Problems and possibilities related to

Healthy and active living of elderly before death in Finland

10.11.2010Erkki Vauramo

Aalto University

Ageing in Finland

• Where are we in Finland?

• How big is the change required?

• How can the problem be solved?

• What it does mean for the built environment?

Age groupstotal 5 378 165 5 508 728 5 635 938 5 752 572 5 850 097 5 926 673 5 985 356

-14 886 705 908 322 937 331 948 011 942 715 931 229 926 800

15 - 24 659 828 639 659 605 777 617 997 642 503 655 456 656 930

25 - 44 1 349 828 1 359 182 1 411 263 1 403 571 1 378 236 1 372 906 1 366 742

45 - 64 1 537 819 1 463 457 1 391 424 1 367 690 1 361 488 1 375 329 1 427 116

65 - 74 506 749 647 907 719 024 685 065 678 092 661 978 618 662

75 - 437 236 490 201 571 119 730 238 847 063 929 775 989 106

Tilastokeskus 9.2009

Population projection, whole Finland 2010-2040, both sexes

Age, 80% livingAge,20%living

1986 65 years 87years

2009 71years 91years

Increase 6 years 4 years

Life-born, probability of death per mill

Death is compressing rapidly – less elderly care services?

Avoidable cause of death 85%

10 years

Deaths by age in 1980 and 2008Life expectation is increasing rapidly

Countries CountriesFinland 20,3 Turkey 1,3 Finland 243 Canada 27Ireland 15,8 Belgium 1,1 Hungary 148 Denmark 24Japan 15,0 Italy 0,9 Austria 115 Norway 23Iceland 10,6 United States 0,8 Luxembourg 80 Italy 20Korea 2,5 United Kingdom 0,6 France 79 Czech Republic 12Slovak Republic 9,5 Netherlands 0,0 Iceland 75 Spain 12France 7,7 Australia Slovak Republic 54 United States 9Hungary 4,7 Denmark Belgium 44 Ireland 8Czech Republic 4,6 Germany United Kingdom 41 Japan 7Austria 2,9 Greece Switzerland 39 Poland 7Poland 3,2 Luxembourg Germany 38 Portugal 7Canada 1,5 Mexico Sweden 36 Netherlands 6Spain 2,0 New Zealand Korea 35 Mexico 1Sweden 1,6 Norway Australia 28 Greece

Portugal Canada 27 New ZealandSwitzerland Turkey

2004 Long-term care beds Per 1 000 population aged 65 years old and over

2005 Dementia Per 100 000 population

Long term wards are generally gone (in other countries)!How does the ward cure or help people with dementia?

2008Dementia

Countries

Per 100 000 population

Finland 231Austria 110Hungary 92Korea 92France 85Iceland 76Slovak Republic 57Switzerland 37

New Zealand 36Germany 34United Kingdom 32Norway 24Denmark 21Czech Republic 15Japan 11Portugal 10Spain 10Ireland 9Slovenia 9Netherlands 7Poland 5Israel 4Turkey 3Mexico 1

2008Total hlth.& social empl.

Countries

Density per 1 000 population (head counts)

Norway 105,28Denmark 94,01Netherlands 83,55Iceland 81,44Sweden 78,23Finland 72,36Switzerland 68,37

United Kingdom 60,13United States 59,88Canada 57,51Germany 54,19Belgium 53,64Australia 52,71Ireland 52,69New Zealand 47,75Japan 46,83Austria 43,77Czech Republic 31,93Spain 28,82Portugal 28,74

Slovak Republic 28,57Italy 28,18Hungary 24,83Korea 17,52Mexico 11,96Turkey 7,94

2008Dicharge rates by diagnostic catgories

Alzheimer's disease

Countries

Per 100 000 population

Finland 107Austria 34France 30Switzerland 24Iceland 23Germany 21New Zealand 13United Kingdom 12Czech Republic 9Korea 8Japan 7Spain 7Ireland 6Poland 6Norway 4Turkey 3Denmark 2Hungary 2Portugal 2Slovak Republic 2Slovenia 2Israel 1Mexico 0Netherlands 0

