Chapter 6 - The Health of older people

Key Messages

• People are generally living longer and ageing in better health.
• Older people are a diverse population but share common concerns about health and current and future access to health and other social services.
• Older people, particularly those in very old age, are relatively high users of health and disability support services.
• The healthy ageing of the population is dependent on the effective implementation of a range of general and population specific health strategies.

Introduction

Health is a primary concern of older people. While people are living longer, as a general rule, the older a person becomes the greater the likelihood that they will experience deterioration in their health. This leads to increasing concern about their health and the need for health services.

Older peoples sensitivity to health issues, especially to changes in health policies and services, reflects reality and their perceptions. The reality is that there is a greater need for health assistance as people move into older age and experience greater reliance on medical interventions.

The perception is that older people view changes to the health system in terms of their own real or potential reliance on the system and its capacity to deliver to meet their needs. Changes or discussion about proposed changes, including policies to address the increasingly ageing population, are often perceived by older people as discriminatory and threatening.

As people age their need for, and usage of, health services increases. For this reason discussion around older peoples health is often focused on their high usage of health services and the financial burden this will create as the proportion of older people increases. Also, age related disability becomes more likely as a person moves into old and very old age. These factors need to be addressed in policy development and in the planning, funding and delivery of health services.

Older peoples health is a complex issue. It is significantly influenced by health promotion and illness and disability prevention in earlier stages of life. Health policy for, and health promotion among, older people does not exist in isolation. The effectiveness of public health promotion strategies impacts on the health of people as they enter old age, which can in turn influence the effectiveness of health strategies and policies targeted to the older population.

The cornerstone of ageing policy in New Zealand is the Positive Ageing Strategy. It has as its health goal equitable, timely, affordable and accessible health services for older people. The Health of Older People Strategy sets the policy framework for health sector action to 2010 to support the health and independence goals of the Positive Ageing Strategy. These two strategies provide the vision and policy framework for developing an environment where older people can maintain capacity, contribution and participation for as long as possible but can also receive services if and when they become needed.

General health characteristics

General population

There is an accepted view in developed countries that older people are now living longer and are also ageing in better health. The increasing life expectancy of the general population can be verified by statistics.

Table 1: Average Life Expectancy at Birth

Source: Statistics New Zealand

While it is generally accepted that people are living healthier into older age, this view is less easily confirmed and quantified. There is evidence that there is a larger number of very old and frail people in the population than there were several decades ago. For example, residential care providers report that the average age of residents is greater, and dependency levels among residents have increased significantly over the last 15 to 20 years. However the average length of stay is also shorter.

These trends are influenced by a number of factors, including an older age of entry into residential care, improvements in community based health services, and peoples ongoing reluctance to leave their homes. The income and asset testing regime that applies to the Residential Care Subsidy results in many older people having to use the equity in their home to pay for their residential care. This can be a disincentive to move into residential care.

The very old and the very young are high users of health services. Per capita health costs increase and accelerate significantly from age 65. While people over the age of 65 make up 12% of the population, they use 37%[1] of total public health expenditure. The population over age 65 is not a homogeneous group in that they all do not have the same general level of need for health services, or a similar health status. There is considerable variation in life expectancy and health status both between and among older women, older Māori, and older Pacific peoples.

Māori population

The number and proportion of older Māori is projected to increase over the next three decades. The Māori population aged 65 and over numbered approximately 18,000 in March 2001, an increase of 61% (6,700 persons) from 1991. Older Māori made up 3.4% of all Māori in 2001, up from 2.5% in 1991.

In the 2001 Census, those identifying with the Māori ethnic group made up 4% of the 65 years and over age group, but made up 16% of the under 65 years age group. The representation of Māori decreases with age. In 2001 they accounted for 6% of all 65-74 year olds, 3% of 75-84 year olds and 2% of those aged 85 and over. Almost three-quarters of older Māori are aged between 65 and 74 years.

Health issues for older Māori identified from reports and consultations include:

• reduction of the prevalence of respiratory disease, heart disease and diabetes among Māori in the 55+ age group;
• access to primary health care due to older Māori having a lower median annual income than Europeans;
• access to specialist hospital services because of the higher proportion of older Māori who live in rural areas; and access to home support services for the older age group
• access to home support services for the older age group requiring support.

