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).

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.

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.

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.

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.