OECD

Health

Data

2010

Annual Client inventory in Finland –Results from 31.12.2009

• National Institute for health and welfare undertakes annually (at January 31th) client inventory in all Finnish long term institutions including– Long term hospitals– Elderly care homes– 24-h service homes– service homes with daytime service

• The inventory give a useful picture of the elderly care system– Clients’ date of arrival defines the amount of used inpatient days or

resources in ongoing and unfinished treatment– It is possible to sort the patient in groups according to the length of

stay– By using average price of service/day, an estimation of distribution of

resources can be made

Inventory of in-house elderly care 31.12.2009 ,all Finland

Figures are patients or residents

Since arrival

Primary care

hospitalElderly care

home24 - h service

home Service home Total %

days

0 1- 9 3667 1007 772 137 5583 7,9

1 10-29 2835 818 984 220 4857 6,9

2 30-59 1743 789 1210 285 4027 5,7

3 60-90 878 631 1117 269 2895 4,1

4 91-179 1609 1684 2778 730 6801 9,7

5 180-364 1846 2803 4739 1137 10525 15,0

6 365-729 2030 3905 5492 1811 13238 18,8

7 730-1094 1081 1902 3019 1127 7129 10,1

8 1095-3599 2111 3384 5092 2867 13454 19,2

9 3600-9999 140 195 481 919 1735 2,5

Total 17940 17118 25684 9502 70244 100,0

Red area, maximum stay at ward 30 day, maximum stay at any institution 2 years covers 24 384 persons or 35 % of all

Inventory of in-house elderly care 31.12.2009 ,all Finland

Figures are total inpatient days in each category

Since arrival

Primary care

hospitalElderly care

home

24 - h service

homeService

home Total % days0 1- 9 13 588 3 995 3 038 554 21 175 0,0

1 10-29 49 164 14 149 18 014 4 100 85 427 0,2

2 30-59 75 076 35 066 52 212 12 134 174 488 0,3

3 60-90 64 893 46 128 82 375 19 568 212 964 0,4

4 91-179 208 425 222 888 364 065 97 235 892 613 1,7

5 180-364 495 989 755 758 1 267 504 301 763 2 821 014 5,5

6 365-729 1 047 820 1 935 615 2 804 080 918 094 6 705 608 13,1

7 730-1094 981 042 1 718 728 2 708 488 1 016 732 6 424 988 12,6

8 1095-3599 3 789 862 6 069 256 8 919 360 5 661 844 24 440 320 47,8

9 3600-9999 651 749 959 319 2 334 740 5 415 708 9 361 520 18,3

Total 7 377 608 11 760 904 18 553 872 13 447 736 51 140 128 100,0

Inventory of in-house elderly care 31.12.2009 ,all Finland

Figures are Euros for one period since arrival

Since arrival Primary care

hospital Elderly care

home 24 - h service

home Service home Averagedays Day: 180 € Day: 125 € Day: 110 € Day: 95 € Day: 120 €0 1- 9 667 496 433 384 4551 10-29 3 122 2 162 2 014 1 770 2 1112 30-59 7 753 5 555 4 747 4 045 5 2003 60-90 13 304 9 138 8 112 6 911 8 8284 91-179 23 317 16 545 14 416 12 654 15 7505 180-364 48 363 33 703 29 421 25 213 32 1646 365-729 92 910 61 960 56 163 48 161 60 7857 730-1094 163 356 112 955 98 686 85 705 108 1508 1095-3599 323 153 224 189 192 681 187 609 217 9909 3600-9999 837 963 614 948 533 932 559 839 647 483Averrage 74 023 85 881 79 463 134 449 87 364Expensive period, over 75 000 € , indicate with purple

