English Longitudinal Study of Ageing (ELSA) Natasha Wood Presentation is split into two parts. I am going to give a brief background to ELSA then Mai Stafford from UCL is going to present some of the findings from the study.

A study of people aged 50+ and their partners Background A study of people aged 50+ and their partners Multi-disciplinary - health, economic and social circumstances Longitudinal - change over time Comparative - USA (HRS) and Europe (SHARE) Funding - National Institute on Aging (US) & UK Government Departments ELSA is a multi-disciplinary cover a wide range of topics. ELSA aims to measure outcomes across all aspects of people’s lives as they age beyond 50 and provide data that can shed light on the cause and consequences of these outcomes. ELSA aims to answer the following questions: What explains who has good health in later life and who does not? When do people retire and how do they plan for their retirement? Do people have enough savings to provide for their older age? How do changes in memory and concentration affect well being? What is the relationship between all the factors involved in ageing? Also collect objective physical measurements through a nurse visit. 2

Dept of Epidemiology and Public Health, UCL Research Team Dept of Epidemiology and Public Health, UCL National Centre for Social Research Institute for Fiscal Studies Universities of Manchester, East Anglia and Cambridge This is the research team.

History of ELSA Wave 1 2002/3 Wave 2 Nurse visit 2004/5 Wave 3 Original sample interviewed in HSE 1998/1999/2001 Age 50+ on 1 Mar 2002 Wave 1 12,099 2002/3 Wave 2 9,432 Nurse visit 7,666 2004/5 Refreshment sample HSE 2001/02/03/04 Age 50-52 on 1 Mar 2006 Wave 3 9,771 Life-history 7,855 2006/7 Refreshment sample from HSE 2006 Age 50-74 on 1 Mar 2008 2008/9 Wave 4 11,050 Nurse visit 8,641 ELSA Wave 1 began in 2002, the original sample was taken from the Health Survey for England (HSE) – we call the HSE Wave 0 – those aged 50 and above on 1 March 2002. Wave 1 consisted of just a main interview ELSA Wave 2 took place in 2004, at this wave there was a core interview and a nurse visit. ELSA Wave 3 was carried out in 2006 and consisted of a core interview. As our sample ages it is no longer representative of those aged 50-52. So the sample was refreshed by the HSE 2001-04 sample at this wave. ELSA Wave 4 took place in 2008, there was a core interview and a nurse visit. The mainstage sample was refreshed by the HSE 2006 sample at this wave for those aged 50 – 74 years – replenish the sample. Wave 5 began in June 2010 and finished last month. We carried out a financial risk taking module with a sub-sample of respondents aged 50-74 which will talk more about in a moment. Wave 6 will commence in April 2012, we are just preparing for this now. Wave 6 will include a nurse visit. We will also refresh the sample this year from HSE 2009 and 2010 for people aged 50-55 years. Wave 5 Approx 10,274 Risk module Approx 1,065 2010/11 Refreshment sample from HSE 2009/10 Age 50-55 on 1 Mar 2012 Wave 6 Nurse visit 2012/13 4

Main Interview Content Household and individual demographics Health Social participation Work and pensions Income and assets Housing and consumption Cognitive function (assessments) Expectations Effort and reward (of voluntary work and caring) Psychosocial health Timed walk (for those 60+) Self-completion These are the sections of the main ELSA interview. Interview is roughly 80 mins for 1 resp 120 mins for two. Health – questions on whether diagnosed with particular health conditions, quality of care, help around the house, experience pain, smoking, Social participation – questions on transport – private and personal, a couple of questions on how they feel about their local area. Cognitive function – respondents carry out a number of activities to measure their short and long term memory, prospective memory (remembering to remember), verbal fluency, mental speed and visual scanning, numeracy and literacy. Expectations – expectations for the future – what degree of certainty they have about future events occurring e.g. living to a certain age, their future health, receiving an inheritance Psycho social health – views on life e.g. how often during the last week they were happy, depressed, lonely Timed walk – ask those aged 60 and above to walk 8ft (244cm) twice. Self-completion – includes questions on quality of life, social participation, life satisfaction, well-being, personality, social networks, religion, discrimination, diet and alcohol consumption.

Blood sample (fasting where possible) Height (standing, sitting) Nurse Visit Content Blood pressure Grip strength Blood sample (fasting where possible) Height (standing, sitting) Weight Waist and hip measurement Lung function Balance Leg rise Chair raise Saliva sample (after visit) This is the content of the nurse visit. Each nurse interview takes an hour. Balance tests Saliva sample – measuring cortisol.

