disability in practice pxecise

enough to be used as a basis for developing crossnational research tools designed to quantify health

and disability at individual and population levels?

● Aremeasures available (or likely to be developed)

that may be applied cross-culturally or crossnationally to the assessment of health status in the

field with efficiency, reliability, and validity?

Do existing andproposednational data collections

provide coverage of health and functioning of the

population in such a way that it will be possible to

derive valid, internationally comparable measures

of specific changes in population health status in

terms of frequency (incidence and/or prevalence),

distribution, and consequences?

Do existing methods of data analysis provide

appropriate derived measures that are capable of

interpreting existing patterns as well as projecting

future trends of population health status and aging

in a form that is internationally relevant to health

and social policy and planning considerations?

Each of these questions is capable of generating a

whole symposium in its own right, so I plan to focus

specifically on the questions related to study design

and methodology and to explore the impact of variations in method and in the application of similar

methods in different circumstances.

Lawrence Branch (5) noted at the National Institute on Aging (NIA) 1977 Second Conference on the

Epidemiology of Aging that the concept of “functional abilities” is amorphous, and to a considerable

extent the functional abilities of the elderly will reflect

those aspects that are measured in a particular study.

Disabilities or functional limitations, he went on to

note, could usefully be viewed as a continuum from

minimal or zero limitation to high or severe, and most

measures deal with only one part of the spectrum. The

need forandvalueof a composite measure of functional

limitation was argued.

The desirability of such a composite measure is

clearly evident, but the difficulty in deriving a satisfactory tool in practice illustrates thecomplexityof the

issues with which we are grappling. We still lack a

universally accepted composite measure, and international research remains plagued by a myriad of

variations in such basic measurement arenas as activities of daily living, cognitive functioning, general

activities scales, physical performance measures, and

general health status. This situation attests to the

fundamental barriers to achieving what appear to be

relatively modest objectives in this essential exercise.

136
Part of the explanation for this situation, I think,

lies in the general approach that has been taken to

research on aging over the last couple of decades.

Increasing attention has been paid to the scientific

examination of aging and age-related phenomena at

every level from basic biological, social, behavioral,

economic, biomedical, and demographic perspectives.

All of this has progressed our understanding of aging

in individual and societal terms very substantially. We

now know a great deal more about older individuals in

various circumstances and locations than we knew

some decades ago. The vast majority of these new

insights are, however, based upon simple descriptive

data. For instance, with regard to any specific older

age group living in a particular location in the developed world at present, we could with a fair degree of

confidence estimate their physiologic, health, mental,

and functional status; their rates of utilization of health

services and social services; economic circumstances;

and so on. We would, however, have a great deal of

trouble explaining the dynamics behind these categorical descriptions of the population: Why some are

demented and others not of those who show signs of

dementia, why some are in institutions and some are

nou etc. We also strike some significant difficulties

when we attempt to compare detailed findings between

different locations, across nations, between cultures,

or between developed and developing countries.

Our problems are thus multifold we are largely

confined to using simple descriptions of point prevalence of states, and such measures as we have to assess

these we rarely standardized across populations. If

any effective attempt isto bemadein applying available

data to international geographic comparisons, then we

have to develop either highly standardized measures

or a means of calculating the effects of variations in

study design and methods applied indifferent settings.

Problems associated with

research design and sampling

Sampling

It is evident from the literature on population

studies and aging that often different approaches are

taken to sampling in most studies. National representative sampling is costly, technically diftlcult, and

rare. However, the design effects of sampling methods

used to reduce costs, such as stratification and clustering, can be taken into account in analysis. Sampling

frames, sample generation method, and sample size

calculation should be clearly defined. Any systematic

bias should be identified at the outset and controlled

for in subsequent analysis. In practice it is often not so

simple. Enumeration of the older population is often

inadequate in many of the standard sampling frames

used, such as electoral rolls, social security beneficiary

lists, health service registers, and community registers

of various kinds. If true nationally representative

probability sampling is not possible (and it usually is

not), then at least precise definition of the chosen

sampling frame and method and identification of

variation in composition from national demographic,

socioeconomic, ethnic, andothercharacteristics should

be the rninimumrequirements. This at least allows for

appropriate weighting in analysis.

Nonsampling errors including response

rates

There are in any data collection and survey efforts

a variety of potential major sources of error. Some of

the more common problems are the following.

● “ Observerbkzs—Reflecting variations in interpretation of responses by different observers.

● Assumptionbkm-Faulty logic or mistaken belief

of the investigator.

● Recall bias—Particularly important in the elderly.

● Questionnaire~ailure—Ambiguous or misleading items.

Other errors can occur as a function of time, data

processing, or interpretation. It is clear that all these

issues are particularly relevant to cross-national

research and call for close attention to be paid to

interviewer training (and retraining), precise definition

and instructions, along with stringent quality control

measures.

Response (or nonresponse) rates are often not

systematically reported by researchers. In our experience, response rates have generally been higher in

developing country studies, perhaps reflecting cultural differences or less previous exposure to social or

health survey research. The basic characteristics of

137
nonrespondents should always be investigated by

whatever means are available so at least potential bias

introduced by their exclusion can be assessed. In our

experience, generally there has been little difference

noted in the characteristics of respondents and

nonrespondents. We do have the impression that there

are some cultural variations; for example, in some

societies disabled individuals maybe underrepresented

if disability is considered a social stigma.

Proxy respondents

If one is concerned about including information on

the severely disabled and particularly those with severe

mental disability, then provision for proxy responses

to factual questions is very important. The choice of

proxy, the precise definition of what is acceptable as

proxy information, and the specification of proxy

responses in analysis are all important. A consistent

approach to proxy responses when information is

collected sequentially is essential, and data should be

collected from the same proxy over time whenever

possible. Although there are reservations about surrogate interviewing, it is clearly preferable to receiving no information at all.Recent studies have suggested

that in many situations proxy interviews have been

successfully used (6).

Institutional populations

A majority of studies of aging populations exclude

those who are resident in institutions and deal only

with the so-called “community-based” or “noninstitutionalized” elderly. While such an approach is acceptable for many purposes, it does result in samples

that cannot be said to be representative of the whole

population. Usually rates of institutionalization increase with age so that, apart from geographic variations, different proportions of various age groups will

be available for inclusion in studies of the communitybased elderly. Institutions for the elderly are now

found everywhere in both developed and developing

countries; differing administrative definitions of institutions themselves, variation in admission policies,

differing levels of care classifications, and so forth,

mean that comparisons of institutional populations

can be difficult. Separately collected data on institutional populations can be usefully taken into account,

but such data need to be defined precisely, as methods

of information collection will vary widely. In general

population studies, the institutionalized account for

only a small proportion of the total study group;

therefore it is necessary, if information on them is

specifically required, to either oversimple or to study

those in institutions separately.

Modes of data collection

McKinlay and others (7) have reviewed various

methods for field data collection of sociomedical

information among the elderly, including face-toface, telephone: and self-administered formats. They

concluded that “all field approaches are useful, some

appear more useful than others depending on the topic

and objective of the study and the characteristics of the

population under investigation.” There appears to be

a good case for mixed-mode approaches. The main

difficulties arise in trying to compare data that have

been collected using different modes. In the view of

McKinlay et al., in-person interviews can no longer be

considered the “gold standard,” and they may increasingly be a luxury from which researchers need to

be weaned, especially in situations of financial stringency. In our experience, a combined approach is

often useful so that the benefits of particular methods

in specific areas can be achieved.

Performance-based measures of physical

function

In the search for more objective measures of

physical functioning, theU.S. Established Populations

forEpidemiologic Study oftheElderly (EPESE) studies

have begun using a series of simple physical performance tests that can be administered in an elderly

subject’s own home by a tester with minimal training

(8).This approach has alsobeenemployedin theThird

U.S. National Health and Nutrition Examination Survey as well as in a number of smaller surveys, and we

are trying the method in our Southeast Asian studies.

The method is simple and appears to be highly reliable. The tests, which primarily evaluate gait, strength,

and balance, relate primarily to the lower limb and

trunk and do not give any indication of upper extremity function. In some countries, legal difficulties arise

in conducting physical tests without the direct supervision of a medical practitioner. Nevertheless, the

approach shows considerable promise and deserves

138
wide application and further evaluation as a potentially

culture-free means of quantification of certain aspects

of disability. One of the criticisms of the use of

objective performance-based tests is that they are

actually assessing impairment, which is defined in the

World Health Organization (WHO) International

Classification of Impairment, Disability and Handicap

as being a loss of physiologic or anatomic function,

rather than disability, which is a restriction in an

individual’s functional performance as a result of

impairment (9).

Timeframes

Different studies are conducted according to differing timeframes fordatacollection, with consequent

variations in seasonal influences and potential significant cohort effects. Compensating for variations in

timeframes or projection periods can be a complex

exercise, and data collected and projected on the same

or similar schedules are preferred.

Clinicai assessment

The place of clinical assessment in both community and institution studies is often a vexing issue. Full

clinical examination is a costly process clinical methods and records are very hard to standardize. Some

basic clinical information, at least in such terms as

diagnosis and procedures conducted, can usually be

obtained by interrogating primary care and/or institutional records. Such records are not always easily

accessible or able to be linked with survey data.

When resources allow them, some basic standardized clinical assessments can provide valuable data.

These include, for instance, anthropometric measures,

blood pressure recording, and tests of vision and

hearing. More sophisticated clinical measurements

can be performed using reliable instrumentation for

testing respiratory and cardiac function, bone density,

etc. In addition, clinical laborato~ investigation may

be undertaken toprovidebiochemical, hematological,

immunological, hormonal, and other basic physiologic

data with minimum distress to subjects. The conduct

of these procedures is generally justified only when

there are specific hypothesis-driven questions under

investigation. It is worth noting that in many areas selfreported information yields comparable results to objective testing, e.g., in assessment of vision and hearing.

institution-based, popuiation-based, and

administrative data iinkages

With rare exceptions, record linkage arrangements

that are able to provide sets of data on individuals

across a range of sources are not available. There are

also major problems in linking aggregate data from

these sources due to great variation in definitions,

methods of collection, timeframes, coverage, etc. This

is especially so in less developed countries. A prospective approach may be feasible, with the long-term

goal of developing population information systems

that can link various sources of aggregated data through

use of some common identifier such as a health insurance or social security number. One of the barriers to

this development is the growing concern over privacy

and confidentiality within many communities.

Other issues

In general, it must be said that the absolute standardization of study designs, sampling rules, definitions, measurement procedures, etc., in cross-national

studies is no simple task. Even the most straightforward effort can be confounded by cultural, language,

custom, religious, legal, and other considerations.

Anecdotes abound: In our studies, we have come

across people who had never held a writing implement

in their lives, so that a simple test requiring the copying

of a drawing did not work, people who had no conception of and no need to know the current date; people

who never used beds; people who never used chair$

people who lived below the ground rather than in

upper level housing; others who ate routinely with

their hands and used no utensils; others who identified

a “spirit presence,” which by Western standards would

be enough to classify them as paranoid; and soon. The

application of many otherwise highly standardized

measures of function in these individuals would invariably give misleading results, as would the simple

comparison of findings from studies of populations

with differing characteristics in these and many other

respects (10).

Measurement of mental function is particularly

difficult in cross-cultural studies, and in spite of vigorous attempts, especially over the past decade, there

are still considerable problems in assessing mental

139
health. The lack of a wholly internationally portable

instrument available suggests that there is a need to

define mental health and cognitive functioningculturespecific terms andtodevelop instruments that measure

the same mental functions but use different culturally

appropriate items. For this to be an effective way

around the problem, there is clear need for indepth

validation studies linking assessment and outcome in

different cultural settings.

Cross-national comparison may be complicated

by the diverse health care “environments” in which

studies are conducted. Health care systems show

considerable regional and national variation, including differing funding arrangements, disparate forms

of health legislation, varying administrative structures, diverse categorization of health workers, and

different health care practices. In this latter instance,

attention needs to be paid to the relative importance of

traditional health practices in developing country

settings.

In addition, there is some question about the

meaning of “healthy” in different settings. David

Curb, formerly of NIA, has raised elsewhere the

issue of whether the idea of “healthy aging,” “successful aging;’ or “disability-free aging” may in a

sense discriminate against those who show little or

no significant disability (or handicap) broadly defined, but who nevertheless have significant defined

chronic morbidity and are apparently remarkably

well adapted to their situation. Adaptation of this

sort may well have some very culturally specific

features, reflecting different expectations, requirements, and environments. The finding in the Boston

EPESE study that only 15.3 percent of the population

65 years of age and over exhibited neither disability

nor chronic disease does seem to suggest some

broader criterion is needed, at least for successful

aging (11).

Political considerations can intrude in the conduct

of cross-national and cross-cultural research. The way

in which data are interpreted may have politically

sensitive overtones, and there may be pressure on

investigators in some circumstances to present and

report theirdatain certain waysthat are notscientifically

valid but are acceptable politically. It is important to

be aware of this potentially embarrassing possibility

and to have the ground rules laid down at the outset in

order to avoid such conflicts and to ensure scientific

rigor in the reporting of cross-national findings.

Time-series (longitudinal) data

There are good arguments for moving toward

longitudinal rather than cross-sectional data collections on aging and function for both national and

international purposes. There is already a considerable

amount of data available from longitudinal studies

conducted in a number of countries, and further

initiatives in this area are currently being planned.

The problems outlined above are further magnified,

however, in the conduct of longitudinal research.

Those studies already completed and under way show

great variation in design, sampling, coverage,

timeframes, and methods, making comparability very

difficult. Newer studies, such as The Australian

Longitudinal Study of Aging and the Determinants of

Healthy Aging project of WHO, present an excellent

opportunity for a more collaborative international

approach (12). The WHO project, which is planned as

a multicountry effort involving both developed and

developing countries at the outset, is particularly well

placed to foster the idea of the development and use

of internationally accepted standardized design and

instrumentation. While international collaborative

longitudinal studies are a welcome prospect, even

greater attention will need to be given to design and

measurement issues, quality control, analysis, and

interpretation.

Technical considerations

Apart from the scientific and methodological issues discussed above, there are a number of potential

pitfalls in conducting cross-national research that I

have labeled “technical problems.’’They are all easily

resolved but can constitute major barriers to good

cross-national endeavors if they are not effectively

addressed at the outset.

● Communication is a critical issue. A good communication network is essential, supported by

140
●

●

●

whatever means available and, if possible, utilizing international electronic mail systems such as

BITNET.

Standardization of procedures, not just the research tools, is necessary. Investigators need to

know precisely what is expected of them in terms

of recods, reporting, and administrative procedures.

A clear set of agreements covering data recording,

entry, transfer, processing, and analysis is essential. We generally argue for a highly centralized

approach to ensure project objectives are achieved,

to maintain quality control, and to achieve maximum efficiency in this phase of the work. It is,

however, very important that the data be turned

around quickly and that national investigators be

able to get their own data back on disk or tape, in

addition to whatever preliminary analysis is available, as early as possible.

Finally, agreed-upon guidelines regarding reporting and publication of results should also be established at the beginning in order to avoid potential

conflict andmisunderstandingin this often sensitive

area. In my view, it is highly desirable that the data

from significant cross-national studies be made

available in the public domain within a reasonable

time, say after 12 months, and this needs to be

planned for and understood by all involved at the

commencement of the project.

Conclusion

There exists a substantial body of argument in

favor of cross-national and cross-cultural research on

aging. Much is to be gained by analyses of crossnational variance and the critical examination of

differing experience of population aging and its

consequences.

There are, however, a number of conceptual and

practical barriers to effective cross-national comparativeresearch. These barriers need to be systematically

addressed. Considerable effort needs to be applied to

definitional, methodological, and analytic issues associated with cross-national research to ensure that the

rich opportunities for valid comparative analyses can

be effectively exploited.

References

1.

2.

3.

4.

5.

6.

7.

8.

9.

10,

11,

12.

United Nations. Vienna international plan of action,

Division for Economic and Social Information. DESI

publication no E94. Department of Public Information.

1982.

Department of International Economic and Social Affairs. The world ageing situation: Strategies and policies. New York: United Nations. 1985.

Torrey BB, Klnsella K, Taeuber CM.An agingworld.

International population reports; series P–95, no 78.

Washington: U.S. Bureau of the Census. 1987.

Kinsella K. Aging in the third world. International

population reports; series P–95, no 79. Washington

U.S. Bureau of the Census. 1988.

Branch LG. Functional abilities of the elderly: An

update on the Massachusetts health care panel study.

Second Conference on the Epidemiology of Aging.

National Institutes of Health. 1980.

Kovar MG. Health of elderly people living in the

community. Milbank Q 64:180-92.1986.

McKhday JB, Tennstedt SL, Brarnbilla D, et al. Building on others’ experience: Optimal field approaches

forsociomedical studies of olderpeople. In: SuzmanR,

Willis D, Manton K, eds. The oldest old. Oxford

University Press. To be published.

Guralnick JM, Branch LG, Cummings SR, Curb JD.

Physical performance measures in aging research. J

Gerontol Med Sci 44:M141-6. 1989.

Jette AM, Branch LG. Impairment and disability in the

aged. J Chronic Dis 38(1):59–65. 1985.

Andrews GR, Esterman AJ, Braunack-Mayer AJ,

Rungie C. Ageing in the Western Pacific: A fourcountrystudy.Manila: WesternPacificRegionWorld

Health Organization. 1986.

CurbJD.Theestablishedpopulationsforepidemiologic

studiesin the elderly: Design and methodologic implications for international studies. Unpublished

working paper, National Institute on Aging, Washington. 1988.

World Health Organization. Special Programme for

ResearchonAgeing-descriptionofpmgramme(SPRA).

Copmhagen WorldHealthOrganization.1987.

141
Part VI

Comparative analysis

of health statistics for

selected diseases

common in older

persons in the

United States
Introduction

by Tamara Harris, M.D., Medical Officer,

National Center for Health Statistics

The objectives of this project are threefold. The

first goal, which complements theprojectproposedby

Dr. Rosenberg in Part II (Chapter 5), is to understand

methodologic constraints in cross-national comparisons, both constraints generic to cross-national comparisons for any age group and constraints particular

to older populations. The second goal includes identification of methodologies to validate the statistics for

the disease that will be selected for cross-national

comparison as part of this project. The third goal is to

collect data and to attempt to contrast rates of selected

diseases, taking into consideration the methodologic

constraints identified earlier in the project. From these

comparisons, it would be possible to develop hypotheses regarding geographic differences of observed

prevalence rates in selected diseases common in older

persons.

145
Chapter 16

Opportunities for

international collaborateion:

Comparisons of morbidity

and mortality for chronic

diseases in older persons

by Jacob A. Brody, M.D., Dean, School of Public

Health, The Universityof Illinoisat Chicago

Population data are improving and becoming more

available (l), while data on morbidity and functional

abilities are more difficult to ascertain and, therefore,

more difficult to use and compare. Thus, the goals for

utilization of data on nonfatal events for the International Collaborative Effort on Aging must be realistic

and perhaps humble.

The world is experiencing a unique historical occurrence. Atthesame time that more people are dying

at older ages, the elderly themselves are experiencing

an increase in life expectancy at a rate faster than that

of the rest of the population. Two general pathways

toward longevity have emerged. One, representing

developed countries, is exemplified by the Swedish

experience, and the other by that ofJapan. Sweden and

perhaps a few other small nations are approximately

10-30 years ahead of the other developed countries of

the world. At present 17 percent of the Swedish

population is 65 years of age and over. Low birthrates

this century coupled with very low mortality rates

produced a pattern in which about 80 percent of all

deaths occur after age 65. Very low mortality at younger

ages is a phenomenon being experienced increasingly

throughout the world and will continue and become the

norm for humankind, barring the introduction of major

new diseases or extreme social disruption. Sweden has

achieved most of what could be termed the Phase I

increase in survival. Only major scientific breakthroughs can greatly increase Swedish longevity. All

developed countries are rapidly approaching the

Swedish standard, and within about 30 years most will

have approximately 20 percent of their populations 65

yearn of age and over. Higher birth rates could alter

this, as could gains in premature mortality (deaths

under age 65). Medical and social progress should

reduce premature mortality by 25–50 percent in the

foreseeable future, but because in Sweden this represents only 20 percent of all deaths, the gainsin longevity

are limited.

The Japanese experience represents the apogee of

what is possible in the developing world. Obviously,

no other country is likely to have the material wealth

of Japan that has caused so rapid a decline in premature deaths. It is also likely that few developing nations

will have as low birth rates as have occurred in Japan

since its postwar Baby Boom. The lesson to be learned

is how rapidly and massively the change in the age

structure of the population can be effectuated. Japan

actually is doubling its population 65yearsof ageand

over within the span of 26 years-an event that was

accomplished in 45 years in the United Kingdom, 66

years in the United States, 85 yearsin Sweden, and 115

years in France (l). Life expectancy in Japan is now

greater than 77 years—the longest in the world. The

inevitability ofrapid increase in life expectancy within

developing nations is already clearly visible and frequently is occurring in the face of poverty, social

instability, and relatively higher birth rates. These

phenomena give the lie to Alexander Pope’s poetic

plea, “The proper study of Mankind is Man” (Know

Then Thyself ‘).The proper study is now Old Men or,

more properly, Old Women.

Life expectancy at age 65 is an increasingly useful

statistic in view of the decline of premature deaths. By

knowing how long half our elderly population will

survive, we can recognize the diseases and conditions

147
that our societies must address. Among 17of the most

developed Western nations, life expectancy has risen

steadily since 1950, and with the exception of the

astonishing leap forward by Japan, the relative position of these nations has changed little. ~

The United States has had one of the longer life

expectancies at age 65, although life expectancy at

birth isin the lower grouping. It appears that increased

life expectancy among the elderly will be occurring

worldwide even without major medical or social intervention. In all developed countries, at least 65–70

percent of total deaths occur after age 65, and of these

deaths, 80 percent are from heart disease, stroke, and

cancer, while only 20percent are from all other causes.

It is likely, therefore, that medical intervention in

terms of prevention and postponement of disease,

medical and technological advances, and social policy

and attitude may affect longevity and will affect the

quality of this increased life expectancy.

Recommendations

Age-specific onset of indicator diseases

and conditions

As we increase life expectancy, most data suggest

that we are accomplishing this by providing a few

additional years of active life expectancy at the expense of many years of compromised health and wellbeing. We must develop a protocol that will yield data

about the age-specific onset of diseases, conditions,

and other measurable events. We should identify

sources that are currently available, or with affordable

input, we could successfully address this subject prospectively. Without age-specific data, we cannot determine if we are extending or indeed “compressing”

morbidity.

Age at menopause isimportant and can be studied.

In developed countries, women have added 20-30

years of life this century. Has a concomitant change

occurred in age at menopause; or is this important

hormonal landmark a fixed event for the species?

Considerable information could be gained from the

various studies already published. -For the most part,

these studies reveal no change in the age at menopause. A surrogate approach would be to review

records in countries with excellent birth certificate

records since the turn of the century. The item to be

studied isthe maximum age for the oldest 100or 1,000

mothers per year since about 1900. The figures will

surely be much less dramatic than the change in age at

death, but if no trend for older ages at final parity is

encountered it makes more expensive and complex

studies less attractive.

Hip fracture

Data on the age-specific, sex-specific, racespecific onset of hip fracture overtime maybe available

in several developed countries or specific areawide

populations. Current data suggest an increase in agespecific hip fracture incidence in Northern Europe;

this has beenreportedin NorthAmericaasapreliminary

observation by the National Center forHealth Statistics

during this meeting. Hip fracture is an age-dependent

condition (2,3) and is a surrogate for measuring many

other aging parameters. Data will thus be useful in

terms of physiologic aging, medical and social needs,

and perhaps in determining causal factors.

Sensory diseases and conditions

The eyes and ears are remarkably complex structures that seem to be maintained in the vast majority of

people for 40 or more years with only limited deterioration. Thereafter, an array of deleterious events occur

to the eyes and ears progressively with age. Because

the very high age-dependent increase has a most

unhappy impact, knowledge leading to a better social

adjustment for what is now considered inevitable and

new hope for understanding of mechanisms that

can postpone or prevent these conditions is of great

importance.

We must also learn if the age-specific onset of the

various forms of deafness and blindness has been

stable over time or has changed with increasing longevity. Various opportunities probably exist in which

vision and hearing were tested in given populations

over time. There may also be opportunities to determine age-specific onset of cataracts or the more dramatic onset of macular degeneration in the elderly.

Terminal decline

The medical literature frequently refers to an event

or phenomenon called the terminal decline, which

refers to a clinical state in which the patient deteriorates

148
regardless of intervention. Does the terminal decline

exist? If so, in what percent of deaths does it occur?

How long is a person in terminal decline, and how

can we recognize it clinically? If it is indeed a frequent and important event, we must learn to identify it

and address it. It would tell us a great deal about the

physiology involved in dying, as well as provide

us with a discernible clinical event in which the

need for medical intervention is radically altered.

There are considerable ethical and financial implications if we can succeed in defining and recognizing

the terminal decline. Mortality followback studies

may be of some use, but most useful would be

population-based studies that follow clinical course to

fatal outcome.

Alzheimer’s disease and related dementias

This constellation of diseases is being widely

studied. We must continue our attempts to achieve

specific diagnoses and the natural history of these

diseases. We must develop methods to determine the

age-specific onset of dementias and document whether

the onset can be postponed or prevented and whether

curative measures are a realistic expectation.

Prevalence of the dementias rises to about 20

percent by age 80.In the next 30 years in the developed

world, and in perhaps 50 years in most of the world,

about half of all deaths will be occurring after age 80.

Life expectancy at age 65 is already greater than 80

years throughout the world. Unless the age-specific

incidence of the dementias is postponed by 5–10

years, we are facing a prospect that will greatly alter

my enthusiasm and ethical perspective concerning

increased longevity.

Functional status

This topic is also addressed in other portions of the

report. My impression is that better conceptualization

and experimentation are needed before we attempt

comparisons of age-specific changes in functional

status over time indifferent countries. Problems relate

to how to measure functional status and why. The

methods of measurement are becoming better but

certainly have not achieved the status of a robust

predictor of subsequent life events. Functional status

isfrequentl y used as a surrogate measure of composite

disease impact, but the correlations between diseases

and functional status are not well defined. Functional

status is also used to determine need. In various

parameters it does this well. It is disturbing, however,

that in the United States, three of four current legislative proposals to provide long-term care are based on

the activities of daily living, only one of the many

approaches to evaluating functional status. This illustrates the risk of promoting a single approach, since we

run the risk now of having achieved our goal of

influencing policymakers, but with a faulty tool that

will not effectively pick up some of the most prevalent

age-dependent disabilities, such as Alzheimer’s disease. Therefore, I suggest collaborative research and

evaluation studies to evolve criteria for functional

assessment in terms of their intended use.

Concluding remarks

By 2020 the developed countries and some of the

developing countries will have achieved a population

profile resembling that currently observed in Sweden.

Fully 80 percent of deaths will occur after age 65. With

small variations, 80 percent of these deaths will be

caused by cardiovascular and cerebrovascular disease

and cancer. About 20 percent of the entire population

will be over age 65.

Gains in preventing premature mortality (deaths

under age 65) will be made, but since only 20 percent

of all deaths will be premature, the impact on life

expectancy will not be great. The gains we shall see

will result from continuing increased life expectancy

after age 65. Currently, life expectancy at age 65 is

15–20 years and rising.

As death is postponed, are we also postponing the

age-specific onset of the age-dependent nonfatal diseases and conditions that increase inexorably with

age? These include failing vision and hearing, arthritis, and the dementias. Data concerning hip fkacture

suggest that the reverse is actually occurring, with an

increase in age-specific incidence. We have no real

data on trends in age-specific onset in other agedependent, nonfatal conditions that consume life’s

quality and override and confound many of our

functional measurements. Menopause has not been

postponed appreciably inpopulationsin which women

have added 20-30 years of life expectancy this century.

149
Data available throughout the world must be ana- References

lyzed retrospectively and ultimately prospectively to ~

determine the age-specific onset of the nonfatal age- “

dependent conditions. Unless we learn how to measure trends in age-specific onset and ultimately how to ~

postpone their onset at a faster rate than we postpone “

mortality, the net result will bean increase in morbid- ~

ity and disability rather than the hoped-for cornpres- “

sion of morbidity.

TorreyBB,KinsellaK,TaeuberCM.An agingworld,

International population reports; series P-95, no 78,

Washington:U.S.Bureau of the Census. 1987.

Brody JA, Schneider EL. Diseases and disorders of

aging: An hypothesis.J ChronicDis 39:871-6, 1986.

Brody JA. Aging: A vision from here to 2020, In:

Health,longevityandvitality. Washington:American

Associationof Retired Persons.To be published.

150
Chapter 17

Epidemiology of aging in

Hong Kong: Health status

of the Hong Kong Chinese

elderly

by Suzanne C. Ho, Ph.D., M.P.H., Department

of Community and Family Medicine, The

Chinese University of Hong Kong

Introduction

Demographic trends and population projections

have indicated a rapid increase in the world’s elderly

population, expected to reach 410 million by the year

2000. Of this population, 59 percent will be living in

the less developed countries (1, p. 22). These demographic changes call for close examination of the

implications of aging and formulation of national

policies to cater to the emerging issues related to aging

poptdations.

Hong Kong is a city-state located in the southern

tip of Mainland China, It has gone through tremendous industrialization and population growth in the

past 40 years.The life expectancy at birth in Hong

Kong in 1986 was 74 years of age for men and 79.8

years of age for women, which compares favorably

with that in the United States (men, 72 years of age,

and women, 79.3 years of age) and Japan (men, 75.1

years of age, and women, 80.8 years of age). The

longer life expectancy, together with the dramatic

decline in the birth rate, has resulted in a fast-aging

population in Hong Kong. The population 60 years of

age and over has increased from 150,000 (4.8 percent

of the total population in 1961) to 653,200 (11.5

percent of thetotalpopulationin 1986) and is expected

toreach 12.6percent in 1991.The older old population

(85yearsof age andover) will also increase from 1986

to 2006, from 4,900 to 31,000 for men and from

18,600 to 61,000 for women (2,3).

The changes in economic situations, traditional

values, and family structure in Hong Kong are also

affecting the care and well-being of the fast-growing

elderly population. Because the developed countries

have gone through an earlier phase of aging and the

problems associated with an aging population will be

increasingly faced by many developing countries,

cross-national comparisons among different counties

will provide the necessary groundwork for future

planning and development of strategies toward this

common concern.

This paper presents the available health statistics

for the Hong Kong elderly, together with a description of the health status of the population 70 years of

age and over, based on the cross-sectional baseline

data from a longitudinal study, which aims to investigate the determinants of health in a Hong Kong

elderly cohort.

Methods

The mortality and cancer incidence data for the

population 65 years of age andover me extracted from

the departmental reports of the Director of Medical

and Health Services of Hong Kong. The health status

of the Hong Kong elderly cohort is based on crosssectional baseline data from a longitudinal study that

began in 1985. The sampling method has been described in previous reports (4-6).

Briefly, a cohort of subjects 70 years of age and

over—including both persons living in the community and those living in homes for the elderly—was

recruited into the longitudinal study from Shatin New

Town (the major town in the New Territories of Hong

Kong, where the Chinese University of Hong Kong is

located). Of the community cohort,711 were sampled

from subjects who enrolled in the non-means-tested

151
Old Age Allowance Scheme (which has as its only

criteria for eligibility an age of 70 years and over and

residence in Hong Kong for at least 5 years) and the

social centers for the elderly. Another 321 subjects

were residents of the homes for the elderly in Shatin.

These homes mainly provide accommodation, and the

subjects were independent with regard to their activities

of daily living (ADL’s) on admission to the homes.

The main objectives of the study are:

“ To test the hypothesis that social support parameters are related to mortality.

● To study the factors related to mortality and morbidity and to construct the predictors of mortality

and determinants of healthy aging among the

Chinese elderly.

However, the baseline cross-sectional data alone are

useful to describe the characteristics and health status

of the Hong Kong Chinese elderly.

The subjects were personally interviewed upon

first contact at their place of residence, and information was collected with the use of standard questionnaires. The interview schedule was largely based on

the World Health Organization (WHO) Eleven Countries Study (7) and on some existing instruments that

had established validity and reliability overseas

and/or in other surveys carried out in Hong Kong. The

instruments were modified to suit local conditions and

the elderly sample. The questionnaire was translated

into the local dialect and pretested. Data on more than

35 social, health, behavioral, and biological variables

were recorded at the baseline interview. The following is a description of the relevant variables presented

in this report.

Self-reported symptoms and diseases or

conditions

In addition to sociodemographic data, a checklist

of 24 symptoms experienced in the preceding 2 weeks

and a separate checklist of 25 diseases or conditions

experienced in the previous 12 months were adrninistered. Both checklists were based on the WHO Eleven

Countries Study (7). The former included symptoms

such as headache, lack of appetite, tiredness, and

feelings of faintness, and the latter included diseases

or conditions such as arthritis, high blood pressure,

heart problems, stroke, tuberculosis, and chronic

bronchitis. Their capacity in coping with ADL’s was

obtained from the subjects’ response to 14 questions

based on the WHO Study. The questions ranged from

whether they had difficulties with basic self-care, such

as eating or dressing, to more high-level activities,

such as carrying heavy weights and doing heavy

housework.

Mental health

The VIRO Orientation Scale (8), modified to suit

the local situation, was used to assess each subject’s

cognitive functioning with regard to intactness and

orientation in time, person, and place. The level of

psychosomatic ill health was measured by an index

derived from 17 symptoms possibly experienced during the past 2 weeks; the items used were also adopted

from the WHO Eleven Countries Study.

Health behavior

Health behavior variables included smoking

(smoked regularly every day for at least 1 year),

drinking, physical exercise, and sleeping pattern. The

subjects were classified into ever, ex-, or never smokers. The average number of hours of sleep per day was

also obtained.

Results

Health statistics

Table A shows the mortality pattern of the Hong

Kong elderly population 65 years of age and over. In

1986, cancer, heart disease, and cerebrovascular diseases accounted for approximately one-half of all

deaths. There has been some decline in mortality from

cerebrovascular diseases in the past 25 years, while

the mortality rate due to heart and hypertensive heart

disease fluctuates around 8–10 per 1,000. Cancer has

now overtaken heart disease as the leading cause of

death, having increased from 5 to 9.7 per 1,000 in the

population 65 years of age and over. Injury and poisoning (including suicide), respiratory problems such

as chronic bronchitis and asthma, and tuberculosis are

also among the 10 leading causes of death in elderly

persons (9).

There has been a notable decline in deaths from

infectious and parasitic diseases. Tuberculosis was

152
Table A. Rate and percent distribution of causes of

death for the population 65 years of age and over, by

cause of death: Hong Kong, 1961, 1976, and 1986

Table B. Rate of cancer mortality for the population

65 years of age and over, by sex and type of cancer:

Hong Kong, 1986

Cause of death 1961 1976 1986 Type of cancer Men Women

Allcauses . . . . . . . (001-999)

Malignant

neoplasms. . . . . . (140-208)

Heart diseases, including

hypertensive heart

disease ... . . . .. (390-429)

Cerebrovascular

disease . . . . . . . . (430-438)

Pneumonia, all

forms, . . . . . . . . . (480-486)

Nephritis, nephrotic syndrome,

and nephrosis . . . (580-589)

Another causes . . . . . . . . . . .

Allcauses . . . . . . . (001-999)

Malignant

neoplasms. . . . . . (140-208)

Heart diseases, including

hypertensive heart

disease, . . . . . . . (390-429)

Cerebrovascular

disease ,,..,,.. (430-438)

Pneumonia, all

forms . . . . . . . . . . (480-486)

Nephritis, nephrotic syndrome,

and nephrosis . . . (580–589)

Another causes . . . . . . . . . . .

Rate per 1,000 persons

45.2 46.4 38.1

5.0 8.3 9.7

8.2 10.1 7.6

7.5 6.5 5.2

4.4 5.5 3.1

0.9 0.6 1.6

19.3 15.4 10.9

Percent distribution

100.0

11.1

18.1

16.5

9.6

1.9

42.8

100.0

17.9

21.8

14.1

11.9

1.2

33.1

100.0

25.6

19.9

13.7

8.1

4.1

28.7

NOTE:Numbers in parentheses indicate the detailed list

number from the 9th Revision International Classification of

Diseasesfor 1976and 1986.Figures may not add to totals

because of rounding.

among the five leading causes of death in Hong Kong

in the early 1960’s, but the death rate has dropped from

60.2per 100,000 in 1961 to 7.4 in 1986. At present,

mortality from tuberculosis is largely confined to the

older age group, with 64 percent of all tuberculosis

deaths in 1987 occurring to those 65 years of age and

over (8). The average age of death from tuberculosis

was 43 in 1961, as compared to 69 in 1987.

Table B shows the major categories of cancer

mortality in the elderly group. In 1986, lung cancer

was the major cause of cancer deaths for both men and

women. Death rates from lung cancer among Hong

Kong women are among the highest in the world.

Cancers of the gastrointestinal system form the next

major cause of cancer deaths. Liver cancer is of

Trachea, bronchus, and

iung . . . . . . . . . . ..(l62)

Liver and intrahepatic bile

ducts . . . . . . . . . . . (155)

Stomach . . . . . . . . . (151)

Esophagus . . . . . . . (150)

Colon . . . . . . . . . . . . (153)

Bladder . . . . . . . . . . (188)

Rectum . . . . . . . . . . (154)

Pancreas . . . . . . . . . (157)

Nasopharynx. . . . . . (147)

Female breast . . . . . (107)

Cervix uteri . . . . . . . (180)

Prostate . . . . . . . . . . (185)

Rate per 1,000 persons

4.53 2.22

1.56

1.01

0.84

0.79

0.49

0.47

0.37

0.37

. . .

o:ii

1.30

0.53

0.18

0.51

0.17

0.25

0.29

0.15

0.44

0.24

. . .

