Successful Ageing Influence of socio-economic factors, gender and health service provision

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Successful Ageing Influence of socio-economic
factors, gender and health service provision
CADENZA Symposium 2008

• Shah Ebrahim
• London School of Hygiene Tropical Medicine

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Outline

• Socio-economic development and life expectancy
• Social class, survival and disability
• Gender, survival and disability
• Life-course influences on disability
• Health services

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Successful ageing requires survival
Socio-economic position
Health services
Survival
Gender
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Socio-economic development and ageing

• Life expectancy comparisons between countries by
  income levels

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Life expectancy and GDP
Lynch et al. BMJ 20003201200
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Prestons curves explanations for better health
1900s
Preston, S. H Int. J. Epidemiol. 2007 36484-490
doi10.1093/ije/dym075
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Prestons conclusion

• Improvements in survival are not all explained by
  economic growth
• Nutrition and education have had only a small
  role.
• Global diffusion of medical and health
  technologies
• innovations in hygiene and sanitation
• maternal and child services
• specific vaccines and drugs for treatment of
  bacterial infections

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Paradoxes of Costa Rica, Cuba, Sri Lanka high
life expectancy but low GDP
Marmot M, Clinical Medicine, 2006
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Social class (an English view)
Im upper class. I look down on both of them
Im middle class. I look up to him but I look
down on him
I know my place
John Cleese Ronnie Barker
Ronnie Corbett
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Social class and life expectancyage 65
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Locomotor disability and social class British
Regional Heart Study men
12.3
19.2
21.5
28.5
33.7
40.1
Source Ebrahim et al, Int J Epidemiology (2000)
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Social class and disability possible explanations
Social class
Disability
Chronic diseases Arthritis, CVD Risk factors
inactivity, smoking, BMI etc
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Locomotor disability and social class British
Regional Heart Study men
Adjusted for smoking, BMI, activity and alcohol
Excluding men with CVD, arthritis and respiratory
disease
12.3
19.2
21.5
28.5
33.7
40.1
Source Ebrahim et al, Int J Epidemiology (2000)
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Material and psycho-social models of causation
Poverty
MATERIAL CONDITIONS Inadequate diet Smoking Poor
housing
PSYCHO-SOCIAL CONDITIONS Lack of
control Increased stress Low social capital
Reduced survival
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A metaphor air travel differences in a
neo-material and psychosocial theory
First class
Cattle class
Lynch Davey Smith BMJ 20003201200-1204
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Material vs. psychosocial explanations
Compare air travellers in first and economy
class. Travellers in economy have worse health
because they sat in a cramped space and couldn't
sleep not because they could see the bigger seats
in first class
Lynch Davey Smith. BMJ 20003201200
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Implications for intervention

• psychosocial interpretation health inequalities
  would be reduced by abolishing first class, or
  mass psychotherapy to alter perceptions of
  relative disadvantage.
• neomaterial viewpoint health inequalities can
  be reduced by upgrading conditions in economy
  class

Lynch Davey Smith BMJ 20003201200-1204
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Social inequalities and survival

• Growing wider
• Not fully explained by smoking, diet, exercise
• Potentially avoidable

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Gender, survival and disability
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Life expectancy at age 65
Office of National Statistics, UK
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Percentage of life expectancy spent able to get
outdoors, 1991
Men
Women
8.6
4.8
11.2
6.1
Source Bone et al Health Expectancy, 1995
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(No Transcript)
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Distribution of walking time
Time to walk 6m.
2 increase per single year increase in age,
plt0.001)
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Adult social class, 2002/3
Time to walk 6m.
4.9 increase in walking time per category
increase in social class, p0.02
Adult occupational social class, 2002/3
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Household income, 1937/9 and walking speed in
2002/3
Time to walk 6m.
3.2 reduction in walking time per category
increase in income, p0.04
high
low
Weekly household income, 1937/9
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You need to walk at 0.8 m/s to cross a Hong Kong
road
The youngest participants (aged 64-66) only
walked at 0.7 m/s!
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Guardian 9 September 2004
Inner-Age? Pharmanex? Isolagen?
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Health services for older people

• Complex interventions - combinations of
  interdisciplinary teamwork for health and social
  problems
• Do they work?

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MRC trial of multidimensional assessment and
management

• 40,000 older people randomized to different care
  death and institutional care
• Comparisons of geriatric service vs. primary care
  service
• Comparison of targeted service vs. universal
  service
• After 10 years work geriatric service slightly
  worse than primary care and universal no better
  than targeted service

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Components of complex interventions

• Assessment
• Primary prevention
• Physical activity
• Environment, home safety
• Self care, immunisation
• Social network
• Secondary prevention
• Treatment of chronic conditions
• Tertiary prevention
• Medication review, rehabilitation

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Meta-analysis of 45 trials
Relative risk of not living in own home
Favours intervention
Favours control
0.87 (95 CI 0.79, 0.94)
Beswick A et al, Lancet 2007
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Health care and social support

• Effective services
• evidence base patchy in LMICs
• Affordability
• privatisation of long-term care
• Accessibility
• waiting lists, local treatment
• Appropriateness
• growing private anti-ageing sector

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Number of admissions to hospitals in the three
years before death, England, 1999-2000.
Dixon, T. et al. BMJ 20043281288
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Projections of long-term care costs
28.0
19.9
14.7
billions
11.1
With Respect to Old Age, Cm 4129, 1999
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Summary

• Socio-economic factors play a major role in
  determining survival and disability
• Women do better than men in terms of survival but
  not in terms of disability
• Health services do improve survival and reduce
  institutionalisation
• But too much health service use is a problem for
  many