Chapter 2 - Impairment transitions

Adults with impairment at both waves

• For all adults with an impairment at both waves, the number of impairments reported was relatively stable between Wave One and Wave Three

• Adults with impairment at both waves were more likely to have multiple impairments than a single impairment

• Adults aged 65 and over were more likely to report 3 or more impairments than those aged 16 to 64

• For adults with impairment at both waves there appears to be an association between age and reporting the following impairment types: mobility, dexterity, sight and hearing

Offset and onset-acquired adults

• Just over a third (35%) of adults who reported impairment at Wave One did not report impairment at Wave Three (offset rate)

• Offset rates varied by age and impairment type, with working age individuals almost twice as likely to have offset from impairment as adults aged 65 and over

• Around 1 in 6 people (18%) who did not report any impairment at Wave One reported at least one impairment at Wave Three (onset-acquired rate)

• Adults aged 65 and over were twice as likely to onset as adults aged 16 to 64

• Long-term pain had a high offset and onset rate, suggesting that adults’ experience of long-term pain can fluctuate

Severity of impairment

• Reported severity of impairment was different for those with impairment at both waves and those who acquired impairment (onset) at Wave Three

• For those with impairment at both waves impairment severity was similar across the 4 main impairment types: long-term pain, chronic health condition, mobility and dexterity - with approximately two-thirds reporting "moderate difficulty" for each impairment

• A lower percentage of adults who were onset-acquired reported "severe" difficulty and frequency as "always" than adults with impairment at both waves. This was true for the 4 main impairment types

This chapter looks at changes in impairment status and impairment types that occurred between Wave One and Wave Three. To simplify the analysis, the focus is on impairment status at Wave One and at Wave Three only. Wave One interviewing took place between June 2009 and March 2010. Adults were interviewed again approximately 3 and half years later between October 2012 and September 2014. The analysis reflects the changing nature of impairment status through time and the different impairment types across the 2 waves.

Diagram 2.1 shows the four analysis groups described in Chapter 1.

At Wave One and Wave Three, adults were classified as having impairment or not having impairment. Having impairment means that an adult reports at least 1 impairment. Adults were classified as having impairment at both waves if they had at least 1 impairment at Wave One and at Wave Three (group 1). However, impairment status can change or can remain stable over time. Some adults may report an impairment at Wave Three that was not reported at Wave One. This impairment may replace impairment at Wave One, or may be in addition to any impairments at Wave One.

In the same way, impairment may be present at Wave One, but no longer reported in Wave Three. For example, suppose that someone reported mobility and dexterity impairments at Wave One. If at Wave Three this person no longer reported the dexterity impairment (but still reported the mobility impairment), then he or she would experience an offset of dexterity impairment but still be classified as having an impairment at both waves.

Where impairment status has changed from Wave One to Wave Three this is known as "offset" and "onset" of impairment. Offset from impairment means that adults have changed from reporting at least 1 impairment at Wave One to no longer reporting impairment at Wave Three (group 2). Where adults did not have impairment at Wave One, but reported at least one impairment at Wave Three, their impairment status is known as "onset-acquired" (group 3).

It is important to note that impairments are based on self-reporting and there are many reasons for onset and offset (for example, improvements in medication or carer assistance).

Finally, adults may not have reported an impairment at either Wave One or Wave Three (group 4).

Diagram 2.1: Summary of analysis groups for Wave Three report

Adults may have more than one impairment. This section looks at adults who reported an impairment type at both Wave One and Wave Three and considers the number of impairments they had. While adults must have reported having an impairment at both Wave One and Wave Three to be included in the analysis, they may have reported a different impairment type.

As can be seen in Figure 2.1, the number of impairments reported by adults was relatively stable between Wave One and Wave Three. There was a slight decrease in the percentage of adults reporting 1 impairment for all adults, although this change was not statistically significant. For those aged 16 to 64, this was largely accounted for by an increase in the percentage of adults reporting 2 impairments. For those aged 65 and over, the increase was seen in the percentage of adults with 3 or more impairments.

