Older People's Health

The Scottish Health Survey Older People’s Health

A National Statistics Publication for Scotland

TopicReport

o s TopicReport

Editors: Catherine Bromley1and Jennifer Mindell2 Principal authors: Damita Abayaratne,2 Maria Aresu,2 Wissam Gharib,2 Vasant Hirani,2 Henry Jones,2 Jennifer Mindell,2 Marilyn Roth,2 Nicola Shelton,2 Faiza Tabassum.2 1 Scottish Centre for Social Research, Edinburgh. 2 Department of Epidemiology and Public Health, UCL (University College London).

© Crown copyright 2011 You may re-use this information (excluding logos and images) free of charge in any format or medium, under the terms of the Open Government Licence. To view this licence, visit http://www.nationalarchives.gov.uk/doc/open-government-licence/ or e-mail: [email protected]. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. This document is also available from our website at www.scotland.gov.uk. ISBN: 978-1-78045-4 - The Scottish Government St Andrew’s House Edinburgh EH1 3DG Produced for the Scottish Government by APS Group Scotland DPPAS12197 (11/11) Published by the Scottish Government, November 2011

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CONTENTS

Editors’ Acknowledgements 4 Introduction 5 Notes to Tables 11 Chapter 1: General and Mental Health 12

1.1 Introduction 13 1.1.1 The health of older people 13 1.1.2 Factors affecting general and mental health 13 1.1.3 Policy 14

1.2 Methods 14 1.2.1 General Health 14 1.2.2 Mental Health 14

1.3 Results 14 1.3.1 Self–assessed General Health 14 1.3.2 Long-term conditions 16 1.3.3 GHQ12 scores 17 1.3.4 WEMWBS mean score 18

Chapter 2: Lifestyle Behaviours 30

2.1 Introduction 31 2.1.1 Alcohol 31 2.1.2 Smoking 32 2.1.3 Diet 32 2.1.4 Physical activity 33

2.2 Results 34 2.2.1 Alcohol 34 2.2.2 Smoking 36 2.2.3 Diet 37 2.2.4 Physical activity 37

Chapter 3: Obesity 53 3.1 Introduction 53 3.2 Results 55

3.2.1 Response to anthropometric measurements by age and sex 55

3.2.2 Prevalence of overweight and obesity by age and sex 56 3.2.3 Prevalence of raised waist-hip ratio (WHR) and waist

circumference (WC) 57 3.2.4 Health risk category with overweight, obesity and waist

circumference 58 Chapter 4: Cardiovascular Disease, Diabetes and Hypertension 69

4.1 Introduction 69 4.2 Results 71

4.2.1 Cardiovascular disease 71 4.2.2 Diabetes 71 4.2.3 Hypertension 74 4.2.4 Factors associated with having cardiovascular disease 74

Chapter 5: Health and Social Care 83 5.1 Introduction 83

5.1.1 Care provision 83 5.1.2 Health-seeking behaviour 84

5.2 Results 84 5.2.1 Provision of care 84 5.2.2 Health-seeking behaviour 85

Chapter 6: Discussion 94

6.1 Introduction 94 6.2 Self-rated physical health 94 6.3 Mental health 95 6.4 Lifestyles and disease risk factors 96 6.5 Disease 97 6.6 Healthcare 98

6.6.1 Health-seeking behaviour 98 6.6.2 Detection and treatment of disease in older people 99

6.7 Provision of care 99 6.8 Ageing well 100

Appendix A: Glossary 104

EDITORS’ ACKNOWLEDGEMENTS Our first thank you is to the 22,991 adults who gave up their time voluntarily to take part in the 2008, 2009 and 2010 surveys and welcomed our interviewers and nurses into their homes. We would also like to thank those colleagues who contributed to the survey and this report. In particular we would like to thank:

• All the interviewers and nurses who worked on the project. We owe a huge debt of gratitude for the dedication and professionalism they applied to their work.

• The authors of the chapters: Damita Abayaratne, Maria Aresu, Wissam Gharib, Vasant Hirani, Henry Jones, Jennifer Mindell, Marilyn Roth, Nicola Shelton and Faiza Tabassum.

• Joan Corbett, whose hard work and expertise has been crucial in preparing the survey data.

• Other research colleagues, in particular: Lesley Birse, Shanna Dowling and Helen Graham (ScotCen); and Barbara Carter-Szatynska (UCL).

Finally, special thanks are due to Julie Ramsay and her colleagues in the Scottish Government Health Directorates, for support at all stages of the project. Catherine Bromley and Jennifer Mindell

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INTRODUCTION Jennifer Mindell

Worldwide, the number of older people is increasing both in absolute numbers and as a proportion of the total population in both more and less developed countries. As with worldwide demographic trends, the number of older people in Scotland is rising rapidly. In the last hundred years Scotland’s life expectancy has doubled; increasing from 40 years in 1900 to 74 in men and 79 in women in 2004.1 By 2009, it had increased further, to 76.0 years in men and 80.6 years in women (Figure 1), but this remains low compared with most countries in Western Europe.2

The number of Scottish residents of pensionable age is projected to rise by around 26% between 2010 and 2035.3

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The number of people aged 75 and over is projected to rise by around 23% in the 2010-2020 period, followed by a more rapid rise up to 2035, resulting in an 82% increase between 2010 and 2035. Three groups have been described: the ‘ young old’ (aged 65-74), the ‘ old’ (aged 75-84), and the ‘ oldest old’ (aged 85+ ). Previous analyses of projected life expectancy identified the 85+ age group as the group that is proportionately the fastest growing.4

Figure 1 Lif e ex pectancy ( LE) and healthy lif e ex pectancy ( HLE) at b irth, Scotland, 1 9 8 0 - 2 0 0 9 5

Figure 1 shows that not only life expectancy but also healthy life expectancy has been rising in Scotland. Although women spend more years in poor health,

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in 2009, healthy life expectancy was 60.0 years for men and 62.2 years for women.5 The method used for calculating healthy life expectancy was changed recently, following the development of a joint World Health Organisation and European Union recommendation on the measurement of self-assessed health to provide consistency across European countries. However, this change in method prevents comparisons with the previous trend. These new figures are over 8 years lower than previous estimates, both of which are shown in Figure 1. The new method has also been used to estimate HLE in some previous years, showing that HLE estimated by the new method has been increasing with a similar trend to the previous HLE measure.6

Figure 2 Healthy Life Expectancy at Birth in Scottish Index of Multiple

Deprivation 15% most deprived areas and the whole of Scotland, 1999-2000 to 2007-2008

Figure 2 illustrates the substantial socially-patterned inequalities in health in Scotland.2 Older people have lower incomes: 56% of participants aged 65 and over in the Scottish Health surveys 2008, 2009 and 2010 combined had household incomes in the bottom two quintiles, compared with 32% of adults aged 16-64 years. However, the proportion of older people living in the 15% most deprived areas of Scotland was lower than for younger adults (Table A). This is almost certainly because of the lower life expectancy among the more deprived groups.

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Table A Socio-economic status of participants in the Scottish Health Surveys, 2008, 2009 and 2010 combined, by age

Age-group (years)

Proportion living in the 15% most deprived areas (%)

Proportion in the lowest two quintiles of income (%)

16-44 16 33

45-64 14 30

65-74 13 53

75+ 11 60

For those who have reached 65 years of age, life expectancy in 2008-10 was a further 16.6 years in men and 19.2 years in women, i.e. the average age at death for people who have reached 65 years would be 81 years for men and 84 years for women.7

The dependency ratio (the ratio of the population younger and older than working age to the working age population) is changing less, but there is concern about the financial implications of the growing numbers of older people. If age-specific disease rates remain unchanged, the numbers of people requiring health and social care will rise exponentially. Age-specific mortality rates have been falling.8 The increase in healthy life years suggests that age-specific disease rates are falling, with many more older people living healthy lives into their 80s and beyond. For example, non-smokers not only have higher life expectancy than smokers but also spend less time in ill-health – ‘compression of morbidity’,9 a concept first described in 1980.10 This compression of morbidity has also been described as compression of disability.11

The Scottish Government is working to enable older people to live healthy, active and independent lives. It works with the UK Government to tackle pensioner poverty and providing security and dignity for older people is central to its social justice agenda.12 A long-term strategy, setting out the Scottish Government’s vision for older people, was published in 2007, addressing the issues of an ageing population and outlining the opportunities for and choices available to older people.1 In April 2011, a consultation was launched about reshaping care for older people.13

Allied to the long-term strategy for older people, there is a strong focus on improving health within the Scottish Government’s National Performance Framework (2007). It aims to “Help people…sustain and improve their health, especially in disadvantaged communities, ensuring better, local and faster access to health care”.14

This aim is assessed against national outcomes including whether the population are living “longer, healthier lives” and whether the “significant inequalities in Scottish society” have been tackled.

This report examines the current health status of people aged 65 and over in Scotland. It uses data from the Scottish Health Surveys (SHeS) of 2008,15

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200916 and 201017

combined to enable analysis by smaller age-groups than the main annual reports. The SHeS design now enables this kind of report to be produced, so that the health and circumstances of older people in Scotland can be explored in detail, rather than always treating the over 65s or over 75s as a homogenous group.

It considers self-assessed health, mental health and well-being, cardiovascular disease, the main lifestyle risk factors for cardiovascular disease and cancers, and health-seeking behaviour. Comparisons are made between different age-groups among older people as well as between older people and those aged 16-64 years. Given the acknowledged importance of the social determinants of health in Scotland and elsewhere,18,19

key aspects of health are also examined in relation to household income, area deprivation, and other measures of socio-economic position (these measures are described in the Glossary). This report does not examine trends over time, as earlier surveys have not included sufficient numbers of older people to do so.

The Scottish Health Surveys are a series of health examination surveys of a nationally representative sample of the household population of all ages living in private homes in Scotland. This report therefore excludes people living in communal establishments. For details of the survey methods, including sample selection and data collection, and results for the general population, readers should consult the three most recent annual reports.15,16,17 In this report, descriptions of the results refer to the figures for men and women separately where these differ, and to all adults where they do not.

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References and notes

1 Scottish Government. All Our Futures: Planning for A Scotland with an Ageing Population. Edinburgh: Scottish Government, 2007. <www.scotland.gov.uk/Resource/Doc/169342/0047172.pdf>

2 General Register Office for Scotland. High Level Summary of Statistics: Population and Migration.

<www.gro-scotland.gov.uk/files2/stats/high-level-summary/j11198/j1119805.htm> 3 Figures taken from Table 3, National Records of Scotland, Projected Population of Scotland

(2010-based), Edinburgh, 2011. <www.gro-scotland.gov.uk/statistics/theme/population/projections/scotland/2010-based/tables.html>

4 General Register Office for Scotland. ‘Demographic change and its implications for health and

well-being’. Chapter 5 in Caring in Scotland: Analysis of Existing Data Sources on Unpaid Carers in Scotland. <www.scotland.gov.uk/Publications/2010/07/23163626/7>

5 Scottish Government. High Level Summary of Statistics: Health and Community Care. Life

Expectancy and Healthy Life Expectancy. <www.scotland.gov.uk/Topics/Statistics/Browse/Health/TrendLifeExpectancy>

6 Further details of the change in method can be found in a Technical report by the Scottish Public

Health Observatory.<www.scotpho.org.uk/nmsruntime/saveasdialog.asp?lID=8064&sID=5808> 7 General Register Office for Scotland. ‘Life expectancy at Scotland level – Table 1’. 4/10/2011.

<www.gro-scotland.gov.uk/statistics/theme/life-expectancy/scotland/interim-life-tables.html> 8 Watt GC, Ecob R. Analysis of falling mortality rates in Edinburgh and Glasgow. J Public Health

Med. 2000; 22: 330-336. 9 Nusselder WJ, Looman CWN, Marang-van de Mheen PJ, van de Mheen H, Mackenbach JP.

Smoking and the compression of morbidity. J Epidemiol Community Health. 2000; 54: 566-574. 10 Fries JF. Aging, natural death, and the compression of morbidity. NEJM. 1980; 303: 130-135. 11 Kalache A, Aboderin I, Hoskins I. Compression of morbidity and active ageing: key priorities for

public health policy in the 21st century. Bull World Health Organization. 2002; 80: 243-244. 12 Scottish Government. Older people. <www.scotland.gov.uk/Topics/People/OlderPeople> 13 Scottish Government. Reshaping Care for Older People. (online).

<www.scotland.gov.uk/Topics/Health/care/reshaping> 14 Scottish Government. Scottish Budget Spending Review 2007. Edinburgh: Scottish Government,

2007. <www.scotland.gov.uk/Publications/2007/11/13092240/0> 15 Bromley C, Bradshaw P, Given L. (eds). Scottish Health Survey 2008 – Volume 2: Technical

Report. Edinburgh: The Scottish Government, 2009. <www.scotland.gov.uk/Publications/2009/09/28102003/0>

16 Bromley C, Given L, Ormston R. (eds). Scottish Health Survey 2009 – Volume 2: Technical

Report. Edinburgh: The Scottish Government, 2010. <www.scotland.gov.uk/Publications/2009/09/28102003/0>

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17 Bromley C and Given L. (eds). Scottish Health Survey 2010 – Volume 2: Technical Report. Edinburgh: The Scottish Government, 2011. <http://www.scotland.gov.uk/Publications/2011/09/27124046/0>

18 Equally Well: Report of the Ministerial Task Force on Health Inequalities. Edinburgh: Scottish

Government, 2008. <www.scotland.gov.uk/Publications/2008/06/25104032/0> 19 Marmot M (Chair). Closing the gap in a generation: Health equity through action on the social

determinants of health. Geneva: World Health Organisation Commission of Social Determinants of Health, 2008. <whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf>

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NOTES TO TABLES 1 The following conventions have been used in tables: n/a no data collected - no observations (zero value) 0 non-zero values of less than 0.5% and thus rounded to zero

[ ] normally used to warn of small sample bases, if the unweighted base is less than 50. (If a group’s unweighted base is less than 30, data are normally not shown for that group.)

2 Because of rounding, row or column percentages may not add exactly to 100%. 3 A percentage may be quoted in the text for a single category that aggregates two or

more of the percentages shown in a table. The percentage for the single category may, because of rounding, differ by one percentage point from the sum of the percentages in the table.

4 Values for means, medians, percentiles and standard errors are shown to an

appropriate number of decimal places. Standard Error may sometimes be abbreviated to SE for space reasons.

5 ‘Missing values’ occur for several reasons, including refusal or inability to answer a

particular question; refusal to co-operate in an entire section of the survey (such as a self-completion questionnaire); and cases where the question is not applicable to the participant. In general, missing values have been omitted from all tables and analyses.

6 The population sub-group to whom each table refers is stated at the upper left

corner of the table. 7 Both weighted and unweighted sample bases are shown at the foot of each table.

The weighted numbers reflect the relative size of each group in the population, not numbers of interviews conducted, which are shown by the unweighted bases.

8 The term ‘significant’ refers to statistical significance (at the 95% level) and is not

intended to imply substantive importance.

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n n n Chapter 1

1 GENERAL AND MENTAL HEALTH

Henry Jones, Faiza Tabassum, Maria Aresu, Damita Abayaratne

SUMMARY • In 2008/2009/2010, 22% of adults aged 65 and over described their health as

‘very good’, compared with 39% of adults aged 16-64 years. This decreased with age among the 65 and over age group, from 26% of those aged 65-69 to 16% in those aged 85 years and over.

• The proportion reporting ‘bad’ or ‘very bad’ health was significantly higher in adults aged 65 and over (12%) than in those aged 16-64 years (6%). This did not vary by age across the older age groups.

• Logistic regression was used to identify the factors independently associated with people aged 65 and over reporting poor or very poor health. For both men and women, the odds increased as area deprivation increased, and were higher among current and ex-smokers than non-smokers. The odds were lower among people who drank more than the recommended weekly alcohol limits than in those who drank within the limits. This is likely to be due to some people abstaining from alcohol because of poor health.

• 66% of men and 67% of women aged 65 years and over had a long-term health condition compared with 33% of men and 37% of women aged 16-64 years. The prevalence of long-term conditions increased with age, from 62% in adults aged 65-69 years to 73% in those aged 85 years and over.

• The three most common categories of conditions reported by adults aged 65 and over were musculoskeletal conditions, conditions of the heart and circulatory system, and endocrine and metabolic disorders. Mental disorders and skin complaints were the only conditions to have lower rates among men and women aged 65 and over than in the 16-64 age group, nervous disorders were also less common in older than younger women. A lot of older people with mental conditions live in residential care, or cannot consent to taking part in a survey, which contributes to the lower rates of mental disorders in this age group.

• At all ages, women were more likely than men to have a GHQ12 score of 4 or more indicating a possible psychiatric disorder. Adults aged 65 and over were less likely than those aged 16-64 to have a GHQ12 score of 4 or more (9% versus 13% for older and younger men and 14% versus 18%, respectively, for women). GHQ12 scores of 4 or more increased with age among older women (but not men), from 11% of those aged 65-69 to 21% of those aged 85 and over.

• Wellbeing, as measured by the Warwick-Edinburgh Mental Wellbeing Scale, was higher among adults aged 65 and over than those aged 16-64, though it decreased with age among older adults, particularly among men.

• Among adults aged 65 and over, the odds of having poor wellbeing were higher in men who were single, divorced or separated, and men and women who were widowed or surviving civil partners, compared with married or cohabiting people. The odds of poor wellbeing were also higher among people with a long-term condition (compared with those without), and among people with low physical activity levels (compared with people who did the recommended weekly amount of activity).

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1.1 INTRODUCTION This chapter covers two areas; the general and mental health of Scotland’s older population. The former encompasses self-assessed general health and the prevalence of long-term conditions. The latter assesses general mental wellbeing and any recent disturbance in psychological function. Together this affords a balanced insight into the health of Scotland’s older population, and offers a comparison with younger adults.

1.1.1 The health of older people Self-assessed health is known to be related to the incidence of chronic and acute disease, and is also linked to hospital admissions and mortality.1,2 The number of people assessing their health as bad or very bad increases with age, from 3% in the 16-24 age group to 13% in those aged 75 and over in 2010.3 There is a corresponding decrease in self-reported good health with age: 88% of those aged 16-24 said their health was good or very good, compared with 56% of those aged 75 and over. The prevalence of long-term conditions also increases in the Scottish population with age: in 2010, 24% of those aged 16-24, compared with 71% of those aged 75 and over reported having a long-term condition. This increase is more marked with limiting long-term conditions: 12% of the 16-24 age group reported a limiting long term condition compared with 55% of those aged 75 and over.4

Data for Great Britain (England, Wales and Scotland combined) suggests that the prevalence of common mental disorder decreases with age5 but that in each age group the level of reported mental disorder is higher for women than men. This is also the case for some specific psychiatric diagnoses.6

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In Scotland, the prevalence of “possible psychiatric condition” (as measured by a GHQ-12 score of 4 or more) is higher in women than men in most age groups aged 16 years and over (women 17%; men 13%).

1.1.2 Factors affecting general and mental health Both physical and mental health are affected by a number of social determinants.7,8

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For physical health this is well documented, with factors as varied as income, social class, occupation and parental occupation, level of education, housing condition, neighbourhood quality, geographic region, gender and ethnicity all affecting morbidity and mortality.7 In Scotland, poorer mental health has been significantly associated with lower socio-economic position, lower income, and higher levels of deprivation. Employment status is also important, with those not being able to work due to ill health, the long-term unemployed and the retired having higher rates of depression and anxiety symptoms than those in work.4 Marriage is also beneficial for mental health,4 but the effect of this has been found to be more significant in men than in women.9,10

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1.1.3 Policy Many of the policies referred to in the Introduction to this report apply particularly to general and mental health. The Scottish Government has recognised the high economic, social and health burden imposed by mental illness and aims to “enhance mental health, wellbeing and resilience”.11 Specifically in later life it aims to do this by “tackling discrimination, supporting participation in meaningful activity, supporting positive relationships, improving physical health and tackling poverty”.12

1.2 METHODS

1.2.1 General Health Individuals were asked to rate their overall health as very good, good, fair, bad or very bad. They were also asked whether they had a long-term condition or disability that had affected, or was likely to affect them, for at least 12 months. If they did have, they were asked if it limited their daily activities in any way.

1.2.2 Mental Health Mental wellbeing and mental health problems were assessed using two measures: the General Health Questionnaire (GHQ-1213) and the Warwick Edinburgh Mental Wellbeing Score (WEMWBS14

). The GHQ-12 is a twelve question form which is used to assess deviation from the individual’s usual level of psychological function over the preceding few weeks. It is not used to assess chronicity of mental ill health, but is a good indicator for a particular point in time. A score of 4 or more indicates a possible psychiatric disorder.

WEMWBS is designed to assess positive functioning, positive affect and satisfying interpersonal relationships. It contains fourteen statements to which the individual responds on a scale of 1 to 5, according to how often they occur. The lowest score possible is therefore 14 and the highest 70. Three categories were also derived, dividing participants into those with average mental wellbeing (within one standard deviation (1 S.D.) of the mean of all participants aged 16 and over); good wellbeing (WEMWBS score greater than 1 S.D. above the mean); and poor wellbeing (WEMWBS score lower than 1 S.D. below the mean).

1.3 RESULTS

1.3.1 Self–assessed General Health Self-assessed general health varied significantly with age but not by sex. The prevalence of adults reporting ‘very good’ health decreased with age: 39% of adults aged 16-64 years described their health as ‘very good’ compared with 22% of adults aged over 65 years, decreasing from 26% in those aged 65-69 years to 16% in those aged 85 years and over. Although the proportion reporting ‘bad’ or ‘very bad’

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health was significantly different between adults aged 16-64 years (6%) and those aged 65 years and over (12%), prevalence levels were similar across the older age groups. Table 1.1, Figure 1A

0

10

20

30

40

50

60

70

80

90

100

16-64 65-69 70-74 75-79 80-84 85+

Age Group

Perc

ent

Very badBadFairGoodVery good

Figure 1ASelf assessed general health for adults by age (2008/2009/2010 combined data)

Logistic regression was used to examine the factors associated with reporting poor or very poor health among those aged 65 and over. The variables included in the analysis were: age group, smoking status (never smoked, ex-smoker, current smoker), alcohol consumption (within the weekly recommended limits, over the weekly limits), household income and SIMD (the same factors explored in the analysis of all adults conducted in the main SHeS 2008 report).4 By simultaneously controlling for a number of factors, the independent effect each factor has on the variable of interest can be established. Logistic regression compares the odds of a reference category (shown in the table with a value of 1) with that of the other categories. In this example, an odds ratio of greater than one indicates that the group in question is more likely to report poor or very poor health than is the chosen reference category; an odds ratio of less than one means they are less likely. For more information about logistic regression models and how to interpret their results see the glossary at the end of this report. Reporting poor or very poor health among those aged 65 and over was associated with deprivation, smoking status, and alcohol consumption. Adults living in the more deprived SIMD quintiles were more likely to report poor or very poor health, with a greater effect seen among women (odds ratio 2.28 for men and 3.92 for women in the most deprived quintile). Ex-smokers and current smokers were more likely than adults who had never smoked to report poor or very poor health. The odds of men reporting poor or very poor health were 64% lower for those drinking over the weekly recommended alcohol limit (21 units) than for those not drinking or drinking within the weekly guidance.

