Care for the elderly

In 2018 more than two million people were aged 65 years and over in Belgium, representing 19% of the country’s population. According to the Belgian Federal Planning Bureau, this proportion will further increase to 21% in 2025 and will come close to 26% by 2050. This overall ageing of the population will imply a growing number of elderly people requiring long-term care, whether at home or as residents in homes for the elderly ("ROB"-"MRPA") or in nursing homes ("RVT"-"MRS"). Long-term care includes care provided by professionals or, on an informal basis, by patient family members or close relatives. Among the types of care provided by professionals, care at home can be distinguished from residential care (in "Woonzorgcentra"/"MRPA-MRS" facilities- see further).

In this report, we will analyse care for the elderly from 4 different angles:

  • Accessibility of long-term care, by observing the evolution of the proportion of elderly people receiving long-term professional care in residential care (ELD-1) and at home (ELD-2), as well as the number of informal caregivers (ELD-3), the number of long-term care beds (ELD-4), and optimal use of these beds (ELD-5).
  • Accessibility of acute care, as reflected by the number of geriatricians (ELD-6).
  • Safety of care, as reflected by the number of falls (ELD-7), pressure ulcers (bed sores) (ELD-8), resistant staphylococcal infections in residential care (ELD-9), and inappropriate medicine prescriptions (in this case, anticholinergic medicines) (ELD-10).
  • Appropriateness of care, by observing anti-psychotic medicine prescriptions in people who live in residential care (ELD-11) and at home (ELD-12).
 

Other indicators analysed in other sections of this report are also specific to elderly people:

Proportion of the population (aged 65+ years) receiving long-term care in MRPA/MRS facilities or at home (ELD-1 and ELD-2) 

In Belgium as in many other European countries, long-term care policy has for a long time aimed at developing care services at home in order to postpone institutionalisation of elderly people as much as possible. Funding toward care at home has increased significantly, while the capacity of residential care has been limited by moratoriums.

Two main types of residential facilities for elderly people can be distinguished: homes for elderly people ("ROB" -"MRPA" facilities), providing nursing and hygiene services to elderly people who have only mild or moderate limitations in their daily activities and/or in their cognitive abilities, and nursing homes ("RVT"-"MRS" facilities), which are for individuals who are heavily dependent, but do not require permanent hospital care. Each MRS facility is attached to a hospital. Recently, in response to growing needs for residential care, a large number of MRPA beds have been converted into MRS beds.

The level of care covered by the health insurance system is assessed according to the same criteria for care at home and for residential care. This level of care depends on the individual’s degree of dependency in their daily activities, and on their disorientation in time or in space, if applicable.

RESULTS
  • 13.6% of the population aged 65 years and over receives formal long-term care
    • 8.5% in residential facilities
    • 5.1% at home.
  • These results vary strongly, however, depending on age:
    • In people aged 65 to 69 years, the proportion is 1% in institutions and 1.5% at home.
    • In people aged over 90 years, the proportion exceeds 40% for residential care (14% for home care).
  • Women are more often affected than men (11% vs. 5.2% in residential care; 6% vs. 4% in care at home).
  • The socio-economic status also plays a role:
    • Residential care: 16.2% of the BIM population [increased assistance beneficiaries] vs. 5.3% of the non-BIM population
    • Care at home: 9.3% of BIMs vs. 3.4% of non-BIMs
  • The proportion of elderly people in residential care is greater in Brussels (10.3%) and in Wallonia (9%) compared to Flanders (8%), while the inverse can be observed for care at home: 3.3% in Brussels, 4.8% in Wallonia and 5.5% in Flanders (Figures 1 and 2). The proportion of care at home is also highly variable from one province to another, with 3.3% in Brussels-Capital and in the Liege and Luxembourg provinces, 6.7% in Hainaut, and 8.8% in Limburg. 
  • On average, in all OECD countries, 13% of people over 65 years of age receive long-term care, in institutions or at home (2015 data).
Figure 1- Percentage of population 65+ in institution for elderly, by region, 2013-2016
Data source: IMA-AIM
Figure 2- Percentage of population 65+ receiving long-term care at home, by region, 2013-2016
Data source: IMA-AIM

Link to technical datasheet and detailed results

Informal caregivers (ELD-3)

Informal caregivers are an important link in the chain of long-term care. These are individuals (mainly spouses or children) who provide help to an elderly person who is dependent on this help for his/her daily activities.

