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EpidemiologyACTIVE-LIFE EXPECTANCY AND TERMINALDEPENDENCY: TRENDS IN LONG-TERM

GERIATRIC CARE OVER 33 YEARS

R. W. STOUT VIVIENNE CRAWFORD

Department of Geriatric Medicine, The Queen’s University ofBelfast, Belfast BT9 7BL

Summary To determine whether medical advanceswill result in an increasing number of

dependent elderly people, or whether postponement ofdisability in a finite lifespan will lead to a decrease in terminaldependency, an analysis was made of 24 117 admissions to ageriatric unit from 1954 to 1986. During this period, theaverage age on admission for long-term care rose by 0·24

years per year for women and by 0·09 years per year for men.The median length of stay also increased, more for womenthan for men, as did the proportion of the total lifespan spentin long-term care. Active-life expectancy became longer andterminal dependency was postponed, but the duration ofterminal dependency increased. Active-life expectancyincreased more rapidly in women than in men, as did thelength of terminal dependency. As life expectancy continuesto increase, high priority will have to be given to reduction ofdisability and dependency in advanced old age.

INTRODUCTION

THERE are two contrasting opinions on the impact of theageing population on future trends in the care of the elderly.One view is that the survival of many more people intoadvanced old age will lead to an increasing burden ofdisability and dependency in a steadily enlarging elderlypopulation1-a phenomenon that has been described as thefailure of success.2 The other view is that the period ofmorbidity and dependency which often occupies the

terminal phase of a long life may be capable of beingshortened.** This suggestion is based on the notion that thehuman lifespan is finite and that life expectancy is

approaching its maximum. If life expectancy has ceased toincrease, but advances in medicine result in further

prolongation of the period of independent living, then thelength of terminal dependency should be decreasing.We have examined the data on elderly patients admitted

for long-term care over 33 years. In Belfast, this type oflong-term care is provided only in geriatric medical units, sothat these data give an indication of trends in the populationas a whole.

METHOD

The geriatric medical unit at Belfast City Hospital opened in1948.5 Since 1954, a standard index card has been completed for allpatients on discharge or death from the unit. The data from 24 117consecutive cards (1954-6) have been used to obtain informationon patients receiving long-term hospital care.

Analysis of clinical data over such a long period is difficultbecause of changes in the knowledge of disease and in diagnosticconventions, and of changes in bed availability and the use ofalternative accommodation. A standard, but arbitrary definition oflong-term care was, therefore, used: patients who died in hospitalafter an admission of 90 days or more were defined as havingreceived long-term geriatric care. There were 3219 such patients,1192 males and 2027 females. To ensure that those with the severestdisabilities were studied, a further analysis was made of those

Fig I-Mean age on admission for males and females who died inhospital after an admission of 90 days or more, 1954-86.

Both regression lines differ significantly from zero.

patients who died in hospital after an admission of 365 days or more.’There were 1651 such patients, 524 males and 1127 females.The data were analysed by means of SPSSX6 on the Queen’s

University ICL Series 39 Level 80 mainframe computer. Forlength of stay, median rather than mean results were used becausethe data were heavily skewed to the right. Changes with time in ageon admission and in median length of stay were determined bycalculating the variance ratio, which tests the deviation of eachregression coefficient from zero. The regression equations weredetermined with each patient’s age/year pair; thus full account wastaken of the variation about the mean.

RESULTS

Age on Admission for Long-term Care

The results differ between males and females. For

females, the mean age on admission has steadily- increasedwith time for those who died after an admission of 90 days ormore (fig 1) and those who died after an admission of 365days or more, both regression lines deviating significantlyfrom zero. For males, an increase in age on admission withtime was found in those who had an admission of 90 days ormore (fig 1), but not for those who died after an admission of365 days or more, only the former regression line deviatingsignificantly from zero. The mean age on admission forpatients dying after an admission of 90 days or moreincreased by 0-24 years per year for females and 0-10 yearsper year for males-increases which were significantlydifferent from zero in both males and females. For thosewho died after an admission of 365 days or more, the meanage on admission increased by 0-25 years per year for femalesand 0-09 years per year for males-an increase that differed

significantly from zero only in females.

Length of StayThe median length of stay for females increased

significantly with time for both categories of long-term care,but in males the change was significant only for the 90 daysor more category (fig 2). The median length of stay of thosewho died after 90 days or more in hospital increased by 5-59days per year in females, and by 6-08 days per year in males.For those whose admission lasted 365 days or more, themedian length of stay increased by 7-99 days per year infemales and by 2 22 days per year in males. There was nosignificant difference between males and females withineach long-term care category.The proportion of the lifespan spent in long-term care

was calculated by expressing the time spent in long-term

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Year

Fig 2-Median length of stay in hospital for males and females whodied in hospital after an admission of 90 days or more, 1954-86.

