1. DEMOGRAPHY Suggestions for Lecturer 1-hour lecture
Use slides alone or to supplement your own teaching materials.
Supplement your lecture with handouts, such as figures and tables from papers listed as references in the GRS7 chapter on demography.
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2. OBJECTIVES Know and understand:
Projections for population aging globally and in the US
The impact of gender and ethnicity on life expectancy and the socioeconomic status of older adults
Trends in the employment, education, health literacy, and living arrangements of older adults
Variation in physical functioning by age and ethnicity, and leading causes of illness and death of older adults
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3. TOPICS COVERED Global Aging Trends
Demography of Aging in the United States
Life Expectancy
Socioeconomic Status and Employment
Education and Literacy
The Older Foreign-Born Population
Marital Status and Living Arrangements
Trends in Health, Functioning, and Mortality
Trends in Disability and Disability Accommodation
Assisted-Living Facilities and Nursing Facilities
Future Issues
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4. GLOBAL AGING TRENDS (1 of 2)
As a result of declining fertility and mortality rates, the world today is experiencing pervasive and unprecedented population aging. According to the United Nations, by 2050 the number of older adults (≥60 yr old) will exceed the number of young for the first time in history.
1950
2050
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5. GLOBAL AGING TRENDS (2 of 2)
The number of older adults is increasing faster in developing countries than in more developed countries
Between 2006 and 2030, projected to increase by 140% vs. 50%, respectively
Individuals ≥80 yr are the fastest-growing age group in the world
Increasing at a rate of 3.8% per year
Given the pace of population aging, developing countries will have less time to prepare for consequences associated with this demographic shift. For example, older adults’ workforce participation rates tend to be higher in less developed countries, where pension systems are less likely to be established.
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6. DEMOGRAPHY OF AGING IN THE US
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7. AGING OF THE US POPULATION (1 of 2)
Because of declining birth rates and increases in longevity, older adults are anticipated to comprise one of every five Americans by This major demographic shift has prompted numerous concerns regarding US 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 primarily attend to 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 1946 and 1964) will influence the health and social service systems of the United States, although the exact nature of this impact remains unclear.
2000
2030
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8. AGING OF THE US POPULATION (2 of 2)
Number of people 65 yr, in millions
During the 20th century, the US population <65 yr old tripled, while the group ≥65 yr old increased by a factor of more than 11, growing from 3.1 million in 1900 to 36.8 million in This group is anticipated to more than double again 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 numbers 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 ≥60 yr old already comprise 20% or more of the overall population.
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9. REGIONAL DISTRIBUTION OF THE OLDER US POPULATION
Half of people ≥65 yr live in 9 states, led by California, Florida, New York, and Texas
Older adults disproportionately live in urban or suburban areas
Just 1 in 5 lives in a non-metropolitan area
Older adults are not evenly distributed across geographic regions of the United States.
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10. ETHNIC DISTRIBUTION OF THE OLDER US POPULATION
Between 2004 and 2050:
The proportion of adults 65 yr who are minorities will more than double, from 18% to 39%
The older black American population will increase by 50%
The older Asian American and Hispanic American populations will triple
The number of older Hispanic Americans is projected to exceed that of older blacks by 2050
While the older US population is predominantly white, it is becoming increasingly diverse.
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11. LIFE EXPECTANCY IN 2004 All Races White Black All Male Female At birth
77.8
75.2
80.4
78.3
75.7
80.8
73.1
69.5
76.3
Age 65
18.7
17.1
20.0
17.2
15.2
18.6
Age 85
6.8
6.1
7.2
6.0
7.1
6.3
7.5
SOURCE: Data from National Vital Statistics System. December 2007;56(9):3. Available at http// (accessed Nov 2009).
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 life expectancies, and that of black men. Women who survive to age 65 can, on average, expect to live to age 85, 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 are 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 exceed 800,000 by 2050.
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12. SOCIOECONOMIC STATUS (1 of 2)
About 10% of older adults are poor (have incomes below the federal poverty level)
About 7% are classified as “near poor,” ie, with an income between the poverty level and 125% of that level
About 7.5 million older adults are enrolled in both Medicare and Medicaid (“dual eligibles”)
Improvements in the Social Security system and the adoption of Medicare have had an important impact on the economic well-being of older adults in the United States. In the early 1960s, 35% of people ≥65 yr old 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, and 97% were covered by Medicare.
For impoverished seniors (who generally have an income well below the poverty line), Medicaid plays a key role in filling in the gaps in Medicare by covering nursing-home care, other long-term care services, and health care services not covered by Medicare, as well as paying for Medicare premiums and cost-sharing.
