AIMS:We projected the future number of individuals with dementia and long-term care (LTC) residents in Finland by education level through 2040. We also examined the impact of different future scenarios regarding declining dementia and LTC trends, as well as the effect of past educational expansion on the future prevalence of dementia and LTC. METHODS:A multistate model tracks the population aged 65 years and over through states characterised by the presence of dementia, LTC residence, or death. We calculated age, gender, education and year-specific transition probabilities from Finnish registry data under various scenarios. RESULTS:Assuming constant transition probabilities, the number of individuals with dementia is projected to rise by 74% (from 123,800 to 215,900) between 2018 and 2040. The number of LTC residents is expected to increase by 58% (from 73,900 to 116,800). Driven mainly by shifts in population education distribution, the number of people with dementia is projected to decrease by 29% among those with basic education, while increasing by 215% and 260% among those with secondary and tertiary education, respectively. If both dementia incidence and mortality decrease as projected for overall mortality, the number of people with dementia and LTC residents would rise by 67% and 73%, respectively. If the declining trend in LTC use observed prior to 2018 persists, the number of LTC residents could decrease by 10% by 2040. CONCLUSIONS:Even under optimistic assumptions of declining dementia incidence and mortality, the burden of dementia on health and social care systems is projected to persist.

Objective This study quantifies sibling experiences across childhood by birth cohort and maternal education.Background As family structures evolve, sibling complexity-the presence of half and stepsiblings-is becoming more common. Yet, little is known about how sibling constellations unfold across childhood, vary between cohorts, or differ by social background.Method Annual register data of full Finnish birth cohorts 1988 (n = 64,597) and 2000 (n = 56,413) were used to identify all full, half, and step-sibling constellations from birth to age 16. Sequence analysis was employed to create relative frequency plots and calculate the number of and time spent in different sibling constellations.Results By age 16, 35% of children in the 2000 cohort had experienced sibling complexity, nearly 20% more than the 1988 cohort. The most common experience of sibling complexity was growing up with older full and half siblings. Trajectories with stepsiblings were less common, and having both half and stepsiblings remained rare. Children of basic-educated mothers experienced more sibling complexity and instability, with greater increases over time than children of more educated mothers.Conclusion Increases in family complexity extend into changing sibling kinships, but the experiences of sibling complexity vary considerably by social background. Research and policy should acknowledge the growing share of families navigating diverse sibling constellations and attend to both the causes and consequences of these evolving experiences.

British housing systems seem trapped in a ‘perfect storm’ of rising costs, declining choice, affordability stress, and unmet need. Housing outcomes are increasingly polarised, with implications for intergenerational conflict, economic and social inequalities, and environmental sustainability. There is no easy explanation, and no quick fix. These six short reflections, shared during an interdisciplinary meeting of Fellows of the British Academy, on the origins, impacts, and future of the present housing `crisis' are thus timely provocations adding momentum to key debates. This article accompanies another in this issue, ‘The UK housing emergency: personal reflections’, by Shani Dhanda, Susan J. Smith, and Jessie Speer.

Many studies indicate that Total fertility rates (TFR(t)) are negatively correlated with life expectancies at birth (e0(t)). We found that complete random-combinations of TFR(t) and e0(t) would result in about 24

IntroductionHousing is a major influence on health. Housing tenure is associated with housing conditions, affordability, and security and is an important dimension of housing. In the UK there have been profound changes in both housing conditions and the distribution of households by tenure over the past century, that is during the lifetimes of the current population.MethodsWe firstly reviewed and summarise changes in housing conditions, housing policy and tenure distribution as they provide a context to possible explanations for health variations by housing tenure, including health related selection into different tenure types. We then use 2015-2021 data from a large nationally representative UK survey to analyse associations between housing tenure and self-reported disability among those aged 40-69 controlling for other socio-demographic factors also associated with health. We additionally examine changes in the association between housing tenure and self-reported disability in the population aged 25 and over in the first two decades of the 21st century and project trends forward to 2030.ResultsResults show that associations between housing tenure and disability by tenure were stronger than for any other indicator of socio-economic position considered with owner-occupiers having the best, and social renters the worst, health. Differences were particularly marked in reported mental health conditions and in economic activity, with 28% of social renters being economically inactive due to health problems, compared with 4% of owner-occupiers. Rates of disability have increased over time, and become increasingly polarised by tenure. By 2020 the age standardised disability rate among tenants of social housing was over twice as high as that for owner occupiers, with projections indicating further increases in both levels, and differentials in, disability by 2030.DiscussionThese results have substantial implications for housing providers, local authorities and for public health.

