Determinants of institutional care at older ages in Finland

With growing pressure from an ageing population on social and health-care expenditure, it is of policy importance to analyze the reasons for admission to long-term institutional care at older ages. Although there is increasing evidence that cognitive and functional disabilities are not the only major risk factors, and that the social situation and the lack of family members play an important role in explaining admissions, further research is needed. There is a lack of evidence on the effects of a spouse’s death, and previous findings on how income is associated with institutional care are inconsistent, and results on poor housing are seldom available. Furthermore, there is little systematic evidence showing how chronic medical conditions other than dementia affect the risk of admission in the general older population. This study used population-based register data on Finnish older adults aged 65 and over (n=280,722) to analyse individual-level determinants of admission to long-term institutional care from January 1998 to September 2003. The main focus was on how chronic medical conditions, household income and other socio-economic factors, living with a spouse, and the death of a spouse were associated with admissions. The results of the study indicated that dementia, Parkinson’s disease, stroke, depressive symptoms, other mental-health problems, hip fracture, and diabetes were strongly associated with an increased risk of admission when socio-demographic confounders and co-morbid conditions were controlled for. It was also shown that older men and women in the lowest household-income quintile group were more likely to be admitted to institutional care than those in the highest group, when age, first language, and area characteristics were accounted for. Controlling further for living arrangements and other socio-economic and chronic medical conditions markedly reduced these income differences in admission, but they still remained significant. Poorly equipped housing and being a renter were associated with an increased risk of admission, and the possession of a car and living in a detached house with a decreased risk in these same multivariate models. Having a lift in an apartment house was not associated with admission. The results further showed that the lower risk of admission among those living with a spouse compared to those living alone or with others was only partly attributable to and mediated through favorable socio-economic, housing and medical conditions. Moreover, this study was the first to establish that the death of a spouse strongly increases the risk of admission, the excess risk being highest during the first month following the death and decreasing over time in both genders. The findings in this study imply that the future need for institutional care will depend not only on the increasing numbers of older people but also on the development of the prevalence and severity of chronic medical conditions associated with admission, and on older people’s income, housing conditions and access to informal care from their spouse.