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May 1995
Economics and Statistics Administration, U.S. Department of Commerce

America's elderly population is now growing at a moderate pace. But not too far into the future, the growth will become rapid. So rapid, in fact, that by the middle of the next century, it might be completely inaccurate to think of ourselves as a Nation of the young: there could be more persons who are elderly (65 or over) than young (14 or younger)!


The elderly population has grown substantially in this century ....

During the 20th century, the number of persons in the United States under age 65 has tripled. At the same time, the number aged 65 or over has jumped by a factor of 11! Consequently, the elderly, who comprised only 1 in every 25 Americans (3.1 million) in 1900, made up 1 in 8 (33.2 million) in 1994. Declining fertility and mortality rates also have led to a sharp rise in the median age of our Nation's population -- from 20 years old in 1860 to 34 in 1994.


.... and will continue to rise well into the next century ....

According to the Census Bureau's "middle series" projections, the elderly population will more than double between now and the year 2050, to 80 million. By that year, as many as 1 in 5 Americans could be elderly. Most of this growth should occur between 2010 and 2030, when the "baby boom" generation enters their elderly years. During that period, the number of elderly will grow by an average of 2.8 percent annually. By comparison, annual growth will average 1.3 percent during the preceding 20 years and 0.7 percent during the following 20 years. (See graph below.)

Graph of Average annual growth rate (in percent) of the elderlypopulation: 1910-30 to 2030-50


.... especially for the oldest old.

The "oldest old" -- those aged 85 and over -- are the most rapidly growing elderly age group. Between 1960 and 1994, their numbers rose 274 percent. In contrast, the elderly population in general rose 100 percent and the entire U.S. population grew only 45 percent. The oldest old numbered 3 million in 1994, making them 10 percent of the elderly and just over 1 percent of the total population. Thanks to the arrival of the survivors of the baby boom generation, it is expected the oldest old will number 19 million in 2050. That would make them 24 percent of elderly Americans and 5 percent of all Americans.


We're living longer.

Back when the United States was founded, life expectancy at birth stood at only about 35 years. It reached 47 years in 1900, jumped to 68 years in 1950, and steadily rose to 76 years in 1991. In 1991, life expectancy was higher for women (79 years) than for men (72 years).

Once we reach age 65, we can expect to live 17 more years. During the 1980's, post-65 life expectancy improved for all race/sex groups. The biggest improvement (a rise of over 1 year) belonged to White men.


The elderly are becoming more racially and ethnically diverse.

In 1994, 1 in 10 elderly were a race other than White. In 2050, this proportion should rise to 2 in 10. Similarly, the proportion of elderly who are Hispanic is expected to climb from 4 percent to 16 percent over the same period.


California has the largest number of elderly, but Florida has the highest percentage.

Our most populous States are also the ones with the largest number of elderly. In 1993, nine States had more than 1 million elderly. California, with 3.3 million, led the way, followed by Florida, New York, Pennsylvania, Texas, Ohio, Illinois, Michigan, and New Jersey.

Meanwhile, the States with the greatest proportion of elderly are generally different from those with the greatest number. Two exceptions, however, were Florida, where 19 percent of residents were elderly, and Pennsylvania, where 16 percent were. These 2 States led the Nation percentage-wise and, as just mentioned, ranked in the top 4 numerically. In-migration of the elderly contributed to Florida's high rankings. Joining Florida and Pennsylvania in having high proportions of elderly (14 percent or more) were 10 other States, including several sparsely populated Farm Belt States, such as North Dakota and Nebraska. (See map below.) Out-migration of the young contributed to the high proportions in these States and in Pennsylvania.

Graph of percentage of the population that is aged 65 years andover, by State:1993

During the 1980's, the greatest percent increases in elderly population were mostly in Western States and Southeastern coastal States.



Elderly women outnumber elderly men ....

Men generally have higher death rates than women at every age. As a result, elderly women outnumbered elderly men in 1994 by a ratio of 3 to 2 -- 20 million to 14 million. This difference grew with advancing age. At ages 65 to 69, it was only 6 to 5. However, at age 85 and over, it reached 5 to 2. As more men live to older ages over the next 50 years, these differences may narrow somewhat.