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13. SOCIOECONOMIC STATUS (2 of 2)
Although the overall economic position of older people in the United States has improved substantially over the past three decades, these gains have not been shared by all.
Percent who are poor
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14. EMPLOYMENT
Employment of older adults declined throughout most of the past century, but this trend reversed during the last 20 yr
Growth in the number of older adults who are employed is expected to continue
In 2005, an estimated 5.3 million older adults were working or actively seeking work
About 1 in 5 older men
About 1 in 10 older women
Labor force participation is influenced by a variety of factors relating to both economic necessity (eg, declines in defined benefit pension plans, the increase in the full retirement age for Social Security benefits, the high costs of health insurance), as well as personal choice. Higher levels of education and improvements in health have afforded greater numbers of older adults the opportunity to continue to work.
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15. EDUCATION & LITERACY (1 of 2)73
Percent of adults 65 yr 24 19
One of the most dramatic changes in the older US population of the future will be in levels of educational attainment. Education is closely related to lifetime economic status, and many studies have shown that individuals with more education generally enjoy better health and lower rates of disability than those with low levels of educational attainment. 5
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16. EDUCATION & LITERACY (2 of 2)
Despite gains in education level, older adults still rank below working-age adults:
Far lower education and literacy levels
Half as likely to have a personal computer and use the Internet
Lower average levels of health literacy
According to the 2003 National Assessment of Adult Literacy, older adults on average have lower levels of health literacy, defined as “…the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions,” than working-age adults. Given the greater availability of health and medical information via the Internet and mainstream media (eg, direct-to-consumer advertising) as well as the introduction of the voluntary Medicare Part D drug benefit, the relevance of health literacy is arguably more important today than ever before.
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17. ORIGINS OF THE OLDER FOREIGN-BORN POPULATION
In 2003, there were 3.3 million foreign-born people ≥65 yr old in the United States. Older foreign-born people are increasingly likely to originate from Latin America or Asia, as compared with Europe. Older foreign-born people are more likely than their native counterparts to live in family households and to live in poverty; they tend to be concentrated in western states.
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18. MARITAL STATUS All (%) Male (%) Female (%) 65–74 75–84 85+ Married
65.6
51.3
32.0
76.7
72.2
60.6
56.1
36.8
17.6
Widowed
17.5
38.0
61.1
7.3
32.4
26.3
52.3
75.5
Other
16.9
10.7
6.9
16.1
10.3
7.0
10.9
SOURCE: Data from Current Population Survey, 2006; Table A.1. Refers to community-dwelling older adults (individuals as a percentage of column total).
Among Americans living in the United States who are 65–74 yr old, two thirds are married and living with their spouse, approximately twice the proportion of older adults ≥85 yr old (see also the following slide).
Not surprisingly, given 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; 52% of women 75–84 yr old and 76% of women ≥85 yr old are widows, compared with 17.6% of men 75–84 yr old and 32.4% of men ≥85 yr old.
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19. LIVING ARRANGEMENTS All (%) Male (%) Female (%) 65–74 75–84 85+
Lives alone
23.2
35.4
46.9
16.9
21.2
28.8
28.5
45.3
56.0
With spouse
63.9
49.4
29.4
75.1
70.3
57.8
54.3
34.9
15.1
With relatives
10.0
12.9
21.7
6.5
6.9
12.4
14.4
17.8
27.2
With nonrelatives
3.0
2.3
1.9
1.6
1.1
2.7
2.0
1.7
SOURCE: Data from Current Population Survey, 2006; Table A.1. Refers to community-dwelling older adults (individuals as a percentage of column total).
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20. COMMON CHRONIC CONDITIONS
Percent of adults 65 yr
SOURCE: Data from Data Warehouse on Trends in Health and Aging: Health Status and Chronic Conditions, from the National Health Interview Survey. Estimates for 2005–2006.
The burden of disease and disability is greater for older people than for working-age adults or for children. In fact, the vast majority of older adults have one or more chronic conditions. This slide shows the prevalence of selected self-reported chronic conditions among adults 65 yr of age (all races) in 2005–2006.
Hypertension
Arthritic
symptoms
Heart
disease
(all types)
Cancer
Diabetes
Stroke
Kidney
disease
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21. White, non-Hispanic (%) Black, non-Hispanic (%)
PERCEIVED HEALTH
White, non-Hispanic (%)
Black, non-Hispanic (%)
Hispanic (%)
65–74
75–84
85+
Excellent/very good
46.1
38.4
32.5
25.2
23.7 
33.4
21.1
Good
34.5
37.5
36.4
38.9
35.3
30.9
36.7
38.3
Fair/poor
19.4
24.2
31.1
35.8
41.1
50.7
29.9
40.6
45.7
SOURCE: Data from National Health Interview Survey, NCHS Vital and Health Statistics, 2007; Series 10 (235). Table 21.
