VLADISLAV V. BEZRUKOV
SELF-CARE ABILITY AND INSTITUTIONAL / N O N - I N S T I T U T I O N A L C A R E OF T H E E L D E R L Y
ABSTRACT. This paper discusses the relationship between demographic change, health status, self-care ability, and the needs of the elderly for medico-social care. The author introduces ASKORUSS, an instrument used to assess self-care ability and the need for assistance. ASKORUSS organizes the results of the assessment in a visually accessible and compelling way and can be used to determine the patient's needs for level of care, treatment, and rehabilitation. The instrument also can be used to evaluate the efficacy of an institution and its services, the outcomes of the care provided, as well as other purposes.
Key Words: population aging, quantitative assessment, health stares, self-care ability, Ukraine, USSR
AGING OF THE POPULATION OF THE FORMER SOVIET UNION During recent years the aged population of the former USSR has continued to grow both in numbers and in proportion to the rest of the population. In 1989, when the last census of the population of the intact USSR was conducted, there were 40.6 million people aged 60 and over, constituting 14.2% of the total population. However, the rates and extent of population aging across the various republics were not uniform (Table I). During the last intercensus period, the aging of the population occurred most rapidly in Ukraine, Byelorussia, Georgia, Moldavia, and the Russian Federation. As a result, Ukraine took over first place and became the 'oldest' republic (in 1989 17.9% and in 1991 18.6% of the population was 60 or older). The proportion of the population 75 and older was also constantly increasing. From 1979 to 1989 the total population of the USSR increased by 9% while the share of those aged 60+ increased by 20%; that of those aged 75-79 by 31%, 80-84, by 50%, and 85+ by 25%. According to the 1989 Population Census, the average life expectancy for the total population of the USSR was 69.5 years, 64.6 for males and 74.0 for females (Table II) - much lower than for the US as a whole but very close to that of Black Americans. The difference in average life expectancy between males and females remained high (9-10 years). As in the previous census the life expectancy of urban inhabitants exceeded that of rural inhabitants by 1.6 years (1.7 years for males and 1.2 years for females) although in some republics (Armenia, Uzbekistan, Georgia, and Tajikistan) the opposite was the case, i.e., rural life expectancy exeeded urban. Life expectancy also differed considerably among the republics. Thus, in 1990, the highest life expectancy - 72.8 years was noted in Georgia and the lowest - 66.4 years - in Turkmenistan. The aging of the population of a country profoundly affects all spheres of life at both the societal and the individual level: economic development, manpower Journal of Cross-Cultural Gerontology 8: 349-360, 1993. 9 1993 KluwerAcademic Publishers. Printed in the Netherlands.
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TABLE I Aging of population in the republics of the former USSR (Percentage of persons aged 60+ in total population) Republics
1959
1970
1979
1989
Ukraine Latvia Estonia Byelomssia Lithuania Russian Federation Georgia Moldavia Armenia Kazakhstan Kirgizstan Azerbaijan Uzbekistan Tajikistan Turkmenistan Total
10.5 15.0 15.1 10,7 11.9 9.0 t0.9 7.7 8.0 7.8 9.7 8.4 8.4 7.9 7.9 9.4
13.8 17.3 16.8 13.1 14.9 11.9 11.8 9.7 8.2 8.2 8.9 8.0 8.7 7.5 7.2 11.8
15.6 16.7 16.3 13.9 14.4 13.6 t2.5 10.8 7.9 8.4 10.0 7.6 7.1 6.4 6.6 12.9
17.9 17.3 16.8 16.0 15.7 15.3 I4.3 12.6 9.3 9.1 8.2 7.8 6.5 6.1 6.1 14.2
Republics are arranged in descending order with respect to the value of 1989 indices. Source: Derived from "The Population of the USSR, 1987"; Moscow, Finansy i
Statistika, 1988, pp. 48-49; "Vestnik Statistiki", 1990, No. 6, p. 62. resources, labor organization, health status, demand for and organization of medical and social services, employment and well-being of the aged, their position in the family and society, intergenerational relations, etc. In the remainder of this paper we will focus on the impact of population aging on health and health-related services. HEALTH STATUS OFTHEELDERLY Growth in the number of elderly and, especially, of the very old leads to everincreasing numbers of lonely persons in poor physical and mental health and to a rise in chronic pathology and disabilities. Healthy persons account for 27.2% of those aged 60-69 compared to 16.2% of those 70 years and over. At the same time there is an increase in the number of chronically ill subjects in sub- or decompensated states. Among persons aged 60 and over the rates range from 6-12% in towns to 22-25% in villages. According to data from a random complex investigation carried out by Marchenko (1979) on the health of the urban population, only 2.6% of men and 2.0% of women aged 70 and over had no chronic diseases. Chronically sick persons account for 80-85% of the USSR population aged 60 and older (Bedny 1975; Shilova 1978; Sonin and Dyskin 1984). Twenty to 30% of the elderly have restrictions in their physical capacities, including 1.5-3.7% of elders who are bedridden. A peculiar feature of older populations is their multimorbidity.