NOTE: Numbers in parentheses are from the 9th Revision

International Classification of Diseases for 1976 and 1986.

considerable significance, causing 1.6deathsper 1,000

in elderly men and 1.3 deaths per 1,000 women. For

women, breast cancer ranks as the fourth major cause

of cancer deaths, after liver, stomach, and colon cancers (9,10).

Table C shows the incidence of cancer in 1983.

Bronchial cancer has the highest incidence in both

sexes. Although there has been a slight decrease in the

Table C. Rate of incidence of cancer for the

population 65 years of age and over, by sex and type

of cancer: Hong Kong, 1983

Type of cancer Men Women

Rate per 10,000 persons

Trachea, bronchus, and

Iung . . . . . . . . . . ..(l62) 46.8 18.2

Stomach . . . . . . . . . (151) 14.3 7.4

Liver and intrahepatic bile

ducts . . . . . . . . . . . (155) 13.7

Bladder . . . . . . . . . . (188) 12.6 U

Colon . . . . . . . . . . . . (153) 11.6 10.2

Esophagus . . . . . . . (150) 10.6 2.7

Rectum . . . . . . . . . . (154) 8.9 6.7

Nasopharynx. . . . . . (147) 4.7 1.8

Female breast . . . . . (107) . . . 12.4

Cervix uteri . . . . . . . (180) 4.8

Prostate . . . . . . . . . . (185) 7:4 . . .

NOTE: Numbers in parentheses are from the 9th Revision

International Classification of Diseases.

153
incidence of nasopharyngeal cancer in recent years, it

is still high in Hong Kong. Itsrate peaks in the younger

age groups, and it therefore occupies a lower rank in

cancer incidence rates in the aged population. Breast

cancer hasthe second highest incidence rate in women,

and its incidence is increasing in Hong Kong. On the

other hand, the incidence of cancer of the cervix has

been declining over the years.

Results of survey

Sociodemographic characteristics

Some of the social characteristics of the subjects at

baseline have been described in a previous report(5).

As shown in table D, the majority of the subjects

originally came from southern China (Guangdong)

and had been residing in Hong Kong for long periods

of time. Thirty-one percent of the subjects were residents of the old age homes and hostels, and the

subjects were mainly older widowed women. In the

community, the subjects were younger, with about

one-third being men. The characteristics of the community cohort were compared to the overall Hong

Kong elderly population using the 1986 by-census

data (11). (A by-census is a sample census held midway between full-scale censuses, which are conducted

every 10 years.) The distribution of sexes was quite

similar. There was a higher proportion of married

subjects in the Hong Kong general population, probably because the by-census data encompass those 65

years of age and over, while our study population was

restricted to those 70 years of age and over. As with the

Hong Kong elderly, the community subjects were of a

fairly low educational level. While 55 percent had no

formal education, the proportions varied between

women (76 percent) and men (21 percent).

Only 7 percent of the community subjects were

still engaged in some form of work. The main occupation (the type of work they engaged in for the longest

period) of 76percent of the community and 81 percent

of the elderly home subjects was service or production

work, and only 10 percent of both subjects were

engaged in work related to agriculture. About half of

the community andelderlyhome subjects claimed that

the Old Age Allowance was their main source of

income. Although the elderly generally had a low

Table D. Percent distribution of eideriy subjects by

seiected sociodemographic characteristics,

according to residence: Hong Kong, 1986

Home for the

Characteristic Community elderly

Total . . . . . . . . . . . . . . . . . .

Age

70-74 years . . . . . . . . . . . .

75-79 years . . . . . . . . . . . .

80 years and over ., . . . . .

Sex

Male . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . .

Maritai status

Singe. . . . . . . . . . . . . . . . .

Married . . . . . . . . . . . . . . . .

Widowed . . . . . . . . . . . . . .

Divorced or separated . . . .

Educational ievel

No formai education. .

Some primary schooi .

Secondary schooi and

above . . . . . . . . . . . .

Piace of origin

Hong Kong . . . . . . . . .

Guangdong . . . . . . . .

Other parts of China. .

. . . .

.,. .

. . . .

. . . .

. . . .

. . . .

Years in Hong Kong

Lessthan 10 years . . . . . . .

11-30 years . . . . . . . . . . . .

31-50 years . . . . . . . . . . . .

More than 50 years . . . . . .

Number

711 321

Percent distribution

57 17

28

15 ::

13

(~j

86

(62)

17

j~)

6

(5J)

72

(4:)

4

(11)

70

(g)

24

(32)

6

(;5)

4 1

90 95

6 4

4 4

19 25

49 42

28 29

NOTE: Except for sex, for which the distribution is for persons

70 years of age and over, numbers in parentheses indicate the

percent distribution of the Hong Kong elderly population 65

years of age and over.

SOURCE:Census and Statistical Department, Hong Kong bycensus. Hong Kong. 1986.

income, their accessto facilities was excellent compared

to their counterparts in other Asian countries. More

154
than 90 percent of the subjects had access to a telephone (which is an important tool for our followup

survey of the cohort), and most of the subjects had

access to both a refrigerator and a television (table E).

Watching television wasthemostcommon leisuretime

activity, not only for the elderly, but also for all age

groups in Hong Kong.

Health behavior

Table F shows the distribution of health habits by

sex. Forty-three percent of the men were current

smokers, and 29 percent were ex-smokers. About onequarter of the men drank alcohol, but most were only

light or moderate drinkers. About two-thirds of the

women never smoked, and few were drinkers. Walking was the major form of exercise among the subjects,

but the majority of elderly women spent most of their

time indoors.

Activities of daily living and instrumental

activities of daily living

In general, their capacity to perform ADL’s and

instrumental ADL’s decreased with age. Subjects

residing in the homes for the elderly had more problems with mobility and in carrying a load and walking

for any distance (tables G and H). A comparison was

made between the Hong Kong and U.S. elderly ages

75–84 years residing in the community (table J). On

the whole, the Hong Kong elderly seemed to function

better within their homes and were also better with

regard to their walking abilities. On the other hand, the

U.S. subjects were better able to perfomn heavy

housework and carry heavy loads.

Table E. Percent of elderly subjects, by residence

and access to facilities: Hong Kong, 1985

Homeforthe

Facilitv Cofnfnunitv elderlv

Percent

Washing machine. . . . . . . . 60

Refrigerator . . . . . . . . . . . . E 91

Telephone . . . . . . . . . . . . . 95 100

Television . . . . . . . . . . . . . . 95 100

Radio . . . . . . . . . . . . . . . . . 89 68

Tabie F. Percent distribution of eideriy subjects by

seiected heaith habits, according to sex:

Hong Kong, 1985

Health habit Male Female

Total . . . . . . . . . . . . . . . . . .

Smoking

Smoke . . . . . . . . . . . . . . . .

Usedto smoke . . . . . . . . . .

Never smoked . . . . . . . . . .

Drinking

Drink . . . . . . . . . . . . . . . . . .

Do notdrink . . . . . . . . . . . .

Physicai exercise

Waif . . . . . . . . . . . . . . . . . .

Practice taichi . . . . . . . . . .

Do other exercise. . . . . . . .

Do notexercise . . . . . . . . .

Where spend most time

indoors . . . . . . . . . . . . . . . .

Outdoors . . . . . . . . . . . . . .

Both . . . . . . . . . . . . . . . . . .

Number

298 734

Percent distribution

43 15

29 16

28 69

24 8

76 92

52 56

2

1: 8

36 33

48 63

17 8

35 29

Self-reported symptoms and diseases

TableK shows the 10most common complaints or

symptoms experienced in the past 2 weeks. A higher

proportion of the subjects residing in the homes for the

elderly reported symptoms of apsychosomatic nature,

and the rate of complaints was higher in women than

men. Joint pain, sleeping difficulty, tiredness or feelings of faintness, and an unwillingness to do things

were the most commonly reporteds ymptoms among

those in the community. However, worsening memory

was the major complaint among the subjects living in

homes for the elderly. Many of the other complaints

were also of a psychosomatic nature. Constipation

was among the top 10 complaints for both men and

women.

As shown in table L, musculoskeletal conditions

seemed to be a major health problem in subjects living

both in the community and in homes for the elderly.

About two-thirds of the women and 40 percent of the

men reported having arthritis. (Subjects with arthritis

were also found to have lower daily functional abilities.) Cramps in legs, back pain, and stiffness were the

155
Table G. Percent of subjects 70 years and over living in the community with difficulty performing activities of

daily living and instrumental activities of daily living, by sex, age, and type of activity: Hong Kong, 1985

Female Male

80 years 80 years

Activity 70-74 years 75-79 years and over 70-74 years 75-79 years and over

Number

163

Percent

7

3

13

12

Total . . . . . . . . . . . . . . . . . . . . . 244 134 77 66 25

Moveoutdoors . . . . . . . . . . . . .

Walk between rooms . . . . . . . .

Usestairs, . . . . . . . . . . . . . . . .

Walk30 minutes . . . . . . . . . . . .

Carry5 kilograms,walk

10minutes . . . . . . . . . . . . . . .

Use lavatory . . . . . . . . . . . . . . .

Wash and bathe . . . . . . . . . . . .

Dressand undress . . . . . . . . . .

Getinand outof bed .,......

;;;k . . . . . . . . . . . . . . . . . . . . .

Cuttoenils: :::::::::::::::

Do light housework! ., . . . . . . .

Do heavy houseworkl. . . . . . . .

5

2

16

15

8

4

17

17

16

6

25

25

11

7

17

14

24

12

28

24

32

1

2

2

2

3

0

3

5

48

38

4

4

3

4

4

:

9

49

56

:

5

5

5

4

14

19

61

18

1

4

2

1

2

2

3

7

42

29

5

52

12

12

12

8

16

0

16

20

64

6

6

;

2

9

13

52

‘Subjects who claimed that doing housework is not applicable to their situation are excluded.

Table H. Percent of subjects 70 years and over living in homes for the elderly with difficulty performing

activities of daily living and instrumental activities of daily living, by sex, age, and type of activity: Hong Kong,

1985

Female Male

80 years 80 years

Activity 70-74 yeafs 75–79 years and over 70-74 years 75-79 years and over

Number

Total . . . . . . . . . . . . . . . . . . . . . 41 81 154 12 13 19

Percent

Moveoutdoors . . . . . . . . . . . . .

Walkbetween rooms . . . . . . . .

Usestairs . . . . . . . . . . . . . . . . .

Walk30 minutes . . . . . . . . . . . .

Carry5 kilograms,walk

10 minutes . . . . . . . . . . . . . . .

Uselavatory . . . . . . . . . . . . . . .

Washand bathe . . . . . . . . . . . .

Dressand undress . . . . . . . . . .

Getinand outof bed .,..,.,.

Eat . . . . . . . . . . . . . . . . . . . . . .

Cuttoenails . . . . . . . . . . . . . . . .

Do light housework , . . . . . . . .

Do heavy housework. . . . . . . ,

32

7

22

34

73

2

12

;

2

::

52

27

17

19

28

54

29

44

52

9

9

1:

15

8

15

31

21

21

26

32

60

6

7

2

:

1:

36

80

19

18

12

12

6

21

27

59

27

9

9

9

0

9

0

11

0

38

8

8

8

8

1:

8

38

47

0

0

0

0

11

5

7

29

‘Subjects who claimed that doing housework is not applicable to their situation are excluded.

NOTE: Cooking is not included, as meals were provided and the majority did not cook.

156
Table J. Percent of persons ages 75-84 years living

in the community with difficulty performing selected

activities: Hong Kong, 1985, and United States, 1984

Activity Hong Kong United States 1

Activities of daily living Percent

Walk between rooms . . . . . 11 22

Getoutside . . . . . . . . . . . . . 19 12

Bathe orshower . . . . . . . . . 7 11

Transfer to or from bed

orchair . . . . . . . . . . . . . . . 9

Dress . . . . . . . . . . . . . . . . . : 7

Usetoilet . . . . . . . . . . . . . . 6 5

Eat, , . . . . . . . . . . . . . . . . . 4 3

Instrumental activities

of daily living

Doheavy housework . . . . . 46 27

Prepare meals (cook). . . . . 6 8

Delight housework . . . . . . . 13 9

Activities requiring higher

level functioning

Walk30 minutes . . . . . . . . . 23 34

Walkup steps . . . . . . . . . . . 20 28

Carry 5 kilograms, walk 10

minutes ori/2 mile . . . . . . 43 21

‘Study results from: Fitti JE, Kovar MG. The Supplement on

Aging to the 1984 National Health Interview Survey. National

Centerfor HeaithStatistics.Vitai HealthStat 1(21). 1987.

other major musculoskeletal complaints. Except for

men in the community, about one-quarter of the subjects reported having hypertension. Another commonly reported disease of the circulatory system was

varicose veins.

The prevalence of the complaints of diseases or

conditions was similar in both groups of elderly, but

the rates were higher in women than in men. However,

more men than women had complaints of stomach

ulcers, chronic cough, bronchitis, and asthma. Except

for varicose veins, whose prevalence increased with

age in women, there were little differences in the

prevalence of self-reported symptoms or conditions

among the different age groups. The rates actually

declined with age for some conditions, such as hypertension and depression.

The prevalence of multiple conditions was also

high, with about one-third of the women and onequarter of the men having complained of five or more

conditions in the past year (table M). Women, especially those in homes for the elderly, had a high score

of psychosomatic symptoms. A higher proportion of

those in homes for the elderly than those in the community had been hospitalized in the past year.

Self-reported health status

The subjects were also asked about their selfreported health status and health compared with others. About haIf of the subjects said they had average or

bad health, and one-third thought their health was

worse than that of others. Once again, more women

reported poor health, with the distribution being similar

between those in the community and those in homes

for the elderly. A relatively high proportion of the group

80 years of age and over reported having good health.

Table K. Percent of elderly subjects reporting the 10 most common symptoms experienced in the past

2 weeks, by residence and sex: Hong Kong, 1985

Community Home for the elderly

Female Male Female Male

Rank Symptom Percent Symptom Percent Symptom Percent Symptom Percent

1

:

4

5

7

8

9

10

Joint pain

Sleep difficulty

Tiredness

Unwilling to do

things

Faintness

Headache

Nightmares

Constipation

No appetite

Nervousness

52

48

39

30

26

25

25

22

17

14

Sleep difficulty 34

Joint pain 25

Tiredness 25

Unwilling to do

things 20

Nightmares 20

Worsening memory 17

Faintness 16

Constipation 16

Headache 14

Irritability 12

Worsening memory 56

Sleep difficulty 56

Tiredness 48

Joint pain 39

Unwilling to do

things 37

Thirst or polyuria 36

Faintness 30

Headache 30

Depression 28

Constipation 24

Worsening memory 41

Sleep difficulty 34

Tiredness 32

Unwilling to do

things 30

Faintness 25

No appetite 23

Depression 20

Constipation 20

Headache 20

Nervousness 16

157
Table L. Percentof elderly subjects reportingthe 11 most commoncomplaintsof diseases or conditions

experiencedin the past year, by residenceand sex: Hong Kong,1985

Cornn’wnity Home for the elderly

Female Male Female Male

Rank ComDlaint Percent Corntdaint Percent ComDlaint Percent ComDlaint Percent

1 Arthritis 65 Arthritis 43 Arthritis Arthritis 36

2 Cramps in legs 63 Cramps in legs 43 Cramps in legs :: Cramps in legs 30

3 Back pain 35 Constant cough 25 Back pain 34 Hypertension 30

4 Hypertension Varicose vein Tiredness 34 Constant cough 18

5 Tiredness ;: Back pain ;; Paralysis 28 Back pain 16

6 Varicose vein 24 Tiredness 17 Varicose vein 25 Stiffness 16

7 Frequent headache 24 Hypertension 15 Hypertension 24 Tiredness 14

8 Paralysis Paralysis 15 Stiffness 21 Stomach ulcer

9 Constant cough R Stomach ulcer 13 Heart pain 17 Shortness of breath ;:

10 Stiffness 16 Frequent headache 11 Constant cough 16 Chronic bronchitis 11

11 Swollen ankle 14 Stiffness 11 Frequent headache 15 Frequent headache 11

Discussion

Hong Kong has gone through a period of rapid

industrialization in the past 40 years. The mortality

pattern at present closely resembles that of Western

countries, with cancer, heart disease, and cerebrovascular disease as the leading causes of death. The

decline in the death rates from infectious diseases is

largely related to the improvement in economic situations, environmental hygiene, sanitation, nutrition,

health services, and immunization.

While deaths due to heart disease remain stable,

those due to cerebrovascular disease have declined,

and an increasing trend of cancer mortality has been

observed. Such trends have also been reported in the

United States and other countries (12–14). It has been

suggested that the better detection and treatment of

hypertensive diseases are related to the decline in

deaths from cerebrovascular diseases (15). The high

rate of lung cancer among HongKong men isprobably

related to smoking, but the high rate among women

needs further investigation. Chinese women

(Cantonese) in the United States and in Singapore

have also been observed to have a high incidence of

lung cancer (10).

Few data are available on the morbidity pattern of

the Hong Kong elderly. This report is based on the

baseline cross-sectional data of a longitudinal survey

of the elderly population. Although the survey was

carried out in Shatin and the sample was not entirely

158

representative of the Hong Kong elderly as a whole,

the sociodemographic characteristics of the community cohort were similar to those of the general Hong

Kong elderly population (15). As the study was confined to the elderly 70 years of age and over, a large

proportion of the subjects were widowed women.

There are also high widowhood rates in the older

population inothercountries, probably because women

have a longer life expectancy and tend to marry older

men (l). As found in the Pacific Four-Country Study,

the Hong Kong elderly also had a fairly low level of

education, although they seemed to fare slightly better

than their counterparts in Malaysia and Korea (16).

Also, as in the Four-Country Study, more Hong Kong

elderly women than men had no formal schooling.

Unlike the elderly in other Asian countries, who were

more likely to have engaged in agricultural work, the

cohort subjects were mostly engaged in blue-collar

work in the services and production sectors prior to

retirement.

As self-reported health status can be more easily

obtained than objective measurements and examinations in the community setting, the data reported

in this paper are based on self-reported information. However, self-reported data have been found to

be good indicators of health status or subsequent

health outcomes. Sorensen (17) found subjective, selfreported status to provide even better predictors

of health outcomes than objective measurements.

Other studies also found self-reported health status
Table M. Percentof subjects70 years and over, by sex, age, residence,and healthstatus: HongKong, 1985

Female Male

Residence and 80 years 80 years

health status 70-74 years 75-79 years and over 70-74 years 75–79 years and over

Community

Total, . . . . . . . . . . . . . . . . . . . .

Number

244 134 77 163

46

29

19

16

47

37

43

30

27

30

32

38

154

75

42

21

17

44

39

48

29

23

29

28

43

66 25

Percent

Mental function score poor

(Iessthan 16) . . . . . . . . . . . . .

Psychosomatic score high

(80rmore) . . . . . . . . . . . . . . .

Hospitalization in past year . . . .

Number of disease conditions:

o-l ....................

2-4 . . . . . . . . . . . . . . . . . . . .

5ormore, . . .. o. . . . . . . . .

Self-reported health:

Good . . . . . . . . . . . . . . . . . . .

Average . . . . . . . . . . . . . . . .

Bad . . . . . . . . . . . . . . . . . . . .

Health comparedwith others:

Better . . . . . . . . . . . . . . . . . .

Same . . . . . . . . . . . . . . . . . .

Worse . . . . . . . . . . . . . . . . . .

Homes forthe elderly

Total . . . . . . . . . . . . . . . . . . . . .

28 32

32 25

11 14

14

x 52

36 34

46 50

30 34

24 16

x ;:

35 37

10 15 24

21

14

18

30

20

24

38

37

25

30

47

23

32

40

28

55

31

14

39

36

24

36

48

16

35

43

22

Number

12

26

42

32

24

32

44

41 81 13 19

Percent

Mental function score poor

(less than16) . . . . . . . . . . . .

Psychosomatic seore high

(80rmore) . . . . . . . . . . . . . .

Hospitalization . . . . . . . . . . . . .

Numberofdisease conditions:

o-l . . . . . . . . . . . . . . . . . . . .

2-4 . . . . . . . . . . . . . . . . . . . .

5ormore . . . . . . . . . . . . . . .

Self-reported health:

Good. .,.,...,...,...,..

Average . . . . . . . . . . . . . . . .

Bad .,, . . . . . . . . . . . . . . . . .

Health comparedwith others:

Better . . . . . . . . . . . . . . . . . .

Same . . . . . . . . . . . . . . . . . .

Worse . . . . . . . . . . . . . . . . . .

61 64 50

54 36

12 15

34 25

24 40

41 35

46 57

32 21

22 22

17 36

39 33

44 31

38 37

33

8

38

31

26

26

58

8

33

46

38

15

42

47

11

64

18

18

46

23

31

z

16

42

33

25

31

38

31

42

37

21

tobeanimportant predictorofsubsequent healthout- Philippines,where thedisparityofthe educationlevel

comes(18,19). wasnot as great asinsome of the other Asian counAs also found inother Pacific countries, apoor tries,differences incognitivescores betweenmenand

cognitivefunction scorewas associated withincreas- women seemed to be less (16).

ing age, and women had a poorer score than men. The Although with aging there was a consistent trend

generally poorer cognitive function in women could towardincreasing prevalence ofdifficuky inperforming

berelated totheir lower level of education. In the ADL’s andinstrumental ADL’s, most of the study

159
subjects had little difficulty performing most of the

self-care functions. The subjects’ walking ability was

generally good, better than that of their U.S. counterparts. However, the Chinese elderly were less able to

do the heavier work, such as carrying a load for a

distance and performing heavy housework. Private

transportation is not a common asset among the Hong

Kong elderly; most still rely on walking and public

transportation if they need to go out or run errands.

Walking, especially taking a morning walk, was also

the most cornrnon form of exercise performed by half

of the study cohort. Walking was also considered a

form of social activity, as many perform the activity

with friends orotherhousehold members. On the other

hand, the Chinese elderly are not expected to carry out

the heavy household duties; these are usually taken

over by the younger members of the household. The

differences in responses to the questions on instrumental ADL’s could thus be related to the differences

in cultural settings and expectations.

A number of studies have identified the loss of

independence and autonomy (in the form of low

physical activity, inability to work, impaired mobility,

or being housebound) as predictors of mortality in

both the elderly and younger age groups (20-23). It is

also, therefore, a useful indicator of the active life and

quality of living among the elderly. A general decline

of functional ability with age was observed in this and

other studies (7,16). With the rapid increase in the

proportion of the older aged in the population, there

will bean increasing need for the provision of services

catering to rehabilitation and help in ADL’s and instrumental ADL’s for an olderpopulation with chronic

diseases and disability.

Arthritis was the leading complaint of both men

and women in the community and in homes for the

elderly. The present study is based on self-reports, and

it is not possible to assess what proportion of the

arthritis was clinically defined. However, other reported symptoms, such as joint pain, stiffness, back

pain, and leg cramps, are also conditions related to

musculoskeletal problems. Studies have shown that

arthritis and joint problems are associated with impaired independence and loss of function (24) and may

also predispose the elderly to falls and injuries (25).

The high prevalence of arthritis and musculoskeletalrelated disorders certainly calls for urgent attention to

the proper management and monitoring of these

conditions.

Sleep disorders related to difficulties in either

getting to sleep or staying asleep were among the two

most common complaints of symptoms in both men

and women. Such complaints are also quite prevalent

among the elderly in other countries (26,27). Such

disorders affect daytime functioning and the quality of

living of the elderly to a great extent. Physical health

problems, as well as psychological problems such as

anxiety and depression, have also been found to be

associated with sleep disorders (28). Sleeping difficulty, therefore, should not be considered lightly as

part of the normal aging process, and the underlying

causes should be investigated and managed in the

primary health care setting.

Many of the complaints, such as forgetfulness,

unwillingness to do things, feelings of tiredness, and

difficulty sleeping, could berelatedto thepsychological

and mental well-being of the respondents. These were

the most common complaints in both men and women

in the community as well as in the homes for the

elderly. These complaints represent vague symptoms

and could be of apsychosomatic nature. The prevalence

of multiple conditions and the frequent complaints of

vague symptoms call for abetter understanding of and

differentiation between the normal and pathological

processes of aging.

The subjects living in homes fortheelderly seemed

to be worse off in many aspects. With the changing

traditional values and the large number of families

emigrating, especially middle-aged people, there will

be a great need to provide accommodations for the

elderly, preferably in the community setting rather

than in the old age homes.

Women seemed to be less healthy than men, but

men were actually at a higher risk of mortality. Similar

findings are also reported in studies of the elderly in

other countries. This observation may reflect a greater

readiness among women to report their problems. The

use of active lifespan rather than just chronological

lifespan has been suggested as a parameter for

evaluating the differential health and mortality in both

sexes (29).

Although it may seem that health declines with

160
age, many conditions seem to remain at the same level

across different age groups. The prevalence of some

conditions-for instance, hypertension-may even

decline with age. A fairly high proportion of the

subjects 80 years of age and over perceived their

health as being good. Therefore, although health and

functional ability generally decline with age, there are

certain groups who still remain healthy and active. It

will be an important dimension of research to investigate the characteristics of this group of healthy and

active elderly. Longitudinal data will be required, and

attempts will be made to analyze the relationship of

baseline information tomortalityandsubsequenthealth

outcome in this cohort. Such analysis will be better

able to delineate which of the baseline factors have

important longer term consequences for health.

Acknowledgment

Thisstudy was supported in part by the Freemasons’

Fund for East Asian Studies.

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Abramson JH, Gofin R, Peritz E. Risk markers for

mortality amongelderlymen-a community studyin

Jerusalem.J ChronicDis 35:565–72. 1982.

161
22. Waldron I. Sex diffenmces in human mortality: The

role of genetic factors. Soc Sci Med 321-33.1983.

23. Peldcanen J, Martti B, Nissinen A, et al. Reduction of

p~matum mortality by high physical activity: A 20-

year follow-up of middle-aged Fhmish men. Lancet

1473-7.1987.

24. JenkinsonML, Bliss MR, Brain AT, ScottDL. Peripheral arthritis in the elderly: A hospital study. Ann

Rheum Dis 48(3):227–31. 1989.

25. BlakeAJ, MorganK, BendaUMJ, et al. Fall sbyelderly

people at home: Prevalence and associated factors.

Age Ageing 17(6):365–72. 1988.

26. Ancoli-Israel S. Epidemiology of sleep disorders. C1in

Geriatr Med 5(2):347–62. 1989.

27. Daly MP. Sleep disorders in the elderly. Primary Care

16(2):475–88. 1989.

28. Morgan K, Healey DW, Healey PJ. Factors influencing persistent subjective insomnia in old age: A

follow-up study of good and poor sleepers aged 65 to

74. Age Ageing 18(2):117-22. 1989.

29. Sihnan AJ. Why do women live longer and is it worth

it? BrMedJ294:1311–2, 198’7,

.

—

162
Chapter 18

The utility of cross=

national comparisons of

diseases of older persons

by Tamara Harris, M.D., Medical Officer,

National Center for Health Statistics

Much of the task of epidemiology of aging is

focused on health promotion, including the identification ofrisk factors and the formulation ofpreventive

programs. However, the scope of health promotion for

older persons is broader than traditional transitions

from risk factors to disease or death (figure 1) and

includes transitions to disability as well (figure 2). All

these transitions occur against a background of biologic aging and are influenced by the availability of

health care and other health resources.

The goal of cross-national comparisons of diseases of older persons is similar to earlier work in

younger populations (1,2): To delineate geographic

differences in the prevalence of chronic diseases that

could potentially aid in the development of testable

hypotheses for programs aimed at prevention of disease and disability.

However, there are other uses for this type of

cross-national comparison for older persons. Other

International Collaborative Effort projects will consider differences in patterns of disability or patterns of

service utilization, such as nursing home use, within

geographic areas. Patterns of disease will be among

the determinants of patterns of disability. AugmentaDeath

RiskfactorsA Disease

Figure1. Traditionalepidemiologicmodei

Figure2. Epidemiologicmodeifor eider persons

tion of knowledge regarding differences in patterns of

disease may therefore help in understanding patterns

of disability. This goal might be particularly interesting in view of differences in health care resources and

social supports.

Data from the Supplement on Aging to the 1984

National Health Interview Survey (3,4) provide an

example of how data on disease patterns might affect

our understanding of patterns of disability (5). These

data were drawn from a group of 2,104

noninstitutionalized white persons ages 75–84 years

(744 men and 1,360 women) and demonstrate aspects

of the relationship of mobility-related function to

patterns of reported cardiovascular disease and arthritis.

Mobility-relatedfunction was defined byresponses

to questions on functional status that related to lower

extremity function. The three measures used to define

163
mobility-related function included difficulty walking

(defined as difficulty walking one-quarterof smile or

1 difficulty walking), difficulty transferring (defined as \

getting into or out of bed or chair), and difficulty with

balance (defined as difficulty stooping, crouching, or

kneeling). These measures were combined into a fourlevel variable expressing disability with mobilityrelated function: (a) no difficulty on any of the four

measures, (b) difficulty with transfer or balance only,

(c) difficulty walking and difficulty with either transferorbalance, and(d) difficulty walking and difficulty

with both transfer and balance (table A).

A comparison was made between the fourlevels of

mobility-related disability and patterns of reported

diseases, specifically arthritis and cardiovascular disease. Those with neither disease had the lowest levels

of disability (figure 3). Those with either arthritis or

cardiovascular disease had similar levels of impairment in mobility-related function. Those with both

arthritis and cardiovascular disease had the greatest

disability, both in terms of percent disabled and in

Table A. Number and percent distribution of

noninstitutionalized white persons ages 75-84

years, by sex and mobility-related function:

United States, 1984

Mobility-related Sample

function size Total Men Women

Percent distribution

No limitations . . . . . . . . . . 977 48 54 44

Difficulty with transfer or

balance only.... . . . . . . 298 15 15 14

Difficulty walking and with

transfer or balance . . . . . 622 28 24 31

Difficulty walking and with

both transfer and

balance . . . . . . . . . . . . . 207 9 7 11

SOURCE: National Center for Health Statistics. Supplement on

Aging, 1984.

terms of the severity of the impairments. Not only

were patterns of disability at baseline influenced by

medical conditions, but those with arthritis or cardiovascular disease were more likely to incur new-onset

mobility-related disability over short-term followup

100 -

90 -

80 -

.= 70 -

$ 60

z

“~ 50

Eg 40

g 30 -

20 -

10 -

0 -

Neither Arthriiis Cardiovascular Both

cardiovascular alone disease cardiovascular

disease (n = 837) alone disease

nor arthritis (n =191) and arthritis

(n = 761) (n = 315)

Reported comorbidity

SOURCE: National Center for Health Statistics. Supplement on Aging, 1984.

m Difficulty walking and with

both transfer and balance

m Difficulty walking and

with transfer or balance

~ Difficulty with transfer

or balance only

m No limitations

Figure 3. Percent distribution of noninstitutionalized white persons ages 75-84 years by mobility-related

function, according to reported comorbidity: United States, 1984

164
(table B), even

covariates.

These data

controlling for other health-related

suggest that patterns of mobilityrelated disability are conditioned on underlying patterns of disease and that comparison of the patterns of

disease between countries may help to understand

differences in observed patterns of disability relative

to those diseases.

Another utility for cross-national comparisons of

disease in old age relates to understanding the biology

of aging. The research community has begun to carefully isolate the effects of genetically determined

physiologic aging fi-omphysiologic aging that is conditioned on factors which covary with age and which

therefore may be modifiable (6). Comparison of disease patterns geographically can help to delineate the

core of biologic aging, i.e., if “disease” is an expression

of genetically driven biologic changes with age, then

the prevalence of that “disease” from one geographic

area to another might be similar, given a similar age

structure and controlling for other potential confounders. If theprevalenceof the disease appears quite

different, it would be less likely that genetically determined changes accounted for the “disease,” but that

environmental factors played a modifying role.

Benign prostatic hypertrophy might be uninteresting example of this type of phenomenon. Prostatic

hypertrophy is thought to affect most older men in the

United States. Although the specific etiology is unTable B. Odds of developing new-onset mobilityrelated disability for noninstitutionalized white

persons ages 75-84 years, by multivariate

correlates: United States, 1986

/bfu/tivariate corre/ate 1 Relative odds

Cardiovascular disease . . . . . . 1.6 (1.0, 2.4)

Vision . . . . . . . . . . . . . . . . . . . . 1.8 (1.0, 3.3)

Arthritis . . . . . . . . . . . . . . . . . . . 2.0 (1.5, 2.8)

Body-mass index (4th

quartile versus 2d) . . . . . . . . . 1.5 (1.0, 2.2)

Social isolation-women . . . . . 2.9 (1.6, 5.1)

Education (grades 7-12

versus grade 13 or

higher) . . . . . . . . . . . . . . . . . . 1.6 (1.0, 2.5)

Older age (X+ 10 versus X) . . 3.2 (2.7, 3.8)

‘Controlling for sex, diabetes, and hearing impairments.

SOURCE: National Center for Health Statistics. Longitudinal

Study of Aging, 1986.

known, the disease is felt to represent a result of

normative age changes that occur within the prostate,

mediated by an intraprostatic accumulation of

dihydrotestosterone (7).Epidemiologic efforts directed

toward identification of environmental factors that

modulate this process have not revealed factors leading to preventive strategies (8). Because prostatic

hypertrophy can result in blockage of urine flow from

the bladder, leading to urinary retention, increased

risk of infection, incontinence, and even renal failure,

surgery for removal of prostatic tissue is one of the

most commonly conducted surgeries in the United

States, with rates for hospital discharges, prostatectomy, andcystoscopy increasing with age (table C)

at least through age 85 (9). The surgical intervention

for prostatic hypertrophy has become the focus of

outcomes research (10,1 1).

There is arelatively small amount of data available

on prostate disease for comparison intemationall~ at

the moment, there are no widely accepted screening

procedures that could be implemented, nor is any set

of interview questions pathognomonic for prostate

disease. What little data exist suggest there may be

some variation in rates of disease. Autopsy data comparing rates of prostatic enlargement among Chinese

and foreigners in Hong Kong (12) suggest that

prostatic hypertrophy was very uncommon among

older Chinese men of that period (the 1930’s). Data on

mortality related to prostatic hypertrophy also suggest

Table C. Rate of hospital discharge for benign

prostatic hypertrophy and rates of prostatectomy

and cystoscopy, by age: United States, 1984

Benign

prostatic

hypertrophy All-cause

hospital prosta- A1l-cause

Age discharge tectorny cystoscopy

Rate per 10,000 men

55-64 years . . . . . . . 62 67.1 90.6

65-74 years. . . . . . . 151 206.9 222.6

75-84 years. . . . . . . 200 317.3 397.1

85 years and over . . 193 281.1 337.4

SOURCE: Moien M, Liu BM. Use of health care: Care in shortstay hospitals. In: Havlik RJ, Liu BM, Kovar MG, et al. Health

statistics on older persons, United States, 1986. National

Center for Health Statistics. Vital Health Stat 3(25). 1987.

165
wide geographic variation, with Asian countries

reporting the lowest death rates (with rates ranging

from 5.5 per 100,000 persons in HongKong and 7.1 in

Japan) and European countries reporting the highest

rates (with 50.5 for The Netherlands, 52.1 for Switzerland, and 75.1 for Germany, for example) (13). While

there are multiple potential explanations for these

data, it is of interest that both of these references

suggest prostate disease is rare in Asian countries. If

this variation were true, these findings would tend to

undercut the argument that benign prostatic hypertrophy is largely genetically determined and would suggest that environmental influences, such as diet, may

play a role. Comparative statistics on surgical rates

might be quite interesting.

In summary, then, the task of this workshop regarding cross-national comparison of statistics for

diseases common in old age is to focus on an index

disease for international comparison and to develop

minimum criteria for acceptable data. Two more diseases may be designated for additional data collections to compare their geographic variation with that

of the index disease. There are multiple benefits to

making a comparison of diseases common in old age

it remains to be seen if the methodologic problems of

making those comparisons can be surmounted.

References

1. KeysA, ed.Coronaryheart diseasein sevencountries.

Circulation Suppl 141(2): 1–121. 1970.

2. Doll R, Peto R. The causes of cance~ Quantitative

estimates of avoidable risks of cancer in the United

Statestoday. J Natl Cancer Inst 661191–1308. 1981.

3. Fitti JE, Kovar MG. The Supplement on Aging to the

1984National Health Interview Survey. National Center for HealthStatistics.VitalHealthStat 1(21).1987.

4.

5.

6.

7.

8.

9.

KovarMG. Aging intheeighties,peopleliving alone—

two years later. Advance data from vital and health

statistics; no 149. Hyattsville, Maryland: National

Center for Health Statistics. 1988.

HarrisT, KovarMG. National statistics on the functional

health status of olderpe~ons. In: WeindruchR, Hadley

E, Ory MG, eds. Reducing frailty and fall-related

injuries in older pemons. Springfield, Illinois: Charles

C Thomas. To be published.

Gilchrest BA, Rowe JW. The biology of aging. In:

Rowe JW, Besdine RW, eds. Health and disease in old

age. Boston Little, Brown. 1982.

Morimoto I, Edmiston A, Horton R. Alteration in the

metabolism of dihydrotestosterone in elderly men with

prostatic hyperplasia. J Clin Invest 66:612-5.1980.

GlynnRJ, CampionEW, Bouchard GR, SilbertJE.The

development of benign prostatic hyperplasia among

volunteers in the Normative Aging Study, Am J

Epidemiol 121:78–90. 1985.

Moien M, Liu BM. Use of health care: Care in shortstay hospitals. In: HavliiRJ, Llu BM, KovarMG, et al.

Health statistics onolderpersons, United States, 1986,

National Center for Health Statistics. Vital Health Stat

3(25). 1987.

10. Roos NP, Wennberg JE, Malenka DJ, et al. Mortality

and reoperation afier open and transurethral nxection

of the prostate for benign prostatic hyperplasia. N Engl

J Med 320:1120-4.1989.

