40-Year Projections of Disability and Social Isolation of Older Adults for Long-Range Policy Planning in Singapore

Round 1

Reviewer 1 Report

A very important article in the current context of an again population and shrinking services and political will to cater to vulnerable populations. The article indeed sheds light on the social isolation faced in an important demographic living in the far East. As someone looking into disabilities and vulnerable communities I believe it is very important to present a complete picture of the situation globally and compare it with the situation in Singapore. Merely reading out data without a global comparison is not enough.

Please provide a global picture in the discussion and also highlight in the introduction.

A table comparing demographics of social isolation, institutionalization and other variables would be highly valuable.

DISCUSSION SECTION

Discussion needs to be expanded, it is too brief, followed by key recommendations for practice . I would suggest more data from NHS in the UK and Public health agencies in USA /Australia. This is a an important topic that needs a comparison in the discussion , preferably in the form of a chart ,detailing geographical projections , assessment and assimilating them in a form that is readily available for key policy makers to read and implement in their practice .

CONCLUSION SECTION

Covid19 has taken a hit on the elderly and vulnerable populations across the global, it would be nice to include a section about this in the conclusion.

Below I have put forward a key list of articles that might be useful for the author in creating a comparative analysis.

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The article in the current form is incomplete and in my opinion doesn’t add much value to the subject accept for a commentary on the situation in particular country in the world. Once the comparison is complete , it will be a very valuable contribution , it has the potential to be a very valuable contribution if done properly. I would like to see more tables, more analysis and comparison with regional countries and with Eu/UK/US/Australia .

Author Response

Please see detailed responses in the attachment. Thank you.

Author Response File: Author Response.docx

Reviewer 2 Report

Summary: The current manuscript is aimed to analyze a 40-year projection of long term care demand based on disability and social isolation. Results evidenced that Disability prevalence across the mild to severe spectrum is projected to increase by five-fold over 40 years, and the number of socially isolated elders living alone is projected to grow by four-fold. Moreover, other interesting results are evidenced by risk factor analysis, such as ethnic differences.

I think the study is well conducted, and I have only a few minor comments.  

Specific comments follow:

Introduction: The introduction fits with the goal of the study. Maybe it is useful to distinguish between physical and cognitive decline.

Methods: The method is succinct. Some information should be added about sampling recruitment and could be useful to give more information about respondents.

Results: The summary of the study fits the planned analyses.

Discussion: This section could be improved, emphasizing the novelty of this research. It would be interesting to provide more information on the risk factors highlighted. This, as well as making the results clearer to the reader, could have major clinical implications.

General comment: Generally, I found the study well conducted, although novelty and utility were few emphasized. My advice to the authors is to highlight the innovative nature of the study. This is one of the firsts (presumably the first) study on these fields, and this aspect could be emphasized in discussions. Furthermore, it would be interesting to provide some other implications of results as well as the social implications of this study.

Author Response

Please see detailed responses in the attachment. Thank you.

Author Response File: Author Response.docx

Reviewer 3 Report

The regression analysis is incorrectly used in this study. The ordered logistic model is obviously not suitable for the analysis.

Normally, the ordered logistic model should be used when the outcome variable has intrinsic rationality to be sequenced. For example, the allocation of pension investment in risky asset (0%, 50%, 100%), or the test score (low, medium, high) etc. usually serve as outcome variables in ordered logistic model.

In this study, the outcome variable (living arrangement) include following categories: living alone, living with spouse only, living with others, and living with children/grandchildren. There is no internal rationality to sequence the outcome variable in a certain order. Can we indicate the rationality why "living with spouse only" should or should not be placed before "living with others". As such, the outcome variable in this study is inappropriate for sequencing. The authors should consider other types of model. 

Author Response

Please see detailed responses in the attachment. Thank you.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

The work after a major overhaul has been greatly improved. The comparison with services present in other countries and the evaluation of recent literature on the subject made the manuscript interesting for readers and increased its scientific value.

A good job has been done

Author Response

Thank you very much.  We are indebted to your important feedback that strengthened the paper. 

Reviewer 3 Report

In the revised manuscript, the critical flaw of this study has still not been adequately addressed. The ordered logit model lacks justification. The empirical results remain highly rely on and sensitive to the specific order/sequence of outcome variable. The slight change of the order would definitely yield a very different result.

The authors propose that living alone implies the least living efficacy and living with children/grand children implies the most, through which to justify why the latter one should be ranked after the former one.

However, the authors still avoid explaining why "living with others" should be ranked after "living with spouse" and before "living with children/grandchildren".

Moreover, what does the word "others" exactly mean in the phrase "living with others"? We can't find any description in the manuscript. Besides, what's the rationale "others" should be ranked after "spouse" and before "children/grandchildren"?

Not all variables are suitable for ordered logit model, unless there is sound justification for the sequence of outcome variable. Otherwise, the empirical results would be highly sensitive to the arbitrary sequence of outcome variable, and fail to yield any meaningful conclusion.

Author Response

Thank you for the valuable feedback.  We agree that “living with others” is a problematic category and have removed it.  We also ran a multinomial logistic regression that corroborated our earlier findings.  These models are described on p3 of the manuscript and and we present the output table from our multinomial logit model in the attached document.  We are indebted to your important recommendations that helped strengthen the paper. 

Author Response File: Author Response.pdf