.... consequently, while most elderly men are married, most elderly women are not.

In 1993, noninstitutionalized elderly men were nearly twice as likely as their female counterparts to be married and living with their spouse (75 percent versus 41 percent). Elderly women, on the other hand, were more than three times as likely as elderly men to be widowed (48 percent versus 14 percent). The remaining men and women were either separated, divorced, had never married, or had absent spouses. Thus, while most elderly men have a spouse for assistance, especially when health fails, most elderly women do not.


Many elderly live alone.

Another consequence of the relative scarcity of elderly men is the fact that elderly women were much more likely than men to live alone. So much more likely, in fact, that 8 in 10 noninstitutionalized elderly who lived alone in 1993 were women. Among both sexes, the likelihood of living alone increased with age. For women, it rose from 32 percent for 65- to 74-year-olds to 57 percent for those aged 85 years or more; for men, the corresponding proportions were 13 percent and 29 percent.


More of us may face dependency ....

Many assume health among the elderly has improved because they, as a group, are living longer. Others hold a contradictory image of the elderly as dependent and frail. The truth actually lies somewhere in between. Poor health is not as prevalent as many assume. In 1992, about 3 in every 4 noninstitutionalized persons aged 65 to 74 considered their health to be good. Two in three aged 75 or older felt similarly.

On the other hand, as more people live to the oldest ages, there may also be more who face chronic, limiting illnesses or conditions, such as arthritis, diabetes, osteoporosis, and senile dementia. These conditions result in people becoming dependent on others for help in performing the activities of daily living. With age comes increasing chances of being dependent. For instance, while 1 percent of those aged 65 to 74 years lived in a nursing home in 1990, nearly 1 in 4 aged 85 or older did. And among those who were not institutionalized in 1990-91, 9 percent aged 65 to 69 years, but 50 percent aged 85 or older, needed assistance performing everyday activities such as bathing, getting around inside the home, and preparing meals. (See graph below.)

Graph of percentage of persons needing assistance with everydayactivities, by age: 1990-91


... and increasing numbers of people will have to care for very old, frail relatives.

As more and more people live long enough to experience multiple, chronic illnesses, disability, and dependency, there will be more and more relatives in their fifties and sixties who will be facing the concern and expense of caring for them. The parent-support ratio gives us an approximate idea of things to come. This ratio equals the number of persons aged 85 and over per 100 persons aged 50 to 64. Between 1950 and 1993, the ratio tripled from 3 to 10. Over the next six decades, it could triple yet again, to 29.


Heart disease, cancer, and stroke are the leading causes of death among the elderly.

Of the 2.2 million Americans who died in 1991, 1.6 million (or 7 in 10) were elderly. Seven in 10 of these elderly deaths could be attributed to either heart disease, cancer, or stroke. Though death rates from heart disease have declined for the elderly since the 1960's, this malady remains the leading cause of death among them. Death rates from cancer, on the other hand, have increased since 1960.


Poverty rates vary greatly among subgroups ....

The perception of "elderly" and "poor" as practically synonymous has changed in recent years to a view that the noninstitutionalized elderly are better off than other Americans. Both views are simplistic. There is actually great variation among elderly subgroups. For example, in 1992 -

  • The poverty rate, 15 percent for those under age 65, rose with age among the elderly, from 11 percent for 65- to 74-year-olds to 16 percent for those aged 75 or older.
  • Elderly women (16 percent) had a higher poverty rate than elderly men (9 percent).
  • The rate was higher for elderly Blacks (33 percent) and Hispanics (22 percent) than for Whites (11 percent). As the graph below shows, poverty became less prevalent during the 1980's for every elderly sex/race/ethnic group. In addition, within each race/ethnic group, poverty was more common for women than for men at both the decade's beginning and end.

Graph of percent of persons aged 65 and over who were poor, bysex, race, and Hispanic Origin:1979 and 1989


.... as does median income.

In constant 1992 dollars, the median income for elderly persons more than doubled between 1957 and 1992 (from $6,537 to $14,548 for men, from $3,409 to $8,189 for women).