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TABLE II Life expectancy in the republics of the former USSR Republics
1979-1980
1989
1990
Georgia Armenia Lithuania Byelorussia Azerbaij an Ukraine Estonia Latvia Tajikistan Uzbekistan Russian Federation Kazakhstan Kirgizstan Moldavia Turkmenistan Total
71.2 72.8 70.5 71.1 68.1 69.7 69.4 68.9 66.3 67.6 67.5 67.0 66.0 65.6 64.6 67.7
72.1 72.0 71.8 71.8 70.6 70.9 70.6 70.4 69.4 69.2 69.6 68.7 68.5 69.0 65.2 69.5
72.8 71.8 71.5 71.3 71.0 70.5 70.0 69.6 69.6 69.5 69.3 68.8 68.8 68.7 66.4 69.3
Republics are arranged in descending order with respect to the 1990 indices. Source: National economy of the USSR in 1990. Statistical Yearbook, Moscow, Finansy i Statistika, 1991, p. 94. The number of diseases diagnosed in the same patient increases with age. Data from a complex medical examination of urban residents by Tokareva (1979) showed that 54.5% of those aged 60-64 but 92.1% of those aged 75-79 had 3 or more chronic diseases. Health status, self-care ability, and need for assistance depend on many factors. According to a WHO study (Fillenbaum 1984), a person's health status is 50% a function of his/her condition and mode of life, 20% a function of environment, 20% a function of genetics, and only 10% a function of health services. The results of our own 15 year longitudinal study more or less confirm the importance of these influences, such as individual life style, environment, material well-being, and various types of activities, on the physical and mental health, survivorship, and mortality rates of urban pensioners (Bezrukov 1992; Minaeva, Sachuk, and Boiko 1991). The relationships among these parameters are shown in Figure 1. We found that physical health depended very much on life style factors, e.g., diet and activity patterns as well as social and cultural activities (Figure 2). This dependence was even greater than for the group of factors reflecting the material conditions of daily life, occupancy with household work, etc. Over the course of the 15 year study men and women with healthy life styles experienced higher rates of survival. In fact a healthy life style added 2 to 5 extra years of life over the course of the 15 year study period. These findings indicate that preventive measures at the level of behavior and public health can be quite effective in extending life expectancy. An analysis
352
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Figure 1. Factors affecting health and lifespan. of deaths from heart disease of persons 55-64 years of age in the US between 1960 and 1980 revealed that actual mortality figures in 1980 were much lower than those predicted on the basis of the trend from 1960-1970 (National Center for Health Statistics 1985). Although this decline in mortality is not fully understood, many believe that it can be attributed largely to preventive measures such as changes in diet, increases in physical activity, and reductions in smoking. Improvements in medicine, health care, and medical technology are also bringing increases in life expectancy. According to Mackenbach (cited in van der Maas 1988), developments in medicine in the Netherlands between 1950 and 1984 brought about more than 2 years of life to males and 6 years to females. These developments included improvements in surgery (adding 0.36 years of life to men and 0.25 to women), improvements in antenatal and perinatal care (0.72 years to men and 0.83 to women), chemotherapy and antibiotics (0.94 and 1.43 years), and hypertension detection and treatment (0.43 and 1.42). When analyzing possible lifespan extension due to the hypothetical extermination of four major causes of death in 14 countries of Europe, some authors calculated that elimination of deaths from cardiovascular pathology would bring 7.1 years of additional life to males and 8.6 to females. Eliminating malignant tumors would bring 2.6 years to both, and full prevention of death from pulmonary diseases and accidents would bring !3 to 18 months of extra life to males and 7 to 10 months to females. Thus, eliminating all of the above causes would add 12.3 years to the lives of men and 12.6 years to those of women and
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Figure 2. Correlation coefficients of factors affecting physical health would bring life expectancy at birth to 81.1 years for males and 87.2 for females. There is much debate about the consequences of lifespan extension on a population's morbidity pattern. There is strong evidence that increased life expectancy leads to increased periods of incapacity, invalidity, and reliance on others for assistance. In the elderly complex chronic pathology occurs against the backdrop of marked age-related changes in organs and organ systems, atypical disease courses, lengthy recovery periods, and reduced self-care abilities. These special problems combine to produce high levels of needs for various kinds of medical care.
354
VLADISLAV V. BEZRUKOV PROVISION OF CARE TO THE ELDERLY
In the former USSR and in the newly emerged states the institutional care for elderly people is provided mainly through systems under the Health Ministry and the Social Security Ministry while non-institutional care is provided by both Ministries as well as by some other governmental and non-governmental organizations, such as the Red Cross, various voluntary funds, etc. (Figure 3). Geriatrics as an official medical specialty was not introduced into the former Soviet Union. At present it is established in some republics, i.e., Ukraine. CURATIVE-PREVENTIVE INSTITUTIONS
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Figure 3. Structure of providing care to the elderly urban population.
Ambulatory care is provided by out-patient departments, dispensaries, and at home. Health care services aimed specifically at the elderly such as geriatric consulting rooms at out-patient clinics are gradually coming into being. Usually they are established within out-patient clinics of big towns. Geriatricians working at these facilities are responsible for coordinating and providing health care to the elderly and for counselling (consulting) physicians of other specialties involved in this care. If need be, they function as intermediaries between elderly patients and 'narrow' specialists, e.g., neurologists, ophthalmologists and the like, or between patients and social services. The central figure in the provision of health care to the aged at the community level is the district physician. The district physician provides the primary medico-social services and prescribes the preventive and treatment measures; assesses the needs of the elderly for various kinds of health care; takes responsibility for its organization and the coordination of treatment and drug prescrip-