11. Kolrnert T, Norlen H. Transurethral resection of the

prostate: A review of 1111 cases. Int Urol Nephrol

21:47-55.1989.

12. Chang HL, Char GY. Benign hypertrophy of prostate.

Chin Med J 50: 1707–22. 1936.

13. RotkinID. Epidemiology of benign prostatichypertrophy: Review and speculations. In: Grayhack JT,

Wilson JD, Scherbenske MJ, eds. Benign prostatic

hyperplasia. Washington: U.S. Government Printing

OffIce. 1976.

166
Chapter 19

Utility of cross-national

comparisons of diseases

of older persons:

Osteoporosis as an

example

by Jennifer L. Kelsey, Ph.D., Head, Division of

Epidemiology, Columbia University School of

Public Health

My task at this workshop isto define the characteristics of a disease so as to make it suitable for internationalcomparisons, using osteoporosis as an example.

It appears that at least six characteristics are important:

●

●

●

●

●

●

In countries where eithermortality or hospital data

are readily available, does the disease almost invariably result in hospitalization or cause death?

If the disease results in hospitalization or causes

death, does it do so quickly, so that death or

hospitalization from other diseases does not

complicate the situation?

Can the disease be easily diagnosed?

Is the necessary diagnostic equipment readily

available?

Can the disease be adequately defined?

Is the disease socially acceptable, so to speak? If

not, it may not be recorded, even if it is diagnosed.

It would seem that hip fracture does meet these

criteria as well as any other common disease of the

elderly. However, these criteria would not be met if

one considered osteoporosis and falls specifically,

two major contributors to hip fracture. The only one of

these criteria met by osteoporosis is that it can be

easily diagnosed. However, not many medical centers

even in the United States have the necessary equipment. Falls, on the other hand, can be defined but do

not meet any of the other criteria. Therefore, as one

attempts to go beyond a simple comparison of hip

fracture incidence statistics to consideration of potential etiologic factors for hip fracture, an international

comparison may be considerably more complicated.

Some work has been done in making international

comparisons of hip fracture incidence rates. Two

papers that make these comparisons were published in

1980 (1, 2). Gallagheret al. (1) compared all published

data available on hip fracture incidencq at that time,

the United States, speciilcally Olmstead County, Minnesota, had the highest rates. The lowest rates were

found in Hong Kong and Singapore and among the

Bantu of South Africa. Reasons for this variation in

rates are unclear, since known risk factors for hip

fracture or osteoporosis do not correlate well with the

hip fracture incidence rates, except perhaps for lack of

physical activity. An additional feature of the geographic variation is that in the countries where the

incidence rates are highest, the female-to-male ratio

is highest. For instance, among the Bantu, a population in which the incidence rate is low, the female-tomale ratio is close to one. These differences in the ratio

of female to male cases are unexplained as well.

The other 1980 report (2) attempted an ecologic

correlation of certain variables with incidence rates in

various countries. For instance, rank order of hip

fracture incidence was compared with rank order of

per capita motor vehicles for each country. The rank

order was almost, although not quite, identical.

These types of ecologic analyses are interesting but

speculative.

In comparisons of intemationaldata, there appears

to be apattem that as countries become more industrialized, hip fracture rates rise and the incidence curve

shifts to earlier ages. For instance, an increase in hip

fracture incidence rates has been reported in

England (3) and in Scandinavian countries (4-7) in

recent years. In Oxford County, England, there was a

167
doubling of incidence rates in each age group from

1954 to 1958 to 1983. This trend was seen for Scandinavian countries as well. Morerecent datafromlowincidence areas such as Singapore and Hong Kong,

especially for the oldest age groups, would be of great

interest.

One other noteworthy observation from studies in

Western Europe is that the incidence rates for trochanteric fi-acturesseem to have increased markedly, while

there has been little increase in incidence rates for

fracture of the neck of the femur (5,7). It would be of

interest to look at subtypes of fractures and regional

variation within the United States as well asin some of

the developing countries.

From a review of these issues, a list of critical

questions that could be addressed by international

comparisons of hip fracture can be developed. These

questions include:

●

●

●

●

Do hip fracture incidence rates in areas such as

Hong Kong and Singapore stay relatively level

throughout the age span, oris there a sharp increase

in the oldest age groups?

What are the trends over time in the low-risk

countries? Both of these questions would be interesting to address in areas such as Hong Kong,

where one could examine hip fracture incidence

in persons in their eighties and nineties.

Do almost all hip fractures come to medical attention, particularly in the low-risk countries? Even

in developed countries, people in nursing homes

who are very sick may not be considered suitable

for surgery and may not be seen in a hospital.

Howdoriskfactors for osteoporosis correlate with

geographic and temporal variations in hip fracture

incidence rates? For instance, it is thought that the

declining physical activity in some of the Western

European countries is resulting in higher hip

fracture rates; it would be worthwhile to look at

these correlations across countries and also across

time periods within countries. Likewise, examination of risk factors for falls in relation to the

geographic and temporal variations in hip fracture

incidence rates would be useful. It is of interest

that in Japan, bone mineral density is generally

low, but hip fracture rates are also low (8,9). It may

be that people fall less frequently in Japan, or if

●

they do fall, they fall in such a way that the fall

seldom results in a hip fracture.

Finally, it would be helpful to look at the distribution of bone mineral density at various body sites

in countries with high and low incidence rates for

hip fracture. Even if the measurements were not

done on probability samples of the population, we

would be able to obtain some useful information

for comparative purposes.

For this International Collaborative Effort project,

obtaining age- and gender-specific incidence rates for

hip fracture by 5-year age groups would be important,

Considering all persons 80 years and over as a group

is a problem, because the incidence rates for hip

fracture are so steep and mortality so high that smaller

age groups are needed to make meaningful comparisons across countries. Examination of incidence rates

in the oldest age groups-80-84 years, 85–89 years,

and 90 years and over—would be interesting, since

hip fracture is so important in these age groups and

since the age-specific incidence rates are rising so

rapidly.

It would also be useful to look at trends and

incidence rates over the past few decades, both for

low-risk countries and in the United States as a whole,

as has been done for Olmstead County, Minnesota

(10). I think the data are available, and trends for both

cervical and trochanteric fractures should be studied.

For all countries it would be worthwhile to gather

indicators of exposure for risk factors for osteoporosis

and forfalls. In addition, measurements of bonemineral

density by 5-year age group, gender, and body size

would be helpful in interpreting the data.

References

1.

2.

3.

GallagherJC,MeltonLJIII,RiggsBL, et al.Epidemiologyof fracturesof the proximalfemurinRochester,

Minnesota.Clin Orthop 150:163–71. 1980.

Lewinnek GE, Kelsey JL, White AA III, et al. The

significance and a comparative analysisof the epidemiology of hip fractures. Clin Orthop 152:3543.

1980.

BoyceWJ,VesseyNIP.Risingincidenceoffractureof

the proximalfemur. Lancet 1:150-1.1985.

168
4.

5.

6.

7.

Johnell O, Nilsson B, Obrant K, et al. Age and sex

patterns of hip fracture: Changes in 30 years. Acts

Orthop Stand 55:290-2.1984. 8.

Zain Elabdien BS, Olerud S, Kalstrom G, et al. Rising

incidence of hlp ffacture in Uppsala, 1965–1980. Acts

Orthop Stand 55:284-9.1984.

Finsen V, Benum P. Changing incidence of hip frac- 9.

ttms in rural and urban areas of central Norway. Clin

between the 1950’s and the 1980’s in Malmo, Sweden.

Clin Orthop 238:139-47. 1989.

Yano K, Wasnich RD, Vogel JM; et al. Bone mineral

measu~ments among middle-aged and elderly Japanese

residents in Hawaii. Am J Epidemiol 119:75 1–64.

1984.

Nordin BEC. International patterns of osteoporosis.

Clin Orthop 45:17–30. 1966.

(kthop 218:104-10.1987. 10. Melton LJ III, O’Fallen WM, Riggs BL. Secular trend

Sernbo I,Johnell O. Changes inbonemass andfracture in incidence of hip fractures. Calcif Tksue Int 41:

type in patients with hip fractures. A comparison 57-64.1987.

169

\
Part VU

Measuring risk

factors and outcomes

of institutional

long-term care
Introduction

by Joan F. Van Nostrand, M.P.A., Coordinator

of Data on Aging, National Center for Health

Statistics

It is a pleasure to be able to introduce the topic

Measuring Risk Factors and Outcomes of Institutional

Long-Term Care (LTC). My introduction addresses

two philosophical issues about the topic. They are:

Why is long-term care part of a conference about

vitality and wellness? Why is there a concentration on

the outcomes of such care?

The model of the relationship of the International

Collaborative Effort (ICE) topics, which Dr. Feinleib

presented yesterday, can help to illustrate why LTC is

included in the conference (figure 1). As the model

shows, vitality is the central theme of the ICE on

Aging. The areas of disability andvariationsin chronic

disease constrain vitality. Further, amajorconsequence

of severe disability is a need forlong-term care, that is,

care over an extended period of time to assist persons

Vitality

Health womotion activities ‘

SOURCE: National Center for Health Statistics.

Figure 1. Interrelationship of International

Collaborative Effort on Aging topics

unable to care for themselves due to chronic physical

or mental conditions.

I would like to ask you to add mentally another set

of arrows to this figure. Add a two-way arrow that

directly connects disability to long-term care. Add

another that connects variations in disease patterns to

long-term care. The new model (figure 2) emphasizes the interrelationship among these concepts.

Disability and variations in chronic diseases can

oftentimes lead to long-term care. These interrelationships are symbolized by two-way arrows to

highlight the transition that can occur from long-term

care to improved vitality. Although chronic conditions cannot be cured, their disabling effects can be

mitigated so that long-term care is no longer needed.

In my initial discussions with international

SOURCE: National Center for Health Statistics.

Figure 2. Relationship of long-term care to vitality

in aging

173
collaborators who are members of the long-term care

research team, I found that the generic label given to

the project, “institutional long-term care~’ was soon

translated into the more specific one of “nursing home

care.” In the United States, for instance, the bulk of

formal long-term care is provided in nursing homes. I

am looking forward to learning more from our international speakers about the situation as it exists in

other countries.

Now Iwouldliketo turn tothesecondphilosophical

issue, why the ICE’s emphasis is on the outcomes of

long-term care. As many of you are aware, there has

been considerable research in the United States on

nursing home care. Most of it has concentrated on

identifying risk factors for admission. The thinking

behind thisfocus is thatifriskfactors couldbechanged

in some way, then nursing home stays could be prevented, delayed, orreducedin length. While researchers

have had considerable success in identifying risk

factors, I think the success in preventing nursing home

stays has been rather limited. Research as to why this

is so is a subject for another conference.

Given an institutional bias to long-term care in the

United States, there is a growing realization that for

some elderly a nursing home stay, whether it is appropriate or not, will occur at some time during the

lifespan. This realization calls attention to outcomes

of nursing home care. Itfocuses attention, in particular,

on outcomes that are positive; on why they occur and

on how they can be achieved. The more positive the

outcome of long-term care is, the greater is the vitality

of the older person. Hence, this topic on outcomes of

nursing home care is the application of the concept of

vitality to long-term care.

As you know, the ICE objective forlong-terrn care

is to improve the measurement of nursing home outcomes. However, we should not lose sight of a broader

goal. It is to use this increased knowledge to move

toward improving outcomes for older persons in

nursing homes and increasing their vitality.

My colleagues on this research team have all made

important contributions to the area of long-term care.

I know them to be knowledgeable, insightful, dedicated, and at times provocative. This strikes me as a

winning combination in undertaking the challenges

that this comparative research presents.

174
Chapter 20

Research on institutional

long-term care in Australia

by Anna L. Howe, Ph.D., Aged Care Research

Group, Lincoln School of Health Sciences,

La Trobe University, Melbourne, Australia

Development of research on

institutional long-term care

Research into long-term care for the aged, both

residential and community care, is a relatively recent

endeavor in Australia. Since the introduction of Federal Government benefits for nursing home care in

1963, the number of nursing home beds grew to some

75,000 by 1985, and expenditure grew to 1 billion

Australian dollars. Until recently, remarkably little

was known about the residents of these institutions,

their patterns of utilization of long-term care, or the

outcomes of that care. Early research through the

1970’sindicated more diversity and dynamism in the

long-term care system than was generally seen to be

the case and pointed to ways in which measures for

change might be introduced. Major policy reform was

started in the mid- 1980’s, and restructuring of the

system is now in progress, with research focusing

on monitoring and evaluating the outcomes of these

measures.

At the same time, there has been a growth in the

information available on many aspects of long-term

care provision and outcomes. Much of the data now

generated through administrative systems provides an

information base for monitoring and evaluation, and a

close relationship is emerging between these activities

and further policy development. Before detailing this

current research, some brief background needs to be

given on the context in which it is taking place.

Demographic context

In setting Australia in the context of other countries participating in the International Collaborative

Effort, it is useful to outline some basic dimensions of

the demography of aging (l). Australia has a small

population, 15.6 million at the 1986 census, of which

some 13 percent was 60 years of age and over. The

proportion now this age is similar to that in the United

States and Canada but lower than in many other

advanced industrialized nations. Although theproportion of the population 60 years of age and over is

projected toincreaseto 16percent by 2001, Australia’s

demographic aging even then will be less pronounced

than that currently experienced by most European

countries and less rapid than that expected in North

America over the next 20 years.

The very old population, over 80 years, which

makes the greatest use of long-term care, accounted

for 15 percent of the population 60 years of age and

over in 1986. It is projected that this cohort will

increase by 76 percent over the next two decades. This

growth is much more rapid than the increase of 50

percent projected for the total aged population.

The long-term care system

As of 1985, there were 74,013 nursing home beds

for the aged in Australia, a ratio of 70 beds per 1,000

persons 70 years of age and over. This level is seen to

be higher than that in many countries, but caution is

needed in comparing the variety of facilities and

services that are labeled “nursing homes” in different

countries. Nursing homes were first defined as separate entities in the Australian health care system in

1963, when Federal benefits were introduced; in a

somewhat circular fashion, nursing homes were defined as those facilities approved for receipt of these

benefits. Federal benefits are the major financial input

to the nursing home system and are paid on the same

basis to individuals in private for-profit and voluntary

nonprofit homes; Federal funding to public sector

beds operated by State governments is currently under

review but can be expected to move to the same basis

in the next few years. Benefits are paid irrespective of

175
the recipient’s income, and no spenddown of assets is 

required; the financing of long-term care is independent from either the system of universal health insurance for medical care or private health insurance 

schemes that provide supplementary cover mainly for 

hospital care. 

The second element of the institutional care system comprises hostels, which provide personal care 

and social support but not nursing services. In 1985, 

there were 34,885 hostel places, aratioof 33 places per 

1,000 persons 70 years of age and over. 

There is considerable variability among the Australian States in the overall level of institutional care, 

in the balance between nursing home and hostel provision, and in the share of beds in the private for-profit, 

voluntary nonprofit, and public sectors. The extent of 

variability in Federal funding among set tars and among 

States has also been considerable (2,3). Inequities 

arising from these variations constituted one of the 

main grounds for recent reforms. 

Policy context 

While demographic trends are commonly seen as 

prompting greater attention to issues of aged care on 

the part of policymakers, service providers, and researchers, initial policy attention predates the emergence of pronounced population aging. The Care of 

the Aged Report (4), presented in 1975, was prompted 

by the political climate of the early 1970’s, which saw 

major reviews and reforms in Australia’s health and 

welfare system. Since then, a series of policy reviews 

were mounted to address concerns about unsatisfactory outcomes of programs providing long-term care, 

despite rapid growth of expenditure. A full account of 

the development of policy on nursing homes in Australia (5) demonstrates that shifts in policy concerns 

have reflected the interplay among political, bureaucratic, provider, and public interests, with formal 

reports of policy reviews documenting the pressures 

for change and responses that were forthcoming at 

different periods. 

It was one of these reports, of the House of Representatives Standing Committee on Expenditure Inquiry into Home Care and Accommodation for the 

Aged (6), that presaged the framework for reform that 

was adopted by theLabor Government, which came to 

176 

office in early : 983. Added impetus for reform came 

from a report of a Senate Select Committee Inquiry 

into Private Nursing Homes (7), which was tabled in 

1985. In response to the Senate report, a strategy for 

restructuring the long-term care system was set out in 

the Nursing Homes and Hostels Review (8), which 

reported in early 1986. 

Restructuring is now in progress, with a series of 

measures being implemented to achieve clearly defined goals over a lo-year period. Principal among 

these measures are the following: 

Assessmen: for all those seeking admission to 

nursing home care by multidisciplinary Geriatric 

Assessmen; Teams (GAT’s), which are able to 

make recommendations on a range of care options 

to meet individual needs, including referral to 

rehabilitation and community care services. 

Guidelines for assessment have been published 

(9) and teams have been established nationwide 

under the Cleriatric Assessment Program. 

Changes ir program structure in regard to the 

relative roles of nursing homes and hostels, with 

the former directed to the needs of highly dependent aged people and the latter directed to those 

needing moderate levels of assistance (10,ll); 

expansion of home and community care services 

and housing programs were further means of 

achieving J better balance between needs and 

services (1 Z-1 4). 

Control of growth of residential care to maintain 

an overall provision of 100 places per 1,000 persons 70 ye;us of age and over (to be distributed 

between 40 nursing home beds and 60 hostel 

places) and to achieve greater equity in regional 

distributior . 

Innovative programs to address the needs of special groups. notably dementia sufferers, the ethnic 

aged and A.boriginals, and the aged in rural and 

remote areas. 

Standards of care to be defined with a view to 

developing a more effective system for the determinatiora and enforcement of outcome standards (15) and protection of residents’ rights (16). 

Recurrent f unding of benefits to move from a costreimbursement basis to a system based on standard 
infrastructure costs and variable care costs related

to resident dependency and care needs (17).

c Capital funding to be directed to special needs

groups, as noted above, and high-need areas.

In summary, policy initiatives aimed at controllingandredirecting institutionalcareare complemented

by expansion anddiversificationof home and community care services, with assessment providing the key

means of matching services to the needs of individuals, These sepwate measures are being pursued within

an overall policy philosophy that isseeking to optimize

the independence of frail older people by enabling

them to choose the most appropriate options to meet

their needs. That the outcomes being sought will

require attitudinal change as well as structural adjustments in the institutional system is perhaps best

signified by references to “patients in institutional

care” being replaced with “residents in residential

care.”

Research context

Research has become increasingly closely linked

to policy development in long-term care, not least

because policymakers have had to commission research to provide an empirical basis to inform their

deliberations. Applied studies in long-term care have

been a significant component of research in aging in

Australia (18), and four phases of research development can be identified from the mid- 1970’s to the

present, as shown in table A.

lnitialsumgs—The initial dearth of data on longterm care was such that in the mid-1970’s basic

information such as the age distribution of nursing

home residents was not known. A 1976 report of a

census made in New South Wales (NSW) (19) gave

some indications that the profile ofresidents was more

variable than had been assumed and that some of this

variation could be attributed to the level of provision

of and interaction with other services, notably longterm psychiatric facilities. A 1978 census of nursing

homes in Melbourne (20), which largely followed the

format of the NSW survey, found that the Victoria

nursing home population differed considerably from

that in NSW, prompting questions about relationships

between the structure of provision and characteristics

of the resident population.

Table A. Development of research into long-term

institutional care in Australia

TimesDan Research development

Mid-1970’s ● Not even age distribution of nursing

home residents known.

● Initial censuses in New South Wales

and Victoria.

1980-82 ● Series of separate surveys of resident

characteristics carried out by State

health authorities.

● Only item collected in standard was

sex: Male or female.

1983-85 ● More sophisticated measurement and

classification of dependency.

● Comparative analysis using combinational method.

1988-present ● Research into dynamics and

outcomes:

Utilization (individual nursing

home)—length of stay,

turnover, access, seasonality,

longitudinal trends in dependency profiles.

Care (nursing home system)—

standards, staffing, quality of life,

regulation.

State surveys andcomparisons-The early 1980’s

saw a number of basic census-type surveys carried out

by State health authorities. These accounts of the

demographic profile of residents of nursing homes

showed the significance of social support factors,

indicated by marital status and sex ratios of residents.

The data collected in these separate surveys were used

in a comparative analysis of nursing home populations

made in 1983–85 (21).This study sought to investigate

the consequences of interstate differences in the provision of nursing homes for the composition of the

resident population. In particular, it was concerned to

examine the effect of higher levels of provision on the

dependency profile of the resident population and on

variations in rates of admission among the total aged

population for demographic subgroups defined by age

and sex.

The comparative analysis dealt with two methodological issues arising from these surveys. First,

a regrettable feature of the basic surveys was the lack

of comparability or standardization in most of the

items collected, the only item collected in a standard

way in six different surveys was recording of sex as

male or female. Reconciliation of the definitions and

177
categories adopted enabled satisfactory comparison

of key variables, but the need for more systematic

approaches to data collection was made readily apparent. Second, some attention was given to the development of descriptive classifications using combinations of key variables (22). This approach proved

particularly useful forhandlingdata sets characterized

by presence-absence measures on a small number of

basic variables for large populations. An example of

the application of this method is given below in

presenting some key findings of long-term care research. A further important achievement of this

comparative study that has yet to be realized is that it

provides a baseline for tracing subsequent change in

the aged care system.

Understanding of utilization and outcomes of

long-term care was also advanced at this time

through analysis of other secondary data sets. Analysis of longitudinal data on separations produced a

different account of length of stay than that based

only on cross-sectional data (23), and analysis of

death records challenged the view that the majority

of the elderly would end their days in long-term

care (24).

Policy-oriented research—Progressin the measurement and analysis of different aspects of the

long-term care system advanced from the mid-1980’s

through research commissioned by the Federal

Government. Major consultancies investigated

relationships among dependency, staffing levels,

and quality of care in both nursing homes (25) and

hostels (26). The nursing home study was followed

by the development of a five-tier classification of

resident dependency that provided the basis of new

arrangements for payment of nursing home benefits

(17). Federal funding of pilot Geriatric Assessment

Teams also supported monitoring and evaluation

studies to be built on a standard data collection

system (9).

Currentinvestigations—1’wostrands of research

now in progress are directed to examining outcomes of

long-term care. Analyses of the dynamics of utilization of the long-term care system are concerned with:

● Changesin length of stay and resident turnover.

● The effects of short-term and seasonal fluctuations

as compared to longer term tnmds in

rates.

‘ Long-term shifts in the dependency

resident populations.

Analyses of standards are investigating:

“ Standards of care.

admission

profile of

● Aspects of staffing, particularly staff turnover asit

affects the standards of care.

“ Issues of quality of care and quality of life.

These studies are being carried out at varying levels of

analysis, ranging from individual nursing homes to

the aggregate nursing home system. An intermediate

level of analysis in which nursing homes are grouped

on the basis of variables expected to influence outcomes, such as size of home, ownership, and funding,

should facilitate explanation of variations found at the

system-wide level.

Current research is able to draw on a number of

administrative systems set up in conjunction with the

implementation of various policy measures. Evidence

of the advances in data bases becoming available over

the decade is seen in an account of nursing homes and

their residents published.by the Department of Community Services and Health in 1988 (27), which drew

on the NH5-Application for Admission form for data

on admissions and the NH3-Claim for Commonwealth Benefits form for turnover data. A further

account to be released in mid- 1990 (28) is to include

data on dependency from the resident classification

instrument (RCI). A standard minimum data set

(MDS) being collected by all GAT’s will provide information on clients presenting for assessment and

outcomes. Information on standards of care will shortly

be available from two sources, the formal schedules

used by the Standards Monitoring Teams to monitor

compliance with outcome standards, and returns from

complaints units.

There is still scope for further development in two

areas. First, moves are under way to standardize reporting across all long-term residential care services

and to provide statistics comparable to acute care data

bases (29). Second, the development and application

of more sophisticated analytic techniques, including

time-series analysis and disaggregation of the total

nursing home population, need to be pursued.

178
The aged care system study

Research to monitor the operation and impact of

GAT’s began in late 1984, when a number of GAT’s

received Federal funding on a pilot basis. A group of

researchers were identified in each State as the State

Evaluation Unit, to work in conjunction with the

GAT’s and the relevant Commonwealth and State

departments on the development of a research program. In Victoria, the group nominated as the State

Evaluation Unit had carried out several studies that

provided relevant background to the monitoring of the

GAT’s, and after preliminary work with the pilot

teams, the research program was consolidated in mid1987 as the Aged Care System Study (ACSS).

Systems framework

As assessment for admission to nursing home care

is a central element in the restructuring of the aged care

system, GAT’sare the central focus of the ACSS. The

GAT’s can be seen as a valve controlling flows of

older people between different services in the care

system. The aged population makes up the content of

the system, and relationships between the service

components are conceptualized in a systems framework as a set of “stocks” and “flows,” with changes in

the stocks of residential and community services engendering and in turn responding to changes in the

flows between the service components.

Itis expected that while some of these changes will

be evident in the short term, 1–2 years, others will

emerge only in the medium to longer term, 5-10 years.

The speed with which the different parts of the system

adjust is itself an area of interest, as are blockages or

barriers in the system that cause delays in adjustment

or backlogs—for example, in the form of waiting lists

for services that are inadequately available to meet

need.

The aims of the ACSS are to provide baseline data

on the system at the beginning ofrestructuring, to trace

changes associated with the implementation of various policy measures, and to examine outcomes for

clients moving through the system and also in terms of

adjustments in the various service components. The

“audience” for the ACSS is firstly the GAT’s and

other health care providers who are the participants in

the project, secondly the Commonwealth and State

Governments, and thirdly the wider academic research and gerontological communities.

Data sources

The range of research encompassed in the ACSS

is achievable only through the use of a number of

secondary data sources, with only limited primary

data collection to be undertaken. The basic requirement of the monitoring of the GAT’s set down by the

Commonwealth was the collection of a common minimum data set. The development of the content of the

MDS was discussed with the GAT’s to maximize

compatibility with their normal recording practices,

and a trial collection period was instituted with the

four pilot teams. This MDS was adopted by the additional teams as they came on stream with the expansion of the Geriatric Assessment Program. All 17

GAT’s have been collecting the M.DS since early

1987, and the data are forwaxded to the Evaluation

Unit for analysis. The M.DShas yielded a substantial

data base of high-quality data, with some 10,000

clients covered in each of five 6-month reporting

periods to the end of 1990. Comparable data are also

collected in other States.

The 15 items of the MDS are collected for all

clients presenting to the GAT and cover demographic

data (age, sex, marital status, country of birth, and

functional knowledge of English), date of assessment

and discharge from the team, whether a first assessment orreassessment, source of and reason for referral,

usual living arrangements and location at assessment,

use of community services, and recommended care

plan. While each GAT collects disability and diagnosis data, it has proved difficult to arrive at a recording

system that is acceptable to all teams. Further work in

this area is ongoing.

The structure of the MDS makes it possible to

compare the GAT clients with populations covered by

a number of other data sources, ranging from census

and other surveys of the Australian Bureau of Statistics to information systems generated in other parts of

the health care system. The secondary sources used in

various parts of the ACSS are detailed below, and the

areas in which primary data collection was undertaken

are also noted.

179
Structure of the study

The six components of the study are:

● Population studies aim to describe the population

from which clients are drawn into the service

system. Demographic studies have made extensive

use of census data, Australia having a complete

census conducted every 5 years (30). Particular

attention has been given to the very old population

(31–33) andtopopulation change at the local level

(34).Otherhigh-riskgroupshavebeeninvestigated.

For example, a study of tenants of public housing

drew upon records held by the housing authority of

transfers out of public housing to other forms of

accommodation (35).Following on earlier analyses

of data collected in the 1981Handicapped Persons’

Survey (36,37), further epidemiological work is

using data collected in the 1988 Ageing and Disability Survey carried out by the Australian Bureau

of Statistics (38).

● Following on from earlier work that has indicated

the importance of acute care as a precipitator of

admission to nursing home care, investigations are

being made of the use of acute care by the elderly.

The characteristics of long-stay aged patients,

their utilization patterns, and eventual outcomes

have been of particular interest. The Patient Reporting System, a comprehensive data base covering Victoria’s public hospital system, has been

used for these studies (39,40). A detailed study of

the interaction between the GAT and acute care

hospitals has been made in one region (41).

● The regional GAT’s are the core of the ACSS, and

the MDS generated by the GAT’s is the core data

base. Basic analyses of the MDS are prepared to

show client flows and outcomes for the 17GAT’s,

and more advanced analyses are carried out to

investigate relationships between these key variables (42,43). In order to explain some of the

variations among the GAT’s stemming from differencesinregionalpopulations, team settings and

staffing, and local service provision, additional

data arecollectedon these areas, again using either

census data or information held by the GAT’s.

Followup studies of clients recommended for different care plans have recently been instituted.

Independent research by one of the GAT’s has

monitored the operation of a placement system for

clients assessed as needing nursing home care (44)

and investigated factors accounting for variations

in waiting time to placement (45,46).

● Dynamics and standards of residential care are

under investigation through studies using avariety

of data bases. Early modeling of the dynamics of

the system (47), a baseline study of turnover (48),

and a comparative study of access to nursing home

care using data from Australia, the United States,

and Canada (49) can be extended to time-series

analysis as further data on turnover are generated

by administrative systems. The purpose of this

work isto differentiate short-term fluctuations due

to factors such asseasonalityfromlong-termtrends

in turnover due to the impact of assessment and

changes in the resident dependency profile. Approaches to regulating quality of care in Australia

and the United States have been reviewed (50),

and a method of measuring quality of care has

been developed using population norms for various dependency and care-related outcomes (51).

Several aspects of nursing home staffing are seen

to be closely related to standards of care (52), and

studies have been made of staff turnover and

satisfaction (53,54). Surveys to collect data on

factors affecting staff turnover, with followup

over a 12-month period, were the main primary

data collection exercise of the ACSS.

o Research into the dynamics and standards of community care has so far provided background information for developing new empirical studies. A

review of a number of surveys of use of community care services identified the impact of methodological considerations on the findings (55), and

interstate variations in funding and provision have

been examined (56).Theestablishmentofanational

data base on services provided through the Home

and Community Care Program by the Commonwealth Department of Community Services and

Health will enable further work in this area, including the development of benchmarks forservice

provision.

● Recognizing that the kinds of information available and the methods used to analyze it will affect

180
the findings obtained, the final part of the ACSS is

concerned with reviewing andrefiiningdata sources

and research methodologies appropriate to longterm care. Issues range from overall research design to specific measurement questions-for example, how to measure length of stay and turnover

in nursing homes-for a single home and for

system-wide measures. Some attention is being

given to the development of an inventory of

Australian data bases on long-term care.

Key findings on residential care

Significant findings of the ACSS and the earlier

studies on which it has built can be presented in six

main areas of research into residential care. As well as

reporting substantive findings of relevance to longterm residential care in Australia, each of these areas

has involved consideration of some methodological

issues.

Description of resident population by

dependency groups

Adequate description of the population resident in

long-term care institutions is a very basic and necessary starting point for the examination of outcomes.

Dependency profiles of resident populations were

compiled using datafiom the surveys conducted in the

early 1980’s, following the combinational method

developedbyHowe andFreston (21). Briefly, dependencies in mobility, continence, and mental impairment were coded 1/0, 2/0, and 4/0 in turn for presence/

absence according to set criteria and when summed,

unique scoresresult to define eight groups covering all

possible combinations of dependencies. While the

+ classification of the three variables loses a degree of

detail, this method of description has several advantages: It has enabled data from several different surveys to be reconciled in a consistent mannev it is

economical in data, focusing on crucird distinctions in

key characteristics; the computation required to derive the groups is extremely simple; and the combination ofvariables in the groupings captures something

of the interactive effects of multiple handicaps.

A summary of the Victorian and Tasmanian residential care populations described by this combinational method is set out in table B; these States have

been selected as data were collected using the same

survey schedule. The data presented on each of the

three variables separately suggest that the Tasmanian

population is less dependent than the Victorian, but a

much clearer indication of the extent of potentially

inappropriate residential care is given by the distribution of the population over the eight dependency

groups. Fully 30 percent of the Tasmanian population

were not dependent in any of the three key areas, and

only 21 percent were dependent in all three; the

respective proportions for Victoria were 11 percent

and 43 percent. Considerable variations were also

found in the dependency distributions in the other

States.

Relationship between level of bed provision

and dependency profile

As the level of nursing home provision varies

considerably among the States, a major question was

to determine whether these differences reflected

variations in population dependency characteristics or

Table B. Percentand percent distributionof residential care population by dependency profile: Victoria

and Tasmania, Australia

Dependency profile Victoria Tasmania

Individualdependency

Nonambulant . . . . . . . . . . .

Incontinent . . . . . . . . . . . . .

Confused . . . . . . . . . . . . . .

Combination of

dependencies

Total . . . . . . . . . . . . . . . . . .

Ambulant:

Continent:

Not confused . . . . . . .

Confused . . . . . . . . . .

Incontinent:

Not confused . . . . . . .

Confused . . . . . . . . . .

Nonambulant:

Continent:

Not confused . . . . . . .

Confused . . . . . . . . . .

Incontinent:

Not confused . . . . . . .

Confused . . . . . . . . . .

Percent

79 56

61 39

58 39

Percent distribution

100 100

11 30

5 7

2

4 :

16 17

7 7

13 . 11

43 21

NOTE: Percent distributions may not add to 100 because of

rounding.

181
whether the level of provision influenced the resident

dependency profile. An analysis of the prevalence of

disability in the aged population carried out as part of

this study found no differences among the States (36);

hence any variation in resident dependency profiles

could not be attributed to underlying differences in

disability.

Overall, an inverse relationship was found between the level of bed provision and the proportion of

beds occupied byhigh-dependency residents. Victoria,

the State with the lowest provision, had the highest

proportion of beds oecupiedbyhigh-dependency residents, while Tasmania, with the second highest provision of the six States, had a higher proportion of

residents in the lowest dependency group. This pattern

was generally consistent across the remaining States.

Rates of institutional residence per 1,000 for population groups defined by sex and age (under and over 80

years) were also calculated foreachdependency group.

It was found that while these rates were relatively

constant for the high-dependent y groups, rates for

low-dependency groups tended to increase with rising

bed provision.

Three main conclusions were drawn from the

study. First, dependency profiles of nursing home

residents reflect the sensitivity of admission rates

for different population groups to the level of bed

provision. Second, the relatively constant rate of admission of high-dependency residents to institutional

care suggests that even in the States with lower bed

provision, that level is adequate to meet the needs of

such people seeking nursing home admission. Third,

where bed provision is in excess of this level, beds

must be filled by individuals of lower dependency,

since the “supply” of high-dependency residents has

been exhausted.

The main policy implications arising from these

findings were that limiting the number of nursing

home beds would tend to exclude low-dependency

residents, that the level of provision even in the lowbed States appeared sufficient to meet the needs of

high-dependency residents, and that with control of

bed growth, thedependencyprofile might be expected

to converge toward that of the lower bed States as bed

ratios elsewhere were reduced over time. Establishing

these relationships laid some of the foundation for the

measures for restructuring long-term care instituted

through the Nursing Homes and Hostels Review,

which was to restructure residential long-term care.

Length of stay

Analysis of data on length of stay of nursing home

residents in Australia, as in the United States, has

dispelled the myth that the typical stay is a long one,

up to 2 years, ending only in death. This correction has

come about by adjusting the picture of stays based on

cross-sectional data on the duration of stay of current

residents with analyses of data on separations over a

period of time. The extent of underrepresentation of

short stays in cross-sectional data is shown in an

analysis of NSW data (22): The proportion of stays of

less than 2 months shifted from only 9 percent for

inpatients at a given date to 49 percent of separations

over a year in NSW (22).

Short stays in Australian nursing homes are not,

however, a product of reimbursement arrangements,

asin the United States, and further research isrequired

to differentiate short-stay and long-stay residents. To

the extent that high-dependency residents can be expected to have shorter stays, changes in the dependency profile of residents can be expected to result in

more short stays, with consequences for turnover and

access to beds.

Analyzing access to long-term care

The preceding findings have been combined in analyzing access to nursing home care (48). Recognizing

that access will depend not only on the number of beds

available but also on the rate of turnover in those beds,

nine different approaches to measuring aspects of utilization of long-term care we~ canvassed. An accessibility index was derived by multiplying average bed provision in a defined region by average annual turnover,

The index obtained shows the number of admissionsto

available beds occurring per 1,000 aged persons in the

region. Results for three Australian States set out in

table C show that the interaction of bed numbers and

turnover results in differences in access to care that are

not evident from figures on bed provision alone. Other

outcomes examined were the proportion of residents

with short,medium, and long stays and theproportion of

separations in each of these categories due to death,

The study pointed to the powerful distributional

effects that could be exerted on the nursing home

182
Table C. Outcome measures for nursing homes:

Victoria, Tasmania, and New South Waies, Austraiia,

1985

New

South

Outcome measure Wctorja Tasmanja Wales

Totai beds per 1,000

persons 70 years of age Number

Andover . . . . . . . . . . . . . . . 55 77 78

Length of stay Percentdistribution

Less than 2 months . . . . . . . 36 --- 50

2-12months . . . . . . . . . . . . . 28 --- 26

More than 12 months . . . . . . 36 --- 26

Proportion of separations

due to death Percent

Aii lengths of stay . . . . . . . . . 57 --- 57

Less than 2 months . . . . . . . 25 --- 25

2-12 months ... ,.. ,

More than 12 months

Accessibility

Annuai turnover . . . .

Accessibility index . .

. . . . . . 55 --- 41

. . . . . . 80 --- 59

. . . . . . 36 56 80

Index

. . . . . . 31 43 62

NOTE:Figureshavebeen recalculated from previous

published data to standardize for bed ratio per 1,000 persons

70 years of age and over. Percent distributions may not add to

100 because of rounding.

system by using assessment and reimbursement arrangements to influence the kinds of residents who

gain access to long-term care. The accessibility index

provides a quantitative measure of outcomes of policies aimed at changing utilization, although it remains

to be judged whether increased access for more shortstay residents, achieved by higher turnover, is a “better” outcome than other uses of nursing home beds.

