Introduction

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With the historic rise in life expectancy during this century, the human life span is now divided into four ages: the first is an age of dependency, childhood, and education, the second is an age of independence, maturity, and responsibility, and although the third age is considered a period of fulfilment for physically and mentally fit people in retirement, the fourth age is associated with disability and dependence.¹ The size and pattern of the fourth age is of critical importance not only for the quality of life of elderly people but also because disability is closely associated with use of health and social services.² The rising costs of the fourth age have precipitated policy discussion across the developed world,³ a national plan in Japan,⁴ reform of long term care funding in Germany,⁵ and the appointment of a Royal Commission in the United Kingdom.

The pattern of disability in the elderly population in England and Wales was last studied in detail in 1986.⁶ This study showed rising rates of disability with age and significantly higher rates for women. The patterns of disability associated with cognitive impairment, however, have been less clear. ^{7 8} Accurate national estimates of the numbers of cognitively impaired and physically disabled elderly people, subdivided by a range of sociodemographic, dependency, care receipt and survival variables are needed to support debates over the form and funding of government health and welfare support and for local service planning. The Medical Research Council's cognitive function and ageing study and resource implications substudy provide a basis for contemporary estimates. This longitudinal cohort study of elderly people began in 1991-2, and follow up data from the first 2 years provide estimates of the use of the range of provisions to those who are disabled.

	Subjects and methods

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Study design
A full description of the study design can be found elsewhere.⁹ Briefly, random population samples of people in their 65th year and above were obtained from Family Health Service Authority lists in six areas of England and Wales (although data on resource use were collected in only the four sites included in this analysis). Sites were chosen as representing the main national variation in urban-rural differences, regional heterogeneity, and the presence of academic groups experienced in population studies. Ethical approval was obtained in each study site.

Scales and classification
The modified Townsend activities of daily living scale covers washing all over, cutting toenails, getting on a bus, going up and down stairs, doing heavy housework, going shopping and carrying heavy bags, preparing and cooking hot meals, reaching an overhead shelf, and tying a good knot in a piece of string. ^{11 12} Scores are: 0, if the person can perform the activity with no difficulty; 1, if the person can perform the activity but with difficulty; and 2, if the person needs help to perform the activity. Totalled scores ranged from 0 (no incapacity), to 1 or 2 (slight incapacity), 3-6 (some incapacity), 7-10 (appreciable incapacity), 11 or more (severe incapacity). Severe incapacity might describe a person who needs help to do at least two of the activities and has some difficulty with all of the rest.

	Results

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Table 1 shows the estimated numbers of disabled elderly people by type of disability, age, and sex. Using the study definitions, there were an estimated 1.3 million disabled elderly people in England and Wales (15.7% of those aged 65 and over, 95% confidence interval, 15.1% to 16.3%). These and subsequent estimates were weighted by sex and 5 year age groups to reflect the population structure of England and Wales in 1996,¹⁶ and calculation of confidence intervals took account of each age and sex weighted group separately. Prevalence rates were lower in men (10.6%, 9.7% to 11.5%) than in women (19.2%, 18.3% to 20.1%).

Women accounted for 72% of the disabled group, with the preponderance of women becoming more pronounced with age. Cognitive impairment was present in over a third of all disabled elderly people (38.3%, 36.0% to 40.6%), and these were more or less equally divided between the cognitive only or combined categories. People aged 85 and over made up 37.6% (35.6% to 39.7%) of the total number with disability.

A good summary of overall level of dependence was the critical interval of need for care. Of the 1.3 million disabled elderly people, 3% (35 576) were independent, 14% (171 586) needed care less often than daily, 62% (778 401) needed care at some time every day (short interval) and 21% (268 863) needed care or supervision continuously (critical interval).

Only 1% of the subjects who were not disabled by study definitions lived in institutional care. However, 17% of those with only cognitive impairment, 18% of those with only physical disability, and 52.8% (47.3% to 58.3%) of those with combined disability lived in institutions. Overall, 46% of all those living in institutions had diagnostic levels of cognitive impairment. By contrast, accommodation with a warden provided care for only 9% of those with combined disability and catered for many people who were not classified as disabled. The proportions of disabled elderly people living alone or in institutions increased sharply with age, especially among women56% of institutional places for the disabled were filled by people aged 85 or over and 79% were filled by women.

Table 2 shows the proportions of each disability group in the community by type of help received and type of helper. Although most of the care required involved household tasks, 38% of those with combined disability received help with personal care tasks. Most of this help was supplied by informal care givers, but the contribution of formal community support including, for example, home help, care workers, meals on wheels, and community nurses, was far from insignificant. Formal services were the sole reported source of support for 29% of people who were physically disabled only and 23% of those with combined disability, and these services complemented informal support in a further 10% and 11% respectively.

Over the 2 year period of follow up from baseline interview (undertaken in subjects in the resource implications study only, which excludes those without disability), 63.2% (60.7% to 65.8%) used acute hospitals, with 43% doing so as inpatients. Rates of acute hospital use were even higher in disabled people living in the community (table 3). Cognitive impairment was associated with relatively lower use of all forms of hospital care. For those living in the community there was also a small decrease in use of all hospital services with age, with 72% of those aged 65 to 74 using hospital care compared with 71% aged 75 to 84 and 63% of those aged 85 and over.

In the 2 years after initial interview, 10% of the whole group of elderly people died, but rates were far higher in those with cognitive impairment (25%), physical disability (26%), or combined disability (48%).

	Discussion

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Throughout the developed world, the funding of care for disabled elderly people has become a highly publicised political issue. In the United Kingdom, total public expenditure on long term care is already estimated to account for 3.6% of the gross domestic product,¹⁷ and some have suggested that overall costs might rise as high as 10.8% by 2030.¹⁸ Not surprisingly, UK governments have undertaken a series of reforms in this area, including narrowing access to NHS continuing care and thereby extending means testing.¹⁹ In future policy debates, estimates of the numbers and types of people who need long term care should be central.

Comparison with general household survey estimates
Several problems with the estimates presented above should be noted. The four areas included in the study are diverse, but are not fully representative of England and Wales. However, comparisons of study estimates for 1991 with those produced by the nationally representative general household survey for the same year²⁰ mostly show remarkable similarity, for example, in the proportion of people living at home who had no difficulty with particular tasks. However, reported proportions of elderly people who were living in residential or nursing home care in 1994 were marginally higher than study estimates for that year.²¹ These differences may be the result of having no study sites in the retirement areas of the country. However, government policy aims to reduce rates of elderly people living in nursing and residential homes and thus the estimates presented give a picture that is appropriate for future care planning.

Implications
In considering the results, it is important to remember that disability is not an attribute that is clearly present or absent, but rather a matter of degree. While policy makers may like to classify people as fit or disabled, in need or not, in reality a full spectrum of disability is present, from slight to very severe. This lack of a natural cut off point between those in need of long term care and those not in need of long term care has obvious implications for establishing workable eligibility criteria for long term care funding. It also means that providers of care have substantial scope to offer services to comparatively less disabled groups, thus expanding the size and cost of long term care programmes.