Care for older people

At the beginning of 2023, there were about 2.3 million people aged 65 years or more in Belgium. This age group now makes up nearly 20% of the population, and the Belgian Federal Planning Bureau expects this share to exceed 25% by 2050.

This growing older population also needs specific health services: aside from an increased use of acute care, many of them also require longer term assistance with their daily activities and sometimes nursing care. Informal caregivers like family and friends often play an important role in providing long-term care to older people, but professional services are also available when informal care is not an option (anymore) or insufficient. Typically, this formal care will initially be delivered at home by home assistance services (“thuishulp”-“aide à domicile”) who can help with daily activities like cleaning, cooking, shopping, etc. Home nursing services (“thuisverpleging”-“soins à domicile”), on the other hand, are also available for those who need medical care or help with e.g. personal hygiene.

When staying at home is no longer desirable or possible, the person can be moved to a residential care facility. In Belgium, residential care falls into two main categories: “rest homes”, which provide nursing and personal care to older persons whose needs are low to moderate, and “rest and nursing homes” for people who strongly depend on care. In most cases, residential care facilities will offer a number of places (beds) in both categories. In Dutch, they are referred to as “woonzorgcentra”, with some beds having additional accreditation (“bijkomende erkenning”) to provide more intensive nursing care. In French, they are known respectively as “maisons de repos pour personnes âgées” (MRPA) and “maisons de repos et de soins” (MRS).

A number of other options are also available, like centres offering daytime care or short-term stays, but also service flats (“assistentiewoningen/résidences-services”) where older people can lead a largely independent life in an environment suited to their needs, with optional community and support services.

The responsibility for long-term care for older people is split between the federal level and the federated entities (regions and communities), which can have an impact on the care offer itself but also on data availability.

The indicators in this section relate to various dimensions of care:

• Accessibility, through indicators on the share of older people receiving long-term professional care in a residential facility (OLD-1) or at home (OLD-2), the number of informal caregivers (OLD-3), the number of long-term care beds (OLD-4) and the number of geriatricians (OLD-6). A last indicator on the number of older people living in residential care facilities while their care needs are limited (OLD-5) relates both to accessibility and to appropriateness of care.
• Safety, through indicators on the number of falls (OLD-7) and pressure ulcers (bedsores) (OLD-8).
• Appropriateness, through indicators on the use of “anticholinergic” medication, known to cause problematic side effects in older people (OLD-10), the use of antipsychotic and antidepressant medications in residential care (OLD-11) and in older people living at home (OLD-12), and multiple treatments (polypharmacy) (OLD-13 ).

Indicators on care for older people

ID	Indicator	Score	BE	Year
Accessibility of long-term care services
OLD-1	Long-term care in homes for older people (% of pop. 65+)	C	5.7	2018
OLD-2	Long-term home nursing care (% of pop. 65+)	C	7.6	2021
OLD-3	Informal carers (% of pop. 50+)	C	23.5	2019
OLD-4	Number of long-term care beds in homes for older people (per 1 000 population 65+)	C	65.4	2022
Accessibility of acute care
OLD-6	Practising geriatricians (per 10 000 pop. 65+)		1.7	2021
Safety in residential care
OLD-7	Fall incident during the last month in homes for older people (% of residents)		12.8 *	2021
OLD-8	Prevalence of pressure ulcers (grade II-IV) in homes for older people (% of residents)		2.9 *	2021
Appropriateness of care
OLD-10	Prescription of anticholinergic drugs >80 DDD in older people (% of pop. 65+)		18.7	2021
OLD-11 A	Use of antipsychotics ≥1 DDD in homes for older people (% of residents 65+)		27.3	2021
OLD-11 B	Use of antidepressants ≥1 DDD in homes for older people (% of residents 65+)		48.3	2021
OLD-12 A	Use of antipsychotics ≥1 DDD outside homes for older people (% of pop. 65+)	→	4.4	2021
OLD-12 B	Use of antidepressants ≥1 DDD outside homes for older people (% of pop. 65+)	→	18.1	2021
OLD-13	Polypharmacy among older people (5 or more drugs of >80 DDD per year) (% of pop. 65+)		42	2022

* Data are only available for Flanders

Link to the full synoptic table and the report

Percentage of older people receiving long-term care in residential facilities (OLD-1) or at home (OLD-2)

The share of the population receiving formal long-term care (and its evolution over time) is an indicator of the accessibility and sustainability of the long-term care component of the health system.

