Brenda C. Spillman
February 3, 2003
This report was prepared under contract #HHS-100-97-0010 between the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy and the Urban Institute. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact the ASPE Project Officer, William Marton, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. His e-mail address is: William.Marton@hhs.gov.
An earlier version of this work was presented at the annual meeting of the Association for Health Services Research and Health Policy in Atlanta, June 2001, and at the 15th Private Long-Term Care Insurance Conference in Miami, August 2001. The author acknowledges the research assistance of Heidi Kapustka and programming support from Mary Lee and Jeanne Yang. The views expressed are those of the author and should not be attributed to the DALTCP or to the Urban Institute or its funders.
Recent research has provided promising evidence that aggregate age-adjusted disability among older Americans has decreased. There also is evidence that cognitive impairment and physical limitations, such as lifting 10 pounds, walking short distances, and climbing a flight of stairs, which may be precursors to disability, may have declined in recent years. On the other hand, some studies show increases in chronic disease, increases in the use of paid long term care, and increasing disability levels within the disabled population. This study was undertaken in order to better understand these trends and their potential implications for use of acute and long term care.
Studies to date have primarily examined aggregate age-adjusted trends. In this study aggregate trends are decomposed into trends in underlying aspects of disability. Specific questions addressed are the following:
How has the prevalence of chronic disability among the elderly changed since the mid-1980s?
Does the trend in disability differ for specific components of disability, such as disability only in basic activities necessary for independent living or in use of equipment?
Do declines differ for younger ages and older cohorts?
Are there particular activities which have declined more than others or which appear to be more amenable to independence with special equipment or other environmental/social factors?
What are the implications for future costs?
Data and Methodology
Data are from four waves of the National Long Term Care Survey (NLTCS) representing three five-year periods between 1984 and 1999. The NLTCS is conducted by the U.S. Census Bureau under the direction of researchers at the Center for Demographic Studies (CDS) at Duke University.
Chronic disability (defined as lasting at least 3 months) was examined in the aggregate and then decomposed along two dimensions. The first distinguishes the use of human help--long term care--from the use of assistive devices to perform basic activities. The second distinguishes disability only in instrumental activities of daily living (IADLs), which are activities such as money management and meal preparation that are associated with the ability to maintain independence at home, from disability in activities of daily living (ADLs), which are basic personal care activities such as dressing and eating that indicate a higher level of disability or frailty.
The relationship between age-adjusted declines in disability and the actual prevalences in a steadily aging elderly population also were examined, as well as trends for individual IADL and ADL activities and for the mean number of disabilities among the disabled elderly in the community and in institutions.
The aggregate prevalence of chronic disability among the elderly declined significantly over the 15-year period, from 22.1 percent in 1984 to 19.7 percent in 1999.
The decline was the result of two countervailing factors--a 3.9 percentage point decline in the percent of the elderly receiving help from someone for ADLs or IADLs and a 1.4 percentage point increase in the percent of the elderly who managed chronic ADL disability in the community with assistive devices only.
More than 80 percent of the 3.9 percentage point decline in the percent of the elderly receiving human help for a chronic disability was due to a decrease (from 7.4% in 1984 to 4.2% in 1999) in the percent of elderly persons receiving human assistance for IADLs only.
The percent independent with IADL equipment in the community (0.7 percent) for the one IADL for which we could measure independent equipment use was stable and did not contribute to the disability decline.
The prevalence of institutional residence, the most costly form of long term care, was about 5 percent of the elderly throughout the period.
Population aging moderated the decline in the prevalence of chronic disability.
Nearly all individual IADLs declined over the period, but the most dramatic change was a 3.7 percentage point drop in help with money management between 1984 and 1989, when Social Security direct deposit became the norm, raising a question whether IADL declines reflect improvements in health or improvements in the physical environment.
No individual ADLs declined in prevalence over the period.
The mean number of IADLs among the disabled in the community declined over the 15-year period, but the mean number of ADLs for which assistance was received increased for the disabled in both the community and institutions.
The disabilities that saw the most improvements over the 15-year study period were not ones that necessarily imply better health and lower health and long term care costs among the elderly. Rather, a substantial part of disability declines may reflect improvements in the external environment that make it easier to perform such activities as managing money, shopping, and telephoning, regardless of physical state. Help with ADLs changed only slightly from the beginning to the end of the study period. For those receiving ADL help in the community, the total number of chronic disabilities, which is correlated with hours of long term care, fell initially but had returned to its 1984 level by 1999. These findings suggest a need to examine directly both Medicare costs and hours of paid and unpaid long term care for different subgroups of the elderly and the elderly disabled in order to understand the cost implications of disability changes since the mid 1980s.
The growth in the percent of persons who manage various ADL activities with only equipment also suggests the need to know more about which types of equipment are being used and whether the equipment substitutes for or supplements hours of human assistance. Only for bathing was the increase in the prevalence of equipment use accompanied by a decline in the prevalence of human help, but it remains to be seen whether those who manage some activities with equipment use fewer hours of long term care.
Better understanding of the real implications of aggregate disability changes is not an academic exercise as policymakers consider changes in Social Security and Medicare to ensure their long-range financial health. Many argue that declines in disability need to be taken into account in projecting future spending. Until there is a better understanding of these trends and their cost implications, however, it is not clear how they should be taken into account.
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