Age and Ageing 1997; 26-S2: 3 -12

Nursing homes in 10 nations: a comparison between countries and settings
M I E L W . RIBBE, GUNNAR LJUNGGREN1, KNIGHT STEEL2, EVA TOPINKOVA3, CATHERINE HAWES4,
NAOKI IKEGAMI5, JEAN-CLAUDE HENRARD6, PALMI V. JONNSON7
Department of General Practice, Nursing Home Medicine and Social Medicine, Medical Faculty,
Vrije Universiteit, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
'Stockholm, Sweden, 2Hackensack, NJ, USA, 3Prague, Czech Republic, ^Research Triangle Park, NC, USA,
5
Tokyo, Japan, 6Paris, France and Reykjavik, Iceland

Abstract
Aim: to illustrate demographic differences and recent trends in the provision and structure of long-term care systems in the 10 countries participating in the Resident Assessment Instrument studies (Denmark, France, Iceland,
Italy, Japan, The Netherlands, Sweden, Switzerland, the UK and the USA).
Method: data were assembled from government documents, statistical yearbooks and articles from journals; supplemental data on long-term care and nursing homes were solicited from colleagues.
Results: All 10 countries are developed nations with high life-expectancies. Sweden has the oldest and Iceland the youngest population in this study, with Japan showing the highest ageing rates over the next three decades.
Between 2 and 5% of elderly people reside in nursing homes. Interestingly, Iceland, as the youngest country' in this study, has the highest rate of institutionalization (living in residential or nursing homes), while the 'oldest country'
(Sweden) has a low rate of institutionalization. In all countries the support ratio (number of elderly people per 100 younger adults) is high and increasing rapidly.
Conclusions: no relation appears to exist between the ageing status of a country and the number of nursing home beds. Institutionalization rates among the nations studied differ even more, due at least in part to differences in the organization and financing of long-term care services, in the amount of responsibility assumed in the care for disabled elderly people by each sector and the availability of long-term care beds. Facing a rapid ageing of their population, many countries are in the process of health and social care reforms.
Keywords: ageing population, health care reforms, institutionalization, long-term care, nursing homes, residential homes, support ratios Introduction
Demographic trends and age-related morbidity rates are important determinants of the need for long-term care services, such as nursing homes. In addition, a host of socio-cultural factors, including the availability and type of housing, the structure of families and the preferences of elderly people and their caregivers significantly influence both the demand for and the availability of long-term care services. The increase in the numbers of elderly people (65 years of age and

over) and especially the oldest old (those 80 years of age and over), who generally have a greater level of disability secondary to multiple chronic diseases, has resulted in most developed nations experiencing a striking growth in the demand for long-term care over the last two to three decades. It is projected that there will be an even greater need for such services in the future [1].
The policy responses to this demand by health care and social services agencies vary greatly from country

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Address correspondence to: M. W. Ribbe. Fax: (+31) 20 444 8231. E-mail: MW.Ribbe.gpnh@med.vu.nl

M. W. Ribbe et al.

Methods
We assembled data from government documents, statistical yearbooks and journal articles. Data on population characteristics were obtained from each country's national bureau of statistics or its equivalent, when possible. In addition, a questionnaire was sent to the authors of all papers in this supplement, requesting data on their countries' long-term care system. This questionnaire included items on the definition of terms, the characteristics and functions of nursing homes and policies pertinent to patient care. The participating countries in this study were
Denmark, France, Iceland, Italy, Japan, The Netherlands, Sweden, Switzerland, the UK and the USA. These countries have been selected because they have one or more members in the international research group interRAI of the RAI and these members were able to provide data of sufficient quality for the questionnaire.
Results

the net rate of migration. The growth rate in Iceland, the Netherlands, Switzerland, Sweden and the USA has been between 0.7 and 1.1% annually, while in Japan, the UK and Italy it has been only 0.3%. Sweden is the
'oldest' country in the study, and the USA, Iceland and the Netherlands are the 'youngest' (Table 1) [1-4]. The most rapid ageing of the population [the increase in the percentage of the elderly population (^65 years) between 1993 and 2025] will be experienced by Japan
(almost 100%). Most other countries show in that period an increase of the elderly population of around 50%, with the exceptions of the Netherlands (an increase of
70%) and Sweden and the UK (35%). Sweden, Denmark, UK, Switzerland and France have the highest percentage of oldest old at present (around 4% of their population is ^80 years). In all countries this age group has about twice as many women as men. In 2025 the category of the oldest old in Japan, Sweden and Italy will comprise 7% or more of the population (Table 1).
Support ratios, useful both to clinical administrators and national policy makers, indicate the number of elderly people who depend on younger adults (elderly and parent support ratios) or on a member of their own age group (oldest old support ratio; Table 2) [1 - 4]. The elderly support ratios reveal that at this time there are about 20-25 elderly people for every 100 individuals aged 20-64 years, with marked increases in this ratio over the next 30 years especially in Japan (a 2.2-fold increase) and the Netherlands and Italy (a 1.8-fold increase). The parent support ratios (the number of people 80 years of age and over per 100 people 50-64 years old) in most of the countries studied also range from 20 to 25, with considerable variation. Nonetheless, all countries have shown approximately a doubling of the parent support ratio over the past two decades, highlighting the potential need for elder care responsibility even among those at or near retirement age themselves. In countries like Japan and Sweden the parent support ratio will have increased to about 40 by the year 2025. On average, at present about one of every four elders is at least 80 years of age (the oldest old support ratio), apart from in Iceland. In 2025 in
Japan, Sweden and Italy one of every three elders will be in this subpopulation (Table 2) [1-4].