From the point of view of healthcare policies, informal care is often considered as a way of avoiding or postponing the placement of an elderly person in an institution (institutionalisation) and of avoiding public expenditure related to such institutionalisation. However, it should not be forgotten that informal care also has an (indirect) cost, since for caregivers, it means a reduction in employment and higher prevalence of mental health problems. A policy of support to informal caregivers through financial compensation, extension of legal and social rights, and/or training opportunities could have a positive impact on the supply and quality of care for elderly people in coming decades (see KCE Report 223). Paid time off for informal care is a measure which has been implemented in order to address these problems.

RESULTS
  • According to data from the SHARE Survey (2015), Belgium has a high proportion (20%) of people over 50 years of age who report being informal caregivers (9% on a daily basis and 11% on a weekly basis). This is one of the highest-ranking figures compared to other European countries.
Figure 3- Percentage of the population over 50 reporting to be informal carers either on daily or weekly basis (2015 or nearest year)
Data source: OECD

Link to technical datasheet and detailed results

Number of long-term care resident beds and optimal use of these beds (ELD-4  and ELD-5)

With the ageing of the population, the need for long-term care is growing, not only at home, but also in institutions. According to a prediction model set up in 2011 by the Belgian Federal Planning Bureau and KCE, 149,000 to 177,000 beds will be needed by 2025. After 2025, it is likely that the needs will rise at an even faster rate. These needs could be partially mitigated by an increase in care at home (both formal and informal care) and by allocating available beds by priority to elderly people requiring more intensive care. The question may, in particular, be raised about whether residential care services are the most appropriate option for elderly people who are independent or mildly dependent on care (categories O and A per Katz Index), for whom alternative solutions could be suggested.

In anticipation of these needs, we have added a new indicator (ELD-5) which will help monitor the percentage of elderly people in Katz Index categories O or A who are in residential facilities. As an example, it appears that over one third of the elderly people living in MRPA/MRS facilities in Brussels-Capital still have a certain amount of independence.

The degree of dependency of individuals placed in MR/MRS facilities is measured using the Katz Index:
- Category O relates to individuals who are totally independent physically AND have no cognitive problems.
- Category A is for individuals who are physically dependent for washing and dressing, or individuals who are mentally dependent or disoriented in time or space, but are totally independent physically.

RESULTS
Number of long-term care resident beds (ELD-4)
  • The number of long-term care resident beds is 144,000, representing 68 per 1,000 individuals aged 65 years and over (2018). This is a relatively high number compared to other OECD countries (Figure 4).
  • Based on a prediction model developed by the Belgian Federal Planning Bureau and KCE, it was foreseen that the number of beds required would reach 149,000 to 177,000 by 2025.
  • Major differences can be observed between regions: 61 beds/1,000 individuals aged 65+ years in Flanders, 74 in Wallonia, and 99 in Brussels. When considered separately, the density level in the German-speaking community is much lower, with 50 beds per 1,000 individuals aged 65+ years.
Table 1- Number of beds in residential care facilities per region/community
Source: RIZIV-INAMI

Region                        

Nursing homes

Homes for the elderly

Coma beds

Total beds

Beds/1 000 persons 65+

Beds/1 000 persons 75+

Flanders

45 441

34 515

80

80 036

61

127

Wallonia*

22 922

25 733

65

48 720

74

163

Brussels

6 067

9 566

10

15 643

99

203

Total

74 430

69 814

155

144 399

68

143

             
German-speaking
Community
464 269 0 733 50 98

*Wallonia with German-speaking community included

Figure 4- Number of long-term care beds in institutions per 1 000 population aged 65 and over (2015 or nearest year)
Data source: OECD

Link to technical datasheet and detailed results

Proportion of elderly people in Katz Index categories O or A staying in MRPA and MRS facilities (ELD-5)
  • Over the 2011-2018 period, the proportion of patients at O or A level decreased steadily, changing from 32% in 2011 to 25% in 2018.
  • The differences among regions are significant: 20% in Flanders, 31% in Wallonia and 34% in Brussels (Figure 5). When considered separately, the German-speaking community obtains a result of 27.6%.
Figure 5- Level of dependency of residential care patients by region (2018)
Data source: RIZIV-INAMI

Link to technical datasheet and detailed results

Number of practising geriatricians  (ELD-6)   

The ageing of the population has an effect not only on long-term care for elderly people, but also on acute care. Since there is a shortage of geriatricians in Belgium, a certain number of measures have been taken in order to encourage more medical students to choose this area of specialisation. In particular, the Superior Council of Specialists and General Practitioners has proposed a reform of the Internal Medicine specialisation area, which consists of a common three-year core training course during which each student has an opportunity to become acquainted with geriatrics. Only at the end of these 3 years, students specify their choice of a super-specialisation area. The purpose of this new approach is to encourage more young doctors to specialise in geriatrics. In addition, new RIZIV-INAMI codes have been created in order to improve financial compensation for geriatricians.