Both regression lines differ significantly from zero.

care as a percentage of the total lifespan for those who diedafter an admission of 90 days or more. The proportionincreased significantly with time in both males and females(fig 3). The proportion of lifespan spent in long-term careincreased by 0-023% per year in women and 0-006% peryear in men. In 1986, women spent 2 75% of their lifespanin long term care, and men 1-84%.

Life ExpectancyData for life expectancy, at birth and at age 65 years, for

the Northern Ireland population from 1955 to 1983 were

Fig 3-Proportion of total lifespan spent in long-term hospital carefor males and females who died in hospital after an admission of90 days or more, 1954-86.

The data are 5-yearly mean values. The proportions for both males andfemales increase significantly with time.

Fig 4-Life expectancy at birth in Northern Ireland, 1955-83.Both regression lines differ significantly from zero. (Source: Registrar

General for Northern Ireland.)

Fig 5-Life expectancy at age 65 in Northern Ireland, 1955-83.

Only the regression line for females differs significantly from zero. (Source:Registrar General for Northern Ireland.)

obtained from the Registrar General for Northern Ireland(data for 1954, 1956, and 1984-86 were not available) and areshown in figs 4 and 5. Life expectancy for females hasincreased significantly (p < 0-00005) at both birth and age65. The mean increase in life expectancy for females at birthis 0- 15 years per year, and at age 65 it is 0-08 years per year.For males, life expectancy at birth has increased significantly(p < 005) with time, by 0-10 years per year, but male lifeexpectancy at age 65 years has not changed since 1955.

DISCUSSION

This study supports the hypothesis that, with advances inmedical, social, and economic conditions, the age of onset ofterminal dependency has been postponed,4 and active-lifeexpectancy has increased.7 However, there has also been anincrease in the length of stay in hospital of elderly patients interms of both absolute length of stay and the proportion ofthe lifespan spent in long-term hospital care. Thus, there isno evidence for compression of terminal morbidity.4

Between 1954 and 1986 there has been an increase in the

age of elderly patients admitted to long-term care in hospital.The rate of increase has been greater in females than inmales: women are now about 5 years older than men onadmission to long-term care. It is likely that this resultrepresents a real change in the age of onset of terminaldisability, rather than a change in clinical practice, becausethe aim of the unit (to restore independence by treatmentand rehabilitation) has not changed, and there was

continuous pressure on the facilities available for long-termcare over the years studied. The possibility that the youngerelderly are now receiving care in other facilities cannot beexcluded, but no new facilities for the young chronic sickhave opened during the period studied.

Life expectancy is the average number of years of life

expected in a population at a specific age, while lifespan isthe maximum attainable age by a member of a species.During this century, life expectancy has increased, butlifespan has remained almost constant.8 Fries4 suggests thatas life expectancy approaches the lifespan, life expectancywill cease to increase, and will plateau at about 85 years sometime in the next century. If the age of onset of chronic

disability continues to be postponed, the period of terminaldependency will be compressed between the later onset ofdisability and the fixed occurrence of death.

In the present study, the age of onset of terminal disabilityhas increased, but the duration of this disability has alsoincreased. This may be explained by the fact that life

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expectancy has not yet reached the maximum lifespan. Thisis confirmed by data for life expectancy in the populationstudied which show a continuing rise9 (figs 4 and 5). Thenumber of very old people, including centenarians,10 hasalso steadily risen. In addition, there is evidence from theUnited States and New Zealand, respectively, that

disability" and dependency12 have increased within theperiod studied. In Canada, 70% of the gain in life

expectancy in men between 1951 and 1978, and 80% of thatin women, consists of increased years of disability.13 Fries’prediction cannot be fully tested, therefore, since life

expectancy has not yet reached its theoretical maximum of85 years:9 the age on admission for long-term care of ourpatients is only approaching 85 years for women, and is wellshort of that for men.An additional factor affecting length of stay in hospital is

that improvements in the treatment and management ofthese frail elderly people, although often motivated towardsimproving quality of life rather than longevity, will almostcertainly result in increased survival. Rather than

eliminating chronic disabling conditions, medical advancesmay have altered various factors contributing to their

severity and eventual terminal outcome, and hence

prolonged their duration. 14 Thus this progress has producednot only an increase in active-life expectancy, but alsoincreased years of disability and dependency at the end oflife.One finding of this study is of the differences between

males and females. Increased longevity in females is wellknown although the reasons are unclear.15 Even in the veryold, mortality is declining more rapidly in women than inmen.16 This study shows that active-life expectancy7 is alsoincreasing more rapidly in females than in males, as is theduration of terminal dependency. Male life expectancy atage 65 has not increased between 1955 and 1983, and the ageon admission and the length of stay of men in the longest staycategory has remained unchanged for 33 years.The findings of this study suggest that the aim of

maintaining elderly people in the community for as long aspossible is being achieved. However, the demand for

hospital resources is also increasing owing to improvedsurvival of the most dependent elderly, and to the increasingnumbers of aged people. As a measure of the health of oldpeople, this study gives equivocal results: survival has

improved, but at the expense of increased levels of

dependency. Further improvements in health will require ahigh priority to be given to means of reducing disability anddependency in advanced old age. Meanwhile, as life

expectancy continues to increase, the need for health andsocial services resources for elderly people will also increase.