Life History Interview Follow up interview at Wave 3 Asks about childhood and important life events Aim to enhance our understanding of how early life and events throughout life impact upon circumstances of older people Calendar technique to enhance recall Going back to people who agreed to do the LHI at end of their Wave 3 interview (varied gap - weeks to many months) The interview asks about birth up until the present day - quite a long period Ask about childhood and any important life events Aim of the life history interview is to understand how the life course can impact upon the circumstances of older people. We used an event history calendar to enhance recall. Record events on a calendar 7

Relationship with parents as a child Other important life events Topics covered Children & fertility Partners Where lived Work history Health Relationship with parents as a child Other important life events Children - natural, adopt, foster, miscarriages, abortions, still births Partners - cohabiting and non-cohab (social networks) Accommodation - addresses for 6 months or more, - more detail about where lived when 10 (who lived with, no. of bedrooms, facilities, no. of books) Work - jobs for 6 months or more, changes in employer, pt or ft, salaries, activities between jobs, whether left because of ill health Health - injuries, - childhood health (missed school, hospitalisation, list of conditions and when, impact on current life) - adult health (conditions lasting for more than 1 yr, age, long term effects) - smoking history - gynaecology (age periods started, hysterectomy, ovaries removed, menopause, HRT) Parents - separation from mother, divorce - care and protection Other - experience of difficult life events (e.g. physical attack, abuse, bereaved) - open ended questions - 3 aspects of life especially important, and how affected them 8

Life history was a follow up interview to Wave 3. Life history interview asked about the respondents’ lives prior to joining ELSA – from early childhood to the date they joined ELSA. We know very little about respondent’s lives before they joined ELSA and early life events impact on circumstances in later life. Respondents trying to recall information from a long time period we developed a life grid – to aid recall. 5 domains of respondent’s lives we asked about: Children - natural, adopt, foster, miscarriages, abortions, still births Partners - cohabiting and non-cohab (social networks) Accommodation - addresses for 6 months or more, Work - jobs for 6 months or more, changes in employer, pt or ft, salaries, activities between jobs, whether left because of ill health Health - injuries, childhood health (missed school, hospitalisation, list of conditions and when, impact on current life) - adult health (conditions lasting for more than 1 yr, age, long term effects) This is a screen shot of the life history interview Top is the question. Then the life grid – 5 topics down the side Years along the top and underneath that the age of the respondent during that year Full shaded square shows that date moved into that accommodation etc. Shaded square in the children line is when this respondent had their children. At the bottom are the important events in that year and personal events in that year – help respondent remember what they were doing that year. Found that both the respondents and the interviewers enjoyed the life history interview.

Plans for Wave 6 Social care Fluid intelligence We are now preparing for Wave 6 which will commence in April 2012. We are adding a number of new topics at this wave. Questions on social care – which have been developed by a collaboration of NatCen, Personal Social Services Research Unit at Universities of Kent, LSE and Manchester. Now been introduced on HSE. We will be introducing a shortened module. Fluid intelligence or fluid reasoning is the capacity to think logically and solve problems in new situations, and is essential for many forms of problem solving. It is relevant to how people negotiate life, and shows age-related declines.

Fluid Intelligence Example 17. . . BLANK . . . 12. . . 8 What number belongs in the blank? Correct answer is 15, as there are four between 8 and 12 and then 3 between 12 and 15 and 2 between 15 and 17.

Plans for Wave 6 Social care Fluid intelligence Sexual functioning We are going to be including a self-completion on sexual functioning, or we are calling it sexual relationships and activities. Sexual function and satisfaction are related to health and wellbeing. Alongside increasing life expectancy, evidence suggests an increasing proportion of people remain sexually active in later life, with current opinion increasingly viewing waning sexuality associated with ageing as a pathological outcome requiring medical and lifestyle interventions. There is very limited data to address questions relating to sexual function and satisfaction in later life and its determinants and consequences. Collecting relevant data from the ELSA cohort, would permit important and novel examination of this topic, particularly as repeat measures in subsequent waves would allow a separation of age and cohort effects and an examination of causal direction. We have developed male and female self-completion questionnaire.

Plans for Wave 6 Social care Fluid intelligence Sexual functioning Nurse visit, biomarkers

Wave 6 biomarkers Wave 2 Wave 4 Wave 6 Anthropometric Grip, balance, chair rise, tandem stand, leg raise Blood pressure, lung function Lipids, triglycerides, HbA1c, glucose C-reactive protein, fibrinogen C-reactive protein, fibrinogen, white cell count Haemoglobin, ferritin DNA (DNA) IGF-1, DHEAS ?IGF-1, Vitamin D Apolipoprotein E Anthropometric – height, weight, waist, hip Very few changes from wave 4.

