Aging into the 21st Century

Health

• Life expectancy
• Health status
• Disability
• Nursing home usage

We have noted that, during the next 3 to 4 decades, there will be a very significant increase in the number of elderly persons, particularly the older aged; a sharp increase in the share of elderly persons in the population; and changes in the overall age composition of the elderly population. These changes will be brought about mainly by historical and prospective shifts in birth rates and declines in death rates, particularly at the older ages. Moreover, there will be large increases in the numbers of some very vulnerable groups, such as the oldest old living alone, especially women; elderly racial minorities living alone and with no living children; and unmarried elderly persons with no living children or siblings. We turn now to the specific basis for a large part of the demand for both formal and informal support and special services, namely health conditions among the elderly.

Predicting health conditions is difficult because it requires consideration of prospective developments in medical diagnosis and treatment, in lifestyle and behavior patterns, in community actions related to health, in the health delivery system, in the possibility of the reduction and control of various existing diseases and of the emergence of new diseases, in the state of the economy, and in other related factors.

There is a wide divergence of views held by experts in these areas. An additional difficulty of predicting health conditions among the elderly is the differing approaches in measuring recent changes in morbidity. In this report we choose from the great variety of materials on health projections to present one combination of data on these topics from several sources that we hope will provide reasonable and useful projections in the areas of: life expectancy, health status, disability and nursing home and home care usage.

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Life expectancy

First, we consider the expected course of life expectancy at birth and at age 65 underlying the new population projections of the Bureau of the Census (Table 17). The most optimistic series, the high series, posits an increase in life expectancy at birth by 2050 to 86 years for males and 92 years for females. At age 65, the figures are 25 years and 30 years, respectively. These projections imply considerable increases over the current figures of 72.5 and 15.5 for males, and 79.3 and 19.2 for females. The middle series shows smaller, yet substantial, increases to 80 and 20 for males and 84 and 22 for females in life expectancy at birth and at age 65, respectively. Life expectancy at age 85 is also projected to increase, especially in the high series.

SOURCE: U.S. Bureau of the Census (1996a).

¹Persons of Hispanic origin may be of any race.

Table compiled by the National Aging Information Center

The inference that might be drawn from these projections is that there could be much progress in extending the average length of life and that a larger proportion of the population is likely to survive to the very advanced ages. Note that these projections are independent of any assumptions regarding the extension of human life span. Higher life expectancy is expected for blacks and Hispanics as well as whites, but convergence between white and black mortality is not anticipated. The Office of the Actuary of the SSA has published an alternative set of projections of life expectancy for use in cost projections of the Social Security system. They closely resemble those of the Bureau of the Census but are, on the whole, more conservative.

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Health status

For many scholars, as well as the general public, the basic question is: Will people live well during these added years of life or will they be physically dependent on others because of serious health problems? More generally, how healthy will theelderly population be? First, we consider some projections of self-reported health status, which is a simple, yet rather informative measure of health, known to be associated with longevity. Projections of respondent-assessed health status for 2030 were prepared jointly by the University of Illinois at Chicago and the University of Chicago (Table 18). About 10 percent of the elderly reported themselves to be in poor health in 1990. Blacks reported poor health almost twice as often as whites and others. There is a general tendency for the proportion reporting fair or poor health to increase with advancing age. Assuming that essentially the same proportion of each race group falls in each health category in 2030 as in 1990, the numbers of elderly with poor health are projected to increase sharply from 1990 to 2030, paralleling the population increase. From 1.0 to 1.4 million blacks would be in poor health in 2030, implying well over a doubling or even tripling of the number reported in 1990.

SOURCE: 2030 data-National Center for Health Statistics, Centers for Disease Control and Prevention, January, 1996. Unpublished study. 1989-91 data-National Center for Health Statistics, National Health Interview Study.

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Disability

Of critical importance are the number and proportion of our elderly population that will be disabled. We first consider the series of projections of disabled persons prepared by Kunkel and Applebaum (1992). Even when they assume reduced disability ratios, albeit with increased longevity (the high series of life expectancy), the number of disabled persons at all levels of disability would grow rapidly between 1986 and 2040. According to this series of projections, the number of those severely or moderately disabled would more than triple during this period. Even if longevity improves more moderately (middle mortality series) and disability ratios are held constant, the number of disabled persons would nearly triple. Moreover, there is the possibility of a combination of high life expectancy with increased disability ratios. These assumptions result in a massive increase in the projected number of moderately or severely disabled elderly persons by 2040. The number would grow from about 5.1 million in 1986 to 22.6 million in 2040, or nearly 350 percent; the elderly population overall would grow by only 175 percent.

