Policy Research Institute page Health Status of the Elderly from the Perspective of Long-Term Care Data -Analysis Using Complementary Indicators of Healthy Life Expectancy

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One of the important goals of next-generation health care is the "extension of healthy life expectancy," and one of the key players is the elderly. In considering the extension of healthy life expectancy, it is important to understand the health status of the elderly. In Policy Research Institute News No. 65*1, we examined the health status of the elderly over time and by age group based on long-term care data, and examined the main causative diseases that impair health. The study also aimed to examine the contribution of drugs to the causative diseases. This paper presents excerpts from the study.

1) Relationship between health status and healthy life expectancy based on nursing-care data

Understanding the health status of the elderly based on long-term care system data is closely related to understanding the status of healthy life expectancy among the elderly. Healthy life expectancy is a measure of "the average period during which a person is expected to live in a certain state of health. There are several types of healthy life expectancy*2, but the challenge in calculating it lies in the conceptual definition of "healthy/unhealthy" and the method of calculating healthy life expectancy. In Japan, "healthy" and "unhealthy" are defined as "having no or limited daily life" and calculated using the Sullivan method*3 based on data obtained from the National Survey of Living Standards conducted every three years by the Ministry of Health, Labor and Welfare. More specifically, to the question, "Do you currently have any health problems that affect your daily life?" a response of "no" is defined as "healthy" and a response of "yes" is defined as "unhealthy. In other words, the "average length of time without limitations in daily life" is the main indicator of healthy life expectancy*4.

Health" is a very broad concept. It is inappropriate to judge merely by the presence or absence of injury or disease. Even if a person is physically well, if he or she is not mentally and socially well, it would be difficult to say that he or she is "healthy. In this regard, the current indicator, "average duration of unrestricted daily life," is considered to be the most appropriate among currently available indicators of healthy life expectancy, as it is considered to represent not only physical factors but also mental and social factors to a certain extent in a broad and comprehensive manner. However, due to the fact that the National Life Expectancy Survey is conducted every three years, a complementary indicator is being considered, and the "average duration of independence in activities of daily living" using long-term care insurance data is considered most appropriate as a complementary indicator. More specifically, in the categories of care required ( Table 1 ), "care required 1 or less" is defined as "healthy" and "care required 2 or more" as "unhealthy "*5.

Table 1 Guideline for classification of nursing care needs
Source: Longevity Science Foundation What is the nursing care level of long-term care insurance*6
Source: Compiled by the Pharmaceutical and Industrial Policy Research Institute from the above data

Based on these findings, we proceeded to examine the health status of the elderly and others by utilizing relatively easily accessible long-term care-related data. In other words, in another sense, it is a part of understanding the status of healthy life expectancy of the elderly, etc. It should be noted, however, that unlike the current indicator, the complementary indicator that utilizes long-term care system data mainly reflects physical factors.

2) Situation of the Elderly Based on Complementary Indicators of Healthy Life Expectancy

We examined the situation of the elderly based on the number of people certified as "requiring nursing care 2 or more," which is defined as "unhealthy" in the complementary indicator of healthy life expectancy. The Long-Term Care Insurance Business Status Report (Annual Report)*7 was used as the long-term care system data. The report is conducted annually for municipalities (including wide-area federations and partial administrative associations), and data for fiscal years 2000 through 2019 are accessible (as of January 2022). Figure 1 shows the annual changes in the "number of persons certified as requiring nursing care 2 or more" for Category 1 insured persons (those aged 65 or older), divided into two groups: a. the elderly in the first term (aged 65-74) and b. the elderly in the second term (aged 75 or older). As a result, the number of the elderly in the first term (aged 65-74) either remained flat or decreased gradually after reaching the highest number (approximately 367,000) in FY2014, and reached approximately 357,400 in FY2019, a decrease of 3.4% from FY2014. The number of people in the late-stage of life (75 years old and older) has increased almost year by year, reaching the highest number (approximately 3,023,600) in FY2019.

Figure 1: Annual changes in the number of persons certified as requiring long-term care 2 or more
a Category 1 insured persons (elderly in the first term: 65-74 years old)

b Category 1 insured persons (elderly in the latter term: 75 years old and over)
Source: Long-term care insurance business status report (annual report)*7
Source: Created by the Pharmaceutical and Industrial Policy Research Institute based on the above data.

The number of people who need long-term care 2 or more showed different trends, but the population numbers fluctuated from year to year. Therefore, in order to adjust for the fluctuation in the population counts, we examined the "ratio of the number of people certified as needing long-term care 2 or more to the population," which is calculated by dividing the number of people certified as needing long-term care 2 or more by the annual estimated population corresponding to the age of each group. The data for population counts was taken from the population estimates (population as of October 1 of each year)*8 available on e-Stat (a comprehensive window of government statistics). The results are shown in Figure 2.