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Similarly, the odds were 62% lower for women drinking more than 14 units a week compared with women not exceeding this limit. This finding is likely to be related to the fact that people in poor health who have been advised not to drink were included in the reference category along with people who drink within the recommended limits; this point is discussed further in Chapter 6. Poor/very poor self-rated health was not related to age once other factors were taken into account. The same was true for income. Table 1.2

1.3.2 Long-term conditions Long-term conditions were reported by one-third (33%) of men aged 16-64 years and two-thirds (66%) aged 65 years and over. Prevalence was slightly higher in younger women (37%) than younger men, but similar in older women (67%). The prevalence of long-term conditions increased with age above 65 years in a similar manner for both sexes, from 62% in adults aged 65-69 years to 73% in those 85 years and over. The prevalence of non-limiting conditions was similar between the sexes, however from the age of 80, women were more likely than men to report a limiting long-term illness: 65% of women and 57% of men aged 85 years and over. Table 1.3 The three most common categories of conditions in men and women aged 65 and over were musculoskeletal conditions (280 per 1,000 in men, 370 per 1,000 in women); conditions of the heart and circulatory system (298 per 1,000 in men, 266 per 1,000 in women); and endocrine and metabolic disorders (124 per 1,000 in men, 137 per 1,000 in women). Although musculoskeletal conditions were also the most common condition for those aged 16-64, the corresponding rates were much lower (117 per 1,000 in men, 126 per 1,000 in women). Heart and circulatory system conditions were the next most common in men aged 16-64 (69 per 1,000) while mental disorders were the next most common condition among younger women (78 per 1,000). Mental disorders and skin complaints were the only conditions to have higher rates among men and women aged 16-64 than in the 65 and over age group. In addition, nervous disorders were more common in younger than older women. Among those aged 65 and over, heart and circulatory conditions, musculoskeletal conditions, ear and eye problems, and skin conditions increased with age (though heart conditions in men and skin conditions in women declined in the oldest age group). In contrast, mental disorders and endocrine and metabolic conditions decreased with age (though mental disorders in women increased again in the 85 and over group). Respiratory conditions decreased with age in women, while there was no effect of age in men; thus these conditions were more common in the ‘young old’ women and in the ‘older old’ men. While heart and circulatory disease, ear conditions, and genito-urinary disorders were more common in men than women, musculoskeletal problems and mental disorders were generally more common in women. The prevalence of neoplasms, infections, and conditions of the

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digestive system and blood and related organs did not vary by age or sex. These results are discussed further in chapter 6. Table 1.4

1.3.3 GHQ12 scores More women than men across all age groups had a GHQ12 score of 4 or more indicating the possibility of psychiatric disorder. For both sexes, the prevalence of GHQ12 scores of 4 or more was higher in those aged 16-64 years compared with adults 65 and over (13% vs 9% for younger and older men and 18% vs 14% respectively for women). There was an increase in prevalence of GHQ12 scores of 4 or more with age for women, from 11% of those aged 65-69 years to 21% of those aged 85 years and over, whereas the equivalent figures among men did not vary by age. The prevalence of GHQ12 scores of 1-3 increased with age among both older men and women. Table 1.5, Figures 1B, 1C

010

2030

405060

7080

90100

16-64 65-69 70-74 75-79 80-84 85+

Age Group

Perc

ent

Score 4+

Score 1-3

Score 0

Figure 1BGHQ12 scores for men by age group (2008/2009/2010 combined data)

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0

10

20

30

40

50

60

70

80

90

100

16-64 65-69 70-74 75-79 80-84 85+

Age Group

Perc

ent

Score 4+

Score 1-3

Score 0

Figure 1CGHQ12 scores for women by age group (2008/2009/2010 combined data)

1.3.4 WEMWBS mean score Although the differences were small, the mean WEMWBS score was significantly higher among men and women aged 65 and over (men 50.5, women 50.0) than among those aged 16-64 (men 50.0, women 49.5) and among men than women in these age groups. The mean score decreased with age among the older adults, with the trend being more pronounced for men than women. The mean WEMWBS score was 51.4 and 51.3 for men and women respectively aged 65-69 years compared with 47.8 and 48.2 for men and women respectively aged 85 years and over. The proportion of men and women with good, average, or poor wellbeing did not vary between the younger and older adults. However, this did vary with age among older adults. 20% of adults aged 65-74 had good and 11-13% poor mental wellbeing. Those aged 80 and over were less likely to have WEMWBS scores indicating good wellbeing (12-15%) and more likely to have poor mental wellbeing (18-19%), with those aged 75-79 having intermediate values. Table 1.6 Logistic regression models were created to examine the association between individual factors and having poor mental wellbeing. This found that marital status, the presence of a limiting long-term condition, and reporting low physical activity levels were each significantly associated with poor wellbeing. Compared with married or cohabiting people, the odds ratios for poor mental wellbeing were 2.22 for men who were single, separated or divorced, 2.03 for widowers or surviving civil partners, and 1.47 for widows or surviving civil partners. In women but not men, living in the most deprived 15% of areas increased the odds of poor mental wellbeing, but drinking above the weekly limit decreased the odds. The odds of poor mental wellbeing were 4.16 times higher in men with a limiting long-term condition than in men with

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no condition; the equivalent odds ratio for women was 2.76. Men and women with low physical activity levels also had higher odds of poor wellbeing than those who met the activity recommendations (ORs of 3.32 and 2.98, respectively). Age was not significantly associated with the outcome in men or women once other factors were included in the model, nor were smoking status, income, or NS-SEC, an occupation-based measure of socio-economic position. The potential inter-relationship of physical activity and longstanding illness is discussed further in chapter 6 section 6.3. Table 1.7

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References and notes 1 Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community

studies. Journal of Health and Social Behaviour. 1997; 38: 21-37. 2 Hanlon P, Lawder R, Elders A, et al. An analysis of the link between behavioural, biological and

social risk factors and subsequent hospital admission in Scotland. Journal of Public Health. 2007; 29: 405-412.

3 McManus, S. Chapter 1: General health and mental wellbeing. In Bromley C and Given L (eds). Scottish Health Survey 2010 – Volume 1: Main Report. Edinburgh: The Scottish Government, 2011. <www.scotland.gov.uk/Publications/2011/09/27084018/6>

4 Bromley C, Bradshaw P, Given L (eds). Scottish Health Survey 2008 – Volume 1: Main Report. Edinburgh: Scottish Government, 2009. <www.scotland.gov.uk/Publications/2009/09/28102003/7>

5 Evanse O, Singleton N, Meltzer H, Stewart R, Prince M. The Mental Health of Older People. London: TSO, 2003. <www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_4081092>

6 Marmot M (Chair). Fair Society, Healthy Lives - The Marmot Review. Strategic Review of Health Inequalities in England post-2010. London: The Marmot Review, 2010. <www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLives.pdf>

7 Measuring Inequalities in Health Working Group. Inequalities in Health. Report of the Measuring Inequalities in Health Working Group. Edinburgh: Scottish Executive, 2003. <www.scotland.gov.uk/Resource/Doc/47171/0013513.pdf>

8 Marmot M (Chair). Interim first report on social determinants of health and the health divide in the WHO European Region. Copenhagen: World Health Organisation, 2010. <www.euro.who.int/__data/assets/pdf_file/0003/124464/E94370.pdf>

9 Jacobs S. An epidemiological review of the mortality of bereavement. Psychosomatic Medicine. 1977; 39: 344–357.

10 Berkman LF, Syme SL. Social networks, host resistance, and mortality: a nine year follow-up study of Alameda county residents. American Journal of Epidemiology. 1979; 109: 186–204.

11 Equally Well – Report of the Ministerial Taskforce on Health Inequalities. Edinburgh: Scottish Government, 2008. <www.scotland.gov.uk/Resource/Doc/229649/0062206.pdf>

12 Scottish Government. Towards a Mentally Flourishing Scotland. Edinburgh: Scottish Government, 2009. <www.scotland.gov.uk/Resource/Doc/271822/0081031.pdf>

13 Goldberg, D. and Williams, P.A. (1988). Users Guide to the General Health Questionnaire. Windsor: NFER-Nelson.

14 Stewart-Brown S, Janmohamed K. Warwick-Edinburgh Mental Well-being Scale (WEMWBS). User Guide Version 1. Warwick and Edinburgh: University of Warwick and NHS Health Scotland, 2008.

20

Table List Table 1.1 Self-assessed general health, 2008, 2009 and 2010 combined, by age and

sex Table 1.2 Estimated odds ratios for factors associated with bad/very bad self-assessed

general health, 2008, 2009 and 2010 combined, by associated risk factors and sex

Table 1.3 Prevalence of long-term conditions, 2008, 2009 and 2010 combined, by age and sex

Table 1.4 Rate of reported long term conditions per 1000 adults, 2008, 2009 and 2010 combined, by age and sex

Table 1.5 GHQ12 scores, 2008, 2009 and 2010 combined, by age and sex Table 1.6 WEMWBS scores, 2008, 2009 and 2010 combined, by age and sex Table 1.7 Estimated odds ratios for factors associated with poor wellbeing score, 2008,

2009 and 2010 combined, by associated risk factors and sex

21

Table 1.1 Self-assessed general health, 2008, 2009 and 2010 combined, by age

and sex

Aged 16 and over 2008, 2009 and 2010 combined

Self-assessed general health

Age Total 65+

16-64 65-69 70-74 75-79 80-84 85+

% % % % % % % Men Very good 40 25 22 20 15 17 21 Good 40 40 37 35 39 38 38 Fair 14 23 29 29 29 32 27 Bad 4 9 9 12 11 12 10 Very bad 1 3 2 5 6 0 3 Very good/good 80 65 59 55 54 56 59 Bad/very bad 6 12 12 17 17 12 14 Women Very good 39 28 25 18 18 16 22 Good 41 39 38 36 36 36 37 Fair 15 22 27 32 36 35 29 Bad 5 8 8 11 9 10 9 Very bad 1 2 2 3 1 3 2 Very good/good 79 67 63 54 54 52 59 Bad/very bad 6 11 11 14 10 13 12 All adults Very good 39 26 24 19 17 16 22 Good 40 40 38 36 37 37 38 Fair 14 23 28 31 33 34 28 Bad 5 9 9 11 10 10 10 Very bad 1 3 2 4 3 2 3 Very good/good 80 66 61 54 54 53 59 Bad/very bad 6 11 11 15 13 13 12 Bases (weighted): Men 8331 584 504 378 235 118 1818 Women 8657 669 596 537 355 263 2420 All adults 16988 1253 1100 914 590 381 4238 Bases (unweighted): Men 6781 794 665 509 314 174 2456 Women 8991 862 778 636 419 305 3000 All adults 15772 1656 1443 1145 733 479 5456

22

Table 1.2 Estimated odds ratios for reporting poor/very poor general health, 2008,

2009 and 2010 combined, by associated risk factors and sexa


Independent variables Men Women

Base (weighted)

1818

Odds Ratio 95% Confidence

interval

Base (weighted)

2420


interval Ageb (p=0.285) (p=0.437) Age (as a continuous

variable) 1818 1.01 0.99,1.03 2420 1.01 0.99,1.02

Scottish Index of

Multiple Deprivation (SIMD) quintile

(p<0.001) (p<0.001)

5th (least deprived) 392 1 476 1 4th 387 0.97 0.61,1.54 518 1.63 1.00,2.64 3rd 398 1.21 0.79,1.89 507 2.32 1.45,3.72 2nd 356 1.91 1.24,2.94 480 2.89 1.83,4.52 1st (most deprived) 285 2.28 1.48,3.51 439 3.92 2.45,6.08 Cigarette smoking

status (p<0.001) (p=0.002)

Never smoked cigarettes 607 1 1164 1 Ex-cigarette smoker 948 1.70 1.24,2.32 909 1.35 1.03,1.78 Current cigarette smoker 264 2.56 1.68,3.74 346 1.30 1.17,2.66 Weekly alcohol

consumption (p<0.001) (p=0.006)

0 units up to weekly limit (21 units men / 14 units women)

1432 1 2216 1

>21 units (men) / >14 units (women)

386 0.36 0.24,0.54 205 0.38 0.19,0.76

a BMI (body mass index) and WEMWBS wellbeing scores were not significantly associated with reporting poor or very poor health, except for the ‘missing data’ category. Quintile of equivalised income was significantly associated with reporting poor or very poor health in a univariate model but was no longer significant once SIMD, smoking status, and weekly alcohol consumption were added into the model.

b Age was not significantly associated with reporting poor or very poor health in men or women aged 65 and over but it has been left in the models, as shown.

23

Table 1.3 Prevalence of long-term conditions, 2008, 2009 and 2010 combined, by

age and sex


Long term conditions and limiting long-term conditions

Age Total 65+

16-64 65-69 70-74 75-79 80-84 85+

% % % % % % % Men No long-term conditions 67 38 36 33 28 31 35 Limiting long-term

conditions 19 41 45 50 53 57 47

Non-limiting long-term conditions

14 21 20 16 19 12 19

Total with long-term conditions

33 62 64 67 72 69 66

Women No long-term conditions 63 38 34 31 31 25 33 Limiting long-term

conditions 23 40 45 48 57 65 48


14 22 21 21 12 10 19


37 62 66 69 69 75 67

All adults No long-term conditions 65 38 35 32 30 27 34 Limiting long-term

conditions 21 41 45 49 56 62 48


14 21 20 19 15 11 19


35 62 65 68 70 73 66

Bases (weighted): Men 8332 584 503 378 235 118 1818 Women 8659 669 596 537 356 263 2421 All adults 16991 1253 1100 914 591 381 4239 Bases (unweighted): Men 6780 794 664 509 314 174 2455 Women 8992 862 778 636 420 305 3001 All adults 15772 1656 1442 1145 734 479 5456

24

Table 1.4 Rate of reported long term conditions per 1000 adults, 2008, 2009 and

2010 combined, by age and sex

Aged 16 and over 2008, 2009 and 2010 combined Condition Group (ICD 10 chapters)a Age Total

65+ 16-64 65-69 70-74 75-79 80-84 85+

Rate per 1000 Men XIII Musculoskeletal

system 117 266 286 289 304 269 280

IX Heart & circulatory system

69 257 309 318 356 280 298

IV Endocrine & metabolic 47 134 132 125 107 72 124 X Respiratory system 66 113 114 79 123 98 107 XI Digestive system 32 43 60 68 93 56 60 VII Eye complaints 12 29 31 55 84 105 47 VIII Ear complaints 8 26 46 49 101 135 53 II Neoplasms & benign

growths 8 39 50 64 66 56 52

VI Nervous System 36 53 39 36 52 27 44 V Mental disorders 53 35 12 23 5 19 21 XIV Genito-urinary system 11 50 38 54 47 92 50 III Blood & related organs 3 6 13 12 18 6 11 XII Skin complaints 13 8 7 3 17 17 8 I Infectious disease 2 - 7 1 - - 2 Other complaints 2 1 4 4 1 8 3 Women XIII Musculoskeletal

system 126 319 322 403 433 441 370

IX Heart & circulatory system

57 243 273 273 271 289 266

IV Endocrine & metabolic 64 155 125 161 111 100 137 X Respiratory system 70 103 99 105 65 40 90 XI Digestive system 42 78 77 63 59 82 72 VII Eye complaints 7 22 34 49 76 151 53 VIII Ear complaints 10 26 31 36 54 85 40 II Neoplasms & benign

growths 13 39 41 46 23 31 38

VI Nervous System 48 57 37 36 45 23 42 V Mental disorders 78 47 36 37 18 28 36 XIV Genito-urinary system 15 18 24 18 38 23 20 III Blood & related organs 9 8 13 11 18 29 14 XII Skin complaints 14 3 9 13 23 4 10 I Infectious disease 2 6 3 2 9 - 4 Other complaints 2 3 2 6 8 8 5

Continued…

25

Table 1.4 - Continued

Aged 16 and over 2008, 2009 and 2010 combined Condition Group (ICD 10 chapters)a Age Total

65+ 16-64 65-69 70-74 75-79 80-84 85+

Rate per 1000 All adults XIII Musculoskeletal system 122 295 305 356 382 388 330 IX Heart & circulatory system 63 249 289 292 305 286 280 IV Endocrine & metabolic 56 145 128 146 109 91 131 X Respiratory system 68 107 106 94 88 58 97 XI Digestive system 37 62 69 65 73 74 67 VII Eye complaints 10 25 33 51 79 137 50 VIII Ear complaints 9 26 38 42 73 101 46 II Neoplasms & benign growths 11 39 45 53 40 38 44 VI Nervous System 42 55 38 36 47 25 43 V Mental disorders 66 42 25 32 13 25 30 XIV Genito-urinary system 13 33 30 32 41 45 30 III Blood & related organs 6 7 13 11 18 22 12 XII Skin complaints 14 6 8 9 21 8 9 Other complaints 2 2 3 5 6 8 4 I Infectious disease 2 3 5 2 5 - 3 Bases (weighted): Men 8332 584 503 378 235 118 1818 Women 8659 669 596 537 356 263 2421 All adults 16991 1253 1100 914 591 381 4239 Bases (unweighted): Men 6780 794 664 509 314 174 2455 Women 8992 862 778 636 420 305 3001 All adults 15772 1656 1442 1145 734 479 5456 a Conditions are presented in descending order of the rate among all adults.

26

Table 1.5 GHQ12 scores, 2008, 2009 and 2010 combined, by age and sex


GHQ12 scorea Age Total 65+

16-64 65-69 70-74 75-79 80-84 85+

% % % % % % % Men 0 64 73 69 67 56 61 68 1-3 23 18 23 25 34 29 23 4 or more 13 9 9 9 10 10 9 Women 0 58 69 61 55 52 40 59 1-3 25 21 26 29 32 39 27 4 or more 18 11 13 16 16 21 14 All adults 0 61 71 64 60 54 47 63 1-3 24 19 25 27 33 36 25 4 or more 16 10 11 13 13 18 12 Bases (weighted): Men 7692 533 449 323 199 93 1598 Women 8086 617 537 458 275 194 2081 All adults 15778 1150 986 782 474 287 3679 Bases (unweighted): Men 6268 728 595 433 264 137 2157 Women 8418 797 702 548 329 223 2599 All adults 14686 1525 1297 981 593 360 4756 a Scores range from 0-12.

27

Table 1.6 WEMWBS scores, 2008, 2009 and 2010 combined, by age and sex


WEMWBS scores Age Total 65+

16-64 65-69 70-74 75-79 80-84 85+

% % % % % % % Men Mean 50.0 51.4 51.2 50.4 48.2 47.8 50.5 SE of the mean 0.12 0.33 0.37 0.42 0.61 0.76 0.20 Standard deviation 8.24 8.62 8.65 8.04 8.67 7.96 8.56 % Good wellbeinga 13 20 21 16 11 10 18 % Average wellbeing 73 68 67 71 68 72 69 % Poor wellbeing 14 12 13 14 20 18 14 Women Mean 49.5 51.3 50.6 48.4 49.6 48.2 50.0 SE of the mean 0.11 0.32 0.37 0.36 0.54 0.63 0.18 Standard deviation 8.58 8.19 9.01 7.65 8.72 8.31 8.46 % Good wellbeing 12 20 20 11 17 13 17 % Average wellbeing 72 70 67 73 66 69 69 % Poor wellbeing 16 10 13 16 18 18 14 All adults Mean 49.8 51.4 50.8 49.3 49.0 48.1 50.2 SE of the mean 0.9 0.24 0.27 0.29 0.41 0.48 0.14 Standard deviation 8.42 8.39 8.85 7.87 8.72 8.18 8.50 % Good wellbeing 13 20 20 13 15 12 17 % Average wellbeing 72 69 67 72 67 70 69 % Poor wellbeing 15 11 13 15 19 18 14 Bases (weighted): Men 9237 534 441 319 188 92 1575 Women 10090 605 530 449 263 183 2031 All adults 19327 1139 972 768 451 275 3606 Bases (unweighted): Men 8375 728 585 428 248 137 2126 Women 10939 782 693 540 316 212 2543 All adults 19314 1510 1278 968 564 349 4669 a Good wellbeing: WEMWBS score more than one standard deviation (1 S.D.) above the mean for

all adults; average well-being: WEMWBS score within 1 S.D. of the mean; poor wellbeing: WEMWBS score lower than 1 S.D. below the mean.

28

Table 1.7 Estimated odds ratios for factors associated with poor wellbeing,a 2008, 2009

and 2010 combined, by associated risk factors and sex



Base (weighted)

1575


interval

Base (weighted)

2031


interval (p=0.672) (p=0.854) Age 1575 0.99 0.97,1.02 2031 1.00 0.98,1.02 Scottish Index of

Multiple deprivation (p=0.259) (p=0.001)

85% least deprived areas 1422 1 1778 1 15% most deprived areas 153 1.26 0.84,1.88 253 1.73 1.27,2.35 Marital / partnership

status (p<0.001) (p=0.037)

Married/civil partner/living as married

1147 1 956 1

Single/separated/divorced 178 2.22 1.49,3.31 232 1.06 0.67,1.68 Widowed/surviving civil

partner 250 2.03 1.39,2.98 843 1.47 1.08,1.99

Weekly alcohol

consumption (p=0.108) (p=0.003)

0 units up to weekly limit (21 units men / 14 units women)

1229 1 1842 1


346 0.73 0.49,1.07 189 0.38 0.20,0.71

Limiting long-term

conditions (p<0.001) (p<0.001)

No conditions 560 1 668 1 Non-limiting condition 302 1.78 1.06,3.01 399 1.11 0.71,1.74 Limiting condition 713 4.16 2.79,6.18 964 2.76 1.96,3.89 Physical activityb (p<0.001) (p<0.001) Meets recommendations 291 1 267 1 Some activity 431 1.05 0.55,2.02 549 1.85 1.02,3.35 Low activity 852 3.32 1.87,591 1215 2.98 1.69,5.30 a Poor wellbeing: WEMWBS score lower than 1 S.D. below the mean (based on SHeS participants aged

16+); compared with those with WEMBWS score higher than that. b Meets recommendations= 30 or minutes on at least 5 days a week; Some activity= 30 minutes on 1 to 4

days a week; Low activity= fewer than 30 minutes of moderate or vigorous activity a week.

