Nowcasting and forecasting the care needs of the older population in China: analysis of data from the China Health and Retirement Longitudinal Study (CHARLS)

BACKGROUND: An ageing population coupled with an increase in morbidity places a considerable burden on health and social care systems. The aim of our study was to estimate the trends in functional dependency and project future care needs for older people in China. METHODS: We analysed data from the China Health and Retirement Longitudinal Study, a nationally representative survey of a cohort of Chinese people (aged ≥45 years) from 150 counties or districts and 450 villages or urban communities across 28 provinces, who were selected by use of multistage stratified probability-proportionate-to-size sampling. The baseline survey was conducted in 2011 and follow-up surveys were conducted in 2013, 2015, 2018, and 2020. We excluded people younger than 60 years or people who had missing variables on dependency in the five follow-up interviews. Three dependency levels were determined on the basis of activities of daily living (ADLs) and instrumental activities of daily living (IADLs): any ADL items (level 1 dependency); any ADL items or difficulty cooking, shopping, or taking medications (level 2 dependency); and difficulty in any ADL or IADL items (level 3 dependency). The dependency rates were extrapolated to derive the number of people older than 60 years with dependency in China from 2011 to 2020. We used a regression model to project future changes and forecast the size of the older population with dependency between 2021 and 2030. FINDINGS: A total of 89 031 individuals across five waves completed the surveys, of whom 46 619 were eligible for inclusion. The prevalence of level 1 dependency among older Chinese adults declined from 11·7% (95% CI 10·6-12·8) in 2011 to 8·1% (7·5-8·7) in 2020. Level 2 and level 3 dependency also declined. The total number of older people requiring care in 2020 was 20·61 million (95% CI 19·01-22·20) with level 1 dependency, 36·33 million (34·27-38·40) with level 2 dependency, and 45·30 million (43·02-47·59) with level 3 dependency. Improved education, housing, and access to health care was associated with 41·84% of the decline in level 3 dependency prevalence between 2011 and 2020. By 2030, the projected dependency rates could decline to 8·04% for level 1 dependency, 13·28% for level 2 dependency, and 16·05% for level 3 dependency. Nonetheless, the cohort size will grow, resulting in more older Chinese people who need care (29·71 million [27·07-32·36] in level 1, 49·07 million [45·98-52·16] in level 2, and 59·32 million [55·94-62·70] in level 3) in 2030. By 2030, we estimate that 14·02 million more older Chinese people will need care than in 2020. INTERPRETATION: Rapid ageing of the population could offset the decline in dependency and result in a substantial increase in the population with complex care needs. Promoting healthy ageing and investing in an age-friendly environment are important in reducing care burdens in China. FUNDING: National Institute on Aging, Natural Science Foundation of China, China Medical Board. TRANSLATION: For the Chinese translation of the abstract see Supplementary Materials section.