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Age and Ageing Advance Access originally published online on February 4, 2008
Age and Ageing 2008 37(2):187-193; doi:10.1093/ageing/afm185
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Copyright © The Author 2008. Published by Oxford University Press on behalf of the British Geriatrics Society.

Changes in the prevalence of chronic disease and the association with disability in the older Dutch population between 1987 and 2001

M. T. E. Puts1,6, D. J. H. Deeg1,, N. Hoeymans2, W. J. Nusselder3 and F. G. Schellevis4,5

1 EMGO Institute, VU University Medical Center, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
2 National Institute of Public Health and the Environment (RIVM) 3720 BA, Bilthoven, The Netherlands
3 Erasmus University Medical Center, Department of Public Health, 3000 CA Rotterdam, The Netherlands
4 Netherlands Institute of Health Services Research (NIVEL), 3500 BN Utrecht, The Netherlands
5 Department of General Practice, VU University Medical Center, Amsterdam, The Netherlands
6 Present address: Centre for Clinical Epidemiology and Community Studies, Solidage Research Group, Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montréal, Québec, Canada

Address correspondence to: D. J. H. Deeg. Tel: + 31 20 4446770; Fax: + 31 20 4446775. Email: djh.deeg{at}vumc.nl


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conflict of interest
 Supplementary data
 References
 
Background: most studies of older populations in developed countries show a decrease in the prevalence of disabilities, and an increase in chronic diseases over the past decades. Data in the Netherlands, however, mostly show an increase in the prevalence of chronic diseases and mixed results with regard to the prevalence of disability. This study aims at comparing changes in the prevalence, as well as the association between chronic diseases and disability between 1987 and 2001 in the older Dutch population using data representative of the general population. Most studies, so far, have only dealt with self-reported diseases, but in this study, we will use both self-reported and GP-registered diseases.

Study Design: data from the first (1987) and second (2001) Dutch National Survey of General Practice were used. In 1987, 103 general practices, compared to 104 in 2001, participated. Approximately 5% of the listed persons aged 18 years and over was asked to participate in an extensive health interview survey. An all-age random sample was drawn by the researchers from the patients listed in the participating practices (in 1987 n = 2, 708; in 2001 n = 3, 474). Both surveys are community based, with an age range between 55 and 97 years. Data on chronic diseases were based on GP registries and self-report.

Results: the prevalence of disability and of asthma/COPD, cardiac disease, stroke, and osteoarthritis decreased between 1987 and 2001, while the prevalence of diabetes increased. Changes were largely similar for GP-registered and self-reported diseases. Cardiac disease, asthma/COPD, and depression led to less disability, whereas low back pain and osteoarthritis led to more disability.

Conclusions: in general, there were reductions in GP-registered chronic diseases as well as in self-reported diseases and disability. Results suggest that the disabling impact of fatal diseases decreased, while the impact of non-fatal diseases increased.

Keywords: general practice, disability, co-morbidity, functional limitations, mobility, elderly


   Introduction
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 Abstract
 Introduction
Methods
 Results
 Discussion
 Conflict of interest
 Supplementary data
 References
 
Studies investigating trends in disability show different results across countries and periods [1], but most studies show a decline in the prevalence of less severe disability since the 1980s [2–6]. The majority of these studies have been conducted in the United States. In European countries, however, different trends have been reported [1, 2, 7]. Furthermore, studies have shown an increasing prevalence of chronic diseases in the past 20 years [7, 8]. This may partly be explained by earlier diagnoses and improved medical treatments. As a result, persons with chronic diseases may live longer. In addition, persons suffering from a chronic disease may be less disabled because their disease is diagnosed at an earlier stage or because improved medical care and increased use of assistive devices have reduced its deleterious effects [9]. Most studies have shown that specific chronic diseases have led to less disabilities during the past 20 years [7, 10, 11].

Studies investigating changes in the prevalence and the disabling impact of diseases so far have only used self-reported diseases. Trends in self-reported diseases might differ from trends observed in doctor-diagnosed diseases, in particular, when reporting behaviours or when the propensity to seek care changes over time.

