中国老年人口失能失智轨迹联合研究——兼论长期护理保险评估政策的优化

A Joint Study of Disability and Dementia Trajectories in China's Elderly Population——Optimizing Disability Evaluation of the Long-Term Care Insurance

老年人失能与失智的发展趋势及其相互关系,是失能治理与长期护理保险政策设计需关注的关键议题。文章基于2002~2018年中国老年健康影响因素跟踪调查数据构建了考虑样本损耗的组基轨迹拓展模型,分析了中国老年人日常生活活动能力和认知感知能力的变化轨迹及其影响因素。研究发现:(1)日常生活活动能力的退化轨迹分为晚发平稳型、晚发上升型和早发上升型3类,认知感知能力的退化轨迹分晚发平稳型和早发上升型2类;(2)成年期的吸烟等不良生活习惯会导致老年人进入更快的失能发展轨迹,受教育水平和医疗保险则会降低老年期进入快速失能轨迹的风险,其他非时变特征对失能和失智发展轨迹的影响存在差异;(3)从失能程度的影响因素看,患重病经历会加重失能程度,社交参与则有助于减缓失能失智程度的加深,独居会加重老人的失能程度,居住在城镇的老人失能程度平均更低;(4)老年期失能与失智过程既有一定的伴生性,又不是完全同步。在分析样本中,中度或重度失智老人当中大约27.9%的人日常生活活动能力完好,按照现行长期护理保险标准无法获得相应待遇。优化长期护理保险政策,需要在制度设计中充分考虑失能和失智的叠加与分离现象。

The concomitance in disability and dementia trajectories calls for an efficient policy design of the long-term care insurance by taking dementia into consideration.Using data from the 2002-2018 CLHLS and the Group-Based Trajectory Extension Model considering nonrandom participant attrition,this study estimates the trajectories of activities of daily living(ADL)and cognitive-perceptual abilities(MMSE score)of older population in China,as well as the joint probabilities of the two trajectories,and explores their proximate determinants.We find that:(1)the trajectories of ADL fall into three categories,including late-onset and stable type,late-onset and rising type,and early-onset and rising type;the trajectories of cognitive-perceptual ability fall into two types,namely late-onset and stable type and early-onset and rising type.(2)In terms of the factors affecting trajectory types,unhealthy life style in adulthood such as smoking predicts to a poorer trajectory,while education and medical insurance have significant protective effects on the trajectories,and factors such as birth cohort,occupation,childhood experiences,pension resources and regular exercises in adulthood have different effects on the two trajectories.(3)In terms of factors affecting the degree of disability,serious diseases predicts a severe disability in each trajectory,while social activity participation mitigates the deterioration of both abilities.Older adults with severer disability are more likely to live in urban areas.(4)Under current evaluation criteria of the long-term care insurance,27.9%of older adults with moderate to severe dementia are unable to receive appropriate services or treatments due to their intact ability to perform activities of daily living.Therefore,it is crucial to consider both the interdependence of disability and dementia processes in the policy design of the long-term care insurance.