This new indicator will therefore help measuring the effects of this reform by monitoring changes in the number of geriatricians.

RESULTS
  • In 2016, there were 331 geriatricians licensed to practise, which represents an increase of 13 geriatricians compared to 2015 (Figure 6).
  • This increase is lower than the quota of the Planning Commission, which recommends admitting 29 students to the geriatrics training course annually (16 in the Flemish-speaking Community, 13 in the French-speaking Community).
  • Compared to all G-7 countries, Belgium has a lower geriatrician workforce with 0.3 per 10 000 population aged over 65. In the G-7 countries rates range from 0.4 in Canada up to 2.4 in the UK.
Figure 6- Number of geriatricians
Data source: RIZIV-INAMI

Link to technical datasheet and detailed results

Prevalence of falls in nursing facilities (and care facilities) (ELD-7)   

Among elderly people, it is estimated that one in ten falls causes a hip fracture or another serious injury, which in turn often leads to a functional limitation. Falls are also a major cause of death (28%) in elderly people aged 60 years and more, particularly in women. In addition, people who have fallen once are at a higher risk of falling again. Recovery after a fall is strongly linked to the functional status of the person before the fall. Falls also have a significant societal cost, with more days of hospitalisation and higher medical costs, which are expected to increase further in the future due to the ageing population. It is therefore imperative that fall prevention policies be set up for elderly people.

This indicator measures the percentage of residents ("WZC"-"MRPA/MRS") who have had a fall during the past month. These data are currently only available for Flanders, through the Flanders Initiative for Quality Indicators for MR/MRS Facilities (Vlaams Indicatorenproject Woonzorgcentra). Data from the National Health Survey will be added as soon as they become available (end of 2019). In future, when the BelRAI assessment tool is deployed on a national scale, this indicator will be recorded in the Long-Term Care Institutions and Care at Home modules.

RESULTS
  • In 2017, the median figure for the percentage of MRPA/MRS facility residents having had a fall during the past month was 12% in Flanders.
  • This figure is similar to that of 2016, but since this indicator has only been recorded for 2 years, we cannot yet derive any trend.

Link to technical datasheet and detailed results

Pressure ulcers (bed sores) in nursing (and care) facilities (ELD-8)  

The development of pressure ulcers (bed sores, supine ulcers) in a patient (whether hospitalised or in residential care) has a highly negative impact on the future of his/her health status. Good quality nursing care should help avoid (or at least limit) this complication.
For this reason, the development of bed sores has been selected as a quality indicator in the Flanders Initiative for Quality Indicators for "WZC"-"MRPA/MRS" Facilities (Vlaams Indicatorenproject Woonzorgcentra).  

This indicator measures the proportion of "WZC"-"MRPA/MRS" residents who have a pressure ulcer (with severity degrees of 2, 3 or 4) on a given day. At this time, we only have data available on "WZC"-"MRPA/MRS" facilities located in Flanders.

RESULTS
  • The data for Flanders (Vlaams Indicatorenproject Woonzorgcentra) show that 2.0% of WZC residents have a category 2, 3 or 4 pressure ulcer.
  • 1.3% of these ulcers developed during the WZC stay (the others were pre-existing ulcers).
  • This figure is slightly lower than that of 2016, but since this indicator has only been recorded for 2 years, there is not sufficient hindsight to derive any trend.

Link to technical datasheet and detailed results

Multi-resistant staphylococcus carrier prevalence in long-term care  (ELD-9)   

When an elderly person needs to be hospitalised, it is not rare that Methicillin-Resistant Staphylococcus aureus (MRSA) is detected in them. This is particularly frequent when these people are transferred from an "RVT"-"MRS" facility. For this reason, it is important to monitor the extent and development of this bacterium in "RVT"-"MRS" facilities, so that policies of prevention and control of this multi-resistant bacterium can be better adjusted in Belgian hospitals and in long-term care institutions.

This indicator measures the proportion of individuals infected with MRSA within a sample of Belgian "RVT"-"MRS" facilities. Until now, three measurement campaigns have been conducted in Belgium: in 2005 (60 facilities), 2011 (60 facilities) and 2015 (29 facilities).

RESULTS
  • The weighted average prevalence of MRSA in "RVT"-"MRS" residents was 9.0% in 2015.
  • There are major differences between facilities, from 0% to 21.6%.
  • When comparing the results of the three surveys, one can observe a continuous reduction in the prevalence of this bacterium in facilities, from 19% in 2005 to 12.2% in 2011 and 9.0% in 2015. This reduction matches the decrease in the incidence of MRSA infections in hospitals.
  • The presence of MRSA is not significantly related to the type of facility (public, private charity, commercial charity), its size, or the proportion of medicalised beds.

