1 DEMOGRAPHY Suggestions for Lecturer 1-hour lectureUse 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 GNRS chapter on demography. The GNRS Teaching Slides reflect care that can be provided to older adults in all settings. The words patient, resident, and older adult have been used interchangeably, as have the words provider, clinician, and primary care provider. Given the continually ongoing changes in health care today, some of the guidelines around reimbursement may have changed since publication.

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 Topic

3 Demography of Aging in the United StatesTOPICS 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 Topic

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. 2050 1950 Topic

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, the number of older adults is projected to increase by 140% vs. about 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. Topic Slide 5

6 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-provider relationship are a function of the cohort to which he or she belongs. Aging baby boomers (the generation born between 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 Topic Slide 6

7 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. Topic Slide 7

8 REGIONAL DISTRIBUTION OF THE OLDER US POPULATIONHalf 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. Topic Slide 8

9 ETHNIC DISTRIBUTION OF THE OLDER US POPULATIONBetween 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. Topic Slide 9

10 LIFE EXPECTANCY IN 2009 White Black All Male Female At birth 78.8 76.481.2 74.5 71.1 77.6 Age 65 19.1 17.7 20.4 17.8 15.8 19.3 Age 85 6.6 5.8 7.0 6.8 5.9 7.2 SOURCE: Data from National Vital Statistics System as reported in Table 14b. Available at: 2.aspx (accessed Jan 2013). In the United States, the average life expectancy is currently highest for white women, followed by black women and white men, then white men. 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 91. 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 was estimated at approximately 0.2% of the overall population 65 years old in Their numbers are growing and are expected to exceed 800,000 by 2050. Topic Slide 10

11 SOCIOECONOMIC STATUS (1 of 2)About 10% of older adults are poor ― income below the federal poverty level About 26% are classified as “low income” ― income below 200% of the poverty level About 5.5 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. Topic Slide 11

12 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 Topic Slide 12

13 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 2009, an estimated 6.5 million older adults (17.2%) were working or actively seeking work 3.6 million older men 2.9 million 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. Topic Slide 13

14 EDUCATION & LITERACY (1 of 2)77 Percent of adults 65 yr 24 21 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 Topic Slide 14

15 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. Topic Slide 15

16 MARITAL STATUS All (%) Male (%) Female (%) 65– 74 75–84 85+ 65–7465– 75–84 85+ 65–74 Married 66.2 52.8 32.0 78.0 73.2 58.3 55.9 38.1 18.0 Widowed 15.8 36.5 59.6 6.4 17.2 34.6 24.0 50.4 72.9 Other 10.7 8.4 15.5 9.6 7.1 20.1 10.5 9.3 SOURCE: Data from Current Population Survey, 2010; as reported in Tables 3 and 5a. Available at: aspx (accessed Jan 2013). 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. Not surprisingly, given women’s greater life expectancy, older men are far more likely to be married than are older women. Topic Slide 16

17 Approximately half of older adults live with a spouse LIVING ARRANGEMENTS Approximately half of older adults live with a spouse Living arrangements vary dramatically by age, gender, and race/ethnicity subgroups For example, older women are nearly twice as likely as older men to live alone (37% vs. 19% in 2010) or with relatives other than a spouse (17.9% vs. 5.9%) Topic Slide 17

18 PREVALENCE OF SELF-REPORTED CHRONIC CONDITIONSPercentage of adults 65 yr Topic Slide 18

19 White, non-Hispanic (%) Black, non-Hispanic (%)PERCEIVED HEALTH White, non-Hispanic (%) Black, non-Hispanic (%) Hispanic (%) 65–74 75–84 85+ Men Good to excellent 80.9 75.3 68.2 67.9 57.8 54.0 67.0 60.8 54.9 Fair or poor 19.1 24.7 31.8 32.8 42.3 46.0 33.0 39.3 45.1 Women 82.7 76.7 70.7 66.7 55.9 54.3 64.4 59.0 49.9 17.3 23.4 29.9 33.3 44.1 45.7 35.6 40.8 50.2 SOURCE: Data are based on a 3-year average from 2008–2010 from the National Health Interview Survey, NCHS Vital and Health Statistics, Table 18. Available at: Jan 2013). Topic Slide 19

20 Percent of Medicare beneficiariesPHYSICAL FUNCTIONING Percent of Medicare beneficiaries SOURCE: Data from Medicare Beneficiary Survey, 2009 as reported in Table 20d. Available at: http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/Data_ 2012.aspx (accessed Jan 2013). Age (yr) Topic Slide 20

21 LEADING CAUSES OF DEATHRank Cause of death Number of deaths Rate All causes 1,762,494 4,454 1 Diseases of heart 479,046 1211 2 Malignant neoplasms 391,855 990 3 Chronic lower respiratory disease 117,048 296 4 Cerebrovascular diseases 109,055 276 5 Alzheimer disease 78,058 197 6 Diabetes mellitus 48,811 123 7 Influenza and pneumonia 43,433 110 8 Nephritis, nephrotic syndrome, nephrosis 40,341 102 9 Accidents (unintentional injuries) 39,316 99 10 Septicemia 26,810 68 SOURCE: Data from National Vital Statistics Reports, Vol 59, No 4 (Table 7). Available at: www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_04.pdf (accessed Jan 2013). For many decades, heart disease, cancer, respiratory diseases, and stroke have been the leading causes of death among people ≥65 years old, accounting for 6 of 10 deaths. Causes of death vary by race, ethnicity, and gender, however. For example, Alzheimer disease ranked fifth among all causes of death but is more prominent among white non-Hispanic older adults and less prominent among black non-Hispanic and Hispanic older adults. Rates of suicide deaths among people ≥65 years old is approximately 14 per 100,000 versus 11 per 100,000 in the general population. Approximately 85% of suicides in older adults occur among men. The highest suicide rates among older people occur among white non- Hispanic men ≥85 years old; their rate of suicide death approaches 50 per 100,000 persons. Topic Slide 21

