LIVING ARRANGEMENTS AND MARITAL STATUS
THE OLDER FOREIGN-BORN POPULATION
TRENDS IN HEALTH AND FUNCTIONING
In 2000 about one in eight Americans living in the United States was aged 65 or older, but by 2030 that rate is expected to be one out of every five. This major demographic shift has prompted numerous concerns regarding U.S. social and health policy in recent years. Not only will the sheer number of older adults increase dramatically, but the composition and characteristics of the older population will also change. Although clinicians are primarily concerned with the needs of individual patients, some of the attributes that an older patient brings to the patient-physician relationship are a function of the cohort to which he or she belongs. Aging baby boomers (the generation born between 1940 and 1960) are expected to have a major impact on the health and social service systems of the United States, although the exact nature of this impact remains unclear.
During the 20th century the U.S. population under age 65 tripled, while the age group 65 years and older increased by a factor of more than 11, growing from 3.1 million in 1900 to 35.6 million in 2002. This group will more than double by the middle of the next century, to 82 million people, with most of this growth occurring between 2010 and 2030. The United States is not unique in its growing share of older people. At present it is surpassed by many other developed countries, including Italy, Japan, Germany, Sweden, and the United Kingdom, where the proportion of people aged 60 and older is already at 20% or above.
The older population of the United States is not evenly distributed geographically. Half of persons aged 65 or older live in nine states, led by California, Florida, New York, and Texas. The midwestern states, however, have the highest percentages of older persons living alone (30% or greater). The older U.S. population is predominantly white, but the proportion of older persons of other races is expected to grow from about one in 10 currently, to two in 10 in the next 50 years. The number of older black Americans is expected to triple in this period, whereas the size of the older Hispanic American population, which is growing much faster, may exceed that of the older black population within 30 years.
In the United States the average life expectancy is currently highest for white women, followed by that for black women and white men, who have nearly identical in life expectancies, and black men (Table 1.1). Women who survive to age 65 can, on average, expect to live to age 84, and those surviving to age 85 can expect to live to age 92. Up to age 85, the life expectancy of white American men and women exceeds that of their black counterparts. At age 85, these racial differences in life expectancy largely disappear. There is disagreement about whether these findings reflect errors in documenting age (for older black Americans) or a true cross-over in mortality rates.
The exact number of centenarians in the United States is difficult to gauge, but their numbers are growing and are expected to be over 800,000 by 2050. For persons born in 1899, the odds against living to 100 were 400 to 1; for persons born in 1980, the odds are estimated at 87 to 1.
Improvements in the Social Security system and the adoption of Medicare have had an important impact on the economic well-being of older persons in the United States. In the early 1960s, 35% of people aged 65 or older had incomes below the federal poverty level, and only 70% received Social Security pensions. By the early 1970s, over 90% of older people received Social Security retirement benefits (accounting for at least 50% of income for 63% of beneficiaries, and 90% or more of income for 26%), and 97% were covered by Medicare. The percentage of older people with incomes below the poverty line today is about 10%. Another 6.5% are classified as “near poor,” that is, with an income between the poverty level and 125% of this level. For impoverished seniors (generally having an income well below the poverty line), Medicaid plays a key role in filling in the gaps in Medicare by covering prescription drugs, nursing-home and other long-term care services, and health care services not covered by Medicare, as well as paying for Medicare premiums and cost sharing. Currently there are approximately 4.5 million seniors enrolled in both Medicare and Medicaid (ie, “dual eligibles”).
Although the overall economic position of older people in the United States has improved significantly over the past three decades, these gains have not been shared by all. Poverty rates among older people are higher among black Americans (22%), Hispanic Americans (22%), persons aged 85 and older (12%), those who never finished high school (21%), those living in rural areas (13%) and central cities (14%), and those living alone (21%). Rates in some groups of older persons are much higher—half of older black American women living alone are poor, for example.
Older workers have declined as a share of the U.S. work force, and this trend is expected to continue. In 1950, 60% of men aged 65 to 69 were still in the work force, whereas in 1990, 28% of the same age group were working. Overall, in the early 1990s, 16% of older men and 8% of older women were working. Today, more than half of those who continue to work do so part time and largely by choice, rather than because of restricted opportunities for full-time work.
Compared with their parents at the same age, baby boomers typically have higher income, are preparing for retirement at largely the same pace, and have accumulated more private wealth. On the whole, boomers are on track to have higher incomes in retirement than their parents and appear much less likely to live in poverty after they retire.