Alternative projections of "impaired" persons prepared by Lewin/ICF, shown in Table 15, are rather consistent with those of Kunkel and Applebaum. The former's figure of 9.9 million impaired persons (i.e., moderate or severe disability) in 2020 corresponds to the latter's constant-model figure of 9.7 million. The Lewin/ICF figure reflects a 68 percent increase in the number of impaired persons between 1990 and 2020, paralleling the increase in the middle population series. The Lewin/ICF figures on income status in Table 15 also reveal the dramatically greater risk of impairment for persons with lower incomes: 71 percent of the impaired elderly population in the community have incomes under 200 percent of the poverty level, while only 48 percent of the general elderly population fall in this income class. The projections of the population with Activities of Daily Living (ADL) limitations and, among these, the severely disabled, prepared by Manton and Liu on the basis of the 1982 National Long-Term Care Survey and the 1977 National Nursing Home Survey, represent an alternative set of figures on disability (Table 19). The differences between these figures strongly underline the risk of error in projections of disability, a set of health conditions which are subject to wide interpretation. Manton and Liu projected that there would be 2.8 million severely disabled persons in 2040, whereas the lowest projection of the wide range of projections prepared by Kunkel and Applebaum is 7.6 million. The total from the former source for all persons with ADL limitations in 2040 is 14.4 million, whereas the lowest figure from the latter source for moderate or severe disability is 14.8 million and the highest figure is 22.6 million. However, all sets of data suggest that the number of persons who will be disabled will increase sharply.

SOURCE: Calculated on the basis of projections of the U.S. population prepared by the U.S. Social Security Administration and preliminary data from the 1982 National Long-Term Care Survey. See K. Manton and K. Liu (1984).

¹Base includes the institutional population.

Table compiled by the National Aging Information Center

Among those included in the severely disabled category are those with clinically diagnosed Alzheimer's disease. A team of researchers (Evans et. at., 1992) has compiled a set of projections of persons with this condition. These analysts expect 10.2 million cases (middle series) at ages 65 and over by 2050, and possibly 14.3 million cases (high series) by 2040, as compared with about 3.8 million (both middle and high series) in 1990. There is the expected progression in numbers of cases with increasing age, a pattern that intensifies with the passage of time. By 2040, most of these cases, some 70 percent, occur among ages 85 and over. The number of cases at these ages will increase by over 300 percent, as compared with 25 to 50 percent for ages 65 to 74. This change reflects the entry of the baby-boom cohorts into the highest ages by 2040.

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Serious health or disabling conditions usually lead to residence in a nursing home because of the grave difficulties of home management of the patient. This outcome is all the more likely when social, financial, and housing resources are limited. Like Alzheimer's disease, nursing home residence is most common at the highest ages. In 1985, according to the National Nursing Home Survey, at ages 65 and over, the percent of the population in nursing homes was only 5 percent, but for ages 85 and over, the figure was 22 percent (Table 20). A wide gap of this magnitude is likely to continue for the indefinite future. The very high concentration of women in nursing homes, with increasing proportions of women in older age groups as age increases, is also likely to continue, if only because of the continuation of the difference in mortality between the sexes.

SOURCE: National Center for Health Statistics, Centers for Disease Control and Prevention, January, 1996. Unpublished study.

Table compiled by the National Aging Information Center.

The projections of a joint team from the University of Illinois and the University of Chicago indicate that, if residency ratios remain unchanged, the number of persons residing in nursing homes will double or triple by 2030 (Rivlin and Wiener, 1988). The number could rise by over 300 percent for those aged 85 and over. Even if residency ratios decrease by 6.5 percent per decade to 2030, as the report of the team assumes in one projection series, the number of residents of nursing homes will increase at the least by 57 percent. Contrary to the general view, there is considerable turnover in nursing homes and residents often are discharged after short periods. Discharges because of death account for one-quarter to one-third of the total discharges in any year. An average resident, particularly one discharged to a residence or other similar arrangement, stays only a few months. Hence, one realistic indicator of the demand for nursing home services is the number of persons residing in nursing homes at any time during a year. Rivlin and Weiner (1988) have prepared projections of persons requiring home health care and nursing home care that incorporate this "flow" concept. Their projected estimates for 1986 to 1990 and their projections for years 2001 to 2005 and 2016 to 2020 reflect the increase in the number and proportion of persons in nursing homes with increasing age, and the transfer of disabled persons from home health care to nursing home care with increasing age. The projections show no net temporal rise in the proportion of those requiring nursing home care or home care at ages 65 and over and at ages 85 and over between 1986 to 1990 and 2016 to 2020, but they do show substantial percentage increases in the number requiring care in this period, with the larger increase occurring for nursing home care than home care and at ages 85 and over than at ages 65 and over.

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