The potential for changing access to long-term

care was demonstrated in modeling of the nursing

home system, taking into account not only growth in

the number of beds but also the distribution of admissions between short- and long-stay residents and

the rate of turnover among long-stay residents (46).

Thus, even with constant bed provision, an increase in

the proportion of admissions who were short-stay

residents from 30 to 50 percent would increase turnover and access by almost 30 percent. Assessment and

community care were seen as means of achieving

these outcomes insofar as they could furestall admission of low-dependency individuals who would otherwise become long-stay residents. Modeling of this

kind provides a means of specifying alternative outcomes for the long-term care system and points to the

measures required to achieve them.

Short-term and long-term changes

While little is known so far about the time scale

over which adjustments in the nursing home care

system can be expected to come about, it isrecognized

that the period over which measurement is made will

influence the results observed. In attempting to evaluate the impact of GAT’s on rates of admission to

nursing homes, it is particukrly important to separate

short-term fluctuations due to otherfactors from longer

term trends that can be attributed to assessment or

other policy measures (56). Seasonality in death rates

is the principal factor producing short-term changes in

nursing home separations: A late winter peak has been

observed, with separations in these months being 30-

percent higher than in the midsummer months. The

converse of these fluctuations is the emergence of

queues over the summer months in the placement

systems operated by GAT’s, and unless there is an

awareness of the underlying seasonal factors, the

effectiveness of GAT’s may be called into question.

Measurement of long-term trends in turnover and

access will need to take these short-term fluctuations

into account and require measurement over a sufficient timespan for real trends to become evident (57).

Standards of care

An approach to monitoring standards of care in

residential care was developed by Phillips (51). Population norms for prevalence of key indicators such as

contractures, decubiti, and restraints were calculated

and adjusted for case mix based on activities of daily

living categories and demographic variables. Differences between predicted and observed prevalence

were then interpreted asindicators of quality of care in

individual homes. This developmental project, supported by a Gerontological Society of America fellowship, yielded results that were promising not only

for application in the Rhode Island Department of

Health, where the work was carried out, but also for

use with other suitable data sets generated by standards monitoring systems in Australia.

183
Issues for development

Beyond consolidation of research activities already in progress, three areas can be identified as

warranting further development, particularly in the

context of international collaborating research.

First, a number of issues of data collection and

methodology need to be addressed, with particular

attention given to standardization in line with World

Health Organization and other conventions. The work

of theU. S. Panel on Statistics for an Aging Population

(58) provides a model. An additional requirement is

the disaggregation of large data bases into (a) meaningful subpopulations defined in terms of variables

that are significantly related to outcomes and (b)

geographic scales relevant to service planning. These

advances are necessary if the impacts of interventions

on risks of institutionalization are to be properly

measured in local areas. Given that such risk is highly

dependent on the structure of local long-term care

provision, national averages, which may apply nowhere in particular, are of little relevance to this

measurement task, more attention needs to be given to

such local variability than has occurred to date.

Such information would have been useful in setting the context of the various channeling and casemanagement demonstration projects mounted across

the United States with the objective of reducing institutionalization. The evaluation of these projects generally reported inconclusive findings (59), yet without

an indication of the likely risk of admission to care and

with its variation from one project locality to another,

it is impossible to establish the margin of impact

required. Further, aggregate comparisons of experimental and control groups may obscure marked differences between subgroups and fail to distinguish

between individuals for whom successful outcomes

may have been achieved and those for whom no

amount of help would have prevented admission.

Such differentiation is essential if community care

programs are to be efficiently targeted. Where the

phenomenon under consideration has averylowprobability overall, with wide differences depending on

individual characteristics, as is the case for institutional admission, the failure to measure significant

outcomes in randomized control studies maybe a fault

of research design as much as a failure of the projects

themselves. The need for careful consideration of

these andothermethcxlologicalissueshasbeen flagged

in the development of a strategy to evaluate the Community Options Projects now being established in

Australia (60).

Second, quality of care and outcome standards are

identified policy priorities in Australia that need supporting research. Recentresearchin Israel (61)provides

a framework for complementary lines of investigation

that can be built on databases now becoming available

in Australia. The RCI data might be used to develop

the quantitative population norms approach to monitoring, with qualitative information from the Standards

Monitoring Teams providing complementary measures

of standards for individual homes and the system of

residential care overall. Complaints units now being

established will add further data on standards. Finally,

search conference and focus group techniques might

be used with groups of residents, relatives, direct-care

staff, administrators, and community. representatives

to canvass their different perspectives on quality of

care. The combination of these approaches should

leadtotheidentification of homesthat achieve preferred

outcomes, the factors contributing to them, and ways

in which they might be more widely promoted in the

long-term care system.

Finally, comparative studies of the long-term care

systems in Australia and the United States (62) and the

United Kingdom (63) suggest several lines for future

research. Most of the differences found between national systems have been attributed to funding and

other administrative arrangements that reflect major

differences in policy orientation. As it might be expected that recent initiatives in one system will give

some indications ofpotential changes elsewhere, some

areas are noted as of interest for more detailed comparative study. Replication studies will be useful in

showing where variations in outcomes arise from

differences in the structure of the aged care system or

from differences in the populations under study. Thus,

studies of the oldest old in the United States (64)

provided a framework for analysis of census data and

other sources on information on this cohort in Australia (31–33). Additionally, the kinds of incentives and

outcomes generated by different reimbursement systems in the United States (65) demonstrate some of the

effects that might eventuate from recent funding

184
changes in Australia that separate the costs of patientrelated and non-patient-related services. Moreover,

the changing care needs of long-term care clients,

particularly in relation to changes in acute hospital

care occurring in response to implementation of

diagnosis-related groups in th~+Jnited States (66),

may foreshadow similar trends m Australia.

Research in residential Iong-termcarein Australia

has made considerable advances since the early interest shown in the 1970’s, and therapidchanges currently

occurring make monitoring and evaluation research

an essential adjunct to policy development. Participation in the International Collaborative Effort on Outcomes of Institutional Long-Term Care thus offers a

timely opportunity for the further development of this

research.

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Howe AL, Sharwood P. Present and potential roles of

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triennial review of the Home and Community Care

Program. Final report. Canberra: Australian GovernmentPublishing Service. 1988.

Auditor General. Efficiency audit report: Department

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nance and Public Administration. There’s no place like

home: A review of an efficiency audit of the Department of Community Services and Health: Home and

Community Care Program. Canberra: Australian Government Publishing Service. 1989.

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Publishing Service. 1987.

Ronalds C. Residents’ rights in nursing homes and

hostels. Final report. Canberra: Australian GovernmentPublishing Service. 1989.

Commonwealth State Working Party onNursingHome

Standards. Fhd report. Canberra: Commonwealth

Department of Community Services and Health. 1988.

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homes in New South Wales. Sydney: Health Commission of New South Wales. 1976.

Howe AL. Report of a survey of nursing homes in

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An electronic social atlas. Melbourne: National Research Institute for Gerontology and Geriatric Medicine, 1987.

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Part 1:Demographictrends andprofile of the population aged 80 years and over. J Aust Popul Assoc

5(1):82-99. 1988.

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Part 2: Healthstatus and trendsof the populationaged

80yearsandover.JAustPopul Assoc6(1):18–38.1989.

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187
Chapter 21

Long-term care in the

United States: Issues in

measuring nursing home

outcomes

by Joan F. Van Nostrand, M.P.A., Coordinator

of Data on Aging, National Center for Health

Statistics

The purpose of this presentation is to explore

several research issues in measuring nursing home

outcomes within the context of long-term care (LTC)

in the United States. My approach to this topic has four

segments:

To describe briefly the provision of nursing home

care in the United States to enable comparisons to

the presentations about LTC in Australia and

Canada.

To identify some of the salient data on nursing

home outcomes available from the National Center

for Health Statistics (NCHS).

To develop a framework for studying outcomes

using this NCHS data base.

To present some examples of measurement issues

on outcomes of nursing home care as potential

research topics for international collaboration.

Note that the title of this presentation equatesLTC

in the United States with nursing home care. This is not

an attempt at poetic license. The bulk of LTC in the

United States is provided in nursing homes. This

institutional bias exists for two reasons:

● Nursing home care is a benefit of government

health programs, in particular Medicaid and, to a

lesser extent, Medicare.

● The supply of substitute LTC services-that is,

home health, adult day care, and hospice—is

limited. In many geographic areas, it is virtually

nonexistent.

Institutional LTC in the United States is provided in

places generally called nursing homes or, sometimes,

personal care homes. They are defined in a broad way

as institutions providing rehabilitation, nursing care,

or personal care. The clients are persons who require

institutional services below the level of hospitals and

above the level of room and board. It is a slippery

definition, difficult to pin down in specifics.

Nursing home care in the United States is of

particular relevance to the care of older persons. The

oldest old are the greatest users. In 1985,22 percent of

those 85 years of age and over were nursing home

residents (l). In that year, there were 1.6 million

nursing home beds—more beds than in the acute care

hospital sector. The oldest old are the most rapidly

growing segment of the older population in the United

States, as they are in most developed countries.

Therefore, the heavy use of nursing home care by the

oldest old has major implications for the future of the

Nation as a whole as well asfor the individual nursing

home resident.

For the Nation as a whole, costs of care are a

growing concern. About 8 percent of the health care

dollar in the United States is spent on nursing home

care. Nursing home care ranks as the third largest

healthcareexpenditure afterhospitalcare andphysician

services (2). Half of the cost of nursing home care is

paid by the government, mainly through the Medicaid

program.

For the individual nursing home resident, the

impact of nursing home care can be devastating in two

ways. One impact is the loss of independence and

autonomy. Decisions about everyday life—when to

get up, when to eat, what to eat—are no longer made

by the individual but by the administrator and staff of

the nursing home. The second negative impact is

impoverishment, often referred to as “spenddown.”

189
Thatisthetermused todesignatetheprocess by which

persons deplete their assets in paying for care to such

an extent that they qualify for Medicaid, i.e., the

government health care program for those who meet

welfare criteria. Spenddown is not an isolated phenomenon. Of persons discharged after at least a 6-

month nursing home stay, 23 percent “spent down” so

that Medicaid was the major payer at discharge (3). In

summary, the bulk of LTC in the United States is

provided in nursing homes. The heaviest users are the

oldest old, who may face impoverishment in paying

for care after a prolonged stay.

Now I would like to turn to the second segment of

my presentation, namely, the identification of some of

the salient data onnursinghome outcomes as collected

by NCHS. The source of the data is the National

Nursing Home Survey (NNHS), which was initiated

in the early 1970’s. It is conducted periodically, most

recently in 1985 (l). Data about a nationally representative sample of nursing homes, their residents,

and discharges are collected from facilities’ records

and staff. The data about residents provide a crosssectional profile of the population in nursing homes on

any given day. NNHS is a rich source of information

about residents because the data from each nursing

home’s records are augmented by the knowledge of

the nursing home staff. The data about discharges, in

contrast, represent discharge events that occurred in

the 12 months prior to the survey. In comparison to

data about residents, the amount of data about the

characteristics and outcomes of discharges is limited.

This is because the nursing home records are the only

source of information. Available data focus on basic

transitions in health and functioning and on outcomes

of care. Serious gaps in data about outcomes and

nursing home quality have been identified, and remedies have been proposed (4). Data about the characteristics ofresidents and discharges prior to admission

were collected via telephone calls to the next-of-kin.

The availability of national data on nursing home

discharges isrelativelyrecent. Data were first collected

in NNHS in 1977. The 1977 data on discharges (5)

dispelled some negative myths about nursing home

outcome. The prevailing myth about nursing home

care was that most olderpersons were discharged dead

after very long stays. According to the 1977 data, 72

percent of older persons were discharged alive. Furthermore, one-third of the discharges stayed 1month

or less, and the median stay was about 82 days. These

data dispelled the notion that negative outcomes were

inevitable and turned attention toward positive outcomes of nursing home care.

There isthe potential to use two other data systems

from NCHS to learn more about outcomes after discharge. One system is the National Death Index. It can

provide data on whether the death of a discharge in the

NNHS sample occurred, when it occurred, and the

cause. The second system isthe followup survey ofthe

1985NNHS resident and discharge samples. Followup

was conducted in 1987, again in 1988, and is planned

for 1990. Data about the discharge sample collected at

the time of followup included information on nursing

home and hospital stays subsequent to the 1984-85

discharge event.

I would like to turn now to the third segment of my

paper and present a framework that uses NNHS for

studying outcomes. The framework borrows from the

epidemiologic model in that it addresses risk factors

and outcomes. It also borrows from Donabedian’s

work (6)in assessingquality in relation to the following

concepts:

●

●

●

Structure-the personnel, facilities, and medical

technologies of the health care system and its

components.

Process—what and how services are delivered to

the individual patient.

Outcome—the impact of the structure and process

of health care on health status.

Figure 1 presents my conceptual framework for

addressing measurement issues of nursing home outcomes. It is a systems approach and emphasizes the

relationship among itsmajor components: Risk factors,

nursing home structure and services, and outcomes,

Note themultidimensional nature ofeachofthemodel’s

components. The model deals not with one risk factor

or one outcome but with various risk factors and

several outcomes. The small blocks within the larger

cube emphasize the interaction among the individual

dimensions of each of the components.

Figure 2 shows a detailed example of the framework with specific variables from the 1985 NNHS.

190
structures and services

Figure 1. Conceptual framework for measuring nursing home outcomes

Note that the risk factors go beyond the biological

processes of an epidemiologic model to include

psychosoeialvariables and functioning. Note also that

this detailed model does not include specific services.

This reflects the fact that service data, although important to the conceptual model, are minimal in the

1985 NNHS. Some of the outcomes, such as functioninganddeath, are sirnilartothose intheDonabedian

model of quality. Other outcomes, such as subsequent

need for care and the length ofstay, have been included

because they are of particularrelevance to the delivery

of nursing home care.

I would now like to turn to the fourth and finzd

segment of my presentation. Using this model as

background, I will present two proposals concerning

the measurement of outcomes that could be possible

topics for international research. My proposals are

intended to stimulate discussion in the workshop on

nursing home outcomes and to contribute to the development of a plan (see chapter 34) for collaborative

measurement research.

One possible topic forcollaborativeresearch isthe

measurement of functioning as an outcome. There are

two central measurement issues here. One is the valid

assessment of functioning when facility policies direct

staff to provide assistance regardless of whether it is

needed. This issue was highlighted in the pretest to the

1985 NNHS. There were major differences between

the report of patient functioning made by the family

prior to admission and that made by the nursing staff

immediately after admission. The next-of-kin generaIIyreported better functioning of the patient than did

the nursing home staff.

In some cases, these differences are possible.

Some catastrophic events, such as stroke or hip fracture, could have caused a major reduction in functioning between the two points in time. However, this

situation would account for only a small number of the

191
‘eocare aod,or~

ce~ification

Wicaid

%d~~e

~e~efof care ‘egist@r@dour8e8 ‘erbobed~

structures and services

Prior need for care

Prior state of health

Informal sup~rt

Functioning

Chronic conditions

Mental status

Figure2. Detailedframeworkfor measuringnursinghomeoutcomesusing NationalNursingHomeSurvey

variables

cases. One hypothesis to explain this discrepancy is

the impact of nursinghomepolicy. ManyU. S. nursing

homes have a policy to provide assistance, particularly in bathing and in walking, regardless of whether

it is needed. It is a double-sided protection. It is

intended to protect the patient horn falling and the

facility from being sued in the case of a patient injury

due to a fall. The measurement question associated

with this situation is how to determine the valid

functioning of the patient when facility policy requires

that assistance be provided. Possible solutions to research are to rely on next-of-kin reports or to ask staff

to report the patient’s capacity rather than actual

performance.

The second measurement issue concerning functioning focuses on transitions. If measurement research is to assist in improving nursing home outcomes, then an important issue is determining which

transitions in functioning are positive and should be

replicated and which are negative and should be reduced. Table A shows transitions between admission

and discharge in the two activities of daily living

(ADL’s) available from the 1985 NNHS, walking and

incontinence. The outcomes on the diagonal of the

matrix were easy to classify as stable because no

change in ADL’s occurred. Some transitions also

were extremely easy to classify as positive or negative. The outcomes at the lower left of the matrix

represent improvements, usually from limitations at

admission in either walking or incontinence to no

limitations in these ADL’s at discharge. The outcomes

at the upper right of the matrix represent deterioration,

from no limitations at admission to one or both limitations at discharge.

192
Table A. Transitions In resident functioning from

admissionto dischargefrom nursinghome, by

Ilmltatlon at discharge and at admission

Limitation at discharge

Limitation Trouble /nconat admission None walkina thence Both

Outcome

None . . . . . . . . . . . . . . S DD

Trouble walking . . . . . . I : D

Incontinence ., . . . . . . I ? :

Both . . . . . . . . . . . . . . . I I I :

NOTE: I = improved, S = stable, D = deteriorated,

? = undetermined outcome.

The question mrwksin the matrix pinpoint those

transitions that are very difficult to classify as either a

positive or negative outcome. Is it an improvement to

shift from being incontinent at admission to being

limited in walking at discharge? The care providers in

nursing homes, the patients themselves, and their

informal support systems may all have divergentviews

on this question. Their views may depend on the type

and amount of care that is needed. Determining care

needs, of course, raises another set of measurement

issues. While such issues are beyond the scope of my

presentation, they are critical to pursue in making

judgments about positive or negative outcomes.

Another possible topic for collaborative research

is identifying similar groups of nursing home patients

among the collaborating countries and assessing if

they have similar outcomes. If some countries have

more favorable outcomes, can the reasons for positive

outcomes be measured and replicated so that they

might be applied in other countries? This research

topic raises several challenging measurement issues.

One challenge is to identify existing data that are

comparable across countries to measure patient risks

and outcomes. Another is to develop comparable

profiles of similar groups of nursing home patients. A

third is to determine, given the serious nature of

chronic illness in this LTC population, which outcomes are“favorable.” In some situations,for example,

retardation in the rate of decline may be a favorableoutcome.

While I have discussed functioning and comparability of patients and outcomes as possible topics for

international research, this is not to imply that they are

priority topics. Rather, they are illustrations of the

variety of issues and the complexities inherent in

measuring outcomes of nursing home care.

I will close my remarks by making some observations on the overarching goals of measurement

research about nursing home outcomes. As you have

heard these past few days, the central theme of the

International Collaborative Effort on Aging is vitality

and wellness of older persons. In a sense, the effort on

outcomes of nursing home care is the application of

the concepts of vitality and wellness to LTC. Our

overarching goal is not only to strengthen measurement

and increase international comparability of outcomes.

It is also to use this information to gain insights into

how outcomes forolderpeople who experience nursing

home stays can be improved.

References

1.

2.

3.

4.

5.

6.

HingE, Sekscenski E, StrahanG.TheNationalNursing

Home Survey: 1985 summary for the United States.

National Center for Health Statistics. Vital Health Stat

13(97). 1985.

Health Care FmancingAdrninistration. National health

expenditures, 1987, Health Care Fhmnc Rev 10(2).

1989,

Sekscenski ES. Discharges from nursing homes: 1985

National Nursing Home Survey. National Center for

Health Statistics. Vital Health Stat 13(103). 1990.

Van Nostrand JF. Data needs for policy analysis of

LTC. In: Health of an aging America: Issues on data for

policy analysis. National Center for Health Statistics.

Vital Health Stat 4(25). 1988.

Van Nostrand JF, Zappolo A, Hing E, et al. The

National Nursing Home Survey, 1977 summary for~e

United States. National Center for Health Statistics.

Vital Health Stat 13(43). 1979.

DonabedianA. Explorations inqualhy assessment and

monitoring, vol I: The definition of quality and approaches to its assessment, Ann Arbor, Michigan

Health Administration Press. 1980.

193
Chapter 22

Measuring outcomes of

institutional long-term

care: The problem of both

the dependent and

independent variables

by Rosalie A. Kane, D, S.W.,School of Social

Work and Health Services Research and

Policy, School of Public Health, University of

Minnesota

My task is somewhat more conceptual and less

concrete than that of many of the other speakers at the

conference. In the title to my remmks, I decided to

emphasize the double problem of the independent and

dependent variabIe. I do so not to be discouraging.

International comparisons Iooking at outcomes of

institutional care, and, for that matter, long-term care

in general, will be extraordinarily important and could

cast new light on how we might be able to improve the

ways in which we serve functionally impaired elderly

people. So, difficult asthe task of measuring outcomes

of institutional care maybe, I am eager for us to do so.

The comments that I make emphasize measuring

the outcomes of care more than measuring the risk of

needing it. I think we understand quite a bit, at least in

the United States, about the characteristics of those

people who use nursing homes. Further, we can

probably say something about the characteristics of

people who use other kinds of long-termcare services.

So we can talk about sex, age, diagnosis, cognitive

condition, marital status, and so on, and describe

characteristics of those at risk of needing care.

Our ability to predict whether any particular man

or woman who exceeds age 65 is likely to use a

nursing home, however, is much harder. We must be

aware as we embark on this kind of inquiry that the

need for institutional care or the need for any kind of

long-term care cannot be developed as a straight-line

extrapolation from use patterns that already exist.

Public policy has an inordinate effect on patterns of

use of institutional care, so it is always important to

tease out the context of care.

Independent variable

At this conference, nursing home care and personal

care have been defined as anything in between an

acute hospital and a room-and-board situation. That

allows infinite variations within the definition. We

have a welter of names, even in the United States, that

we use for residential settings with some services

attached, e.g., nursing homes, rest homes, homes for

the aged, retirement homes, congregate housing, assisted living centers, adult foster care, board and care

homes.

For example, adult foster homes have become a

viable option for long-term care for the elderly, particularly in the State of Oregon, where we have studied

them (l). Oregon’s adult foster homes are private

homes licensed for one to five residents; there is a fulltime person living there preparing the meals, cleaning,

giving personal care, and doing anything else that

needs to be done. It is hard to know whether to call that

institutional care, residential care, or home care. In

other words, it is hard to know the players without a

program.

In anyone of the residential services, regardless of

its name, one could have different personnel mixes.

Moreover, the purpose of institutional care can bevery

different, even among facilities of the same name. In

our U.S. nursing homes, the purpose for a given

resident’s care may be rehabilitation, or it may be

terminal care, or it may be to provide efficiently those

socially oriented personal care services that people

need routinely. Depending on the purpose, aresearcher

195
would use a different independent variable and would

want to measure outcomes somewhat differently.

All of these services with distinctly different

purposes are taking place within what we in the United

States call a nursing home. I imagine there is the same

kind of variability in other countries. This makes it

extremely hard to look at the black box of outcomes.

If we start taking an international look at outcomes of

institutional care, the endeavor might have the very

desirableresultof forcing researchers to stop confusing

the place of care with the type of care. It is a very

dangerous kind of shorthand to say “nursing home

care, “ “home care,” “day carej’ or for that matter

“hospital care~’ because all sorts of things can happen

under each of those rubrics.

Ultimately, what we really need are measures that

will allow a comparison of outcomes across sites of

care and modalities of care as well as overtime. This

also permits examining patterns in the way services

are combined. It is very hard to attribute causality to

outcomes observed for a particular slice of care. For

instance, taking the practical example that we are now

dealing with in our studies in Oregon, we find that

people move from hospitals to nursing homes,

sometimes for some recuperation, and then to foster

homes, and then back to nursing homes-or vice

versa. It is, therefore, really quite difficult to determine what outcomes should be attributed to which

type of care.

With large longitudinal data sets capable oftracking

people as they use different services, we can make

comparisons of service settings, singly and in combination. We can also identify people who have certain characteristics and use care in different ways, for

example, people with strokes.

Of course, the use of hospitals becomes a very

important factor. It occurred to me, when hearing

the previous presenters describe the large number

of people who are discharged from nursing homes

alive, that this might be a little misleading to some

of our international visitors. That is because, although

a surprisingly high number of people do leave nursing

homes for the community, a goodly subset of those

people are discharged alive to hospitals, where they

either die or are discharged back to nursing homes.

Again, it becomes important to be able to track users

of long-term care and related acute care as they move

from setting to setting.

Dependent variable

Turning to the dependent variable, it is extremely

important to array the kinds of outcomes that we might

measure, not only to look at those that are available in

existing data sets, but also to consider which ones we

might want to include. Functional abilities have already

been discussed and are surely an important outcome to

look at in long-term care.

It is easy enough to provide a laundry list of

candidate measures, but none of them is unambiguous. Functional abilities, physiological health and

survival, emotional health, social activities, and social

participation are all possible. So too is satisfaction

with the care received. We can also consider financial

outcomes in terms of public outlays and financial

outcomes in terms of personal outlays.

It is also necessary to divide personal outlays into

those of the resident and those of family members.

Family members’ contributions come in terms of

direct care as well as monetary support, and to our

surprise, it is becoming apparent now that a great deal

of family care goes on when people are in so-called

institutional or residential settings. That in itself is

something worthy of looking at. We cannot assume

that informal family care occurs while people are in

the community and ceases when the relative is in

institutional care. Yet family care tends not to be

measured for those living in nursing homes.

Each outcome may or may not be desired or

expected for a particular long-term care recipient.

Survival may not always be the goal, particularly for

palliative care. Functional ability is clouded by the

question of capacity versus performance, and it is

difficult to decide which attribute of functioning one

wants to measure; that is, does one measure what the

subject can do or does do? Many facilities have policies

against allowing people to bathe themselves or to take

theirown medicines, and if we measured performance,

their functioning would be poor. We may be most

interested incapacity if we are planning for discharge.

But if we are interested in looking at the quality of

institutional life, it may not matter that the capacity to

196
bathe has been kept intact for 10 years if the resident

has never been allowed to do it.

Satisfaction has a lot of measurement difficulties.

People set their sights lower as they adjust to environments that have lower opportunities. Also, people

complain slot in some of the best kinds of environments

because complaining is encouraged. Once again, the

measure is difficult to use.

To operationa.lize these dependent variables in

different countries, we will encounter fascinating

cultural issues. Some years ago, I attended a very

interesting meeting in Utrecht, where representatives

of 9 or 10countries sought universal agreement about

how to measure a high quality of institutional care(2).

Those of us from North America and Europe thought

that privacy certainly would be one universal good,

but it turned out it was not. Even autonomy as operationally defined did not win uniform approval.

Eventually, something like “continuity with previous

lifestyles” won considerable acceptance from all

participants. That has face validity, because it seems

we should be able to compare the people receiving

various kinds of long-term care services in different

kinds of residential facilities, including their own

home, against some kinds of norms that are suitable

for the country.

I have mentioned global measures—satisfaction,

emotional well-being, functional abilities, and so on.

Some process measures are, in themselves, worth

looking at. For example, the use of psychoactive drugs

orphysicalrestraints areprocesses of care experienced

as outcomes to the person who is experiencing that

particukir process. It is worth further explanation to

see if there is any international agreement about collectable outcomes of that nature.

Technical issues

Let me conclude by summarizing some of the

complications in measuring these outcomes of institutional care. There is, first of all, the heterogeneity of

the population, including heterogeneity in prognosis,

background, cognitive abilities, andvaluepreferences.

This raises the question, then, of how outcomes

should be interpreted. My hope is that we can look at

actual outcomes compared to expected outcomes.

Such expectations can be modeled, as we did some

years ago in a Rand Corporation study (3). One can

thenlookat statistics regarding what kinds offunctional

outcomes would be expected with a population with

specific characteristics in anursing home and examine

the variance around that expected outcome.

It is probably useful, too, to look at actual outcomes

compared to desired outcomes, which give rise to

another kind of policy issue. We should be interested

in the outcomes the people using care desire, as well as

the outcomes that people paying for, organizing, and

providing care desire.

Looking at actual outcomes against expected

outcomes brings us back to the questions of functional

measures that were discussed yesterday and to the

questions of the risks of entering some kind of care.

Thus, case-mix adjustment foroutcomesisan important

step. It would allow us to compare outcomes, adjusted

for expectations across sites. In my opinion, case-mix

adjustment is much more valuable for quality control

and evaluation of outcomes than for reimbursement

purposes, which carry so many negative incentives.

We must also consider the source of outcome

information. Here we have a few choices. I would

hope that we could make actual observations of

demonstrated abilities wheneverpossible. Aresident’s

self-report will be needed for some outcomes, such as

satisfaction and emotional well-being, and selfreporting isindeed preferable to asking a staff member

to rate the resident’s happiness or mental state. A

worrisome methodological issue is hidden in measurement of emotional well-being. I have seen measures

of depression or anxious affect used to label the person

as an unreliable informant about other things, such as

satisfaction. This is troublesome because depression

or anxiety may well be secondary to the person’s

living situation.

With all of this, one would hope for information

systems that would allow us internationally to look at

a group of people who are receiving care in various

guises—residential care of different types, home care,

and even no care-and see what happens to them over

time, measured against their baseline functioning.

Other issues arise about the intervals of data collection, what will tigger the new assessment, and so

197
on. Various States in this country have developed

information systems that are quite rich that way.

Again using Oregon as an example, at 6-month intervals,reassessments are done onmultipledimensions

for people who are receiving any subsidized care

offered in the State, including home care from agencies, home care managed directly by clients, foster

care, care in residential care facilities that are less than

nursing homes, and care in nursing homes themselves.

With a huge data system like this, it is possible to

construct homogeneous groups and look at their patterns of use overtime.

I think there will be other such possibilities. In the

United States, rich information systems will be biased

toward low income. Almost all the State data systems

have this bias, because systematic assessment and

case management tend to occur only when people are

eligible for publicly subsidized services. Income eligibility is still the norm, although it is not as stringent

in some States for the community-based services as it

is for the institutional-based services.

To conclude, it is an exciting prospect to do

international comparisons of the characteristics and

outcomes of the elderly in various forms of long-term

care. We will need clear observable measures, ability

to track patterns over time, ability to make comparisons across different kinds of care within a country as

well as internationally, ability to compare actual outcomes to expected outcomes, and a very careful description of the programs themselves so we are clear

what the independent variable is.

References

1.

2.

3.

Kane RA, Illston LH, Kane RL, Nyman JA. Adult

foster care in Oregon: Evaluation, Administration on

Aging and Southmark Foundation on Gerontology,

1989.

Tropman JE, ed. Quality of long-term cm. Dan Med

Bull, Special Supplement Series in Gerontology 5:1-

98.1987.

Kane RL, Bell RM, Hosek SD, et al. Outcome-based

reimbursement for nursing home care. Santa Monica,

California: Rand Corporation. 1983.

198
Chapter 23

Outcomes of community

and institutional

long-term care

by Betty Havens, Manitoba Department of

Health

Introduction

Inthisbrief presentation, a shortbackground to the

Canadian long-term care system and the Manitoba

Provincial long-term care system will be provided.

This will be followed by a brief description of the

Manitoba longitudinal data bases, leading to discussion of episodes of care and outcomes. The final

portion of this presentation will deal with the database

potential in the areas of community long-term care and

the comparison of outcomes across long-term care

settings.

Canadian long-term care system

To quote Susan Fletcher in a recent publication:

Canada has a long-standingcommitmentto its older

citizens,andit offersa varietyofprogramsandservices

that demonstratethis commitment.Manyof theseprograrnsaddresstheissueof longtermcare.Someofthese

programs and services are provided by the federal

government,whilemostaredeliveredby theprovincial

governments.Still othershavebeen developedby volunteer and nonprofitorganizationsin individual communities.(1, p, 31)’

It is important to recall that the Canadian longterm care system is embedded in the Canadian Health

Care System, which has established hospital and

medical care as the minimum insured services across

Canada (2). Essentially, no Canadian can be pauperized by illness, either his or her own or that of a family

member, regardless of age, type or duration of disability, or place of residence.

aCopyright,1987,AmericanAssociationof RetiredPersons.

Reprintedwithpermission.

The Federal Government contributes to long-term

care in a variety of more indirect yet important ways.

Forexample,guidelinesfortheprovisionofselectedserviceshavebeenpreparedinconsuhationwiththeprovinces

and territories.Theseguidelinescovera widevarietyof

topics, such as long term institutional care, geriatric

assessmentunits,palliativecareunits,anddesignconsiderationsforgeriatriccare,Afederal/provincial/territorial

subcommitteeon long term care also has been establishedto promotethe developmentand coordinationof

long term care serviceson a provincial,national,and

internationalevel.Thesubcommitteeaddressesavariety

of issues,includinglinkagesbetweeninstitutionaland

community-deliveredlongtermcareservices.(1,p. 32)’

NoLwithst.andingthiswide-rangingfederalinvolvement,

constitutionalresponsibilityforthe actualprovisionof

long termcare servicesto the elderlyrests with the ten

provinces.TheorganizationanddeIiveryoftheseservices programs are carriedout mainly at the provincial

andlocallevels.Thefederalgovernmentretainsservice

deliveryresponsibilityfor certain specialgroups,such

as native Canadians, veterans, and residents of the

Territories.(1, p. 32~

Unlike the American system:

The long termcare systemin Canada dependsheavily

on donations and the free contributionof time on the

part of a multitudeof volunteers.Whethermoney donated by large corporationsto furnish rooms or buy

specialequipment,or communitygroupsraising funds

to build a new old age home, or individualsgiving of

their time to drive people to doctor’s appointmentsor

bring themhot meals,all have an impxtant role in the

long term care system.(1,p. 33)a

There are no off-the-shelf prescriptions or right

waysof doingthings.Canadahas essentiallyten sovereign stateswhen it comesto long term care programs

for the elderly.Each hastailoredits programsto meet

the quite diversehealthand socialserviceneeds of its

elderlypopulationandto conformto thebroaderorganizational,economic,andpoliticalparameters.(1,p. 39)’

199
The Manitoba model of

continuing care

The Manitoba program is a Province-wide, universal, no-cost-to-consumer program initiated by the

Provincial governmentin 1974andgradually expanded

throughout the Province by 1975. The Program assesses persons requiring care, whether for placement

in nursing homes or for home care, and delivers

services to those who remain at home. The model is a

coordinated service program with a broad range of

services to meet the needs of persons who require

assistance or support to remain at home or whose

functioning without home care is likely to deteriorate,

making it impossible for the person to stay at home in

the community. Upon identiilcation of needs, services

are organized to avoid deterioration and to maintain

and enhance health. This purpose is accomplished

within established policy guidelines.

The Program is delivered through regional offices

and suboffices and through health centers and private

voluntary agencies identified within the Program service delivery framework as coordinating agencies. These

agencies are responsible for participating with the

central Program office in Program planning and development and forproviding coordinated quality service delivery within Program guidelines.

Service delivery frameworks are based on professionally coordinated and conducted need assessments, care planning, and service delivery supervision.

Ongoing services provided in the home are delivered

by both professionally skilled and paraprofessionally

skilled persons.

For persons of any age who are referred from any

source, determination of need for services is based on

a clinical, health functioning, and social functioning

assessment. Assessment is focused on identifying

those who, without services, would beat risk of not

being able to remain at home but who, with homedelivered services, could have their care needs managed appropriately. This Program model calls for each

referred person to be served primarily by one staff

person, the case coordinator, and for assessment and

care planning to be multidisciplinary.

Program guidelines call foreachperson to be fully

assessed, including identification of those activities

that the person can perform; those that family members, friends, or neighbors can realistically perform;

and those that require placement of services. A care

plan is developed to provide for needed services

existing within the Program. When needed services

are not available within the program, every effort is

made, as part of the care plan, to secure such help from

other community sources. Services provided by the

Program are to be the minimum required to meet need

and to foster independence. Delivery isto be organized

so that services are provided by the person with the

minimum skillrequired toperforrnthe task.Throughout

the Province, the Program utilizes professional and

nonprofessional skills, including those of nurses, social workers, licensed practica.1nurses, aides, orderlies,

therapists, home attendants, home helpers and personal

care homemakers, volunteers, and the staff of voluntary agencies, as well as civil servants and hourly paid

casual employees.

Seldom does a client need only a single service to

remain in his or her own home in the community, so

coordination of services becomes a major concern

of both a providing agency and the client. If the

community-based long-term care program does

not include service coordination in its functions,

clients or their families are left with the time- and

energy-consuming task of trying to coordinate a variety

ofservicedeliverers.All oftheseproviders areemployed

by and responsible to a variety of organizations. For the

community-based program to comlinate health and social servicesflom a variety of public, private, and voluntary agencies with those tasks performed by the client

and his or her family, friends, and neighbors, a comprehensive multidimensional assessment is essential.

Assessments for long-term care normally concentrate on client weaknesses and functional deficits. By

operating in the community from a premise of maintaining independence, however, assessments are more

appropriately focused on strengths of the client and his

or her informal support network. The ability of an

assessment to identify strengths initially and then to

proceed to identifying weaknesses that inhibit independence allows the assessment team to develop a

care plan and assign a case coordinator toprovideonly

those services that fill gaps in supporting a client’s

independence.

200
A common assessment process is used across all

sectors of long-term care, and the assessment itself is

designed to establish types and amounts of care required. The last step in the process is to deterrnine the

most appropriate location for that care; that is, only

after all the strengths and weaknesses of the client and

the informal support network have been adequately

assessed does the assessor begin to consider the site of

care. In addition to the “total” solution of nursing

home placement and the “minimum” solution of care

in one’s own home, many other potential sites of care

should be considered as options in making a final

assessment decision. New options are developed all

the time, such as home sharing, supportive seniors

housing, care cooperatives, and boardandcare homes.

Consequently, long-term care assessment staff and

case coordinators must keep up to date on new developments and options in their own communities to

provide the broadest possible range of options to each

potential client at the final stage of determining site of

care.