However, income disparities persist among various elderly subgroups. Age, sex, race, ethnicity, marital status, living arrangements, educational attainment, former occupation, and work history are characteristics associated with significant income differences. For instance, elderly White men had much higher median incomes than other groups. In 1992, their income was more than double that of elderly Black and Hispanic women ($15,276 versus $6,220 and $5,968, respectively). The difference in median income between Black and Hispanic women was not statistically significant.


The elderly of the future will be better educated.

Research has shown that the better educated tend to be healthier longer and better off economically. In 1993, noninstitutionalized elderly were less likely than those aged 25 to 64 to have completed at least high school (60 percent versus 85 percent) and more likely to have only an eighth grade education or less (24 percent versus 6 percent). The percent with less than a 9th-grade education rose with age for the elderly.

Fortunately, the proportion of elderly with at least a high school education will increase in the coming decades. That's because nearly 8 in 10 persons aged 55 to 59 in 1993 had at least a high school education; the same was true for nearly 9 in 10 persons aged 45 to 49. Additionally, while only 12 percent of the elderly had college degrees, 20 percent of 55- to 59-year-olds and 27 percent of 45- to 49-year-olds did.


More information:

Sixty-Five Plus in the United States, an upcoming report supported by funding from the National Institute on Aging (NIA), greatly expands on the information in this Brief. It will be released in summer 1995. Call Customer Services (301-763-INFO(4636)) then for ordering information. In addition, "Housing of the Elderly," Statistical Brief 94-33, contains information on topics such as the chances of elderly householders owning their home, the type of structures they lived in, and the odds of their lacking amenities such as plumbing and telephones in their homes. Customer Services can send you a free copy.

 SOURCE: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group; U.S. Bureau of the Census.



Nursing facility providers in the United States(1)

1,813,665 total nursing facility beds;
16,995 total nursing facilities;
13 percent of facilities are hospital-based;
52 percent of facilities are part of a chain ("Chain" facilities are owned or leased by a multifacility organization. The remaining facilities are individually owned and operated);
107 facility bed size (average);
83 percent nursing facility occupancy rate.
Nursing facility ownership in the United States (1)
66 percent for profit;
27 percent not-for-profit;
7 percent government.
Nursing facility direct care staff in the United States (1)
53 total direct care staff (average);
35 certified nurse assistants (average);
11 licensed practical nurses (average);
6 registered nurses (average).
Nursing facility reimbursement in the United States (1)
8 percent Medicare;
68 percent Medicaid;
23 percent private pay.
Nursing facility special care beds in the United States (1)
105,066 total special care beds; including
65,304 Alzheimer beds;
3,013 AIDS beds;
4,304 hospice beds;
5,699 ventilator beds;
26,746 other special care beds.
Elderly Population in the United States (4)
The elderly population, ages 65-74 is 7 percent (18,759,000 people) of the total population;
The elderly population, ages 75-84 is 4 percent (11,145,000 people) of the total population;
The elderly 85 and older are 1 percent (3,625,000 people) of the total population; and
The total elderly population, aged 65 and older is 13 percent of the total population.
Medicaid in the United States (2, 3)
1,031,364 Medicaid only beds;
400,122,716 Medicaid nursing facility days;
1,667,319 total Medicaid nursing facility residents;
$85.05 per diem Medicaid nursing facility rate.
Ancillary services -- included in the per diem Medicaid rate.