There is great heterogeneity in health status among older adults. Data on self-assessed health, which have been shown to correlate highly with mortality and risk of functional decline, illustrate this.
As might be expected, this slide shows that the percentage of older adults who view their health as only fair or poor increases with age. The proportion of older adults who report their health to be “fair” or “poor” is higher in all age groups among black and Hispanic Americans than white Americans.
Cell sizes too small for reliable estimates
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22. Percent of Medicare beneficiaries
PHYSICAL FUNCTIONING
Percent of Medicare beneficiaries
ADL = activity of daily living
IADL = instrumental activity of daily living
SOURCE: Data from Medicare Beneficiary Survey, 2006.
Physical functioning is closely associated with both chronic disease and age. This slide shows self-reported functional limitations of community- dwelling Medicare beneficiaries, by age group, in Approximately 70% of adults 65–74 yr old and 56% of adults 75–84 yr old reported no difficulty with ADLs or IADLs, compared with just one third of individuals ≥85 yr old. Older women exhibit a higher percentage of limitations in functioning at all ages than older men.
Age (yr)
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23. LEADING CAUSES OF DEATH
Rank
Cause of Death
Number of Deaths
% of Deaths
All causes
1,755,669
100 1
Cardiac diseases
533,302
30.4 2
Malignant neoplasms
385,847
22.0 3
Cerebrovascular diseases
130,538
7.4 4
Chronic lower respiratory disease
105,197
6.0 5
Alzheimer’s disease
65,313
3.7 6
Diabetes mellitus
53,956
3.1 7
Influenza and pneumonia
52,760
3.0 8
Nephritis, nephrotic syndrome, nephrosis
35,105
2.0 9
Accidents (unintentional injuries)
35,020 10
Septicemia
25,644
1.5
SOURCE: National Vital Statistics Reports 2007:56(5) (Table 1). Available at (accessed Nov 2009).
Deaths of older people comprise nearly 75% of all deaths in the United States. About one fourth of all deaths occur at age 85 or older, and given broader demographic trends, this proportion is expected to grow. For many decades, heart disease, cancer, and stroke have been the leading causes of death among people ≥65 yr old, accounting for 6 of 10 deaths.
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 seventh among older white Americans. Alzheimer’s disease ranks fifth 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, the death rate from motor vehicle accidents is twice as high in older men as in older women, both overall and within racial and ethnic groups. The highest suicide rates among older people are for white men aged ≥85 yr old (48.4 per 100,000, compared with 3.6 per 100,000 for older white women of comparable age).
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24. TRENDS IN DISABILITY
Even if there is a limit to increases in life expectancy, increases in disability-free years could produce a compression of morbidity before death
A number of national surveys have documented a decline in IADL disability and general stability in ADL disability
The magnitude of decline across types of disability and subgroups of older Americans is more controversial, due to:
Variation in sampling strategy
Variation in how disability is measured
Several longitudinal studies of older adults indicate that aggregate declines in disability have occurred over the last 20 yr. The magnitude of decline across types of disability and subgroups of older Americans is more controversial. For example, data from the National Long Term Care Survey show that the proportion of chronically disabled or institutionalized older adults declined from 25% to 20% between and However, most of this decline is attributable to lower rates of IADL disability (shift from 6% to 3%). Rates of ADL disability were more stable (shift from 13% to 12%) during this time period.
Variability in sampling strategy and measurement of disability make it difficult to draw definitive conclusions regarding the magnitude of such findings. For example, the extent to which questions explicitly assess respondents’ use of assistive devices (eg, remote devices, canes, walkers) or the built environment (eg, growth in residential settings that have adopted universal design) may influence disability estimates.
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25. DISPARITY IN DISABILITY: Older Adults without Disability
Percent of Medicare beneficiaries
SOURCE: Data from Medicare Beneficiary Survey, 1996 and 2006.
Whether the benefits of greater literacy and increased longevity have been universally experienced by all subgroups of older Americans in terms of improved functioning is less clear. Recent studies substantiate the existence of disparities in disability across racial and ethnic subgroups and by education, and suggest that such disparities are growing. For example, this slide shows that between 1996 and 2006, the proportion of community-dwelling older adults without functional limitations or disability was relatively stable among white non-Hispanic Americans and increased among black non-Hispanic Americans, but decreased among Hispanic Americans.
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26. DISPARITY IN DISABILITY: Older Adults with 3 Disabilities
Percent of Medicare beneficiaries
SOURCE: Data from Medicare Beneficiary Survey, 1996 and 2006.