Because of the differences in health care systems and developments in medical care, trends cannot be easily translated from one country to another [1]. In the Netherlands, there is little evidence that the prevalence of diseases has increased and that the prevalence of disability has decreased [11–14]. The aim of this study is to investigate the changes in the prevalence of chronic diseases and disability, and to examine the association between chronic diseases and mobility limitations/activities of daily living (ADL) disability between 1987 and 2001 in the older Dutch population.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conflict of interest
 Supplementary data
 References
 
Study sample
Data from the first and second Dutch National Survey of General Practice (DNSGP1/2) were used [15, 16]. Both surveys were conducted according to Dutch privacy legislation, and a privacy regulation was approved by the Dutch Data Protection Agency. They were conducted in 1987 and in 2001, in samples of general practices in the Netherlands, and are representative for all general practices. Because in the Netherlands all non-institutionalised inhabitants are registered in a general practice, this sample is population based. In 1987, 103 general practices, compared to 104 in 2001, participated. These practices were representative of the Netherlands' population with respect to sex, age, and level of urbanisation. Approximately 5% of the listed persons aged 18 years and over were asked to participate in an extensive health interview survey. An all-age random sample was drawn by the researchers from the patients listed in the participating practices. In 1987, 10,127 (response 76%) while in 2001, 9,685 (response 65%) participated. The non-response was shown not to be selective considering age and sex. In this study, persons aged 55 and older are included (1987 n = 2, 708, 2001 n = 3, 474).

Measuring instruments

GP-registered and self-reported chronic diseases
GP-registered diseases were collected prospectively by the GPs during contact with patients over a 3-month (1987) or 1-year (2001) period. To enhance the comparability of these studies, a 3-month random sample was drawn from the 2001-database. The GP diagnoses were coded using the International Classification of Primary Care (ICPC) [17]. In 1987, the diagnoses were registered on forms, and clerks coded these retrospectively. In 2001, ICPC codes were automatically derived from the patients' electronic medical records. We selected ten GP-registered diseases, which were included in both years (Table 1): diabetes mellitus, cardiac disease, cardiac arrhythmia, stroke, rheumatoid arthritis, osteoarthritis of the hip or knee, lower back complaints (LBP) (including osteoarthritis of the spine and hernia nuclei pulposi), asthma/chronic obstructive pulmonary disease (COPD), depression, and anxiety disorder.


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  		Table 1. Description of the study samples in 1987 (n = 2,708) and 2001 (n = 3,474) (after standardisation for age and sex)

 
In both health interviews, respondents were asked whether they had had any specific condition in the 12 months preceding the interview. In each interview, the latest version of the questionnaire as developed by Statistics Netherlands was used. The 1987 and 2001 questionnaire allowed for the comparison of four self-reported diseases; diabetes mellitus, cardiac diseases, asthma/COPD, and LBP.


Mobility limitations and ADL disability
Both interviews included questions about mobility and ADL. Mobility consisted of 4 items: climbing a staircase, carrying a bag of 5 kg for 10 m, lifting an object while standing, and walking for 400 m without resting (with a walking aid if needed). ADL consisted of three items: transfer to another room on the same floor, getting in and out of bed, and dressing and undressing oneself. The questions on mobility and disability in 1987 had three response categories: no difficulty, much difficulty, and unable. The questions in 2001 had four response categories: no difficulty, a little difficulty, much difficulty, and unable. We defined mobility limitations/ADL disability as a report of much difficulty or inability to perform at least one out of the four/three tasks. Mobility difficulty and ADL disability were dichotomised.


Confounders
Age and sex were known for all respondents from the practice administration. Age was divided into categories (55–64, 65–74, 75–84, 85+). The level of education attained was classified into four categories: low (none or primary school), middle (secondary school, lower, or middle vocational education), high (high vocational education or university) and missing. This last group did not differ from the other groups with regard to age, sex, self-assessed health, chronic diseases, or disability. Another confounder was the level of contact with the GP during the 3-month period (none/one/two or more contacts). A higher level of contact increases the chance of having a disease diagnosed. Co-morbidity was considered a confounder when examining the association between disease and disability. For each disease, we calculated a dichotomous co-morbidity score (no additional diseases versus one or more) using the GP-registered diseases or the self-reported diseases listed above.


Statistical analyses
Logistic regression was used for investigating the change in the prevalence of disease and mobility limitations/ADL disability, and in the association between both. Further details of the statistical analyses are given in Appendix 1 of the Supplementary data.


   Results
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 Abstract
 Introduction
 Methods
 Results
Discussion
 Conflict of interest
 Supplementary data
 References
 
Table 1 presents the characteristics of both samples. The level of education and the number of persons with no face-to-face contacts with a GP increased between 1987 and 2001.

The prevalence of mobility limitations and ADL disability decreased for both men and women. The decrease in mobility limitations was larger for men than for women.