29

i s iou s Chapter

2 LIFESTYLE BEHAVIOURS

Wissam Gharib, Henry Jones, Marilyn Roth, Nicola Shelton, Faiza Tabassum

SUMMARY • Mean weekly alcohol consumption in 2008/2009/2010, and the proportion of

adults drinking above the weekly guideline amounts, was lower among adults aged 65 and over than those aged 16-64. For example, 30% of men aged 16-64 and 65-69 drank more than 21 units per week, compared with 11% of men aged 85 and over. 22% of women aged 16-64 drank more than 14 units per week, compared with 13% aged 65-69, and 4% aged 85 and over. Men drank more alcohol per week than women at all ages.

• Alcohol consumption on the heaviest drinking day in the last week was also lower among older adults, and was lower among women than men at all ages. For example, 48% of men aged 16-64 had drunk more than 4 units on their heaviest drinking day versus 24% of those aged 65 and over. The equivalent difference for women drinking more than 3 units was even larger (41% versus 11%). Among older adults, men drinking over 4 units declined from 36% of those aged 65-69 to just 7% of those aged 85 and over. The corresponding figures for women drinking more than 3 units were 18% and 3%.

• Consuming more than twice the recommended daily units followed similar patterns, though lower proportions did this (31% of men aged 16-64 versus 8% of men aged 65 and over drank more than 8 units; 21% and 2% of women, respectively, drank more than 6).

• Just over half the population aged 65 and over drink within both the weekly and daily guidelines (51% of men and 57% of women), compared with only 37% of men and 43% of women aged 16-64. Men aged 65 and over were twice as likely as women to exceed the weekly and/or daily alcohol guidelines (33% of men, 15% of women). In marked contrast, 53% of men and 45% of women aged 16-64 exceeded the recommendations.

• Older adults were half as likely to be current cigarette smokers as those aged 16-64 (14% versus 28%). Almost half of men and women aged 16-64, and women aged 65 and over, had never smoked, compared with a third of men aged 65 and over.

• 45% of male smokers aged 65 and over smoked 20 or more cigarettes a day compared with 34% of those aged 16-64. The number of cigarettes smoked by women did not differ by age. The proportion of older adults smoking 20 or more cigarettes a day declined with age in both sexes.

• The mean number of portions of fruit and vegetables consumed by women aged 16-64 and 65 and over (3.4), and men aged 65 and over (3.3), was very similar. Men aged 16-64 consumed fewer portions (3.0), and were the least likely group to have consumed five or more portions. Adults aged 65 and over were half as likely as those aged 16-64 to have eaten no fruit or vegetables (5% versus 10%), though the proportions that had eaten five or more portions were similar in both groups (23% and 22% respectively).

30

• 17% of men and 12% of women aged 65 years and over met the physical activity recommendation of 30 or more minutes of moderate or vigorous activity on at least 5 days a week. In contrast, 50% of men and 38% of women aged 16-64 met the recommendations. The proportion meeting the recommendations decreased with age and was consistently higher in men than women.

• 60% of adults aged 65 years and older reported low levels of activity (fewer than 30 minutes of moderate or vigorous activity per week). Low activity levels increased markedly with age, from 46% of men aged 65-69 to 84% of those aged 85 and over, and from 44% to 91%, respectively, among older women.

• 63% of men and 56% of women aged 65 years and over had participated in at least 10 minutes of physical activity in the last 4 weeks. In contrast, the corresponding figures for adults aged 16-64 were 88% for men and 87% for women. The difference in activity levels between men and women increased with age among the older age groups compared with those aged 16-64.

2.1 INTRODUCTION The main focus of this chapter is lifestyle behaviours, including smoking, alcohol consumption, diet (fruit and vegetable consumption), and physical activity. Health behaviours are important among older adults. A recent study of 20,000 men and women in Eastern England over a twenty year period showed that all-cause mortality and deaths from cardiovascular disease and cancer were closely associated with four behaviours: smoking, drinking heavily, not eating healthily (five or more servings of fruit and vegetables), and not being physically active.1 Physical activity, not smoking, and eating a healthy diet are associated with improved physical functioning in older people. In addition, a healthy lifestyle pattern may both promote a longer life span in older people2 and increase quality of life by delaying a deterioration in health status.3

2.1.1 Alcohol

Heavy alcohol consumption is less common among older adults. Yet it remains a significant problem in the UK. Heavy alcohol consumption is associated with mortality in older adults.4,5 Physiological changes that occur with ageing mean that blood alcohol levels are higher for the same intake and alcohol has greater effects on the body.6 The value of moderate alcohol consumption in preventing cognitive decline and the reduction of physical risks of all-cause mortality among older adults has been established.5,7,8

Generally, the prevalence of alcohol consumption and alcohol abuse decreases with age, and the proportion of non-drinkers increases. The reason for this decline in consumption is connected to changes in life circumstances and attitudes, and because of increasing ill health.9 There is probably also a cohort effect, particularly among older women.10 Older heavy drinkers have a history of either excessive consumption over a period of 40 or 50 years, or moderate consumption which increases at times of strain.11,12 These patterns of drinking in older people are often related to loneliness, loss of a spouse, disabling illness, and isolation.13 Many older people take prescribed medication,

31

including for anxiety, depression and insomnia.14

Alcohol can interact with these medications, with adverse consequences.

Alcohol misuse leads to a wide range of health problems, including liver disease, high blood pressure, an increase in obesity, and mental health issues, each of which has associated costs. Overall, the cost of alcohol misuse to Scottish society in 2007 was estimated at around £3.6 billion.15 In 2009/10 there were 39,278 discharges related to alcohol from Scottish hospitals for all age groups in the adult population16 while alcohol-related deaths have doubled in the past twenty years.17

Health problems due to alcohol in older people are often difficult to diagnose, especially as they may be attributed to old age, and screening questions, such as those on the CAGE questionnaire, are less reliable in older people.18

2.1.2 Smoking

Smoking is less common among older people because half of those who smoke die prematurely.19 The effects on current and ex-smokers are particularly noticeable among people who smoked for longer. Older smokers are at greater risk than non-smokers of developing cardiovascular disease or cancer, and of suffering cognitive decline (including dementia); they also have increased mortality.20,21 Although the relative effects of smoking on health are lower in older adults, because those most susceptible have already succumbed, the absolute effects of smoking become larger, as the overall risks of cancer and cardiovascular diseases increase exponentially with age. Smoking also leads to reduction of bone mineral density among postmenopausal women, and thus contributes to a higher risk of hip fracture. It is also the main cause of chronic obstructive pulmonary disease (COPD), a condition involving impaired air flow and gas exchange in the lungs, which is the fifth leading cause of death worldwide.22,23

2.1.3 Diet

Much of Scotland’s poor health can be attributed to its unhealthy eating habits. Adequate fruit and vegetable consumption is an important part of a healthy diet, and current recommendations in the UK stress the importance of eating at least five portions a day. There is much evidence that fruit and vegetable consumption protects against cardiovascular disease24,25,26 and cancer.27,28

The nutritional status of older people is an important indicator of quality of life, morbidity and mortality.29 The prevalence of malnutrition is much higher in older people than in the general population and is estimated to cost the UK £7.3 billion a year.30 The reasons for the higher prevalence in older people are multi-factorial and span psychological, for example depression; social, including poverty, loneliness, and social isolation; and physical, particularly changed gastrointestinal function with an increase in signals inhibiting appetite.31

32

There is also evidence of specific dietary needs in older people. For example, the adult recommended daily allowance of protein may be insufficient to maintain skeletal muscle in older people.32 The importance of micronutrients for older people is also well documented; vitamin D deficiency is common and associated with poor bone health,33,34 and vitamin B12 and folate deficiencies are associated with depression.35,36

2.1.4 Physical activity

Another important lifestyle behaviour which decreases with age is physical activity.37 Reduced activity levels contribute to decreased strength and stamina in older ages.38 Although structured exercise may be difficult for some older adults, any activity that contributes to energy expenditure may help reduce mortality,39 with longer duration and more intense exercise being of greater benefit.40

New UK guidelines for physical activity were published in July 2011. They included, for the first time, separate recommendations for older people (Table 2A) and also recommended including activity to increase muscle strength and improve balance, and minimising sedentary time.41

Table 2A

Table 2A UK physical activity guidelines for older adults Some physical activity is better than none, and more physical activity provides greater health benefits (including maintenance of good physical and cognitive function).

Older adults should aim to be active daily. Over a week, activity should add up to at least 150 minutes (2½ hours) of moderate intensity activity in bouts of 10 minutes or more – one way to approach this is to do 30 minutes on at least 5 days a week.

For those who are already regularly active at moderate intensity, comparable benefits can be achieved through 75 minutes of vigorous intensity activity spread across the week or a combination of moderate and vigorous activity.

Older adults should also undertake physical activity to improve muscle strength on at least two days a week.

Older adults at risk of falls should incorporate physical activity to improve balance and co-ordination on at least two days a week.

All older adults should minimise the amount of time spent being sedentary (sitting) for extended periods.

The decrease in mortality associated with regular physical activity is thought to be due primarily to a decrease in the incidence of diseases that physical activity helps prevent: cardiovascular disease, type 2 diabetes, and hypertension.42 It may also be through an improvement in body composition, with a reduction in fat mass (see chapters 3 and 4 for details of how these are linked), although there is evidence that exercise is also beneficial in those who remain obese.43 An increased

33

quality of life has also been demonstrated in those who exercise in later life.44

Most people are able to walk, even if slowly. Walking reduces anxiety and depression,45 can maintain mental wellbeing,46 reduces mood disturbance in women, and increases positive affect in men. Walking also increases bone density in the legs and trunk of postmenopausal women,47

and improves pain in people with osteoarthritis.46

The health benefits of walking at any age are well recognised:

“It is a year-round, readily repeatable, self-reinforcing, habit-forming activity and the main option for increasing physical activity in sedentary populations. Thus, walking is ideal as a gentle start up for the sedentary, including the inactive, immobile elderly, bringing a bonus of independence and social well-being.” Morris & Hardman,199747

2.2 RESULTS

2.2.1 Alcohol Estimated weekly consumption of alcohol varied by age and sex. As Table 2.1 and Figure 2A illustrate, adults aged 16-64 drank more per week than older adults, and among older adults, there was a marked decline in alcohol consumption with age. This was true for men and women both for the mean number of units and for the proportion of the population drinking above the weekly guideline amounts. For example, among men, 30% of those aged 16-64 and 65-69 drank more than 21 units per week, compared with 11% of men aged 85 and over. Among women, 22% of those aged 16-64 drank more than 14 units per week, compared with 13% aged 65-69, and 4% aged 85 and over. At every age, men drank more alcohol than women but the difference was proportionately wider among older men and women than was the case for those aged under 65. Table 2.1, Figure 2A

34

0

10

20

30

40

50

16-64 65-69 70-74 75-79 80-84 85+

Perc

ent

0

2

4

6

8

10

12

14

16

18

20

Mea

n un

its

Men Women Men mean units Women mean units

Figure 2AProportions exceeding Government guidelines on weekly alcohol consumption (21 units for men, 14 units for women), and mean weekly number of units, by age and sex (2008/2009/2010 combined data)

Table 2.2 and Figure 2B show that alcohol consumption on the heaviest drinking day in the last week also varied by age and sex, both between younger and older adults and among older adults. Consumption was lower in older groups, and men drank more than women at every age. For example, men aged 16-64 were twice as likely as those aged 65 and over to drink more than 4 units on their heaviest drinking day (48% versus 24%). The equivalent difference for women drinking more than 3 units was even larger (41% versus 11%). Among older men, drinking over 4 units declined from 36% of those aged 65-69 to just 7% of those aged 85 and over. The corresponding figures for women were 18% and 3%. Consuming more than twice the recommended daily units followed similar patterns, though lower proportions did this (31% of men aged 16-64 versus 8% of men aged 65 and over drank more than 8 units; 21% and 2% of women, respectively, drank more than 6). At most ages, a higher proportion of men and women exceeded the daily recommendations than had exceeded the weekly recommendations, but the reverse was true for men and women aged 80 and over. Table 2.2, Figure 2B

35

0

10

20

30

40

50

16-64 65-69 70-74 75-79 80-84 85+

Perc

ent

0

1

2

3

4

5

6

7

Mea

n un

its

Men Women Men mean units Women mean units

Figure 2BProportions exceeding Government guidelines on daily alcohol consumption (4 units for men, 3 units for women), and mean number of units consumed on heaviest drinking day in the last week, by age and sex (2008/2009/2010 combined data)

Table 2.3 shows that a much higher proportion of women than men aged 65 and over had never drunk alcohol (16% versus 5%). The proportion of women who had never drunk was much higher in those aged 65 and over than in those aged 16-64 (but was similar for men), and was higher in the older age groups, particularly men aged 85 and over and women aged 75 and over. However, the proportion of adults who were ex-drinkers did not vary by sex, although it was higher in older than younger adults (12% of adults aged 65 and over versus 6% of those aged 16-64) and increased less with age in those aged 65 and over. Just over half the older population in Scotland drink within both the weekly and daily guidelines (51% of men and 57% of women aged 65 and over), compared with only 37% of men and 43% of women aged 16-64. Among adults aged 65 and over, twice as many men as women exceeded the weekly and/or daily alcohol guidelines (33% of men, 15% of women). In marked contrast, these figures were 53% of men and 45% of women aged 16-64. The proportion of the population exceeding either or both guidelines fell with age in both sexes. Table 2.3

2.2.2 Smoking Older adults were half as likely to be current cigarette smokers as those aged 16-64 (14% versus 28%). Smoking status varied considerably by both age and sex, with a different age-related pattern among men and women. While smoking status was very similar among men and women aged 16-64, there were marked differences between older men and women. Almost half of men aged 16-64 had never smoked cigarettes (48%), similar to the proportion of women of that age (49%) and also of women aged 65 and over (48%) who had never smoked. However, only one-third of older men had never smoked (33%), with more than half being ex-smokers (52%), whereas 37% of older women were ex-smokers. Among older adults, the proportion of current smokers was lower in the older age groups for both men and women, and the proportion of ex-smokers increased with age among men.

36

Among current cigarette smokers, 45% of men aged 65 and over smoked 20 or more cigarettes a day compared with 34% of male smokers aged 16-64. In contrast, older women’s cigarette consumption did not differ markedly from their younger counterparts. The proportion of older adults smoking 20 or more cigarettes a day declined with age in both sexes. In men, the proportion smoking 10 to fewer than 20 cigarettes a day increased with age, whereas among women the proportion smoking fewer than 10 increased. Table 2.4, Table 2.5

2.2.3 Diet The number of portions of fruit and vegetables eaten by adults in Scotland did not vary significantly by age or sex, except that the mean number of portions of fruit and vegetables consumed by men aged 16-64 (3.0 portions) was significantly lower than the amount consumed by women aged 16-64 or 65 and over (3.4) or by men aged 65 and over (3.3). Although adults aged 65 and over were half as likely as those aged 16-64 to have eaten no fruit or vegetables in the previous 24 hours (5% versus 10%), similar proportions in both groups had eaten five or more portions (23% and 22% respectively). The proportion of older adults eating no portions at all was generally static across the age groups, however the proportion eating five or more portions declined steadily with age from 27% of those aged 65-69 to 18% of those aged 85 and over. Table 2.6

2.2.4 Physical activity Table 2.7 shows that 17% of men and 12% of women aged 65 years and older met the physical activity recommendations for adults (i.e. they participated in 30 or more minutes of moderate or vigorous activity on at least 5 days a week) compared with 50% of men and 38% of women aged 16-64. The proportion meeting the recommendations decreased with age and was consistently higher in men compared to women. Overall, 60% of adults aged 65 years and older reported low levels of activity (fewer than 30 minutes of moderate or vigorous activity per week). Low activity levels increased markedly with age, from 46% of men aged 65-69 to 84% of those aged 85 and over, and from 44% to 91%, respectively, among women. Table 2.7 Table 2.8 presents further information about the kinds of activities people had carried out. 63% of men and 56% of women aged 65 years and older had participated in at least 10 minutes of physical activity in the last 4 weeks. In contrast, the corresponding figures for adults aged 16-64 were 88% for men and 87% for women. On average, men aged 65 and over were active for 4.4 hours per week compared with 2.6 hours for women of this age. Figure 2C shows that the difference in activity levels between men and women increased with age among the older age groups compared with those aged 16-64. Table 2.8, Figure 2C

37

0

10

20

30

40

50

60

70

80

90

100

16-64 65-69 70-74 75-79 80-84 85+

Perc

ent

0

1

2

3

4

5

6

7

8

9

10

Hou

rs

Men - percent participating Women - percent participatingMen - mean no. hours Women - mean no. hours

Figure 2CPercent of adults participating in any physical activity in the last 4 weeks (for at least 10 minutes), and mean hours per week, by age and sex (2008/2009/2010 combined data)

Participation in heavy housework was the most common activity in both men (40%) and women (44%). Only 16% of men and 13% of women reported walking at a brisk or fast pace in the last 4 weeks. There was no significant difference in the proportion of men and women participating in walking, though as Figure 2D shows, men spent more time walking than women. Participation and time spent in each type of activity decreased with age for both sexes. Women were more likely to participate in and spent more time doing heavy housework than men, while men were more likely to participate in and spent more time doing heavy manual/gardening/DIY and sports and exercise (Figure 2E). Table 2.8, Figure 2D, Figure 2E

0

10

20

30

40

50

60

70

16-64 65-69 70-74 75-79 80-84 85+

Perc

ent

0

0.5

1

1.5

2

2.5

3

Hou

rs


Figure 2DPercent of adults walking at brisk/fast pace in the last 4 weeks (for at least 10 minutes), and mean hours per week, by age and sex (2008/2009/2010 combined data)

38

0

10

20

30

40

50

60

70

16-64 65-69 70-74 75-79 80-84 85+

Perc

ent

0

0.5

1

1.5

2

2.5

3

Hou

rs


Figure 2EPercent of adults participating in sport or exercise in the last 4 weeks (for at least 10 minutes), and mean hours per week, by age and sex (2008/2009/2010 combined data)

As noted in the introduction, the new UK guidelines on physical activity contain specific recommendations for the 65 and older age group. These findings illustrate the importance of targeting interventions towards this age group.

39


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42

Table List Table 2.1 Estimated usual weekly alcohol consumption, 2008, 2009 and 2010

combined, by age and sex Table 2.2 Estimated alcohol consumption on heaviest drinking day in last week, 2008,

2009 and 2010 combined, by age and sex Table 2.3 Adherence to weekly and daily drinking advice, 2008, 2009 and 2010

combined, by age and sex Table 2.4 Prevalence of smoking, 2008, 2009 and 2010 combined, by age and sex Table 2.5 Cigarette consumption among current smokers, 2008, 2009 and 2010

combined, by age and sex Table 2.6 Prevalence of fruit and vegetable consumption, 2008, 2009 and 2010

combined, by age and sex Table 2.7 Summary physical activity levels, 2008, 2009 and 2010 combined, by age and

sex Table 2.8 Participation in different activities in the past 4 weeks, 2008, 2009 and 2010

combined, by age and sex

43

Table 2.1 Estimated usual weekly alcohol consumption, 2008, 2009 and 2010



Drinking categorya/ alcohol units per week

Age Total 65+

16-64 65-69 70-74 75-79 80-84 85+

% % % % % % % Men Never drank 4 3 4 5 7 11 5 Ex-drinker 5 10 12 13 15 15 12 Moderate 61 58 65 64 64 63 62 Hazardous 23 23 16 15 14 10 18 Harmful 7 7 3 2 1 1 4 Drank over 21 units per week 30 30 19 17 15 11 21 Mean units per week 18.1 16.7 12.1 10.3 8.7 7.4 12.5 Standard error of mean 0.41 0.85 0.64 0.69 0.99 0.99 0.39 Women Never drank 6 10 12 20 21 27 16 Ex-drinker 6 11 11 10 12 13 11 Moderate 66 65 67 62 61 56 64 Hazardous 18 11 8 7 5 3 7 Harmful 4 2 1 - 1 1 1 Drank over 14 units per week 22 13 9 7 6 4 8 Mean units per week 9.1 5.7 4.3 3.5 2.9 1.7 4.0 Standard error of mean 0.19 0.36 0.31 0.35 0.37 0.35 0.17 All adults Non drinker (never or ex) 11 17 20 25 29 35 23 Moderate 64 62 66 64 62 59 63 Hazardous 20 17 12 10 8 5 12 Harmful 5 5 5 2 1 1 1 Drank over 14/21 units per

week 26 21 14 11 9 6 14

Mean units per week 13.5 10.8 7.9 6.3 5.2 3.5 7.7 Standard error of mean 0.24 0.48 0.38 0.37 0.49 0.42 0.23 Bases (weighted): Men 8158 582 503 377 236 116 1814 Women 8534 667 594 534 355 259 2409 All adults 16675 1249 1097 910 591 375 4222 Bases (unweighted): Men 6687 791 663 508 315 172 2449 Women 8900 858 776 633 419 301 2987 All adults 15571 1649 1439 1141 734 473 5436 a Moderate: >0 up to 21 (men) or 14 (women) units; Hazardous: >21 up to 50 (men) or >14 up to

35 (women) units; Harmful: >50 (men) or >35 (women) units.