Figure 2: Annual changes in the number of persons certified as requiring long-term care 2 or more and the ratio of the number of persons certified as requiring long-term care 2 or more to the population
a. Category 1 insured persons (elderly in the first term: 65-74 years old)

b. Category 1 insured persons (elderly in the latter term: 75 years old and over)
Source: Long-Term Care Insurance Business Status Report (Annual Report)*7, Population Estimates*8
Source: Prepared by the Pharmaceutical and Industrial Policy Research Institute based on the above data.

As a result, it is clear that the trend of the "ratio of persons requiring long-term care 2 or more to the population certified" is different from that of the "number of persons requiring long-term care 2 or more certified. For the Category 1 insured persons (the elderly in the first term), the "ratio of the number of persons requiring long-term care 2 or more to the population certified" was the highest in 2007 (about 2.415%) and then gradually decreased, reaching about 2.054% in 2019, a decrease of about 14.9% from the 2007 level. For the elderly in the first semester, the declining trend was more clear compared to the change in the "number of persons certified as requiring nursing care 2 or more". For the Category 1 insured persons (Late-Stage Senior Citizens), the "ratio of population certified as requiring 2 or more years of care" was the highest (approximately 17.115%) in FY2014 and then leveled off or declined gradually to approximately 16.352% in FY2019, a decrease of approximately 4.5% from FY2014. Among the elderly in the later stages of life, the "number of persons certified as needing care 2 or more" expanded with each year, but the "ratio of persons certified as needing care 2 or more to the population" has shown a flat or gradual declining trend since FY2014.

In recent years, the aging rate (the percentage of the population aged 65 and over) has continued to rise, and it is necessary to consider the "number of persons certified as requiring long-term care 2 or more" (i.e., the status of healthy life expectancy as seen in the complementary index) by distinguishing those attributable to the number of people requiring long-term care and those attributable to their health status. The recent study focusing on the "ratio of people certified as requiring long-term care 2 or more to the population" suggests that the health status of the elderly in the early stage of life is moving in a positive direction, and that the health status of the elderly in the later stage of life may also be maintaining or improving. At the very least, the results support the importance of examining the elderly in different age groups, rather than taking a one-size-fits-all approach.

Main causes of the need for long-term care (4) Main causes of the need for long-term care

The main causes of the need for long-term care were examined based on data from the National Survey of Basic Living*9. The National Survey is conducted every three years by the Ministry of Health, Labour and Welfare for the purpose of surveying basic matters of national life such as health, medical care, welfare, pensions, and income, etc. The most recent survey results for fiscal 2019 are now available*10 The caregiver questionnaire data in this survey includes a list of "main causes of needing care*11 ", including the following The data of this survey shows the number of representative diseases*12 per 100,000 persons in need of care by age group as the "main causes of need for care*13". We also examined the composition ratio in order to better grasp the weight of each cause.

Figure 3 shows the status of the main causes of the need for long-term care among those aged 65-74 who fall into the category of Category 1 insured persons (elderly in the first term). The number of major causes that resulted in the need for nursing care (including other diseases) showed a decreasing trend after reaching the highest number (17,545) in 2004, and reached 10,383 in 2019 ( Figure 3-a). In terms of composition, cerebrovascular diseases (stroke) and joint diseases (rheumatism, etc.) accounted for about 40% and 10%, respectively, followed by diabetes, fractures/falls, malignant neoplasms (cancer), dementia, and Parkinson's disease, which showed almost parallel proportions in 2019 at about 7% to 6% ( Figure 3-b). In particular, the number of causes of cerebrovascular disease (stroke) showed a decreasing trend over the years, but a downward trend was observed in scattered cases in recent years. The percentage of stroke cases remained flat at around 40%, indicating the importance of cerebrovascular disease (stroke) countermeasures. The results also suggest that a wide range of disease countermeasures are required for the certification of long-term care for the 65-74 age group. A certain number of care certifications were also given for causes other than the typical diseases (other diseases), and close examination of these certifications was also considered to be important.