As found in an earlier Life Opportunities Survey (LOS) report, adults who had an impairment were more likely to report having multiple impairments than a single impairment. Adults aged 65 and over were more likely than those aged 16 to 64 to report having 3 or more impairments, and less likely to report having only 1.

These findings suggest that there is an increase in the number of impairments experienced as people age.

Around two-thirds of adults who reported at least 1 impairment at Wave One had at least 1 impairment at Wave Three. Overall, 35% of adults no longer reported an impairment at Wave Three (Offset).

For adults with impairment at both waves, the most commonly-reported impairments for Wave One and Wave Three were long-term pain, chronic health condition¹, mobility and dexterity (see Figure 2.4). This is regardless of age. There has been a noticeable increase at Wave Three in the percentage of adults reporting chronic health condition and mobility impairments. The addition of new categories to the chronic health condition may have influenced this result². As the LOS has followed the survey population over 3 years these increases may reflect changes in impairment as individuals age. The adults reporting a particular impairment type at Wave One may not necessarily be the same group of adults reporting that impairment type at Wave Three.

Looking at impairments by age group (Figures 2.5 and 2.6) there is an increase at Wave Three in the percentage of adults aged 65 and over reporting memory, breathing, sight and hearing impairments.

For ease of comparison, Figure 2.7 shows the percentage of impairment types reported at Wave Three for working age adults and adults aged 65 and over. Some impairment types are more frequently reported by those aged 65 and over than working age adults. For example, a higher percentage of those aged 65 and over reported mobility, dexterity, sight and hearing impairments at Wave Three. These impairment types may generally be associated with ageing. Memory is also often thought to deteriorate with age, but Figure 2.7 shows no statistically significant difference between the percentage of working age adults and those aged 65 and over with memory impairment. However, it should be noted that adults in residential homes were excluded from the sample for LOS. If those requiring more help and support are receiving it in a residential home this will affect the results presented here.

Adults aged 16 to 64 were more likely than those aged 65 and over to have reported a mental health condition (21% and 5%) and a learning impairment (11% and 1%) at Wave Three. It may be that working age adults are more likely to be diagnosed with such conditions, or more likely to report these conditions when interviewed.

Notes for 2.4 Impairment types reported at Wave Three by adults with an impairment at both waves

1. Chronic conditions are defined as long-term conditions that have lasted or are expected to last 12 months or more and that have been diagnosed by a health professional. These include but are not limited to: Asthma or severe allergies; Heart condition or disease; Kidney condition or disease; Cancer; Diabetes; Epilepsy; Cerebral Palsy; Spina Bifida; Cystic Fibrosis; Muscular Dystrophy; Migraines; Arthritis or rheumatism; Multiple Sclerosis (MS) ; Paralysis of any kind; Chronic Obstructive Pulmonary Disease (COPD); and Depression

2. Wave Three included two additional categories to chronic health condition – Chronic Obstructive Pulmonary Disease (COPD) and Depression

The severity of impairment can be assessed by looking at the level of difficulty¹ and frequency of the limitation associated with the impairment. Tables 2.1 to 2.4 show the level of severity reported at Wave Three for the 4 most commonly-reported impairments by adults with impairment at both waves² (long-term pain, chronic health conditions, mobility and dexterity).

For all 4 impairment types, approximately two thirds of adults with an impairment at both waves reported moderate difficulty for that impairment. This was the same for working age adults and those aged 65 and over.

When considering the frequency of limitation, the majority of adults reported experiencing limitation "often" or "always". This was true for the 4 impairment types considered here, and for both age groups. A lower percentage of adults who had a long term pain impairment reported always experiencing limitation (34%) than those who had a chronic health condition (52%), mobility impairment (57%) and dexterity impairment (49%).