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tions, and resolves the questions pertaining to the patient's hospitalization or receipt of domiciliary care. Since each district doctor is in the best position of anyone in the community to make contact with the older people, he/she may assess their needs in social and daily living services and undertake the organization of such services through the domiciliary social care system and Red Cross nurses. The district doctor together with his nurse prepares elderly people for their resettlement either to a geriatric institution within the social security system or to a special residential home for single elderly. Still, up till now, much more of this practice is on paper than in operation. In-patient services for the elderly are delivered within the general health care network. Some general multi-profile hospitals have geriatric wards, and large psychiatric clinics have geropsychiatric departments. There are numerous hospitals for war veterans, and special sanatoria set up for pensioners operate as rehabilitiaton centers. In rural areas of Russia, Byelorussia, Ukraine, and the states of the Baltic region, small village (district) hospitals are widely used for long-term stay of the elderly - for both health and social reasons. Under the Ministry of Social Security, medico-social care to single and frail elderly persons is provided at homes for the aged, nursing homes, homes for mentally sick patients, and hospitals for war and labor veterans. Recently medico-social territorial centers, day-care centers, and residential homes have been added to the spectrum of services being provided within the framework of medico-social services. Territorial centers are established under the auspices of the Ministry of Social Protection. They may be built together with an in-patient hospital, in a flee-standing setting, or in conjunction with a functioning nursing home. It is currently recommended that territorial centers be developed in conjunction with a residential house equipped with a complex of social and daily living services designed for single persons and veterans. The centers offer physical, socio-occupational, and psychological rehabilitation of hospitalized elderly citizens or those visiting a day unit. With advancing age come increases in needs for domestic help and medicosocial care. The health care system for the elderly in the former USSR is homeoriented not only because of an 'ideology of care providing' but also because of a shortage of beds in hospitals and nursing homes. For example, the need of persons aged 60 or older for in-patient services is 3 times higher than that of the rest of the population (Revutskaya 1978). At the same time only 1/3 of those elderly who need in-patient services can be accommodated in hospitals. In 1988 there were 380,000 places in 1,772 nursing homes in the former USSR, an amount insufficient to satisfy all the elderly who require this kind of service. Because of this scarcity waiting lists for these institutions were at least 3-6 months long. Usually non-emergency patients apply to or attend the out-patient clinic prior to hospitalization. Paradoxically although the needs of the elderly for medical aid increase with advancing age, the number of visits they make to out-patient clinics decreases. This phenomenon is at least partially due to their restricted physical capacity and mobility. The complex medical study of aged people in
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Ukraine and Russia by Tokareva (1979) revealed that morbidity rates estimated from the number of visits per person per year were 2.3 times less than the actual morbidity of those aged 60-64, 3.1 times less for those aged 65-69, and almost 4 times less for those aged 80 and over. At the same time medical aid at home is provided to every tenth elderly person (including women between 55-59), to every third person aged 70 or older, and to every second person aged 80 or older (Revutskaya 1978). According to experts' evaluations every tenth person of retirement age visiting an out-patient clinic and every fifth person calling an emergency medical team required hospitalization. The need of hospitalization is much higher for single men and aged persons living alone (more than twice that for elderly persons living in families). In many cases the elderly who live alone require institutionalization for social rather than for medical reasons. It has been found, for example, that the main cause of institutionalization of elderly people are poor health (42.5%), need for care (37.8%), low income (8.7%), bad living conditions (5.4%), and conflicts in a family (4.7%) (Barmashina and Verzhikovskaya 1990). An exceptionally important aspect of geriatric services for the elderly is rehabilitation - medical, physical, psychological, domestic, social, and occupational. This importance applies to both out- and in-patient care. The demand for various kinds of rehabilitation increases with age. For instance among the patients suffering from cardiovascular pathology about 45% of subjects aged 60 and over and about 60% of those aged 80 and over are in need of various kinds of rehabilitation. In developing the system of rehabilitation, special emphasis is laid on the stimulation of motor activity, mobility, and self-care ability - on encouragement of an active mode of life. An analysis of the treatment of geriatric patients in specialized divisions of municipal hospitals revealed inadequate attention paid to the problems of rehabilitation. Many clinics lack rehabilitation units, In hospitals there is a tendency to discharge undertreated elderly patients without any follow-up rehabilitation to be conducted in the clinic. Although the medico-social needs of the elderly are ever-increasing, an infrastructure of institutional care and services for the elderly in Ukraine and the whole of the former USSR is underdeveloped. There are no sound criteria in use for determining the appropriateness of placement of elderly patients in institutions, e.g., nursing homes, chronic hospitals, etc. In some cases the problem of bed-blockers is quite evident. A team assessment of the health problems and the needs of the elderly for various types and forms of care, treatment, and rehabilitation is not practiced. Much more attention should be paid to new approaches and instruments in this field. ASSESSMENT OF SELF-CARE ABILITY AND NEEDS Ever-increasing numbers and percentages of old and very old people lead to increases in the number of people with impaired health, of patients who are
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'burdened' with multiple, complex, and chronic diseases, and of individuals with impaired mobility and losses in self-care ability. All these conditions lead to increased dependence on others and require various kinds of medico-social assistance, both non-institutional and institutional. The range and volume of needed services depends on the health and functional status of the individual. This fact is especially true of the elderly living alone. There are various approaches to and instruments for assessing an individual's functional capacities and self-care ability, need for institutional care, and need for a particular range and volume of services. These instruments include, for example, the comprehensive assessment and referral evaluation (CARE), the Philadelphia Geriatric Center Multilevel Assessment Instrument (MAI), the Older American Resources and Services Multidimensional Functional Assessment Questionnaire (OARS), and others. (Descriptions of the above approaches and instruments can be found in Fillenbaum 1984, Toner and Gurland 1985, and McCaslin and Golant 1990.) In 1989 a special multidimensional tool for quantifying the self-care ability of the elderly was developed at the Kiev Institute of Gerontology (Bezrukov, Gichev, Chaikovskaya, Sidorov, and Povoroznjuk 1991). The Quantitative Assessment of Risk to Lose Self-Care Ability (referred to herein as ASKORUSS) yields an integrated index that expresses the degree of loss/preservation of self-care ability. This integrated index is derived from 10 separate indices based on 10 blocks of questions measuring a variety of capabilities and activities (see Figure 4). A group of experts (general practitioners, neurologists, cardiologists, geriatricians, public health managers, etc.) evaluated the prevalence rates and importance of various symptoms or items included in a structured questionnaire. Next a series of weighting algorithms was developed through consensus producing indices of the importance of the particular symptom or question to its block. Subjects under assessment can complete the questionnaire themselves or with the help of health or social service professionals, paraprofessionals, relatives, or others. The results of the questionnaire are computerized, and algorithms are used that evaluate the level of risk of losing self-care ability within a '0' (zero) to ' 1' (one) interval (Figure 4). The closer value of the integrated index to 1, the greater is the risk of complete loss of self-care ability. Depending on the value the elderly are subdivided into those who may stay in their own homes (values of 0 to 0.3) and those who should be recommended for placement in either a shelter house or special housing with services (values of 0.3 to 0.75), in a nursing home (0.75 to 0.95), or in a geriatric or long-stay hospital (0.95 to 1.0). Figure 4 shows the results of the assessment of an 82 year old person. Vectors/blocks 1-10 depict the indices calculated for, respectively, the cardiovascular, nervous, and genito-urinary systems; locomotion; sensory organs (eyes and ears); physical capacity; psychological status; self-rated health, social activities, and use of health services. The assessment yields an integrated index of 0.77 indicating that placement in a nursing home is required. ASKORUSS has been pilot-tested with 86 residents of a shelter house and 52