Figure 3: Main causes of the need for long-term care among Category 1 insured persons (elderly in the first term: aged 65-74)
a Number of main causes of needing long-term care
Note: Includes other diseases and does not include unknown/unknown.

b Composition of major causes of need for nursing care
Note: Includes other diseases, not known/unknown.
Source: National Survey of Living Conditions (Nursing Care Survey)*9
Source: Created by the Pharmaceutical and Industrial Policy Research Institute based on the above data

Figure 4 shows the main causes of the need for long-term care for those aged 75 and over who are Category 1 insured persons (late-stage elderly). The number of major causes for which long-term care was needed (including other diseases) has shown a consistent upward trend since FY2001, reaching 82,709 in 2019 ( Figure 4-a). In terms of composition, there was a considerable discrepancy between the elderly in the first semester and the elderly in the second semester. Dementia showed an increasing trend over time, with the largest percentage in recent years at over 20%. Frailty due to old age and fractures/falls followed at around 15%. Cerebrovascular diseases (strokes) accounted for almost all of the declines over time, falling to the low 10% range in recent years. These four diseases appeared to be important in the identification of care for the elderly in later life. In particular, the number and composition of causes of dementia showed a consistent upward trend, suggesting that measures against dementia are of paramount importance in the certification of care for the elderly in later stages of life. The number and proportion of causes of fractures and falls also showed a slow but steady increase, suggesting that countermeasures against these causes are also important. The number and composition of causes of debility due to old age showed a flat to slightly decreasing trend, while the number and composition of causes of cerebrovascular disease (stroke) showed a clear downward trend.

Figure 4: Main causes of the need for nursing care among Category 1 insured persons (aged 75 and over)
a Number of main causes of needing nursing care
Note: Includes other diseases and does not include unknown/unknown.

b Composition of main causes of needing nursing care
Note: Includes other diseases, not known/unknown.
Source: National Survey of Living Conditions (Nursing Care Survey)*9
Source: Created by the Pharmaceutical and Industrial Policy Research Institute based on the above data

4. consideration of contribution of drugs to the main causative diseases requiring long-term care

In the National Survey of Family Life, the main causes of the need for nursing care (representative diseases, etc.; hereafter referred to as "main causative diseases") were listed as follows. However, there is no data on the main causative diseases examined in depth, and the impact of drugs is unknown. Therefore, we decided to infer the impact of drugs on the main causative diseases by comparing and referencing the results of the "Medical Needs Survey on 60 Diseases (6th) [Analysis]" (hereafter, Medical Needs Survey)*13 conducted by the Human Science Foundation (hereafter, HS Foundation), which examined the contribution of drugs to diseases and the level of treatment satisfaction. The Medical Needs Assessment has been conducted since FY1994.

The Medical Needs Survey is a fixed-point survey of medical needs conducted approximately every five years from FY1994 to FY 2019, in which physicians and others were surveyed regarding the drug contribution and treatment satisfaction for 60 socially important diseases. Due to the nature of the survey, the results are not presented by age group, so we decided to proceed with inferences after presenting the main causative diseases that unavoidably required nursing care for those aged 40 years and older collectively Figure 5 shows the status of the main causative diseases that required nursing care for those aged 40 years and older.

Figure 5 Main causes of needing nursing care (persons aged 40 and over)
a Number of major causes of needing care
Note: Includes other diseases and does not include unknown/unknown.

b Composition of major causes of needing care
Note: Does not include other diseases, don't know, and unknown

c Changes in particularly important causes
Source: National Survey of Basic Living Conditions (Nursing Care Sheet)*9
Source: Created by the Pharmaceutical Industry Policy Institute based on the above data

As a result, in the number of major causes of the need for long-term care ( Figure 5-a), cerebrovascular disease (stroke) was the leading cause in 2001 with 27,960 cases, but it decreased over time to 16,095 cases in 2019, representing a 41.9% decrease from 2001. On the other hand, dementia showed an increasing trend from 17,742 in 2001 to 17,578 in 2019 and has been the leading cause since 2016, with an increase of 63.6% since 2001. In terms of the composition of the main causes of the need for care ( Figure 5-b), cerebrovascular disease (stroke) accounted for 28.8% in 2001, but has decreased over the years to 18.4% in 2019. The rate of decline was 36.0%. On the other hand, dementia increased from 11.2% in 2001 to 20.1% in 2019, representing an increase of 80.1%. The individual trends for the two particularly important causes of the disease ( Figure 5-c) were as described above. The trends in the HS Foundation Medical Needs Assessment results for these two particularly important causes are shown in Figure 6.

Figure 6 Trends in HS Foundation Medical Needs Survey (Treatment Satisfaction and Drug Contribution)
a Cerebrovascular disease (stroke)-related

b Dementia-related
Source: Human Science Foundation Medical Needs Survey on 60 diseases
(6th) [Analysis] *13
Source: Created by the Pharmaceutical and Industrial Policy Research Institute based on the above data.