We thank Mrs Jean Smith-Davidson for transferring the data from thepunch cards to computer cards, Dr J. D. Merrett for statistical advice, andMiss Andree Best for typing the manuscript. This work was supported bygrants from the Department of Health and Social Services (NorthernIreland). We are also grateful to the Registrar General for Northern Irelandfor supplying the information on life expectancy.

REFERENCES

1. Brody JA. Prospects for an ageing population. Nature 1985; 315: 463-66.2. Gruenberg EM. The failures of success. Milbank Mem Fund Q 1977; 55: 3-24.3. Isaacs B, Gunn J, McKechan A, McMillan I, Neville Y. The concept of pre-death.

Lancet 1971; i: 1115-19.4. Fries JF. Ageing, natural death and the compression of morbidity. N Engl J Med 1980;

303: 130-35.5. Adams GF The third phase in genatric medicine Design and purpose of a hospital

geriatric department. Lancet 1960; i: 815-17.

6. SPSSX. User’s guide. New York: McGraw-Hill, 1983.7. Katz S, Branch LG, Branson MH, Papsidero JA, Beck JC, Greer DS Active life

expectancy. N Engl J Med 1983, 309: 1218-23.8. Schneider EL, Reed JD Jr. Life extension. N Engl J Med 1985; 312: 1159-689. Registrar General Northern Ireland. Annual report 1984. Belfast: HM Stationery

Office, 1987.10. Thatcher AR. Centenarians. Pop Trends 1981, 25: 11-14.11. Colvez A, Blanchet M. Disability trends in the United States population 1966-1976:

analysis of reported causes Am J Publ Health 1981; 71: 464-70.12. Campbell AJ, Bunyan D, Shelton EJ, Caradoc-Davies T. Changes in levels of

dependency and predictors of mortality in elderly people in institutional care inDunedin NZ Med J 1986; 99: 507-09.

13. Wilkins R, Adams B Health expectancy in Canada, late 1970s: demographic, regionaland social dimensions. Am J Publ Health 1983; 73: 1073-80.

14. Manton KG. Changing concepts of morbidity and mortality in the elderly population.Milbank Mem Fund Q 1982; 60: 183-244.

15. Bayliss R, Clarke C, Whitfield AGW. The female life span. J R Coll Physns Lond 1986;20: 290-93.

16 Rosenwaike I, Yaffe N, Sagi PC. The recent decline in mortality of the extreme aged:an analysis of statistical data. Am J Publ Health 1980; 70: 1074-80

Child Health

IDENTIFICATION OF CHILDREN WITHCEREBRAL PALSY UNABLE TO MAINTAIN A

NORMAL NUTRITIONAL STATE

ERIKA G. GISEL1 JOHN PATRICK2School of Physical and Occupational Therapy, McGill University,

Montreal, Quebec H3G 1 Y5, Canada;1 and Department ofBiochemistry, Faculty of Health Sciences, University of Ottawa,

Ontario2

Summary 7 children aged 2-16 with severe cerebralpalsy and growth failure were compared

with children of the same weight in respect of their eatingefficiency. Children with cerebral palsy took 2-12 timeslonger to chew and swallow a standard amount of pur&eacute;edfood and 1-15 times longer for solid food than did theirweight-controls. A behaviour score of feedingcharacteristics was higher in children with cerebral palsythan in controls. Even long meal times do not compensatefor the severity of these childrens’ feeding impairment. Themeasurement of feeding efficiency provides the basis forearly identification of children who cannot be adequatelynourished without ancillary feeding by nasogastric tube orby enterostomy.

INTRODUCTION

IN children with severe cerebral palsy, subnormal growthmay be partly due to inadequate nutrient intake. 1

Contributing factors are oral-motor defects that hamperchewing and thus prolong mealtimes,2 as well as seizures andabnormal movements that increase energy requirements. 3The low subcutaneous fat, cold peripheries, and stuntedgrowth of these patients, once believed to be inevitable, cantoday be countered by supplementary nasogastric feeding.4Efforts to improve oral-motor function have not beensuccessful. 5-7 In one study a nine-week intensiveintervention programme resulted in no functional or

nutritional improvement; there was no discussion of thequantitative nutritional needs for growth. 5

If an adequate nutritional state is to be maintained in thesechildren feeding time must be lengthened to compensate forany reductions in efficiency of feeding.8 We describe themeasurements of feeding efficiency in children with severecerebral palsy.