Manitoba longitudinal data

bases

The 1971, 1976, and 1983 samples and the identification of the panel members, who were resident in

Manitoba, were obtained from the registry of the

Manitoba Health Services Commission, which established the registry in 1969. The 1971 sample of

4,803 persons was a random sample of all persons 65

years of age and over, stratified on the basis of age,

sex, and location. Simultaneously, each fust sample

respondent drawn was matched by a second sample

respondent, identical to the first on the basis of age

range, sex, location, and residential status (3). This

technique of randomly assigning a second sample

counterpart provided the means for maintaining appropriate sampling for statistical purposes while reducing the bias of sampling error in a high-risk

population based on respondent loss for reasons of

death, serious illness, migration, and changed residential status.

As less funding was available in 1976, both the

size and the geographic distribution of the sample

were reduced, producing an area probability sample of

1,302 respondents (4). The sample was drawn from

persons 60 years of age and over who were resident in

the community. A second matched sample was again

drawn to minimize the loss of respondents.

In December 1982a new stratified random sample

of 2,854 Manitobans 60 years of age and over resident

in the community was drawn for a third cross-sectional

survey. This sample was also stratified on the basis of

age, sex, and location, and again a matched second

sample was drawn. The variables in the interviews are

listed in figure 1.

At the same time, the records of the Manitoba

Health Services Commission were searched for any

participants in the 1971 and 1976 surveys who were

still resident in the community in Manitoba, and

identification information was printed for these panel

members. The 1983 interviewers surveyed both

members of the 1983 cross-sectional sample and

community resident panel members. It was necessary

to delay until 1984 the interviewing of panel members

resident in care facilities, as it was not possible to

identify those in residential facilities until after the

community survey of survivors had been completed.

During 1984 panel members resident in facilities and

those in the community who had not been available for

interviews in 1983 were surveyed. During 1983–84,

2,307 panel interviews were completed. Those who

were reinterviewed, refused to be reinterviewed, could

not be matched for administrative reasons, or were too

ill to be reinterviewed in 1983–84 were deleted from

the list of 1971 and 1976 respondents. The name, sex,

location, birth date, and approximate date of death,

when known, for the remaining respondents were

forwarded to the Manitoba Bureau of Vital Statistics,

which conducted a manual and computer search of its

records, This search resulted in information on the

date, cause, and place of death of 3,323 respondents.

By the end of 1985, the search for respondents in

the 1971 and 1976 Aging in Manitoba surveys who

either were living in Manitoba or had died in Manitoba

was complete, and information had been obtained

from or about all but 372 respondents, most of whom

were believed to have left the Province. The records of

the Canadian Mortality Data Base were then searched

for these remaining respondents. The information

201
Pem9.tarW

Age

Sex

Marital status

$oclal struct~ .

Education

Prior occupation

Retirement status

Ethnicity

Residential status—e.g., private home, apartment

Residential location-e.g., urban, rural

Religion

PsychosocM

Lie satisfaction

Problems with visiting physician

Perceived income

Life Space Index

/%sessed needs

Economic needs

Proximity to family, friends, familiar community

Family, friends as available resources

Shelter needs

Household maintenance, food and clothingneeds

Ethnocultural needs

Physical health functioning needs

Mental health functioning needs

Psychosocial needs

WliL!

Income

Perceived adequacy of income

Regular source of care

Adequacy of transportation

QJJlm@Y

Urban-rural-remote character

Resources’ ability to meet needs

Perceived heaIt~

Disability-Shanas Index of lncapacityl

Activities of daily living

Recent days in bed due to illness

Self-rated health

Number of conditions

j+aluated health

Mental statusz

Specific disease prevalence

‘Shanas E, Townsend P, Wedderburn D, et al. Old people

in three industrial societies. London: Routledge and Kegan

Paul.1968.

‘Kahn RL, Pollock M, Goldfarb A. Factors related to

individual differences in mental health status of

institutionalized aged. In: Hoch R, Zuben J, eds.

Psychopathology of aging. New York: Grune and Stratton.

1961.

Figure 1. Aging in Manitoba survey variabies:

Canada, 1983

202

provided for this search included surname, given

names, date of birth, country of birth, sex, spouse’s

name, last known year alive, last known place of

residence, and last known marital status. The Canadian Mortality Data Base can provide information

only on persons who have died in Canada or on

Canadian residents who have died abroad. The names

for those for whom the Canadian Mortality Data Base

could not provide information, approximately 200,

were forwarded to the Office of Old Age Security

(OAS). This Office forwarded a letter from the study

to the remaining participants in the 1971 and 1976

studies who were recipients of OAS, asking them to

contact theresearchers. Those who responded (n =72)

wereinterviewed unperson, by telephone, or by mailed

questionnaire, and the Mortality Data Base was

searched again.

These processes yielded the final status shown in

table A. Death has been confirmed for 3,556 of the

respondents, including 61 for whom certificates have

still not been secured. These include two deaths in

Europe, three in the United States, and 17 in Canada

outside Manitoba, as well as 39 who have died too

recently for certificates to be secured through the

Canadian Mortality Data Base. It is still anticipated

that the certificates, with the exception of those for the

two European deaths, will be obtained.

Interviews were conducted with 2,400 surviving

panel members. It is of interest to note that death

certificates have been secured for 270 of these respondents who have died since they were reinterviewed. The 89 refusals include 14who were too ill to

be interviewed and for whom no proxy could be

located. Of the 28 respondents who have been declared lost, 21 were administratively lost due to

problematic record linkages prior to the 1983

survey. Therefore, the search procedure since 1983

has been remarkably successful, as only seven

respondents were lost during this process.

The longitudinal utilization portion of the study

includes entirely service-based data. It contains all of

the service consumption data based on the health

services system. Included are all medical services, i.e.,

all of those services that are billed on a fee-for-service

basis through the medical claims system, all hospital

services, i.e., services in both acute and extended care
Table A. Number of persons who responded to the 1971 and 1976 Aging in Manitoba surveys, by record status

and birth year: Canada

Record status

Death Interviewed Refused

Birth year Original 1 information 2 1983-88 ‘ interview 4 Lost

Totai . . . . . . . . . . . . . . . . . . . . . . . 6,073 3,,556 2,400 28

(61) (270) (1?;

1912-16 . . . . . . . . . . . . . . . . . . . . 405 318 11 1

; &

1907-11 . . . . . . . . . . . . . . . . . . . . 353 0

(7) (25) {

1902-06 . . . . . . . . . . . . . . . . . . . . 1,517 626 854 4

(17) (89) (6)

1897-1901 . . . . . . . . . . . . . . . . . . 1,315 733 558 6

(lo) (79) ;!

1892-96 . . . . . . . . . . . . . . . . . . . . 1,044 757 274 4

(llj (41) (1/

1887-91 . . . . . . . . . . . . . . . . . . . . 771 102 7

(4) (2:J

Before 1887 . . . . . . . . . . . . . . . . . 668 632 1 6

(7) (6)

11971—n=4803” 1978-n= l,302,including32who were also interviewed in1971.

‘Numbers in ~are~thesesindicatethose for whom deaths are confirmed but certificates are not available (n= 61).

aNumbers in parentheses indicate those who have died since being reinterviewed (n= 270, which includes 144 males and 126

females).

‘Numbers in parentheses indicate those who were too ill to be interviewed and for whom no proxy could be located (n= 14).

units, mental health and mental retardation facility

and service consumption, and home care and personal

care home services. (Personal care homes in Manitoba

include all care levels; in the U.S. context, personal

care homes are a combination of nursing homes,

intermediate care facilities, and skilled nursing

facilities.) In other words, if individuals have come

into contact with the health service sector at all in

Manitoba, and if they were in the original 1971, the

1976 followup, or the 1983 cross-sectional study, we

have all their service consumption data. We also have

the service consumption data on the spouses of our

interviewees (5).

Therefore, the utilization data file includes 16,000

individuals-the original 4,803 cases (1971), the additional 1,302 cases (1976), and the 2,854 cases from

1983, plus their spouses. This file covers an 18-year

timeframe, from 1970 through 1987. The major issue

from the standpoint of dealing with these data is the

sheer volume of data, in addition to avery large sample

size. We have more than 500 interview items from the

original sample, 96 from the second interview sample,

and 250 items from the third sample, plus potentially

asmany as 30 separate interactions ordataitems on the

individual within the health care system on each of

5,836 days. With a potential of up to 30 items of

service information on each day of the 18 years, this

can safely be called a very large data set, and it is very

cumbersome to handle and analyze. One of the immediate problems that we faced was the necessity to

put the data into an analytic form to allow us to deal

and work with it without passing through the whole

file every time (6).

Another important factor is that the 16,000 people

have non-uniform-length utilization records. Everyone learns that in order to do analyses of this nature

you should have uniformrecord size oruniformrecord

length, but this cannot happen: That is, if someone did

not get into the home care program, there are no home

care data at all; hence, records cannot be uniform.

Similarly, some people will be assessed three or four

times within the personal care home placement file

before they get into a persomil care home, plus there

will be subsequent assessments following placement.

All of these conditions and others potentially vary the

length of the record. We have had to develop rate

203
variables in order to put all of these nonuniform data

records into a uniform format for analysis. We have

done this within three different categories. One of

these categories is the data arranged in 3-month

summary units rather than daily or monthly. A second

category is based on the summary of data for 1 year.

The third category is not a summary file at all; it is a

locator file.

The locator file has been created because we lose

some important data through summarizing to 3months

or a ye=, that is, we have maintained each of the 5,836

days as separate file units, but with only one variable

per day. This variable indicates whethertheindividual

is: Alive and at home; alive in a facility, and if so, the

kind of facility (a different value is used for each

different type of facility); alive but not in Provinc%

and, finally, dead. Because the files include the data on

spouses, as well as on the individual respondents, the

Iocatorfile contains information on whether the spouse

is alive and living: Together with the responden~ in a

facility (and what type of facility); out of Province;

and, again, dead. The spouse, in a sense, really is not

relevant to the use of the locator file, but by locating

the spouse, we have more rapid access to locating

some information in the summary files.

Theinterviewmaterials werefoundto be extremely

reliable and valid (7). The service utilization data have

also been nonproblematic in terms of reliability and

validity because these data were abstracted from fully

functioning administratively maintaineddatasystems.

The reliability and validity of the data are part of the

administrative responsibility of the system; consequently, as researchers using the data for secondary

analyses, we do not have a problem (8). Given the

volume of data involved in these analyses, it is very

fortunate that wedonot need to worry about reliability

and validity.

Having identified some of the issues and concerns

relative to having a very large sample, to having very

detailed service records, and possibly to drowning in

the data, we have found ways to compensate for these

problems. In addition to the use of the timeframe

summaries discussed above, we have operationally

defined and developed or used summary variables;

that is, wherever possible, we have constructed an

index or a scale, as opposed to retaining multiple

items. In this way, we have anew single-item variable

rather than 10 variables. Researchers, particularly

researchers who work with longitudinal data, are

inveterate data hoarders. This characteristic does not

seem to afflict cross-sectional analysts to the same

extent that it does longitudinal researchers. Therefore,

whenever summary variables are developed, all of the

original items are retained on the raw data tapes,

Consequently, should we wish to construct a different

summary variable, we have the capacity to do so.

From the standpoint of longitudinal studies, this produces an extremely important additional problem

relative to coping with the data. Such studies usually

begin with large volumes of data, then create both

summary mechanisms for analytic purposes and summary variables. At the same time, each new data item

must be added to the original tapes, which will also

contain allof the original items. Asthe studyprogresses,

it may be desirable or necessary to use different

combinations of items and create new summary

variables.

Episodes of care and outcomes

Given that the residents of personal care homes in

Manitoba areextremelyfrail, without support systems,

and old on entry, very few return to the community.

The average age on entry to a personal care home is

84.3 years, and in most cases the persons (largely

women) have outlived the members of their support

network. They tend to be widowed, childless, and

largely lacking in other relatives or others in the

household. Therefore, most of the episodes of care that

we have analyzed are episodes of acute care hospitalization within the period of residence in a personal

care home (9). Further, the major outcome variable

that we have studied has been death (10-12). However,

analysis of surgery as a specific case within acute

hospitalization has begun (13,14).

However, with the community samples and the

community long-term care program in Manitoba, we

have also analyzed personal care home placement as

an outcome variable among community long-term

care consumers (11, 15). Further, outcomes of health

service nonusers also can be studied within these

combined data bases.

204
Research potential with

community long-term care

Based on the foregoing, perhaps it is obvious that

the Manitoba longitudinal data bases contain a rich

source of information on older community residents

who consume long-term care, as well as residents of

Iong-termcareinstitutions. It is my understanding that

the National Center for Health Statistics will be undertaking a survey of home health care and hospices in the

near future. As this effort moves forward, the possibility for even greater comparability and the opportunity for additional cross-national comparisons should

increase.

The defining characteristics of personal care

home entrants, which were referred to earlier, are

the result of analyses of those whose health outcomes include institutional long-term care as opposed to or following community long-term care.

We have also been able to look at a broader range

of long-term care settings, i.e., own home, commercial apartments, seniors housing units, and residential care facilities, as well as personal care homes.

All but the residents of personal care homes are

consumers of community long-term care or home

care. The use of a common assessment in both

institutional and community long-term care enables

USto compare those persons requiring the same levels

of care across settings,

This latter research strategy is especially important in policy considerations: That is, who will be able

to use community long-term care services and for how

long, and how do these individuals differ from those

who use institutional long-term care services? This

information enables policymakers to develop more

appropriate bases for fiscal decisions relative to longterm care over the next several years.

References

1. Fletcher S, Stone L, Tholl W. Cost and financing of

long term care in Canada. In: Gibson MJ, ed, Income

security and long term care for women in midlife and

beyond: U.S. and Canadian perspectives. Washington

American Association ofRetiredPersons, 31+8. 1987.

2. Rosenfeld GB. Testimony on international perspectives on health care: Learning from other nations. A

SelecI Committee on Aging hearing. May 1984.Comm

Pub no 98450, 16-29.1984.

3. Manitoba Department of Health. Aging in Manitob&

vol I. Wimipeg: Government of Manitoba. 1973.

4. Hull E, et al. An analytic comparison of the 1971 and

1976 studies of aging in Manitoba. Health and Welfare

no 1216-6-918. Winnipeg: Manitoba Department of

Health and Community Services. 1979.

5. MosseyJ, Havens B,RoosNP, ShapiroE.TheManitoba

Longitudinal Study on Aging: Description and methods. Gerontologist 21 :551–8. 1981.

6. Havens B. Possibilities and problems in using service

generated data for longitudinal research on aging, part

II: Experience from Manitoba. In: Gutman GM, ed.

Canada’s changing age structure: Implication for the

future. Burnaby, British Columbia Simon Fraser

University Publications. 1982.

7. Havens B. Needs assessment and community resource

surveys. In: Mangen DJ, Peterson WA, eds. Handbook

of research instruments in social gerontology, vol III.

Minneapolis: University of Minnesota Press. 1984.

8. Roos LL,RoosNP, Cageorge SM, Nicol JP. How good

are the data? Reliability of one health care data bank.

Med Care 20:26&76. 1982.

9. Roos NP, Montgomery P, Roos LL. Health care utilization in the years prior to death. Milbank Mem Fund

Q 65:231-54.1987.

10. Roos NP, Shapiro E, Havens B. Aging with limited

resources: What should we redly be worried about? In:

Economic Council of Canada. Aging with limited

health resources. Ottawa: Minister of Supply and

Services Canada, 50-6.1987.

11. Roos NP, Roos LL, Mossey J, Havens B. Using administration data to predict important health outcomes.

Med Care 26:221–39. 1988.

12, Montgomery P, Kirshen AJ, Roos NP, Long-term care

and impending mortalhy: Influence upon place of

death and hospital utilization. Gerontologist. To be

published.

13, Roos LL, Roos NP. Managing surgical admissions. In

Finkel ML, ed. The delivery of surgical care in the

U.S.: A policy perspective. Baltimore: Johns Hopkins

University Press, 107–24. 1988.

14. Roos LL. Non-experimental data systems in surgery.

Int Technol Assess Health Care. To be published.

15. Shapiro E, Tate R. Predictors of long term care facility

use among the elderly. Can J Aging 4: 11–9. 1985.

205
Part Vlll

Assessment of

vitality and aging
Introduction

by Richard J. Havlik, M.D., Office of Planning

and Extramural Programs, National Center for

Health Statistics

I guess this position in the program order has

disadvantages and advantages. We got a little break to

go outside, but we got the postprandial lag. However,

we will try to keep up the energy level and be vital!

Also, I think we are at another disadvantage. I was

home last night looking at the television coverage of

Gorbachev’s speech to the United Nations, and so we

will try to duplicate that excitement as well. I think the

other advantage of being late in the session is that we

can build on what has gone on before and remind you

about things, since it does all fit together.

I hope you are seeing a pattern here. Both yesterday and today you saw our logo with vitality and

health promotion in the center, with the arrows going

out to disability and disease. This interrelationship is,

hopefully, something that we will keep in mind as we

try to put all of this together in our session, and then

tomorrow as well. I am going to call on some things

that Dr. Cohen said—that is, the possible definitions

of health, wellness, and vitality. He gave us some

dictionary definitions, but I think healsoindicated that

we should not get hung up on the specific definitions.

We will know vitality when we see it. Our presentations in this session will actually be about two studies

in which we think we are going to see vitality and

quality of life addressed.

In planning this session, there were two opposite

sides to consider. One is the really immense effort that

needs to be done in just defining the topic. Then there

is being under the gun to come up with a protocol and

to get something done that is very narrow. Sometimes

when you have abroad topic it is easier to come right

down. So we chose to be very, very specific in what we

are going to discuss.

209
Chapter 24

Quality of life among the

elderly in Veneto, Italy:

A cross-sectional study

by Stefania Maggi, M.D., M.P.H., Department

of Epidemiology, The Johns Hopkins

University, and Institute of Internal Medicine,

University of Padua; Trudy L. Bush, Ph.D.,

M.H.S., Department of Epidemiology, The

Johns Hopkins University; and Giuliano Enzi,

M.D., and Gaetano Crepaldi, M.D., Institute of

Internal Medicine, University of Padua

Introduction

Italy, and all thedevelopedcountries, are aging. At

the last census, in 1981, 13.2 percent of the total

population was 65 years of age and over(l). According to the projections of the National Institute of

Statistics, in the year 2021 elderly people will number

about 11 million, or 20 percent of the total population

(2). This increase in number and proportion implies an

urgent need for collection of epidemiologic data in

order to better understand the socioeconomic and

health status of the elderly population.

The elderly are at higher risk of morbidity and

disability and are in need of more medical services

than younger individuals (3). The risks of isolation

and of low social support are also higher for the

elderly, and it is well documented that these factors are

predictors of higher morbidity and mortality (4,5).

Measurements of health and of the quality of life

in the older population are difficult to make, as these

factors are affected by dtiferent definitions and methods of assessment and by cultural factors. I believe that

a comprehensive assessment of the quality of life in

elderly individuals should include four areas:

● Physical functioning.

● Cognitive functioning.

● Social functioning.

c Self-perceived health status.

Epidemiologic studies of the

elderly in Veneto

Veneto is a region in the northeast of Italy with a

total population of about 4,500,000, 13 percent of

whom are 65 years of age and over (1). Veneto is

considered representative of Northern Italy in terms of

percentage of elderly in the total population, socioeconomic status, and health services availability and

distribution in rural, suburban, and urban areas. In

Padua, a city in Veneto, there is a large university with

an active Department of Geriatrics and Gerontology

that has coordinated previous epidemiologic studies

of the elderly. One study done in this region is the

assessment of the nutritional status of the population

65 years of age and over, a multicenter investigation

supported by the National Council of Research. The

objectives of the study were to assess nutritional and

health status (by questionnaire and clinical visit) in

order to identify subgroups of the elderly population

with nutritional impairments (malnutrition, metabolic

diseases). These individuals will then be targeted for

therapeutic interventions. The data are being analyzed

and will be published shortly.

211
Study on the quality of life

among the elderly

In Italy, as in many other countries, there is little

information on the quality of life among the elderly.

Those studies that have been done often lack standardization and validation of the instruments. The project

describedin the rest of this paper will use standardized

instruments to assess functioning. When possible, the

reliability of the measurements and the validity of the

instruments will be assessed.

Study design

The study design is cross-sectional and consists of

a personal interview of 3,000 community-dwelling

elderly persons living in 10 geographically different

areas of Veneto. If a respondent is unable to be

interviewed, a proxy will be asked to provide the basic

information (demographic characteristics and functional status).

Objectives

The major objective of this study is to assess the

quality of life of the elderly population. This includes

measurement of functional capacity to pex-forrnphysical activities and to participate in social events and

assessment of cognitive status and self-reported health

status. The information gathered will be used to plan

health and social interventions.

Method

Each city or town in Italy has available a list of all

the citizens resident in the area, with information on

their date of birth, marital status, and current address.

A random sample of individuals 65–84 years of age

,md all persons 85 years and over in the 10 defined

weas of Veneto will be selected for the study.

The participants will be interviewed at home by a

trained interviewer. The interviewers will be 30 physicians who are completing a residency in gerontology

at the University of Padua. There are two reasons why

we have chosen physicians as interviewers. First,

residents in gerontology at the University of Padua are

involved in clinical as well as in epidemiologic studies. In this project, particularly, the participants will be

asked to do performance tests of physical functioning,

and visual and hearing tests will also be administered.

212

In case of falls or any other health problems during the

tests, the interviewer will be able to intervene, avoiding medical and legal consequences. Second, in Italy,

unlike the United States, we do not have nurses trained

for health interview work.

There will be a 7-day training period for all of the

interviewers. Random reinterviews will be done by

the principal investigator to check the quality of the

data collected. Moreover, each interview will be recorded on audiotape. At the end of each interview, the

interviewer will fill in a form evaluating the respondents’ attitude toward the questions and providing a

general description of the living arrangements.

Questionnaire

The items used for the determination of the quality

of life are:

●

●

●

●

●

●

●

●

●

●

●

●

●

●

●

●

●

Demographic data.

Living arrangements.

Family composition and support.

Social activities and support.

Education and occupation.

Retirement and income.

Sensory impairments.

Dental conditions.

Chronic diseases.

Fecal and urine incontinence.

Sleeping problems.

Activities of daily living (ADL’s) and instrumental activities of daily living (IADL’s)(6-8).

Current health perception.

Drug consumption.

Alcohol and smoking habits.

Health services use.

Emotional and cognitive status (9,10).

Direct measurements to be made are:

● Visual acuity test.

s Maddox lens test.

● Hearing test.

● Physical performance test.

● Weight and height.

Validity and reliability

The respondents’ self-assessment of the quality of

life may raise questions about the validity and the
reliability of the information gathered. However, our

primary concern is not to obtain a detailed report on

specific conditions in order to formulate a “diagnosis”

but to assessthe vitality of the elderly from the perspective of physicaI, mental, and socia.Ifimctioning. Even if

it is impossible to validate each section of the interview,

we will be able to validate information on the respondents’ health status and on their physical fi.mctioning.

Several methods will be used to check the validity

and the reliability of some of the self-reported information in a sample of participants:

●

●

●

●

Medical validation—Physicians will be asked to

provide medical information about health status,

drug consumption, and hospitalization for the

participants.

Clinical assessment—Assessment of the visual

and hearing functions will be done in a random

sample to check the validity of the tests administered during the home visit.

Pe&ormancetest—During the interview, each individual will be asked to perform some physical

function, such as walking, getting in or out of a

chair, moving the arms above the shoulders,

kneeling, or writing.

Interviewof aproxy-A proxy will be interviewed

to assess the reliability of demographic data, family

composition and support, social activities, physical functioning, drug consumption, and alcohol

and smoking habits.

Conclusion

The assessment of the quality of life among the

elderly is an important task in our aging societies. The

information gathered by interview may have some

shortcomings, but several studies, some of them very

recent, have shown the accuracy of the data collected

by questionnaire in the elderly to be quite good (1l–

14).Moreover, it has been shown that self-rated health

statusis abetterpredictorof mortality than aphysician’s

assessment (15). The use of the methods previously

presented for the validation of the self-reported information could ako give more confidence in the accuracy of the data collected.

The study on the quality of life in the elderly

population of the Veneto region will:

●

●

●

●

●

Use standardized measurements for some relevant

variable-ADL, IADL, Center for Epidemiological Studies–Depression (CES–D) scale, Mini

Mental State—that allow comparisons with other

major studies.

Include a representative sample of the elderly

population.

Have staff responsible for the project who already

have been involved in previous epidemiologic

studies on aging.

Provide common training for the interviewers.

Work with international consultants from The

Johns Hopkins University and the National Institute on Aging.

References

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

National Institute

italiano, ed. 1985.

of Statistics. Annuario statistic

National Institute of Statistics. Compendio statistic

italiano, ed. 1986.

National Institute of Statistics. Annuario di statistiche

sanitarie, ed. 1985.

Berkrnan LF, Breslow L. Health and ways of living.

New York: Oxford University Press. 1983.

House JS, Robbins C, Metzner H. The association of

social relationship and activities with mortality: Prospective evidence from the Tecumseh Community

Health Study. Am J Epidemiol 116:12340, 1982.

Katz SC, Ford AB, Moskowitz RW, et al. Studies of

illness in the aged. The index of ADL: A standardized

measure of biological and psychological fimction.

JAMA 185:914-9.1963.

Nagi S2. An epidemiology of disability among adults

in the United States. MilbankMem Fund Q 6:493–508.

1976.

Resow 1, Breslau N. A Guttman health scale for the

aged. J Gerontol 21:556-9.1966.

Radloff LS. The CES-D scale: A self-report depression scale for research in the general population. Appl

Psych Measur 1:385401.1977.

Folstein MF, FoIstein SE, McHugh PR. Mini Mental

State: A practical method for grading the cognitive

state of patients for the clinician. J Psychlatr Res

12:189–98. 1975.

213
11. BushTL, MlllerSR, Golden AL, Hale WE. Self-report 14. Suchman EG, Streib G, Phillips B. An analysis of the

and medical record report agreement of selected con- validity of health questionnaire. Soc Fomes 36:223-

ditionsintheelderly. Am JPublicHealth79(l 1):1554- 32.1958.

6.1989. 15. Mossey JM, Shapiro E. Self-rated health: A predictor

12. Rodgers WL, Herzog AR. Interviewing older adults: of mortality among the elderly. Am J Public Health

The accuracy of factual information. J Gerontol 72:80&8. 1982.

42(4):387–94. 1987.

13. Friedsam H, Martin H. A comparison of self-reported

and physicians’ health ratings in an older population. J

Health Hum Behav 4:179-83.1963.

214
Chapter 25

Physical, social, and

mental vitality

by Richard J. Havlik, M.D., Office of Planning

and ExtramuralPrograms, NationalCenter for

HealthStatistics

Introduction

“VitaIity-Exuberant physical strength or mental

vigo~ A person of great vitality” (l).

The image of older persons is changing in both the

popular press and the scientific literature. Articles in

magazines and newspapers now emphasize the positive aspects of growing oldratherthan onlythenegative

ones. For example, pictures of jogging older men are

shown, as are aging chess players with grandchildren

looking on (2). Also, reports are appearing about

sexual aspects of the lives of older persons (3). This lay

notion has been complemented by scientific inquiry

using the concept of “successful aging’: (4). The term

“successful” is in contrast to usual or normal aging,

which may be affected adversely by the environment

or personal habits. These potentially negative factors

could bereversibleto some extent. “Productive aging”

emphasizes the identification and encouragement of

work equivalents in older persons, such as

volunteerism, unpaidchildcare, or other such activities,

but the concept also considers broader beneficial aspects of aging (5).

The idea of extolling a positive side to health and

life experience is not a new one, but the application to

older persons may be. The concept that health is a

continuum from disease and disability atone extreme

to maximal well-being at the other was written into the

World Health Organization’s definition of health as

not only the absence of disease or infirmity but a state

of complete physical, mental, and social well-being

(6). The measurement of well-being, especially the

mental or psychological aspects, has been challenging

to investigators. Terms such as’’happiness’’are difficult

to define or measure (7). Some investigators have

raised an important question as to whether much of

self-reported well-being might be considered a personality trait and therefore not susceptible to shortterrn manipulation. For example, when a well-being

measure was applied to a nationally representative

population of olderpersons at two points in time, there

was minimal change in question responses with age or

with time (8). Presumably, even in the face of the onset

of diseases associated with aging, the measure of wellbeing did not change substantially. Those who scored

high at baseline were commonly the same ones who

scored high 10years later. Some authorshave suggested

that health-related quality of life is a more appropriate

focus of survey research (9). However, besides emphasizing morbidity measures, this construct includes,

among otherfactors, social,psychological, andphysical

functioning as they might affect health.

The problem of describing psychosocial wellbeing or vitality becomes magnified when considering strategies for cross-national studies of older persons.There may be cultural differencesin such concepts

that must be addressed (10). However, cross-national

studies offer the potential to measure true differences

between groups of people and possibly to identify

differences in other associated factors. One study

approach is to take a concept such as vitality, translate

relevant questions into different languages, and use

similar interview techniques. However, care must be

taken, because questions and techniques appropriate

in a particular cultural setting may not be appropriate

in another (11).

As an initial strategy it is possible to identify

appropriate questions within the data systems of the

National Center for Health Statistics (NCHS) for

which comparable international data might be available. For example, some survey participants have

been asked directly the following global question:

“How much energy, pep, or vitality have you felt

215
during the past month? Rate yourself from the extreme

of Oor no energy at all, listless, to very energetic or

dynamic, or 10.” This question was administered to

the First National Health and Nutrition Examination

Survey Epidemiologic FoUowup Study population in

1982–84 (12). Subjects were interviewed in their

homes, and because of the original cohort’s structure,

the oldest members could be only 86 years of age.

Figure 1 shows the distribution of responses for both

sexes combined. Generally, more older people rate

themselves on the positive side (scores of 7–10) than

on the negative end of the continuum. Almost onethird are in the upper range. In other analyses, men

tend to rate themselves higher than women do at older

ages. If we compare this subpopulation to the group

ages 32-64 years, there are fewer positive responders

in the older group.

Clearly, for international comparisons, investigators must be much more specific in the entities they are

attempting to study and use for comparisons. In fact,

it would be wise to take a pragmatic approach and

suggest questions that are currently in use and quite

simple rather than complicated. However, it is evident

that there is complexity in defining vitality. For example, regular physical activity can become fitness or

physical vitality, which can lead to positive wellbeing, increased social function, and mental vitality.

For discussion purposes, therefore, it maybe best to

disaggregate the general concept of vitality into its

various components: Physical vitality first, then social

vitality, and finally mental vitality.

Physical vitality

Background

There may be positive health effects for older

persons who participate in regular physical activity,

For example, walking at least 1 mile three times per

week appeared to be associated with diminished

fracture risk in a prospective study in Florida (13). In

aCalifornia community, more than 90 percent of those

50–93 years of age reported some form of exercise in

the previous 2-week period (14). Although physical

o 1 2 3 4 5 6 7 8 9 10

Score

SOURCE: National Center for Health Statistics. National Health and Nutrition Examination Survey I Epidemiologic Followup Study. 1982-84.

Figure1. Percentof personsages 65-86 years, by self-ratingof energy, pep,vitality in past monthon a scale

of 0-10: UnitedStates, 1982-84

216
activity and exercise are often used interchangeably,

exercise usually connotes the improvement or maintenance of physical fitness (15). Physical vitality would

beat this higher end of the performance continuum.

Representative questions and NCHS data

In the National Health Interview Survey (NHIS)

Supplement on Aging in 1984, subjects were asked

about difficulty in walking one-quarter of a mile or

two to three blocks (16). About 20-25 percent of those

ages 65–74 years and 50-60 percent of those 85 years

of age and over had difficulty (table A). This distance

translates to about 400 meters in Italy or The Netherlands, and a similar question is in the Veneto, Italy,

study and the Health Interview Survey of The Netherlands. It is a very powerful predictor of health

outcome 2 years later. One would like to measure

individuals accurately aIong the continuum from low

to high activity, However, there is the problem of selfselection, because medical problems such as pain,

shortness of breath, orexcessivefatigue might preclude

walking.

Considering the positive side of the vitality continuum, the Health Promotion and Disease Prevention

(HPDP) survey asked a question about activity in the

past 2 weeks, Among those 65 years of age and over,

41 percent reported walking for exercise (17). Popular

types of exercise forolderpersons were the following:

First, walking for exercisq second, gardening; and

third, calisthenics orgeneralexercise. Such exercise is

clearly on the opposite end from difficulty walking

one-quarter of a mile. Certain questions about regular

exercise were asked only of those participants in the

1984 Supplement on Aging capable of answering for

themselves. There were rules for authorizing the use

of a proxy, The assumption was made that if the

Table A. Percent of persons 65 years of age and over

who have difficulty waiking l/Amiie (2 or 3 biocks or

400 meters), by age and sex: United States, 1984

individual needed a proxy, such as a spouse or family

member, it was unlikely that the individual participated

in regular exercise. At all the older ages, except in the

oldest old females, about 25percentreportedexercising

regularly (table B). By way of comparison, in the

HPDP survey, 29 percent of those 65 years of age and

overreported that they exercise orplay sportsreguk-irly.

Methodological issues

It is likely that the definition of exercise will vary

between the United States and other countries, such as

Italy. There are simihuities and differences between

physical activity and exercise. Generally, physical

activity is bodily movement produced by skeletal

muscles that results in energy expenditure. Exercise

goes one step further because the bodily movement is

done to improve or maintain one or more components

of physical fitness (15). Such definitions of physical

activity and exercise would need to be operationalized

in various countries.

A general survey question is perhaps the easiest to

ask but the most difficult to quantify. In particular,

after you get beyond frequency and duration to intensity

of exercise, this quantification becomes difficult. For

example, one might have to time walking to estimate

speed. This would have to be done in various countries,

because the speed at which people walk may vary

among countries. Because of the high prevalence of

reported walking, it may be necessary to improve

intensity estimates to obtain better differentiation in

the population of older people.

As with any survey instrument, reliability and

validity of even the simplest questions need to be

assessed. Reliability is usually measured in a testretest setting. As a routine part of NHIS, the U.S.

Bureau of the Census reinterviews participants (18).

Tabie B. Percent of persons 65 years of age and over

who exercise reguiariy, by age and sex:

United States, 1984

65–74 75-84 85 years

Sex Years vears and over

65-74 75-84 85 years

Sex vears vears and over

Percent

Female . . . . . . . . . . 24.5 39.4 61.5

Maie . . . . . . . . . . . . . 21.9 29.1 48,3

Percent

Female . . . . . . . . . . 27.7 23.7 15.4

Male. . . . . . . . . . . . . 30.1 26.0 23.1

SOURCE:NationalCenterfor HealthStatistics.Supplementon

Aging, National Health Interview Survey. 1984

SOURCE:NationalCenterfor HealthStatistics.Supplementon

Aging, National Health Interview Survey. 1984.

217
For the HPDP survey, there were about 1,300 individuals with repeat interviews. Unfortunately, the

analysis was not stratified by age, but the general

results are of interest. Four of the exercise questions

were repeated within approximately the same month.

Although the Census Bureau used special statistical

tests, generally the results indicated that such exercise

questions were in the moderate to high inconsistency

range. Among the questions, “Do you exercise or play

regularly?” scored slightly better than those in which

more detailed responses were necessary. There is no

doubt that care will have to be taken in interpreting

results with questions of low reliability.

However, validity measures might be more important and more difficult to complete. The validation

criterion, or “gold standard,” would need to vary

depending on what was being measured. If cardiovascular fitness were measured, then some oxygen

consumption studies would be necessary. More appropriately for a walking survey, it may be necessary

to use a pedometer or an inshoe step counter. Performance tests for walking are part of the current National

Health and Nutrition Examination Survey III.

Social vitality

Background

Measures of social support and social functioning

have been used in epidemiologic studies as variables

that predict afavorablemortality ormorbidityoutcome

(19). It has been suggested that this concept needs

refinement and focus for use with older persons by

emphasizing, for example, questions specifically about

socialnetworks(20).However,in the present context

of possible indicators of social vitality, such measures

are not used asdescriptors but as outcomes themselves.

They are measures of important family and sociai

contributions as well as social activities that could

represent a construct for social vitality. Social vitality

has been described in various terms, including a description of types of social organizations or social life

worlds, e.g., collecting stamps or listening to music at

one extreme and formal work organizations at the

other (21). Within such social organizations, there

might be a hierarchy that represents at one end social

dependency, as exemplified by consuming things or

receiving services, versus evaluating and goal setting

at the higher level. Thus, judging ballroom dancing

could bean indicator of social vitality.

Representative questions and NCHS data

In the Supplement on Aging, a nationally representative sample of persons ages 55 and over were

asked a special battery of questions beyond the usual

NHIS core questions (16). They are consistent with

the Social Health Battery developed by Rand Health

Insurance Corporation investigators (22). However,

the timeframe of reference is the past 2 weeks rather

than month, as in the Rand instrument. For example,

during the past 2 weeks, 80-86 percent telephoned a

friend or relative (figure 2). Also, about 50 percent

attended church or synagogue or related activities, and

about 25 percent went to a show or movie, sports

event, club meeting, class, or other group event.

Methodoiogicai issues

Donald and Ware have done reliability studies on

similar questions in a younger population (22). Over a

year’s time there was a test-retest correlation of about

0.6-0.7. More detail andothercommentary areincluded

in (22), a valuable reference source. With such questions, there should be measures of construct vaiidity or

the consistency of a number of questions in the social

area, not just a single question. In addition, family

contact should probably be confiied with the children.

Also, it needs to be determined who initiated the

contact. Cross-sectional studies between the United

States and countries, such as Italy, with known strong

family orientation, large farniiies, and religious traditionswouldhave to be interpretedcarefullyto avoid

a cultural bias in comparisons.

Mental vitality

Background

There is potential overlap among the related concepts of cognitive functioning, intelligence, psychological well-being, mental well-being, and mental

vitality. Even quality of life and satisfaction are interrelated. A general well-being schedule was developed for use with national health surveys (12). “Pep or

218
Telephone relative

Telephone friend

.~

~ See relative

>

~

#

See friend

75

g

3U2 m Attend church or synagogue

s

Participate in group event

o 20 40 60 80 100

Percent

SOURCE: National Center for Health Statistics. Supplement on Aging, National Health Interview Survey. 1984.