The prevalence of cardiac disease, osteoarthritis, depression, and asthma/COPD declined, although the decline in asthma/COPD was only significant in men (see Table 2). The prevalence of diabetes increased, but again, only statistically significantly in men. These results apply to doctor-diagnosed diseases. The results for self-reported diseases are largely similar. The increase in diabetes is significant for both men and women. The decrease in self-reported cardiac diseases is significant only in women, while the decrease in asthma/COPD is only significant in men. Self-reported LBP decreased significantly.


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  		Table 2. Change in the prevalence of chronic diseases, mobility limitations, and ADL disability for men and women, presented as Odds Ratio (OR) and 95% confidence interval (95% CI)

 
For most GP-registered diseases, the association with mobility limitations and ADL disability did not change between 1987 and 2001 with the exceptions of LBP, depression, and osteoarthritis (see Table 3). The association between mobility limitations and depression weakened but became stronger between mobility limitations and LBP. The association between ADL disability and osteoarthritis also became stronger.


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  		Table 3. The association between chronic diseases and mobility limitations/ADL disability presented as Odds Ratio (OR) and 95% confidence interval (95% CI)

 
For the self-reported diseases, there were more changes in their association with disability. The association between self-reported LBP and disability became stronger (both ADL and mobility limitations). The association between self-reported cardiac diseases, asthma/COPD, and mobility limitations weakened.

The results for the sensitivity analyses can be found in the supplementary data.


   Discussion
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 Abstract
 Introduction
 Methods
 Results
 Discussion
Conflict of interest
 Supplementary data
 References
 
The prevalence of mobility limitations and ADL disability decreased between 1987 and 2001, which is in agreement with the results of most studies from other countries reporting over the same time period [2, 18]. Another Dutch study found a small decrease in the prevalence of mobility limitations between 1990 and 1998 only among men [19], while a second Dutch study regarding community-dwelling persons aged 55–64 showed an increase in disability between 1992/1993 and 2001/2002 [20]. However, the selection of mobility limitations and ADL disability differed, and therefore the trends might be justifiably different.

The prevalence of most diseases, whether GP-registered or self-reported, also decreased, with the exception of diabetes mellitus, which increased. The decrease in the prevalence of cardiac disease might be due to increasing attention paid to high cholesterol and hypertension by GPs. Furthermore, there have been active campaigns in the Netherlands since the 1980s to persuade the population to quit smoking, to eat less saturated fat, and have an active lifestyle. As a result, the percentage of smokers and the dietary intake of saturated fats have decreased considerably in the Netherlands [14]. The prevalence of asthma/COPD decreased in men but not in women, which could reflect that the percentage of smokers began to decrease earlier for men than for women [21]. Our findings of the declining prevalence of most diseases are in contrast with studies from other countries which reported an increase over the same period [7, 8]. An increase in the prevalence of asthma, diabetes, and depression, and a decrease in the prevalence of COPD has been reported in the Netherlands [14]. The prevalence of rheumatoid arthritis and osteoarthritis has been shown to fluctuate substantially in the period 1971–2003. (http://www.rivm.nl/vtv/object_document/o1716n18370.html). The fact that both the prevalence of self-reported and GP-registered diseases decreased suggests that changes in reporting behaviour are unlikely to have driven these trends. However, it remains unclear as to why reductions in prevalence for most diseases are seen in this study.

The association between disease and mobility limitation/ADL disability show different trends depending on the disease. Some fatal diseases such as cardiac disease and asthma/COPD became less disabling, while some non-fatal diseases, such as LBP and osteoarthritis, became more disabling. For others, no change was observed. Similar changes in disabling effects have been reported elsewhere [7, 10].

The reduction of the prevalence of most diseases might have contributed to the substantial reductions in mobility limitation and ADL disability. For some diseases with a known high impact on disability, such as stroke and rheumatoid arthritis, there was no change in their disabling effect. Therefore, their lower prevalence is likely to have reduced the prevalence of disability from this cause. Other diseases, such as cardiac disease and asthma/COPD, both became less prevalent and led to less disability. In the last 30 years, a strong focus on the treatment of fatal diseases has resulted in an improvement in care for persons suffering from cardiac disease [22]. For non-fatal diseases, only recently has much effort been put into reducing their consequences. This corresponds to the findings that health care use related to these diseases was much lower than for fatal diseases despite their prevalence and limitations [23].

