The drivers of institutionalization among the elderly in Europe

Beatriz Rodríguez Sánchez. Show Author details

Elderly institutionalization drivers exercise class
Exercise class with the elderly

Nowadays, there are 900 million people aged 60 years old and above worlwide, from which 16% are older than 80 years old (UN, 2019). By 2050, 2,000 million people will be older than 60 (WHO, 2018), 21% of them being 80 years and above. In addition to ageing, increasing life expectancy poses a major challenge to current societies and to the sustainability of welfare systems as we know them so far due to (among others) the prevalence of chronic health conditions in the population and the vast increase in the age-dependency ratio, defined as the number of inactive older adults aged 65 years old and above over the total number of employed people (European Commission, 2021). One of those chronic conditions that have emerged as a top health priority is diabetes, since its prevalence and incidence have rapidly increased globally. Future projections indicate a near quadrupling of the prevalence figures at the turn of the century (2.8%) by the year 2030 up to 11.3% of the whole population (more than 640 million people) and 12.2% by 2045 (783 million people) (more about the burden of diabetes worlwide here). Older adults will lead this increase, representing around 50% of the people with diabetes and with a prevalence of diabetes around 25%, meaning that one in every four people older than 65 years old will have diabetes. 

Furthermore, partly due to the aforementioned increasing age-dependency ratio, population ageing will come along an increase in the demand for long-term care, including residential care (OECD Health Statistics, 2018). These projections have made healthcare policymakers to define organizational changes in the models of care services provision (this topic has been covered in this blog here and here), placing the focus on quality of life and aiming to ensure the maximum autonomy as possible subject to specific functional status, ranging from completeley independent to severely dependent people, as older people in nursing homes might be. 

Diabetes and nursing home admission

Traditionally, diabetes has been associated with a higher risk of being dependent and of being institutionalized. Some evidence from the US reported that diabetes is a determinant of nursing home placement among the frail elderly and, moreover, old people with diabetes are 1.8 times more likely to be institutionalized (Matsuzawa et al., 2010; Newton et al., 2013). 

The effect of diabetes on nursing home admission is expected to be mediated by both clinical and functional complications, which might be at the same time caused by other diseases and other factors, as the figure below shows. Sociodemographic factors such as age, gender, marital status, education, and number of children are associated with the risk of institutionalization. Other factors such as employment status and income should be considered, as well as a list of chronic conditions, functional and cognitive impairment, since they might be associated with the risk of being transferred into a nursing home.

Diabetes functional complications nursing home placement

When designing public policies, it is essential to identify target populations, in addition to understand their characteristics and the drivers of healthcare use. Using data from the Survey of Health, Ageing and Retirement in Europe (SHARE) and information on total expenditure for nursing homes per country from the OECD data and statistics, I assess the factors leading to institutionalization and the associated costs among older Europeans with diabetes (Rodríguez-Sánchez et al., 2017). By merging both datasets, I was able to assess which factors are associated with higher odds of being admitted to a nursing home and the nursing home expenditures attributable to diabetes and its complications, including sociodemographic indicators (age, gender or education, among others), clinical conditions (a set of chronic conditions, in addition to diabetes) and functional status (four categories according to the number of limitations in the activities of daily living, such as bathing, dressing or toileting). Moreover, I analysed whether there were differences across European countries and other subgroups of analysis, distinguishing by age or gender and by length of stay. The analyses referred to the period 2004-2010 and covered twelve European countries: Austria, Belgium, Czech Republic, Denmark, France, Germany, Greece, Italy, The Netherlands, Spain, Sweden, and Switzerland.

The results obtained confirmed that diabetes increases the risk of institutionalization, although its effect decreases when diabetes-related clinical complications are included and especially when functional status is introduced. This points towards a mediation effect of functional complications that reduces the impact of diabetes on the probability of being admitted to a nursing home, since these complications are related to this disease. We can see this in the figure below. If we first focus on individuals without functional impairments (left bars), factors also related to diabetes – stroke, cognitive impairment and cancer – explain nursing home admission. Still, when functional impairment severity was considered, chronic diseases were no longer the main determinants (right bar), as various degrees of potentially diabetes-associated functional impairment account for the largest fraction of nursing home admissions, and the relative importance of cancer, stroke and cognitive impairment decline.

