Bollettino epidemiologico nazionale

Health, Autonomy, and Social Integration of the Elderly in the Comune of  Caltanissetta, Sicily, 2001

In the last 10 years in Italy, the percentage of the population over the age of 65 years has increased from 15% in 1990 to 18% in 1999. By 2010, it is estimated that this proportion will further increase to 21% (1); such changes are a result of a declining birth rate and a consistent reduction in deaths from all causes that began in the 1970s.

The aging of the population has both social and economic consequences. Age is the principal determinant of health, and after the age of 65 years, the rates of death, disability with accompanying loss of self-sufficiency, and social isolation begin to increase substantially (1). As a consequence, this age group accounts a substantial proportion of health service utilization, accounting for 37% of hospitalisations (2), and an estimated 50% of drug costs (3).

In response to these demographic shifts, a National Plan for the Elderly (Progetto Obiettivo Anziani) was developed and has been added to the National Health Plan 1998-200. This document outlines the strategies that regions and local health units can adopt to improve the conditions of this vulnerable population group.

In May, 2001 an applied epidemiology course was held in May 2001 in Caltanissetta, a small provincial town in Central Sicily. As part of this course, a survey was conducted by to furnish the local government with information useful for planning appropriate interventions for the elderly. The purpose of the study was to describe the health status, level of self-sufficiency, and the social integration of the elderly province of the commune.

The study population consisted of 233 residents >70 years of age residing in the Commune of Caltanissetta who had been selected randomly from the local registrar’s list maintained in each commune. For each person chosen, their general practitioner was identified using records of the Local Health Authority, and a letter and a questionnaire was sent to each asking them to complete a standardized questionnaire on major medical conditions, overall health and mental status, and needs for assistance. Over a two-day period in mid-May, the epidemiology course trainees, after a brief training, visited the homes of the elderly selected for inclusion in the sample and administered a questionnaire containing a series of questions on their ability to perform primary activities of daily living (ADL; moving from one room to another, being able to wash oneself, bladder control, ability to take a shower or bath, to eat without assistance, to dress oneself, to be able to use the toilet), and as well as instrumental activities of daily living (IADL; preparing meals, clean the house, carry shopping bags, etc). In addition questions were asked about self-perceived health, sources of assistance for various activities, living situation, and social activities.

On the basis of the responses to the ADL questions, a Katz index was calculated (4). The elderly were classified as self-sufficient if they were able to do all of the ADL, partially dependent if they were unable to do at least one of the ADLs, (excluding using the toilet without assistance and dressing oneself), and fully dependent if they were unable to use the toilet without assistance or wash themselves and/or they were unable to move from one room to another and/or feed themselves and/or were incontinent). They were considered to have adequate social contact if in the last two weeks that had had contacts outside their home, even if only via telephone.

Data from the two sets of questionnaires were entered in Epi Info, which was also used to determine prevalences and calculate 95% confidence intervals (CI) around these estimates.

A total of 188 of the 233 persons (81%) selected in the sample were successfully interviewed, of whom 56% were women. The median age was 76 years. The age and sex distribution was similar to that of the resident population >70 years of age. Most (95%) had attended at least a few years of elementary school, and 98% of their households had telephones.

Most of the elderly had chronic diseases that required pharmaceutical management and regular medical visits; 94% had been seen by their physicians at least once in the past year. The 5 most frequent conditions were osteoarthritis (71%), hypertension (59%), chronic obstructive pulmonary disease (30%), cardiovascular diseases (27%), and diabetes (16%).

Results regarding levels of self-sufficiency for the entire population and by age category are shown in the Figure. Overall, 22% (95% CI 16%-28%) were fully dependent, although in the population ³80 years, this value rose to 50% (95% CI 36%-64%). Except for ability to do heavy housework, most of those who were self-sufficient with respect to activities of daily living were also able to carry out instrumental activities.

For the elderly who had partial or full dependence, the family represented the major source of support (Table). To a lesser extent, they reported receiving help with regular treatments (editor’s note: in Italy, injections are commonly performed outside health facilities by family members or paid paraprofessionals). At present, the role of the public health care system appears minimal.

A total of 26% of the population surveyed lived alone; 45% lived with their spouses or relatives of their same generation, and 29% lived with their children. These percentages varied with the level of self-sufficiency; only 8% of the fully dependent elderly lived alone, while 42% lived with their children and 37% with their spouses or other older family members.

Persons who were fully dependent were more frequently socially isolated as well; 24 persons were identified (13% of the total) who were fully dependent but who had not had outside contact, even by telephone, in the past 15 days.

Reported by participants of the May, 2001 Italian Epidemiology in Action course: [Antonietti MP (Aosta), Battistella G. (Treviso), Battisti A. (Roma), Bertozzi N. (Cesena), Busani L. (Roma), Candura R. (Trapani), Capriani P. (Roma), Casuccio N. (Palermo), Coccioli S. (Lucca), Culotta C. (Genova), D' Argenzio A. (S. Maria C.V.), De Togni A. (Ferrara), Di Noia S. (Bari), Drogo L. (Caltanissetta), Ferrera G. (Ragusa), Frongia O. (Oristano), Mancini C. (Ancona), Marinaro L. (Alba), Michieletto F. (Venezia), Modolo G. (Torino), Montagano G. (Potenza), Morbidoni M. (Ancona),  Nastri A. (Tremestieri Etneo), Pasquale A. (Citta' Di Castello), Passatempo R. (Recanati), Pizzuti R. (Napoli), Protano D. (Caserta), Raffaelli C. (Viareggio), Salaris M. (Rimini), Sammarco S. (Palermo), Vaccaro P. (Raffadali), Zanzani L. (Rimini), Zappia F. (Marina Siderno)]

Staff: Massimo Ciccozzi, Antonio Bella, Paolo D’Argenio, and Nancy Binkin (Laboratorio di Epidemiologia e Biostatistica, Istituto Superiore di Sanità), Guiseppe Salamina (Servizio di Epidemiologia ASL Gruguasco (Torino).