One of the most dramatic changes in the older U.S. population of the future will be in levels of educational attainment. Between 1970 and 2001, the percentage of those aged 65 or older who completed high school increased from 28% to 70%. By 2030, 83% of older people will have completed high school. The percentage with a bachelor’s degree or more will have increased to 24% from the current level of 15%. Education is closely related to lifetime economic status, and, as many studies have shown, those with more education generally are in better health and at lower risk of disability than those with low levels of educational attainment. There is also speculation that the better-educated older baby boomers will be both more activist health care consumers and more demanding of the health care system. Today, approximately 50% of U.S. households have personal computers, but Internet use is much more common among persons under the age of 55. Despite concerns about the accuracy of much of the health and medical information available on various Internet Web sites, the use of these alternative information sources is likely to grow. In addition, pharmaceutical companies are increasingly marketing directly to consumers as a means of developing demand.
Among Americans living in the United States who are aged 65 to 74 years, two thirds are married and living with their spouse; in contrast, only about one fifth of those aged 85 and older are living with their spouse (Table 1.2). Not surprisingly, given older women’s greater life expectancy, older men are far more likely to be married than are older women. Conversely, widowhood is much more common among older women; 56% of women aged 75 to 84 and 82% of women aged 85 and older are widows.
Older men and women who live alone, often having lost a spouse, usually prefer to remain independent and continue living alone as long as their health and economic means allow them to do so. Many of those who live alone have families or friends nearby, and about three in five have lived in the same place for 10 years or more. These persons may also be vulnerable, however. They are more likely than older people who live with others to use community services and to report greater levels of loneliness and social isolation.
In 2000, there were 3.1 million foreign-born persons aged 65 or older in the United States. More than one third (39%) of this older foreign-born group are from Europe, and another 31% are from Latin America; 22% are from Asia, and 8% are from other parts of the world. In the future, the older foreign-born resident is more likely to be from Latin America or Asia. Almost two thirds of the older foreign-born group have lived in the United States for more than 30 years. About one third of them live in the western states.
Older foreign-born persons are more likely than their native counterparts to live in family households. Eight of 10 older foreign-born men are married; nearly half of older foreign-born women are widowed. Older foreign-born women are much more likely than older foreign-born men to live alone. The poverty rate is higher for the older foreign-born population than for the older native population. Households with older foreign-born householders participate in means-tested programs at higher rates than households with older native householders.
Assisted living represents one of the fastest-growing trends in residential settings for older people in the United States. This type of facility seeks to fill the need for greater supervision and assistance than may be possible in a private home while avoiding the detrimental aspects of institutional care.,000 people were estimated to be living in 33,000 assisted-living facilities in the United States in 2002. A typical assisted-living resident is a woman between 75 and 85 years of age who is mobile but needs assistance with about two activities of daily living (ADLs). Residents move to assisted-living residences from a variety of settings. Just under half (46%) come from their home, 20% come from another assisted-living residence, 14% come from a hospital, and 10%, from a nursing home. The average length of residency is 2 years. (See also the section on assisted living in Community-Based Care, and the AGS statement on assisted living in the Appendixes.)
The 1999 National Nursing Home Survey showed 1.6 million residents in 18,000 homes and an 87% occupancy rate. The rate per thousand population for those aged 65 and over was 429.2: 108 per 1000 for those aged 65 to 74, 429.7 for those 75 to 84, and 182.5 for those 85 years and over. Nationally, the percentage of older people residing in nursing homes has remained fairly constant, at about 5% overall, rising to 20% of persons aged 85 and older. The lifetime chance of ever being in a nursing home is much higher, however, at nearly 1 in 2. In part, this is due to increased use of nursing homes for short stays for recovery and rehabilitation following hospital discharge, stays that are paid for by Medicare if preceded by a 3-day hospital stay. The resident population is older and more disabled today. Over the past decade, the proportion of residents aged 85 and older has risen from 49% to 56% for women, and 29% to 33% for men; the proportion needing help with three or more ADLs rose from 72% to 83%.
The rate of all full-time equivalent employees for all facilities was 53.2 per 100 beds, with a slightly higher rate for voluntary nonprofit and government-owned facilities than for proprietary nursing homes. The rate per 100 beds for registered nurses was 7.6; for licensed practical nurses, 10.6; and nurse’s aides and orderlies, 32.9.
In the past 10 years, nursing homes have put more resources into developing special care units, and almost one fifth of all nursing homes now have one. Two thirds of these units are for Alzheimer’s disease and other dementias. Studies comparing the performance of these units with that of traditional units have not shown that residents of special units receive more direct care or experience better outcomes.
The burden of disease and disability is greater for older people than for those under age 65. In the United States in 2000, 84% of persons aged 65 or older had one or more chronic conditions. Hypertension is the most common chronic condition reported, followed by arthritic symptoms, heart disease, chronic obstructive pulmonary disease, and cancer (Figure 1.1). Although 80% of very old persons (aged 85 and older) report two or more chronic conditions, only 36% report being in fair or poor health (Figure 1.2). There is great heterogeneity in health status among older people (Table 1.3). Data on self-assessed health, which has been shown in several studies to correlate highly with mortality and risk of functional decline, illustrate this. Among white non-Hispanic Americans aged 65 to 74, 18% regarded their health as excellent and another 31% as very good; 13% indicated only fair health and 5%, poor health (Table 1.3). As might be expected, the percentages who viewed their health as only fair or poor increases with age. Also, self-reports of only fair or poor health were higher for older black and Hispanic Americans than for older white Americans.