Inventory of in-house elderly care 31.12.2009 ,all Finland

Total capital invested since clients arrival until 31.12.2009, number are €

Since arrival Primary care

hospital Elderly care home 24 - h service

home Service home Total %

days

0 1- 9 2 445 840 € 499 375 € 334 180 € 52 630 € 3 332 025 € 0,1

1 10-29 8 849 520 € 1 768 625 € 1 981 540 € 389 500 € 12 989 185 € 0,2

2 30-59 13 513 680 € 4 383 250 € 5 743 320 € 1 152 730 € 24 792 980 € 0,4

3 60-90 11 680 740 € 5 766 000 € 9 061 250 € 1 858 960 € 28 366 950 € 0,5

4 91-179 37 516 500 € 27 861 000 € 40 047 150 € 9 237 325 € 114 661 975 € 1,9

5 180-364 89 278 020 € 94 469 750 € 139 425 440 € 28 667 485 € 351 840 695 € 5,8

6 365-729 188 607 600 € 241 951 875 € 308 448 800 € 87 218 930 € 826 227 205 € 13,5

7 730-1094 176 587 560 € 214 841 000 € 297 933 680 € 96 589 540 € 785 951 780 € 12,8

8 1095-3599 682 175 160 € 758 657 000 € 981 129 600 € 537 875 180 € 2 959 836 940 € 48,4

9 3600-9999 117 314 820 € 119 914 875 € 256 821 400 € 514 492 260 € 1 008 543 355 € 16,5

Total investment 1 327 969 440 € 1 470 113 000 € 2 040 925 920 € 1 277 534 920 € 6 116 543 280 € 100,0

Total red investment 1 316 674 080 € 1 093 412 875 € 1 535 884 680 € 1 148 956 980 € 5 094 928 615 €

Total red investment % 99 74 75 90 83 83

Inventory 31.12.2008Number of clients

Clients %

Inpatient days from arrival

Days %

Average treatment time Age

Need of support

Cost of period €

Total million cost €

€ per 75 + (403692)

Incable for self care 14562 21 12065352 23 829 82 4,2 91 190 € 1 327 € 3 288 €

Physical Problems or inabilities 8972 13 7633756 14 851 82 4 93 610 € 840 € 2 080 €Somatic Disorders, Dg. or treatment 16424 23 5992644 11 365 81 4,1 40 150 € 659 € 1 633 €

Lack or imperfections of mobility 4794 7 5720760 11 1193 78 4,1 131 230 € 629 € 1 559 €

Amnesia 7409 10 5593372 10 755 83 4,5 83 050 € 615 € 1 524 €

Dementia 5048 7 3031916 6 601 82 4,8 66 110 € 334 € 826 €

Loneliness, Insecurity 2186 3 2549440 5 1166 85 2,9 128 260 € 280 € 695 €

Other psycho-social Reasons 2127 3 2385858 4 1122 78 3,7 123 420 € 262 € 650 €

Housing Problems 1584 2 2345072 4 1480 81 2,8 162 800 € 258 € 639 €

Psychiatric illness / symptom 1304 2 1762449 3 1352 72 4,1 148 720 € 194 € 480 €

Communication imperfections 434 1 818905 2 1887 73 3,7 207 570 € 90 € 223 €

Other Causes of neurogenic condition 877 1 784205 1 894 82 4,3 98 340 € 86 € 214 €