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Figure 4. Chart of ASKORUSS assessment of an 82-year-old person. patients of a nursing home. Comparative analysis of the questionnaire results with extensive clinical assessments of the same persons showed the instrument to be highly effective. Findings obtained from using ASKORUSS were highly correlated with those obtained through clinical assessments. A follow-up study of tenants of a shelter house 2 and 3 years after the first study gave further strong support to the initial findings. After the pilot study and its data processing had been completed, the questionnaire was reduced from 200 to 68 items. These positive results allowed us to use this tool in many other institutional settings and in a survey of non-institutionalized populations in various regions of Ukraine. Already over 2000 assessments have been carried out. The ASKORUSS system can provide recommendations for the individual, for institutions, and for services. At the individual level the system provides a means of determining the risk of loss of self-care ability in each block as well as overall and a means of monitoring changes in those risks over time. On the basis of the correlation between the individual risk profile and established profile norms, personnel can determine where on the continuum of care the person is likely to receive the most appropriate services. On the basis of this determination personnel can then draw up a personalized list of recommendations such as how often to visit an out-patient clinic, what kind of lifestyle or treatment to follow, etc. On the basis of changes in risk over time, the efficacy of the recommendations can be measured. By calculating the risk indices of various groups of patients, ASKORUSS can also be used to estimate the workload of a given institution and, thereby, its need for staff, and by tracking changes in the needs of groups of patients over time, administrators can modify staffing levels accordingly. Similarly by taking into account changes in the risk indices of all patients or subgroups of patients over
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time, administrators can evaluate the outcomes of the care their institution provides. There are many additional potential applications of the instrument. For example, planners and evaluators of care could use ASKORUSS-based assessments of: (1) risk in a random population to estimate the need for new facilities or for new types of facilities providing particular levels of care as well as to determine the optimal location for such facilities; (2) risk-mix of the patients in comparable facilities to allocate resources; (3) degree of change in risk over time compared with norms to evaluate the effectiveness (in terms of outcomes of care) of facilities of the same or different types. Additional applications could include research on the comparable effectiveness of various treatments or forms of care in institutional and non-institutional settings and, thereby, evaluations of the quality of the prescribers of care, i.e., physicians. CONCLUSIONS As populations age, policymakers must face the challenge of meeting the growing medico-social needs of the elderly. One aspect of this challenge is developing an appropriate array of services, programs, and settings to meet these ends. Another is devising a way to ensure that the best possible match is made between an individual elder and the existing network of services. While not capable of solving all the problems and complexities involved in assessment of the needs of the elderly population, ASKORUSS appears to be a short, effective, and very simple instrument that does not require high levels of training of its users.
ACKNOWLEDGEMENTS The work was partly supported by grants from the Cabinet of Ministers and Health Ministry of Ukraine. Most subjects discussed in this article are the result of collaborative studies which a number of scientists performed in our laboratory. Collaborations of Drs. N.V. Verzhikovskaya, N.N. Sachuk, V.P. Minaeva, V.V. Chaikovskaya of this Institute and Dr. Y.P. Gichev from the Institute of Experimental Therapy, Novosibirsk, are specially acknowledged. The excellent technical assistance of Ms. Maya Tourta is gratefully acknowledged. REFERENCES Barmashina, M. and N.V. Verzhikovskaya 1990 Urbanization and 'Third Age'. Kiev: Budivelnik. Bedny, M.S. 1975 Socio-Hygienic Characteristics of Morbidity of the Urban and Rural Population. Moscow: Meditsina. Bezrukov, V.V. 1992 Life Style, Health Status, and Survivorship of Urban Population. IIIrd Conference on Aging, Physical Activity, and Sports. Jyvaskyla. May-June. Abstract No. 114.
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Bezrukov, V.V., Y,P. Gichev, V.V. Chaikovskaya, A.I. Sidorov, and V.V. Povoroznjuk 1991 Automated System for Quantitative Assessment of Risk to Lose Self-Care Ability as a New Approach to Defining the Needs of the Elderly. Problemy Starenija i Dolgoletija 1(1): 63-69. Fillenbaum, G.G. 1984 The Wellbeing of the Elderly: Approaches to Multidimensional Assessment. Geneva: World Health Organization. Marchenko, A.G. 1979 Criteria for Evaluation of Health of the Population: A Complex Study. Sovetskoje Zdravookhranenije, No. 2, pp. 23-28. McCaslin, R. and S.M. Golant 1990 Assessing Social Welfare Programs for the Elderly: The Specification of Functional Goals. Journal of Applied Gerontology 9(1): 4-19. Minaeva, V.P., N.N. Sachuk, and E.B. Boiko 1991 The Role of Individual Life Style in Formation of Health and Physical Capacity of Elderly Town Residents. In Social Hygiene, Public Health Care Organization, and History of Medicine. Kiev: Zdorovja, Issue 22, pp. 30-33. National Center for Health Statistics 1985 Charting the Nation's Health: Trends Since 1960. DHHS publication number (PHS)85-1251, Hyattsville: National Center for Health Statistics. Revutskaya, Z.G. 1978 Medico-Social Care of Elderly and Old People. In Life Conditions and Older Man. D.F, Chebotarev, ed. Pp. 262-282. Moscow: Meditsina. Shilova, S.P. 1978 Socio-Hygienic Characteristics of Health of the Elderly Population in West Urals. Sovetskoye Zdravookhranenije 2: 35-40. Sonin, M.A. and A.A. Dyskin 1984 The Elderly in the Family and Society. Moscow: Finansy i Statistika. Tokareva, L.P. 1979 Comparative Evaluation of Morbidity Indices in Persons of Retirement Age. Sovetskoje Zdravookhranenije 2: 28-32. Toner, J. and B. Gurland t985 The CARE Interview: An Efficient, Systematic, Multidimensional Assessment Tool to Measure Health Status of Older People. In Aging: The Universal Human Experience. G.L. Maddox and E.W. Busse, eds. Pp. 380-390. New York: Springer Publishing Company. Van der Maas, P.J. 1988 Aging and Public Health. In Health and Aging: Perspectives and Prospects. J.J.F. Schroots, J.E. Birren, and A. Svanborg, eds. Pp. 95-115. New YorkLisse: Springer Publishing Company, Swets and Zeitlinger.