Results

• In 2021, in Belgium, just under 8% of people aged 65 years or more received nursing care at home. However, figures show considerable variation between regions (about 8% in Flanders, 7% in Wallonia and 4% in Brussels) and even more so between provinces, ranging from 4.2% in Walloon Brabant to 11.7% in Limburg.
• Data on long-term care in residential care facilities for 2019-2020-2021 is not complete, especially for Brussels and Wallonia. In 2018 (the last complete year available), just under 6% of people aged 65 years or more lived in a residential facility (about 5% in Flanders, 6% in Wallonia and nearly 8% in Brussels).
• International data are difficult to compare; however, overall, Belgium seems to have more older persons receiving long-term care in residential facilities than other EU countries, while long-term care at home is somewhat less common than in other EU countries.

Link to the technical sheet and detailed results

Percentage of the population aged 50 years or more providing informal care (OLD-3)

Informal care is often regarded as a cost-effective way to avoid or delay moving older people to residential facilities. However, it is important to remember that this type of care can also cause indirect costs for society and for the caregivers themselves, because caring for an ageing relative might force them to reduce or pause their professional activities, but also impact their health and well-being.

The availability of informal care is also expected to decline in the coming decades due to a variety of reasons (families getting smaller, more people settling far away from their loved ones, more women with a career…), and a shift towards more formal care can be expected. Nonetheless, policy measures should continue to encourage and facilitate informal care and support informal caregivers in the future, e.g. through cash payments, legal rights, training opportunities, etc.

This indicator examines the share of the population aged 50 years or more that reports providing informal and non-professional help or care at least once a week.

Results

• In 2018, about 17% of the Belgian population aged 50 years or more reported providing informal help or care at least once a week.
• People aged 50 years or more with a higher income were more likely to report being informal carers than their peers with a smaller income.
• The highest percentage of informal caregivers (just under 22%) was found in the 55-64 age group.
• The data used in international comparisons finds an even higher percentage of informal caregivers in the Belgian population aged 50 years or more, with nearly 24% reporting that they provide informal care on a daily (9%) or weekly (14%) basis. This rate is well above EU-14 and EU-27 averages.

Link to the technical sheet and detailed results

Number of beds in residential facilities for older people (per 1000 population aged 65 years or more) (OLD-4)

As the population gets older and the availability of informal care declines, the need for formal care is likely to increase sharply in the coming years. Beds in residential care facilities are a costly option which should preferably be avoided when suitable alternatives are available, but they will undoubtedly remain an important part of the long-term care offer for older people.

Results

• In 2022, residential care facilities for older people totalled a little under 150 000 beds. This comes down to a little over 65 beds per 1000 senior citizens (aged 65 years or more) – about 60/1000 in Flanders, 70/1000 in Wallonia and 104/1000 in Brussels (2021 data for Brussels, 2022 data for Flanders and Wallonia). Overall, this is slightly less than in previous years.
• Belgium has a relatively high number of beds in residential care facilities compared to other European countries. In 2019, it reached 69/1000, which was considerably above the EU-27 average of 44.5/1000.

Link to the technical sheet and detailed results

Low care-dependent people living in residential care facilities (% of residents) (OLD-5)

The need for residential care beds is expected to increase substantially in the near future. Keeping older people in their familiar home environment when possible will be an important measure to mitigate this evolution, while making sure residential facilities have enough beds for those who are really dependent on care.

Currently, however, a substantial part of the population of residential facilities for older people are older people who are still mostly independent or only mildly dependent on care (those belonging to the O and A categories based on the Katz Index, see box), for whom alternative options might be more suitable. In a number of cases, such individuals end up in a nursing home for lack of other solutions to their need for mental health care or social lodging, highlighting the need to develop alternative care options so that residential care beds can be used for those who need them most.