Nurse visit, biomarkers Multiple drug use (polypharmacy) Plans for Wave 6 Social care Fluid intelligence Sexual functioning Nurse visit, biomarkers Multiple drug use (polypharmacy) The use of multiple drugs in older people is an important and poorly understood health care issue, with both risks and benefits for health and independent functioning. Potentially inappropriate prescribing is common, with up to one third of all older people in the UK receiving a potentially harmful drug prescription (De Wilde et al, 2007). These high levels of potentially inappropriate prescribing are likely to lead to adverse drug reactions, a major cause of avoidable hospital admissions. Data on prescribed drugs will complement existing ELSA information on diagnosed conditions and quality of care, by linking information on diagnosis and receipt of indicated care for conditions such as coronary heart disease, hypertension, diabetes mellitus, osteoarthritis, and depression to prescriptions received. Combining these data with existing ELSA data will enable important insights into the factors that identify successful use of prescribed drugs in older people, such as socio-economic status and cognitive ability, building on existing research that has found potentially inappropriate prescribing increased with age and deprivation (Carey et al, 2008). The information on prescriptions will be collected during the nurse visit in wave 6 of ELSA.

Findings I am now going to talk through some findings from ELSA.

Disease outcomes at older ages in the US & England Health and Retirement Study is ELSA’s sister study in the US. Results from HRS and ELSA are directly comparable. A paper written by colleagues at the IFS compared health of older American with older English and found that all types of disease were more prevalent in older Americans than older English. This finding was used by Michael Moore in his film Sicko which investigates healthcare in the US. “In a study of older Americans and Brits, the Brits had less of almost every major disease. Even the poorest Brit can expect to live longer than the richest American.” Source: Banks et al. (May, 2006) Disease and Disadvantage in the United States and in England; JAMA, Vol 295, No.17

Childhood disease in the US & England A life history health module was introduced on the HRS in 2006. The module was broadly comparable to the ELSA health life history module. Using the data collected in the ELSA Life History Interview and a similar life history module in the HRS we can explore how childhood health and circumstances relate to outcomes in late life in both the US and England. What we see here is that the relative prevalence of self-reported childhood diseases was very similar across the two countries. However, in general, prevalence of childhood health conditions can be seen to be higher in the US than in the England. This is similar pattern to that seen in later life. Source: Banks et al. (May 2011) Childhood health and differences in late-life health outcomes between England and the United States, NBER Working Paper 17096 and forthcoming in Wise et al (ed), Investigations into the Economics of Ageing, NBER 20011 18

Unemployment before 50 & quality of life SHARE – European carried out a similar life history interview as ELSA Looked at period of unemployment before the age of 50 and what impact this had on quality of life in later life for men and women. Unemployment was classified as a period of 6 months or more. Quality of life was measured using CASP 19 – measure of quality of life used on many studies. ELSA – is down as Anglo-Saxon (not Angle Saxon). In Scandinavian, Bismarckian and Anglo-Saxon countries (men only) people experiencing a period of unemployment before 50 generally report lower quality of life in later life. Results remain stable if wealth and age are considered in the multivariate analyses. However, no significant results are found for Southern and Eastern countries, probably countries were non-institutional factors, such as family are a more important role of welfare. Source: Wahrendorf,M.; Blane D. & J. Siegrist 19

Wave 4 Report Findings A quarter of households experienced at least a 10% increase in the share of their income devoted to basics. Spending on domestic fuel rose by more than a third The poorest fifth are more sedentary, heavier and least likely to eat five portions of fruit and vegetables than the wealthiest fifth –trend has been increasing over time Half of those aged 50 to 74 provide some form of help to friends and neighbours, with more than 1 in 10 actively providing care for someone - partner or parent Increasing reports of feeling lonely and less happy with life We published the Wave 4 report late last year. Here are some findings from the report. Source: Financial circumstances, health and well-being of the older population in England; The 2008 English Longitudinal Study Of Ageing (Wave 4)

Data Available

ELSA data in the archive File Wave 0 Wave 1 Wave 2 Wave 3 Wave 4 Core Data  Nurse Data N/A Index File Updates TBA Life History Data Ryff Self Completion Data Telephone Interview (with non -responders) Data End of Life Interview Data Financial Derived Variables Pension Wealth Derived Variables Pension Grid Mortgage Data Mortgage Grid Technical Report N/A5 Go through table Wave 3 was archived late last year. Wave 4 main interview was interviewed late last year Index file updates – W3 index file now available soon. The index file contains all the respondents who were ever selected for ELSA including those that have died or have consistently refused. It contains reference information such as whether they had an interview at certain waves and whether they are still alive or not. Life history data – was archived earlier this year Telephone interview data for Wave 3 will be ready later on this year End of life interview data – Waves 2 and 3 will be archived in autumn of this year 22

Data and associated documentation: http://www.esds.ac.uk/longitudinal/ Further information ELSA website: http://www.ifs.org.uk/elsa Data and associated documentation: http://www.esds.ac.uk/longitudinal/ Contact me: natasha.wood@natcen.ac.uk ELSA website – reports and journal articles, documentation ELSA data housed at uk data archive Can contact me at this email address.

Questions?