PREVENTION OF LOSS OF

INDEPENDENCE AMONG

THE ELDERLY

Building a shared priority

Public thematic report

Abstract and annexe 7

November 2021

2

Introduction

The prevention of loss of independence has been widely discussed for ten years in

parliamentary proceedings

1

, by researchers and specialists from various backgrounds, and in

administrative reports. The analyses often cover the same ground, in particular in their

emphasis of the importance of the issue of predictable ageing among the general public, but

also their desire to live independently at home for as long as possible.

However, prevention stakeholders are disparate, and their work often overlaps. This

situation markedly reduces the effectiveness of this policy, and creates a form of inertia among

stakeholders. The purpose of this report is to identify and analyse problem areas, then to

outline approaches that may remedy this lack of effectiveness.

The current situation: people live longer in France than elsewhere,

but not necessarily in better health

The Court’s investigation covers the stage prior to the loss of independence; that is,

prevention. In medico-social terms, the selected target is individuals who retain independence

in terms of essential daily activities (GIR 6)

2

or merely require occasional assistance (GIR 5).

Comparisons were made with seven other countries, and the Court was also assisted by a

committee of experts.

The French population is ageing, in common with OECD countries in general, and this

ageing will accelerate once the many “baby boom” social sectors reach the age at which loss

of independence most often occurs, i.e. over 85 years old. France had 100 centenarians in

1900, and 1,120 in 1970; the number is currently 26,300 and will be approaching 200,000 by

2060.

Although the likelihood of loss of independence increases statistically with age (Chart 1),

it is not an inevitable consequence of ageing. Consequently, its prevention is not only

essential

–

given the anticipated demographic development

–

but also feasible.

1

One such analysis is the information report by Mr Bernard Bonne and Ms Michelle Meunier for the Senate Social

Affairs Committee on the prevention of loss of independence (March 2021) which proposes to enshrine home

support in positive law, provide for preventative visits at age 75 and unify tools for assessing the situation of

individuals.

2

The degrees of loss of independence are classified into six groups with equivalent resources (GIRs) addressing

different assistance needs. Only GIR 1 to 4 result in an entitlement to APA. Individuals covered by GIR 5 (requires

one-off assistance with washing, preparing meals and cleaning) or 6 (still independent for essential daily activities)

are not entitled to APA, but may ask for help from their pension fund.

3

Rate of loss of independence between 2007 and 2014 by gender

Source: Court of Accounts, based on Drees data

Note to reader: the percentage of Health in Daily Life (VQS) scores > 40

3

is 12% among women aged

75-79 in 2007, against 10% in 2014.

In its current state, however, the French prevention system does not demonstrate an

ability to face the problems to come. It needs to be improved.

A life expectancy of 65 may well be higher in France than in other European countries.

On the other hand, the healthy years of life represent only half of the desired time, while many

other countries

–

eleven in Europe

–

do better.

3

The “VQS score” is calculated to produce a single figure summarising the difficulties encountered by the elderly

(physical, sensory, cognitive functional limitation, chronic disease). An elderly person reporting major limitations

across many activities will thus have a high VQS score. A person with a VQS score greater than 40 is considered

to have lost their independence (source: Mr Brunel

–

A. Carrère, “Incapacities and loss of independence among

the elderly in France: a positive change between 2007 and 2

014”,

no. 13, March 2017).

4

Life expectancy of 65 in 2019

Source: Court of Accounts, based on Drees data

The Court calculated that a one-year increase in disability-free life expectancy (EVSI)

would save health insurers an amount of around €

1.5 billion4. In addition to the individual and

collective benefit to the people concerned, these financial issues provide full justification for

public intervention in preventing loss of independence.

The disparate nature of stakeholders means that a policy generally

accepted in principle fails to deliver practical benefits

There are a large number of stakeholders involved, in one form or another, in managing

the prevention of loss of independence (departmental councils, pension funds, regional health

agencies, primary health insurance funds, the

Agence nationale de l’habitat

housing agency,

municipalities and inter-municipal cooperation agencies, regional councils, social landlords,

mutual bodies, associations, etc.). It is true that the restructuring process began in 2015 with

the creati

on (by means of the “ASV” Adaptation of Society to Ageing law of 28 December

2015)

5

, of funders’ conferences, chaired by the presidents of departmental councils.

4

Using the Pandora health expenditure projection, the Court estimated a gain of one year of life expectancy without

disability over the 2021-2031 period. In the absence of data on average medico-social expenditure by age, this

estimate does not take into account the savings in terms of APA, accommodation or day care linked to a one-year

improvement in EVSI. It is therefore underestimated.