Objectives Excess winter mortality is a well-established phenomenon across the developed world. However, whether individual-level factors increase vulnerability to the effects of winter remains inadequately examined. Our aim was to assess long-term trends in excess winter mortality in Finland and estimate the modifying effect of sociodemographic and health characteristics on the risk of winter death.Design Nationwide register study.Setting Finland.Participants Population aged 60 years and over, resident in Finland, 1971–2019.Outcome measures Age-adjusted winter and non-winter death rates, and winter-to-non-winter rate ratios and relative risks (multiplicative interaction effects between winter and modifying characteristics).Results We found a decreasing trend in the relative winter excess mortality over five decades and a drop in the series around 2000. During 2000–2019, winter mortality rates for men and women were 11% and 14% higher than expected based on non-winter rates. The relative risk of winter death increased with age but did not vary by income. Compared with those living with at least one other person, individuals in institutions had a higher relative risk (1.07, 95% CI 1.05 to 1.08). Most pre-existing health conditions did not predict winter death, but persons with dementia emerged at greater relative risk (1.06, 95% CI 1.04 to 1.07).Conclusions Although winter mortality seems to affect frail people more strongly—those of advanced age, living in institutions and with dementia—there is an increased risk even beyond the more vulnerable groups. Protection of high-risk groups should be complemented with population-level preventive measures.

Objectives Residential long-term care (LTC) use has declined in many countries over the past years. This study quantifies how changing rates of entry, exit, and mortality have contributed to trends in life expectancy in LTC (i.e., average time spent in LTC after age 65) across sociodemographic groups.Methods We analyzed population-register data of all Finns aged >= 65 during 1999-2018 (n = 2,016,987) with dates of LTC and death and sociodemographic characteristics. We estimated transition rates between home, LTC, and death using Poisson generalized additive models, and calculated multistate life tables across 1999-2003, 2004-2008, 2009-2013, and 2014-2018.Results Between 1999-2003 and 2004-2008, life expectancy in LTC increased from 0.75 (95% CI: 0.74-0.76) to 0.89 (95% CI: 0.88-0.90) years among men and from 1.61 (95% CI: 1.59-1.62) to 1.83 (95% CI: 1.81-1.85) years among women, mainly due to declining exit rates from LTC. Thereafter, life expectancy in LTC decreased, reaching 0.80 (95% CI: 0.79-0.81) and 1.51 (95% CI: 1.50-1.53) years among men and women, respectively, in 2014-2018. Especially among women and nonmarried men, the decline was largely due to increasing death rates in LTC. Admission rates declined throughout the study period, which offset the increase in life expectancy in LTC attributable to declining mortality in the community. Marital status differences in life expectancy in LTC narrowed over time.Discussion Recent declines in LTC use were driven by postponed LTC admission closer to death. The results suggest that across sociodemographic strata older adults enter LTC in even worse health and spend a shorter time in care than before.