Figure 2. Percent of persons 65 years of age and over, by selected measures of social vitality during the

pa~ 2 weeks: United-States, 1984

vitality” is one of the 18 factors that make up the

generalwell-being scale.However, there is a vitality

score that combines the question on pep or vitality

with“wakingfreshandrested,” in contradistinctionto

“feeling tired and worn out.” Practically, there could

beoverlapwiththepresenceof underlying depression.

On the opposite pole, there are the concepts of happiness, the difference between positive and negative

affect,andthepresenceof highmorale.Becauseofthe

complexnatureandlargenumberofpotentialquestions,

a summaryofvariousapproachesis helpful (22).The

use of extant questionnaires with knownvalidity and

reliability is recommended.

Representative questions and NCHS data

In the context of the NHANES I Epidemiologic

Followup Study, the National Institute of Mental

Health Center for Epidemiological Studies–Depression (CES-D) scalewas administered (12).Although

the CES-D consists of 20 questions directed at manifestations of depression, 4 of the questions involve

positive rather than negative factors, Subjects are

—

asked if they can rate their past week’s experience on

feeling happy, feeling as good as others, enjoying life,

and feeling hopeful about the future. In older persons,

50-63 percentreported positive feelingsfor 5–7 days

per week (tableC).When older persons are compared

Table C. Percent of persons ages 65-86 years who

had positive feelings in the past week based on the

Center for Epidemiologlcal Studies-Depression

(CES-D) scale, by number of days and type of

positive feeling: United States, 1982-84

Positive Less than 1-2 3-4 5-7

feeling 1 day days days days

Percent

Feeling happy . . . . . . . . 12.1 8.7 11.7 57.2

Feeling hopeful about

the future . . . . . . . . . . . 18.3 10.4 11.3 49.6

Feeling as good as

others.. . . . . . . . . . . . . 16.7 4.8 4.8 63.3

Enjoying life . . . . . . . . . . 12.1 5.6 8.6 63.1

SOURCE:NationalCenterfor Health Statistics. National

Health and Nutrition Examination Survey I Epidemiologic

FO!IOWUP Study. 1982-84.

219
with younger ones on this measure, responses are

slightly lower in the older group, but not markedly so.

Men we generally more positive than women, except

for the category “feeling as good as others.” The

reasons for these differences are not apparent.

Methodological issues

If problems with international comparisons in

physical and social activity can be anticipated, problems with mental vitality will be even more severe.

This is because of the potential effect of culture and

language that could distort comparisons. Using only

recognized instruments that have been validated in

various countries is a preferred strategy. For example,

the CES–D questionnaire has been translated into a

number oflanguages (23). Specifically, validity studies

for depression and replication of the scaling have been

done in Northern Italy (24). Clearly, there are other

questions related tomentalvitality that could be asked.

There are higher order mental functions, including

creativity, not just in the arts but in business and in

science. Education for the Third Age, a program

existing in France and elsewhere in Europe, emphasizes learning opportunities for older persons. A

comparable program, Elderhostels, is found in the

United States. In the latter program, older persons

study at universities during the summer. If participation in such programs becomes common enough,

specific questions could be developed. Finally, at least

in the popular press, some have suggested that sexual

function represents agoodindicatorof not only mental

vitality but general vitality, including physical and

social aspects (3).

Conclusions

The concepts of quality of life, general well-being,

productive aging, and successful aging are topics of

intense interest in the lay and scientific communities.

There are a variety of possible constructs for scientific

inquiry addressing the higher end of functioning in

older persons. Although there is a natural resistance to

adding yet another approach to the many existing

ones, a natural extension of the World Health Organizationdefinitionof healthis the construct of physical,

social, and mental vitality. Although well-being or

vitality must be considered a holistic entity, there

should be subdomains that interrelate. Individuals

could have a different mix of the physical, mental, and

social components, but more descriptive data are

necessary.

In order to contemplate the study of vitality in

countries with differing cultures and languages, the

use of well-validated and reliable measures is mandatory. Although the approach outlined (of using

available questions and data) appears straightforward,

it will still be necessary to evaluate various methodological issues in participating countries. Such a

strategy would allow a start to the problem of defining

vitality.

If successful, such an approach might provide

valuable data that would allow studies of different

levels of vitality and further allow the identification of

correlates and causes. This information might then

lead to interventions which, if successful, could Ieadto

changes in policy and a better life forolderAmericans.

References

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4.

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EF, Montgomery RJV, eds. Critical issues in aging

policy—Linking research and values. Beverly Hills,

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9. Patrick DL. Erickson P. What constitutes quality of

life? Concepts and dimensions, Clin Nutr 7:53-63.

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Houghton Mifflln. 1972.

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1984NationaI HeaIth Interview Survey. National Center for Health Statistics. Vital Health Stat 1(21). 1987.

17. Schoenborn CA. Health promotion and disease prevention, United States, 1985.National CenterforHealth

Statistics. Vital Health Stat 10(163). 1988.

18. Pennie K. Analyses of the reinterview data from the

1985 Health Promotion Disease Prevention Supplement to the National Health Interview Survey.

Memorandum from U.S. Bureau of the Census, Ott 8,

1987.

19. House JS, Landis KR, UmberSon D. Social relationships and health. Science 241:540-5.1988.

20. Lubben JE. Assessing sociaI networks among elderly

populations. Fam Community Health 11(3):42–52.

1988.

21. McCollum J. A perspective on social involvement

(social vitality?). In: Butler RN, Gleason HP, eds.

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York: Springer. 143J1. 1985.

22. McDowell I, Newell C. Measuring healtlx A guide to

rating scales and questionnaires. New York: Oxford

University Press. 1987.

23. Radloff LS, Ten L. Use of the Center for Epidemiological Studies–Depression scale with older adults. In:

Brink TL, ed. Clinical gerontology. New York:

Haworth Press. 1986.

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221
Measurement of vitality in

the Americans’ Changing

Lives study

by A. Regula Herzog, Ph.D., Institute for Social

Research and Institute of Gerontology, The

University of Michigan

Introduction

Efforts in the medical tradition to conceptualize

physical and mental health define good health as the

absence of symptoms, impairments, and illness conditions. The definition by the World Health Organization (WHO) (1) suggests that good health is more

than the absence of disease and infirmity-namely a

state of complete physical, mental, and social wellbeing. In other words, persons who do not suffer any

known illness condition or impairment can exhibit

quite a range of levels of functioning. For example,

older people who compete in athletic events, hold fulltime responsible employment positions, or contribute

their expertise to political or social causes are quite

different from fully retired, largely passive and sedentary older persons, even if the latter are healthy by

traditional definitions. The former, who function at a

high level of competence, exemplify what is meant by

vitality or successful aging and what isintended by the

WHO definition of good health.

The concept of vitality serves to refocus the study

of health in older age, which for too long has been

focused exclusively onthoseolderadults whose failing

physical health and mental competence make their

daily functioning difficult and number their days. At

the same time, the study of those older adults who do

exceptionallywellhasbeen neglected and, consequently,

it is not well understood what differentiates them from

those who do “just average.” The point is that the

conceptualization of health needsto spanthe entire range

ftom severe impairments to high levels of competence.

Two observations underscore the advantage of a

broad definition of health. First, the projections are for

a longer lived and, some believe, healthier older population (2,3). According to this view, major chronic

conditions and impairments will have later onsets and,

if those are the major definers of illness and health, a

largerproportion of theolderpopulation will k termed

“healthy.” This suggests that it might prove fruitful to

examine more closely those termed “healthy,” to

explore the range of functioning among them, and to

investigate predictors and trajectories for those who

function exceptionally well.

Second, the description of the progression from

health to death is a research objective of prime importance (4). Obviously, health starts to deteriorate in

subtle ways long before major symptoms of chronic

conditions and impairments become evident to individuals and their physicians. Identifying and tracing

early indications of deteriorating health will provide

critical information about the nature of the progression

from health to death. Even slight declines in vigor and

speed of functioning or in the extent and breadth of

social and leisure activities may be forerunners of

more traditionally defined health problems.

This conceptualization of vitality will be illustrated

here by presenting some measurement efforts from he

study entitled Americans’ Changing Lives (ACL) and

by displaying some of the data collected with those

measures.The ACLis aprograrnproject attheUniversity

of Michigan’s Survey Research Center that focuses on

productivity, stress, and health across the lifespan. It

is sponsored by the National Institute on Aging (NW)

and directed by James House. The major data source is a

national survey of about 3,600 noninstitutionalized

adults 25 years of age and over who were originally

interviewed in 1986andreinterviewedin early 1989.The

survey oversarnpled persons 60 years of age and over,

and thus includes more than 1,600 older persons. Only

data from ACL respondents 60 years of age or over

interviewed in 1986 are used in this paper.

223
Measurement

Measurement of physical health

Some of the traditional and widely used measures

of physical health, such as scales of the ability to

perform basic activities of daily living (ADL’s) or of

chronic conditions, yield very skewed distributions

toward the healthy extreme in the communityresiding older population. In the ACL study, a series of

questions were asked to measure functional impairment. They included a question on bed- or chairboundness, oneon difficulty bathing, oneon difficulty

climbing stairs, one on difficulty walking several

blocks, and one on difficulty with heavy housework.

Respondents who reported no difficulty with any of

these activities were termed not functionally impaired,

those who reported difficulties with heavy housework

only were termed a little functionally impaired, those

who reported difficulties with climbing stairs and/or

walking several blocks were termed modestly functionally impaired, and those who reported difficulty

with bathing or that they spend most of the day in bed

or a chair were termed severely functionally impaired.

Also asked were questions about a number of chronic

conditions. The full list included arthritis or rheumatism, lung disease, high blood pressure, heart attack or

heart trouble, diabetes or high blood sugar, cancer or

malignant tumor, foot problems, stroke, broken or

fractured bones, and urine loss. The response disrnbutions for ACLrespondents 60 years of age and over are

indeed rather skewed: About two-thirds of all respondents report no functional impairment, and over

40 percent report no chronic condition or only one.

A further differentiation among those who report

no ADL difficulties, or report no chronic condition or

only one, is achieved by asking for a self-rating of

physical health and for a self-assessment of functional

impairment because of health problems. Questions

like these are standard questions in health surveys.

The ACL data show that these questions do indeed

provide further differentiation of the respondents

termed healthy according to the questions on functional impahment and chronic conditions, because

they show considerable variation among respondents

who report no impairments or at most one chronic

condition (table A).

Table A. Percentdistributionof persons60 years of age and over by self-assessedhealthand activity

limitation,accordingto functionallimitationand chronicconditions:UnitedStates, 1986

Functional limitation Chronic conditions

Measure None Any o-1 2 or more

Healthstatus

Unweightedtotal . . . . . . . . . . . . . . . . . . . . . 1,019

Total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

Excellent. . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Verygood . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Good . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Fair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Poor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Activity limitation because

of health problems

Unweighted total . . . . . . . . . . . . . . . . . . . . . l,ol9

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

Notat all . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

A little . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Some . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Quite a bit... . . . . . . . . . . . . . . . . . . . . . . . . 3

A great deal . . . . . . . . . . . . . . . . . . . . . . . . . 1

Number

650 618

Percentdistribution

100 100

3 20

46

E 23

37 10

17 1

Number

650 618

Percentdistribution

100 100

12 70

14

: 10

23 3

23 3

1,051

100

4

26

31

28

11

1,051

100

34

14

25

15

12

224
Based on the sarnerationale, three questions about

the frequency of working in the yard, engaging in

active sports or exercise, and taking walks were included. These measures are typically referred to as

risk factors, or health-promoting behaviors. The frequencies with which these activities are performed

may also be used to further differentiate among healthy

respondents because they show considerable variation

among those respondents without any functional

limitations or at most one chronic condition (table B).

However, the measures of physical activities illustrate a common problem with broadening the measurement of health: It is difficult to establish the capacity

for challenging activities that might be considered

reflections of a vital person because, unlike bathing

and eating, many of the more demanding physical

activities, such as sports and exercises, are performed

by only a subset of all respondents. Persons who for

reasons of personal choice or role prescriptions do not

perform the activity in question will often be unable

to report how much difficulty they would have performing it. In the ACL survey, the only measured

function that was considered relatively physically

demanding, yet is performed by most adults in this

society, is heavy housework (such as shoveling snow

or washing walls). The capacity for heavy housework

was used to establish the mildest level of functional

impairment in the ACL measure. If capacity cannot

be measured because of a lack of relevant experiences, one is often forced to measure performance—

such as when one uses measures of physical activity.

See Branch (5) for further discussion of this point.

Table B. Percent distribution of persons 60 years of age and over by physicai activity, according to functional

imitation and chronic conditions: United States, 1986

Functional limitation Chronic conditions

Phvsical activitv None Anv o–1 2 or more

Yardwork

Unweightedtotal . . . . . . . . . . . . . . . . . . . . . 1,018

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

Often . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Sometimes . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Rarely . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Never . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Sports and exercise

Unweighted totai . . . . . . . . . . . . . . . . . . . . . 1,018

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

often . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Sometimes . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Rarely,., . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Never . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Walks

Unweighted totai . . . . . . . . . . . . . . . . . . . . . 1,018

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

Often . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Sometimes . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Rareiy ,0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Never ,, .,.0.0.. . . . . . . . . . . . . . . . . . . . . 14

Number

648 616

Percent distribution

100 100

31 54

15 19

10 8

44 19

Number

647 617

Percent distribution

100 100

14 33

8 15

11 17

67 35

Number

649 617

Percent distribution

100 100

26 45

20 21

18 17

36 17

1,050

100

41

18

10

31

1,048

100

20

12

:;

1,050

100

36

21

E

225
The fact that measures of self-reported health and

physical activities can provide additional differentiation among elderly people with no functional impairments or chronic conditions is a necessary but not a

sufficient condition to establish usefulness as measures of physical vitality; validity as measures of

physical health status also needs to be established.

Correlations of the self-reported health and activity

measures with the measures of functional impairment

and chronic conditions speak to the former’s validity.

In the ACL study, these correlations range from 0.25

to 0.60, except for correlations between the number of

chronic conditions and the frequency of physical activities, which are in the O.10’s to 0.20’s. These findings are consistent with other reports (6) and provide

empirical support for the validity of self-reported

health and activity measures as measures of physical

health status. The validity of these measures has also

been suggested by their n4ationship to the timing of

subsequent mortality and to physician assessment (7,8).

Measurement of mental health

Mental health measures include measures of affective mental health, indexed by concepts such as

depression or psychological well-being, and of cognitive functioning, indexed by concepts such as intelligence and cognitive impairment.

A similar argument may be made for cognitive

functioning as that just presented for physical health.

Traditional measures for cognitive status in older age

are the Mental Status Questionnaire (MSQ) (9) and the

Mini Mental State Examination (10). These measures

identify major cognitive impairments of orientation

and memory. However, in the absence of such impairments, these measures do not further differentiate

cognitive functioning in terms of high functioning. In

the ACL, one-thirdof allrespondents made no mistakes

on a slightly abbreviated version of the MSQ another

third made only one mistake. According to the instructions, respondents who give zero or one incorrect

answerto a total ofseven questions would reconsidered

cognitively intact. Accordingly, at least two-thirds of

all olderACLrespondents are not cognitively impaired.

Yet, aside from this fact, the level of their cognitive

functioning has not been established.

Tests of general intelligence are designed to

provide differentiation among the general adult population, who for the most part have no major cognitive

impairments. In the ACL, we included a brief test of

verbal aptitude from the Lorge-Thorndike scale (11).

The test consists of a sentence completion task with

six items. This represents a subset of one of the

subscales of the Lorge-Thorndike, or what, according

to Horn (12), may be called a test of crystallized

intelligence. Respondents who made at most one

mistake on the MSQ varied considerably on the brief

Lorge-Thorndike subtest (table C). In other words,

those who do not have even a minor cognitive impairment according to the MSQ still show quite a range of

verbal aptitude according to the Lorge-Thorndike

subtest. Nevertheless, the two tests seem to measure a

similar underlying concept, because they are significantly correlated with each other (r= 0.35).

Traditional scales of affective mental health probe

for symptoms of mental distress and often provide

cutoff points beyond which a mental health problem is

considered clinically significant. In line with the argument developed so far, such measures of affective

mental health have at least two limitations. They do not

provide for a differentiation in the positive direction of

happiness and elation because they include only items of

distress,andthey furtherlimit the differentiationbyusing

a cutoff that reduces the overall score to a dichotomy.

Table C. Percentdistributionof persons60 years of

age and over by Lorge-Thorndikesubtestscore,

accordingto MentalStatus Questionnairescore:

UnitedStates, 1986

MentalStatus

Questionnaire score

Lorge-Thorndike 2 or more

subtest score All correct 1 mistake mistakes

Number

Unweighed total . . . 548 544 577

Percentdistribution

Total . . . . . . . . . . . . 100 100 100

All items correct. . . . 4 3

l mistake ..,...... 11 8 ;

2mbtakes .,...... 29 19

3 mistakes.,...,.. 44 z 34

4mistakes . . . . . . . . 9 13 21

5 mistakes .,...... 1 5

6 mistakes . . . . . . . . 2 : 13

226
Table D. Number and percent distribution of persons

60 years of age and over by satisfaction with iife and

depression: United States, 1986

Percent Unwe@hted

Measure distribution total

Satisfactionwith life

Total ..,. .,.,,. ,, . . . . . . 100

Compieteiy satisfied. . . . . . 32

Verysatisfied, . . . . . . . . . . 41

Somewhat satisfied . . . . . . 21

Not very satisfied . . . . . . . . 5

Not at all satisfied.. . . . . . . 1

Depression

Totai . . . . . . . . . . . . . . . . . . 100

3.00-2.51 (most) . . . . . . . .

2.50-2 .01 . . . . . . . . . . . . . . :

2.00-1 .51 . . . . . . . . . . . . . . 23

1.50-1,01 . . . . . . . . . . . . . . 57

liOO(ieast) . . . . . . . . . . . . . 15

1,653

492

668

368

95

30

1,659

J

422

901

230

More recent scales have addressed these limitations, First, several scales have incorporated at least

some positively worded items that array respondents

between a neutral and positive extreme, rather than

between a neutral and a negative extreme. An example

is the often-used Center for Epidemiological Studies–

Depression (CES–D) scale, which contains four positively worded items among its 20 items. Probably the

most systematically developed scale in this regard is

Bradburn’s Affect Balance Scale (13), which contains

a balanced set of positively and negatively worded

items. Bradburn has demonstrated that the positively

and the negatively worded items form two dimensions

that are independent of each other and relate differentially to various predictors. However, more recent work

has suggested that the well-replicated independence

may be afunctionof thedichotomizedresponse scale and

that a frequency response scale would yield negative

correlations between positive and negative affect (14).

Another approach, which is based on the assumption of one dimension ranging from a positive to a

negative pole, is the measurement of satisfaction or

quality of life developed at the Institute for Social

Research (15, 16). Satisfaction with life in general and

with several specific life domains are probed using

scales ranging from “completely dissatisfied” to

“completely satisfied’’orfrom’’terrible” to’’delighted.”

For more detail on the validity of these measures, see

the above-mentioned references. For more detail on

the validity of the CES–D scale with the general

population, see Radloff (17); with older adults, see

Himmelfarb andMurrell(18).

Secondly, the CES–D-as well as other scales—

can also be used as a continuous variable by summing

or averaging responses across items and utilizing the

full range of scores, rather than by using a somewhat

arbitrary cutoff point. This was done in the ACL,

where an abbreviated version of the CES-D depression scale (19) was included, along with several satisfaction questions. Response categories were(a) hardly

ever, (b) some of the time, and(c) most of the time, and

scores were averaged across the depression items. The

frequency distributions for both types of measures are

shown in table D.

Measurement of social functioning

Alternative measures ofphysicalandmental health

discussed so far correspond fairly closely to those

concepts, while at the same time providing more

variation toward the healthy extreme. However, in

moving from illness and impairment to health, the

concepts become broader. Concepts such as competence, successful aging, effective functioning, and

vitality, which are often used to describe the positive

extreme of functioning, suggest a blend of social,

mental, and physical functioning. The example of the

measure of instrumental activities of daily living

(IADL’s) will illustrate this point. The IADLmeasure

(20) is generally regarded as a measure of more subtle

functional impairment than the measures of ADL. The

IADL measure includes activities such as managing

money, making a telephone call, or cooking a meal.

All are activities that are not restricted to narrowly

defined physical health but include social and cognitive functioning and competencies.

In the ACL, we have made an effort to measure

social functioning from two different but intersecting

perspectives. First and foremost, we have tried to

conceptualize and measure the extent of productive

activities-that is, activities that generate goods or

services. Special emphasis was placed on “nonwork”

activities that occur outside of paid employment and

227
the conventional market economy, although paid

employment was also included. We view productive

activity to be at the very core of effective social

functioning: Itindicates the contributions an individual

makes to maintaining the functioning of this society.

It derives from the social-gerontological concern with

social and other activities of older adults and with

socially usefulroles that can impart a sense of usefulness

at a stage of life when paid work is often no longer a

major activity (21). Second, we also included in the

ACL study measures of interpersonal contacts that

intersect—and occasionally overlap-with measures

of informal productive activity. Although it is not

quite as obvious that high social activity implies high

vitality as it is that good physical, affective, and

cognitive functioning do, the general public considers

social and role functioning to be important indicators

of health (22).

To describe the measures briefly, the ACL questionsonproductive activities cover three main domains:

(a)paidworkeitherin theregularorirregulareconomy

(b) unpaid work at home (i.e., housework, child care,

and home maintenance) and unpaid work for organizations; (c) informal help to friends, neighbors, and

relatives. Performance of these activities (rather than

capacity) is measured in the form of hours spent in

each of nine productive activities during the past 12

months. The productivity of these activities has been

demonstrated by various methods (23). A sense of the

validity of the measures was obtained by comparing

the estimates of average hours spent by various subgroups with published information from similar and

dissimilar (i.e., time budget) measures (24).

The number of hours that older adults spend in the

various productive activities is shown in table E. The

response distributionsshow considerable variation, with

larger variations in unpaid work and helping others,

smaller variations in paid work. This confms one of the

basic hypotheses that led to our interest in productive

activities: Paid employment is not a good indicator of

productive involvement among older adults because

retiement at a certain age islargely societally ~gulated.

If one broadens the measurement of productive

activities by including unpaid work and helping others

in the manner suggested here, one finds that many

older persons are quite productive (24).

Table E. Number and percent distribution of persons

60 years of age and over, by hours of productive

activity in past 12 months: United States, 1986

Percent Unwe@hted

HOUI’Sof productive activity distribution total

Paid work

Total . . . . . . . . . . . . . . . . . . 100 1,669

None . . . . . . . . . . . . . . . . . . 75 1,263

1-200 ................. 5 77

2010r more . . . . . . . . . . . . 20 329

Unpaid work

Total . . . . . . . . . . . . . . . . . . 100 1,669

None . . . . . . . . . . . . . . . . . . 3 46

1-200 ................. 10 131

201-500 ............... 20 293

501-1,000 ............. 27 495

1,001-1,500 ............ 19 327

l,5010r more . . . . . . . . . . . 21 377

Helping activities

Total . . . . . . . . . . . . . . . . . . 100 1,669

None . . . . . . . . . . . . . . . . . . 24 456

1-200 ................. 63 1,005

2010r more . . . . . . . . . . . . 13 208

Correlations between productive activities and the

two physical health measures are generally lower than

those reported before, confirming the impression that

the concepts of physical and social health are different.

The ACL questions on interpersonal contacts (or

social integration) include three items on the frequencies of interacting with others on the telephone

and in person and of attending meetings of groups and

organizations. Response distributions among older

respondents again show some variation (table F).

Again, however, correlations between physical health

and social activities are generally low,rarely exceeding

0.10, suggesting little similarity between the concepts.

International comparisons

Quite obviously, without a special data collection,

international comparisons willdependon the availability

ofrelevant information. Severalpossible data sourcesare

discussed in this publication. Others maybe available.

Several considerations, in addition to general issues of data quality, are important when examining

228
Table F. Numberand percentdistributionof persons

60 years of age and over, by frequencyof social

activity:UnitedStates, 1986

Percent

Frequency of social activity distribution

Telephone conversation

Total, . . . . . . . . . . . . . . . . . 100

Onceaday ormore . . . . . . 52

Once a week or more. . . . . 38

Lessthanonce aweek . . .

Never, . . . . . . . . . . . . . . . . :

Visits with friends

Total . . . . . . . . . . . . . . . . . . 100

Onceaweekormore . . . . . 56

Once amonthormore . . . . 29

Less thanonce amonth . . . 10

Never . . . . . . . . . . . . . . . . . 5

Attendingmeetings

Total .,...........,.,.. 100

Onceaweekormore . . . . . 24

Once amonthormore . . . . 27

Lessthanonce amonth . . . 7

Never, . . . . . . . . . . . . . . . . 42

Unwe@hted

total

1,665

900

582

110

73

1,668

900

473

192

103

1,666

404

443

126

693

data sets forkternational comparisons. First and foremost, surveys must include large enough numbers of

older persons to allow for reliable results. Ideally,

surveys cover the entire older population of a nation

and use a scientific sample in order to represent the

population within weH-defined error margins. If they

do not cover the entire older population, they should

cover comparable subpopulations, such as the

community-residing population, women, or metropolitan elderly, to name just a few examples. Local

surveys or other surveys of noncomparable subgroups

yield statistics in which national comparisons are

confounded withotherdifferences between the specific

populations,

Survey procedures must also be comparable. While

the wording of the questions is the most obvious

example, the mode of data collection, the rate and

handling of survey nonresponse, the training of

interviewers, and missing data can introduce further

confounders if they are not comparable.

Although identical measures across nations may

suggest confidence in the validity of the comparisons,

such confidence often may not be justified for the

measures of vitality suggested here. In order to maintain equivalence of concepts across nations, different

measures may have to be used (25). Consider the

following examples from the conceptualization of

vitality. Because of laws and/or customs that regulate

behaviors such as employment, heavy housework,

walking, or yardwork, these behaviors may not be

pure expressions of individual vitality. For example,

dependingontheretirement lawsinaparticularcountry,

larger or smaller numbers of older adults will be

gainfully employed. Walking and yardwork, which

are among the most popular physical exercises for

older adults in this society (26), may not have many

followers in other societies. Likewise, interpersonal

contacts may assume very different forms indifferent

societies depending on the geography, architecture,

lifestyle, economy, and customs of a society.

CulturaI equivalence of concepts becomes even

more difficult when concepts are relatively abstract,

such as in cognitive functioning and mental health.

Measures of cognitive functioning and intelligence

are very much influenced by the culture and the

experiences to which an individual is exposed. As an

example, consider the questions about the names of

the current and past Presidents that arepartof standard

cognitive impairment measures. In a society without a

president of such high profile as the one in the United

States, giving a correct answer may be much more

difficult than in this society. Consequently, lower

proportions of correct answers are not necessarily

indicative of lesser cognitive functioning. Likewise,

the meaning and symptoms of depression may vary

across societies; if this is the case, translations from

and back to the original languages will not be sufficient

to establish the cultural equivalence. Even when

measures indicate the same concept across nations,

their metric and structural equivalence remains to be

established (27).

Conclusions

In this paper, the argument was developed that the

traditional measures of physical and mental health can

be expanded to further differentiate amongolderadults

who have no major health and cognitive problems.

229
The ultimate goal of such efforts at reconceptualizing

the measurement of health is to identify those older

adults who maintain a high level of functioning, to

pinpoint the factors that are related to such vitality and

effective functioning, and to examine the decline in

vitality as apossibleforerunnerof deteriorating health.

To summarize, it isimportant to measure a broader

range of health and effective functioning than is often

accomplished, because the study of older people who

function particularly well is likely to yield equally

important insights into the progression from age to

death as will the study of those whose functioning is

significantly impaired. Thispaperdocuments theACL

efforts at broadening the measurement of health. Other

conceptualizations and measures are possible. Toestablish such measures with cultural invariance for

cross-cultural comparisons presents a formidable

challenge because the performance and reporting of

most of the proposed behaviors, affects, and cognitive

processes areculture-bound. Nevertheless, the concept

of vitality is an important extension of the concepts of

illness and impairment. It is to be hoped that the

International CollaborativeEffort accepts the challenge

toidentifymeasures ofvitality andeffectivefunctioning

in older age across societies and to mount whatever

modest cross-cultural comparisons may be warranted

as a start.

Acknowledgment

Data collection and analysis of the Americans’

Changing Lives study were supported bygrant number AG-05561 from NIA.

References

1.

2.

3.

4.

WorldHealthOrganization.ConstitutionoftheWorld

Health Organization.Geneva: World Health Organization. 1948.

Fries JF. Aging, natural death, and the compression of

morbidity. N Engl J Med 303:130-5.1980,

Fries JF. The compression of morbidity. Milbank Q

61:397-419.1983.

MantonKG,SoldoBJ.Dynamicsof healthchangesin

the oldest old: New perspectives and evidence. Milbank

Q 63:206-85.1985.

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5.

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17.

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20.

Branch LG. Assessing physical functioningthe elderly,

Clin Geriatr Med 3:29–51. 1987.

Liang J. Self-~ported physical health among aged

adults. J Gerontol 41:248-60.1986.

Maddox GL. Self-assessment of health status: A longitudinal study of selected elderly subjects. J Chronic Dis

17:449-60.1964.

Mossey JM, Shapiro E. Self-rated health: A predictor

of mortality among the elderly. Am J Public Health

72:800-8.1982.

PfeifferE. A short portable mental status questionnahc

for the assessment of organic brain deficit in elderly

patients. J Am Geriatr Soc 22:43341.1975.

Folstein MF, Folstein SE, McHugh PR. Mini Mental

State: A practical method for grading the cognitive

state of patients for the clinician. J Psychiatr Res

12:189-98.1975.

Lorge I, Thorndike RL, eds. The Lorge-Thorndike

intelligence tests: General manual. Houghton Mifflin

Company. 1955.

Horn JL. Organization of data on life-span development of human abilities. In: Goulet LR, Baltes PB, eds.

Life-span developmental psychology. New York:

Academic Press. 1970.

Bradburn NM, The structure of psychological wellbeing. Chicago: Aldine. 1969.

WarrP, BarterJ, Brownbridge G. Ontheindependence

of positive and negative affect. J Pers Soc Psychol

44:644-51.1983.

Andrews FM, Withey SB, eds. Social indicators of

well-being: Americans’ perceptions of life quality.

New York: Plenum. 1976.

Campbell A, Converse PE, Rodgem WI+ eds. The

quality of American life: Perceptions, evaluations, and

satisfactions New York: Russell Sage. 1976.

Radloff L. The CES-~ scale: A self-report depression

scale for research in the general population. Appl

Psychol Meas 1:385+01. 1977.

Himmelfarb S, Murrell SA. Reliability and validity of

five mental health scales in older persons. J Gercmtol

38:333–9. 1983.

Kohout FJ, Bcrkman LF, Evans DA, Cornoni-Huntley

J. Two shorter forms of the CES-D scale for indexing

depressive symptoms in epidemiological surveys.

Unpublished manuscript. 1989.

LawtonMP. Assessing the competence ofolderpeople.

In: Kent DP, Kastenbaum R, Sherwood S, eds. Research, planning, and action for the elderly. New York:

Behavioral Publications. 1972.
21. Committee on an Aging Society. America’s aging:

Productive roles in an older society. Washingtorx

National AcademyPress. 1986.

22. Wa~ JEJr.The assessmentofhealth status.In:Aiken

LH,MechanicD, eds.Applicationsofsocialscienceto

clinical medicine and health policy. New Brunswick,

New Jersey:Rutgers UniversityPress. 1986.

23. HerzogAR,MorganJN. Ageandsexdifferencesinthe

value of productive activities.ArmArbor,Mlchlgam

Institute for SocialResearch. 1989.

24. Herzog AR, Kahn RL, Morgan JN, et al, Age differences in productive activities. J Gerontol Soc Sci

44:S129-38, 1989.

25. KahnR, White KL, eds. Health care: An international

study. OxfordUniversityPress. 1976.

26. McPhillipsJB,PelletteraKM,Barrett-ConnorE, et al.

Exercisepatternsin a populationof older adults.AmJ

Prev Med 5:65–72, 1989.

27. MarkidesKS,LiangJ, JacksonJS.Race,ethnicity,and

aging: Conceptual and methodological issues. W

GeorgeLK,BinstockRH, eds. Handbookof agingand

the socialsciences.3ded.NewYork AcademicPress.

1990.

231
Part IX

Special activities

related to measuring

health and health

care
Chapter 27

Contribution of the World

Health Organization

Program for Research on

Aging to activities related

to measuring health and

health care

by Jorge Litvak,M.D., Chief, Program for

Research on Aging, World Health Organization

The world is growing older, but it is growing older

very unevenly. The number of persons 60 years of age

and over has been projected to reach 1 billion by the

year 2020, but 72 percent of them are expected to live

in developing countries. Also, elderly women outnumber men in most countries of the world: The

social, economic, and health problems of older persons, therefore, are largely the problems of elderly

women (l).

These demographic projections raise a considerable challenge to public policy, particularly in developing countries. The projections demand the institution of policies and programs to ensure the availability

of health, social, and economic services for the elderly, promoting their continued participation in a

socially and economically productive life.

The World Health Organization (WHO) l%ogram

for Research on Aging is an integral part of the

Organization’s Global Program on Health of the

Elderly. The Medium-Term Program of the Global

Program fortheperiod 1990-95 identifkd as one of its

main objectives support to Member States in undertakinga situationalanalysisof the healthand health

care of the elderfi~ for the formulation of national

policies and programs.

In 1985 an advisory group made a first attempt to

prepare a prototype of a national demographic and

health profile of the elderly in support of the development of national policies related to aging. Basic health

monitoring statistics and population projections are

available from a number of international data banks,

such as the WHO Mortality Data Base, the United

Nations (LJ.N.) Demographic Yearbook Data Base,

and the U.N. Disability Statistics Data Base.

The research and the development of the data are

currently ajoint exercise between the WHO Programs

on Health Statistics and Epiderniological Trends Assessment and the Program on Health of the Elderly.

The aim of this work is to make health data policy

related and intelligible to planners.

Profiles of social, demographic, and mortality

data by country are being prepared as partially completed templates for verification and completion by

countries. Data are provided on diskette, country by

country, in a WHO-standard and portable data format

exactly as printed. These data are already available for

about 50 countries and ready for submission to these

countries for revision, correction, and filling in of

missing values from national data. This project received anew impetus from the U.N. Statistical Office

and the Department of International Economic and

Social Affairs: The impetus was to produce these data

as Special Topics in the 1989 Demographic Yearbook

and the 1990 World Health Statistics Annual.

The assessment of health status among the elderly

on an international basis is essentially limited to mortality data. With few exceptions, comprehensive data

forthe elderly population on morbidity, self-perceived

health, use of services, and indexes of activities of

daily living are not available.

It became obvious, therefore, that WHO had to

seek the collaboration of the world scientific community to generate, collect, and disseminate knowledge

gained through research on aging on a cross-national

235
basis. Cross-national research has been shown to be a

powerful method to understand both the determinants

of healthy aging and, particularly, the appropriate

technologies to apply this knowledge optimally with

a view to formulating, evaluating, and implementing

policies and programs for older persons.

WHO has undertaken epidemiological activities

since 1978 through studies of the situation and the

needs of the elderly in different regions of the world:

The 1l-country study in Europe, the 4-country study

in the Western Pacif3c, the 13-country study in the

Americas, and ongoing studies in 5 countries of the

Eastern Mediterranean and 4 countries of Southeast

Asia.

In May 1987, the World Health Assembly, acting

upon the recommendation of the WHO Advisory

Committee on Health Research, requested that the

Director General establish an international research

program on aging. The WHO Research Program on

Aging is now based at the National Institute on Aging,

following an agreement signed between WHO and the

National Institutes of Health (2).

The WHO Advisory Committee on Health Research recommended the following four initial priority areas for the Program: Determinants of healthy

aging age-associated dementias; age-related changes

in immune function; and nutritional changes associated with aging, with special emphasis on osteoporosis

(3). Consultation groups of international experts for

each of these four initial priority areas made specific

recommendations that were adopted by the Program’s

Scientific Advisory Committee.

The project on determinants of healthy aging will

explore the biomedical, social, cultural, economic,

behavioral, and environmental factors that contribute

to the achievement of healthy aging. The elucidation

of those factors that are important in influencing

transitions among health, morbidity, and disability in

an aging population will require that data be gathered

over time. The project will undertake rigorously designed longitudinal and cross-sectional studies of aging in at least six sites in developed and developing

countries. It will address agreed-upon research questions and specific hypotheses relevant to the primary

aims of the project.

The determinants of the healthy aging project will

have ramifications well beyond its direct outcomes,

The methodological aspects of the project have relevanceformany current andplannedresearch endeavors on population aging worldwide. The project will

provide the background data and a population base for

pursuing studies relevant to the otherprogrampriority

areas. Finally, the information that the proposed studies

will generate will add a new and vital dimension to

world knowledge of aging in areas of direct relevance

to the formulation of national plans of action in response to the projected global demographic and

epidemiologic transition.

The cross-national project on age-associated

dementias is a multiphase, population-based epidemiological study with specific emphasis on etiology,

standardization of instruments, determination of ageand sex-specific prevalence and incidence rates, and

assessment of risk factors in different nations, cultures, and ethnic groups. The coordinating center for

the project is in Florence, Italy, and the participating

countries are Canada, Chile, Malta, Nigeria, and Spain.

The project on age-related changes in immune

function will furnish new knowledge with regard to

the basis of the irnrnune senescence and thereby provide insights into the development of more effective

vaccines and immunization techniques.

Thecross-nationalresearch project on osteoporosis

will be conducted in six countries representing Asia,

Latin America, Africa, and Europe. The project will

focus on international comparison of the frequency of

hip fractures asitrelates to relevant risk and protective

factors.

