TIS

Chapter 4
Geriatrics - The Older Population


The longevity revolution has arrived in the United States. By 2030, the number of older Americans will have doubled to more than 70 million. These changing demographics means that one in every five Americans will be older than 65 by 2010. Demographers anticipate that the growing number and proportion of older adults will place increasing demands on the health care system and social services.

The Federal Interagency forum on Aging Related Statistics has been tracking demographic changes throughout the US. Through a report, Older Americans 2004: Key Indicators of Well-Being, the older population has been analyzed. This Chapter is based on information from that report along with information for researchers on the Centers for Medicare and Medicaid (CMS) website and the US Census bureau information related to the years 2003 and beyond.

Overview:
In 2003, nearly 36 million people age 65 and older lived in the US. This group accounted for 12 percent of the total population. This is the most rapid growing demographic in the US. The oldest-old grew from 100,000 in 1900 to over 4.2 million in 2000. Projecting to 2030, this population is estimated to twice as large from 35 million to 71.5 million accounting for at least 20 percent of the total US population.

From 2030 onward, the proportion of those over age 65 is forecast to be relatively stable, at or around 20 percent even though the absolute number of people age 65 and older is projected to continue to grow. The oldest-old population is projected to grow rapidly after 2030.

The US Census Bureau projects that the population age 85 and over could grow from 4.2 million in 2000 to nearly 21 million by 2050. Some researchers predict that death rates at older ages will decline more rapidly than is reflected in the US Census Bureau’s projections, which could lead to even faster growth of this population.

The proportion of the population age 65 and over varies by state, too. Interestingly, population proportions are affected by fertility and mortality levels and partly by the number of older and younger people who migrate to and from each state. For example, in 2002, Florida had the highest proportion of people age 65 and older, 17 percent. Pennsylvania and West Virginia also had high proportions with 15 percent.

At an even more micro level, the proportion of ages varies even more by county. In 2002, 35 percent of McIntosh County in North Dakota was age 65 and older, the highest proportion of any county in the US. At the other end of the age spectrum, Chattahoochee County in Georgia has only 2 percent of its population over 65 years old.

The US has to look to Europe when analyzing demographic statistics. In comparison, the US is young with 12 percent of its population age 65 and older. Most European counties have at least 15 percent of their population attributed to this age group with both Italy and Japan over 19 percent in 2003.

Gender:
Similar to European countries, older women outnumber older men, with the proportion of females in the older age cohorts increasing with age. In 2003, women accounted for 58 percent of the population over age 65 and for 69 percent of the population age 85 and older.

Ethnicity:
Diversity in older adults is rising as the demographic changes continue. By 2050, programs and services for older people will require greater flexibility to meet the ever growing diversity of the older population.

In 2003, non-Hispanic whites accounted for nearly 83 percent of the US older population. Blacks 8 percent; Asians 3 percent; and Hispanics nearly 6 percent. Projections to 2050 point to a the non-Hispanic white population of shrinking to 61 percent while all other ethnic groups will rise with projections for 18 percent Hispanic; 12 percent black, and 8 percent Asian.

Ethnicity plays an even greater role in how the population ages. The Hispanic population is projected to grow the fastest from just over 2 million in 2003 to 15 million in 2050. The Hispanic population is projected to be larger than the older black population by 2028. The older Asian population is also projected to experience a large increase from 1 million older Asians living in the US in 2003 to a projected population of almost 7 million by 2050.

The face and ethnicity of older Americans is changing in a parallel focus to the ethnicity of younger Americans. How the various ethnic groups age in conjunction to their projected health care needs are the focus of many national initiatives and studies. From the limited research available thus far, it is apparent that ethnicity does impact longevity and does play a role in health care needs along with the amount and severity of chronic diseases.

Marital Status:
As the population ages, older persons are living to be older, healthier, wealthier with a spouse. Studies indicate that marital status strongly affects one’s emotional and economic well-being. Also, factors such as living arrangements and the availability of caregivers enter the mix to healthy aging.

In 2003, the latest marital statistics available, older men were more likely than older women to be married. For men ages 65-74, 78 percent were married, compared with 56 percent of the women in the same age group. This statistic continues to show that there are more women in this age group than men. Further, the proportion married is lower the older the age group analyzed. For example, 36 percent of women ages 75-84 and 14 percent of women age 85 and older were married. For men, the proportion married is also lower at older ages, but not as low as for older women. Even among the oldest-old, the majority of men were married (59 percent).

Widowhood is more common among older women than older men.  Forty-four percent of women age 65 and older were widowed as compared to 14 percent of men in that age bracket. Further, in 2003, 78 percent of women age 85 and older were widowed, compared wit 35 percent of men.

Divorce is not common among the older population. In 2003, only 9 percent of women and 7 percent of men were divorced. An even smaller proportion of the older population had never married. Marriage is an important factor to consider when studying issues related to aging in America.

Education:
Education impacts lifestyle, buying ability, and access to health care. In 1950, 17 percent of the older population had graduated from high school, and only 3 percent had at least a Bachelor’s degree. By 2003, 72 percent were high school graduates, and 17 percent had at least a Bachelor’s degree. This is a significant rise in education in 40 plus years.

Gender comparisons for degree attainment are constantly changing. It was believed in 2003 that older men were more likely than older women to have graduated from high school. Though that statistic was 72 percent for men compared to 71 percent for women. However, this gender gap has swapped places by 2006, with older women having a slightly higher percentage of high school and college graduation rates than men. It is anticipated that this trend will continue with women narrowly outpacing men into the future as researchers see women in younger cohorts earning advanced degrees at the same or greater pace as that of men.