Abstract Background Residential long-term care (LTC) coverage has declined in many countries over the past decade. However, it is unclear to what extent the decline is attributable to a smaller proportion of older people entering or shorter time spent in LTC, and if the change has been similar across sociodemographic groups. This study analysed changes in life expectancy in LTC at age 65, the proportion ever entering, and years spent in LTC among those who entered, and quantified the contributions of changing rates of admission, mortality and exit to the change in life expectancy in LTC. Methods We analysed linked population register data that covered all Finnish residents aged 65+ between 1999 and 2018 (n = 2,016,987) on dates of entries to and exits from LTC, dates of death, and sociodemographic characteristics. We estimated transition rates between home, LTC and death, and calculated multistate life tables by sex, marital status and education across four periods 1999-2003, 2004-2008, 2009-2013 and 2014-2018. Results Life expectancy in LTC increased from 0.75 to 0.89 years among men and from 1.61 to 1.83 years among women between 1999-2003 and 2003-2008. The increase was mainly attributable to declining rates of exit from LTC, and thereby longer time spent in LTC for those who entered. Life expectancy in LTC started declining in 2009-2013 and reached 0.80 years among men and 1.51 years among women in 2014-2018. The decline mainly related to an increasing death rate in LTC. In all periods, declining mortality in the community contributed to an increase in life expectancy in LTC, but this was offset by steady declines in admission rates. Life expectancy in LTC changed similarly across marital status and education groups. Conclusions Recent declines in LTC use - driven by lower rates of entry and higher mortality in LTC when entered - imply that across sociodemographic strata it is has become more difficult to find LTC placement and older people enter LTC in ever worse health. Key messages • Overall LTC use increased in early 2000s despite declining admission rates. The increase was mainly due to declining exit rate from LTC indicating longer time spent in LTC for those who entered. • The recent shortening of life expectancy in LTC derives from entering LTC at a later stage and closer to death, indicating greater level of disability and worse health at the time of entry.

The burden of type 2 diabetes (T2D) differs between socioeconomic groups. The present study combines ongoing and plausible trends in T2D incidence and survival by income to forecast future trends in cases of T2D and life expectancy with and without T2D up to year 2040. Using Finnish total population data for those aged 30 years on T2D medication and mortality in 1995–2018, we developed and validated a multi-state life table model using age-, gender-, income- and calendar year-specific transition probabilities. We present scenarios based on constant and declining T2D incidence and on the effect of increasing and decreasing obesity on T2D incidence and mortality states up to 2040. With constant T2D incidence at 2019-level, the number of people living with T2D would increase by about 26% between 2020 and 2040. The lowest income group could expect more rapid increases in the number with T2D compared to the highest income group (30% vs. 23% respectively). If the incidence of T2D continues the recent declining trend, we predict about 14% fewer cases. However, if obesity increases two-fold, we predict 15% additional T2D cases. Unless, we reduce the obesity-related excess risk, the number of years lived without T2D could decrease up to 6 years for men in the lowest income group. Under all plausible scenarios, the burden of T2D is set to increase and it will be unequally distributed among socioeconomic groups. An increasing proportion of life expectancy will be spent with T2D.

OBJECTIVES:To investigate the slowdown in mortality improvement in the United States, United Kingdom, and comparator countries observed in the first decade of the twenty-first century and critically evaluate proposed explanations.METHODS:Change-point analysis to identify the year of change in comparison of national mortality trends and linear spline models in the investigation of subnational differences using data from the Human Mortality Database, Global Burden of Disease cause-specific data, and, for the United Kingdom, national statistics data. Consideration of the impact of using different methods to estimate overall mortality is also concluded together with a review of methodological assumptions made in previous studies.RESULTS:The results confirm the slowdown in mortality improvement observed in the early twenty-first century but indicate that proposed explanations for this are inadequate on a range of counts.DISCUSSION:Mortality improvement slowed down in the early twenty-first century but the explanations advanced, such as opioid use in the United States or influenza epidemics and austerity programs in the United Kingdom, seem unlikely to account for this. Further research considering longer-term life course and cohort influences is needed.

The annual percentage improvement in standardised mortality rates in the period 2011-19 was the lowest for 70 years, whereas the 2001-10 value was the highest since records began in 1841. A similar slowdown occurred from around 2011 in most European Union countries, although this was generally less severe than in Britain. Life expectancy at birth actually fell in USA for three successive years in period 2014-17. The downturn in Britain since 2011 was wide-ranging, affecting young and old, women and men and the more and the less advantaged to a broadly similar extent. Year-to-year variation in mortality increased mainly due to increased volatility in winter excess mortality from 2011, but all seasons showed lower rates of improvement in underlying longer-term trends. Mortality had started to improve at the end of the decade and the 2019 value was the lowest-ever value in Britain. Two main explanations for these trends have been advanced: UK Government post-2008 austerity policies, especially in the health and social care sectors, and the role of seasonal influenza. However, the evidence for a dominant role for either of these is weak. Longer-term overall trends have been determined principally by trends in cardiovascular rather than non-cardiovascular causes of death, although recent changes in discovery and coding of dementias makes it difficult to draw firm conclusions. Healthy life expectancy trends are also affected by changes in data and methods, but the proportion of life spent in good health for both women and men over age 65 has increased slightly since 2010.