Results

• The proportion of residents with an O or A Katz score in Belgian residential care facilities has steadily decreased in recent years, falling from 36% in 2008 to 20% in 2021. There are substantial differences between regions (29% in Brussels, 27% in Wallonia and 16% in Flanders in 2021).

Link to the technical sheet and detailed results

Number of practicing geriatricians (OLD-6)

The ageing of the population will be a challenge not just for the long-term care offer, but also when it comes to dealing with the acute care needs of older people. Geriatricians play an important role in this type of care, but unfortunately seem to be in short supply in Belgium according to the estimates of the medical workforce planning commission.

Those past few years, measures have been taken to increase geriatricians’ incomes and to motivate more medical graduates to specialise in this field. However, further actions may still be required to remedy shortages.

Results

•  The number of practising geriatricians per 10 000 population aged 65 years or more has slightly increased, from 1.35 in 2012 to 1.66 in 2021 (from 1.00 to 1.22 in FTE per 10 000 population). according to the medical workforce planning commission, this is not enough to cover expected needs.
• In 2021, the density of practising geriatricians was higher in Brussels (2.56 in headcount/1.33 in FTE) than in Flanders (1.58/1.26) and Wallonia (1.63/1.10), with considerable variation between provinces. It should also be noted that geriatricians in Belgium only work in hospitals. Their distribution therefore depends on that of hospitals.

Link to the technical sheet and detailed results

Fall incidents during the last month in residential care facilities (% of residents) (OLD-7)

Fall incidents are a common cause of injuries and even death in older persons. About one in ten falls is thought to end in a broken hip or other severe injury which, aside from the associated healthcare costs, can also cause other issues like difficulties in getting around or performing daily tasks. According to the European Injury Database, they are also a major cause of death (28%) in people aged 60 years or more, particularly women.

Data on fall incidents in residential care facilities are only available for the Flemish community, where they are measured in the context of the Flemish Indicator Project. Belgian data from the Health Interview Survey (HIS) are available on fall incidents in older people overall, regardless of their living environment.

Results

• In 2021, a median of 13% of residents in Flemish residential care facilities had had a fall incident over the course of the last month. This high percentage reflects the high care need of this population and the need for further preventive actions.
• The occurrence of falls in older persons (living at home or in a residential facility) has improved considerably over time in Belgium, dropping from 23.8% in 2008 to 17.4% in 2018 (based on HIS survey data on fall incidents during the 12 months preceding the interview in people aged 65 years or more). Women tended to fall more than men (20.9% vs 12.8%), and falls were more common in Brussels (24.5%) than in Flanders (17.4%) and Wallonia (15.6%).

Link to the technical sheet and detailed results

Percentage of older persons in residential care facilities experiencing pressure ulcers (OLD-8)

Older people living in residential care facilities are vulnerable to pressure ulcers (also known as bedsores), especially when they are wheelchair-bound or bedridden. Those pressure ulcers are difficult and expensive to treat, can lead to various complications including infections, and have a serious negative impact on health and quality of life. However, they can also be prevented by suitable nursing care, which makes them a useful indicator of the quality of care in residential care facilities for older people.

Data on this indicator are only available for Flanders, where they are measured in the context of a project on quality indicators in homes for older people.

Results

• On average, 2.9% of older people living in Flemish residential care facilities had a severe pressure ulcer (category 2, 3, 4 or undetermined) in 2021. However, only 1.6% of residents developed the pressure ulcer after moving to the facility.

Link to the technical sheet and detailed results

Use of anticholinergic medications in older persons (OLD-10)

Older people are more sensitive than younger patients to certain medications. This is the case, in particular, for drugs which reduce the activity of acetylcholine, a neurotransmitter which plays an important role in the nervous system. This category of anticholinergics includes medications to treat a variety of symptoms and conditions like depression, agitation, dementia, Parkinson’s disease, bladder problems, asthma, COPD, stomach ulcers, etc.

Side effects of anticholinergics include problems like low blood pressure, mental confusion and sedation, which in turn increase the risk of falls. They are more common in older adults, but also often more problematic, especially when compounded with underlying conditions like dementia. This type of medication should therefore be used sparingly in this population, or avoided altogether if possible.