There are ethnic differences with educational attainment among older Americans. In 2003, 76 percent of non-Hispanic whites age 65 and older had completed high school. Older Asians also had a high proportion of at least a high school education with 70 percent falling into this category. However, only 52 percent of older blacks and 36 percent of older Hispanics had completed high school.

Education and affluence will impact the needs of older adults into the future. Understanding the education/ethnic gaps will further help society prepare to meet the medical and social needs of all older Americans.

Living Arrangements:
Where people live and how people live also impacts health care needs and the ability to age successfully. As age increased and widowhood rises, the percentage of the population living alone increases, too. Historically, older women lived alone at much higher rates than older men. However, in the last decade, the rates for women have decreased slightly while the rates for men have increased slightly.

Older people who lived alone also had higher poverty rates than those who lived with a spouse. In 2002, 16 percent of older men and 21 percent of older women who lived alone lived in poverty. In contrast, the poverty rate for older married men and women did not differ with about 5 percent each.

The choices of living arrangements have broadened across the nation in the last decade. While skilled nursing facilities have seen a decline in overall occupancies, there has been a rise in alternative housing arrangements including assisted living centers, senior retirement centers, and foster grandparent arrangements. Also, through federal legislation the amount and kind of home care services has dramatically increased through home and community-based service (HCBS) waiver programs.

In 2006, skilled nursing facilities housed less than 3% of the entire US population over the age of 65. In addition, the average length of stay in a skilled nursing facility fell to 8 months. Though there is a subset of older adults that require long-term, skilled care, the actual number of those in need is relatively small.

Most older people live in adequate, affordable housing. However, some older Americans are forced to allocate a larger proportion of their total expenditures to housing. When housing costs comprise a high proportion of total expenditures, less money is available for health care, savings, and other material needs.

Older Veterans:
Older Veterans are a significant demographic group in the US. According to the 2000 Census, there were 9.8 million veterans age 65 and older. This group included World War II, Korean War, and, increasingly, Vietnam era cohorts. Two of thee men age 65 and older were veterans.

Driven by military expectations of past generations, 95 percent of all veterans over the age of 65 are male. Further, older veterans make up an increasing proportion of older males. Between 1990 and 2000, the proportion of males age 65 and older who were veterans rose from 54 percent to 65 percent.

Projections from the Department of Veterans Affairs anticipate a veteran spike after 2010 when the largest group of Vietnam era veterans hit age 65. Along with the observation of the population growing to be older, veterans are anticipated to live to older ages than ever before.

Income:
Poverty, income, and the availability of cash resources have undergone dramatic changes for older Americans. Since 1974, the proportion of older people living in poverty and in the low-income group has generally declined. By 2002, 10 percent of the older population living in poverty and 28 percent of the older population were in the low-income group. In 2003, people in the middle income group made up the largest share of older people by income category (35 percent). The proportion with high income has increased over time. In 2002, 26 percent of persons 65 and older were considered in the high income bracket.

The trend in median household income of the older population has also been positive. Though most older Americans are retired from full-time work, they now have pension plans, savings reserves, and most importantly, Social Security to depend upon for ongoing wealth. Originally created in 1965, Social Security was designed as the safety-net floor to older Americans to ensure that there were resources available to prevent financial destitution in old-age. Over time, Social Security has taken on a greater importance to many older Americans covering many more than the originators had anticipated.

In 2002, aggregate income for the population age 65 and older came from four sources:

Pension coverage expanded dramatically in the two decades after World War II. Also, private pensions accounted for an increasing proportion of income for older people during the 1960s and early 1970s. Since then, the coverage rate has been stable at about 50 percent of all workers on their current jobs.

There has been a major shift in the types of pensions provided by employers. From the defined-benefit plans (in which a specified amount is paid as a lifetime annuity) to defined-contribution plans such as 401(k) plans (in which the amount of the future benefit varies depending on investment earnings). The percentage of workers with pension plans who have a defined-benefit coverage method has decreased from 80 percent in 1985 to 33 percent in 2003. Over the same period, participation in defined-contribution plans increased from 41 percent to 51 percent. In recent year, a growing number of employers have converted their defined-benefit plans to cash balance plans. Cash balance plan participation has increased nearly fourfold between 1997 and 2000, from 6 percent to 23 percent.

Mortality and Chronic Health Conditions:
This Chapter has provided an overview of issues related to the aging population of the US. Most notably, death rates in the US have declined during the past century. Life expectancy varies by race, but the differences decreases with age. In 2001, life expectancy at birth was 5.5 years higher for white people than for black people. At age 65, white people can expect to live and average of nearly 2 years longer than blacks. Among those who survive to age 85, however, the life expectancy among blacks is slightly higher than among whites. Differences in life expectancy at birth have been decline over time.

With the decline in deaths, there is a rise in chronic health conditions.  - those long-term illnesses that are rarely cured. Chronic diseases such as heart disease, stroke, cancer, and diabetes are among the most common and most costly health conditions. Five of the six leading causes of death among older Americans are chronic diseases.

Much of the illness, disability, and death associated with chronic disease are known to be avoidable through prevention measures. Key measures include healthy lifestyles that include physical activity, healthy eating, and tobacco avoidance. Early detection of cancers and diabetes also offer life prolonging efforts.

Aging in America is a dynamic process. The analysis and study of statistics continues to enlighten all as we grow older together.

References:

www.cdc.gov/aging
Federal Interagency Forum on Aging Related Statistics www.agingstats.gov/

www.census.gov/

www.cms.gov/researchers


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