44

Table 2.2 Estimated alcohol consumption on heaviest drinking day in last week,

2008, 2009 and 2010 combined, by age and sex


Alcohol units per day

Age Total 65+

16-64 65-69 70-74 75-79 80-84 85+

% % % % % % % Men Non drinker (never or ex) 10 12 16 18 22 26 17 0 up to and including 4 units 42 52 58 65 67 67 59 Over 4 and up to and including 8

units 17 21 18 15 9 7 17

Consumed over 4 units 48 36 26 17 11 7 24 Consumed over 8 units 31 15 8 3 2 1 8 Mean units per day 6.7 4.1 3.0 2.1 1.7 1.4 2.9 Standard error of mean 0.13 0.18 0.15 0.13 0.14 0.16 0.08 Women Non drinker (never or ex) 12 21 23 30 33 40 27 0 up to and including 3 units 47 61 61 61 64 58 61 Over 3 and up to and including 6

units 20 15 14 7 2 2 10

Consumed over 3 units 41 18 15 8 3 3 11 Consumed over 6 units 21 4 1 1 - - 2 Mean units per day 3.8 1.7 1.3 1.0 0.7 0.4 1.1 Standard error of mean 0.08 0.08 0.07 0.08 0.08 0.06 0.04 All adults Non drinker (never or ex) 11 17 20 25 29 35 23 0 up to and including 3/4 units 45 57 60 63 65 60 60 Over 3/4 and up to and including

6/8 units 19 18 16 10 5 4 13

Consumed over 3/4 units 45 27 20 12 6 5 17 Consumed over 6/8 units 26 9 4 2 1 1 4 Mean units per day 5.3 2.8 2.1 1.4 1.1 0.7 1.9 Standard error of mean 0.08 0.10 0.09 0.08 0.08 0.07 0.05 Bases (weighted): Men 8104 582 503 376 236 117 1814 Women 8482 669 594 535 355 259 2412 All adults 16586 1251 1098 911 591 376 4226 Bases (unweighted): Men 6662 790 664 507 315 173 2449 Women 8873 861 776 634 419 301 2991 All adults 15535 1651 1440 1141 734 474 5440

45

Table 2.3 Adherence to weekly and daily drinking advice, 2008, 2009 and



Adherence to weekly and daily drinking advice

Age Total 65+

16-64 65-69 70-74 75-79 80-84 85+

% % % % % % % Men Never drunk alcohol 4 3 4 5 7 11 5 Ex drinker 5 10 12 13 15 15 12 Drinks within government

guidelinesa 37 43 50 57 59 59 51

Drinks outwith government guidelinesb

53 45 34 26 19 15 33

Women Never drunk alcohol 6 10 12 20 21 27 16 Ex drinker 6 11 11 10 12 13 11 Drinks within government

guidelinesa 43 55 58 57 61 56 57


45 24 18 12 6 5 15

All adults Never drunk alcohol 5 7 9 14 15 22 11 Ex drinker 6 10 12 11 13 13 12 Drinks within government

guidelinesa 40 49 54 57 60 57 55


49 34 26 18 11 8 23

Bases (weighted): Men 8041 581 502 375 235 116 1809 Women 8425 667 594 534 355 259 2409 All adults 16466 1248 1096 909 590 375 4218 Bases (unweighted): Men 6619 789 662 506 314 172 2443 Women 8827 858 776 633 419 301 2987 All adults 15446 1647 1438 1139 733 473 5430 a Drank no more than 4 units (men) or 3 units (women) on heaviest drinking day, and drank

no more than 21 units (men) or 14 units (women) in usual week. b Drank more than 4 units (men) or 3 units (women) on heaviest drinking day, and/or

drank more than 21 units (men) or 14 units (women) in usual week.

46

Table 2.4 Prevalence of smoking, 2008, 2009 and 2010 combined, by age and sex


Cigarette smoking status Age Total 65+

16-64 65-69 70-74 75-79 80-84 85+

% % % % % % % Men Never smoked cigarettes at all 48 32 36 33 31 35 33 Used to smoke cigarettes

occasionally 4 3 2 3 3 5 3

Used to smoke cigarettes regularly

19 48 47 48 55 57 49

Current cigarette smoker 29 18 15 16 11 3 15 Women Never smoked cigarettes at all 49 41 51 48 53 56 48 Used to smoke cigarettes



18 33 29 32 34 30 32

Current cigarette smoker 28 21 15 15 8 5 14 All adults Never smoked cigarettes at all 49 37 44 42 44 50 42 Used to smoke cigarettes



18 40 37 39 42 38 39

Current cigarette smoker 28 19 15 15 9 4 14 Bases (weighted): Men 8231 584 503 377 236 117 1817 Women 8590 669 594 535 355 260 2413 All adults 16821 1253 1098 912 591 377 4230 Bases (unweighted): Men 6732 794 664 508 315 173 2454 Women 8944 861 776 634 419 302 2992 All adults 15676 1655 1440 1142 734 475 5446

47

Table 2.5 Cigarette consumption among current smokers, 2008, 2009 and 2010


Aged 16 and over currently smoking cigarettes 2008, 2009 and 2010 combined

Cigarette consumption Age Total 65+

16-64 65-69 70-74 75-79 80-84 85+

% % % % % % % Men < 10 per day 25 16 21 17 a a 17 10 to under 20 per day 40 36 29 42 a a 38 20 or more per day 34 48 50 41 a a 45 Women < 10 per day 29 30 22 43 [53] a 33 10 to under 20 per day 44 38 44 35 [39] a 39 20 or more per day 27 32 34 22 [8] a 28 All adults < 10 per day 27 24 22 32 37 a 27 10 to under 20 per day 42 38 38 38 48 a 39 20 or more per day 31 39 41 30 15 a 35 Bases (weighted): Men 2260 96 70 58 21 4 249 Women 2338 139 88 80 28 12 346 All adults 4598 235 158 138 49 16 596 Bases (unweighted): Men 1869 133 93 72 28 6 332 Women 2470 168 116 85 30 12 411 All adults 4339 301 209 157 58 18 743 a Data not shown due to small bases.

48

Table 2.6 Prevalence of fruit and vegetable consumption, 2008, 2009 and 2010



Portions per day Age Total 65+

16-64 65-69 70-74 75-79 80-84 85+

% % % % % % % Men None 12 7 7 6 6 5 6 Less than 1 portion 5 4 4 5 6 1 4 1 portion or more but less than 2 19 16 15 19 18 17 17 2 portions or more but less than 3 17 19 20 20 17 25 19 3 portions or more but less than 4 15 16 18 16 17 16 16 4 portions or more but less than 5 11 12 13 14 15 18 13 5 portions or more 20 26 23 20 22 18 23 Mean portions 3.0 3.4 3.3 3.1 3.3 3.3 3.3 SE of mean 0.04 0.09 0.10 0.10 0.14 0.18 0.04 Women None 9 6 4 2 6 6 5 Less than 1 portion 4 5 5 4 5 4 5 1 portion or more but less than 2 17 15 17 16 14 19 16 2 portions or more but less than 3 17 16 17 20 25 20 19 3 portions or more but less than 4 17 16 19 16 18 19 17 4 portions or more but less than 5 12 15 12 19 13 13 15 5 portions or more 24 27 25 22 20 18 23 Mean portions 3.4 3.6 3.5 3.4 3.2 3.1 3.4 SE of mean 0.04 0.09 0.09 0.09 0.10 0.13 0.03 All adults None 10 6 6 4 6 6 5 Less than 1 portion 4 4 5 4 5 3 4 1 portion or more but less than 2 18 15 16 18 16 18 16 2 portions or more but less than 3 17 17 18 20 21 22 19 3 portions or more but less than 4 16 16 19 16 17 18 17 4 portions or more but less than 5 12 14 12 17 14 15 14 5 portions or more 22 27 24 21 21 18 23 Mean portions 3.2 3.5 3.4 3.3 3.3 3.2 3.4 SE of mean 0.03 0.07 0.07 0.07 0.09 0.11 0.04 Bases (weighted): Men 8327 584 504 377 236 117 1818 Women 8657 669 595 537 355 263 2419 All adults 16984 1253 1099 914 591 380 4237 Bases (unweighted): Men 6780 794 665 508 315 173 2455 Women 8990 862 777 636 419 305 2999 All adults 15770 1656 1442 1144 734 478 5454

49

Table 2.7 Summary physical activity levels, 2008, 2009 and 2010 combined, by

age and sex


Summary activity levela Age Total 65+

16-64 65-69 70-74 75-79 80-84 85+

% % % % % % % Men Meets recommendations 50 24 19 14 10 6 17 Some activity 27 30 28 26 18 10 26 Low activity 23 46 53 60 72 84 57 Women Meets recommendations 38 21 15 9 4 2 12 Some activity 36 35 30 23 18 7 26 Low activity 25 44 56 68 78 91 62 All adults Meets recommendations 44 22 17 11 7 3 14 Some activity 32 33 29 24 18 8 26 Low activity 24 45 55 65 76 89 60 Bases (weighted): Men 8324 584 504 377 236 116 1816 Women 8651 668 595 534 355 262 2414 All adults 16976 1252 1099 911 590 378 4230 Bases (unweighted): Men 6775 794 664 508 315 171 2452 Women 8982 861 777 633 418 304 2993 All adults 15757 1655 1441 1141 733 475 5445 a Meets recommendations: 30 minutes or more on at least 5 days a week; Some activity= 30

minutes or more on 1 to 4 days a week; Low activity= fewer than 30 minutes of moderate or vigorous activity a week.

50

Table 2.8 Participation in different activities in the past 4 weeks, 2008, 2009 and



Participation for at least 10 minutes at a time

Age Total 65+

16-64 65-69 70-74 75-79 80-84 85+

% % % % % % % Men Heavy Housework Any participation in last 4

weeks 51

48 42 39 27 18 40

Mean hours per weeka 0.9 0.8 0.8 0.6 0.4 0.3 0.7 Standard error of the mean 0.03 0.07 0.08 0.09 0.08 0.07 0.04 Heavy Manual/ Gardening/ DIY

Any participation in last 4 weeks

27

28 23 20 11 9 22

Mean hours per weeka 1.4 1.9 0.9 1.2 0.5 0.7 1.2 Standard error of the mean 0.08 0.24 0.12 0.29 0.20 0.51 0.11 Walking (brisk/fast pace) Any participation in last 4

weeks 45

22 18 13 9 5 16

Mean hours per weeka 2.8 1.6 1.3 0.8 0.5 0.3 1.1 Standard error of the mean 0.12 0.18 0.18 0.16 0.17 0.15 0.09 Sports and Exercise Any participation in last 4

weeks 58

37 35 29 25 12 31

Mean hours per weeka 2.5 1.7 1.5 1.4 0.8 0.5 1.4 Standard error of the mean 0.07 0.14 0.14 0.17 0.13 0.17 0.07 Any physical activities Any participation in last 4

weeks 88

73 68 59 48 33 63

Mean hours per weeka 9.4 6.1 4.6 3.8 2.2 1.7 4.4 Standard error of the mean 0.17 0.37 0.30 0.35 0.34 0.47 0.18

Continued…

51



Participation for at least 10 minutes at a time

Age Total 65+

16-64 65-69 70-74 75-79 80-84 85+

% % % % % % % Women Heavy Housework Any participation in last 4

weeks 69

60 52 40 25 12 44

Mean hours per weeka 2.0 1.7 1.3 0.7 0.5 0.3 1.1 Standard error of the mean 0.05 0.16 0.11 0.08 0.09 0.11 0.06 Heavy Manual/ Gardening/ DIY

Any participation in last 4 weeks

10

12 8 5 3 1 7

Mean hours per weeka 0.3 0.3 0.2 0.2 0.0 0.0 0.2 Standard error of the mean 0.02 0.05 0.06 0.10 0.01 0.01 0.03 Walking (brisk/fast pace) Any participation in last 4

weeks 37

22 15 11 7 3 13

Mean hours per weeka 2.1 1.3 0.9 0.5 0.2 0.1 0.7 Standard error of the mean 0.07 0.15 0.13 0.11 0.05 0.09 0.06 Sports and Exercise Any participation in last 4

weeks 50

34 29 19 15 7 24

Mean hours per weeka 1.3 1.0 0.8 0.5 0.3 0.1 0.6 Standard error of the mean 0.04 0.08 0.07 0.10 0.05 0.03 0.04 Any physical activities Any participation in last 4

weeks 87

73 65 52 38 20 56

Mean hours per weeka 6.7 4.5 3.2 1.9 1.0 0.5 2.6 Standard error of the mean 0.10 0.27 0.21 0.21 0.12 0.15 0.11 Bases (weighted):

Men 8317 583 503 376 236 117 1815 Women 8647 667 593 532 355 262 2410 Bases (unweighted): Men 6771 793 663 507 315 173 2451 Women 8977 859 774 632 419 304 2988 a Means are based on all participants.

52

si Chapter

3 OBESITY Henry Jones, Vasant Hirani, Faiza Tabassum, Damita Abayaratne

SUMMARY • Mean body mass index (BMI) was higher among adults aged 65 and over

(28.1 kg/m2) than those aged 16-64 (27.3 kg/m2) but did not vary by sex. Mean BMI decreased with age among older adults, from 28.6 kg/m2 in those aged 65-69 to 26.6 kg/m2 in those aged 85 and over.

• At every age, men were more likely than women to be overweight or obese (BMI of 25 kg/m2 and over), for example 77% of men versus 71% of women aged 65 and over, and 66% of men and 59% of women aged 16-64.

• The prevalence of obesity (BMI of 30 kg/m2 and over) was similar for both men and women at all ages. It was higher among older adults (31%) than younger adults (27%) but decreased with age among older people, particularly among men aged 80 and over.

• The prevalence of a raised waist-hip ratio (WHR) was markedly higher in older adults (64% in men and 62% in women) than in those aged 16-64 (30% in men, 36% in women).

• Having a raised waist circumference (WC) was also more common in older adults for both sexes, especially men, where it affected 52% of those aged 65 and over and 29% of those aged 16-64 years (56% and 43% respectively among women).

• The Scottish Intercollegiate Guidelines Network (SIGN) supports the WHO’s recommendation that waist circumference should be used in combination with BMI to classify risk of diseases such as CVD and type 2 diabetes. Just over one in four older adults did not have an increased risk of disease (28% of men and 27% women), compared with one in two men and four in ten women aged 16-64.

• Of those aged 65 and over, 18% had an increased risk of disease, 24% had a high risk, 27% had a very high risk and 2% had an extremely high risk.

3.1 INTRODUCTION Obesity is due to the long term intake of energy from food and drink consumption exceeding the energy the body uses for metabolism and physical activity. It is a particular issue in older people as less energy is expended with increasing age, due to a lowered metabolic rate and increased levels of sedentary behaviour1 resulting in weight gain. Furthermore, specific changes in body composition associated with ageing, such as a decrease in muscle mass (sarcopenia), have been shown to be particularly dangerous when combined with obesity.2 There are a number of ways of measuring and defining obesity. The Body Mass Index (BMI) is used to assess general obesity.3 A value of 25 kg/m2 to less than 30 kg/m2 is considered overweight; a value of 30 kg/m2 or above indicates obesity. Although BMI measurement is a common means of assessing nutritional status, it is a relatively crude marker that does not take into account where body fat is stored. This is relevant as certain body fat distributions are linked with particular health hazards. For example, visceral abdominal obesity (fat surrounding the abdominal organs, also called central obesity) has been linked with a combination of insulin resistance/type 2 diabetes and risk factors

53

for ischaemic heart disease (IHD), known as the metabolic syndrome.4 Such abdominal fat distribution is better assessed using the waist circumference (WC), or the ratio of the waist circumference to the hip circumference (waist to hip ratio; WHR). There is further debate regarding whether BMI is a reliable indicator of weight in older people.5,6 For these reasons this chapter includes WC and WHR data in addition to BMI. A recent follow-up of SHeS participants has shown that raised WC is more important in predicting future mortality than BMI.7 Worldwide, the number of overweight individuals has more than doubled since 1980: 1.5 billion adults were estimated to be overweight in 2008. Of these, 200 million men and 300 million women were classified as obese.8 In Scotland there is a high prevalence of overweight and obese individuals. In 2010, 65% of adults were overweight or obese (BMI ≥25kg/m2), whilst 28% of adults were obese (BMI ≥ 30kg/m2).9 These figures place it third behind the USA and Mexico in rankings of obesity in OECD countries. By 2030 the proportion of obese individuals in Scotland could rise above 40%.10 Being overweight or obese increases both morbidity and mortality.5 There are increased risks of developing type 2 diabetes, high blood lipids, and hypertension. Together these diseases increase the risk of IHD, including myocardial infarction (heart attack), and of stroke (see chapter 4, cardiovascular diseases). There is also an increased rate of respiratory problems such as obstructive sleep apnoea and asthma. Certain cancers are also more common: colorectal, prostate, endometrial, ovarian and breast. There is also an increased risk of blood clots as well as the musculo-skeletal problems of osteoarthritis and chronic low back pain. Through increasing the risk of these diseases, studies have shown that a BMI of 30-35kg/m2 leads to a decrease in median survival by 2-4 years. For a BMI of 40-45kg/m2, the reduction is 8-10 years.11 This is comparable to the decrease in life expectancy associated with smoking.4 A number of studies in recent years have found conflicting results, with some, including the recent study following up SHeS participants, finding the lowest all-cause mortality among overweight individuals,7 while others have found the optimum BMI to be within the generally acknowledged normal range.12 Some of the difference is due to a cohort effect, with greater effects of obesity in younger cohorts.13 In general, increased cardiovascular mortality has been associated consistently with raised BMI but respiratory and cancer mortality are often greatest in those who are not overweight or obese: where the majority of the population are overweight or obese, those who lose weight due to existing malignant or other disease may become of normal weight, if those dying within a couple of years are not excluded from the study. NHS Scotland estimates that direct health care costs to treat obesity for the year 2007-2008 were around £175 million. If overweight individuals are also included, the total cost is estimated at around £312 million.10 There are also three indirect costs to society: lost productivity as a result of premature death; lost productivity through time away from work; and increased infrastructure costs. The combined value of indirect and direct costs gives an estimated total cost to Scotland in 2007-2008 of £0.6-£1.4 billion. Using the future estimates for the prevalence of obesity, by the 2030 the total cost could be £3 billion per year.10

54

Obesity is a concern in the older population.14,15 In Scotland, both waist circumferences and waist to hip ratios increased between 1995 and 2009 for those aged 65 years and above.16 However, there is debate about whether all the implications of a raised BMI in older people are necessarily negative.17,18,19 Whilst obesity is linked to increased levels of IHD, type 2 diabetes and osteoarthritis, a BMI above the target range (≥ 25 kg/m2) is associated with decreased rates of osteoporosis and hip fractures, especially if the weight was gained after the age of 65. Furthermore, it has been shown that such BMIs are associated with decreased mortality in the elderly.13,20 The Scottish Government published a route map in February 2010 to help tackle obesity.10 The report detailed cross-portfolio investment to fund numerous initiatives. Together these aimed to decrease levels of sedentary behaviour and calorie intake at the same time as increasing levels of physical activity. It was emphasised that the burden of responsibility lay not only with individuals but also with wider society, and a range of initiatives from advice for employers to changes in the built environment were suggested. Specific SIGN guidance has also been produced to meet these aims. Guideline 115 provides evidence based recommendations on tackling obesity within the clinical setting both in the form of primary and secondary prevention.21 Key recommendations include restricting the intake of energy dense foods and alcohol, eating 600 kcal less than are required each day, and exercising a sufficient amount to burn around 2,000 kcal per week.

3.2 RESULTS

3.2.1 Response to anthropometric measurements by age and sex Table 3.1 presents the proportions of valid measurements obtained by age and sex. Response to height and weight – and therefore the proportion with valid BMI measurements – was lowest among older women. Consequently, there was a larger gap between the proportion of valid BMI measurements for younger and older women (86% versus 76%) than was the case for men (87% versus 81%). Rates of refusal to these measurements were broadly similar across all age groups (data not shown). The declining level of participation was largely accounted for by an increase in the proportion of people for whom height or weight measurements were not attempted, for example due to difficulties in standing. Non-response to the measurements would bias the estimates for the oldest age groups if there was a correlation between someone’s weight and their ability to stand (for example, if overweight older people were less likely to be measured the BMI figures will underestimate the true population value, and if underweight or normal weight older people were less likely to be measured the figures will overestimate BMI). The nature of the bias is unknown, however the BMI results presented below should be interpreted with this potential for bias in mind.

55

In contrast, response to the waist/hip measurement was similar across all age groups among men, and was a little lower among older women. This will be caused by higher rates of refusal to the nurse visit among older people, particularly those who did not participate in the interview measurements. Note that the sample size for the waist/hip measurement (taken in the nurse visit) is much smaller than for height and weight. The results for waist/hip in Table 3.3 therefore use larger age groups. Table 3.1

3.2.2 Prevalence of overweight and obesity by age and sex Mean BMI varied with age but not by sex. For those aged 16-64, mean BMI was 27.3 kg/m2 compared with 28.1 kg/m2 for adults 65 and over. Mean BMI decreased with age over 65, from 28.6 kg/m2 in those aged 65-69 to 26.6 kg/m2 in those aged 85 and over. There were significantly more men than women at every age who were overweight or obese (BMI of 25 kg/m2 and over), for example 77% of men versus 71% of women aged 65 and over, and 66% of men and 59% of women aged 16-64. Prevalence of obesity (BMI of 30 kg/m2 and over) was similar between men and women aged 16-64 and aged 65 and over. It was higher among older adults (31%) than younger adults (27%) but decreased with age among older people, particularly among men aged 80 and over (19% of men aged 80-84, 14% of men aged 85 and over), in whom prevalence was much lower than in women of those ages (26% and 22% respectively). Table 3.2, Figure 3A, Figure 3B

56

0

20

40

60

80

100

16-64 65-69 70-74 75-79 80-84 85+Age

Perc

ent

Figure 3A Prevalence of overweight and obese by age, men (2008/2009/2010 combined data)

Overweight (BMI 25 to <30)

Obese (BMI 30 or more)

0

20

40

60

80

100

16-64 65-69 70-74 75-79 80-84 85+

Age

Perc

ent

Figure 3BPrevalence of overweight and obese by age, women (2008/2009/2010 combined data)

3.2.3 Prevalence of raised waist-hip ratio (WHR) and waist circumference (WC) The prevalence of a raised waist-hip ratio (WHR) was markedly higher in older adults (64% in men and 62% in women) than in those aged 16-64 (30% in men, 36% in women). The percentage of adults with raised waist circumference (WC) was also higher in older adults for both sexes, especially men, where it affected 52% of those aged 65 and over and 29% of those aged 16-64 years (56% and 43% respectively among women). However, neither the prevalence of a raised WHR, nor of a raised WC, varied by age among older adults. Table 3.3

57

3.2.4 Health risk category with overweight, obesity and waist circumference Table 3.4 uses the combined categories of BMI and waist circumference recommended by the WHO and set out in SIGN 11521 to assess obesity-related health risks. Of those aged 65 and over, 18% had an increased risk of disease, 24% had a high risk, 27% had a very high risk and 2% had an extremely high risk. Just over one in four older adults were not at increased risk (28% of men and 27% women), compared with one in two men and four in ten women aged 16-64. Figure 3C shows the proportion of adults aged 16-64 and aged 65 and over in the different categories of raised risk (the very and extremely high groups have been combined for clarity). Those aged 65 and over were more likely than younger adults to have a raised risk, particularly so for the high and very high risk categories. Table 3.4, Figure 3C

0

20

40

60

80

100

16-64 65+Age

Perc

ent

Very/extremely high risk

High risk

Increased risk

No increased risk

Figure 3CPrevalence of obesity-related health risk, by age group (2008/2009/2010 combined data)

58

References and notes 1 Phillips F. Nutrition for Healthy Ageing. British Nutrition Foundation Nutrition Bulletin. 2003; 28:

253-263. 2 Zamboni Z, Mazzali G, Fantin F, Rossi A, Di Francesco V. Sarcopenic obesity: A new category of

obesity in the elderly. Nutr Metab Cardiovasc Dis. 2007; 18: 1-8. 3 BMI = weight in kilograms (kg) divided by height in metres squared (m2). 4 Grundy SM, Cleeman JL, Daniels SR. Diagnosis and management of the metabolic syndrome: an

American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. 2005; 112: 2735-2752.