Link to technical datasheet and detailed results

Prescription of anticholinergic medicines (ELD-10) 

Elderly people are more sensitive than younger patients to certain medicines, whose side effects they may experience within a shorter period of time. This is the case, in particular, with medicines known as ‘anticholinergics’ which can expose elderly people to risks of low blood pressure and falling, mental confusion, or urinary retention; these medicines can also cause dry mouth, constipation, or vision disorders. 

Among these medicines are certain anti-depressants (tricyclic anti-depressants [TCAs], but also  commonly used SSRIs [selective serotonin re-uptake inhibitors]), neuroleptics used for agitation or dementia, Parkinson’s disease medicine, medicine used for bladder problems, asthma, and chronic bronchitis (COPD [chronic obstructive pulmonary disease]), gastric ulcer, or still other, more anecdotal diseases.

This indicator measures the proportion of elderly people (aged 65+ years) who have received a prescription for anticholinergic medicines (for more than 80 Defined Daily Doses (DDD) per year, which indicates chronic use), with a particular focus on anticholinergic anti-depressants.

RESULTS
  • In 2016, 22% of people aged 65+ years received anticholinergic medicines, including 12% receiving anti-depressants (Figure 7).
  • These medicines are more often prescribed to women (25%) than to men (17%).
  • Prescriptions also increase with age: from 19% in people aged 65-74 years to 29% in people aged over 85 years.
  • The problem appears to be more acute in residential care: 52% of MR/MRS residents aged over 75 years receive anticholinergic medicines, versus 22% of people aged over 75 years who are living at home (Figure 8).
  • Prescriptions of anticholinergic medicines are more frequent in Wallonia (26%) and in Brussels (24%) than in Flanders (20%) (Figure 9).
  • This indicator has shown no improvement since 2011.
Figure 7- Percentage of the population 65+ prescribed anticholinergic drugs or antidepressant drugs with anticholinergic effects (>80 DDD)
Data source: EPS
 
Figure 8- Percentage of the population 75+ prescribed anticholinergic drugs or antidepressant drugs with anticholinergic effects (>80 DDD) in institution versus at home (2016)
Data source: EPS
 
Figure 9- Percentage of the population 75+ prescribed anticholinergic drugs or antidepressant drugs with anticholinergic effects (>80 DDD) per region and per province (2016)
Data source: EPS

Link to technical datasheet and detailed results

Prescription of neuroleptics in MRPA/MRS facilities (ELD-11) and outpatient care (ELD-12)

Some elderly people with dementia may show behavioural disorders, such as, for example, aggressiveness, which makes caring for them more difficult and sometimes encourages the use of neuroleptic medicines (antipsychotics) in order to tranquillise them. However, these medicines should be avoided as much as possible in these people, since they increase the risk of stroke and sudden death. Guidelines recommend to only use neuroleptics as a very last resort, if the person’s behaviour involves a threat to themselves or to others. If these medicines are used, the treatment duration must be as short as possible, and the dose must be as low as possible.
This indicator measures the proportion of elderly people who receive neuroleptics.

 RESULTS
  • In 2016, neuroleptics were prescribed to 6% of the population aged over 65 years.
  • The frequency of prescription increases with age: 4% for people aged 65-74 years and 11% for people aged over 85 years (Figure 10).
  • The problem is of particular concern in MRPA/MRS facilities, where 32% of residents aged over 75 years receive neuroleptics (Figure 11).
  • Significant geographical variations can be observed, with 4% of prescriptions in the Antwerp province, and up to 8% in the Limburg and Liege provinces (Figure 12).
  • OECD data show that Belgium is a leading prescriptor of neuroleptics in elderly people. In Sweden and in the Netherlands, the number of prescriptions is half that of Belgium (Figure 13). However, a slight reduction has been observed in Belgium since 2011.
Figure 10 - Percentage of the population 65+ prescribed antipsychotics (>0 DDD) by age group (2016)
Data source: EPS
Figure 11 - Percentage of the population aged 75+ prescribed antipsychotics, institution versus ambulatory (2016)
Data source: EPS
Figure 12- Percentage of the population 65+ prescribed antipsychotics (>0 DDD) by region and province (2016)
Data source: EPS
Figure 13- Percentage of the population 65+ prescribed antipsychotics (>0 DDD): OECD data (2015 or nearest year)
Data source: OECD

Link to technical datasheet and detailed results