Predictors nursing home admission

My analyses also show that the effect of functional impairment on the risk of institutionalization is age-dependent (right panel). As people become older, the risk of nursing home placement increases among individuals with various degrees of functional impairment, especially if they exhibit severe and moderate levels. 

Age funtional impairment institutionalization

Total average nursing home costs reached $12.66 per capita over all countries, as the figure below shows. Importantly, 78% of these costs can be attributed to complications from several degrees of functional impairment. The most important among these degrees is mild functional impairment, which happens when the individual reported to have some problems in one or two activities of daily living. When assessing cross-country differences, this pattern is confirmed: the largest cost shares relate to functional status. In countries such as Spain, The Netherlands and Germany such costs actually represent the greatest proportion, usually followed by stroke. 

Costs associated diabetes related complications

Towards a fairer and more efficient health care sector

My research provides so far a deeper knowledge of the economic drain of diabetes regarding its associated healthcare (Rodríguez-Sánchez & Cantarero Prieto, 2019), drug treatment, medical visits (Mata-Cases et al., 2020) and non-healthcare (nursing home use) costs. This is an essential matter in the healthcare policy making process in order to achieve an efficient allocation of scarce resources. Diabetes prevalence, together with other chronic conditions, is increasing and, in addition to population ageing, their associated costs are highly likely to noticeably grow in the subsequent years, constituting a challenge, but also an opportunity for current societies. These trends should not be regarded as problematic: would it be fair to state that young people use too many places in schools or universities? Why do we talk about older adults ‘overusing’ healthcare? From a well-being and humanitarian perspective, people matter regardless of their age. Therefore, keeping the elderly as independent and healthy as possible should be in any policy agenda that aims at improving the lives of citizens.

Further information:

  • This article is based on the following publication by the author: Rodríguez-Sánchez, B., Angelini, V., Feenstra, T., & Alessie, R. J. (2017). Diabetes-associated factors as predictors of nursing home admission and costs in the elderly across Europe. Journal of the American Medical Directors Association, 18(1), 74-82. (link)
  • The associated image of this post is taken from Flickr (link). 


  • European Commission (2021). The 2021 ageing report. Economic and budgetary projections for the EU member states (2019-2070). Economic and Financial Affairs, Institutional Paper 148, Brussels.
  • Mata-Cases, M., Rodríguez-Sánchez, B., Mauricio, D., Real, J., Vlacho, B., Franch-Nadal, J., & Oliva, J. (2020). The association between poor glycemic control and health care costs in people with diabetes: a population-based study. Diabetes Care, 43(4), 751-758.
  • Matsuzawa, T., Sakurai, T., Kuranaga, M., Endo, H., & Yokono, K. (2010). Predictive factors for hospitalized and institutionalized care-giving of the aged patients with diabetes mellitus in Japan. Kobe J. Med. Sci, 56(4), E173-E183.
  • Newton, C. A., Adeel, S., Sadeghi-Yarandi, S., Powell, W., Migdal, A., Smiley, D., … & Umpierrez, G. E. (2013). Prevalence, quality of care, and complications in long term care residents with diabetes: a multicenter observational study. Journal of the American Medical Directors Association, 14(11), 842-846.
  • Organisation for Economic Co-operation and Development. OECD health statistics 2018. Paris, France.
  • Rodríguez-Sánchez, B., Angelini, V., Feenstra, T., & Alessie, R. J. (2017). Diabetes-associated factors as predictors of nursing home admission and costs in the elderly across Europe. Journal of the American Medical Directors Association, 18(1), 74-82.
  • Rodríguez-Sánchez, B., & Cantarero-Prieto, D. (2019). Socioeconomic differences in the associations between diabetes and hospital admission and mortality among older adults in Europe. Economics & Human Biology, 33, 89-100.
  • United Nations (2019). Department of economic and social affairs, population division. World population ageing (link). Accessed on the 14th of March 2022.
  • World Health Organization (WHO) (2018) – ageing and health (link). Accessed on the 14th of March 2022.

Author details

Assistant professor (Complutense University of Madrid)
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