The health and healthcare needs of a population cannot be measured or met without knowledge of its size and characteristics. Demography is the scientific study of population and is concerned both with the measurement, or estimation, of population size and structure and with population dynamics—the interplay between fertility, mortality, and migration which determines population change. These are pre-requisites for making the forecasts about future population size and structure which largely determine the health profile of a population and should underpin public health planning. This chapter presents information on demographic methods and data sources, their application to health and population issues, information on demographic trends and their implications, and the major theories about demographic change. The aim is to illustrate and elucidate the complex inter-relationship between population change and human health.

Counterfactual population projections have been used to estimate the contributions of fertility and mortality to population ageing, a method recently designated as the gold standard for this purpose. We analyse projections with base years between 1850 and 1950 for 11 European countries with long-run demographic data series to estimate the robustness of this approach. We link this approach with stable population theory to derive quantitative indicators of the role of fertility and mortality; consider ways of incorporating net migration; and examine the effect of using alternative indicators of population ageing. A number of substantive and technical weaknesses in the counterfactual projection approach are identified: (1) the conclusions are very sensitive to the choice of base year. Specifically, the level of base year fertility has a major influence on whether fertility or mortality is considered the main driver of population ageing. (2) The method is not transitive: results for two adjacent intervals are unrelated to results for the combined period. Therefore, overall results cannot be usefully allocated between different sub-intervals. (3) Different ageing indices tend to produce similar qualitative conclusions, but quantitative results may differ markedly. (4) Comparisons of alternative models should be with a fixed fertility and mortality projection model rather than with the baseline values as usually done. (5) The standard counterfactual projections approach concatenates the effects of initial age structure and subsequent fertility and mortality rates: methods to separate these components are derived.

BACKGROUND The aim of the study is 2-fold. Firstly, it attempts to investigate the potential impact of major political and economic changes on inequalities in all-cause mortality among men and women with different levels of education in three Eastern European countries. Secondly, to identify changes in contribution of smoking and drinking to educational differences in all-cause mortality. Study covers the period from 1982 to 2013. METHODS Data were collected in 2013-14 as a part of the PrivMort retrospective cohort study. Participants in Russia, Belarus and Hungary provided information on their educational attainment, health-related behaviors and vital statistics of their close relatives (N = 179 691). Odds ratios for mortality and relative indices of inequality (RII) were estimated for individuals aged 20-65 years, stratifying by three levels of educational attainment: higher, secondary and less than secondary education. RESULTS Those in lower educational groups were significantly more likely to die, through most time periods and sub-groups. The RII increased over time in all countries and both genders, except for Hungarian men. Alcohol consumption and smoking have increasingly contributed to educational inequalities in mortality during this period. CONCLUSION Educational inequalities in mortality in these Eastern European countries have increased during recent decades. Smoking and alcohol consumption, two major health-related behaviors, made a significant contribution to these increases in inequality.

BACKGROUND:A large proportion of premature deaths in Russia since the early 1990s, following the transition from communism, have been attributed to hazardous drinking. Little is known about the correlates of alcohol consumption. We present new data on the consumption of alcoholic beverages among middle-aged and older Russians and identify socio-demographic, socio-economic, and life-course correlates of frequent drinking.METHODS:Within the framework of the PrivMort project, conducted in 30 industrial towns in the European part of Russia, we acquired information on the frequency of drinking among 22,796 respondents and 57,907 of their surviving and deceased relatives. We fit three-level mixed-effects logistic regression models of frequent drinking in which respondents' relatives, aged 40 and over, are nested in their families and towns.RESULTS:Deceased male relatives consumed alcohol significantly more often, while deceased female relatives consumed alcohol significantly less often than the respondents of corresponding gender. In a multivariable analysis, we found that individuals' education, communication with family members, labour market status, history of unemployment, and occupational attainment are all significant correlates of frequent drinking in Russia. These associations are stronger among men rather than among women.CONCLUSION:There are significant differences between frequency of drinking among surviving and deceased individuals and frequent drinking is associated with a wide array of individual socio-demographic, socio-economic, and life course factors that can partially explain high alcohol consumption in post-communist Russia.