Strengthening of national research capability is an

important goal of the Program. The emphasis centers

on cooperation and exchanges among industrialized

and developing countries. Related measures to

strengthen the national research capability of developing countries have been identified as an effective

point of entry to promote the development of

national policies and programs.

The Program’s Scientific Advisory Committee

strongly endorsed research on measurement of health

care as a needed contribution to policymakers in

developing countries (4). Advancing age brings more

susceptibility to chronic and long-term disease and

disability, with a greater demand for services in the

236
most complex levels of care. This entails the threat of

higher health care service costs. On the one hand,

therefore, plans with targeted measures that promote

health and prevent disease atlaterages are essential for

these countries in order to avoid the staggering burdens of expensive medical care now experienced by

developed countries. On the other hand, the aging of

the population makes it essential to investigate awider

range of health care options than are now in place.

These should include innovative strategies to achieve

efficiency and efficacy of services, including preventive care, home and community care, and primary

health care, as well as long-term and institutiomd care

for acute, chronic, and rehabilitation cases.

To this end, the WHO Global Program for Health

Care of the Elderly and the Research Program on

Aging are preparing a multiphase project to be implemented in three developing countries. In the initial

phase, the project intends to identify the information

necessary to create the database that will give service

providers and policymakers the basis for reorienting

the traditional models of health care to cope with the

needs of the growing number of older persons.

References

1.

2.

3.

4.

World Health Organization. Health of the elderly:

Reportof a WHOexpertcommittee.TechnicalReport

Series no 779. Geneva: World Health Organization.

1989.

WorldHealthOrganization.ResolutionWorldHealth

Assembly 40.29: International research program on

aging.Geneva:WorldHealth Organization. 1987.

World Health Organization.Special Programfor Research on Aging. Washington: U.S. Government

Printing Office. 1988.

World Health Organization. Final report of the first

meeting of the Scientific Advisory Committee, ResearchProgramonAging.Internaldocument,Sept22–

24, Ottawa,Canada. 1988.

237
Chapter 28

Health for the elderly by

the year 2000: Statistical

needs

by Ronald G. Blankenbaker, M.D., Vice President for Medical Affairs, St. Vincent Hospital

and Health Care Center

Introduction

Today, we live in a health care environment that is

changing sorapidly thathealthplanners, policymalcers,

and researchers find it very difficult to keep up. Much

of this change is the result of the push toward maintaining or improving the quality of health care while

significantly decreasing the expense. In response to

this dilemma, local, State, national, and international

agencies are beginning to create health policies and

plans that are more proactive and less reactive. Their

thirst for data is rapidly surpassing the public and

private sectors’ ability to assess the health status of

their various populations and subpopulations. Consequently, the stress on the scientific community to

develop meaningful studies that provide accurate results in a timely fashion is intense. This is particularly

true for studies of the elderly segment of our society.

I am associated with two quite different organizations that are keenly interested in efforts of the International Collaborative Effort (ICE) on Aging to measure health and health care of older persons. The frostis

the National Committee on Vital and Health Statistics

(NCVHS, 6525 BelcrestRoad, Hyattsville, Maryland

20782), an advisory committee to the Secretary of the

U.S. Department of Health and Human Services

(DHHS) on broad matters of vital and health statistics.

The second is the Society of Prospective Medicine

(P.O. Box 55110, Indianapolis, Indiana 46205; phone

(317) 549-3600), a group of health professionals

committed to the concept that the strategy of preventive medicine can and should be applied to all persons

regardless of age, sex, race, socioeconomic status, or

nationality. From these two perspectives, I will

attempt to present to you what is being done

and/or what we perceive is statistically needed to

evaluate the health status of the elderly population

of the United States as well as the world.

In a sense, I am representing the user committees

for the work being done by the ICE on Aging project.

If we are successful in our efforts, the resulting information will need to be converted into appropriate

health policy for the elderly, as well as to be put into

effective practice by health workers in the United

States and other countries.

National Committee on Vital and

Health Statistics

NCVHS was created as the result of a 1948 recommendation by the World Health Assembly to all

member countries, and it has provided an important

advisory role to a variety of Federal health agencies

since that time.

In 1974, Public Law 93–353 (Public Health Service Act) broadened the role of NCVHS to include

essentially all matters regarding vital and health statistics, and officially made the Committee advisory to

the Secretary of what is now DHHS. The interest and

expertise of those selected to be members of the

Committee have been broadened over the past 6 years

to include individuals interested in public policy,

clinical medicine and nursing, and hospital administration, along with a variety of other health and statistically related areas. The 1987 amendments to the

Public Health Service Act increased the Committee

membership to 16, with a turnover of 4 members each

year. Currently, the Committee has determined that its

function is to monitor, as best it can, the full spectrum

of issues regarding vital and health statistics. This

includes the evaluation of available data and advice on

239
the development of new data necessary for the creation of effective public polic y.

To accomplish these broad mandates, NCVHS

had developed an ongoing and dynamic 2-year work

plan ~at is updated every 3 months, and it encourages

formal reports every 1–2 years horn each of its areas

of activity. The Committee receives regular brief but

informative updates on broad statistical issues from a

variety of public and private agencies, as well as from

individuals. In addition, individual members of the

Committee have been assigned to special areas of

interest to monitor and provide regular reports to the

Committee. The gathering of data related to the aging

population is an example of one of these areas.

To deal in depth with key areas of interest, the

Committee functions through formal subcommittees,

composed of members of the parent National Committee, and informal work groups that give regular

reports to the main Committee. The National Committee works closely with the various agencies, the

Secretary, and the key staff, and it regularly seeks

public views on current issues (l).

International Classification of Diseases

As you well know, the International Classification

of Diseases (ICD) is the basis for cause-specific death

rates among countries. For example, for those 65 years

of age and over, cardiovascular disease is usually the

most common cause of death in developed countries.

More recently, the clinical modification of the 9th

revision of the ICD (2) has been used for comparison

of hospital statistics between the United States and

other countries. Of course, the use of these diagnoses

for payment systems is specific to the United States.

A major effort of our Subcommittee on Medical

Classification Systems has been support of the efforts

of the National Center for Health Statistics (NCHS) to

review the content of the 10th revision of the ICD,

which is scheduled for implementation in 1993;

evaluate the need for a clinical modification; and

consider the implications of using such instruments.

Obviously, this system will continue to be the backbone of international comparisons of mortality and

morbidity in older persons. Cooperation of all of us

will be imperative as we move toward the implementation of the 10th revision.

Death certificate conference

Recently there has been increased concern over

the validity or accuracy of the identification of cause

of death ondeathcertitlcates. This may recompounded

by inadequate education of certifiers; a very low

autopsy rate; social pressures, such as underreporting

of acquired immunodeficiency syndrome (AIDS); and

certain laws that might affect the diagnoses used on

death certificates. NCVHS is planning a national

meeting in 1989 to address this dilemma.

Prior to the meeting, staff at NCHS and others will

prepare summaries of the various issues, which will be

made available to the invitees for review and discussion at the meeting. During the 1- to 2-day meeting

there will bean open, frank discussion of these review

papers andrelatedconcerns by invited representatives

of the appropriate national organizations.

The summary and final recommendations from

this meeting will be presented to NCVHS for review

and comment. NCVHS will then prepare a transmittal

document with critique to be sent to the Office of the

Secretary of DHHS. The summary and recommendations of the meeting, along with NCVHS response and

reaction of the Department, should ultimately be

published through the appropriate public and private

sources.

Finally, we plan to have a followup meeting 2-3

years later to assess progress, along with continuing

and emerging problems, and to make additional recommendations as necessary. We anticipate that many

countries may behaving similar problems. We would

be happy to communicate with you about your efforts

to improve this situation and to keep you apprised of

our progress.

Other National Committee on Vital and

Health Statistics interests

Other relevant ICE on Aging issues are being

addressed by standing subcommittees of NCVHS. For

example, the National Health Care Statistics Subcommittee is evaluating the comparability of health statistics in different sites, such as hospitals, doctors’ offices, and nursing homes. The Ambulatory Care

Subcommittee is attempting to work with governmental

agencies to agree on a uniform data set for recoding

outpatient data. The Long-Term Care Subcommittee is

240
considering possible quality-of-life measures for

those in nursing homes. Additionally, members of

thissubcommittee have been investigating the improvement of current instruments for measuring disability.

Disease prevention and health promotion, especially the establishment of U.S. goals for the year

2000, have been an ongoing interest of NCVHS. This

relates quite well to the World Health Organization’s

activities regarding Health for All by the Year 2000

(3). In the past, the elderly subgroup has been targeted

for special attention, and this will likely be the case in

the future.

This brings me to my second “hat” at this meeting,

the Society of Prospective Medicine.

Society of Prospective Medicine

The Society of Prospective Medicine (SPM) is an

international organization that was founded almost 15

years ago on the premise that useful life expectancy

can be increased through the assessment and reduction

of individual health risks. The original means of

accomplishing the Society’s goals was through the use

of the Health Hazard Appraisal (HEM), developed by

Drs. Lewis Robbins and Jack Hall in Indianapolis,

Indiana, in 1970(4). I had the good fortune of working

with these two pioneers during that time and have been

a strong proponent of those concepts ever since.

While the HHA is still considered the best basic

instrument available to assess individual health risks,

there have been a number of modifications to the

original HHA by a variety of sources. However, none

has approached the issue in such a comprehensive,

innovative, and open manneras has The Carter Center,

with its Health Risk Appraisal (HRA) Update of 1987

(5). Many of us believe that the concepts developed in

this new HRA have set the stage for a model HRA that

can be easily modified for use in any country. In turn,

such a model could be used as a basic instrument for

the development of disease prevention and health

promotion programs worldwide. Regardless of the

importance of this new update and its worth to future

appraisals, there is much yet to be done, in our opinion,

to prove to the world that HRA is valid and effective.

The problem we face in the further implementation of health assessment programs from which health

providers can serve effectively andhealthpolicymakers

can plan appropriately are that:

1.

2.

3.

4.

5.

6.

Much needs to be done to better understand the

natural history of disease and the precursors (predictors) of these diseases.

a.

b.

c.

d.

e.

There are many situations in which it is difficult to assess individual risk based on group

data, e.g., the speed, size, and quality of construction of the automobile in relation to a

predictable motor vehicle accident fatality.

Many risk factors are solid predictors, e.g.,

smoking and lung cancer, while others are

soft, such as high-density lipoprotein and heart

disease.

There are multiple gaps in the available data,

e.g., the effect of exercise on health.

There is much to be done to determine the

impact of race, sex, and sociocultural and

economic factors on the disease process so that

the HRA can be used in the various world

populations.

As our concern for the elderly moves from

acute to chronic diseases and from death to

quality of life, our need for statistics on morbidity must be emphasized. This will be a

strong challenge to all of us and extremely

costly, but one that we cannot ignore.

Each time we update the HRA we create a “snapshot” of an ever-changing, dynamic process. The

HRA that is valid today may not be tomorrow.

HRA is a young, inexact science, which probably

will always utilize a sprinkling of judgment and

assumption that requires the interpretation of a

clinician. Because of this it will always seem fiat

there are not enough available data.

Multiple approaches and studies are currently being carried out by organizations and agencies at all

levels. This often results in confusion, duplication,

and inefficiency due to a lack of appropriate coordination.

Most of the data we accumulate regarding mortality come from death certificates, with the concerns

for accuracy and validity already addressed.

It is very expensive to implement a long-term

prospective study that will stand up to scientific

241
scrutiny. Consequently, many of these good, important efforts do not reach the refereed journals.

In spite of these difficulties, the future has never

appeared brighter for HRA. The American public and

many other populations me developing a very supportive attitude toward disease prevention and health promotion, and the scientiilc world is becoming more and

more receptive. To continue this momentum, we mus~

1.

2.

3.

4.

5.

Develop the resources (funding and expertise)

necessary to collect accurate and relevant data that

can be effectively translated to proactive health

policymaking and planning. This should include

ourbest efforts to encourage physicians tocarefully

and accurately complete each death certificate so

that it truly reflects the actual disease(s) involved,

plus any contributing conditions, e.g., smoking

related to lung cancer.

Create longitudinal prospective studies that will

meet the scrutiny of the scientific world, e.g., the

Framingham studies. Approaches to this could

include:

a. Isolated studies of individual diseases and risk

factors.

b. International, national, or regional comprehensive evaluation of all diseases.

c. A combination of the two.

Seek funding for these prospective studies and

assist in the publication of the results in the appropriate scientific literature. While the Proceedings

of SPM’S annual meetings are still the single best

source of such information, these efforts must be

presented in the regular disease prevention and

health promotion journals.

Develop a mechanism to maintain and continually

update the policies and procedures for HRA. This

should be accomplished on an annual or biennial

basis at the least and maybe the most important of

these recommendations. The Carter Center in

Atlanta is making this an ongoing project.

Encourage DHHS and other appropriate national

and international agencies to continue to move in

the direction of proactive health policies that are

based upon a sound intelligence system. This will

require coordination and cooperation among all of

the agencies involved in this arena.

242

6.

7.

Modify our medical education system so that it

teaches howtoprevent disease and promote health.

Once this is accomplished we will be able to

develop a much more effective working relationship between clinical medicine and health education. This will enhance disease prevention and

health promotion programs and provide the cooperation necessary to see usinto the 21st century.

Continually evaluate and reevaluate the results of

our plans and programs. To do this will provide an

automatic mechanism that will direct the need for

plan changes and the necessary improvements or

modifications in the way we collect data. We will

then be able to assess the productivity of these

efforts as well as their accountability. This should

move us into the creditable position we all are

seeking.

Conclusion

NCVHS and SPM have vested interests that are

complementary to those of the ICE on Aging, and I

hope we can be supportive of each other’s efforts. We

would like to remain involved with these activities and

commit our resources whenever possible to assist in a

successful outcome.

References

1.

2,

3.

4.

5.

National Committee on Vital and Health Statistics.

1988AnnualReport.National Centerfor Health Statistics. Washington Public Health Service. 1989.

PublicHealth Service andHealthCareFinancingAdministration.InternationalClassificationof Diseases,

9th Revision, cliical modification. 3d ed, Washington: PublicHealth Service. 1989.

WorldHealthOrganization.Formulatingstrategiesfor

health for all by the year 2000. Geneva:WorldHealth

Organization.1979.

Robbins LC, Hall JH. How to practice prospective

medicine. Indianapolis: Methodist Hospital of Indiana,Inc. 1970.

The Carter Center of Emory University. Healthier

people.Decatur,Georgia:TheCarterCenterofEmory

University. 1988.
Part X

Summary
Chapter 29

Overview

by Manning Feinleib, M. D., Dr.P. H., Director,

National Center for Health Statistics

We have had a very informative 3 days here. We

have learned a good deal from the splendid presentations at the plenary sessions, and the working group

sessions have been very productive. The issues that

have been brought up involve a number of methodological issues aswell asseveral substantive ones. One

of the main challenges of this International Collaborative Effort on Aging is to redirect the primarily

substantively oriented research toward the methodological and data collection issues that can enhance the

measurement aspects of a wide variety of health and

health care projects.

Virtually every speaker at this Symposium stressed

the need for better data on the elderly population and

the need to develop and test new instruments tomeasure

the many diverse and complex aspects of aging. There

was clear recognition of the need to enhance current

data collection systems, such as improving the quality

of death certificate information for the aging; obtaining more detailed information from hospitals, nursing

homes, and other health care providers; and achieving

wider use of population-based examination and interview surveys of the elderly. Before implementing

all of these improvements, however, we should frost

examine to what extent the currently available instruments and data bases in our several countries are

comparable and, where there are differences, which

ones are the most useful and whether standardized

methods can be achieved.

The working groups have deliberated vigorously

and have come up with several dozen different research proposals. We now have to flesh out these

proposals and decide which of them—undoubtedly a

relatively small number-can actually be implemented

during the next 3 or 4 years. During the next few

months the planning group will review the suggestions

from the working groups, discuss them with our colleagues at the National Institute on Aging and other

Federal agencies, and recommend which of them

should be implemented during the next few years.

Joan Van Nostrand, Bob Hartford, and Sam Notzon

will be in touch in a few months to let you know which

are the priority projects that have been approved and

to seek your enlistment for the joint collaborative

activities that will ensue. I am optimistic that we will

forge a successful international collaborative effort.

Thank you all again for your efforts and splendid

contributions, which have made this Symposium such

a success.

245
Chapter 30

Comparing cardiovascular and cancer statistics

by Harry M. Rosenberg, Ph.D., Chief, Mortality

Statistics Branch, National Center for Health

Statistics

In preparing the notes of the report of the working

group, I would like to thank mycolleagueMr. Kenneth

Kochanek, also of the National Center for Health

Statistics (NCHS), as well as the members of the

working group, which included Dr. Harvey J. Cohen,

Dr. Tamara Harris, Dr. Millicent Higgins, Mr. James

Lubitz, Dr. David MacFadyen, Dr. Callum Muir, Ms.

Constance Percy, Dr. Thomas Strasser, Mr. Thomas

Thorn, and Ms. Valerie Van Holten. The purpose of

ourworking group’s activities wasto develop aresearch

proposal on the comparability of diagnostic statistics

in international studies, focusing on cancer and cardiovascular diseases, the two leading causes of death

among the elderly.

To achieve international comparability in diagnostic statistics requires a high degree of standardization in definitions, measurement instruments, data

processing and quality control, and data presentation.

This is being accomplished by a number of ongoing

efforts, such as the MONICA (Multinational Monitoring of Trends and Determinants in Cardiovascular

Diseases) study described by Dr. Millicent Higgins,

which focuses on cardiovascular diseases, as well as

the recently initiated World Health Organization

(WHO) Special Program for Research on Aging,

described by Dr. Jorge Litvak, which focuses on ageassociated dementias, age-related changes in immune

function, and osteoporosis. Such large-scale initiatives—through which new data are being collected—

are the principal mechanisms forensuringinternational

comparability in diagnostic statistics for specified

medical conditions.

In addition to such efforts, improvements in international comparability can be achieved through international agreements such as the International

Classification of Diseases (ICD) of WHO. Since the

beginning of this century, the ICD has played a key

role in promoting the international comparability of

diagnostic statistics, particularly in the area of mortality, and now increasing y in morbidity statistics.

International compacts such as ICD are central to

promoting international comparability in health statistics, particularly for ongoing data collection

mechanisms, such as vital statistics and hospital discharge statistics, that serve both administrative and

statistical purposes. Specially designed studies such

as MONICA are important for generating internationally comparable health statistics through

standardized data collection instruments, diagnostic

protocols, data presentation and analysis, and data

quality assurance activities.

Further promoting international comparability of

diagnostic statistics are national evaluation studies on

the reliability and validity of diagnostic information

on health records. Many such studies have been carried out for mortality. These compare information

from the death certificate with other sources, such as

autopsies, clinical records, and clinical-pathological

correlations. International efforts such as the ICD and

the new WHO Special Program for Research on Aging,

as well as national efforts such as evaluation studies of

cause of death, are important to enhancing the internationalcomparability of diagnostic statistics.

Within the context of these considerations and

guided by theoperatingprinciple that this International

Collaborative Effort (ICE) on Aging initiative will use

existing data, with few if any additional resources, our

working group explored the following areas:

● Data bases.

c Methodological approaches.

● Conceptual frameworks.

● Methodological considerations.

s Potential research collaborators.

247
While there was a far-ranging discussion of these

topics, closure was not achieved on a specific research proposal within the working group deliberations. However, Dr. Callum Muir developed a

specific proposal that will be presented after my

general presentation of the working group

recommendations.

The working group identified a number of areas

that may be the basis for fi,uther activities. These

include the analysis of existing national data, both

underlying and multiple cause-of-death data, as well

asliterature surveys in a number of areas related to the

comparability of diagnostic statistics. The areas need

to be prioritized and their feasibility determined. The

principal areas of consideration follow.

Data bases

A number of data bases were proposed for consideration, including the following:

1.

2.

3.

4.

5.

6.

7.

The SEER (Surveillance, Epidemiology, and End

Results) program (in the United States) and its

international equivalents.

Hospital and physician use and expenditure data

from the Health Care Financing Administration,

possibly linked with other data sets. It is not known

if this U.S. data base has counterparts in other

countries.

The Global Epidemiological Surveillance Program of WHO, which may have useful information forcause-of-death validation studies basedon

consistency checks, time and age trend checks,

etc.

Existing databases from international studies such

as MONICA, which have the advantage of highly

standardized methods and good quality control. It

is believed that participants and researchers in the

ICE on Aging could have access to these data.

The Intersalt Study (sodium and blood pressure);

however, the numbers in the data base are quite

small for the elderly population.

ARIC (Atherosclerosis Risk in Communities).

The CARDIA (Coronary Artery Risk Factors

Development in Young Adults) Study, which also

is limited by small numbers.

248

8. Otherinternational community registries, although

they often have a low age limit.

Methodological approaches

A number of methodological approaches were

suggested, as follows:

1.

2.

3.

4.

5.

Literature review of existing studies of cancer and

cardiovascular diseases to determine if findings

for younger old can be extended to oldest old.

MONICA is oneexampl~ however, the age cutoff

for MONICA is under 85 years.

Literature review of existing studies of clinicalpathological confrontations; however, it is recognized that these data bases may be biased.

Analysis of trends, such as the work currently

being done by Thomas Thorn of the National

Heart, Lung and Blood Institute (NHLBI), with

Dr. Fred Epstein and Dr. Paul Leaverton. This is a

monograph that compares trends in death rates

from 1950 through 1985 for 27 countries by sex

for the age groups 35-44, 45-54, 55-64, and

65–74 years for all causes of death combined and

forheartdisease, stroke, and cancer. One aspect of

this work is Dr. Epstein’s analysis of these data in

terms of concordance or discordance of trends

among the three causes of death (actually four,

since lung cancer and all other cancers are behg

tracked separately). For ages 65–74 years, thiswork

might be relevant to the thrust of the Symposium and

this working group. However, the analysis is based

on the underlying cause-of-death data compiled by

WHO, and the data are taken at face value.

Use of linked records, as in the Oxford study;

however, linked record information is not widely

available internationally, and issues of confidentiality are even more pressing in Europe than in the

United States. The workshop did not thoroughly

explore what types of linked records are available

for this purpose.

Literature review of cause-of-death validity and

reliability studies, drawing, for example, on

Constance Percy’s knowledge of international

differences with respect to applying ICD coding

principles to cancer mortality.
6.

7.

8.

Analysis of existing data bases, such as the

FraminghamHeart Study, to determine the extent

to which cause of death reported on the death

certificate is consistent with diagnostic information collected in the study. A focus of such an

analysis isto determine ifsuch comparisons change

with increasing age, with a focus on the elderly

population.

Another type of analysis would use multiple causeof-death data, available for the United States and

possibly some other counties. The data would be

used to tabulate the leading causes of death not

only in terms of the traditional underlying cause of

death but also in terms of combinations of causes

of death for the older population. While it is

recognized that the issue of quality and completeness of reporting is even more critical for

multiple than for underlying cause of death, such

applications seem relevant to the elderly, many of

whom have a number of concurrent chronic conditions at the time of death.

Analysis of age curves of mortality among countries, with an emphasis on comparisons between

the old and the oldest old. This would reveal how

variable death rates are among counties and find

some way to judge the quality of numerators and

denorninators, that is, to see if the differences are

spurious or real.

Analysis of indicators of quality in cause-of-death

data, such as the percent of deaths classified to the

category “symptoms and ill-defined conditions.”

This could be extended to categories such as

“sudden death” and “cardiac arrest” and tabulated

by age, with an emphasis on the old and oldest old.

Conceptual frameworks

Twobroadconceptual frameworks were suggested,

as follows:

1.

2.

A framework based on avoidable diseases and

causes of death, such as the work by Walter

Holland. The question was raised whether this can

be related to service utilization.

A framework based on the validity of the survey

instrument and its impact on different diagnoses in

terms of morbidity, mortality, survival, risk, and

burden.

Methodological considerations

Methodological considerations were considered

by the workshop to be of overriding importance in

examining the international comparability ofdiagnostic

statistics. They include the following:

1.

2.

30

4.

5.

6.

7.

8.

9.

Examining data for the oldest old (85 years of age

and over), possibly in comparison with the younger

age groups (65–74 and 75–84 years). It was noted

that, for the United States, age curves show unusually low death rates for the oldest old compared

with those in other countries.

Consider severity and staging of disease, if possible.

Focus on specific diseases, such as cancer of

breast, prostate, stomach, and lung, chronic obstructive pulmonary disease (COPD), sudden

death, acute myocardial infarction, fatal coronary

heart disease, and stroke, for which very reliable

data are available.

Look attreatment comparisons (e.g., angioplasty);

however, this was considered difficult to carry out.

Look at both mortality and morbidity data, although the latter are very limited internationally.

Take into account overlapping categories, such as

COPD and congestive heart failure.

Examine the role of physicians’ attitudes and

knowledge in the comparability of diagnostic statistics. The WHO/World Hypertension League

Hypertension Management Audit Project may

provide a model for this.

Take into account selection bias and differences in

coding when looking at the comparability of diagnostic statistics.

Attempt to identify the basis for diagnoses on the

death certificate. This may be a basic area that

needs to be addressed, drawing on existing literature. NCHS is currently undertaking a feasibility study on this subject.

10. Consider whether differential access to medical

care may have an impact on the international

comparability of diagnostic data.

249
11. Consider possible settings for which data may be

available. They include: For cancer, United States,

Japan (Osaka), Norway, France (Strasbourg),

Sicily, Shanghai, and India (Bangalore); for

cardiovascular disease (CVD), the MONICA

countries.

12. Take into account the fact that, for developing

countries, information from registries tends to be

better than data on mortality from vital statistics.

13. Consider that treatment for CVD among the elderly population is increasingly taking on the characteristics of treatment for cancer. Also, with time,

procedures that were developed using younger

patients are being applied to the elderly. Examples

are coronary bypass, kidney dialysis, and

angioplasty.

14. Consider whether methodologies and results for the

younger population are applicable to the elderly.

15. Consider what indexes should be used for international comparisons, for example, mortalityincidence ratios.

16. Make a special effort to identify possible sources

of data on morbidity and comorbidity for both

cancer and cardiovascular diseases. Such data

could be used to address the issue of avoidable

morbidity. For the elderly population, such an

approach could also provide some clues related to

item no. 13 above and may provide guidance to

clinicians in their approach to treatment and ethical

decisions for elderly patients with these common

diseases.

Potential research collaborators

(including workshop

participants)

The following are potential research collaborators

on studies of international comparability of diagnostic

statistics with emphasis on cardiovascular diseases

and cancer:

1. MONICA network out of Helsinki.

2. Ruth Hegyeli (NHLBI).

3. CVD unit in Geneva (the replacement for

Dr. Bothig).

4.

5.

6.

7.

8.

9.

Avoidable mortality and morbidity: Oliver

Stamburg, Gary Andrews, and Alan Lopez.

Japan: Hiroshi Shibata, Tokyo Metropolitan Instituteof Gerontology Shigematsu,FukuokaMedical

School, Fukuok~ Isabura Fujimoto, Osaka Cancer Registry, Osaka.

Strasbourg: Paul Schaffer, Bas Rhin Cancer Registry.

Sicily: Luigi Dardenoni, Ragusa Cancer Registry,

Ragusa.

Bangalore: Krishna Bherghava, Kidwai Memorial Cancer Institute.

Germany: Wahrendorf, Cancer Research Center,

Heidelberg.

10. U.S-Federal Republic of Germany Collaborative

Agreement (G. Payne, E. Greiser) and other collaborative agreements (Z. Piss).

11. Additional addresses can be found in Cancer

Incidence in Five Continents, Vol. V, International Agency for Research on Cancer.

Proposal for an international

study of precision of diagnosis

by C.S. Muir, M.B., Ph.D., Deputy Director, International

AgencyforResearchon Cancer

The aim of the proposed study is to determine

whether apparent differences in the precision of diagnosisof cancerorheartdisease influence the validity

of estimates of incidence and survival at national and

international levels. The study would be carried out in

two phases. The fiist phase would use existing data to

examine the definitions used for histological verification of diagnosis for solid tumors, for lymphomas,

for leukemias, and cytological specimens—needle

biopsies, for example; to examine the varying interpretations of cause of death as recorded on death

certificates only; and to examine the clinical diagnosis-theprecision andaccuracyassigned toradiological

modes of diagnosis, for example, computerized axial

tomography (CAT) scanners, nuclear magnetic resonance, and biochemical estimation. Having looked at

the definitions used in various parts of the world, ask

whether these can be standardized, that is, can one

promulgate a standard set of definitions? If one cannot, can differences be adjusted for when one is

250
comparing data? The first phase of the proposed study,

then, would use existing data to examine existing

definitions and practices.

The second phase would require new data, which

often requires funding. We want to assess whether

these apparent differences identified in the fnst phase

in the diagnosis of cancer and heart disease influence

the validity of the estimates of incidence and survival.

This could bedoneby examining the validity and basis

of the clinical-only diagnosis in various settings. How

different are the clinical-only diagnoses in various

parts of the world? We could examine the reasons for

failure to have histological verification of diagnosis,

which is so common in the United States but much less

common elsewhere.

We could examine reasons for differences in the

mortality-to-incidence ratios. Are these due to better

treatment? Are they due to a more favorable stage of

the tumor at the time of presentation across countries?

Are they due to some other factors, perhaps more

subtle, such as differences in the definition of malignancy? If we are to carry out these second phase

studies, then we need to meet the following criteria.

First, we must conduct our studies in areas where there

are reasonably large numbers of older persons with

cancers. We would probably confine ourselves to

medical records on a nominal basis to get out an

individual’s medical record. We need to have access

to histological material for some of the studies that

have been proposed. We need to be able to link the

incidence and health records with death certificates,

something that is not possible in a considerable number

of big countries today.

To sum up, the aims are to determine whether

apparent differences in the precision of diagnosis of

cancer and heart disease influence the validity of

estimates of incidence and survival at the national and

international level. We are going to do this in two

phases: First looking at how these things are defined

using existing data and then going onto a series of ad

hoc studies to find out whether these really do have an

influence on the endpoints of interest. Let me end by

quoting from an article that appeared in the New Scientist in the middle of this year, written by Richard

Smith, the assistant editor of the British Medical

Journal, who was taking about the failure of the

British Health Service “to use the vast amount of data

which is available to our universal state funded health

service for epidemiological purposes.” He concluded,

“the fhrther from the molecule, the more difficult it is

to get funding.” I was glad to hear from Dr. Feinleib

that there may be a chance of having some funding.

selected sites. We need to have the ability to access

251
Chapter 31

Health promotion and

disease prevention

among the aged

by Gerry E. Hendershot, Ph.D., Chief, Illness

and Disability Statistics Branch, National

Center for Health Statistics

I want to do three things: (a) briefly review the

presentations that were made in theplenaxy session on

health promotion and disease prevention; (b) then

summarize the discussions that took place in the

workshop on that topic the same afternoon; (c) and,

finally, summarize some discussions that took place

after the workshop, both among individuals and in a

small group meeting that we held this morning before

the opening plenary session.

Plenary session

In the first plenary session on health promotion

and disease prevention, I suggested that these could be

thought of—for the purposes of this project—as including efforts by communities and governments to

intervene in the lives of individuals to improve their use

of preventive services and their personal habits related

to health.Iaskedthequestion, Why arewe attheNational

Center for Health Statistics, particularly in the Division

of Health Interview Statistics, interested in health promotion and disease prevention among the aged?

First of all, health promotion is a major emphasis

in U.S. public health policy. The National Center for

Health Statistics (NCHS) has a commitment to providing statistics to track the progress of programs on

healthpromotion anddiseaseprevention. The National

Health Interview Survey is a major component of

NCHS activities in tracking health promotion and

disease prevention objectives. Finally, the measures

we have for many behaviors related to health promotion

and disease prevention are inadequate for the aged

population. They were developed for other age groups

and simply do not do a good job of measuring those

activities among the elderly.

I said that in this international collaborative effort

on measuring health promotion and disease prevention among the aging, my vote would be that we

improve and standardize measures across nations,

enabling us to do some comparative analysis of health

promotion and disease prevention among the elderly

in different countries. As a beginning, we hope to

establish a collaborative relationship with The Netherlands’ Health Interview Survey and theUnited States’

National Health Interview Survey and some others

which may be mentioned later. We then heard from

Henk Swinkels of The Netherlands Health Interview

Survey, who talked about health promotion and disease prevention policy and data in that country.

I would like to touch just briefly on John

McKinlay’s provocative discussion of measuring behaviorrelatedto health promotion anddiseaseprevention among the elderly and some possible solutions to

those problems. He pointed out that the social situation of elderly people is often such that

it is difficult to conduct household personal interviews successfully, and that impairments in hearing

and vision add to the difficulty. He pointed out

that telephone and mail survey techniques have improved substantially in recent years and are now

competitive with personal household interviews

for some purposes. He said we lack a total design

approach to selecting the best mix of data collection

techniques for elderly subjects, and choice of methods

is complicated by the impairments and social situations of the elderly. Thus he indicated that we need a

very flexible approach to data collection techniques

among this population.

This flexible approach should improve the response in general and maybe essential, he argued, for

attaining some kinds of information from the elderly,

especially the older old. Such a change in approach to

data collection has some very important effects,

253
because the questionnaire and protocol development

must be very different if you are using different

methods in the same survey. The training of interviewers is greatly complicated, Ishould suspect. There

is a problem of having different responses in different

modes used in the same survey. This is not something

that is easy to do, but I think Dr. McKinlay made a

good case for looking into the possibility of using

mixed-mode surveys, especially with the older

population.

He also suggested that for some kinds of surveys,

especially among the older old, surveys should be

done at the convenience of the respondent, meaning

that they should be conducted in the home or at work.

That might not have been practical until the recent

development of a variety of portable equipment that

makes possible inhome electrocardiogram and blood

pressure tests, for example. He argued that those

inhome test techniques are often as good as a clinical

test and that the only way to get some kinds of data,

especially for the oldest old, is through the use of these

portable tests.

Workshop summation

Our workshop was attended by about 25, a very

lively group, and we had what seemed at the time to be

a very complex discussion.

I set out some assumptions for the workshop. In

this international collaborative effort, I am assuming

that we have limited resources of staff and dollars, that

there will be a logistical problem in coordinating a

project across countries, and that all of us will have

competing priorities. This is not the only project and

probably not the most important project we will be

doing in the next few years. These assumptions suggested that our strategy in planning projects should be

to focus on good existing data sets, select a few

variables, and look for some short-run payoffs.

When asked what I meant by short-run payoffs,

my answer was that over the next 10-12 years we will

be doing probably four surveys on health promotion

and disease prevention, including among the elderly.

Health promotion among the elderly is going to be a

priority area fortheU.S. Year 2000 Health Objectives,

so we have a real need in the near future to develop

good techniques for measuring health promotion

254

variables among the elderly. If I could get from this

project some input for our planning process, that

wouldbea short-run payoff that would be very valuable

to the outcome and also justify my efforts and those of

my staff.

I said that we should then ask some questions,

which I addressed to the workshop. First, What good

national data sets on health promotion and disease

prevention are available? Right away, I got questions.

What did I mean by “national”? Is Hong Kong national? Scotland? TheProvinceof Venetoin Italy? We

didnotresolve that question. Isaid that, from my point

of view, the major payoff in the long run and in the

short run is a benefit to the statistical systems of

NCHS, particularly the National Health Interview

Survey, and these are national data systems. It would

be most beneficial to focus on national data sets,

meaning a nation, not a province. However, I thought

that Dr. Maggi made a good case that Veneto, even

though it is one province of Italy, is representative of

a whole nation and therefore might be a comparable

data set.

Thenit was asked what I meant by “available.” We

decided that available meant that actual data would be

available to look at during the course of this International Collaborative Effort project, which means that

while they might not yet be available, they would be

available soon. Also, there would be opportunities for

persons to participate who hope to benefit from the

efforts of the project for future projects of their own.

We then tried to list a good many national data sets

that are available. They represented Scotland, Hong

Kong, the United States, Canada, Australia, The

Netherlands, Finland, and Italy. The workshop attendees thought that there were data sets from these

nations that would be useful in a cross-national study

of health promotion and disease prevention among the

elderly.

My second question was, In those data sets, which

behaviors are measured by two or more data sets? The

behaviors, of course, are those related to health promotion and disease prevention. We listed them first

but then observed that they fell into a number of

categories that are useful to recognize. Personal characteristics make up one category of variables related to

health promotion available in these data sets that

should be considered. We are thinking hereof things
such as age and marital status. Personal behaviors

affecting health, such as smoking and exercise, make

up another category. These are examples; there were

more in the list that the workshop made up.

Use of preventive services such as breast examinations and dental care on a regular basis is another

category. Then disease and functional outcomes of

health conditions and measures of those, such as

activities of daily living and chronic conditions, form

another category. Another is personal satisfaction,

such as self-reported health and perceived control of

health.

These are categories of variables that were listed

by the workshop participants and can be found in two

or more of the data sets that you saw previously. I

would consider some of these-the personal behatiors

and pre~entive services-as most central to the health

promotion issues with which I arn concerned. I would

see the personal characteristics as control variables

or stratification variables, and the disease and fimction outcomes and the personal satisfaction outcomes

as consequences of the health promotion variables that

we are studying. My preference, and this is not

necessarily that of the workshop, would be to focus

our attention on these two categories of variables:

Personal behaviors and preventive services.

My next question to the work group was, Which of

these behaviors are important? Immediately I was

asked, What is “important”? So we discussed what we

meant by the importance of behaviors, health promotion, and disease-related behaviors. One point that

was made is that to be important a variable or behavior

must be related in some significant way to the health

outcomes. If it is not related, then it is questionable as

to whether it is important. The magnitude of that

relationship is also important. Participants also made

the point that an impmtantvariable should be amenable

to change for health promotion and disease prevention

purposes. If the behavior is not amenable to change,

then it may not be relevant to health promotion and

disease prevention activities. The objective of health

promotion and disease prevention is to alter behavior

in such away as to improve the outcomes.