Functional disability also increases with age and is closely associated with chronic disease. In the United States, the majority of people under the age of 85 report no difficulty in ADLs or instrumental activities of daily living (IADLs); much lower proportions of those aged 85 and older report little or no difficulty (Figure 1.3). Older women exhibit a higher percentage of limitations at all ages than older men do. Differences between racial and ethnic groups exist as well. Among those aged 70 and older, black Americans are 1.5 times as likely as white Americans to be unable to perform one or more ADLs.
In the United States older persons who need assistance with functioning in routine ADLs rely first and foremost on family. In 1995, of those providing assistance to community-dwelling persons aged 70 or older, 73% were unpaid or informal helpers. Nine out of 10 informal or unpaid caregivers were family members, one fourth were spouses, and about half were children. Half of these informal caregivers resided with the person receiving help. Estimates of the use of paid helpers vary across studies, but use is consistently found to be higher among persons living alone and to rise with increasing age.
Deaths of older persons make up nearly 75% of all deaths in the United States. About one fifth of all deaths occur at age 85 or older, but this proportion is expected to grow. For many decades, heart disease, cancer, and stroke have been the leading causes of death among people 65 or older, accounting for six out of 10 deaths (Table 1.4). Causes of death vary by race, ethnicity, and gender, however. Diabetes mellitus was the fourth leading cause of death among older Hispanic and black Americans, while ranking sixth for older white Americans. Alzheimer’s disease ranked seventh among all causes of death.
Some causes of death usually associated with younger people also are of concern in the older population. In the United States, older men have motor vehicle accident death rates two to three times those of older women, overall and within racial and ethnic groups. The highest suicide rates among older people are for white men (43.7 per 100,000, compared with 6.5 per 100,000 for older white women), who are more likely to commit suicide than die in a motor vehicle crash.
There are conflicting opinions about whether rates of disability in the United States are declining among people aged 65 and over. Some studies suggest a decline in the past decade in the proportion unable to do some activities (one or more ADLs or IADLs), but there is also evidence for an increase in the proportion unable to perform one or more ADLs. Differences in study populations and measures contribute to conflicting findings. The measurement of disabilities varies across studies, and assessments of the presence and severity of disability can differ when histories are taken from an older person, the family caregiver, or the physician.
Trends in disability are of special interest because increases in life expectancy overall and for people aged 65 and older have led to debate over whether these additional years will be free of disability. Studies of active life expectancy, which use mortality and disability estimates to project disability-free years, suggest an advantage for persons with more education. Because of their greater total life expectancy, older women also experience both greater active life expectancy and more years of disability than do older men. It has also been suggested that if there is a limit to increases in life expectancy, increases in disability-free years could produce a compression of morbidity, with the period of disability prior to death gradually compressed as active life expectancy (or disability-free years) increases. Increases in active life expectancy must occur if compression of morbidity is to be achieved, but debate continues regarding whether there is a maximum human life span, and whether compression of morbidity is possible if total life expectancy continues to increase.
As more longitudinal studies are conducted and other evidence is brought to bear, the trend in active life expectancy among older people may become clearer. Regardless of its true direction, however, preventing and reducing disability among older people remains a major objective of much geriatrics research.
The assumption has been that disability is irreversible, but studies show that up to one third of persons who experience disability in a basic ADL recover. Age less than 85 years, good nutritional status, and greater mobility are all associated with increased likelihood of recovery from basic ADL disability.
On average, older people in the United States have more contacts with health care professionals than do younger adults, from a mean of 10 per year among those aged 65 to 74, to nearly 15 per year among those aged 85 and older. Those who assess their health as fair or poor have twice as many contacts per year as do persons in excellent or good health. Older adults accounted for 20% of the hospital discharges and used a third of the days of care in 1970; in the year 2000 they made up close to 40% of discharges and used almost one-half of the hospital days. Variations in length of stay can be considerable, however.
Diseases of the heart were the leading discharge diagnosis in the United States for older people, with heart disease and stroke together accounting for more than one fourth of all hospital discharges among older men and women aged 85 and older. Malignant neoplasms were the next most common discharge diagnosis, followed by pneumonia and bronchitis. Fracture-related hospitalizations were more common among women than men and accounted for nearly 10% of discharges for those aged 85 and older.