Eastern European men have among the highest cancer mortality rates globally. Prevalence of smoking and alcohol intake in this region is also high. The aim of our study was to calculate population attributable risk fraction (PARF) of cancer deaths from smoking and alcohol in Russia, Belarus and Hungary, and to examine the contribution of these lifestyle factors to differences in male cancer mortality in the three countries. Data were collected as part of the PrivMort retrospective cohort study. Randomly selected participants living in mid-size towns in Russia, Belarus and Hungary provided information on smoking habits, alcohol consumption, vital status and cause of death (if applicable) of male relatives (fathers, siblings and partners). PARF of cancer deaths (age 35-79) due to smoking, alcohol consumption and both combined was estimated between 2001 and 2013. Among 72,190 men, 4,702 died of cancer. Age standardized cancer mortality rates were similar to official data in all three countries. The estimated PARF (95% CI) associated with measures of smoking, alcohol consumption, both combined, and overall smoking or drinking were 25% (19-30), 2% (0-4), 29% (19-39), 43% (32-53) in Russia, 18% (8-28), 2% (-1 to 6), 28% (20-35), 38% (25-50) in Belarus and 17% (13-20), 1% (0-3), 25% (20-30), 35% (28-42) in Hungary, respectively. These results suggest that in Eastern Europe, at least one third of cancer deaths in males may have been attributable to smoking and/or alcohol consumption in recent years. Health policies targeting these lifestyle factors can have a major impact on population health.

The very high rates of smoking among men and the rapid changes among women in the Post-Soviet countries mean that this region offers an opportunity to understand better the intergenerational role of parental influences on smoking.

This chapter presents some findings from the research project ‘Modelling Needs and Resources of Older People to 2030’ (MAP2030). The project developed a set of projection models to estimate future family circumstances, incomes, pensions, savings, disability and care needs of older people in England. These projections included public and private expenditure on pensions, disability benefits and care services under different scenarios for reform of pensions and long-term care funding under a range of alternative population futures. The chapter focuses on the projected future costs and impacts for the different income quintiles of the older population of proposed reforms to the system of funding adult social care, in particular the impact of a cap on individual liability to meet care costs.

Physical frailty increases the risk of future activity limitation, which in turn, compromises independent living of older people and limits their healthspan. Thus, we seek to identify moderators and mediators of the effect of physical frailty on activity limitation change in older people, including gender- and age-specific effects. In a longitudinal study using data from waves 2, 4, and 6 of the English Longitudinal Study of Ageing, unique physical frailty factor scores of 4638 respondents aged 65 to 89years are obtained from confirmatory factor analysis of physical frailty, which is specified by three indicators, namely slowness, weakness, and exhaustion. Using a series of autoregressive cross-lagged models, we estimate the effect of physical frailty factor score on activity limitation change, including its moderation by social conditions, and indirect effects through physical and psychological conditions. We find that the effect of physical frailty on activity limitation change is significantly stronger with older age, while it has significant indirect effects through low physical activity, depressive symptoms, and cognitive impairment. In turn, indirect effects of physical frailty through low physical activity and cognitive impairment are stronger with older age. Sensitivity analyses suggest that these effects vary in their robustness to unmeasured confounding. We conclude that low physical activity, depressive symptoms, and cognitive impairment are potentially modifiable mediators on pathways from physical frailty to activity limitation in older people, including those who are very old. This evidence offers support for population-level interventions that target these conditions, to mitigate the effect of physical frailty on activity limitation, and thereby enhance healthspan.