While considerable advances have been made in the targeting of health services at Māori, including older Māori, it is expected to be some years before the benefits of such programmes are reflected in statistics.

Pacific people populations

Pacific people populations are also experiencing the same trends in ageing as the population as a whole, with the proportion in the over 65 age group expected to increase significantly in the next 20 years. Older Pacific people currently account for just 1.8% of all older people. Fewer than 1% of the population aged 85 or older are Pacific people, compared with 2% of those aged 65-74 years. At the 2001 Census, there were 7,600 older Pacific people.

Health issues for older Pacific peoples identified in reports and Māori make up 4% of people aged 65 years and older consultations include:

• access to primary health care due to lower personal incomes and demands on their incomes through involvement in supporting other family members;
• and lowering the prevalence of respiratory disease and diabetes among Pacific peoples.

Women

In the general population, women currently represent 52% of those aged 65-74 years, 58% of those aged 75-84 years, and 70% of those aged 85 years and over.

Given that health needs increase with age, and are highest in very old age, it is a natural consequence that women make up the bulk of those requiring aged care services. For instance, in 1997 women made up three out of four of those living in residential homes.[2] Similarly women are more represented in the proportion of the older age group who require support services in their own homes.

Although women live longer than men, they do not necessarily require health services over a longer period. This is because for both women and men the greatest need for health services occurs during the last 3-4 years of life, irrespective of whether that is between, for instance, the ages of 70-73 years or 95-98 years.

There is considerable debate about whether living longer means that the period between being healthy and requiring secondary and tertiary health care services up to the time of death is extended. It is the case that new medical practices, technology and pharmaceuticals can inhibit or ameliorate certain conditions, and extend life. However, they do not necessarily improve the quality of life, as the end of life approaches. The debate is of particular relevance to women because of their high representation among the very old.

Planning for an older population

Health planning for the ageing population has been undertaken on two main fronts, through addressing health structures and in drawing up appropriate strategies.

Women

In the general population, women currently represent 52% of those aged 65-74 years, 58% of those aged 75-84 years, and 70% of those aged 85 years and over.

Given that health needs increase with age, and are highest in very old age, it is a natural consequence that women make up the bulk of those requiring aged care services. For instance, in 1997 women made up three out of four of those living in residential homes.[2] Similarly women are more represented in the proportion of the older age group who require support services in their own homes.

Although women live longer than men, they do not necessarily require health services over a longer period. This is because for both women and men the greatest need for health services occurs during the last 3-4 years of life, irrespective of whether that is between, for instance, the ages of 70-73 years or 95-98 years.

There is considerable debate about whether living longer means that the period between being healthy and requiring secondary and tertiary health care services up to the time of death is extended. It is the case that new medical practices, technology and pharmaceuticals can inhibit or ameliorate certain conditions, and extend life. However, they do not necessarily improve the quality of life, as the end of life approaches. The debate is of particular relevance to women because of their high representation among the very old.

Planning for an older population

Health planning for the ageing population has been undertaken on two main fronts, through addressing health structures and in drawing up appropriate strategies.

Structures

In 2000, the Ministry of Health established a Sector Policy Directorate within which there is a specific Health of Older People team. This enables the Ministry to maintain a clear and unambiguous focus on the health of older people at all levels of policy, service development, service delivery and monitoring.

In 2001, the Government also made a decision to devolve responsibility for the funding of disability support services for older people to District Health Boards (DHBs). This will allow for greater integration of support services with other health services at the local level and provide a clearer focus on the total health needs of older people.

The process for the transfer of responsibility to DHBs commences in 2002/03 with the Canterbury District Health Board and the Northland District Health Boards acting as lead agencies for piloting populationbased health initiatives and processes. This will facilitate the smooth transfer of their responsibilities at a later date.

At public hospital level the focus is on specialist services for older people in assessment, treatment and rehabilitation (AT&R) and access to other specialist services. AT&R services are central to the management of older peoples care. Such services also enable a managed interface between disability support services and clinical services and the range of interventions and services that are considered to be in the interests of the person being assessed.

Strategies

The Governments Positive Ageing Strategy, released in April 2001, presents the Governments planning response across the range of its activities that impact on older people.