Institute of Gerontology Academy of Medical Sciences of Ukraine Kiev, Ukraine
SELF-CARE ABILITY AND INSTITUTIONAL / N O N - I N S T I T U T I O N A L C A R E OF T H E E L D E R L Y
ABSTRACT. This paper discusses the relationship between demographic change, health status, self-care ability, and the needs of the elderly for medico-social care. The author introduces ASKORUSS, an instrument used to assess self-care ability and the need for assistance. ASKORUSS organizes the results of the assessment in a visually accessible and compelling way and can be used to determine the patient's needs for level of care, treatment, and rehabilitation. The instrument also can be used to evaluate the efficacy of an institution and its services, the outcomes of the care provided, as well as other purposes.
Key Words: population aging, quantitative assessment, health stares, self-care ability, Ukraine, USSR
AGING OF THE POPULATION OF THE FORMER SOVIET UNION During recent years the aged population of the former USSR has continued to grow both in numbers and in proportion to the rest of the population. In 1989, when the last census of the population of the intact USSR was conducted, there were 40.6 million people aged 60 and over, constituting 14.2% of the total population. However, the rates and extent of population aging across the various republics were not uniform (Table I). During the last intercensus period, the aging of the population occurred most rapidly in Ukraine, Byelorussia, Georgia, Moldavia, and the Russian Federation. As a result, Ukraine took over first place and became the 'oldest' republic (in 1989 17.9% and in 1991 18.6% of the population was 60 or older). The proportion of the population 75 and older was also constantly increasing. From 1979 to 1989 the total population of the USSR increased by 9% while the share of those aged 60+ increased by 20%; that of those aged 75-79 by 31%, 80-84, by 50%, and 85+ by 25%. According to the 1989 Population Census, the average life expectancy for the total population of the USSR was 69.5 years, 64.6 for males and 74.0 for females (Table II) - much lower than for the US as a whole but very close to that of Black Americans. The difference in average life expectancy between males and females remained high (9-10 years). As in the previous census the life expectancy of urban inhabitants exceeded that of rural inhabitants by 1.6 years (1.7 years for males and 1.2 years for females) although in some republics (Armenia, Uzbekistan, Georgia, and Tajikistan) the opposite was the case, i.e., rural life expectancy exeeded urban. Life expectancy also differed considerably among the republics. Thus, in 1990, the highest life expectancy - 72.8 years was noted in Georgia and the lowest - 66.4 years - in Turkmenistan. The aging of the population of a country profoundly affects all spheres of life at both the societal and the individual level: economic development, manpower Journal of Cross-Cultural Gerontology 8: 349-360, 1993. 9 1993 KluwerAcademic Publishers. Printed in the Netherlands.
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TABLE I Aging of population in the republics of the former USSR (Percentage of persons aged 60+ in total population) Republics
1959
1970
1979
1989
Ukraine Latvia Estonia Byelomssia Lithuania Russian Federation Georgia Moldavia Armenia Kazakhstan Kirgizstan Azerbaijan Uzbekistan Tajikistan Turkmenistan Total
10.5 15.0 15.1 10,7 11.9 9.0 t0.9 7.7 8.0 7.8 9.7 8.4 8.4 7.9 7.9 9.4
13.8 17.3 16.8 13.1 14.9 11.9 11.8 9.7 8.2 8.2 8.9 8.0 8.7 7.5 7.2 11.8
15.6 16.7 16.3 13.9 14.4 13.6 t2.5 10.8 7.9 8.4 10.0 7.6 7.1 6.4 6.6 12.9
17.9 17.3 16.8 16.0 15.7 15.3 I4.3 12.6 9.3 9.1 8.2 7.8 6.5 6.1 6.1 14.2
Republics are arranged in descending order with respect to the value of 1989 indices. Source: Derived from "The Population of the USSR, 1987"; Moscow, Finansy i
Statistika, 1988, pp. 48-49; "Vestnik Statistiki", 1990, No. 6, p. 62. resources, labor organization, health status, demand for and organization of medical and social services, employment and well-being of the aged, their position in the family and society, intergenerational relations, etc. In the remainder of this paper we will focus on the impact of population aging on health and health-related services. HEALTH STATUS OFTHEELDERLY Growth in the number of elderly and, especially, of the very old leads to everincreasing numbers of lonely persons in poor physical and mental health and to a rise in chronic pathology and disabilities. Healthy persons account for 27.2% of those aged 60-69 compared to 16.2% of those 70 years and over. At the same time there is an increase in the number of chronically ill subjects in sub- or decompensated states. Among persons aged 60 and over the rates range from 6-12% in towns to 22-25% in villages. According to data from a random complex investigation carried out by Marchenko (1979) on the health of the urban population, only 2.6% of men and 2.0% of women aged 70 and over had no chronic diseases. Chronically sick persons account for 80-85% of the USSR population aged 60 and older (Bedny 1975; Shilova 1978; Sonin and Dyskin 1984). Twenty to 30% of the elderly have restrictions in their physical capacities, including 1.5-3.7% of elders who are bedridden. A peculiar feature of older populations is their multimorbidity.