Demographic indicators

Demographic changes result from both a decrease in fertility rate (live births per woman) and an increase in life expectancy [1, 2]. Fertility rates vary considerably among the countries, with the highest rate in Iceland, folio-wed by the US and Sweden, and the lowest in
Japan and Italy. In all 10 nations under study, life expectancy is high, with Japan having the world's highest from birth and beyond 65 years (Table 1) [1 - 4].
Of all the nations considered, Denmark has the lowest life expectancy for women, both at birth and at age 65.
It also has the lowest life expectancy for men at age 65.
All 10 countries have small population growth rates, a reflection of the fertility rate, the mortality rate and

Descriptive definitions

When making comparisons, it is essential to note that there are no universally accepted definitions for the different long-term care services. Based upon the characteristics of individuals residing in long-term care facilities, we adopted the following definitions for purposes of comparison:
1. A nursing borne is an institution providing nursing care 24 h a day, assistance with activities of daily living and mobility, psychosocial and personal care, paramedical care, such as physiotherapy and occupational therapy, as well as room and board.

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to country. They depend on the structure and organization of the health care system, the availability of community resources, the mechanism of funding care by both the government and the private sector and even on the degree of collaboration between medical and social services. Hence, it can be expected that the use of nursing homes will vary considerably among countries discussed here and differences will exist even within a single nation. It should benefit each country to appreciate more fully how nursing homes are utilized in other nations.
The objective of this paper is to describe and compare the long-term care systems in 10 countries participating in studies employing the Resident
Assessment Instrument (RAI) and to place them in the context of the changing population dynamics in each country. This information provides a background to place into a broader context the research data and results from the specific RAI analytic studies presented elsewhere in this supplement.

USA

17.6
19.6
23.7

8745
8728
8565

Sweden

3.6

9.3

4.3

140
205

Number of women to 100 men in 1993, by age category
>65 years
150
145
120
135
>80 years
210
195
205
185

150
230

14.7
19-2

74.0
80.0

3.0
3.8
5.0

13.1
15.4
22.2

15 341
16 239
16 276

Netherlands

74.3
81.2

215

150

14.4
18.1

145
230

15.7
19.9

73.6
79.0

150
220

15.7
20.1

72.9
81.1

145
205

14.8
18.8

73.5
80.2

7.5

5.8

5.6

5.6
6.3
6.3

3.6

4.1

3.9
4.2

198

24.1

15.5

59 960
59 089
57 075

Italy

14.7
17.2
22.6

57 804
61 001
61 997

France

5.1

14.6
16.6
22.4

6969
7717
7786

Switzerland

3.9

15.8
17.1
21.5

58 227
59 617
60 032

UK

Sources: National Bureaux of Statistics; An Aging World II 1993; Recent Demographic Developments in Europe 1994; United Nations Demographic Yearbook 1991; The Sex and Age Distribution of the World Populations, 1994 Revision | 1 - 4 | .

14.3
17.8

72.4
77.8

6.8

3.9
4.9

15.4
17.8
23.3

5197
5310
5295

Denmark

15.4
192

16.1
19.4

16.4
20.6

75.5
80.8

2.9

75.7
80.9

2.6

2.8
5.7

2.9
3.8

76.0
82.0

4.5
5.9
7.5

10.9
11.4
16.6

265
307
337

Iceland

13.5
21.3
26.7

124764
130 480
125 279

Japan

12.7
133
18.7

Life expectancy (1992/93)
From birth
Male
72.1
Female
79.0
>65 years
Male
15.5
Female
19.1

Elderly (%)
&65 years
In 1993
In 2010
In 2025
>80 years
In 1993
In 2010
In 2025

Total population (xlOOO)
1993
256 556
2010
298 109
2025
334 216

Characteristics

Country

Table I. Future population growth (years 2010 and 2025), life expectancies (1992/1993) and number of elderly women to 100 elderly men (1993)

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M. W. Ribbe et a\.
Table 2. S upport ratios for participating countries calculated for the years 1993, 2010 and 2025
Country
Support ratio/year

USA J apan

Iceland

Sweden

Denmark Netherlands

UK Switzerland

France

Italy

22
22
34

22
37
49

19
20
29

31
34
43

25
30
42

21
25
39

27
29

25
27
38

25

39

24
27
40

34
44

23
25

15
45

21
20

29
38

24
32

20
22

26
30

24
25

27
32

20
32

23
28
23

21
27
35

23
26
21

26
30
32

25
26
27

23
25
22

25
30
30

27
25
25

28
30
24

23
28
32

3

Elderly
1993
2010
2025
Parent13
1993
2025
Oldest oldc
1993
2010
2025

Hostels (residences with limited assistance for individuals with deficits in the activities of daily living) and s heltered housing are e xcluded from the nursing home category. Also excluded are hospitals which provide very intensive medical services, a lthough in some countries frail elders with long-term care needs receive their care in hospitals. Availability of these different types of care (especially paramedical care) may vary from facility t o facility and from country t o c ountry. Nursing homes mainly serve frail elders with chronic diseases, disabilities, either physical o r m ental (mainly dementia) or b oth.
These facilities usually provide care -which c an be characterized as the h ighest level of c are', with residential homes offering lower levels of c are.

Table 3. Percentage of p eople > 6 5 years living at h ome and in institutions (prevalence data; different years in the early 1990s)
Country
Place of r esidence

USA Japan

Iceland3

Sweden

Denmark

Netherlands

UK

France

Italy

Own home, independently or with informal and/or formal care (including domestic help and home nursing) Residential homes, homes for the aged, old people's homes
(low levels of care)
Nursing homes
(high levels of care)
Hospitals
(intensive medical care)

-

94.0

87.0

94.0

85.0

90.0

93.0

94.0

96.0

1.5b

0.5

5.0

30

10.5C

6.5

3.5°

i.O

1.0

5.0

1.5

8.0

2.0

4.0

2.5

2.0