The Strategy also provides a framework within which those activities can be adapted to the needs of an ageing population in a systematic and coordinated way.

In May 2002, the Health of Older People Strategy was launched, setting out the Governments policy for the future direction of health and disability support services for older people. The Strategy was prepared by the Health of Older People team with substantial input from interest groups.

The Health of Older People Strategy proposes actions and key steps for eight key objectives. These objectives are:

• Older people, their families and whānau are able to make wellinformed choices about options for healthy living, health care and/or disability support needs.
• Policy and service planning will support quality health and disability support programmes integrated around the needs of older people.
• Funding and service delivery will promote timely access to quality integrated health and disability support services for older people, family, whānau and carers.
• The health and disability support needs of older Māori and their whānau will be met by appropriate, integrated health care and disability support services.
• Population-based health initiatives and programmes will promote health and wellbeing in older age.
• Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning
• Admission to general hospital services will be integrated with any community-based care and support that an older person requires
• Older people with high and complex health and disability support needs will have access to flexible, timely and co-ordinated services and living options that take account of family and whānau carer needs.

Other health strategies that will impact on the health of older people have been released.

• Disability Strategy (2001). - Older people are highly represented among people with disabilities, especially sensory and physical disabilities. The Disability Strategy addresses attitudinal, policy and service issues.
• New Zealand Palliative Care Strategy (2001). - The support of people who are dying has clinical as well as physical, social, emotional and spiritual aspects. The Strategy seeks to bring these aspects together in a co-ordinated way, addressing issues of supply, effectiveness and service delivery.
• Mental Health Strategy. - Older people experience mental health problems the same as the community as a whole. At the same time people who have had mental health conditions from a younger age also grow old and continue to need clinical services and support. The interests of older people need to be reflected in the planning for the development of mental health services.

Access to health care

A key element in the effective management of the health of older people is their access to timely and appropriate health services.

Primary health care

Access by older people to general practitioner and other primary health care services is subject to the same constraints of income, location and motivation as the community as a whole. However, to the extent that a high proportion of older people are reliant on fixed incomes towards the lower end of the income scale, affordability is a significant issue.

The Community Services Card provides those with little additional income other than New Zealand Superannuation (NZS) with greater government subsidies on GP visits and prescription charges. As at 28 June 2002, 71.1% of people receiving NZS were in receipt of a Community Services Card

In 2001, the Government announced an intention to eventually replace the Community Services Card with an alternative method of targeting government expenditure on primary health care.

Secondary health care

Older people are extensive users of hospital services as outpatients and as inpatients arising from acute or elective referrals. Older people see waiting times as of major importance because of the often debilitating effects of delayed treatment for medical conditions on their health, wellbeing and independence. Some older people interpret delays in treatment as a reflection on the lower value placed on them relative to other population groups.

There is no evidence that older people are disadvantaged when compared with other age groups in terms of waiting times and access to hospital services.

However, because a decline in health and a breakdown in support systems can quickly lead to the need for residential care, it is important to older people that they receive appropriate treatment as soon as possible. The specialist hospital based Assessment, Treatment and Rehabilitation services have proven to be very effective for older people to access clinical services and the full range of community support services to assist them to regain and maintain optimum wellness.

Public health

Maintaining the health, mobility and independence of older people is a task for public health services, community organisations and for individual decision makers.

Optimum health in older age also reflects attitudes and lifestyles formed and developed much earlier in the lifecycle. It requires not only long-term preventative programmes for the general population but also specific age related short-term initiatives, the key components of which are:

• recreational and exercise activities at local community levels;
• advice on diet, exercise and fitness promoted through primary health care providers and formal and informal community groups;
• special targeted programmes such as the falls prevention programme sponsored by ACC; and
• links with communities by utilising older peoples organisations and community groups to publicise health promotion through their periodicals, newsletters and local activities.

While public health strategies can positively influence behaviour and attitudes across all population groups including older people, there are other environmental factors that also play a part in determining an individuals general health. These include quality of housing, climate, geographical location and income.