SELF-CAREABILITYAND CAREOF THE ELDERLY
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TABLE II Life expectancy in the republics of the former USSR Republics
1979-1980
1989
1990
Georgia Armenia Lithuania Byelorussia Azerbaij an Ukraine Estonia Latvia Tajikistan Uzbekistan Russian Federation Kazakhstan Kirgizstan Moldavia Turkmenistan Total
71.2 72.8 70.5 71.1 68.1 69.7 69.4 68.9 66.3 67.6 67.5 67.0 66.0 65.6 64.6 67.7
72.1 72.0 71.8 71.8 70.6 70.9 70.6 70.4 69.4 69.2 69.6 68.7 68.5 69.0 65.2 69.5
72.8 71.8 71.5 71.3 71.0 70.5 70.0 69.6 69.6 69.5 69.3 68.8 68.8 68.7 66.4 69.3
Republics are arranged in descending order with respect to the 1990 indices. Source: National economy of the USSR in 1990. Statistical Yearbook, Moscow, Finansy i Statistika, 1991, p. 94. The number of diseases diagnosed in the same patient increases with age. Data from a complex medical examination of urban residents by Tokareva (1979) showed that 54.5% of those aged 60-64 but 92.1% of those aged 75-79 had 3 or more chronic diseases. Health status, self-care ability, and need for assistance depend on many factors. According to a WHO study (Fillenbaum 1984), a person's health status is 50% a function of his/her condition and mode of life, 20% a function of environment, 20% a function of genetics, and only 10% a function of health services. The results of our own 15 year longitudinal study more or less confirm the importance of these influences, such as individual life style, environment, material well-being, and various types of activities, on the physical and mental health, survivorship, and mortality rates of urban pensioners (Bezrukov 1992; Minaeva, Sachuk, and Boiko 1991). The relationships among these parameters are shown in Figure 1. We found that physical health depended very much on life style factors, e.g., diet and activity patterns as well as social and cultural activities (Figure 2). This dependence was even greater than for the group of factors reflecting the material conditions of daily life, occupancy with household work, etc. Over the course of the 15 year study men and women with healthy life styles experienced higher rates of survival. In fact a healthy life style added 2 to 5 extra years of life over the course of the 15 year study period. These findings indicate that preventive measures at the level of behavior and public health can be quite effective in extending life expectancy. An analysis
352
VLADISLAV V. BEZRUKOV
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Figure 1. Factors affecting health and lifespan. of deaths from heart disease of persons 55-64 years of age in the US between 1960 and 1980 revealed that actual mortality figures in 1980 were much lower than those predicted on the basis of the trend from 1960-1970 (National Center for Health Statistics 1985). Although this decline in mortality is not fully understood, many believe that it can be attributed largely to preventive measures such as changes in diet, increases in physical activity, and reductions in smoking. Improvements in medicine, health care, and medical technology are also bringing increases in life expectancy. According to Mackenbach (cited in van der Maas 1988), developments in medicine in the Netherlands between 1950 and 1984 brought about more than 2 years of life to males and 6 years to females. These developments included improvements in surgery (adding 0.36 years of life to men and 0.25 to women), improvements in antenatal and perinatal care (0.72 years to men and 0.83 to women), chemotherapy and antibiotics (0.94 and 1.43 years), and hypertension detection and treatment (0.43 and 1.42). When analyzing possible lifespan extension due to the hypothetical extermination of four major causes of death in 14 countries of Europe, some authors calculated that elimination of deaths from cardiovascular pathology would bring 7.1 years of additional life to males and 8.6 to females. Eliminating malignant tumors would bring 2.6 years to both, and full prevention of death from pulmonary diseases and accidents would bring !3 to 18 months of extra life to males and 7 to 10 months to females. Thus, eliminating all of the above causes would add 12.3 years to the lives of men and 12.6 years to those of women and
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Figure 2. Correlation coefficients of factors affecting physical health would bring life expectancy at birth to 81.1 years for males and 87.2 for females. There is much debate about the consequences of lifespan extension on a population's morbidity pattern. There is strong evidence that increased life expectancy leads to increased periods of incapacity, invalidity, and reliance on others for assistance. In the elderly complex chronic pathology occurs against the backdrop of marked age-related changes in organs and organ systems, atypical disease courses, lengthy recovery periods, and reduced self-care abilities. These special problems combine to produce high levels of needs for various kinds of medical care.
354
VLADISLAV V. BEZRUKOV PROVISION OF CARE TO THE ELDERLY
In the former USSR and in the newly emerged states the institutional care for elderly people is provided mainly through systems under the Health Ministry and the Social Security Ministry while non-institutional care is provided by both Ministries as well as by some other governmental and non-governmental organizations, such as the Red Cross, various voluntary funds, etc. (Figure 3). Geriatrics as an official medical specialty was not introduced into the former Soviet Union. At present it is established in some republics, i.e., Ukraine. CURATIVE-PREVENTIVE INSTITUTIONS
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Ambulatory care is provided by out-patient departments, dispensaries, and at home. Health care services aimed specifically at the elderly such as geriatric consulting rooms at out-patient clinics are gradually coming into being. Usually they are established within out-patient clinics of big towns. Geriatricians working at these facilities are responsible for coordinating and providing health care to the elderly and for counselling (consulting) physicians of other specialties involved in this care. If need be, they function as intermediaries between elderly patients and 'narrow' specialists, e.g., neurologists, ophthalmologists and the like, or between patients and social services. The central figure in the provision of health care to the aged at the community level is the district physician. The district physician provides the primary medico-social services and prescribes the preventive and treatment measures; assesses the needs of the elderly for various kinds of health care; takes responsibility for its organization and the coordination of treatment and drug prescrip-
SELF-CAREABILITYAND CAREOF THE ELDERLY
355