We then looked at some particular behaviors that

we consider important. There were more than these by

far, but among the behaviors mentioned were smoking, drinking, physical activities, and weight control.

Among the services, some of the candidates were

breast, eye, physical, and dental examinations on a

regular basis.

We had an interesting discussion on the question,

Is smoking cessation among the elderly really important? It had been noted by Dr. Harvey Jay Cohen in

the opening address that a recent article in the New

England Journal of Medicine suggested that smoking

cessation even late in life had some important effects

on the improvement of health. Larry Branch, at the

request of one of the other participants, summarized

that article and critiqued it. He suggested that because

of the number of cases on which it was based and the

selectivity of the population studied, the results may

not be statistically reliable.

We then got into the question of what criteria we

have to apply in order to determine that there really is

a relationship between a health-related behavior and

an outcome. Should the criteria be strictly statistical?

Dr. Branch emphasized that if one assesses all the

available evidence, even though it is not statistically

conclusive, it supports the epidemiological conclusion

that smoking cessation is an important factor in later

life. I would like to draw a moral from this: Statistics

are an aid to good judgment, not a substitute.

The next question we turned to was, Can these

measures be improved? We concluded that for this

project, simple and direct measures may be adequate

for some of the health-related behaviors we want to

look at. To ask for more than that, even though

improvement could be made, may be more than we

should attempt at this time.

The example we spent sometime on was smoking

and smoking cessation as ahealth promotion objective.

I think there was a consensus that for the kind of

purpose that we are undertaking here, it would be

sufficient to get good information from older people

on whether they had ever smoked and whether they

now smoked. Those two items would be very useful

for cross-national health analysis and for improvement in measures. Additionally, if we could find out

when these people began smoking and when they

stopped, this would be information that we would like

to have.

We did turn very briefly in the closing minutes to

the question, If we decided on a few measures that we

think are important, how can they be improved?

255
Suggestions by workshop participants were to improve the operationalizationof concepts andtoimprove

the methods of data collection. By operationalization,

we are talking about questionnaire design and testing

of questionnaires; by methods, we mean the kinds of

things Dr. McKinlay talked about, multimode, mixedmode surveys. It was also suggested that we need to

improve our analytical techniques and develop modeling techniques, and we need to improve the reporting of our data, especially access to data.

Informal discussion

I asked a group this morning to comment on an

understanding of the relationship between health promotion and disease prevention which is developing in

my own mind as a result of the presentations and

workshop on assessment of vitality and aging. That

health promotion and disease prevention are related

was demonstrated in a very effective sociological way

by the fact that the workshop participants for those two

topics were almost identical. There may have beenone

or two who were not in one or the other, but they were

almost the same set of people.

Very simply put, by health promotion and disease

prevention we mean programs to change behavior,

health habits, and the use of health care services. To do

that we -have to change people’s knowledge, their

intentions, and finally their behavior. If we do that, I

think what we are aiming at is vitality. So the ultimate

objective of health promotion and disease prevention

is to improve vitality in the older population through

programs that result in a change of behavior. Health

promotion interests arein howprograms affect knowledge, intentions, and behavior, but not about ultimate

outcome.

The vitality issue, I think, is more general and

includes the health promotion activities but includes

physical, social, and mental factors other than health

promotion and disease prevention that affect vitality.

There was a long discussion yesterday about what is

meant by vitality, and I am sure there will be more of %

that today.

Bernard Wells made a valuable suggestion, that

the behaviors we select for intensive study in this

project should berelatedtoagein the older population.

We should select age-related risk factors for this

project. The affected behaviors or vitality change

rapidly with age among the elderly. When we are

developing measures, it is important to understand

what the effect of differences in age in the sample

population will be on ourprocedures. It was suggested

that we select one or two behaviors whose effect is

greatest for the young old, andone or two whose effect

is greatest for the old old.

We had some discussion of important behaviors

that might be selected in each of these two age groups.

Forthe young old, forinstance, smoking was discussed,

because the cessation of smoking at the younger old

ages will have some health benefits and improve

vitality later on. Also, overweight is a problem in the

young old. Whereas smoking isless of aproblemin the

old old, falls become a much more important problem

than they are in the young old. Malnutrition rather than

overweight may be an important problem in the old

old. The idea is to select a few variables that vary with

age among the older population for intensive study in

this project.

What steps are we going to take now? One idea

that is emerging isto consolidate the health promotion

and vitality projects. In the opinion of some of usin the

work groups, these two things rightly belong together

in some way. We will consider that. We will then

select for the health promotion part, if it is a two-part

project, one to four important behaviors that are available in data sets in different countries and are age

related in the sense I just discussed.

256
Chapter 32

Functional disability

by Mary Grace Kovar, Dr.P.H., Special

Assistant for Data Policy and Analysis, National

Center for Health Statistics

A strategy for studying

functional ability

All of the members of the work group contributed

to the discussions. The strategy owes much to their

generous willingness to contribute their intellectual

and data resources. Although I arn presenting this

paper, we are all authors.

We regard our work as very much part of the

continuum from health promotion through vitality,

successful aging, healthy aging, decreased functioning, and functional disability. Functional ability should

not be separated from that continuum. On the other

hand, we recognize that there are separate needs for

data on functional ability. Very specific measures are

needed to be used as endpoints in themselves as well

as part of that continuum.

Work group discussions

As background, I wanttoreportbrieflyon what the

work group discussion encompassed. The members of

the work group:

1.

2.

Briefly reviewed available data sets, focusing particularly on the national data sets, but with some

attention to subnational data and to longitudinal

studies.

Recognized that there are major questions that

must be kept in mind as we move toward more

international collaboration:

a.

b,

How do you define and measure disability,

health, or autonomy?

What is the purpose of collecting the data?

What is the purpose of cross-national comparisons? Some of the possibilities include:

i. To make prevalence estimates.

ii. To study interrelationships and

tions.

correlaiii. To make estimates and projections of the

need for health and medical services.

iv. To determine eligibility for services.

c. How can we redefine and expand the

measures:

i. To distinguish between physical and social ability.

ii. To include cognitive functioning.

iii. To include emotional health. “

Strategy

With those issues in mind, and based on conversations and miniworkshops that have been held during

this conference, we have developed a strategy.

1. Develop comp~able tabulations from national

surveys or systems.

Purpose: To estimate the prevalence of functional

disability.

Presentation: Symposium in 1992,workinprogress

atintermediate meeting, and presentations at other

national and international meetings.

Publication: Vital and Health Statistics, Series 5.

Format Each report will have data for the United

States andone other country. The reports will have

several sections.

a. Demographic and, insofar as possible, soci~,

economic, geographic, housing, and other

characteristics of the noninstitutionalized

population of older people.

b. Pertinent information about the health care systems that tight influence the estimates. For

example, the proportions of the people

257
in institutions and the policies for institutionalization and provision of formal long-term

care in the community could influence the

estimates.

c. Information about the prevalence of functional

disability.

i. Core data available for all countries.

ii. Other data comparable for the two countries.

iii. Data on higher level functioning (and other

measures), if obtainable.

d. Technical information.

i. Statistical-sampling, estimation, response

rates.

ii. Survey-question wording, who answered.

Procedure: Identify researchers and authors; the

people for three projects have already been identified at this Symposium. Countries to be studied

in the lirstreports are theUnited States and Canada,

Hungary, and Israel. Note that starting with these

three areas does not preclude adding others if

resources (people and data) permit.

The authors will:

● Examine questions for comparability (control

and dependent variables).

● Define table formats.

● Prepare preliminary tables. (Each country will

do its own,)

“ Exchange tables.

● Compare and adjust tables (using intermediate

symposium).

“ Prepare final tables and text.

● Compare and adjust (using intermediate symposium).

● Publish and present.

Thiswill provide somethingthatis notnowavailable

for any two countries--a comparison based on comparable, carefully examined andevaluateddatafkom

the data files rather than from published data.

2. Perform sophisticated analyses from exploratory

data analysis provided in first step.

a. Multivariate analyses and modeling.

b. Incorporation of explanatoryvariables.

i. Beds, physicians, climate—from other

sources.

ii. Smoking, alcohol consumption—from

other surveys.

These more sophisticated analyses are what many

people want to have done. There was a great deal

of excitement about the possibilities of really

understanding what we do and do not know.

However, the comparative analyses must come

first to make certain that sophisticated techniques

are not applied to inappropriate data.

3. Encourage and support analyses of subnational

data.

Because the National Center for Health Statistics

does not conduct subnational surveys, we should

not take the lead role in comparative analyses of

such data. However, we can participate and be

supportive by tabulating national data by, for

example, a geographic area or an ethnic group to

facilitate comparisons of subnational data and to

help make certain that the local area in the United

States is not atypical.

4. Enlarge andupdatetherosteroflongitudinal studies

of aging, paying special attention to studies designed to measure change (or having data that can

be used to measure change) in functioning.

The roster would not be simply a list. It would

include, for example, the sample size and whether

there was adefinedpopulation of inference. (Studies without such a population would probably not

be included.) It would have detail on measures of

functioning and include a checklist on whether

data on covariates were available. It would include

information about linkages with other records

such as death records or hospital records.

5. If feasible, begin collaborative analyses of longitudinal data.

Such analyses are badly needed to show when

repeated cross-sectional data are sufficient and

when longitudinal studies are essential. Comparative analyses are needed within the

United States as well as among nations.

6. Encourage and participate in the development of

better measures, better question wording, and better analytic techniques.

The ideas and techniques of the Cognitive Laboratory at the National Center for Health Statistics are

exportable. The United States and other nations

can use them to understand the data better and to

improve the wording of questions. Within the

United States, those techniques can and should be

258
7.

used with different population groups-Hispanic,

black, and inner-city and rural poor people—so

that we can learn whether we are actually measuring what we think we are measuring.

Performance measures are being incorporated in

the third National Health and Nutrition Examination Survey and in the Established Populations for

Epidemiological Studies of the Elderly. The measures could be incorporated into subsarnples of

other studies, especially studies in other countries.

Using performance measures would also help us

learn more about what the questions actually

measure.

We are convinced that the postponement (or amelioration) of disability depends on better information about the disease (or injury) leading to the

disability and the specific nature of the disability.

Incorporation of covariates into questions, more

analysis of the data now available, and more

specific measures will help us know what we need

to know. These are smaller projects that should be

incorporated into the ongoing analyses.

Encourage and participate in the writing and publication of a book or handbook of techniques for

collecting information about older people.

The people in this room have participated in collecting data from and about older people. We have

used various techniques, and we have learned a lot.

Among other things, we have learned that the

techniques, procedures, sampling frames, and

8.

wording of questions that are appropriate for the

younger adult population are not necessarily appropriate for older adults.

Infact, some of the findings from survey mearch that

we~ based on studies of younger adults are not

comxt for older people. For example, such studies

show that proxy respondents report lower levels of

disability andmedicalcareuse than self-respondents.

That is not necessarily true forolderpeople when the

older person is too sick disabled, or cognitively

impaired to nxpond for himself or herself.

Facilitate informal communication.

The field is moving fast, and the issues are important. We need to share what we learn as rapidly as

we can. I have learned as I have gone along, and I

suspect that everyone else doing studies of aging

has done the same. Much of what we learn does not

appear in print. Even when it does, it is too late to

help many others. Therefore, if we are to improve

the measurement of functional ability and conrnbute to healthy aging, we must facilitate the

rapid informal exchange of information. We urge

that everyone involved in cross-national research

be on an electronic network such as BITNET so

that we can talk with one another.

That is a summary of what we have discussed,

accomplished, and planned. It was a work group with

probably three times as many opinions as there were

people present and with a wealth of experience.

259
Chapter 33

Comparative analysis of

health statistics for

selected diseases

common in older persons

in the United States

by Tamara Harris, M.D., M.S., Medical Officer,

National Center for Health Statistics

Studies of geographic variation in rates of cancer

and coronary heart disease and in patterns of risk

factors for these diseases have been useful in formulating etiologic hypotheses (1,2). However, these

studies frequently provide scanty information on the

old, especially in view of potential bias in measurement

of diseases due to differential patterns of diagnosis or

medical service (3). In addition, there have been

relatively few systematic comparisons of data on

diseases, other than cancer or coronary heart disease,

that are major sources of morbidity and mortality in

older populations in the United States.

For this project, hip fracture was selected as the

main condition for which data would be collected

cross-nationally for comparative analyses, with the

understanding that hip fracture rates would serve as a

proxy for osteoporosis prevalence from country to

country. Hip fracture was selected because it

met criteria enumerated by Dr. Kelsey (Part VI,

Chapter 19):

● Are cases readily identifiable? (Does the disease

cause those affected to come to hospital or does it

cause death?)

● Are mechanisms for diagnosis readily available?

● Are diagnostic criteria adequately defined?

● Is a comparison of this outcome of sufficient

epidemiologic interest?

Hip ffacture is a disease of public healthimportance. Not only is it common in old age (4), but the

consequences are important in terms of morbidity,

mortality, and disability (5). The etiologies of both

osteoporosis and hip fracture are not well understood,

but fracture has been observed to be an age-related

process modified byenvironmental factors (6,7).These

environmental factors, which are thought to include

lack of exercise, smoking, and low dietary calcium,

would be amenable to intervention programs; therefore, this research has practical applications for health

promotion for older persons as well.

Potential benefits to the National Center for Health

Statistics (NCHS) intermsof this project could include

identification of sources of bias in assessment of

outcomes from administrative records, application of

these issues related to bias in an area of increasing

public health importance, and development of a case

model for study of measurement of nonfatal diseases

of interest in older populations.

To develop this project, the following major activities will need to be undertaken:

1.

2.

A comprehensive review of the literature on crossnational comparisons of hip fracture will be performed to identify factors that need to be accounted for in the study design and to identify

existing sources of data.

Candidate countries will need to be identified.

Criteria will involve availability of populationbased data, including age-sex specific denominator data, so that rates can be computed. The goal

would be to have awide breadth of geographic and

ethnic variation. Suggested countries included

Sweden, Finland, Iceland, Great Britain, Spain,

Hungary, Poland, Yugoslavia, Japan, China,Hong

Kong, Singapore, Israel, Egypt, Kenya, United

States, Canada, Barbados, Chile, Brazil, and India. While it may not be possible in developing

countries to obtain reliable data for the entire

country, it may be possible to obtain very useful

State or county information.

261
3.

4.

The data format for the request will include, where

possible, sex-specific data on persons 40-90 years

of age, by 5-year age groups, with special attention

to data for those 70 years of age and over. Age-sex

distributions in the same format for the denominator population would have to be available. Information would be requested on numbers of hip

fractures, numbers of deaths due to hip fractures,

and numbers of hip replacements. It is unclear

whether statistics can be generated by location of

hip fracture on femur. Obtaining data on hip fracture from previous years would be a priority. If

these data were available, they could be used for

cohort and trend analyses.

It is not within the immediate scope of this project

to perform a validity study. The World Health

Organization plans to perform a series of validity

studies for hip fracture as part of the project on

osteoporosis. As part of this International Collaborative Effort project, a short questionnaire

will be sent with the request for information.

Recommended questions include:

a.

b.

c.

d.

e.

f.

262

What is the source of data for diagnosis, i.e.,

what percent of the data is derived from x-rayproven fractures?

What isthe general impression ofthemspondent

regarding whether those with hip fracture

cometomedical attention?Are there any data for

that location that would bear on this question?

Are there data on how quickly those with hip

fracture present for treatment? Are there any

data on wLatproportion of hip fractures seen in

hospital are recent and what proportion are

partially healed? (If there were a large proportion of partially healed fractures, this might

indicate that the overall rate would undercount

the prevalence of hip fracture.)

Who pays for the care of hip fracture? If data

are available, what percent of the health budget goes for this?

Can the respondent identify potential sources

of data on bone density for the population?

Can therespondentprovide or suggest a source

for grouped risk factor information from the

same population, i.e., weight-height distributions, patterns of smoking, general diet information in terms of percent fat, general diet information in terms of calcium intake, physical

activity? For women, it would also be useful to

have population data on patterns of estrogen use

post menopause, trends in fertility rates, trends

in age at menarche and age at menopause,

and percent oophorectomy before age 50.

5. Information on two other diagnoses as well as hip

fracture will be ascertained. The same steps in

defining information, the measurement issues to

be addressed, and the sources of information will

be followed for these companion diagnoses. The

most likely candidates are breast cancer, especially

focusing on the issue of estrogen receptor status in

old age, and prostate disease, comparing

prostatectomy rates.

TheprincipalNCHS collaborator will beDr.Tamara

Harris, 0fi3ce of Analysis and Epidemiology. The two

principal collaborators for this project are

Dr. Jennifer Kelsey, epidemiologis~ Columbia Faculty

of Medicine, School of Public Health, and Dr. Suzanne

Ho, epidemiologist, The Chinese University of Hong

Kong. Dr. Jacob Brody, epidemiologist and Dean, University of Illinois at Chicago, School of Public Health,

may also participate. At NCHS, plans are to involve

Dr. AnneLooker, of theDivision of Health Examination

Statistics, and Dr. Edward Bacon, of the Division of

Health Care Statistics, in the execution of this project.

References

1.

2.

3.

4.

5.

6.

7.

Keys A, ed. Coronary heart disease in seven countries,

Circulation 41(2) Suppl I:1–121. 1970.

Doll R, Peto R. The causes of cancer: Quantitative

estimates of avoidable risks of cancer in the United

States today. J Natl Cancer Inst 66:1 191–308. 1981.

Notzon FC. International differences in the use of

obstetric interventions. JAMA 263:3286-91, 1990.

Farmer ME, White LR, Brody JA, et al. Race and sex

differences in hip fracture incidence. Am J Public

Health 74:137480.1984.

Jensen JS, Bagger J. Long-term social prognosis after

hip fractures. Acts Orthop Stand 53:97–101. 1983.

Riggs BL, Melton LJ III. Involutional osteoporosis. N

Engl J Med 314:167686.1986.

Cummings SR, Kelsey JL, Nevitt MC, et al: Epidemiology of osteoporosis and osteoporotic fractures.

Epidemiol Rev 7:178–208. 1985.
Chapter 34

International collaboration

in measuring outcomes of

nursing home care

by Joan F. Van Nostrand, M.P.A., Coordinator

of Data on Aging, National Center for Health

Statistics

I would like to acknowledge the members of the

work group because their contributions were significant. I would like to thank Bob Clark, from the

Department of Health and Human Services of the

Office of the Secretary; Jack Habib, from Brookdale

in Israel; Betty Havens, from Canad~ Anna Howe,

from AustraliW Raymond Illsley, from the United

Kingdom; Rosalie Kane, from Minnesot% Phyllis

Thorburn, from the Veterans’ Administration; and

Jack Feldman, Jennifer Madans, and Evelyn Mathis,

from the National CenterforHealth Statistics (NCHS).

Thank you for your sage advice.

The overall objective of this project is to conduct

internationalresearch into measuring outcomes of

nursing home care. The goals of this research are:

● To improve the measurement of outcomes and

related patient characteristics for frail older

persons.

● To strengthen thecomparabilityof suchdata among

collaborating countries.

● To disseminate the results of the research to encourage its international application.

Strengthening measurement and prediction of

nursing home outcomes in an international context

cm lead to the development of approaches to improve

outcomes. For those approaches that do improve outcomes, comparable international measures can facilitate cross-national applications.

The approach developed by the work group to

measuring outcomes of nursing home care has three

tiers, orlevels. Each builds on the work ofthe preceding

tier, as in a pyramid in which tier I is the base and tier

III is the apex. For each of these research tiers, I will

outline the purpose, some analytic issues, and the

utputs of the activity.

Tier I addresses the context of the measurement

research. This activity describes the context of nursing

home outcomes in each collaborating country. It provides a background for understanding the structural

and cultural framework within which long-term care

(LTC) is provided. A major focus is the analysis of

service levels and populations served. This analysis

will identify classes of nursing homes for which appropriate comparisons can be made across collaborating countries. The goal is to assure that comparisons

made in research tiers II and III are valid.

The context ofthe nursing home outcomes research

is described by several classes of variables:

● Variables about the system of LTC services (e.g.,

kinds and mix of LTC services, utilization and

payment for nursing home care, links to the acute

care system and social welfare system).

c Cultural variables (e.g., demography, resources

allocated to LTC, role of the family).

“ Descriptions of populations served and service

levels in nursing homes.

The descriptions of populations served and service

levels are important for identifying which types of

nursing homes should be grouped for appropriate

comparisons across the collaborating countries.

Tier I activities are the initial step of the measurement research. Descriptions of the service populations and service levels will be emphasized. Proposed

outputs are (a) a Vital and Health Statistics series report comparing nursing home care in the collaborating

countries and (b) a determination of groupings of

nursing homes for analyses appropriate for crossnational comparisons in tier II.

Tier II addresses research issues in measuring the

outcomes of nursing home care. Its goal is to provide

263
measures of outcomes and risk factors that can be used

in cross-national comparisons. Such comparisons can

facilitate the application of successful approaches

from one nation to another.

There are several components to the measurement

research activities in tier II. The first component deals

with variables to measure outcomes. This component

will develop measures of nursing home outcomes and

related patient characteristics to improve our understanding of outcomes, to improve our ability to predict

outcomes, and to strengthen cross-national comparisons. It will examine classes of outcomes (e.g., death,

short stays, discharges to hospital) to determine if

particular patient characteristics, singly and in combination, are related to and can predict specific outcomes. A major focus of this research isthe analysis of

variables defining outcome classes and associated

patient characteristics and how they are measured. An

initial list of outcomes and patient characteristics was

identified by the work group and will be the starting

point for the analysis.

The second component deals with comparable

measurement of outcomes between LTC in institutions and at home. For many older persons, home

health care is viewed as a substitute for nursing home

care, a substitute that provides greater independence

to the LTC client. This measurement research will

identify the key variables for comparing both outcomes

and patient characteristics between the two settings.

The goal is to identify measures that would provide

comparable data among countries and between the

majorLTC settings as well. Because data from Canada

are rich in outcome and patient data for both nursing

home and home health care, they will be the basis of

initial analysis.

The third component of tier 11research deals with

measuring actual versus expected outcomes. Increasing attention is being given to measuring the quality of

nursing home care. A major approach to defining

quality is to compare the actual outcome of care with

theexpectedoutcome for patients with similar characteristics. In this measurement research, patient characteristics will be analyzed to determine (a) which variables should be measured to determine the expected

outcome and (b) how they should be measured. Once

the expected outcome is determined, approaches for

measuring the extent to which it has been achieved

will be examined. This research must address the

continuum of outcomes for nursing home care ranging

from rehabilitation to pain control for the dying.

Australia has developed an approach for identifying

expected outcomes. This will provide a framework for

developing the research.

There are several proposed outputs for the three

research components of tier II. Results will be presented at professional meetings, in journal articles,

and in a Vital and Health Statistics series report.

Findings also will be available for the development of

major NCHS data collection efforts.

Work on tierIIresearch will begin midway through

the development of tier I research on the context of

LTC. Activities can start at the point when data on

populations served and service Ievelsof nursing homes

have been analyzed and decisions on appropriate

classes for international comparison have been made.

Research activity will continue throughout the project.

It will begin with the first component on variables to

measure and predict outcome. When that has been

established, work on the second component+omparisons across LTC settings-can be initiated. Once

that is well under way, the third component--comparisons between actual versus expected outcomes—

can begin. Research will then proceed simultaneously

on all three components.

Tier IIIaddresses developmental research inmeasuring expected well-being after discharge as an outcome. This research activity focuses on the early

stages of measurement research. It is conceptualized

as “developmental” research because our knowledge

and experience in measuring this concept are rudimentary in comparison to our knowledge and experience about outcomes. While national data are the

focus of much of the research proposed in tiers I and

II, some subnational sources rich in data on this topic

could serve asimportant resources. The goal for tier III

research is to operationalize and develop preliminary

approaches to measuring expected well-being after

discharge. These approaches can be shared crossnationally. Collaborating (and other) countries can

then test and refine the approaches in the context of

developmental research for their data systems.

Expected well-being after discharge as an

264
outcome of nursing home care was conceptualized by

the work group as multidimensional. The dimensions

include expectations about the patients’ functioning

after discharge in terms ofi

s Autonomy and discretion of the patient at discharge.

s Economic and financial concerns.

s Satisfaction with care received and its outcome.

● Social status and function.

● Psychological status and function.

The concept of expected well-being after discharge must be operationalized, and a variety of measurement issues particular to the nursing home setting

must be addressed. (For example, nursing home staff

may report a patient as “satisfied” with care when

the patient is withdrawn and depressed.) Dealing with

expected functioning after discharge based on measures made prior to or at the point of discharge is a

particular challenge of this developmental measurement research.

There are several proposed outputs for tier III

research. Presentations at professional meetings and

conferences as well as journal articles can raise the

measurement issues and report on approaches to

solving them. As the work progresses, there is potential that a Vital and Health Statistics series report on

data methodology can summarize the findings so

that the collaborating countries can build into their

data systems the testing and refining of measures of

expected well-being after discharge.

The work group noted that the potential exists to

establish linkages between this research and other

International Collaborative Effort (ICE) projects. Because activities of daily living (ADL’s) have been

identified as an important patient characteristic for

predicting outcomes, an appropriate linkage is to the

ICE project on functional ability. Information from

the functional ability project on approaches tomeasuring severe disability can feed into tier II research on

measuring and predicting outcomes. Because of the

transitions of the LTC population between the community and the nursing home, comparable measurement of ADL’s between these two settings can

provide important information for approaches not

only to improve outcomes but ultimately to prevent

nursing home stays.

Tier III developmental research on measuring

expected well-being after discharge could be

strengthened by a linkage to the ICE project on measuring vitality in older persons. The social and psychological dimensions of expected well-being are similar

to major components of the vitality research. Approaches andfindingsfiomboth projects can be shared.

While this linkage will not necessarily ensure that

similar concepts will be measured identically, it will

increase the potential of comparability.

Once the research on comparability of common

diagnoses is developed more fully, the possibility

exists of linkages to that project. Causes of negative

outcomes in nursing homes maybe the same as those

under study in the project on common diseases. Hip

fracture is a good example.

We are still in the stages of casting our net to

capture other data bases that would be relevant to tiers

II and III of the proposed research. Additional collaborators are welcome. This research presents some

formidable problems in making international comparisons, but I believe that the experts working on the

project are more than able to meet the challenge.

265
Assessment of vitality

and aging

by Richard J. Havlik, M.D., Office of Planning

and Extramural Programs, National Center for

Health Statistics

Because, as you heard earlier, there are some

linkages between health promotion and disease prevention and vitality, some of the same people attended

both sessions. There is clear overlap. I liked the

analogy that was used of the two-sided coin. On one

side you have health promotion, and on the other side,

you have vitality. It does not holdup completely, but

one is apredictor and the other is an outcome. Exercise

can be on both sides,

Our group generally acquiesced to the construct of

physical, social, and mental vitality. We will get into

that next, but a couple of interesting ideas were presented. One actually overlaps with Joan Van Nostrand’s

suggestion about use of the nursing home in studies of

vitality and quality of life. The concept of vitality and

quality of life is relative. For example, individuals

who can climb mountains, such as the 92-year-old

woman who does these things, have finally in their

older age reached their full potential. In the nursing

home situation, obviously, we are moving in a much

narrower context. Whether we can really measure

such concepts across nations is the question.

The next interesting idea, and this is a subjective

one, is the whole concept of biological age and vitality. This is where one uses health-risk assessment. Dr.

Ronald Blankenbaker has been working with the

people in the Society of Prospective Medicine for a

number of years. They use estimates of risk profiles

and can calculate a biological age, which is compared

to an actual age. If we really had enough information

about vitality, we might be able to have a vitality age

that one could use as an objective measure.

The group was appropriately cautious about crossnational comparisons. Although the other groups have

become excited aboutcross-national comparisons and

publishing, the feeling was that we had to be somewhat more cautious about this with vitality. In the

vitality area, it may very well be that we are all more

alike than we are different. There was not a clear

indication that cross-national hypotheses were

evident in the vitality area, but this may really be

because we do not have enough information to see the

differences in how vitality is conceptualized across

countries.

Additionally, we are limited by culturally bound

factors, things that we just cannot completely eliminate. One of the examples used is that, in a social

sense, it would be nice to be able to compare individuals

who are taking a course in the University of the Third

Age with other individuals. However, in Italy it would

be unusual for someone in the cohort of older women

to venture out to participate in such activity. One could

thus get the false impression that older Italian women

are not interested in education. When we do these

comparisons, we are going to need an interpretation to

go along with them.

Another issue to consider is that the indicators of

a certain type of vitality may vary among countries.

For example, in the analogy of social interaction, one

person may play cards and one person may go to a

club. If we do not ask the right question for the right

country, we may miss part of the social interaction that

occurs. We need a broad span of questioning so that if

we are really talking about social interaction, we have

enough of the potential components. We will go into

some of the details.

After all is said and done, we concluded thatcrossnational comparisons were still worth it. In fact, we are

enthusiastic about doing this and would like to forge

ahead in this collaborative effort.

Let us talk, then, about physical vitality. Because

of the universality of walking, we felt that it should be

part of vitality. We do have a problem of capturing the

different types of walking. For example, it was noted

267
that in analyzing someU.S. data, we should specifically ask about walking to and from work or walking

to and from the store. If we ask only about general

walking, we might miss these other contexts, so the

comparison of prevalence would be misleading.

Since we are building on some of the other discussions, we were able to go hto slightly more detail

about what these questions ought to include. The

feeling was that we should think in terms of what is

measurable and that one-quarter mile or 400 meters is

truly very difficult for people to estimate. Perhaps

time is the more usual way of thihking about the

amount of walking done. However, then one gets into

specifying time for a specific unit—per day or per

week. Thus there is still a very major problem in the

questions that we will use or attempt to compare

between countries. Information on intensity, although

it is important at this older age, might not have to be

collected other than for the very, very highly functioning group.

Another common activity reported in countries is

work around the house and garden. This was another

aspect of physical vitality. Whether we should ask

about this activity in terms of frequency compared to

others or other details was not discussed.

Flexibility is not flexibility in attitudes or scheduling but in movement. Stooping and bending maybe

work-related activities, but they are very important

and merit as much attention as the other aspects of

physical activity such as endurance.

All of us are awareof actual behaviors versus the

capacity for behaviors: “I would walk,” or “I could do

it, but we have somebody else do it,” or “My wife has

always done that.” This is an underlying problem that

we may not be able to address.

Finally, there are exercise and sports. If data are

available, we should try to collect them. Because these

activities are uncommon at older ages and may vary

from area to area, it maybe very difficult to collect

data, but we should try to do it.

The next area of the troika is social vitality. One of

the questions was, How do you define social vitality,

what it is and is not? An overarching theme could be

participation in social networks, such as frequency of

seeing family members, and, separately, of seeing

fkiends, but social vitality also involves organizations,

amusements, and other kinds of social networks.

However, we are also interested in finding out about a

more benevolent and activist kind of role, such as

volunteerism. Attending an organization or participating in a group session is one issue. If you reach out

and help somebody or do something for somebody,

this is another component of vitality that might be

measurable. There have been some questions and

various countries have addressed it.

The issue that I mentioned in my introducto~

remarks comes up again: That is, there are different

types of social interaction within the same construct.

We have to make sure that we cover as many of these

as we can in any comparisons.

We did not really spend much time on mental

vitality. The Center for Epidemiological Studies–

Depression (CES–D) scale scores, which were discussed in the plenary session, seemed to be worth

comparing. Someone raised the concept of locus of

control. That is an old concept, but actually control

over your environment=over what is going on in a

nursing home situation or a workshop or in anything

that we do-maybe a good indicator of vitality. We

tried to differentiate between autonomy and control.

Autonomy is doing what you wanttodoandcontrolling

yourself. Locus of control refers to outward control,

and it might be the more appropriate aspect to measure.

Sets of questions on locus of control exist, including a

set developed by J.B. Rotter.

What is our plan for vitality? It is interesting that

greatmindsmovein the samedirectioninthatwewant

to get our information together. We want to collaborate. That is the only way to go. We will have to get the

questionnaires from the various studies, including the

schedules, protocols, guidelines, and any other information that we can accumulate.

There are small studies on the issues of validity

and reliability. Some of them hinge on national and

subnational data, but others are purely directed at one

small topic or another. Maybe we can get some information on the validity andreliabilityof themeasures

that we can actually use for vitality.

There are other considerations. I have already said

that our group was cautious about the interpretation of

cross-national data. We are going to have a countryvitality matrix that will include at the onset three

indicators of vitality—walking, social interaction, and

CES–D. We will try to have some results, at least

268
preliminary ones, 18 months from now. The matrix used to provide comparable information. Some inforshould be the basis of further thinking and refinement, mation that all of us would be interested in seeing

not conclusions. We are then going to have to expand could be put in one place for descriptive purposes.

and interpret the data. A number of work groups had Data on health, functional ability, and vitality should

the idea that we should get information together. A be put together so that they will be available for

“minimum data set” or “uniform data set” could be interpretation in one place.

i“ U.S. GOVERNMENT PRINTING OFFICE 1991 — 28 1- 79 8 40 0 0 5 269
Vital and Health Statistics

series descriptions

SERIES 1.

SERIES 2.

SERIES 3.

SERIES 4.

SERIES 5,

SERIES 6.

SERIES 10.

SERIES 11.

SERIES 12.

SERIES 13.

SERIES 14.

Programs and Collection Procedures – Reports

describing the generel programs of the National Canter for

Health Statistics and its offices and divisions and the data

collection methods used. They also include definitions and

other material necessary for understanding the data.

Data Evaluation and Methods Research – Studies of new

statistical methodology including experimental tests of new

survey methods, studies of vital statistics collection

methods, new analytical techniques, objective evaluations

of reliability of collected data, and contributions to statistical

theory. Studies also include comparison of U.S.

methodology with those of other countries.

Analytical and Epidemiological Studies – Reports

presenting analytical or interpretive studies based on vital

and health statistics, carrying the analysis further than the

expositov types of reports in the other series.

Documents and Committee Reports – Final reports of

major committees concerned with vital and health statistics

and documents such as recommended model vital

registration laws and revised bitth and death certificates.

Comparative International Vital and Health Statistics

Reports -Analytical and descriptive reports comparing

U.S. vital and health statistics with those of other countries.

Cognition and Survey Measurement- RepoRs from the

National Laboratory for Collaborative Research in Cognition

and Survey Measurement using methods of coghitive

science to design, evaluate, and test survey instruments.

Data From the National Health Interview Survey –

Statistics on illness, accidental injuries, disability, use of

hospital, medical, dental, and other services, and other

health-related topics, all based on data collected in the

continuing national household interview survey.

Data From the National Health Examination Survey and

the National Health and Nutrition Examination Survey –

Data from direct examination, testing, and measurement of

national samples of the civilian noninstitutionalized

population provide the basis for (1) estimates of the

medically defined prevalence of specific diseases in the

United States and the distributions of the population with

respect to physical, physiological, and psychological

characteristics and (2) analysis of relationships among the

various measurements without reference to an explicit finite

universe of persons.

Data From the Institutionalized Population Surveys –

Discontinued in 1975. Reports from these surveys are

included in Series 13.

Data on Health Resources Utilization – Statistics on the

utilization of health manpower and facilities providing longterm care, ambulatory care, hospital care, and family

planning services.

Data on Health Reeources: Manpower and Facilities –

Statistics on the numbers, geographic distribution, and

characteristics of health resources including physicians,

dentists, nurses, other health occupations, hospitals,

nursing homes, and outpatient facilities.

SERIES 15.

SERIES 16.

SERIES 20.

SERIES 21.

SERIES 22.

SERIES 23.

SERIES 24.

Data From Special Surveys– Statistics on health and

health-related topics collected in special surveys that are

not a part of the continuing data systems of the National

Center for Health Statistics.

Compilations of Advance Data From Vital and Health

Statistics – These reports provide early release of data

from the National Center for Health Statistics’ health and

demographic surveys. Many of these releases are followed

by detailed reports in the Vital and Haath Statistics Series.

Data on Mortality –Various statistics on mortality other

than as included in regular annual or monthly reports.

Special analyses by cause of death, age, and other

demographic variables; geographic and time series

analyses; and statistics on characteristics of death not

available from the vital records based on sample surveys of

those records.

Data on Natality, Marriage, and Divorce –Various

statistics on natality, marriage, and divorce other than as

included in reguiar annual or monthly reports. Special

analyses by demographic variables; geographic and time

series analyses; studies of fertili~ and statistics on

characteristics of births not available from the vital records

based on sample surveys of those records.

Data From the National Mortality and Natality Surveys–

Discontinued in 1975. Reports from these sample surveys

based on vital records are included in Series 20 and 21,

respectively.

Data From the National Survey of Family Growth –

Statistics on fertility, family formation and dissolution, family

planning, and related maternal and infant health topics

derived from a periodic survey of a nationwide probability

sample of women 15-44 years of age.

Compilations of Data on Natality, Mortality, Marriage,

Divorce, and Induced Terminations of Pregnancy–

Advance reports of births, deaths, marriages, and divorces

are based on final data from the National vital Statistics

System and are published annually as supplements to the

Monthly Vital Statistics Repori (MVSR). These reports are

followed by the publication of detailed data in Vital

Statistics of the United States annual volumes. Other

reports including induced terminations of pregnancy issued

periodically as supplements to the MVSR provide selected

findings based on data from the National Vital Statistics

System and may be followed by detailed reports in Vital

and Health Statistics Series.

For answers to questions about this report or for a list of titles of reports

published in these series, contact

Scientific and Technical Information Branch

National Center for Health Statistics

Centers for Disease Controi

Public Health Service

6525 Belcrest Road, Room 1064

Hyattsville, Md. 20782

301-436-8500
DEPARTMENT OF 

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DHHS Publication No. (PHS) 91-l 482, Series 5, No. 6