5 Cook Z, Kirk S, Lawrenson S, Sandford S. Use of BMI in the assessment of undernutrition in older

subjects: reflecting on practice. Proc Nutr Soc. 2005; 64(3): 313-317. 6 Keenan, K, Grant, I and Ramsay, J. Scottish Health Survey: Topic Report – Obesity. Edinburgh,

Scottish Government, 2011. < http://www.scotland.gov.uk/Publications/2011/10/25091711/0> 7 Hotchkiss JW, Leyland AH. The relationship between body size and mortality in the linked Scottish

Health Surveys: cross-sectional surveys with follow-up. Int J Obes. 2011;35:838-51. 8 World Health Organisation. Fact Sheet No 311 Obesity and Overweight. Geneva, 2011.

<www.who.int/mediacentre/factsheets/fs311/en/index.html> 9 Gray, L and Leyland, A. Chapter 7: Adult and child obesity. In Bromley, C. and Given, L. [Eds].

Scottish Health Survey 2010 – Volume 1: Main Report. Edinburgh: The Scottish Government, 2011. <www.scotland.gov.uk/Publications/2011/09/27084018/0>

10 The Scottish Government. Preventing Overweight and Obesity in Scotland: A Route Map Towards

Healthy Weight. Edinburgh: The Scottish Government, 2010. <www.scotland.gov.uk/Resource/Doc/302783/0094795.pdf>

11 Whitlock G, Lewington S, Sherliker P. Body mass index and cause-specific mortality in 900,000

adults: collaborative analyses of 57 prospective studies. Lancet. 2009; 373: 1083-1096. <www.ncbi.nlm.nih.gov/pubmed/19299006>

12 Dudina A, Cooney MT, Bacquer DD, et al. Relationships between body mass index,

cardiovascular mortality, and risk factors: a report from the SCORE investigators. Eur J Cardiovasc Prev Rehabil. 2011;18:731-42.

13 Yu Y. Reexamining the Declining Effect of Age on Mortality Differentials Associated With Excess

Body Mass: Evidence of Cohort Distortions in the United States. Am J Public Health. 2011 Sep 22. [Epub ahead of print]

14 Salihu HM, Bonnema SM, Alio AP. Obesity: What is an elderly population growing into? Maturitas.

2009; 63(1): 7-12. <www.library.nhs.uk/booksandjournals/advanced/search.aspx?ItemSubCollection=bnj.ovi.prmz&ItemId=ovid.com:/bib/medline/19328637&Id=7>

15 Witham MD, Avenell A. Interventions to Achieve Long-term Weight Loss in Obese Older People: A

Systematic Review and Meta-analysis. Age and Ageing. 2010; 39: 176-184. <www.medscape.com/viewarticle/717157>

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http://www.ncbi.nlm.nih.gov/pubmed?term=%22Grundy%20SM%22%5BAuthor%5D�

http://www.ncbi.nlm.nih.gov/pubmed/16157765�

16 Gray, L. and Leyland, A. Chapter 7: Adult obesity. In Bromley, C., Given, L. and Ormston, R. [Eds]. Scottish Health Survey Main Report 2009. Edinburgh: The Scottish Government, 2010. <www.scotland.gov.uk/Resource/Doc/325403/0104975.pdf>

17 Bales CW, Buhr G. Is obesity bad for older persons? A systematic review of the pros and cons of

weight reduction in later life. J Am Med Dir Assoc. 2008; 9: 302-312. <www.ncbi.nlm.nih.gov/pubmed/18519110>

18 McTigue KM, Hess R, Ziouras J. Obesity in older adults: a systematic review of the evidence for

diagnosis and treatment. J Obesity. 2006; 14: 1485-1497. <www.library.nhs.uk/booksandjournals/advanced/search.aspx?ItemSubCollection=bnj.ovi.prmz&ItemId=ovid.com:/bib/medline/17030958&Id=4>

19 Bales CW, Buhr G. Body mass trajectory, energy balance, and weight loss as determinants of

health and mortality in older adults. Obesity Facts. 2009; 2: 171-178. <www.library.nhs.uk/booksandjournals/advanced/search.aspx?ItemSubCollection=bnj.ovi.prmz&ItemId=ovid.com:/bib/medline/20054222&Id=2>

20 Zunzunegui MV, Sanchez MT, Garcia A. Body Mass Index and Long-Term Mortality in an Elderly

Mediterranean Population. J Aging Health. 2011: epub ahead of print. <www.ncbi.nlm.nih.gov/pubmed/21628632>

21 Scottish Intercollegiate Guidelines Network. Management of Obesity. SIGN Guideline 115.

Edinburgh: SIGN, 2010. <www.sign.ac.uk/pdf/sign115.pdf>

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Table List Table 3.1 Adult response to anthropometric measurements (height, weight, BMI and

waist/hip), 2008, 2009 and 2010 combined, by age and sex Table 3.2 Adult body mass index (BMI), 2008, 2009 and 2010 combined, by age and

sex Table 3.3 Mean and raised waist-hip ratio (WHR) and waist circumference (WC), 2008,

2009 and 2010 combined, by age and sex Table 3.4 Health risk category associated with overweight and obesity based on BMI

and WC, 2008, 2009 and 2010 combined, by age and sex

61

Table 3.1 Adult response to anthropometric measurements (height, weight, BMI and

waist/hip), 2008, 2009 and 2010 combined, by age and sex


Age Proportion providing valid measurement

16-64 65-69 70-74 75-79 80-84 85+

Total 65+

% % % % % % % Men Height 89 88 87 81 70 71 83 Weight 88 87 87 82 71 73 83 BMI 87 86 86 80 67 70 81 Waist/hip 99 99 99 97 97 100 98 Women Height 89 85 84 77 73 55 78 Weight 86 84 83 78 74 61 78 BMI 86 83 82 74 71 54 76 Waist/hip 98 99 98 95 98 90 97 Bases (weighted): Men Height, weight, BMI (interviewed) 8323 584 504 379 236 117 1820 Waist/hip (saw nurse) 1294 93 76 54 38 22 283 Women Height (interviewed) 8645 669 594 536 356 261 2417 Weight, BMI (interviewed, not pregnant) 8420 669 594 536 356 261 2417 Waist/hip (saw nurse, not pregnant) 1324 103 94 82 44 53 376 Bases (unweighted): Men Height, weight, BMI (interviewed) 6774 794 665 510 315 173 2457 Waist/hip (saw nurse) 1047 130 109 71 48 27 385 Women Height (interviewed) 8980 861 776 635 420 303 2995 Weight, BMI (interviewed, not pregnant) 8767 861 776 635 420 303 2995 Waist/hip (saw nurse, not pregnant) 1395 141 122 89 48 53 453

62

Table 3.2 Adult body mass index (BMI), 2008, 2009 and 2010 combined, by age

and sex

Aged 16 and over with both valid height and weight measurements

2008, 2009 and 2010 combined

Age BMI (kg/m2)

16-64 65-69 70-74 75-79 80-84 85+

Total 65+

% % % % % % % Men Less than 18.5 2 - 1 1 1 1 1 18.5 to less than 25 32 21 20 22 27 34 22 25 to less than 30 40 44 46 47 53 51 47 30 to less than 40 25 33 32 29 19 14 29 40+ 1 2 2 1 0 - 1 All 25 and overa 66 79 79 77 72 65 77 All 30 and overb 26 35 33 30 19 14 30 Mean 27.3 28.7 28.5 28.1 27.2 26.3 28.2 Standard error of the mean 0.08 0.19 0.20 0.22 0.26 0.32 0.11 Women Less than 18.5 2 1 1 2 4 2 2 18.5 to less than 25 38 24 28 26 32 34 28 25 to less than 30 32 39 38 38 38 42 39 30 to less than 40 23 33 30 30 24 21 30 40+ 4 3 2 4 2 1 2 All 25 and overa 59 75 71 72 64 64 71 All 30 and overb 27 36 32 34 26 22 32 Mean 27.3 28.6 28.2 28.4 27.1 26.8 28.1 Standard error of the mean 0.08 0.21 0.22 0.27 0.31 0.43 0.12 All adults Less than 18.5 2 1 1 1 3 2 1 18.5 to less than 25 35 23 24 25 30 34 25 25 to less than 30 36 41 42 42 44 45 42 30 to less than 40 24 33 31 30 22 19 30 40+ 3 2 2 2 1 0 2 All 25 and overa 63 77 75 74 67 65 74 All 30 and overb 27 35 33 32 23 19 31 Mean 27.3 28.6 28.3 28.2 27.1 26.6 28.1 Standard error of the mean 0.06 0.14 0.16 0.19 0.22 0.29 0.09 Bases (weighted): Men 7325 504 434 303 159 83 1483 Women 7242 556 488 395 254 141 1835 All adults 14567 1060 922 699 413 223 3318 Bases (unweighted): Men 5949 688 569 405 215 119 1996 Women 7524 717 634 464 295 161 2271 All adults 13473 1405 1203 869 510 280 4267 a 25 and over = overweight (including obese). b 30 and over = obese.

63

Table 3.3 Mean and raised waist-hip-ratioa (WHR), mean and raised waist

circumferenceb (WC), 2008, 2009 and 2010 combined, by age and sex

Aged 16 and over with both valid waist and hip measurements 2008, 2009 and 2010 combined

Age WHR and WC

16-64 65-69 70-74 75-79 80+

Total 65+

% % % % % % Men Mean WHR 0.91 0.96 0.98 0.96 0.96 0.97 SE of the mean 0.003 0.006 0.006 0.006 0.008 0.003 Mean WC 95.2 101.8 103.2 102.6 101.4 102.2 SE of the mean 0.55 1.05 1.07 1.21 1.26 0.58 % with WHR ≥0.95 30 63 66 66 59 64 % with WC >102 cm 29 50 52 55 52 52 Women Mean WHR 0.83 0.87 0.87 0.86 0.88 0.87 SE of the mean 0.002 0.007 0.006 0.008 0.007 0.003 Mean WC 87.5 93.9 91.4 92.5 88.8 91.7 SE of the mean 0.46 1.34 1.16 1.50 1.08 0.65 % with WHR ≥0.85 36 64 62 52 69 62 % with WC >88 cm 43 63 58 59 45 56 All adults Mean WHR 0.87 0.91 0.92 0.90 0.91 0.91 SE of the mean 0.002 0.005 0.006 0.006 0.006 0.003 Mean WC 91.3 97.6 96.8 96.5 93.7 96.2 SE of the mean 0.38 0.89 0.89 1.09 0.96 0.48 Bases (weighted): Men 1282 92 75 52 59 278 Women 1297 102 92 78 91 363 All adults 2579 194 167 131 150 642 Bases (unweighted): Men 1036 129 108 69 74 380 Women 1366 140 120 84 95 439 All adults 2402 269 228 153 169 819 a A raised WHR is 0.95 or more in men and 0.85 or more in women. b A raised WC is more than 102 cm for men and more than 88 cm for women.

64

Table 3.4 Health risk category associated with overweight and obesity based on BMI

and WC, 2008, 2009 and 2010 combined, by age and sex

Aged 16 and over with valid height, weight and WC measurementsa

2008, 2009 and 2010 combined

Age BMIb and waist circumference classificationc

Health risk categoryd

16-64 65-69 70-74 75-79 80+

Total 65+

% % % % % % Men Underweight Low waist circumference Not applicable 1 - 1 - - 0 High waist circumference Not applicable - - - - - - Very high waist circumference Not applicable - - - - - - All underweight 1 - 1 - - 0

Normal Low waist circumference No increased risk 29 14 14 14 19 15 High waist circumference No increased risk 2 2 6 6 4 4 Very high waist circumference Increased risk - 1 - - - 0 All normal 31 17 20 20 23 20 Overweight Low waist circumference No increased risk 18 13 5 8 7 9 High waist circumference Increased risk 17 18 25 16 207 20 Very high waist circumference High risk 7 18 20 24 27 22 All overweight 42 49 50 48 54 50 Obesity I Low waist circumference Increased risk 1 - - - - High waist circumference High risk 3 5 0 2 1 2 Very high waist circumference Very high risk 16 21 21 25 18 21 All obese I 20 26 21 27 19 24 Obesity II Low waist circumference Very high risk - - - - - - High waist circumference Very high risk - - - - - - Very high waist circumference Very high risk 4 7 7 3 4 6 All obese II Very high risk 4 7 7 3 4 6 Obesity III Low waist circumference Extremely high risk - - - - - - High waist circumference Extremely high risk - - - - - - Very high waist circumference Extremely high risk 1 1 1 1 - 1 All obese III Extremely high risk 1 1 1 1 - 1 Men – Overall riskd Not applicable 1 - 1 - - 0 No increased risk 49 29 2 27 30 28 Increased risk 17 20 25 16 20 21 High risk 11 22 21 26 28 24 Very high risk 20 28 28 29 22 27 Extremely high risk 1 1 1 1 - 1

Continued…

65



2008, 2009 and 2010 combined



16-64 65-69 70-74 75-79 80+

Total 65+

% % % % % % Women Underweight Low waist circumference Not applicable 2 1 2 - 2 1 High waist circumference Not applicable - - - - - - Very high waist circumference Not applicable - - - - - - All underweight 2 1 2 - 2 1 Normal Low waist circumference No increased risk 26 8 11 17 9 11 High waist circumference No increased risk 9 10 13 12 24 14 Very high waist circumference Increased risk 2 2 2 2 0 2 All normal 37 20 26 31 34 27 Overweight Low waist circumference No increased risk 5 3 1 1 - 1 High waist circumference Increased risk 13 14 15 15 15 15 Very high waist circumference High risk 15 20 23.5 21 26 22 All overweight 34 37 39 37 41 38 Obesity I Low waist circumference Increased risk 0 - - - - - High waist circumference High risk 1 1 2 1 5 2 Very high waist circumference Very high risk 14 28 25 22 16 23 All obese I 16 29 27 23 21 25 Obesity II Low waist circumference Very high risk 0 - - - - - High waist circumference Very high risk - - - - - - Very high waist circumference Very high risk 8 6 4 4 2 4 All obese II Very high risk 0 6 4 4 2 4 Obesity III Low waist circumference Extremely high risk - - - - - - High waist circumference Extremely high risk - - - - - - Very high waist circumference Extremely high risk 3 7 2 5 - 4 All obese III Extremely high risk 3 7 2 5 - 4 Women - Overall riskd Not applicable 2 1 2 - 2 1 No increased risk 41 21 25 31 33 27 Increased risk 15 16 17 17 16 16 High risk 17 21 25 22 30 24 Very high risk 22 34 29 26 19 28 Extremely high risk 3 7 2 5 - 4

Continued…

66



2008, 2009 and 2010 combined



16-64 65-69 70-74 75-79 80+

Total 65+

% % % % % % All adults Underweight Low waist circumference Not applicable 2 0 1 - 1 1 High waist circumference Not applicable - - - - - - Very high waist circumference Not applicable - - - - - - All underweight 2 0 1 - 1 1 Normal Low waist circumference No increased risk 28 11 12 16 14 13 High waist circumference No increased risk 6 6 10 10 15 10 Very high waist circumference Increased risk 1 2 1 1 1 1 All normal 34 19 23 26 29 24 Overweight Low waist circumference No increased risk 12 8 3 4 3 5 High waist circumference Increased risk 15 16 20 16 17 17 Very high waist circumference High risk 11 19 22 23 26 22 All overweight 38 43 44 42 46 44 Obesity I Low waist circumference Increased risk 0 - - - - - High waist circumference High risk 2 3 1 1 3 2 Very high waist circumference Very high risk 15 25 23 23 17 22 All obese I 18 28 24 25 20 25 Obesity II Low waist circumference Very high risk 0 - - - - - High waist circumference Very high risk - 6 5 4 3 5 Very high waist circumference Very high risk 6 All obese II Very high risk 6 6 5 4 3 5 Obesity III Low waist circumference Extremely high risk - - - - - - High waist circumference Extremely high risk - - - - - - Very high waist circumference Extremely high risk 2 4 2 3 - 2 All obese III Extremely high risk 2 4 2 3 - 2 All adults - Overall riskd Not applicable 2 0 1 - 1 1 No increased risk 45 25 25 29 32 27 Increased risk 16 18 21 17 17 18 High risk 14 22 23 24 29 24 Very high risk 21 31 29 27 20 27 Extremely high risk 2 4 2 3 - 2

Continued…

67



2008, 2009 and 2010 combined



16-64 65-69 70-74 75-79 80+

Total 65+

% % % % % % Bases (weighted): Men 1209 83 67 49 50 249 Women 1212 92 84 64 67 306 All adults 2421 174 151 113 117 555 Bases (unweighted): Men 972 118 97 65 63 343 Women 1272 127 110 70 72 379 All adults 2244 245 207 135 135 722 a Percentages and bases in this table are based on those who have a valid measurement for waist

circumference, in addition to valid measurements of height and weight. Therefore subtotals for BMI categories by age and sex in this table are not definitive and may vary from estimates shown in Table 3.1.

b BMI categories according to WHO guidelines: Underweight: Less than 18.5kg/m2, Normal: 18.5 to less than 25kg/m2’, Overweight: 25 to less than 30kg/m2, Obesity I: 30 to less than 35kg/m2, Obesity II: 35 to less than 40kg/m2, Obesity III: 40kg/m2 or more.

c Waist circumference categories according to WHO/SIGN guidelines (115): for men, less than 94cm is low, 94–102cm is high, and more than 102cm is very high. For women, less than 80cm is low, 80–88cm is high, and more than 88cm is very high.

d Health risk category according to WHO/SIGN guidelines (115).

68

io scu Dis s Di s n nsion Chapter

4 CARDIOVASCULAR DISEASE, DIABETES AND HYPERTENSION

Marilyn Roth, Henry Jones, Jennifer Mindell

SUMMARY • 41% of men and 31% of women aged 65 years and over reported having any

type of cardiovascular disease (CVD), compared with 10% of men and women aged 16-64. Rates of CVD generally increased with age and peaked in men aged 80-84 (52%) and women aged 85 and over (45%).

• IHD or stroke prevalence followed a similar pattern to that for any CVD condition (it was higher in men than women and increased with age).

• Logistic regression was used to identify the factors independently associated with people aged 65 and over having any CVD condition. For both men and women, the odds increased with age (and were highest among those aged 75 years and older), and were higher among current and ex-smokers, people with low activity levels and diabetes. Among women, the odds of CVD increased as deprivation increased, while among men the odds were lower for those who consumed more than the weekly recommended alcohol limit.

• Prevalence of diabetes was higher in people aged 65 years and over (11%) than in those aged 16-64 (4%), but did not differ significantly by age amongst the older age groups. Diabetes was more common in men (14%) than women (10%) aged 65 years and older.

• Almost half of men (48%) and over a third of women (37%) aged 65 and over reported having any CVD or diabetes. This generally increased with age in both sexes (due to the increasing prevalence of CVD conditions), from 39% in men aged 65-69 to a peak of 59% in those aged 80-84 years and from 31% in women aged 65-69 to a peak of 47% in those aged 85 years and over.

• The prevalence of probable undiagnosed diabetes (as measured by glycated haemoglobin in blood samples) was higher in older adults (6%) than in adults aged 16-64 (2%) but did not vary significantly by age among the older age groups.

• The prevalence of survey-defined high blood pressure (hypertension) was significantly higher in older adults (69%) than in those aged 16-64 (24%), and was similar in both sexes from the age of 65. The majority of younger adults with hypertension were not having any treatment, whereas older adults with hypertension were equally likely to have untreated, treated and not controlled, or controlled hypertension.

4.1 INTRODUCTION Cardiovascular disease (CVD) is one of the leading contributors to the global burden of disease.1,2,3

The term encompasses various disorders affecting the heart and blood vessels, principally ischaemic heart disease (IHD) and stroke. IHD is also known as coronary heart disease (CHD). Both terms include angina and myocardial infarction (“heart attack”). This chapter details the prevalence of CVD and associated risk factors, including diabetes, in the older population (65 years and over), and draws comparisons with the younger adult population (16-64 years).

69

The majority of cardiovascular diseases involve the blockage of blood vessels by atherosclerotic plaques. There are various risk factors for this,3 including diabetes, hypertension (high blood pressure), smoking, insufficient physical activity, and high cholesterol4 (see chapter 2 for further information about smoking and activity). Diabetes involves unregulated blood sugar levels due to the decreased effect of insulin, either through not enough being produced or the body becoming resistant to it. Socio-economic status has a bearing on CVD, with disease rates being higher in lower social classes and deprived areas.4,5

Scotland has the second highest mortality rate from CVD in Western Europe,5,6 with 15% of deaths in 2010 being due to IHD and 9% to stroke.7

7

Ischaemic heart disease (IHD) is the biggest killer worldwide. In Scotland it represents the second largest cause of death after cancer, killing almost 9,000 people in 2010. The premature death rate from IHD (defined as deaths under 75 years) in Scotland is almost two-thirds higher (63%) than in South West England for men and is double (100%) in women.8 In 2010, 16% of men and 14% of women in Scotland aged 16 and over were living with CVD.9

The Scottish Coronary Heart Disease and Stroke Task Force (2002) set out to achieve a 60% decrease in premature CHD mortality between 1995 and 2010.5 Since its publication, service planning has improved, waiting times have decreased, and SIGN guidelines10,11 have set out specific advice for clinicians, including a calculator for risk stratification.12

Outpatient workloads in cardiology and cardiothoracic surgery have increased substantially, and the number of coronary angioplasties and prescriptions for CVD have risen sharply.5

Such initiatives have been effective and mortality rates for CVD are falling. The age-standardised mortality rate (for the under 75 age group) was around 125 per 100,000 in 1995 and around 49 per 100,000 in 2010, a fall of just under 61%.13 Despite these measures, however, recent data suggests that the rate of decrease in mortality rates is slowing.14

This is thought to be due to the increased incidence of several cardiovascular risk factors, particularly obesity and diabetes. From 2003 to 2006 there was also an increase in CVD mortality in the two most deprived quintiles (fifths) of the population, hence the need for further action, as outlined in the 2009 report Better Heart Disease and Stroke Care Action Plan.11

The odds of having cardiovascular disease also increase substantially with age: age has been called ‘the biggest risk factor’ for CVD.4,5 There is a correspondingly higher CVD mortality in older people. The age-sex standardised mortality rate for 0-44 years is around 4 per 100,000; for those aged over 75 years it is just over 1,350 per 100,000.13

There is also evidence of unmet need among older people. Glycated haemoglobin (HbA1C) is a measure of long term blood sugar levels and thus of diabetic control in people with diabetes. A level of ≥ 6.5% is now also considered diagnostic of diabetes.15

An increase in HbA1c levels in older people indicates that there is an increasing prevalence of undiagnosed or poorly controlled diabetes in this age group.4 Cardiovascular disease, and its associated risk factors, are thus a pressing concern in older people.