22 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 1984 and However, most of this decline is attributable to lower rates of disability in instrumental activities of daily living (shift from 6% to 3%). Rates of disability in basic activities of daily living 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. Topic Slide 22

23 DISABILITY ACCOMMODATIONIndividuals may use a variety of approaches to compensate for a physical disability, including assistive technology, personal care, environmental modifications, or change in residential setting Among community-dwelling older adults with limitations in ADLs in 2007: 38% relied on assistive technology alone An additional 22% relied on both assistive technology and personal care Just 6% relied on personal care alone Topic Slide 23

24 RESIDENTIAL-CARE FACILITIESAllow more autonomy and freedom than traditional nursing home As of 2010 there were about 972,000 beds in 31,000 such facilities About half are small (410 beds) Medicare is increasing its financing Average length of residency is 2 yr Topic Slide 24

25 NURSING HOMES Currently, 1.4 million Americans live in nursing homesThe nursing home population has become older and more disabled The proportion of residents 65 years old has steadily increased On average, nursing home residents are prescribed 7–8 medications > 80% of residents require help with 3 ADLS There is some indication that rates of nursing home use have declined. This trend is likely a manifestation of 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 residential-care facilities and continuing-care retirement communities.  Topic Slide 25

26 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? Topic Slide 26

27 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. Topic

28 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, chronic lower respiratory disease, and stroke are the leading causes of death. Topic

29 QUESTION 1 (1 of 2) Which of the following statements is not true about the US population? The population of adults who are ≥65 years old is projected to more than double between 2010 and When the last baby boomer turns 65 in 2029, 19% of adults will be ≥65 years old. Populations of black and Hispanic adults who are ≥65 years old are growing at equal rates. By 2032, there will be more people who are ≥65 years old than children who are <15 years old. Topic

30 QUESTION 1 (2 of 2) Which of the following statements is not true about the US population? The population of adults who are ≥65 years old is projected to more than double between 2010 and When the last baby boomer turns 65 in 2029, 19% of adults will be ≥65 years old. Populations of black and Hispanic adults who are ≥65 years old are growing at equal rates. By 2032, there will be more people who are ≥65 years old than children who are <15 years old. ANSWER: C Between 2010 and 2050, the population of older Hispanic adults is projected to increase faster than any other ethnic group, from 3 million to 18 million; the population of older black non-Hispanic adults is projected to grow from 3 million to 10 million. Older white non-Hispanic adults will remain the largest single ethnic group in the United States, but with comparatively slower growth: from 32 million in 2010 to 50 million in 2050. In 2010, white adults constituted 80% of the population of adults who are ≥65 years old; by 2050, they will make up 58% of that population. As a whole, in the United States the population of adults who are >65 years old is projected to more than double from 40 million in 2010 to 89 million in This represents an increase in the percentage of the total population from 13% to 20%. Baby boomers started turning 65 in 2011, and the last baby boomers will turn 65 in 2029; based on US census population projections, adults who are ≥65 years old will make up 19% of the total US population. By 2029, >70 million adults will be ≥65 years old, and by 2032 the number of adults >65 will surpass the number of children <15 years old. These trends are primarily attributed to decreased birth rates coupled with increased life expectancy in the United States. Topic

31 What is the most common cause of death by injury in older adults? QUESTION 2 (1 of 2) What is the most common cause of death by injury in older adults? Motor vehicle crash Fall Suicide Fire Topic

32 What is the most common cause of death by injury in older adults? QUESTION 2 (2 of 2) What is the most common cause of death by injury in older adults? Motor vehicle crash Fall Suicide Fire ANSWER: B About 30% of injury deaths are caused by falls. Motor vehicle crashes are next most common (18%), and suicide by firearm, suffocation, or poisoning accounts for 13%. Men are more likely than women to die from a fall, perhaps because their falls are more catastrophic or because they have more chronic conditions. The statistics on death from motor vehicle crash include deaths of drivers, passengers, pedestrians, and bicyclists. According to data from the National Highway Traffic Safety Administration, older individuals accounted for 14% of all vehicle occupant fatalities and 18% of all pedestrian fatalities in By 2030, older drivers are projected to account for up to 25% of all driver fatalities. Mortality and morbidity due to injuries are preventable and have public health implications. Many interventions exist to prevent falls, motor vehicle accidents, suicide, and other types of injuries among older adults. Deaths due to fire are not as common as those due to falls. Topic

33 Copyright © 2014 American Geriatrics SocietyGNRS4 Teaching Slides Editor: Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF GNRS4 Teaching Slides modified from GRS8 Teaching Slides based on chapter by Jennifer L. Wolff, PhD and questions by Julie Robison, PhD Managing Editor: Andrea N. Sherman, MS Copyright © 2014 American Geriatrics Society Topic