tions, and resolves the questions pertaining to the patient's hospitalization or receipt of domiciliary care. Since each district doctor is in the best position of anyone in the community to make contact with the older people, he/she may assess their needs in social and daily living services and undertake the organization of such services through the domiciliary social care system and Red Cross nurses. The district doctor together with his nurse prepares elderly people for their resettlement either to a geriatric institution within the social security system or to a special residential home for single elderly. Still, up till now, much more of this practice is on paper than in operation. In-patient services for the elderly are delivered within the general health care network. Some general multi-profile hospitals have geriatric wards, and large psychiatric clinics have geropsychiatric departments. There are numerous hospitals for war veterans, and special sanatoria set up for pensioners operate as rehabilitiaton centers. In rural areas of Russia, Byelorussia, Ukraine, and the states of the Baltic region, small village (district) hospitals are widely used for long-term stay of the elderly - for both health and social reasons. Under the Ministry of Social Security, medico-social care to single and frail elderly persons is provided at homes for the aged, nursing homes, homes for mentally sick patients, and hospitals for war and labor veterans. Recently medico-social territorial centers, day-care centers, and residential homes have been added to the spectrum of services being provided within the framework of medico-social services. Territorial centers are established under the auspices of the Ministry of Social Protection. They may be built together with an in-patient hospital, in a flee-standing setting, or in conjunction with a functioning nursing home. It is currently recommended that territorial centers be developed in conjunction with a residential house equipped with a complex of social and daily living services designed for single persons and veterans. The centers offer physical, socio-occupational, and psychological rehabilitation of hospitalized elderly citizens or those visiting a day unit. With advancing age come increases in needs for domestic help and medicosocial care. The health care system for the elderly in the former USSR is homeoriented not only because of an 'ideology of care providing' but also because of a shortage of beds in hospitals and nursing homes. For example, the need of persons aged 60 or older for in-patient services is 3 times higher than that of the rest of the population (Revutskaya 1978). At the same time only 1/3 of those elderly who need in-patient services can be accommodated in hospitals. In 1988 there were 380,000 places in 1,772 nursing homes in the former USSR, an amount insufficient to satisfy all the elderly who require this kind of service. Because of this scarcity waiting lists for these institutions were at least 3-6 months long. Usually non-emergency patients apply to or attend the out-patient clinic prior to hospitalization. Paradoxically although the needs of the elderly for medical aid increase with advancing age, the number of visits they make to out-patient clinics decreases. This phenomenon is at least partially due to their restricted physical capacity and mobility. The complex medical study of aged people in
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Ukraine and Russia by Tokareva (1979) revealed that morbidity rates estimated from the number of visits per person per year were 2.3 times less than the actual morbidity of those aged 60-64, 3.1 times less for those aged 65-69, and almost 4 times less for those aged 80 and over. At the same time medical aid at home is provided to every tenth elderly person (including women between 55-59), to every third person aged 70 or older, and to every second person aged 80 or older (Revutskaya 1978). According to experts' evaluations every tenth person of retirement age visiting an out-patient clinic and every fifth person calling an emergency medical team required hospitalization. The need of hospitalization is much higher for single men and aged persons living alone (more than twice that for elderly persons living in families). In many cases the elderly who live alone require institutionalization for social rather than for medical reasons. It has been found, for example, that the main cause of institutionalization of elderly people are poor health (42.5%), need for care (37.8%), low income (8.7%), bad living conditions (5.4%), and conflicts in a family (4.7%) (Barmashina and Verzhikovskaya 1990). An exceptionally important aspect of geriatric services for the elderly is rehabilitation - medical, physical, psychological, domestic, social, and occupational. This importance applies to both out- and in-patient care. The demand for various kinds of rehabilitation increases with age. For instance among the patients suffering from cardiovascular pathology about 45% of subjects aged 60 and over and about 60% of those aged 80 and over are in need of various kinds of rehabilitation. In developing the system of rehabilitation, special emphasis is laid on the stimulation of motor activity, mobility, and self-care ability - on encouragement of an active mode of life. An analysis of the treatment of geriatric patients in specialized divisions of municipal hospitals revealed inadequate attention paid to the problems of rehabilitation. Many clinics lack rehabilitation units, In hospitals there is a tendency to discharge undertreated elderly patients without any follow-up rehabilitation to be conducted in the clinic. Although the medico-social needs of the elderly are ever-increasing, an infrastructure of institutional care and services for the elderly in Ukraine and the whole of the former USSR is underdeveloped. There are no sound criteria in use for determining the appropriateness of placement of elderly patients in institutions, e.g., nursing homes, chronic hospitals, etc. In some cases the problem of bed-blockers is quite evident. A team assessment of the health problems and the needs of the elderly for various types and forms of care, treatment, and rehabilitation is not practiced. Much more attention should be paid to new approaches and instruments in this field. ASSESSMENT OF SELF-CARE ABILITY AND NEEDS Ever-increasing numbers and percentages of old and very old people lead to increases in the number of people with impaired health, of patients who are
SELF-CARE ABILITY AND CARE OF THE ELDERLY
357
'burdened' with multiple, complex, and chronic diseases, and of individuals with impaired mobility and losses in self-care ability. All these conditions lead to increased dependence on others and require various kinds of medico-social assistance, both non-institutional and institutional. The range and volume of needed services depends on the health and functional status of the individual. This fact is especially true of the elderly living alone. There are various approaches to and instruments for assessing an individual's functional capacities and self-care ability, need for institutional care, and need for a particular range and volume of services. These instruments include, for example, the comprehensive assessment and referral evaluation (CARE), the Philadelphia Geriatric Center Multilevel Assessment Instrument (MAI), the Older American Resources and Services Multidimensional Functional Assessment Questionnaire (OARS), and others. (Descriptions of the above approaches and instruments can be found in Fillenbaum 1984, Toner and Gurland 1985, and McCaslin and Golant 1990.) In 1989 a special multidimensional tool for quantifying the self-care ability of the elderly was developed at the Kiev Institute of Gerontology (Bezrukov, Gichev, Chaikovskaya, Sidorov, and Povoroznjuk 1991). The Quantitative Assessment of Risk to Lose Self-Care Ability (referred to herein as ASKORUSS) yields an integrated index that expresses the degree of loss/preservation of self-care ability. This integrated index is derived from 10 separate indices based on 10 blocks of questions measuring a variety of capabilities and activities (see Figure 4). A group of experts (general practitioners, neurologists, cardiologists, geriatricians, public health managers, etc.) evaluated the prevalence rates and importance of various symptoms or items included in a structured questionnaire. Next a series of weighting algorithms was developed through consensus producing indices of the importance of the particular symptom or question to its block. Subjects under assessment can complete the questionnaire themselves or with the help of health or social service professionals, paraprofessionals, relatives, or others. The results of the questionnaire are computerized, and algorithms are used that evaluate the level of risk of losing self-care ability within a '0' (zero) to ' 1' (one) interval (Figure 4). The closer value of the integrated index to 1, the greater is the risk of complete loss of self-care ability. Depending on the value the elderly are subdivided into those who may stay in their own homes (values of 0 to 0.3) and those who should be recommended for placement in either a shelter house or special housing with services (values of 0.3 to 0.75), in a nursing home (0.75 to 0.95), or in a geriatric or long-stay hospital (0.95 to 1.0). Figure 4 shows the results of the assessment of an 82 year old person. Vectors/blocks 1-10 depict the indices calculated for, respectively, the cardiovascular, nervous, and genito-urinary systems; locomotion; sensory organs (eyes and ears); physical capacity; psychological status; self-rated health, social activities, and use of health services. The assessment yields an integrated index of 0.77 indicating that placement in a nursing home is required. ASKORUSS has been pilot-tested with 86 residents of a shelter house and 52