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4.2 RESULTS

4.2.1 Cardiovascular disease Ever having had any CVD, IHD, and IHD or stroke varied by age and sex. The proportion reporting CVD, IHD, and IHD or stroke each increased with age and was higher in men compared with women, with the exception of the oldest age group where prevalence fell in men and continued to rise in women, exceeding that in men. Prevalence of any CVD peaked at 52% for men aged 80-84 years and 45% for women aged 85 years and older. Overall, 41% of men and 31% of women aged 65 years and older reported having any CVD condition, compared with 10% of men and women aged 16-64. Figure 4A shows that IHD or stroke followed a similar pattern to that for any CVD condition with prevalence increasing with age, and peaking among men aged 80-84 (44%) and among women aged 85 and over (35%). Table 4.1 reports the prevalence of six different CVD conditions. Men aged 65 and over were more likely than women of this age to report having experienced angina, heart attack, abnormal heart rhythm, other heart trouble and stroke. Angina, heart attack, other heart trouble, and stroke all generally increased with age. Reporting a heart murmur did not vary by age. Prevalence of each of these CVD conditions was higher in older people (aged 65 years and above) than in younger people (aged 16-64 years). Table 4.1, Figure 4A

Figure 4APrevalence of IHD or stroke, by age and sex (2008/2009/2010 combined data)

0

5

10

15

20

25

30

35

40

45

16-64 65-69 70-74 75-79 80-84 85+

Age group

Perc

ent

Men

Women

4.2.2 Diabetes Prevalence of doctor-diagnosed diabetes was higher in people aged 65 years and older (11% of adults) than in people aged 16-64 (4%), but did not differ significantly by age amongst the older age groups (Figures 4B and 4C). Diabetes was more common in men (14%) than women (10%) aged 65 years and older.

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Almost half of men (48%) and over a third of women (37%) aged 65 and over reported having any CVD or diabetes. This generally increased with age in both sexes (due to the increasing prevalence of CVD conditions), and was substantially higher in older people compared with younger people. Reporting any CVD or diabetes increased from 39% in men aged 65-69 to a peak of 59% in those aged 80-84 years and from 31% in women aged 65-69 to a peak of 47% in those aged 85 years and older. Table 4.2, Figure 4B, Figure 4C

The sample size was too small to analyse HbA1C levels in adults with diagnosed diabetes. Among adults who did not report doctor-diagnosed diabetes, the proportion with HbA1C levels of 6.5% or above indicates undiagnosed diabetes. Table 4.3 shows the proportions with survey-determined probable undiagnosed diabetes based on HbA1C levels. These figures are also included in 4B and 4C to illustrate the total level of diabetes in the population. Undiagnosed diabetes was higher in older adults (6%) than in adults aged 16-64 (2%) but did not vary significantly by age among the older age groups. The prevalence of undiagnosed diabetes was higher in men (2%) than in women (1%) aged 16-64 but among older people, more women (7%) than men (5%) had undiagnosed diabetes. Table 4.3

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0

4

8

12

16

20

24

16-64 65-69 70-74 75+

Age group

Perc

ent

Undiagnosed

Diagnosed

Figure 4BPrevalence of diagnosed and undiagnosed diabetes, men(2008/2009/2010 combined data)

0

4

8

12

16

20

24

16-64 65-69 70-74 75+

Age group

Perc

ent

Undiagnosed

Diagnosed

Figure 4CPrevalence of diagnosed and undiagnosed diabetes, women(2008/2009/2010 combined data)

Table 4A shows the proportion of older and younger men and women whose diabetes was diagnosed and those with undiagnosed diabetes (based on their HbA1C levels). It also shows what proportion of all diabetes in each age group is undiagnosed. Undiagnosed diabetes comprised one-quarter to one-third of total diabetes in men in both age groups, however for women the contribution of undiagnosed diabetes was twice as high in those aged 65 and over (two-fifths) than in those aged 16-64 (one-fifth). This is considered further in Chapter 6. Table 4.3, Figures 4B, 4C

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Table 4A Prevalence of diagnosed and undiagnosed diabetes Men Women

16-64 65+ 16-64 65+ % % % % Doctor-diagnosed diabetesa

4.2 13.9 4.2 13.9

Raised HbA1C but no diagnosed diabetes (i.e. undiagnosed diabetes)b

2.3 5.1 2.3 5.1

All diabetes 6.5 19.0 6.5 19.0

Undiagnosed diabetes as a % of all diabetes

35 27 19 41

a Among those interviewed b Among those providing a blood sample at the nurse visit

4.2.3 Hypertension The prevalence of survey-defined hypertension increased substantially with age, from 24% of adults aged 16-64 to 69% of older adults, and was similar in both sexes from the age of 65. Of the younger adults with hypertension, a much smaller proportion were treated, whereas older adults were equally likely to be untreated, treated and not controlled, or have controlled hypertension. Differences between the age groups among those 65 and over were not significant. Table 4.4

4.2.4 Factors associated with having cardiovascular disease Logistic regression was used to estimate the independent effect of a range of factors associated with any CVD conditions among adults aged 65 years and over. The analysis indicates the contribution of each factor once the other variables have been taken into account.16 For both men and women, the risk of having any cardiovascular disease increased with age, and was highest among those aged 75 years and older (odds ratio (OR) 1.6 for men and 1.4 for women). There was a clear gradient for an increased risk of CVD from least deprived area (OR 1.0) to most deprived (1.7) in women, but no significant association among men. A number of lifestyle factors were also associated with an increased risk of CVD. For both men and women, those who were current smokers (1.3 for men, 1.2 for women) or ex-regular smokers (1.5 for men, 1.4 for women) had higher odds of having CVD than those who had never smoked. Men who consumed more than the weekly limit of alcohol had decreased odds of having CVD (0.7), but this association was not significant among women. The odds of CVD were also higher for men (1.7) and women (1.9) who reported a low level of physical activity. Finally, reporting diabetes was also associated with CVD for both men (1.4) and women (1.8). Findings similar to these have been reported in the 2003 and 2009 SHeS reports at all ages and may reflect lifestyle changes, such as giving up smoking and decreasing alcohol consumption, that occur after a CVD event. Table 4.5

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1 Bromley C, Sproston K, Shelton N (eds). Scottish Health Survey 2003 Volume I: Cardiovascular Disease. Edinburgh: Scottish Government, 2005. <www.scotland.gov.uk/Publications/2005/12/02160336/03427>

2 Yusuf S, Reddy S, Ôunpuu S, et al. Global Burden of Cardiovascular Diseases: Part I: General

Considerations, Epidemiologic Transition, Risk Factors, and Impact of Urbanization. Circulation. 2001; 104: 2746-2753. <www.circ.ahajournals.org/cgi/reprint/104/22/2746.pdf>

3 World Health Organisation. Factsheet No 317 Cardiovascular Diseases. Geneva: WHO, 2011.

<www.who.int/mediacentre/factsheets/fs317/en/index.html> 4 WHO (2009) Global Health Risks - Mortality and burden of disease attributable to selected major

risks. Geneva: World Health Organisation. <www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf>

5 Coronary Heart Disease/Stroke Task Force. Report. Edinburgh: Scottish Government, 2002.

<www.sehd.scot.nhs.uk/publications/cdtf/cdtf.pdf> 6 Leon D, Morton S, Cannegieter S, et al. Understanding the Health of Scotland’s Population in an

International Context; A review of current approaches, knowledge and recommendations for new research directions. London: London School of Hygiene and Tropical Medicine, 2003. <www.healthscotland.com/uploads/documents/UnderstandingHealthofScotlandP1.pdf>

7 Scotland’s Population 2010 – The Registrar General’s Annual Review of Demographic Trends

156th edition, Edinburgh: Scottish Government, 2011. Available from: <http://www.gro-scotland.gov.uk/statistics/at-a-glance/annrev/2010/index.html>

8 Coronary Heart Disease Statistics British Heart Foundation London, 2010. <www.bhf.org.uk/heart-

health/statistics/mortality.aspx> 9 MacGregor A, and Mindell J. Chapter 9: Cardiovascular disease diagnoses and symptoms. In

Bromley C and Given L. (eds). Scottish Health Survey 2010 Volume I: Main Report. Edinburgh: Scottish Government, 2011. <www.scotland.gov.uk/Publications/2011/09/27084018/0>

10 Scottish Intercollegiate Guidelines Network. Risk Estimation and Prevention of Cardiovascular

Disease. SIGN Guideline 97. Edinburgh: SIGN, 2007. <www.sign.ac.uk/pdf/sign97.pdf> 11 Scottish Intercollegiate Guidelines Network. Management of Diabetes. SIGN Guideline 116.

Edinburgh: SIGN, 2010. <www.sign.ac.uk/pdf/sign116.pdf> 12 Scottish Government. Better Heart Disease and Stroke Care Action Plan. Edinburgh: Scottish

Government, 2009. <www.scotland.gov.uk/Resource/Doc/277650/0083350.pdf> 13 Information Services Division. Heart Disease Statistics Update. Scotland: A National Statistics

Publication for Scotland NHS, 2011. <http://www.isdscotland.org/Health-Topics/Heart-Disease/> 14 Health in Scotland 2007 - Annual Report of the Chief Medical Officer. Edinburgh: Scottish

Government, 2008. 15 International Expert Committee. International Expert Committee Report on the role of the A1c

assay in the diagnosis of diabetes. Diabetes Care. 2009; 32: 1327 16 Socio-demographic factors (age, SIMD quintile, equivalised household income), lifestyle factors

(cigarette smoking status, drinking in excess of recommended weekly limits, physical activity, fruit and vegetable consumption), and biological factors (BMI and diabetes) were investigated. Data for blood results and hypertension had too much missing data to be included in the analysis. The regression was stratified by sex using combined data for 2008, 2009, and 2010. The factors found

75

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to be significant are discussed in the chapter. The final model included age, SIMD quintile, cigarette smoking status, weekly alcohol consumption, physical activity level, and diabetes.

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Table List Table 4.1 Prevalence of CVD conditions (ever), including any CVD, IHD, and IHD or

stroke, 2008, 2009 and 2010 combined, by age and sex Table 4.2 Prevalence of doctor-diagnosed diabetes and of any CVD or diabetes, 2008,

2009 and 2010 combined, by age and sex Table 4.3 Glycated haemoglobin level in people without doctor-diagnosed diabetes,

2008, 2009 and 2010 combined, by age and sex Table 4.4 Blood pressure level, 2008, 2009 and 2010 combined, by age and sex Table 4.5 Estimated odds ratios for any CVD, 2008, 2009 and 2010 combined, by

associated risk factors and sex

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Table 4.1 Prevalence of CVD conditions (ever), including any CVD, IHD,a and IHD

or stroke, 2008, 2009 and 2010 combined, by age and sex


CVD conditions

Age Total 65+

16-64 65-69 70-74 75-79 80-84 85+

% % % % % % % Men Angina 2 14 19 18 25 18 18 Heart Attack 2 10 16 16 21 15 15 Heart murmur 3 4 6 5 6 7 5 Abnormal heart rhythm 4 11 13 15 14 11 13 ‘Other’ heart trouble 2 5 6 10 11 8 7 Stroke 1 6 9 14 12 12 10 Any CVD 10 33 41 47 52 44 41 IHD 3 19 26 25 36 25 25 IHD or stroke 4 24 31 35 44 32 32 Women Angina 2 12 14 15 14 23 15 Heart Attack 1 5 5 8 10 12 7 Heart murmur 3 7 5 7 5 8 6 Abnormal heart rhythm 4 8 11 10 11 11 10 ‘Other’ heart trouble 1 4 6 5 5 5 5 Stroke 1 5 7 8 10 12 8 Any CVD 10 25 31 32 34 45 31 IHD 2 13 16 18 18 27 17 IHD or stroke 3 16 21 23 25 35 22 All adults Angina 2 13 16 16 18 21 16 Heart Attack 2 7 10 11 15 13 10 Heart murmur 3 5 6 6 5 8 6 Abnormal heart rhythm 4 9 12 12 12 11 11 ‘Other’ heart trouble 2 4 6 7 8 6 6 Stroke 1 5 8 11 11 12 9 Any CVD 10 29 36 38 41 44 36 IHD 3 16 20 21 25 26 20 IHD or stroke 4 20 25 28 33 34 26 Bases (weighted):b Men 8335 584 504 377 235 117 1817 Women 8656 669 595 536 355 263 2417 All adults 16991 1253 1099 913 590 380 4234 Bases (unweighted) b Men 6785 793 665 509 314 173 2454 Women 8988 862 776 635 418 305 2996 All adults 15773 1655 1441 1144 732 478 5450 a IHD: Ischaemic heart disease, reported as doctor-diagnosed heart attack or angina. b Bases vary: those shown are for any CVD.

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Table 4.2 Prevalence of doctor-diagnosed diabetesa and of any CVD or diabetes,



Doctor-diagnosed diabetes or any CVD conditions

Age Total 65+

16-64 65-69 70-74 75-79 80-84 85+

% % % % % % % Men Diabetes 4 13 15 16 13 11 14 Any CVD or diabetes 13 39 48 53 59 51 48 Women Diabetes 3 9 9 12 10 7 10 Any CVD or diabetes 12 31 35 38 40 47 37 All adults Diabetes 4 11 12 13 11 8 11 Any CVD or diabetes 12 35 41 45 48 48 41 Bases (weighted): Men 8337 584 504 379 236 118 1820 Women 8663 669 596 537 356 263 2421 All adults 16991 1253 1099 913 590 380 4234 Bases (unweighted): Men 6787 794 665 510 315 174 2458 Women 8995 862 778 636 420 305 3001 All adults 15773 1655 1441 1144 732 478 5450

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Table 4.3 Glycated haemoglobin level in people without doctor-diagnosed diabetes,


Aged 16 and over with a valid glycated haemoglobin measurement and no doctor diagnosis of diabetes

2008, 2009 and 2010 combined

Glycated haemoglobin ≥ 6.5%

Age Total 65+

16-64 65-69 70-74 75+

% % % % % Men % with glycated haemoglobin

6.5% or above 2 8 4 3 5

Mean 5.5 5.8 5.8 5.9 5.8 Standard error of the mean 0.02 0.05 0.05 0.04 0.03 Women % with glycated haemoglobin

6.5% or above 1 8 6 6 7

Mean 5.5 5.9 5.9 5.9 5.9 Standard error of the mean 0.01 0.06 0.04 0.05 0.03 All adults % with glycated haemoglobin

6.5% or above 2 8 5 5 6

Mean 5.5 5.8 5.8 5.9 5.9 Standard error of the mean 0.01 0.04 0.03 0.03 0.02 Bases (weighted): Men 936 65 44 72 181 Women 979 72 65 121 258 All adults 1915 137 109 193 439 Bases (unweighted): Men 784 92 63 93 248 Women 1012 96 85 117 298 All adults 1796 188 148 210 546

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Table 4.4 Blood pressure level, 2008, 2009 and 2010 combined, by age and sex

Aged 16 and over with a valid blood pressure reading and data on medication

2008, 2009 and 2010 combined

Blood pressure categorya Age Total 65+

16-64 65-69 70-74 75-79 80+

% % % % % % Men Normotensive 72 37 27 29 29 31 Hypertensive controlled 6 18 21 23 21 20 Hypertensive uncontrolled 3 20 23 16 30 22 Hypertensive untreated 19 26 29 32 20 27 Total with hypertension 28 63 73 71 71 69 Women Normotensive 79 38 29 31 24 31 Hypertensive controlled 5 17 22 23 14 19 Hypertensive uncontrolled 3 19 21 25 40 26 Hypertensive untreated 13 26 28 21 22 24 Total with hypertension 21 62 71 70 76 69 All adults Normotensive 76 38 28 30 26 31 Hypertensive controlled 5 17 22 23 17 20 Hypertensive uncontrolled 3 19 22 22 36 25 Hypertensive untreated 16 26 28 25 21 25 Total with hypertension 24 62 72 70 74 69 Bases (weighted): Men 1069 80 68 47 56 251 Women 1116 90 86 75 82 333 All adults 2185 170 153 123 138 584 Bases (unweighted): Men 874 112 97 63 70 342 Women 1188 124 113 82 86 405 All adults 2062 236 210 145 156 747 a Normotensive: Systolic blood pressure (SBP) <140mmHg and diastolic blood pressure (DBP)

<90mmHg and not taking medicine prescribed for high blood pressure; Hypertensive controlled: SBP <140mmHg and DBP <90mmHg and taking medicine prescribed for high blood pressure; Hypertensive uncontrolled: Systolic blood pressure (SBP) >140mmHg or DBP >90mmHg and taking medicine prescribed for high blood pressure; Hypertensive untreated: Systolic blood pressure (SBP) >140mmHg or DBP >90mmHg and not taking medicine prescribed for high blood pressure.

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Table 4.5 Estimated odds ratios for any CVD, 2008, 2009 and 2010 combined, by

associated risk factors and sex



Base (weighted)1

1817

Odds Ratio

95% Confidence

interval

Base (weighted)

2417

Odds Ratio

95% Confidence

interval Age (p<0.001) (p=0.009) 65-69 584 1 669 1 70-74 504 1.3 1.1, 1.7 595 1.3 1.0, 1.6 75+ 730 1.6 1.3, 2.0 1153 1.4 1.1, 1.8 Scottish Index of Multiple

deprivation (p=0.101) (p=0.004)

5th (least deprived) 390 1 476 1 4th 387 0.8 0.6, 1.1 517 1.2 0.9, 1.7 3rd 398 0.9 0.7, 1.2 506 1.3 1.0, 1.8 2nd 357 0.9 0.7, 1.2 479 1.5 1.1, 2.0 1st (most deprived) 285 1.2 0.9, 1.6 439 1.7 1.3, 2.3 Cigarette smoking status (p<0.001) (p=0.009) Never smoked cigarettes at alla 609 1 1172 1 Used to smoke cigarettes

occasionally 55 0.6 0.3, 1.0 132 1.4 1.0, 2.1


890 1.5 1.3, 1.9 767 1.4 1.1, 1.7

Current cigarette smoker 264 1.3 1.0, 1.7 346 1.2 1.0, 1.6 Weekly alcohol consumption (p=0.009) (p=0.345) 0 units up to weekly limit (21

units men / 14 units women)b 1432 1 2213 1


386 0.7 0.6, 0.9 204 0.9 0.6, 1.2

Physical activityc (p<0.001) (p<0.001) Meets recommendationsd 320 1 300 1 Some activity 467 1.0 0.7, 1.3 618 1.1 0.8, 1.5 Low activity 1029 1.7 1.3, 2.2 1498 1.9 1.4, 2.6 Diabetes (doctor-diagnosed) (p=0.004) (p<0.001) No 1568 1 2185 1 Yes 250 1.4 1.1, 1.9 232 1.8 1.4, 2.4 a This category includes 3 men and 9 women who did not answer the question. b This category includes 8 men and 14 women who did not answer the question c Meets recommendations= 30 or minutes on at least 5 days a week; Some activity= 30 minutes on 1 to

4 days a week; Low activity= fewer than 30 minutes of moderate or vigorous activity a week. d This category includes 6 men and 8 women who did not answer the question.

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n oci Chapter 5

5 HEALTH AND SOCIAL CARE Henry Jones, Faiza Tabassum, Jennifer Mindell

SUMMARY • Older men and women were equally likely to be carers (12% of those aged 65

and over). However, younger women were more likely to provide care than younger men (15% vs 9% aged 16-64). The proportion of men providing care varied little with age, though it declined sharply among women from 14% of those aged 65-79, to 5% of those aged 80-84 and 3% of those aged 85 and over. Care provision among those aged 65 and over did not vary significantly by area deprivation.

• Similar proportions of men and women aged 65 and over, and women aged 16-64, had seen a GP in the previous two weeks (20%-23%), compared with 13% of men aged 16-64. The proportions visiting a GP in the previous two weeks and the mean number of annual visits did not vary significantly by age among men or women aged 65 and over.

• 98% of older adults reported having their blood pressure measured at some point, and of those whose blood pressure had ever been measured, 82% had been measured in the previous year. Just 4% reported that their last measurement took place five or more years ago. Measurement rates were similar for older men and women. Younger women were more likely to have been measured than younger men (94% versus 84%).

• 89% of older adults were taking one or more prescribed medications. This did not vary by age or sex among older adults but was significantly lower in younger men (38%) and younger women (54%). Older people’s use of prescription medication did not vary significantly by area deprivation.

5.1 INTRODUCTION This chapter comprises two sections. The first considers the provision of informal care. The second analyses aspects of health-seeking behaviour.

5.1.1 Care Provision The most recent estimates suggest that 11%-12% of adults aged 16 and over in Scotland in the 2008-2010 period provided regular unpaid care to someone inside or outside their home.1

Caring can be time consuming, with around 20% of carers spending more than 50 hours a week on caring activities. If those being cared for – usually first degree relatives – live with the carer, then there is often a greater time commitment.

Most carers have been providing informal care for a significant length of time, with 70% of carers doing so for more than five years. The 2010 figures for Scotland show that women are more likely than men to be carers (14% versus 10%). Carers are also more likely to be from middle or older age groups. It is estimated that informal carers save the Scottish social care sector more than £7.5 billion per year.2

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Carers are twice as likely to suffer ill health as non-carers. Around 50% of carers need to see a GP because of the adverse impact(s) on their health.3,4

3 One in five carers give up work to provide care, thus many

also experience adverse financial consequences. ,5

Three-quarters of elderly carers in Scotland felt they had to cut back on spending, with around 40% feeling worse off since they became carers.5 Many carers also experience social isolation and poverty of experience.