It is noteworthy that a few diseases became less prevalent but led to more disability. For LBP, the decreasing prevalence might reflect occupational changes associated with the increase in levels of education and technological innovations [24]. A decrease in occupational disability due to back and neck pain in the Netherlands between 1980 and 2000 has been reported [25]. There is evidence to suggest that GPs follow the guidelines for back pain management introduced in 1996. These guidelines emphasise good prognoses in LBP and advise staying active. In earlier years, bed rest was recommended, which turned out to be detrimental, leading to more chronic LBP [26]. Statistics Netherlands (http://www.cbs.nl/en-GB/default.htm) reported that the percentage of persons who retire early increased between 1996 and 2001. Combined, this information might explain the decrease in the prevalence of LBP. The smaller group of persons still experiencing LBP might increasingly consist of persons with more severe complaints.

In the case of diabetes, prevalence rose, while the association with disability did not change significantly. This rising prevalence was also reported in other Dutch studies and is most likely the result of improved screening [13, 27]. GPs in 2001 were more likely to screen their older patients with risk factors for diabetes such as high cholesterol, than did GPs in 1987, due to increasing awareness of the under-detection of diabetes [28]. Furthermore, a Dutch Diabetes Association campaign encourages people exhibiting symptoms of diabetes to report to their GP. Our sensitivity analyses showed the highest increase in prevalence to be in the youngest group. A Danish study showed a large increase in the prevalence of diabetes in 60-year-olds between 1974/1975 and 1996/1997 which could be fully explained by the concurrent increase in BMI [29]. The prevalence of obesity is also increasing considerably in the Netherlands and is highest in the 50–59-year-olds. This might explain why diabetes increased most in our youngest respondents (http://www.rivm.nl/vtv/object_document/o1254n18950.html).

The decline in mobility limitation and ADL disability might be the result of improvements in medical treatments and increased availability of assistive devices such as walking aids [2]. Because of these aids, persons may be less likely to report difficulties.

As in the Netherlands, virtually all non-institutionalised inhabitants are registered in a general practice, the respondents in both years were comparable to the Dutch population with regard to age and sex. The response rate in 2001 was lower than that of 1987, but remained considerable at 65%. The responders and non-responders were not different from each other in terms of age and sex. Unfortunately, no data on health status are available for the non-response analysis, so we cannot rule out the possibility that our results may have been affected by the selection bias of the more healthy subjects in 2001. Furthermore, our self-reported prevalence rates were higher when compared with GP-registered diseases. The low prevalence of doctor-diagnosed diseases may have hampered our analyses due to insufficient power, and consequently, wide confidence intervals (CIs). Our sensitivity analyses showed that the overall concordance was satisfactory for all four diseases and the inter-rater reliability for the GP-coding was also satisfactory. Despite a lack of power for the doctor-diagnosed diseases, the results for the four GP-registered and self-reported chronic diseases that we could compare were very similar, indicating that these results are robust.

Another limitation may be that the sampling design in which patients are clustered within the GP practice would require multilevel analysis. However, due to the small number of patients in each practice, we could not perform multilevel analyses. Based on our sensitivity analyses and the random selection of patients from the practices, we believe that our findings are robust from bias caused by potential clustering of the patients. A final limitation is that the response categories of the disability questions were not identical in both years. Changes in the response categories (3 in 1987, 4 in 2001) made it impossible to distinguish severity of the limitation. The reported decrease in disability might be accompanied by an increase in mild functional limitations, findings which our sensitivity analyses supported.

In conclusion, the prevalence of most diseases decreased, and fatal diseases have become less disabling. To assist health care policy and planning, further research is required in order to examine the possible increase of mild disability and to assess the roles of medical technology and assistive devices. More research is required in order to confirm the consistency of the increase in the disabling effects of non-fatal diseases and the underlying mechanisms causing this deterioration, as this increase would have a major impact on future health care use and quality of life.

Key points

  • This study used data from the first (1987) and second (2001) DNSGP (community-based samples) with ages ranging between 55 and 97 years in both surveys.
  • The prevalence of several chronic diseases decreased in the Netherlands. This was shown using both self-report and doctor diagnoses during the period 1987–2001.
  • The fatal diseases became less disabling, while the non-fatal diseases became more disabling in this period.
  • More research is needed to investigate if these findings are consistent across the Western countries, and to clarify the underlying mechanisms, as they imply a major impact on the quality of life of older persons who suffer from non-fatal chronic diseases.


   Conflict of interest
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflict of interest
Supplementary data
 References
 
There was no conflict of interest.


   Supplementary data
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflict of interest
 Supplementary data
References
 
Supplementary data for this article are available online at http://ageing.oxfordjournals.org.


   Acknowledgements
 
The National Institute of Public Health and the Environment (RIVM) in the Netherlands funded this study.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflict of interest
 Supplementary data
 References
 

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Received 9 March 2007; accepted in revised form 17 September 2007.


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