This indicator measures the proportion of people aged 65 years or more who have been delivered more than 80 daily doses of anticholinergics per year, which indicates chronic use, with a particular focus on anticholinergic antidepressants.

Results

• In 2021, just under 19% of the population aged 65 years or more got delivered over 80 daily doses of anticholinergic drugs (including a little over 11% of antidepressants with anticholinergic effects). This percentage was 22% in Wallonia, 19% in Brussels and 17% in Flanders.
• Anticholinergic drug use is higher in women (22%, vs 14% in men in 2021) and in people living in residential care facilities (46% of residents aged 75 years or more used anticholinergic drugs in 2021, vs 18% of those living at home). It also increases with age.
• The use of anticholinergic drugs in general has improved slightly but consistently between 2011 and 2021, while the use of antidepressant drugs with anticholinergic effects has remained stable over time.

Link to the technical sheet and detailed results

Antipsychotic and antidepressant medication use in older persons living in residential care facilities (OLD-11) or at home (OLD-12)

Older people with dementia sometimes display problem behaviour like aggressiveness, which can make caring for them very challenging. Drugs like antipsychotics are sometimes prescribed to improve these issues. However, these medications also seem to increase the risk of stroke and sudden death in older people and should therefore only be used as a last resort, when patients become a danger to themselves or others. The treatment should always be as briefly as possible, and use the lowest possible dose.

This indicator measures the proportion of elderly people who receive antipsychotics, both in residential care facilities and at home. We have also looked at the use of antidepressants, which is particularly high in homes for older people and can also cause a variety of problems (see also above under OLD-10).

Results

• The share of the population aged 65 years or more over receiving antipsychotic drugs has declined from just over 7% in 2008 to 5.5% in 2021. In 2021, this percentage was 5.7% in Flanders, 5.6% in Wallonia and 4.7% in Brussels, with some variation between provinces (from just over 4% in Walloon Brabant to over 7% in Limburg).
• The share of the population aged 65 years or more receiving antidepressants has remained fairly stable since 2008; in 2021, it amounted to 19.5%.
• The use of antipsychotics is higher in older women than in their male counterparts (7% vs 5% in 2021). In spite of the higher risks, it is also substantially higher in older people (65 years or more) than in younger patients. This was also the case for antidepressants.
• The use of antipsychotics among people aged 65 years or more is particularly high in residential care facilities (just over 27% of residents in 2021, vs 12% among older people receiving home care and 3.5% of those who receive no formal long-term care). The use of antidepressants in this group is even more striking (just over 48% in 2021, vs 33.5% for older people receiving home care and 16% for those with no formal long-term care).
• Belgium scores close to the EU-14 and EU-27 averages for prescription of antipsychotics in older persons. However, the use of this type of medication is twice as high in Belgium as in some other countries.

Link to the technical sheet and detailed results

Polypharmacy among older people (OLD-13)

Chronic and multiple diseases (“multimorbidity”) are a common issue in older people. As a result, they who often require several treatments to deal with their medical issues. However, taking several medications at the same time (“polypharmacy”) can cause a number of problems. There is a risk that multiple drugs will interact with each other, which can strengthen or lessen their effects, but which also increases the likelihood of adverse reactions. When they have too many treatments, patients are also more likely to forget them or not take them regularly, particularly if they also experience side effects or have difficulty paying for their medication. In older individuals, polypharmacy can also impair the ability to function normally in daily life and increase frailty.

In view of these potential risks, it is important to find a good balance between the treatments that are medically justified on the one hand, and the necessity to avoid an excessive number of different medications on the other hand.

Different definitions of polypharmacy exist but, for this indicator, we have chosen to focus on the percentage of older adults (aged 65 years or more) who have been taking at least 80 daily doses of 5 or more drugs over the course of a year.

Results

• In 2022, 42% of older adults aged 65 and over took at least 80 daily doses of 5 or more drugs over the past year. This percentage was 41% in Flanders, 45% in Wallonia and 37% in Brussels, with considerable variation between districts.
• Overall, this percentage increases with age, exceeding 50% in people aged 80 years or more in 2022. It is higher in men and in people with a lower educational level.

Link to the technical sheet and detailed results