A parallel trend is observed with regard to trends of severe disability. This slide shows that between 1996 and 2006, the proportion of community- dwelling older adults with three or more ADL limitations was relatively stable for both white non-Hispanic and black non-Hispanic adults, but increased among Hispanic Americans. The reasons for such disparities are multifaceted, reflecting a lifetime of behavior and experience, environmental exposure, and access to and use of medical care.
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27. DISABILITY ACCOMMODATION
Individuals may use a variety of approaches to compensate for a physical disability, including assistive technology, personal care, environmental modifications, or a change in residential setting. Use of assistive technology is widespread among disabled older adults, with mobility- related devices, such as canes and walkers, being used most commonly. Individuals who rely on personal care alone tend to be most highly disabled and are often both physically and cognitively impaired.
The vast majority of older adults who receive personal care rely on help from a family member or a friend (“family caregiver”); less than 1 in 10 receives help from a paid caregiver. Most family caregivers for chronically disabled older adults are spouses or adult children who live with the older adult or in close proximity.
While family caregivers commonly assist with household and personal care task assistance, they are also frequently involved in providing or coordinating older adults’ medical care. For example, family caregivers commonly assist with wound care, medication management, and coordination of care between physicians or across settings of care; approximately 2 in 5 older adults are routinely accompanied to physician office visits by a family member or friend.
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28. ASSISTED-LIVING FACILITIES
Rapidly growing residential setting
800,000 people were estimated to be living in 33,000 assisted-living facilities in the US in 2002
Typical resident is a woman 75–85 yr who is mobile but needs assistance with ADLs
Average length of residency is 2 yr
Assisted-living facilities provide greater supervision and assistance than is typically available in a private home, while allowing more autonomy and freedom than traditional nursing-home facilities. Residents move to assisted-living residences from a variety of settings. More than half move from their own private apartment or residence, with the remainder being about equally distributed from other assisted-living residences, hospitals, nursing homes, or other private residence, such as an adult child’s home.
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29. NURSING FACILITIES Rates of nursing-home residency vary by age group
Highest among adults ≥85 yr
There is a trend toward declining nursing-home residency among older adults
4.2% in 1985 but <1% in 2004, a significant decline
Net effect: the nursing-home population has become older and more disabled
Between 1977 and 1999, the proportion of nursing-home residents ≥85 yr increased from 35% to 47%
Between 1985 and 2004, the proportion of residents needing help with 5 or 6 ADLs increased from 50% to 65%
Over the course of the past 20 yr, nursing facilities have increasingly developed skilled nursing capabilities to provide postacute care to individuals transitioning out of the acute hospital setting. However, nursing facilities continue to play an important role as a provider of long-term care to a particularly vulnerable segment of the population, caring for older adults with cognitive and/or physical impairment, and with considerable ongoing medical needs. Not surprisingly, nursing-home use rates vary considerably by age group. According to the 2004 National Nursing Home Survey, <1% of adults 65–74 yr old were living in a nursing home, compared with approximately 4% of adults 75–84 yr old and 14% of adults ≥85 yr old.
The trend of declining nursing-home use is likely a result of both improvements in older adults’ health and functioning, as well as increases in system-wide community supports and the growth of alternative residential arrangements, such as assisted-living facilities and continuing-care retirement communities.
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30. FUTURE ISSUES
Will gains in longevity after age 65 be accompanied by gains or declines in years of disability-free life?
Will the increasing numbers of better-educated, longer-lived older adults 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?
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31. SUMMARY (1 of 2)
As a result of declining fertility and mortality, the world is experiencing pervasive and unprecedented population aging.
Individuals ≥80 yr old are the fastest-growing age group in the world.
In the US, the composition of the older population is far from static. The large and growing numbers of aging baby boomers are becoming more racially and ethnically diverse. Greater numbers of older adults are surviving to the oldest ages.
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32. SUMMARY (2 of 2)
Relative to their predecessors, older Americans today are generally more educated, better off financially (except for racial and ethnic minorities), increasingly likely to live alone or in alternative residential settings, and less functionally impaired.
The population of older adults is heterogeneous across measures of health status, functioning, and socioeconomic position.
Among older adults, heart disease, cancer, and stroke remain the leading causes of death, while other age- related conditions, such as Alzheimer’s disease, are becoming more common.
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33. © Copyright 2010 American Geriatrics Society
ACKNOWLEDGMENTS
GRS Chapter Author: Jennifer L. Wolff, PhD
Medical Writers: Beverly A. Caley
Faith Reidenbach
Managing Editor: Andrea N. Sherman, MS
© Copyright 2010 American Geriatrics Society
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