For cerebrovascular disease (stroke), we determined that cerebral hemorrhage (including subarachnoid hemorrhage)*14 ("cerebral hemorrhage") and cerebral infarction correspond to the HS Foundation Medical Needs Assessment. For these two diseases, drug contribution and treatment satisfaction showed almost steady trends. In FY2000, the drug contribution was 36.9% for cerebral hemorrhage and 34.0% for cerebral infarction, rising to 63.5% and 76.5%, respectively, in FY 2014. However, in FY 2019, they dropped to 47.4% and 63.1%. Treatment satisfaction was 24.1% for cerebral hemorrhage and 20.2% for cerebral infarction in FY2000, but increased to 63.6% and 66.1%, respectively, in FY2019 ( Figure 6-a). Cerebrovascular disease (stroke) as the main cause of the need for long-term care has been declining, as mentioned earlier ( Figure 5-c). Of course, the improvement in prognosis due to therapeutic intervention such as surgery, rehabilitation, etc. may have had a great deal to do with this, but it was inferred that the improvement in drug contribution and treatment satisfaction for cerebral hemorrhage and stroke seen in the HS Foundation Medical Needs Survey at about the same time may have contributed to the decrease in the number of people certified for long-term care. In other words, it was inferred that the improvement of drug contribution in cerebral hemorrhage and cerebral infarction may contribute to the healthy life expectancy seen in the complementary index.

For dementia, we determined that Alzheimer's disease and vascular dementia from the HS Foundation Medical Needs Assessment would be addressed. Although drug contribution and treatment satisfaction were steadily increasing for these two diseases, the extent of the increase was low. Drug contribution was as low as 9.9% for Alzheimer's disease and 10.0% for vascular dementia in FY2000 and 43.8% and 42.9%, respectively, in 2014, but fell to 25.5% and 27.5% in FY 2019. Treatment satisfaction was extremely low at 3.9% for both diseases in FY2000 and increased over time, but remained at low levels of 21.1% and 30.2% in FY2019 ( Figure 6-b). Dementia as the primary cause of the need for long-term care is on the rise, as noted above ( Figure 5-c). It was inferred that the stagnation in the drug contribution of Alzheimer's disease and vascular dementia observed in the HS Foundation Medical Needs Survey at about the same time may not have contributed to the number of care certifications. In other words, it was inferred that the stagnation of drug contribution in Alzheimer's disease and vascular dementia may not have a positive impact on healthy life expectancy as seen in the complementary indicators.

5. summary

Based on long-term care system data, which is considered the most valid complementary indicator of healthy life expectancy, we examined the health status of the elderly over time and by age group through the status of "care required 2 or more" certification. The results suggest that the health status of the elderly in the first half of their lives, aged 65-74, is moving in the right direction, and that the health status of the elderly in the second half of their lives, aged 75 and older, may also be maintaining or improving. At the very least, we believe that we were able to present the importance of examining the elderly not in a uniform manner, but by age group.

In addition, using data from the National Survey of Living Conditions, we examined the main causes of the need for long-term care. Among the elderly in the early stage of life, cerebrovascular diseases (stroke) accounted for about 40%, followed by joint diseases (rheumatism, etc.), fractures/falls, and dementia at less than 10 to 10%. On the other hand, dementia accounted for the largest proportion of cases among the elderly in the later stages of life, at more than 20%, followed by debility due to old age and bone fractures/falls at around 15%. Cerebrovascular disease (stroke) accounted for a lower percentage, in the low 10% range. We believe that this study also presented the importance of examining the elderly separately by age group.

In addition, the drug contributions to the main causes of the need for long-term care were considered by comparing and referencing the annual trends in drug contributions in the HS Foundation Medical Needs Survey. Although the survey results were relatively concordant for cerebrovascular disease (stroke) and dementia, the results were only inferences based on a simple comparison of results from different data according to age, and it was difficult to examine the results by age group, which was a limitation in examining the relationship between the health status of the elderly and drug contributions through long-term care-related data.

Recently, in addition to disease receipt data from the National Database (NDB) and information on care requirements and care receipts from the long-term care database, a consolidated analysis of the DPC (Diagnosis Procedure Combination) database is now in view*15. 15 By examining information on injuries and illnesses, medications, and tests obtained from these databases, as well as information on care requirements and care costs by year and age group, there is a possibility that the health status of the elderly can be analyzed more scientifically, and in addition to the impact on medical costs, the impact on care costs and drug contributions can also be examined more precisely. We hope that this will be realized as soon as possible and lead to more effective measures and drug development that will contribute to extending healthy life expectancy.

( Minoru Ito, Senior Researcher, Pharmaceutical and Industrial Policy Research Institute)

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