Care and support of older people

Home-based support

Most older people wish to remain in their own home for as long as possible. Recognising the wishes of older people and the economics of providing care and support, central government has responded with an ageing in place policy framework. The goal of ageing in place is to support people to remain in their own homes as long as possible. This is done through a range of programmes within the disability support services currently administered by the Ministry of Health.Programmes include:

• Home help services (cooking, cleaning, etc) without cost to Community Services Card recipients who have been assessed as requiring that assistance. People who do not have a Community Services Card are expected to pay for their own household management services.
• Home support services that offer personal care (for example bathing and showering) to people who require such assistance. Recipients of these services are not subject to financial means testing
• Other forms of assistance such as wheelchairs and aids, appliances and equipment that enable the person to remain in their own home.

Where someone is cared for full-time by a partner, family member or any other person, carer relief is available to give the caregiver a break from their caring responsibilities.

These programmes are currently under considerable financial pressure. Up until the early 1990s they were demand driven, then, together with other Disability Support Services (DSS), they were placed within an overall DSS budget. This budget is adjusted annually according to a population based funding formula.

The various components of home support operate according to terms and conditions that have their origins in historical factors now of questionable relevance. For example, some forms of support in the home are income tested while others are not.

The Ministry of Social Development, in association with the Ministry of Health, is undertaking a review aimed at getting rid of inconsistencies in the terms and conditions applicable to people with disabilities, including older people.

Residential care

Long-term support for older people is monopolised by residential care in terms of resourcing, complexity and public profile. Access to residential care is through a strict assessment process that is designed to ensure services are directed to those for whom there is no alternative. In spite of this, the demand for residential care has until recently increased at a greater rate than the growth in the target older population.

Consequently, controls on access criteria and the utilisation of better home support options have been introduced to allow the growth in demand to be kept within target population levels.

Pricing and contracting issues

When rest homes and continuing care hospitals were administered by Regional Health Authorities they had individual contracts for the payment of Residential Care Subsidies. At that time there were regional differences in the rates of subsidy and the services subsidised. The Ministry of Health has for some time been negotiating on prices and services with the rest home and the continuing hospital care sectors to ensure consistency with costing models.

Residential care standards

Residential care provides a 24-hour comprehensive service for those who have been assessed as needing it. The Health and Disability Services (Safety) Act 2001 replaces provisions which were focused on a process of registration and licensing of residential care facilities, with one more clearly focused on safety, resident services and outcomes, and the ongoing compliance with quality standards as determined by independent audit.

Other community supports

Support for older people living in the community also comes from services provided by a wide range of formal and informal community-based organisations. Some services are organised at a national level while others are local initiatives. While effective in their own right, these services can be enhanced where the organisation works co-operatively and in co-ordination with traditional clinical and professional services.

Issues

There are a number of issues that can be expected to require or attract attention in the next two to three years.

Dementia

Dementia is a significant health and service issue for older people. It has been estimated that 7.7% of people over age 65 have dementia. The prevalence increases with age, rising from 3.8% for those aged 65 to 74 years to 40.4% for those aged over 90.[3]

More importantly, the prevalence of dementia is increasing over time. Studies indicate that the prevalence doubles each 5.1 years between the ages of 60 and 90 years.[4] It is estimated that between 1992 and 2016 the prevalence of dementia will increase by 96-100%, compared with a rise in the general population of 18-26%.[5]

The increasing number of people with dementia has implications for specialist support services. There is strong lobbying from consumer groups to make available new pharmaceutical products which may be utilised in the management of the condition.

New pharmaceuticals

The pharmaceuticals industry is rapidly developing, has delivered major benefits to older people, and can be expected to continue to do so. Older peoples networks are international. Information on drug developments overseas is quickly picked up and feeds the expectations of those who would benefit, if the drugs delivered what is alleged or expected.

New drugs are often very expensive and issues of affordability frequently arise. Pharmac, the Government agency responsible for managing pharmaceuticals, has policies and processes for screening and approving new drugs for subsidies. The tensions between availability, affordability, expectation and utilisation require careful management.

Private health insurance

For many people, private health insurance represents a financial and psychological safety net. Irrespective of changes to, or pressures on, the public health system, those with private insurance can be confident that they will receive the health service they need, when they need it. The likelihood of requiring health services increases as a person ages, which makes private health insurance an increasingly attractive option as one gets older. The cost of private insurance is becoming prohibitive for many older people. This is due to a combination of general increases in premiums, the relatively higher premiums older people pay because of their higher likelihood of health service usage, and the relatively low and usually fixed income of most people in the 65 plus age group. The net effect of increased private health insurance costs is more stress on the public health system.