Home-health care, including medical treatment, physical therapy, and homemaker services, is an alternative to institutional care for older people. Nursing care is the most commonly used service (85% of older home-health patients received nursing care in 1996), and 29% of patients use homemaker services. Medicare has been a major payer for home-health care (nearly half of expenses in 1996), and changes in payment methods have resulted in a dramatic drop in use of these services (both in the numbers of persons served and visits per user).
Prescription drugs have become a major component of medical treatment. Eighty percent of older people in the United States are using one or more prescribed medicines; among those with three to five ADL limitations, 93% use at least one.
The older U.S. population is among the most heterogeneous subgroups, encompassing the entire spectrum of health and functioning, from the bedridden Alzheimer’s patient to the marathon runner. One of the important unresolved questions is whether gains in longevity after age 65 are accompanied by gains or declines in years of disability-free life. It is unlikely that one answer will fit this large and diverse group. There are many questions in other areas as well. While levels of education continue to rise, so do rates of early retirement. Will the increasing numbers of better-educated, longer-lived persons contribute to the larger society, and in what ways? Will the sheer numbers of older people strain to the breaking point the medical care system and public programs that finance health care and retirement, as some analysts fear? Or will improvements in health behavior, medical breakthroughs, and financial prosperity diminish these threats?
Under any scenario, chronic illness will remain a constant in the lives of many older people. Physicians treating this population face the challenge not only of treating chronically ill persons but of assisting all older people in preventing or at least delaying the onset of chronic disease.
■ Administration on Aging, U.S. Department of Health and Human Services. A Profile of Older Americans: 2002. Available at http://www.aoa.gov/prof/statistics/profile/2002profile.pdf (accessed October 2005).
This report contains current statistics on the older population in the following categories: future growth, marital status, living arrangements, racial and ethnic composition, geographic distribution, income, poverty, housing, employment, education, health, health care, and disability.
■ American Association of Retired People (AARP). Public Policy Institute Releases—Topics in Health and Wellness: Disabilities; Spring 2005.
The topics cover disability reports as well as quality of health care, wellness, disease prevention, and health care policy.
■ Federal Interagency Forum on Aging-Related Statistics. Older Americans 2000: Key Indicators of Well-Being. Washington, DC: U.S. Government Printing Office; August 2000. Available at http://www.agingstats.gov/chartbook2000/default.htm (accessed October 2005).
This report covers 31 key indicators selected by the Forum to portray aspects of the lives of older Americans and their families. It is divided into five subject areas: population, economics, health status, health risks and behaviors, and health care.
■ Gill TM, Robison JT, Tinetti ME. Predictors of recovery in activities of daily living among disabled older persons living in the community. J Gen Intern Med. 1997;12(12):757–762.
The disability rate for the geriatric population is typically presented in a static, point-prevalence form. Clinicians can benefit from knowing factors that predict recovery of activities of daily living (ADL) function in their disabled elderly patients. This study is one report from Project Safety, a community-based study that followed 213 disabled elderly persons for 2 years. Fifty-nine (28%) were considered to have recovered their ADL functions. A large number (24) of possible predictors of recovery were subjected to analysis to determine whether any association existed between the demographic, psychosocial, sensory, functional, physical performance, clinical, or nutritional status of the study subjects and their recovery of function. Using bivariate and multivariate analysis, the researchers found that four factors are independently associated with recovery: age of 85 years or younger, Mini–Mental State Examination score of 28 or better, high mobility, and good nutritional status. Interestingly, some variables that did not predict recovery were whether a person lived alone, scored as depressed on a measure of depression, or had specific conditions, such as diabetes mellitus, heart disease, stroke, arthritis, or urinary incontinence.
■ Hall MJ, Owings MF. 2000 National Hospital Discharge Survey. Advance Data from Vital and Health Statistics, No. 329, June 19, 2002. Available at http://www.cdc.gov/nchs/data/ad/ad329.pdf (accessed October 2005).
This report presents information about hospital utilization during 2000 as well as trend data for selected variables.
■ Manton KG, Stallard E, Corder LS. The dynamics of dimensions of age-related disability 1982 to 1994 in the U.S. elderly population. J Gerontol A Biol Sci Med Sci. 1998;53(1):B59–B70.
Declines in chronic disability were observed in National Long Term Care Survey data from 1982 to 1994. Seven dimensions described changes in the age dependence of 27 activities of daily living, instrumental activities of daily living, and physical performance measures in community-dwelling and institutionalized persons. Disability declines were correlated with reductions in selected health conditions over the study period.
■ Stone R. Long-Term Care for the Disabled Elderly: Current Policy, Emerging Trends and Implications for the 21st Century. New York: Milbank Memorial Fund; 2000.
This report describes long-term care for disabled elderly people in terms of key trends and projections for service need, issues in service and work force availability, and problems in financing. It concludes with a discussion of current and emerging trends in long-term-care policy.
Lynda Burton, ScD
Judith D. Kasper, PhD