There was a slight variation by age for some of the conditions. Compared to adults of working age, a greater percentage of adults aged 65 and over with long-term pain and chronic health condition "always" experienced limitation. In contrast, a higher proportion of adults of working age who had a dexterity impairment reported "always" experiencing a limitation (54%) than adults aged 65 and over (42%).

Notes for 2.5 Severity of impairment reported by adults with impairment at both waves

1. The response categories for level of difficulty were: 1. “No Difficulty”; 2. “Mild Difficulty”; 3. “Moderate Difficulty” 4; “Severe Difficulty”; and 5. “Cannot Do”; For some impairment types (chronic condition, breathing, learning, intellectual, behavioural, memory, and mental health impairments), the levels ranged from 1 to 4. For pain, the level of pain was measured by the intensity of the pain experienced: 1.”Mild”; 2.”Moderate”; 3. “Severe”

2. Analysis in Tables 2.1 to 2.4 is based upon only adults who reported the same impairment at both waves

Offset rates show the percentage of adults who have changed from reporting at least 1 impairment at Wave One to no longer reporting an impairment at Wave Three. The differences in offset rates reflect the differences in age group and number of impairments (as illustrated in Figure 2.3). The rates for the different groups in the population are based on their Wave One demographic characteristics: sex, age, ethnic group, region, tenure, education and occupation.

Overall, around a third of adults who had an impairment at Wave One did not have an impairment at Wave Three. Table 2.5 shows that offset rates for men and women are similar (35% and 33%). In general, the rates suggest that the likelihood of offsetting from impairment decreases with age. For example, around half of adults aged 16 to 24 who reported at least 1 impairment at Wave One had no impairments at Wave Three. In contrast, less than a fifth of adults aged 75 and over who reported at least 1 impairment at Wave One no longer reported any impairment at Wave Three. Overall, the offset rate is higher for working age (16 to 64) people, than for those 65 and over.

Age appears to be an important factor influencing the rate of offsetting rather than other demographic characteristics reported (see Table 2.6). The type of impairment experienced at Wave One may also influence an individual’s experience. We turn to this in the next section.

Offset rates can be calculated for a range of impairment types. Table 2.7 shows the offset rate of impairment types for adults who reported an impairment at Wave One but no longer reported any impairment at Wave Three¹. For all impairment types offset may be due to an absence of impairment at Wave Three, a change in the perception of the impairment, or a change in treatment received for the impairment.

Looking at the overall offset rates for impairments, the highest offset rate was for long-term pain (31%). This perhaps reflects the fluctuating nature of long-term pain – as seen in section 2.5, a lower percentage of adults who had long term pain impairment experienced limitation "always" or "often" than those who had other impairments.

"Sight" has a relatively high offset rate. A previous LOS report found that the majority of adults who offset from a sight impairment offset to "mild", that is, they still had a sight condition but it only caused them mild difficulty.

Adults aged 65 and over were less likely to offset from a number of impairment types than those aged 16 to 64, including chronic health condition, long-term pain and dexterity.

Notes for 2.7 Offset rates of impairment types

1. Adults with impairment at both waves can also experience an offset of a specific impairment; these adults are not included in this analysis.

This section looks at the onset rates for adults who did not have an impairment at Wave One but reported at least 1 impairment at Wave Three. These adults are known as "onset-acquired"¹. The onset rate is the percentage of all adults without any impairment at Wave One, who became onset-acquired at Wave Three.

Almost a fifth of adults who did not have an impairment at Wave One reported an impairment at Wave Three – the overall "onset" rate was 18%. As can be seen in Table 2.8, onset rates increased with age, with those aged 65 and over around twice as likely to onset as working age adults. This is in line with what was found in Section 2.6, where adults were less likely to offset as they age.

Table 2.9 shows the onset rates for different demographic characteristics of the population including tenure, education and occupation. As was found with offset rates, age appears to be an important factor influencing the rate of onsetting, rather than other demographic characteristics. For many of the characteristics, adults aged 65 and over were more likely than working age adults to onset.