In 2010 the Scottish Government published its carers strategy detailing support for carers, ranging from better information and advice to carer-friendly employment opportunities and the provision of short breaks.3 Overall the aim is to improve carers’ emotional and physical wellbeing, enhance their ability to undertake their caring role and help them retain a life outside caring.

5.1.2 Health-seeking behaviour In 2010, 18% of all adults aged 16 and over had consulted an NHS GP in the last two weeks.1 This figure has been very similar for the last 30 years.6

1 Women are more likely to visit a GP than men, making an

average of 7 visits per year, compared with 4 for men. Within both sexes the frequency of GP attendances increases with age: in 2010 15% of adults aged 16-24 had seen a GP in the previous two weeks, compared with 25% of those aged 75 and over.1

Blood pressure should be checked at least every five years in adults without known hypertension (as part of a check for cardiovascular risk factors) and at least annually in those on antihypertensive medication (see chapter 4).7 Except where severe, a single raised measurement is not sufficient to establish a diagnosis of hypertension.8

5.2 RESULTS

5.2.1 Provision of care Overall, older men and women were equally likely to be carers (12% aged 65 and over). However, younger women were more likely to provide care within or outside the home than younger men (15% vs 9% aged 16-64), while the oldest women were least likely to be carers (5% aged 80-84 and 3% aged 85 and over). The proportion of men providing care varied little with age (Figure 5A). Although provision of care was reported most commonly by older adults in the most deprived quintile of deprivation (13%), there was no significant variation by deprivation. Tables 5.1, 5.2, Figure 5A

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0

2

4

6

8

10

12

14

16

16-64 65-69 70-74 75-79 80-84 85+

Age group

Perc

ent

Men

Women

Figure 5AProvision of care to anyone inside or outside home by age and sex(2008/2009/2010 combined data)

5.2.2 Health-seeking behaviour Men aged 16-64 were the least likely group to have seen a GP in the previous two weeks. Similar proportions of men and women aged 65 and over, and women aged 16-64, had seen a GP in the previous two weeks (20%-23%) compared with 13% of men aged 16-64. The mean annual number of GP consultations was also substantially lower among men aged 16-64 (four) than among older men (six) or women of any age (seven). The proportions visiting a GP in the previous two weeks and the mean number of annual visits did not vary significantly by age among men or women aged 65 and over. Table 5.3 Almost all older adults (98%) reported having their blood pressure measured at some point. Of those whose blood pressure had ever been measured, 82% had been measured in the previous year and just 4% reported that their last measurement took place five or more years ago. Measurement rates were very similar for all age groups and in both sexes among those aged 65 and over. Women aged 16-64 were more likely than men of this age to have had their blood pressure measured (94% versus 84%). Table 5.4 The vast majority of older adults (89%) were taking one or more prescribed medications. This did not vary by age or sex among older adults but was significantly lower in younger men (38%) and, to a slightly lesser extent, younger women (54%). There was no association between taking prescribed medication and area deprivation among older men or women. Table 5.5 and Table 5.6

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References and notes 1 Scottish Health Survey 2010 Supplementary Web Tables. Edinburgh: The Scottish Government,

2011. </www.scotland.gov.uk/Topics/Statistics/Browse/Health/scottish-health-survey/Supplementary2010>

2 Buckner L, Yeandle S. Valuing Carers- Calculating the Value of Unpaid Carers. University of

Leeds: 2007. <www.sociology.leeds.ac.uk/assets/files/research/circle/valuing-carers.pdf> 3 Scottish Government. Caring Together- The Carers Strategy for Scotland 2010-2015. Edinburgh:

The Scottish Government, 2010. 4 Singleton N, Aye Muang N, Cowie A, et al. The Mental Health of Carers. London: HMSO, 2002.

<www.statistics.gov.uk/downloads/theme_health/Mental_Health_of_Carers_June02.pdf> 5 Carers UK. Caring and Pensioner Poverty, A Report on Older Carers, Employment and Benefits.

London: Carers UK, 2005. <www.carersuk.org/professionals/resources/research-library/item/499-caring-and-pensioner-poverty-a-report-on-older-carers-employment-and-benefits>

6 Dunstan S. General Lifestyle Survey Overview 2009. London: HMSO, 2011.

<www.statistics.gov.uk/downloads/theme_compendia/GLF09/GLFoverview2009.pdf> 7 Scottish Intercollegiate Guidelines Network. Risk estimation and the prevention of cardiovascular

disease. SIGN 97. Edinburgh: SIGN, 2007. <www.sign.ac.uk/pdf/sign97.pdf> 8 Until recently, three elevated readings, taken on separate occasions, have been deemed

necessary for a diagnosis of hypertension. New guidance in England published in August 2011 by NICE, the National Institute for Health and Clinical Excellence, jointly with the British Hypertension Society has recommended that a single raised blood pressure level measured in a clinic should be followed preferably by ambulatory blood pressure monitoring at least twice an hour with at least 14 measurements taken during waking hours, or where this is not an option, by home blood pressure monitoring at least twice a day for four to seven days. However, where blood pressure is severely raised (systolic of 180mmHg or above, or diastolic of 110mmHg or above), treatment may be indicated without waiting for further measurements. National Institute for Health and Clinical Excellence: Hypertension. CG127. London: NICE, 2011.

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Table List Table 5.1 Provision of care to anyone inside or outside home, 2008, 2009 and 2010

combined, by age and sex Table 5.2 Provision of care to anyone inside or outside home, 2008, 2009 and 2010

combined, by Scottish Index of Multiple Deprivation quintile and sex Table 5.3 GP consultations in last 2 weeks and estimated mean number of consultations

per year, 2008, 2009 and 2010 combined, by age and sex Table 5.4 Blood pressure measurements, 2008 and 2010 combined, by age and sex Table 5.5 Prevalence of currently taking prescribed medication, 2008, 2009 and 2010

combined, by age and sex Table 5.6 Prevalence of currently taking prescribed medication, 2008, 2009 and 2010

combined, by Scottish Index of Multiple Deprivation quintile and sex

87

Table 5.1 Provision of care to anyone inside or outside home, 2008, 2009 and



Regular carer Age Total 65+

16-64 65-69 70-74 75-79 80-84 85+

% % % % % % % Men Provides regular care 9 11 12 13 9 10 12 Does not provide regular care 91 89 88 87 91 90 88 Women Provides regular care 15 14 14 14 5 3 12 Does not provide regular care 85 86 86 86 95 97 88 All adults Provides regular care 12 13 13 13 7 5 12 Does not provide regular care 88 87 87 87 93 95 88 Bases (weighted): Men 8329 584 503 378 236 118 1818 Women 8659 669 596 537 355 263 2420 All adults 16987 1253 1099 914 591 381 4238 Bases (unweighted): Men 6780 794 664 509 315 174 2456 Women 8992 862 778 636 419 305 3000 All adults 15772 1656 1442 1145 734 479 5456

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Table 5.2 Provision of care to anyone inside or outside home, 2008, 2009 and

2010 combined, by Scottish Index of Multiple Deprivation quintile and sexa


Regular carer Scottish Index of Multiple Deprivation quintile

(5th) least

deprived 4th 3rd 2nd

(1st) most

deprived

% % % % % Men Provides regular care 10 11 12 12 13 Does not provide regular care 90 89 88 88 87 Women Provides regular care 11 11 11 12 13 Does not provide regular care 89 89 89 88 87 All adults Provides regular care 11 11 11 12 13 Does not provide regular care 89 89 89 88 87 Bases (weighted): Men 392 387 399 355 285 Women 476 518 508 480 438 All adults 868 905 907 835 723 Bases (unweighted): Men 470 550 568 478 390 Women 532 669 666 589 544 All adults 1002 1219 1234 1067 934 a Deprivation did not vary significantly with age therefore this table has not been age

standardised.

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Table 5.3 GP consultations in last 2 weeks and estimated mean number of

consultations per year, 2008, 2009 and 2010 combined, by age and sex


GP consultations Age Total 65+

16-64 65-69 70-74 75-79 80-84 85+

% % % % % % % Men Did not consult a GP in last 2 weeks 87 80 83 78 74 80 80 1 consultation 11 17 15 19 22 17 17 2 consultations 2 2 1 2 3 3 2 3 or more consultations 0 1 1 1 2 - 1 Total consulted a GP 13 20 17 22 26 20 20 Estimated mean number of GP

consultations per yeara 4 6 5 7 8 6 6

Standard error of the mean 0.2 0.6 0.5 0.8 1.1 1.1 0.3 Women Did not consult a GP in last 2 weeks 79 80 76 77 76 78 77 1 consultation 17 17 20 18 20 20 19 2 consultations 3 3 2 4 3 1 3 3 or more consultations 1 1 2 2 0 1 1 Total consulted a GP 21 20 24 23 24 22 23 Estimated mean number of GP


Standard error of the mean 0.2 0.5 0.7 0.7 0.7 0.8 0.3 All adults Did not consult a GP in last 2 weeks 83 80 79 77 75 79 78 1 consultation 14 17 18 18 21 19 18 2 consultations 3 3 2 3 3 2 3 3 or more consultations 1 1 1 1 1 1 1 Total consulted a GP 17 20 21 23 25 21 22 Estimated mean number of GP


Standard error of the mean 0.1 0.4 0.5 0.5 0.6 0.7 0.2 Bases (weighted): Men 8319 584 503 377 235 118 1817 Women 8651 668 595 535 356 261 2416 All adults 16970 1252 1099 912 592 379 4233 Bases (unweighted): Men 6768 794 664 508 314 174 2454 Women 8983 861 777 635 420 303 2996 All adults 15751 1655 1441 1143 734 477 5450 a Annualised by multiplying the mean number of consultations for all informants in the past two weeks

by 26. Based on total sample, not on those consulting.

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Table 5.4 Blood pressure measurements, 2008 and 2010 combined, by age and sex

Aged 16 and over/aged 16 and over and ever had BP measured 2008 and 2010 combined

Whether BP ever measured and when last measureda

Age Total 65+

16-64 65-69 70-74 75-79 80+

% % % % % % Men Ever had BP measured 84 100 99 99 96 99 BP measured in past 12 months 56 76 88 82 88 83 1 year to less than 3 years ago 24 18 6 15 8 12 3 years but less than 5 years ago 9 2 4 2 2 5 years ago or more 11 4 2 1 4 3 Women Ever had BP measured 94 98 98 100 97 98 BP measured in past 12 months 69 79 81 81 87 82 1 year to less than 3 years ago 20 14 12 13 7 12 3 years but less than 5 years ago 6 3 2 1 2 2 5 years ago or more 6 4 5 5 4 4 All adults Ever had BP measured 89 99 98 100 97 98 BP measured in past 12 months 63 78 84 82 87 82 1 year to less than 3 years ago 22 16 9 14 7 12 3 years but less than 5 years ago 7 3 3 1 1 2 5 years ago or more 8 4 3 3 4 4 Bases (weighted): Men (ever measured) 1829 124 115 76 84 399 Women (ever measured) 1901 151 126 117 137 531 All adults (ever measured) 3730 274 241 193 221 929 Men (when measured) 1534 124 114 74 81 393 Women (when measured) 1788 147 122 116 132 518 All adults (when measured) 3323 271 236 190 213 910 Bases (unweighted): Men (ever measured) 1486 167 147 96 102 512 Women (ever measured) 1992 204 164 145 154 667 All adults (ever measured) 3478 371 311 241 256 1179 Men (when measured) 1306 167 146 94 98 505 Women (when measured) 1900 200 159 143 149 651 All adults (when measured) 3206 367 305 237 247 1156 a The figures for when measurements took place are based on those who had ever had their BP

measured. These questions were only asked in the 2008 and 2010 surveys.

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Table 5.5 Prevalence of currently taking prescribed medication, 2008, 2009

and 2010 combined, by age and sex

Aged 16 and over with a nurse visit 2008, 2009 and 2010 combined

Taking prescribed medication

Age Total 65+

16-64 65-69 70-74 75-79 80+

% % % % % % Men Yes 38 86 87 87 92 88 No 62 14 13 13 8 12 Women Yes 54 82 90 96 92 90 No 46 18 10 4 8 10 All adults Yes 46 84 89 92 92 89 No 54 16 11 8 8 11 Bases (weighted): Men 1296 93 76 54 60 283 Women 1346 103 94 82 97 376 All adults 2642 196 170 136 157 659 Bases (unweighted): Men 1048 130 109 71 75 385 Women 1415 141 122 89 101 453 All adults 2463 271 231 160 176 838

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Table 5.6 Prevalence of currently taking prescribed medication, by Scottish Index of Multiple Deprivation quintile and sex a

Aged 65 and over with a nurse visit 2008, 2009 and 2010 combined

Taking prescribed medication

Scottish Index of Multiple Deprivation quintile

(5th) least

deprived 4th 3rd 2nd

(1st) most

deprived

% % % % % Men Yes 86 89 90 84 89 No 14 11 10 16 11 Women Yes 86 88 91 90 94 No 14 12 9 10 6 All adults Yes 86 89 91 88 92 No 14 11 9 12 8 Bases (weighted): Men 69 65 54 41 53 Women 82 85 82 61 66 All adults 150 151 137 103 119 Bases (unweighted): Men 93 94 78 56 64 Women 102 111 98 69 73 All adults 195 205 176 125 137 a Deprivation did not vary significantly with age therefore this table has not been age

standardised.

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Discussion Chapter 6

6 DISCUSSION Jennifer Mindell

6.1 INTRODUCTION This chapter considers the findings across the whole report and brings them together. It also compares the findings of logistic regression models among older people in the Scottish Health Surveys with findings from analyses reported in previous years for adults aged 16 and over.

6.2 SELF-RATED PHYSICAL HEALTH Although the prevalence of self-reported very good health fell with age among older people and the proportion reporting their health as ‘fair’ increased, the proportion of older adults reporting good, poor and very poor health changed little across the older age groups. Logistic regression models found that in both men and women aged 65 and over, deprivation was very significantly related to the odds of reporting poor or very poor health, with the effect stronger in women. The analyses conducted in 2008 for men and women aged 16 and over1

had found a similar but stronger trend towards poorer health both in men living in the more deprived quintiles and, to a significant but lesser extent, in women.

While it is unsurprising that ex-smokers (many of whom stopped smoking because of developing a smoking-related disease) and current smokers were more likely to report poor or very poor health, the reduced odds of poor/very poor health in those drinking above the recommended weekly limits appears counter-intuitive. A similar, though less pronounced effect, was seen in men and women aged 16 and over in SHeS 2008.1 It is likely that this is because the reference category includes not only those who drank alcohol within the weekly guidelines and those who have chosen not to drink alcohol but also those who had stopped drinking alcohol due to disease, whether caused by alcohol or because advised to avoid alcohol. One example of this last category is people with diabetes, where alcohol both contributes calories to those on weight-reducing diets and can precipitate hypoglycaemic episodes. Thus it is likely that this represents, at least in part, confounding by other disease states and should not be interpreted as indicating that exceeding the weekly alcohol limits is to be recommended to reduce the risk of poor/very poor health.

Unlike the SHeS 2008 results for adults aged 16 and over,1 neither age nor quintile of equivalised income were significantly associated with reporting poor or very poor health among men and women aged 65 and over. Marital status was also not associated with poor/very poor self-rated health. GHQ12 score was significantly related to reporting poor/very poor health but was omitted from the final model as the direction of the association could not be determined (i.e. whether having symptoms of possible psychiatric disease led to poor/very poor self-rated health, or whether having such poor health led to an increased likelihood of developing symptoms of poor mental health). Unsurprisingly, the presence of a long-term condition, particularly if limiting, was significantly related to reporting poor/very poor health but was also omitted from the final model, as the confidence limits were very wide and the model presented in

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table 1.2 was limited to demographic, socio-economic, and lifestyle factors, as in the 2008 analyses for all adults.

6.3 MENTAL HEALTH The results for GHQ12 were not straightforward. Adults aged 65 and over were less likely than younger adults to have a raised GHQ12 score of 4 or more, indicative of possible psychiatric disorder; women were more likely to have a raised score than men. The finding that prevalence was higher among women than men at each age concurs with the results of previous studies of both common mental disorders and some specific psychiatric diagnoses (see section 1.1.1).2,3

Those studies have also found that the prevalence of common mental disorders falls with age.2 While this was true in the current report when comparing those aged 65 and over with younger adults, it was not the case among older women, in whom prevalence increased from the young old to the oldest old.

Positive aspects of mental health (assessed using the Warwick Edinburgh Mental Wellbeing Score (WEMWBS)) were higher in adults aged 65 and over than in those aged 16-64, but fell with age among adults aged 75 and over. Comparing the results of the logistic regression reported in Table 1.7 for people aged 65 and over in this report with that reported for those aged 16 and over in the SHeS 2008 report, marital status was important in both sexes and SIMD in women but not men in both sets of analyses: the SHeS 2008 results for adults aged 16 and over had found a significant effect in women and a similar but again non-significant trend towards poorer wellbeing in men living in more deprived quintiles. However, income was not significant in older people, and weekly alcohol consumption was not significant in women aged 16 and over. Employment status was not included as an explanatory variable in the analyses of people aged 65 and over, as most older participants had retired and there were few in other categories. The regression analysis of poor wellbeing also showed that self-reported long-term conditions and physical activity had the strongest associations with poor wellbeing. Physical activity is part of the causal pathway between long-term conditions and poor wellbeing, as current limiting long-term conditions affect the ability to be physically active. In the longer term, physical activity also affects the likelihood of developing a long-term condition but that is less relevant in this cross-sectional analysis. Because of this causal link, the analyses were initially conducted including only one of these two factors. The results shown in Table 1.7 have slightly lower odds ratios for these two variables than when only one of the two is included. Nonetheless, both are strongly related to mental wellbeing even when mutually adjusted for each other and the other significant variables. This is important as physical activity interventions can be designed for those with chronic diseases and may improve their wellbeing, as discussed in sections 6.4 and 6.8 below. When interpreting the finding that women drinking above the weekly guidance had lower odds of poor wellbeing, it should be remembered that this was in comparison with women who never drank alcohol, no longer drank alcohol, had not drunk in the past week, or had drunk within the guidance. It may be that

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those drinking but drinking less had different odds from the non-drinkers, but it was decided to use the same variable in the regression as in the models for other outcomes in this report.

6.4 LIFESTYLES AND DISEASE RISK FACTORS Alcohol consumption above the weekly or daily recommended limits was notably lower among older adults than those aged 16-64. However, a recent report from the Royal College of Psychiatrists recommends that the weekly limits and binge drinking definitions for older people should be lower due to physiological and metabolic changes associated with ageing and evidence that older people have higher concentrations of blood-alcohol than younger people after drinking the same volume of alcohol.4

The report instead recommends a maximum of 11 units per week (and no more than 1.5 units per day) for men and women aged 65 and over, with binge drinking defined as more than 4.5 units for men and 3 for women in a single session. Men aged 65 and over consumed an average of 12.5 units per week, exceeding the 11 units per week advice, whereas older women were below this level by some margin (4.0 weekly units). Older men consumed 2.9 units on their heaviest drinking day in the previous week (almost twice the recommended maximum of 1.5 units). Again, women’s drinking was below this limit (1.1 units). The prevalence of binge drinking in older adults clearly increases as the threshold reduces, for example 11% of women had drunk more than 6 units (the current definition for all ), whereas more than twice as many (24%) had drunk more than 3 units (the suggested definition for older women).

women

It was particularly notable that the proportion of women reporting that they had never drunk rose from one in ten aged 65-69 to over one-quarter of women aged 85 and over, much greater than the rise in men (from one in ten to more than one in seven). This is likely to be the main reason for the increasing difference in mean weekly consumption between men and women with age, as non-drinkers are included in the denominator. Assuming this is a cohort effect, not an effect of age (as the proportion of ex-drinkers changed little), it is likely that alcohol consumption among older women will increase over the coming decades as young women who drink reach older ages. Among older adults, there were two to three times as many ex-smokers as current smokers, among each age and sex group. The prevalence of current smoking was markedly lower among older than younger adults, reflecting a cohort effect (with older women less likely than younger women to have ever smoked), more time to have quit smoking, and higher mortality rates among smokers. Current smoking among older adults has also dropped in the past decade, from one in four adults aged 65-74 in 1998 to fewer than one in five in 2008/2009/2010.5

A positive sign for better health in future generations of older men is the higher prevalence of never smokers among young men, matching that seen in both older and younger women. Of concern, however, are the continuing high smoking rates among younger men and women.

Fruit and vegetable consumption remains worryingly low among adults in Scotland of all ages, with only one in five adults eating five or more portions a day. As expected, physical activity declined markedly with age. Overall, more

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than one in two older adults reported at least moderate intensity activity for 30 minutes less than once a week, with this being three-quarters of adults aged 80 and over. The equivalent figures in the 1998 SHeS were 62% of men and 67% of women (though note that the 1998 estimate was based on activities of at least 15 minutes’ duration whereas activities of 10-14 minutes have also been included since 2008).6 Physical activity remains a very important aspect of aging well, preventing onset and exacerbation of disease; improving functional capacity; and being important for quality of life7 and mental wellbeing (section 6.3). Although one intervention study found only a weak association between increased physical activity and improved wellbeing (and a weak negative association between sedentary behaviour and wellbeing),8 a longitudinal study of GP patients aged 60 and over found that habitual activity (including walking and housework) at baseline was positively, though modestly, associated with changes in life satisfaction at follow-up.9 Importantly, a systematic review showed that exercise interventions can improve mental wellbeing among older, primarily sedentary, people in a community setting. Effective interventions were: designed for such individuals, were delivered to a group by trained leaders, and comprised at least two 45min sessions per week. Such sessions can also improve the mental wellbeing of frail older people.10 Walking is beneficial for health (see section 2.1.4) although generally older people walk at too slow a speed for it to be included as ‘moderate intensity activity’. A study currently underway in Scotland is assessing the effectiveness of encouraging walking among older people.11

As explained in section 3.1 of this report, the significance of a raised BMI in older people is less clearcut than for younger adults. General obesity was markedly lower in the oldest old, particularly those aged 85 and over and in particular among men. Being cross-sectional data, it is not possible to determine the relative contributions of four factors: a cohort effect, with those born in the early years of the 20th century affected much less by the recent obesity epidemic; a survivor effect, with higher mortality among obese individuals; a greater degree of sarcopenia (loss of muscle mass) among the older old, leading to a lower BMI; and a higher prevalence among the oldest group of diseases that lead to weight loss. Of greater concern is the very high prevalence of abdominal obesity among older adults, regardless of age, affecting almost two in three men and women. This is of particular concern because of the much greater risk of diabetes, metabolic syndrome, and circulatory diseases among those with central adiposity.