5

Law no. 2015-1776 of 28 December 2015 relating to the adaptation of society to ageing.

5

Meanwhile, a social initiative by pension funds has established an “inter

-

scheme” association

process

6

. However, change within the system as a whole is still multifarious, administratively

complex and disorderly. Furthermore, there is no obvious way of estimating the value of

expenditure on the prevention of loss of independence. The Court estimate

s it at nearly €

1.5

billion per year, including nearly €

460 million for “technical aids” (chairs, walking frames,

sticks, etc.) for health insurance and nearly €

300 million for the social work of the CNAV fund.

Estimated expenditure on preventing loss of independence

(2019 or 2020, depending on the source)

Funders

€m

Funders’ conference

203

CNAV social measures

7

297

Agirc-Arrco social action

8

135

MSA social action

42

CNRACL social action

130

Social action by State civil service

2.3

Housing adaptation including tax credits

224

Health insurance technical assistance

458

Total

1,491

Whole sections of prevention policy still fall outside the cooperative process. This means

that users are often faced with a proliferation of contacts, and the very real risk of

discouragement. For example, the mutual recognition of GIR classifications between pension

funds and departments, as provided for by the ASV law, has still not come into effect, resulting

in redundant assessments and the shuttling of applicants from one organisation to another. In

another example, the health insurance and pension funds have developed two different

hospital discharge systems.

At a basic level, however, there are areas of concordance.

This is true, for example, regarding individual behaviours to be encouraged or nurtured.

It is commonly believed that the pivotal times in life for preventively changing habits are (1)

around 40-45 years of age and (2) at the time of retirement (for example, for physical exercise).

There is also a need to promote sufficient physical activity for the elderly, which should be

adjusted according to their condition. The failure to implement the medical prescription for

physical activity tailored to patients suffering from chronic diseases, which was approved back

in 2017 but has not met with the expected success, underlines the scale of the work yet to be

done in this area.

There is also a consensus over the urgent need to prevent falls in the elderly, accounting

for more than 10,000 deaths in people over the age of 65 each year. France has a higher

incidence of accidents involving damage to the tip of the femur than the United Kingdom, the

Netherlands or Denmark. According to the work carried out by the Toulouse University Hospital

6

7

8

6

in collaboration with the Court, the additional health expenditure associated with the care of

patients suffering f

alls is in excess of €

900 M in the year following the accident alone. It is

possible to take measures aimed at prevention, in particular by limiting medical9 iatrogenesis,

by making adaptations to the home and by modifying physical activities appropriately, but

France neglects this field of action; indeed, it no longer has any public health goal in this area

and no centralised monitoring mechanism (recommendation 2).

The (also generally accepted) goal of promoting care at home by means of adapted

housing faces obstructions in the form of several factors involving inertia or inefficiency: too

much complexity for potential beneficiaries, lack of monitoring (neither the need for nor the

number of adapted homes is known), and fragmentary technical skills among the agents

responsible for home diagnoses (recommendation 1).

Lastly, there has only been the faintest glimmer of rising awareness in two areas of

prevention: the fight against isolation among the elderly (an aggravating factor in loss of

independence), an

d initiatives to raise health professionals’ awareness of screening for

pathologies

in

old

age

and

techniques

for

maintaining

functional

capabilities

10

(recommendation 3).

Improved structure for prevention

Prevention services are currently disparate and provide unequal levels of support. They

need to be rethought. The Court recommends creating a tiered range of services, comprising

three levels:

- at the first level: general information accessible through communication campaigns for the

general public, improved coordination between national information and information from

local authorities, and the creation of a telephone information system;

-

at the second level: a policy of “moving towards”

11

, combined with the possibility of a home

consultation visit carried out by professionals trained in prevention issues, upon request;

- a third level, reserved for the most socially vulnerable or isolated people, with assistance

plans implemented through social measures by pension funds, which must, for this

purpose, be rethought for greater consistency. This point is also the subject of a

recommendation (no. 4).

If the impact of this policy is to be improved, it will require clarification of the roles of local

and national stakeholders. The steering process should be improved to ensure the integration

of prevention into the fundamental goals of the independence branch. The proposal is

therefore to:

9

Iatrogenesis is defined as harmful impacts on health resulting from medical intervention (diagnostic errors,

inappropriate prescriptions, complications from a therapeutic procedure) or from the use of a health product. It is

particularly worth noting the link between the use of psychotropic drugs and the occurrence of falls. Researchers

also estimate that around 400,000 cases of iatrogenic dependency, acquired during a hospital stay, could be

prevented each year in people aged 75 and over.