Notes for 2.8 Onset rates for adults who did not report any impairment at Wave One

1. Due to the longitudinal survey design there is a potential measurement bias in the onset rate reported by the LOS. A differential onset rate was identified at Wave Two between cases identified through the telephone screener, and those identified within face to face sample (that is, from the "control group" or co-residents of adults with impairments). The weighting method developed for the survey has been designed to adjust for this under estimation, but it should be noted that some bias may remain

This section looks at the percentage of all people without any impairment at Wave One, who then reported a specific impairment type at Wave Three¹. It considers onset rates by impairment type.

The impairment type which had the highest onset rate for all adults was long-term pain (9.2%). We saw in Section 2.7 that long-term pain also has the highest offset rate of the impairment types considered on the LOS. This may suggest that long-term pain fluctuates.

For all impairment types, with the exception of mental health condition, the onset rate was higher for those aged 65 and over than for working age adults (see Table 2.10). The onset rate for long-term pain for adults aged 65 and over was almost twice that for working age adults; for chronic health condition it was around 3 times that of working age adults and for mobility it was around 9 times that of working age adults. For all adults the 4 impairment types with the highest rates were chronic health condition, mobility, long-term pain and mental health condition.

For working age adults, mental health condition impairment onset rate was slightly higher (1.9%) compared to adults aged 65 and over (1.0). For adults aged 65 hearing was in the top 4 onset rates, while for working age adults the onset rate for hearing was low.

Notes for 2.9 Onset rates of impairment types

1. Analysis in this section has been restricted to looking at the onset rates for onset-acquired adults. Adults with impairment at both waves can also experience an onset of an additional specific impairment; these adults are not included in this analysis

For adults who did not report an impairment at Wave One but reported at least one impairment at Wave Three, the 4 most commonly reported impairment types overall at Wave Three were long-term pain, chronic health condition¹, mobility and mental health condition² (see Figure 2.8). The pattern of impairment types experienced by all onset-acquired adults at Wave Three was very similar to that experienced by adults with impairments at both waves (see Figure 2.4).

There appears to be an association between age and certain impairment types. Adults aged 65 and over were more likely to report chronic health condition, mobility, dexterity, memory, sight and hearing impairments than those aged 16 to 64. These impairment types may generally be associated with ageing.

In contrast, adults aged 65 and over were less likely to report a mental health condition. While a smaller proportion of adults aged 65 and over reported long-term pain than those aged 16 to 64, this difference was not found to be statistically significant.

Notes for 2.10 Impairment types reported by adults at Wave Three – onset-acquired impairment

1. Chronic conditions are defined as long-term conditions that have lasted or are expected to last 12 months or more and that have been diagnosed by a health professional. These include but are not limited to: Asthma or severe allergies; Heart condition or disease; Kidney condition or disease; Cancer; Diabetes; Epilepsy; Cerebral Palsy; Spina Bifida; Cystic Fibrosis; Muscular Dystrophy; Migraines; Arthritis or rheumatism; Multiple Sclerosis (MS) ; Paralysis of any kind; Chronic Obstructive Pulmonary Disease (COPD); and Depression

2. The percentages may sum to more than 100 as respondents were able to report more than one impairment

Tables 2.11 to 2.14 show the 4 most commonly reported impairments by adults who onset: long-term pain, chronic health condition, mobility, and dexterity. In general, adults who were not impaired at Wave One but reported an impairment at Wave Three (onset-acquired), rated the severity of their impairments as low in terms of both the level ("moderate") and the frequency ("rarely" or "sometimes") of the limitation they experienced.

For long-term pain and chronic health condition, similar percentages of adults of working age and adults aged 65 and over reported moderate or severe difficulty. The percentages reporting severe difficulty for mobility impairments was higher for working age adults (26% compared to 14%). Percentages of working age adults reporting severe difficulty were also higher for dexterity impairments (26% compared to 16%).