Depression 432 1 460080 1 1065 81 3,6 117 150 € 51 € 125 €

 Lack of relevant assistance 429 1 373374 1 870 82 3,7 95 700 € 41 € 102 €

Drug abusers 387 1 365111 1 943 66 3,7 103 730 € 40 € 99 €

 Confusion 433 1 334071 1 772 82 4,3 84 920 € 37 € 91 €

Lack of appropriate treatment 646 1 314608 1 487 80 4,3 53 570 € 35 € 86 €

Rehabilitation 998 1 252630 0 253 78 3,6 27 830 € 28 € 69 €

Lack of home services 260 0 249087 0 958 81 3,3 105 380 € 27 € 68 €

Nurse in holiday 886 1 169396 0 191 80 4 21 010 € 19 € 46 €

Accident 345 0 150766 0 437 77 3,7 48 070 € 17 € 41 €

Medical Rehabilitation 65 0 18030 0 277 81 4,2 30 470 € 2 € 5 €

Unknown 147 0 11889 0 81 76 1 8 910 € 1 € 3 €

Total 70749 100 53382784 100 755 81 4,1 83 050 € 5 872 € 14 546 €

Reasons for institutionalization

Oversized service system

• In Finland we have some 40 000 death in institutions annually. The capacity of the service system is 70 000 places. Before death 80% of Finns have to stay in the service system for 1.75 years.

• Most of EU citizens stay in institutions only an average of a few (7…8) months.

• The red (inappropriately allocated) figures of some 5.0 billion € indicate that the service system could be reorganized to meet the needs of the ageing population.

Primary care ward used as home for years

Or is the ward a prison with small cells?

Or is the ward a factory producing bedridden elderly?

In Day room there are 6 chairs for 30 patients

or

two hour for a patient in a day

In these condition in 31.12.2009 totally 5362 elderly had lived over a year, each average 3,3 years in these condition.

Chair for a friend

The role of Elderly Care in cost management is underestimated

Euro

2M€

1st-year-perspective (2005)

Life-cycle (2006-2015)

4M€

6M€

Primary0,97M€

Euro

0,5M€

Special 0,2 M€

1,0M€

1,5M€

Stroke Coronary artery

Primary4,34M€

Special 1,4M€

Primary4,30M€

Special 0,1M€

Primary1,36M€

Special 0,01 M€

Annual resource use/costs in stroke and coronary artery for patients in care 31.12.2005 - special vs. primary care from 1st year and life-cycle perspective

1st-year-perspective (2005)

Life-cycle (2006-2015)

Source: Eklund, Vauramo, 2005

Re-organizing means new buildings

• Ministry of Social Affairs and Health recommended the amount of institutions to be as 3 % over 75 years old or 13 000 places

• Today we have 35 000 places. • Municipalities are key players but paralyzed• EU-level minimum quality standards or

recommendations are severely needed

Investment is needed

• Refurbishment requires (22 000 place x 40 m2 x 2000 €/m2 = 1.6 billion €) funding.

• The new care facilities have to be located in village or city centres. – Elderly need to use normal services at walking distance. – The public space of care home is also a living room for

neighborhood.

• The rent will be high, but the self care is possible – Healthy elderly require much less personnel!– Pay-back time of the structural change is 8-10 years

Rehabilitation is a core function• In the future the current

number of personnel are able to take care of about double the amount of elderly, if – A regional rehabilitation

service exist – Rehabilitation will be started

according to the symptoms without delay

– Elderly are located to service facilities by neutral body based on individuals need

– The environment support elderly when they are training and keeping on their physical condition

Regional rehabilitation is the best way to manage the ageing

Treatment Assessment Judgment

Rehabilitation

24-h service home

Sheltered home

Home

Final placement will be done after a rehabilitation period

Forming a regional rehabilitation centre

patie

nt

flow

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alis

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SEGREGATED SILO ORGANISATION

ISOLATED, PROFESSION-CENTERED

Focused on organisation by medical speciality

REGIONAL SERVICE NETWORK

INTERCONNECTED, CUSTOMER-CENTERED

Medical specialities are focused on solving problems collaboratively

Professional devlopment

Regional Centre

for rehabilitation

Ph

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Reh

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Dru

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Men

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Multidisciplinary Teams

Stand-alone elderly care institution

Passive, work-intensive environment

Integration into multifunctional urban blocks

Active environment supporting self-care

Home care services based on the needs of the elderly living in the area

Housing

Housing for the elderly

Common Services and spaces

school

Common spaces

café

services

Care home

shops

Integrating Care from stand-alone institutions back to Society

An ageing society needs more space!