6.5 DISEASE The changing prevalence of disease with age among older adults (section 1.3.1) reflects the net effect of two opposing trends. Most diseases increase with age, due to the length of time people have been exposed to factors that can lead to disease (environmental factors and particularly personal lifestyles, interacting with genetic susceptibility). But the most susceptible die prematurely. This balance of two trends is seen most clearly for diabetes, the main disease in the endocrine and metabolic disease category in Table 1.3. Although the incidence of type 2 diabetes increases exponentially with age, diabetes increases the risk of developing and dying from circulatory diseases12; the prevalence of endocrine and metabolic disease falls with age among the oldest

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women and all but the youngest men aged 65 and over. This probably also explains why for many potentially fatal conditions, the prevalence in men aged 85 and over is lower than in men aged 80-84, while for some non-fatal conditions (ear and eye problems) this was not the case. The lower prevalence for respiratory conditions in older women may represent a cohort effect, with the oldest women the least likely to have ever smoked.13

A fourth factor is the likelihood of participating in the survey. Thus the prevalence of mental disorders decreases with age partially because people with mental illness have greater mortality from physical illness, particularly circulatory and respiratory diseases, associated with smoking.14

However, equally importantly, those with significant cognitive impairment (i.e. all but the mildest forms of dementia) are unable to give informed consent and/or to understand and respond to questions, so are excluded from the survey. This report therefore underestimates the prevalence of dementia and therefore all mental disorders.

With the exception of women aged 65-69, the prevalence of any doctor-diagnosed CVD reported in response to direct questions (Table 4.1) was substantially higher than the prevalence of long-term conditions of the heart and circulatory system (Table 1.3), which was limited to those who reported having a longstanding condition, whether or not it limited their activities. Thus a considerable proportion of older adults with cardiovascular disease do not consider themselves to have a long-term condition (assuming there were few who chose to mention six other co-existing conditions first – the maximum permissible in the questionnaire). A similar pattern was seen for men with diabetes, which was more prevalent among those aged 70 and over than the proportion reporting an endocrine or metabolic condition as a long-term condition. That was not the case, however, for women, but there are a number of other conditions apart from diabetes, such as thyroid disease, which fall into that latter category and are more common in women.

6.6 HEALTHCARE

6.6.1 Health-seeking behaviour Despite the high prevalence of longstanding conditions, four-fifths of men and more than three-quarters of women aged 65 and over had not seen a GP within the previous two weeks, with little variation by age except for younger men. A two-week framework provides more accurate recall than asking about the previous three months, and enables average number of visits per year to be estimated. However, it is not possible to ascertain what proportion of survey participants with longstanding conditions see a GP or practice nurse every three or six months for regular monitoring of their condition and treatment. The proportion of people aged 65 and over in Scotland with two or more emergency hospital admissions in one year has increased over the past decade from 4.2% to 4.9%.15 Whether this reflects increased prevalence of disease, better access to emergency and secondary healthcare, or worse access to primary healthcare is unclear.

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6.6.2 Detection and treatment of disease in older people Detection of disease is a prerequisite for adequate treatment and control. The proportions of older people with survey-defined hypertension who were untreated, treated but not controlled, or controlled were roughly equal among adults aged 65 and over. This contrasts with younger adults, in whom most of the cases were untreated, suggesting that detection and treatment are better in older people, although both remain sub-optimal. It should, however, be noted that a diagnosis of hypertension requires more than a single measurement, thus ‘survey-defined hypertension’ may be an overestimate of the true prevalence of hypertension. Additionally, the indications for treating hypertension are a blood pressure of at least 160/100; existing cardiovascular disease or diabetes; or evidence of end-organ damage.16

Thus drug treatment is not indicated for some adults with hypertension, and this will be more true for younger adults.

A similar pattern was seen for diabetes in men, but not women. A higher proportion of cases of diabetes were diagnosed in older than younger men, but the proportion of undiagnosed cases was twice as high in older than younger women. It is probable that younger women are tested because of healthcare for contraception and pregnancy, as well as greater health-seeking behaviour (see Table 5.3). In contrast, men aged 65 and over, who are considered to be at greater CVD risk, are probably more likely to be tested than women of that age. Additionally, there are more ‘older old’ among the women, and there can be some reluctance among both patients and healthcare staff to investigate and treat older people for conditions that may have primarily long-term benefits if the shorter term side-effects of diagnosis and treatment (including lifestyle changes) are deemed to affect quality of life adversely, in relation to the long-term benefits. However, nine out of ten older people were taking prescribed medication, regardless of age or area deprivation.

6.7 PROVISION OF CARE It is estimated that 14% of Scottish households contain someone requiring care. This number is estimated to rise as the elderly population grows (see the Introduction to this report). In 2008/2009/2010, 9% of younger men, 15% of younger women, and 12% of older adults of each sex provided regular care to someone within or outside the home. Apart from the oldest women, these figures changed little by age (Table 5.1). By 2037 it is estimated that three in five people will act as carers at some point in their lives.17

Although figures for sheltered accommodation in Scotland have changed little in the past 10 years (about 33,000-35,000 units), the amount of very sheltered accommodation has risen every year, from around 700 units in 1996 to 5,300 in 2010. There has been a drop in less specialised medium dependency housing, from 17,600 units in 1996 to 12,800.18

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6.8 AGEING WELL The World Health Organisation defines active ageing as:

“the process of optimising opportunities for health, participation and security in order to enhance quality of life as people age.”19

Maintaining good quality of life in older people is aided by avoiding depression, maintaining good physical function, and having good neighbourhood standards, financial circumstances, and family relationships.20

Some factors associated with ageing well apply primarily to older people; others need a lifelong approach and if implemented now, will affect future cohorts of older people. For example, preclinical mobility disability (decreased ability to walk half a mile, climb up steps, do heavy housework, or get in or out of a bed or chair) occurs more commonly in older women with low educational attainment, even after adjusting for income, marital status, number of diseases, and high self-efficacy.21

“Tackling health inequalities requires action from national and local government and from other agencies including the NHS, schools, employers and Third Sector.”

The authors of that American study commented that this association is important for primary and secondary prevention and can be assessed easily in healthcare encounters. It is also an additional reason for continued efforts to improve educational attainment among young people. Hence the importance of the Scottish government’s recognition in Equally Well that:

22

Living in a deprived area and cigarette smoking, itself socially patterned, were two of the three factors significantly associated with older people in 2008/2009/2010 reporting poor or very poor health. However, community-based walking and exercise programmes can be very cost-effective, with estimates of £7,300 and £12,100 per quality adjusted life year (compared with minimal intervention).10

In the industrialized countries, premature death has fallen so much that the age at which death is deemed to be ‘premature’ is revised upwards at regular intervals, with 75 years being the current threshold in Scotland. Although this report has focused on aspects of poor health, it is important to note that more than one in three adults aged 65 and over did not report any long-term condition (including more than one in four aged 85 and over), and more than half described their health as good or very good, including men and women aged 85 and over. With the exception of women aged 85 and over, more than half of older adults in every age and sex group had a GHQ12 score of zero. Declining rates of disability, cardiovascular mortality, and prevalence of non-communicable disease, and improvements in self-rated health are seen in many countries, resulting in a compression of morbidity and disability.23 Such improvements are thought to be not only through advances in healthcare but primarily through improved environmental circumstances in childhood and educational and financial resources throughout life. But the higher prevalence of smoking in adults under 65, increasing obesity in middle-aged adults, and poor

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diet and insufficient activity across all age groups in Scotland in 2008/2009/2010 could, if not tackled effectively, undo some of these advances.

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1 Given L. Chapter 1: General health and mental wellbeing. In Bromley C, Bradshaw P, Given L (Eds). The Scottish Health Survey 2008 – Volume 1: Main Report. Edinburgh: The Scottish Government, 2009. <www.scotland.gov.uk/Publications/2009/09/28102003/7>

2 Evanse O, Singleton N, Meltzer H, Stewart R, Prince M. The Mental Health of Older People.

London: TSO, 2003. <www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_4081092>

3 Marmot M (Chair). Fair Society, Healthy Lives - The Marmot Review. Strategic Review of Health Inequalities in England post-2010. London: The Marmot Review, 2010. <www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLives.pdf>

4 Our invisible addicts – First Report of the Older Persons’ Substance Misuse Working Group of the

Royal College of Psychiatrists. College Report CR165. London: Royal College of Psychiatrists, 2011. <www.rcpsych.ac.uk/files/pdfversion/CR165.pdf>

5 Boreham, R. Chapter 8: Smoking. In Shaw A, McMunn A, Field J (Eds). The Scottish Health

Survey 1998. Edinburgh: Scottish Executive, 2000. 6 Pitson L. Chapter 6: Adult physical activity. In Shaw A, McMunn A, Field J (Eds). The Scottish

Health Survey 1998. Edinburgh: Scottish Executive, 2000. 7 Drewnowski A, Evans WJ. Nutrition, physical activity, and quality of life in older adults: summary. J

Gerontol A Biol Sci Med Sci. 2001; 56: 89-94. 8 Fox KR, Stathi A, McKenna J, Davis MG. Physical activity and mental well-being in older people

participating in the Better Ageing Project. Eur J Appl Physiol. 2007; 100: 591–602. 9 Morgan K, Bath PA. Customary physical activity and psychological wellbeing: a longitudinal study.

Age and Ageing 1998; 27-S3: 35-40. 10 Windle G, Hughes D, Linck P, Russell I, Woods B. Is exercise effective in promoting mental well-

being in older age? A systematic review. Aging & Mental Health. 2010; 14: 652–669. 11 Macmillan F, Fitzsimons C, Black K, et al. West End Walkers 65+: a randomised controlled trial of

a primary care-based walking intervention for older adults: study rationale and design. BMC Public Health. 2011; 11: 120.

12 Stratton IM, Adler AI, Neil AW, et al. Association of glycaemia with macrovascular and

microvascular complications of type 2 diabetes (UKPDS 35):prospective observational study. BMJ 2000; 321: 405-412.

13 Kemm JR A birth cohort analysis of smoking by adults in Great Britain 1974–1998. J Public Health

2001; 23 (4): 306-311 14 Kendrick T Cardiovascular and respiratory risk factors and symptoms among general practice

patients with long-term mental illness. Br J Psychiatry 1996; 169: 733-739. 15 General Register Office for Scotland. High Level Summary of Statistics: Population and Migration

<www.gro-scotland.gov.uk/files2/stats/high-level-summary/j11198/j1119805.htm> 16 Scottish Intercollegiate Guidelines Network. Risk Estimation and Prevention of Cardiovascular

Disease. SIGN Guideline 97. Edinburgh: SIGN, 2007. <www.sign.ac.uk/pdf/sign97.pdf> 17 Scottish Government. Caring Together - The Carers Strategy for Scotland 2010-2015. Edinburgh,

The Scottish Government, 2010.

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18 Scottish Government. Housing Statistics for Scotland - Housing for Older People, those with Disabilities and those with Supported Tenancies. www.scotland.gov.uk/Topics/Statistics/Browse/Housing-Regeneration/HSfS/SpecialNeedsHousing

19 Scottish Government. All Our Futures: Planning for A Scotland with an Ageing Population.

Edinburgh: Scottish Government, 2007. <www.scotland.gov.uk/Resource/Doc/169342/0047172.pdf>

20 Webb E, Blane D, McMunn A, et al. Proximal predictors of change in quality of life at older ages. J

Epidemiol Community Health. 2011; 65: 542-547. 21 Gregory PC, Szanton SL, Xue QL, et al. Education predicts incidence of preclinical mobility

disability in initially high-functioning older women. The Women's Health and Aging Study II. J Gerontol A Biol Sci Med Sci. 2011; 66: 577-581.

22 Equally Well: Report of the Ministerial Task Force on Health Inequalities. Edinburgh: Scottish

Government, 2008. <www.scotland.gov.uk/Publications/2008/06/25104032/0> 23 Kalache A, Aboderin I, Hoskins I. Compression of morbidity and active ageing: key priorities for

public health policy in the 21st century. Bull World Health Organization. 2002; 80: 243-244.

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APPENDIX A: GLOSSARY

This glossary explains terms used in the report, other than those fully described in particular chapters. Anthropometric See Body mass index (BMI) and Waist-hip ratio measurements Arithmetic mean See Mean Blood pressure Systolic (SBP) and diastolic (DBP) blood pressure were

measured using a standard method (see Scottish health Survey 2010 Report - Volume 2, Appendix B for measurement protocol). In adults, high blood pressure is defined as SBP ≥140 mmHg or DBP ≥90 mmHg or on antihypertensive drugs.

Body mass index Weight in kg divided by the square of height in metres. Adults

(aged 16 and over) can be classified into the following BMI groups:

BMI (kg/m2) Description Less than 18.5 Underweight 18.5 to less than 25 Normal 25 to less than 30 Overweight 30 to less than 40 Obese 40 and above Morbidly obese

Cardiovascular Disease Participants were classified as having cardiovascular disease

(CVD) if they reported ever having any of the following conditions diagnosed by a doctor: angina, heart attack, stroke, heart murmur, irregular heart rhythm, ‘other heart trouble’. For the purpose of this report, participants were classified as having a particular condition only if they reported that the diagnosis was confirmed by a doctor. No attempt was made to assess these self-reported diagnoses objectively. There is therefore the possibility that some misclassification may have occurred, because some participants may not have

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remembered (or not remembered correctly) the diagnosis made by their doctor.

Diastolic blood When measuring blood pressure the diastolic arterial pressure

is the lowest pressure at the resting phase of the cardiac cycle. See also Blood pressure, Systolic blood pressure.

Equivalised Household income Making precise estimates of household income, as is done for

example in the Family Resources Survey, requires far more interview time than was available in the Health Survey. Household income was thus established by means of a card (see Volume 2, Appendix A) on which banded incomes were presented. Information was obtained from the household reference person (HRP) or their partner. Initially they were asked to state their own (HRP and partner) aggregate gross income, and were then asked to estimate the total household income including that of any other persons in the household. Household income can be used as an analysis variable, but there has been increasing interest recently in using measures of equivalised income that adjust income to take account of the number of persons in the household. Methods of doing this vary in detail: the starting point is usually an exact estimate of net income, rather than the banded estimate of gross income obtained in the Health Survey. The method used in the present report was as follows. It utilises the widely used McClements scoring system, described below.

1. A score was allocated to each household member, and these were added together to produce an overall household McClements score. Household members were given scores as follows.

First adult (HRP) 0.61 Spouse/partner of HRP 0.39 Other second adult 0.46 Third adult 0.42 Subsequent adults 0.36 Dependant aged 0-1 0.09 Dependant aged 2-4 0.18 Dependant aged 5-7 0.21 Dependant aged 8-10 0.23 Dependant aged 11-12 0.25 Dependant aged 13-15 0.27 Dependant aged 16+ 0.36

2 The equivalised income was derived as the annual household income divided by the McClements score.

3 This equivalised annual household income was attributed to all members of the household, including children.

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4 Households were ranked by equivalised income, and quintiles q1- q5 were identified. Because income was obtained in banded form, there were clumps of households with the same income spanning the quintiles. It was decided not to split clumps but to define the quintiles as ‘households with equivalised income up to q1’, ‘over q1 up to q2’ etc.

5 All individuals in each household were allocated to the equivalised household income quintile to which their household had been allocated. Insofar as the mean number of persons per household may vary between tertiles, the numbers in the quintiles will be unequal. Inequalities in numbers are also introduced by the clumping referred to above, and by the fact that in any sub-group analysed the proportionate distribution across quintiles will differ from that of the total sample.

Reference: McClements, D. (1977). Equivalence scales for children. Journal of Public Economics. 8: 191-210.

GHQ12 The General Health Questionnaire (GHQ12) is a scale

designed to detect possible psychiatric morbidity in the general population. It was administered to informants aged 13 and above. The questionnaire contains 12 questions about the informant’s general level of happiness, depression, anxiety and sleep disturbance over the past four weeks. Responses to these items are scored, with one point given each time a particular feeling or type of behaviour was reported to have been experienced ‘more than usual’ or ‘much more than usual’ over the past few weeks. These scores are combined to create an overall score of between zero and twelve. A score of four or more (referred to as a ‘high’ GHQ12 score) has been used in this report to indicate the presence of a possible psychiatric disorder.

Reference: Goldberg D, Williams PA. User’s Guide to the General Health Questionnaire. NFER-NELSON, 1988.

Glycated Haemoglobin The percentage of glycated haemoglobin is the percentage of

haemoglobin in the circulation to which glucose is bound. Glycated haemoglobin (HbA1c) concentration is an indicator of average blood glucose concentration over three months and has been suggested as a diagnostic or screening tool for diabetes. Diabetic patients with elevated glycated haemoglobin are at increased risk of microvascular and macrovascular events. In this report, a glycated haemoglobin value of 6.5% or above in people with no existing diabetes diagnosis was taken to indicate possible undiagnosed diabetes.

HDL-Cholesterol See Cholesterol

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High blood See Blood pressure pressure Household A household was defined as one person or a group of people

who have the accommodation as their only or main residence and who either share at least one meal a day or share the living accommodation.

Household Reference Person The household reference person (HRP) is defined as the

householder (a person in whose name the property is owned or rented) with the highest income. If there is more than one householder and they have equal income, then the household reference person is the oldest.

Income See Equivalised household income Ischaemic heart disease Participants were classified as having ischaemic heart disease

(IHD) if they reported ever having angina or a heart attack diagnosed by a doctor.

Long-term conditions & limiting long-term conditions Long-term conditions were defined as a long-standing physical

or mental condition or disability that has troubled the participant for at least 12 months, or that is likely to affect them for at least 12 months. Note that prior to 2008 these were described as long-standing illnesses. Long-term conditions were coded into categories defined in the International Classification of Diseases (ICD), but it should be noted that the ICD is used mostly to classify conditions according to the cause, whereas SHeS classifies according to the reported symptoms. A long-term condition was defined as limiting if the respondent reported that it limited their activities in any way.

Mean Means in this report are Arithmetic means (the sum of the

values for cases divided by the number of cases). Median The value of a distribution which divides it into two equal parts

such that half the cases have values below the median and half the cases have values above the median.

Morbid obesity See Body mass index. Obesity See Body mass index Odds ratio See Logistic regression

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Overweight See Body mass index Percentile The value of a distribution which partitions the cases into

groups of a specified size. For example, the 20th percentile is the value of the distribution where 20 percent of the cases have values below the 20th percentile and 80 percent have values above it. The 50th percentile is the median.

p value A p value is the probability of the observed result occurring due

to chance alone. A p value of less than 5% is conventionally taken to indicate a statistically significant result (p<0.05). It should be noted that the p value is dependent on the sample size, so that with large samples differences or associations which are very small may still be statistically significant. Results should therefore be assessed on the magnitude of the differences or associations as well as on the p value itself. The p values given in this report take into account the clustered sampling design of the survey.

Quintile Quintiles are percentiles which divide a distribution into fifths,

i.e., the 20th, 40th, 60th and 80th percentiles. Scottish Index of Multiple Deprivation The Scottish Index of Multiple Deprivation (SIMD) is the

Scottish Government’s official measure of area based multiple deprivation. It is based on 37 indicators across 7 individual domains of current income, employment, housing, health, education, skills and training and geographic access to services and telecommunications. SIMD is calculated at data zone level, enabling small pockets of deprivation to be identified. The data zones are ranked from most deprived (1) to least deprived (6505) on the overall SIMD index. The result is a comprehensive picture of relative area deprivation across Scotland.

This report uses the SIMD 2009.

http://www.scotland.gov.uk/Topics/Statistics/SIMD

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Standard deviation The standard deviation is a measure of the extent to which the

values within a set of data are dispersed from, or close to, the mean value. In a normally distributed set of data 68% of the cases will lie within one standard deviation of the mean, 95% within two standard deviations and 99% will be within 3 standard deviations. For example, for a mean value of 50 with a standard deviation of 5, 95% of values will lie within the range 40-60.

Standard error The standard error is a variance estimate that measures the

amount of uncertainty (as a result of sampling error) associated with a survey statistic. All data presented in this report in the form of means are presented with their associated standard errors (with the exception of the WEMWBS scores which are also presented with their standard deviations). Confidence intervals are calculated from the standard error; therefore the larger the standard error, the wider the confidence interval will be.

Systolic blood When measuring blood pressure, the systolic arterial pressure is pressure defined as the peak pressure in the arteries, which occurs near the beginning of the cardiac cycle. See also Blood pressure, Diastolic blood pressure.

Unit of alcohol Alcohol consumption is reported in terms of units of alcohol. A

unit of alcohol is 8 gms or 10ml of ethanol (pure alcohol). See Chapter 3 of volume 1 of the 2010 Scottish Health Survey Report for a full explanation of how reported volumes of different alcoholic drinks were converted into units. The method for doing this has undergone significant change since the report of the 2003 SHeS was published, this is also detailed in Chapter 3.

Waist- Circumference Waist circumference is a measure of deposition of abdominal

fat. It was measured during the nurse visit. A raised waist circumference has been defined as more than 102cm in men and more than 88cm in women.

Waist-hip ratio Waist-hip ratio (WHR) was defined as the waist circumference

divided by the hip circumference, i.e. waist girth (m)/ hip girth (m). WHR is a measure of deposition abdominal fat. Unlike BMI there is no consensus to define cut-off point for WHR. For consistency the cut-off values as in the 1995, 1998 and 2003 reports have been used. A raised WHR has been taken to be 0.95 or more in men and 0.85 or more in women.

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Reference: Molarius A, Seidell JC. Selection of anthropometric indicators for classification of abdominal fatness - a critical review. Int J Obes 1998; 22:719-727

WEMWBS The Warwick-Edinburgh Mental Well-being Scale (WEMWBS)

was developed by researchers at the Universities of Warwick and Edinburgh, with funding provided by NHS Health Scotland, to enable the measurement of mental well-being of adults in the UK. It was adapted from a 40 item scale originally developed in New Zealand, the Affectometer 2. The WEMWBS scale comprises 14 positively worded statements with a five item scale ranging from ‘1 - None of the time’ to ‘5 - All of the time’. The lowest score possible is therefore 14 and the highest is 70. The 14 items are designed to assess positive affect (optimism, cheerfulness, relaxation); and satisfying interpersonal relationships and positive functioning (energy, clear thinking, self-acceptance, personal development, mastery and autonomy).

References: Kammann, R. and Flett, R. (1983). Sourcebook for measuring

well-being with Affectometer 2. Dunedin, New Zealand: Why Not? Foundation.

The briefing paper on the development of WEMWBS is available online from: <www.wellscotland.info/indicators.html>

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Older People's Health

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