10

in other words, the ability to carry out ordinary everyday activities.

11

This concept, initially devised as a solution in the fight against poverty, is used in many social policies to

encourage professionals to reach out to users to combat failure to access services, care, etc.

7

- strengthen the department in its leadership role, responsible for the prevention policy in its

own geographical area, in close partnership in particular with the regional health agency

and Carsat (recommendation 4);

- at national level, allow the CNSA to adjust the credits it pays to the local departments, with

the goal of greater geographical equity, and equip it with sufficient resources to enable it

to fulfil its role of national implementer of the policy for preventing loss of independence

(recommendations 5 and 6).

Summary of recommendations

1.

Increase and monitor work to adapt housing while simplifying assistance and standardising

procedures

(Ministry of Social Support and Health, Ministry of Housing)

.

2.

Define an ambitious public health goal of reducing the incidence of falls and induced deaths

by providing regional health agencies with the tools to enable them to implement the

measures identified to achieve this goal, including a systematic statistical register of falls

(Ministry of Social Support and Health)

.

3.

Encourage healthcare professionals to modify their practices (detecting signs of weakness,

prescribing appropriate physical activity, re-examining the benefit of medications, etc.) by

means of financial incentives

(Ministry of Social Support and Health and

CNAM

)

.

4.

Build a tiered service for preventing the loss of independence that the department would

be responsible for implementing within its own geographical scope

(Ministry of Social

Support and Health).

5.

Adapt the credits paid by the CNSA to the departments according to the achievement of

clear goals, with the goal of greater regional equity

(CNSA)

.

6.

Provide the CNSA

–

the national implementer of the policy to prevent loss of

independence

–

with sufficient resources to carry out its work; if necessary, by redeploying

human resources from national social security funds and giving it access to the necessary

data relating to the access of retirees to the prevention service, for all funds

(Ministry of

Social Support and Health and Ministry of the Budget)

.

8

Annexe n° 7 : falls: an international perspective

Worrisome “Global burden of disease” data for France...

A problem specific to certain regions of the world

The issue of falls is a problem specific to certain regions of the world. As shown in the

map below, Western Europe is affected by this public health issue with an overall incidence of

12,766 cases per 100,000 inhabitants over 70 years of age (“Global burden of disease” data).

This is the region in which the countries with the highest incidence rates are located. Canada

and Australia are also affected.

Number of falls per 100,000 inhabitants aged 70 and over (declarative data)

Source: Institute for Health Metrics and Evaluation (IHME)

Among the factors explaining these differences is the prevalence of osteoporosis12

(related to sun exposure and skin pigmentation), genetic factors, diet and lifestyle (sitting

cross-legged or sleeping on a futon would have a protective effect).

12

9

Europe: a particularly strongly affected region

The Global Burden of Disease results13 are obtained mainly from declarative surveys14

based on questionnaires completed by inhabitants of 22 European countries in 201715, and

especially from the answer to the question, “During the last 6 [sic] at least, have you had a

fall?” .

As shown in the map below, Norway has the highest incidence rate (19,796 falls per

100,000 population over 70 years of age). Conversely, Greece has the lowest incidence rate,

with 7,594 cases per 100,000 inhabitants over 70 years of age. This should be considered in

the context of the prevalence of osteoporosis mentioned above, which is higher in the Nordic

countries where exposure to the sun is less16.

Among the countries most closely studied in the Court’s comparative analysis, France

has the worst European results, after Norway, with an incidence rate of 17,682 (6th position

out of 22), followed by Sweden (10th), the Netherlands (12th), Denmark (13th), the United

Kingdom (16th) and finally Spain, with an incidence rate of 10,161, putting it in 18th place.

Incidence and mortality rate of falls in 2017 per 100,000 inhabitants

over 70 years

Source: Court of Accounts, data from the Global Burden of Disease data tool

17

13

Haagsma J. A., Olij B. F., Majdan M., et al.,

. Inj Prev 2020, i67-74, available on https://doi.org/

14

The GBD declarative data may suffer from imprecise collection methods from country to country and therefore

limit comparisons.

15

Börsch-Supan, A.

.

SHARE-ERIC,

2015,

available

at

https://www.share-project.org/

and

the

WHO

Data

Archives

https://apps.who.int/healthinfo/systems/surveydata/index.php/catalog.