Asset testing for Residential Care Subsidy

The current asset testing regime for the Residential Care Subsidy has been a source of considerable public interest for a number of years. The regime has been criticised by some as discriminatory toward older people in that they must pay for their residential care when other sectors of the population who require residential care, have their costs met by the state. Asset testing as a means of targeting the Residential Care Subsidy has also been criticised as a result of being avoided through asset transfer mechanisms and therefore unfair to those who retain ownership of assets and declare them. Older people and their representative organisations have been seeking the removal of the asset test on the Residential Care Subsidy for several years.

The Residential Care Subsidy is a government contribution to a persons residential care. It applies in two forms:

• For those who meet the asset threshold, the subsidy pays the difference between the persons income, including New Zealand Superannuation (less a personal allowance), and the fee that the Ministry of Health has agreed with the residential care provider.
• For those whose income or assets prevents the payment of the subsidy as shown above, a top-up subsidy is payable to ensure that no one in residential care pays more than $636 a week. With this form of Residential Care Subsidy, the subsidy is the amount by which the fee agreed by the Ministry of Health for the provision of residential care in the particular home or hospital, exceeds $636 a week. This form of subsidy is paid without regard to the residents income or assets.

In order to qualify for the Residential Care Subsidy, the person must have assets less than the following limits:

• $15,000 if the person is single or widowed;
• $30,000 in combined assets for a couple if both are in long term residential care; or
• $45,000 in combined assets for a couple if only one partner is in care.

Asset testing has been associated with eligibility for government subsidies for rest home care since the early 1960s. It is a long established policy that was introduced to provide assistance to those whose income and realisable asset base was insufficient to cover the cost of residential care. However, increasingly sophisticated income and asset divestment and transfer means that people can now, to all intents and purposes retain access to cash and other assets that would have been factored into their eligibility assessment for Residential Care Subsidy. Consequently, there is a public perception that there is an element of unfairness in the Residential Care Subsidy regime.

Assets include cash or savings, investments, shares or stocks, and loans made to other people. A family home, chattels and car are counted as assets if the person is single or widowed without a dependent child or, in respect of a married couple, if both partners are in residential care.

Currently, some $460m a year is spent on Residential Care Subsidy. It is estimated that removal of the asset test would cost an additional $200- $300m a year. The removal of asset testing in the assessment of Residential Care Subsidy represents a significant policy change, with major financial implications for the Crown. These financial implications could impact on the ability of a government to fund non-residential care services for older people in the future.

Conclusion

Because of the ageing of the population and the need of older people for health services, the health of older people is a very significant issue for health service planners. Planning for future services for the older age groups has commenced in a systematic manner. However, many of the strategies and structures that are planned to support the health of older people are still in their implementation or developmental stages and will require ongoing and consistent attention if they are to deliver what they promise.

Health has been identified as the number one concern among older New Zealanders. Personal health is a critical component of an individuals capacity to age positively, as is the confidence that health services will be available if and when necessary. For the majority of older people and almost all of the very old, the need for health services is inevitable. For most older people those services will need to be provided through the public health system.

Endnotes

1. Minister for Disability Issues address to South Auckland health providers October 2000.

2. Statistics New Zealand (1998). New Zealand Now 65 Plus, Pg 47.

3. Campbell AJ, McCosh LM, Reinken J and Allan BC. Dementia in old age and the need for services: Age and Ageing 1983 quoted in Guidelines for the Support and Management of People with Dementia: ADARDS and National Advisory Committee on Health and Disability 1997.

4. Henderson AS. Epidemiology of mental disorders and psychological problems: Dementia. WHO, England 1994 quoted in Guidelines for the Support and Management of People with Dementia: ADARDS and National Advisory Committee on Health and Disability 1997.

5. Jorm AF, Korten AE. A method for calculating projected increases in the number of dementia sufferers. Aust NZ J Psychiatry 1988 quoted in Guidelines for the Support and Management of People with Dementia: ADARDS and National Advisory Committee on Health and Disability 1997.