358
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Figure 4. Chart of ASKORUSS assessment of an 82-year-old person. patients of a nursing home. Comparative analysis of the questionnaire results with extensive clinical assessments of the same persons showed the instrument to be highly effective. Findings obtained from using ASKORUSS were highly correlated with those obtained through clinical assessments. A follow-up study of tenants of a shelter house 2 and 3 years after the first study gave further strong support to the initial findings. After the pilot study and its data processing had been completed, the questionnaire was reduced from 200 to 68 items. These positive results allowed us to use this tool in many other institutional settings and in a survey of non-institutionalized populations in various regions of Ukraine. Already over 2000 assessments have been carried out. The ASKORUSS system can provide recommendations for the individual, for institutions, and for services. At the individual level the system provides a means of determining the risk of loss of self-care ability in each block as well as overall and a means of monitoring changes in those risks over time. On the basis of the correlation between the individual risk profile and established profile norms, personnel can determine where on the continuum of care the person is likely to receive the most appropriate services. On the basis of this determination personnel can then draw up a personalized list of recommendations such as how often to visit an out-patient clinic, what kind of lifestyle or treatment to follow, etc. On the basis of changes in risk over time, the efficacy of the recommendations can be measured. By calculating the risk indices of various groups of patients, ASKORUSS can also be used to estimate the workload of a given institution and, thereby, its need for staff, and by tracking changes in the needs of groups of patients over time, administrators can modify staffing levels accordingly. Similarly by taking into account changes in the risk indices of all patients or subgroups of patients over
SELF-CARE ABILITY AND CARE OF THE ELDERLY
359
time, administrators can evaluate the outcomes of the care their institution provides. There are many additional potential applications of the instrument. For example, planners and evaluators of care could use ASKORUSS-based assessments of: (1) risk in a random population to estimate the need for new facilities or for new types of facilities providing particular levels of care as well as to determine the optimal location for such facilities; (2) risk-mix of the patients in comparable facilities to allocate resources; (3) degree of change in risk over time compared with norms to evaluate the effectiveness (in terms of outcomes of care) of facilities of the same or different types. Additional applications could include research on the comparable effectiveness of various treatments or forms of care in institutional and non-institutional settings and, thereby, evaluations of the quality of the prescribers of care, i.e., physicians. CONCLUSIONS As populations age, policymakers must face the challenge of meeting the growing medico-social needs of the elderly. One aspect of this challenge is developing an appropriate array of services, programs, and settings to meet these ends. Another is devising a way to ensure that the best possible match is made between an individual elder and the existing network of services. While not capable of solving all the problems and complexities involved in assessment of the needs of the elderly population, ASKORUSS appears to be a short, effective, and very simple instrument that does not require high levels of training of its users.
ACKNOWLEDGEMENTS The work was partly supported by grants from the Cabinet of Ministers and Health Ministry of Ukraine. Most subjects discussed in this article are the result of collaborative studies which a number of scientists performed in our laboratory. Collaborations of Drs. N.V. Verzhikovskaya, N.N. Sachuk, V.P. Minaeva, V.V. Chaikovskaya of this Institute and Dr. Y.P. Gichev from the Institute of Experimental Therapy, Novosibirsk, are specially acknowledged. The excellent technical assistance of Ms. Maya Tourta is gratefully acknowledged. REFERENCES Barmashina, M. and N.V. Verzhikovskaya 1990 Urbanization and 'Third Age'. Kiev: Budivelnik. Bedny, M.S. 1975 Socio-Hygienic Characteristics of Morbidity of the Urban and Rural Population. Moscow: Meditsina. Bezrukov, V.V. 1992 Life Style, Health Status, and Survivorship of Urban Population. IIIrd Conference on Aging, Physical Activity, and Sports. Jyvaskyla. May-June. Abstract No. 114.
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Bezrukov, V.V., Y,P. Gichev, V.V. Chaikovskaya, A.I. Sidorov, and V.V. Povoroznjuk 1991 Automated System for Quantitative Assessment of Risk to Lose Self-Care Ability as a New Approach to Defining the Needs of the Elderly. Problemy Starenija i Dolgoletija 1(1): 63-69. Fillenbaum, G.G. 1984 The Wellbeing of the Elderly: Approaches to Multidimensional Assessment. Geneva: World Health Organization. Marchenko, A.G. 1979 Criteria for Evaluation of Health of the Population: A Complex Study. Sovetskoje Zdravookhranenije, No. 2, pp. 23-28. McCaslin, R. and S.M. Golant 1990 Assessing Social Welfare Programs for the Elderly: The Specification of Functional Goals. Journal of Applied Gerontology 9(1): 4-19. Minaeva, V.P., N.N. Sachuk, and E.B. Boiko 1991 The Role of Individual Life Style in Formation of Health and Physical Capacity of Elderly Town Residents. In Social Hygiene, Public Health Care Organization, and History of Medicine. Kiev: Zdorovja, Issue 22, pp. 30-33. National Center for Health Statistics 1985 Charting the Nation's Health: Trends Since 1960. DHHS publication number (PHS)85-1251, Hyattsville: National Center for Health Statistics. Revutskaya, Z.G. 1978 Medico-Social Care of Elderly and Old People. In Life Conditions and Older Man. D.F, Chebotarev, ed. Pp. 262-282. Moscow: Meditsina. Shilova, S.P. 1978 Socio-Hygienic Characteristics of Health of the Elderly Population in West Urals. Sovetskoye Zdravookhranenije 2: 35-40. Sonin, M.A. and A.A. Dyskin 1984 The Elderly in the Family and Society. Moscow: Finansy i Statistika. Tokareva, L.P. 1979 Comparative Evaluation of Morbidity Indices in Persons of Retirement Age. Sovetskoje Zdravookhranenije 2: 28-32. Toner, J. and B. Gurland t985 The CARE Interview: An Efficient, Systematic, Multidimensional Assessment Tool to Measure Health Status of Older People. In Aging: The Universal Human Experience. G.L. Maddox and E.W. Busse, eds. Pp. 380-390. New York: Springer Publishing Company. Van der Maas, P.J. 1988 Aging and Public Health. In Health and Aging: Perspectives and Prospects. J.J.F. Schroots, J.E. Birren, and A. Svanborg, eds. Pp. 95-115. New YorkLisse: Springer Publishing Company, Swets and Zeitlinger.
Institute of Gerontology Academy of Medical Sciences of Ukraine Kiev, Ukraine