16

It would be worthwhile analysing these figures in relation to the data on the prevalence of osteoporosis in the

populations of each country. This does not appear to have been done.

17

https://gbd2017.healthdata.org/gbd-search/

10

With regard to the mortality rate associated with these falls, France ranks behind Norway

and the Netherlands, which both have fall-related mortality rates of around 150 deaths per

100,000 inhabitants over 70 years, compared to 133.5 for France. Further down the ranking

are Sweden (8th), Denmark (9th), the United Kingdom (14th) and Spain (19th). The table is

therefore quite similar to the incidence table

–

except for the Netherlands, where falls are quite

rare but often lead to death.

This study from the Global Burden of Disease also shows that 2.7% of deaths in France

are caused by falls

–

the highest proportion in Western Europe after Norway

–

and that the

reduction in the number of years of disability-free life is 4.1% as a result of falls, a figure that

places France second, behind Switzerland.

Deaths from accidental falls in France among people

aged 65 and over and death rate in 2016

Age classes

Total falls

Women

Men

No.

Rate per

100,000

pop.

No.

Rate per

100,000

pop.

No.

Rate per

100,000

pop.

65-74 years

757

11.5

261

7.5

496

16.0

75-84 years

2,223

54.9

1,121

47.5

1,102

65.0

85 or more

years

7,267

350.7

4,741

332.3

2,526

391.4

Total

10,247

12.4

6,123

11.3

4,124

14.4

Source: French Public Health Agency (Cépidc): Number of falls and death rate by age and total

death rate by age and sex, France, 2016.

It is interesting to compare Danish and French dynamics: as mentioned above, Denmark

has a fairly good ranking compared to France in terms of incidence of falls, which indicates

that few elderly Danes fall, although osteoporosis is more widespread in Denmark than in

France. In addition, Danes seem to die less frequently from falls. Finally, the number of years

of life lost or lived in disability due to falls is lower in Denmark than in France. This number is

2,162 years per 100,000 inhabitants of Denmark over the age of 70 compared to 2,812 years

in France, which means that the long-term health of Danes is less badly affected by falls than

for the French. The study of changes over time in this indicator also shows a strong decrease

in Denmark between 1999 and 2017 (- 43%).

This is confirmed by objective data on the number of hospitalisations

following falls

To avoid bias related to reporting surveys, the Court collected data from seven countries

on the number of hospitalisations due to femoral neck fractures18 among the 65 and over

group in 2019. France has a higher incidence rate than the Netherlands, Denmark, United

Kingdom19, even though these countries are located further north than France.

11

Conversely, Spain has a high prevalence (0.7%) with regard to its geographical location

compared to France. Osteoporosis seems to be a very common problem20.

Incidence rate of femoral neck fractures

21

in 2019

among 65s and over in six countries

Source: Court of Accounts, according to DHFA-DICA registration for the Netherlands, Danish

multidisciplinary hip fracture registry22Toulouse University Hospital and INSEE for France23, Social

Affairs Advisor for Spain, Swedish Ministry of Social Affairs, Norwegian Hip fracture register (only 90% of

fractures are registered).

This graph does not show the incidence rate for Japan which, although increasing,

seems particularly low (0.12% in 2017 for all S 72.0 to S 72.9 hip fractures), which may be

partly explained by a different data collection system.

Unlike European populations, the prevalence of vertebral fractures is much higher in

Japan than that of femoral neck fractures24. However, the difference in incidence between

these two types of fracture, both linked to osteoporosis, is narrowing with rapid industrialisation

and the disappearance of the traditional Japanese way of life (diet, use of futon beds, etc.).

Prevention policies often organised by local municipalities and

precise monitoring of results via registers

In

Denmark

, the falls prevention policy takes the form of a guide written by the Public

Health Agency and made available to municipalities. It stresses the importance of identifying

20

Osteoporosis is a skeletal disorder that affects three million people in Spain. Impaired bone strength puts a person

at a higher risk of fractures, especially of the hip (most severe), spine (most common) and wrists. Although men

have less exposure to this pathology, they suffer more severely from it.

21

Femoral neck (S 72.0), trochanteric (S 72.1), subtrochanteric (S 72.2).

22

Period: from 1 December 2018 to 30 November 2019.

23

A slight underestimation of the incidence rate means that the chain key could not be calculated in the PMSI for

0.5% of stays.

24

Bulletin of the World Health Organization, Collection of Articles No. 1, 1999.