Medicare in the United States (1)
53,138 Medicare only beds;
608,070 Dual certification beds;
1,113,237 total Medicare stays;
$234 average per diem Medicare rate;
27 days covered by Medicare (average);
$1,092 total copayment for a Medicare stay (average).
1. HCFA's Online Survey, Certification and Reporting Date (March 1997)
2. HCFA's Medicaid Statistical Information System (MSIS) (1995)
3. HCFA's Medicaid Data System (1995)
4. US Bureau of the Centus, Statistical Abstract of the United States 1996
A review of government documents and court records indicates hundreds of elderly patients in nursing homes are dying from neglect, according to the St. Louis Post-Dispatch, in a weeklong series that began Sunday, October 13. The newspaper reported that the deaths are rarely detected by government inspectors, appraised by medical examiners, or investigated or prosecuted by law enforcers. Most of the deaths are caused by neglect traced to caregivers whom the elderly rely on for food and liquid, and for turning them in their beds to prevent life-threatening sores, investigators and researchers say. The latest national compilation of more than 500,000 nursing home deaths - for 1999 - lists starvation, dehydration or bedsores as the cause on 4,138 death certificates.
Approximately 63% of nursing-home patients of cognitively impaired.
According to the health care financing administration, the percentage of nursing homes cited for dispensing unnecessary drugs has risen steadily to 11% in 1996 from 2% in 1992. Druggist's are not being informed of the various prescriptions that may come from various pharmacies.
38 % of a nursing homes budget goes directly for a patient care including nursing costs. Nurses aids average wage is $6.65 per hour.
25 % of nursing home aids prosecuted for abusing residents had a prior criminal record. A 1994 survey indicated that approximately 5 % of the nurses aids on file with state regulators had a criminal record involving violence and/or theft.
Malnutrition: A professor of German to at St. Louis University estimated that the rate of patients malnutrition varies from about 4 % in the good nursing homes to perhaps 50 % at the bad ones.
20 % of nursing home residents are at some point restrained.
43% of those people who turned age 65 in 1990 will enter a nursing home at some time during their life.
52 percent of all women and 33 percent of all men who are now 65 will spend their last years in a nursing home. 
About 2/3rd's of people in nursing homes have no living relatives. And about 70% of all nursing home patients are women.
About 2/3rd's of people in nursing homes have no living relatives. And about 70% of all nursing home patients are women.
Thinning bones put many older women at risk of fractures-half of all American women older than 65 years will have an osteoporosis-related bone break. For women in nursing homes, the risk is even higher.
The number of deaths in nursing homes has a 66% increase over the past decade. 
Medicaid traditionally pays only about 80% of private pay and not enough for good care overall.
The shortage of nurses and nurse aides is rapidly reaching the crisis point and is threatening the quality of patient care.
Investor-owned facilities averaged 5.89 deficiencies per home, 46.5% higher than nonprofit facilities and 43.0% higher than public facilities. In multivariate analysis, investor ownership predicted 0.679 additional deficiencies per home; chain ownership predicted an additional 0.633 deficiencies. Nurse staffing was lower at investor-owned nursing homes.
Investor-owned nursing homes provide worse care and less nursing care than do not-for-profit or public homes
Investor-owned facilities had more Medicaid patients (68% of all residents) than did nonprofit facilities (49%) or public facilities (62%)
Skimping on staffing by for-profit homes may partly explain their lower quality.
We (and others) have found lower quality at facilities with more Medicaid patients, presumably because Medicaid payments are generally low, and Medicaid patients have fewer options for care.
The Office of Inspector General has released a final inspection report, "Psychotropic Drug Use in Nursing Homes (OEI-02-00-00490; 11/01 2001)pdf," on the use of psychotropic drugs in nursing homes, along with supplemental information intended to provide content for the main report. This inspection was conducted in response to concerns expressed by the Senate Special Committee on Aging about the use of psychotropic drugs as inappropriate chemical restraints. OIG found that this is not a pervasive problem. These drugs are generally being used appropriately. Where there are problems, they are related to inappropriate dosage, chronic use, a lack of documented benefit to the resident, and unnecessary duplicate drug therapy. OIG also noted a lack of adequate documentation for residents' psychotropic drug use in some cases. OIG recommends in its report that CMS consider educating providers to better document the use of these drugs. 
Almost 33% of  nursing homes have been understaffed at least once below the state minimums since 1999, directly impacting residents' quality of care.
Nearly 60% of the RN work force is over 40 years of age and the percentage of nurses under 30 has fallen 40% since 1980. 10% of falls occur in health care institutions (undoubtedly more since they go unreported) and it is due in large measure to the lack of trained aides and nurses. The understaffing of hospitals occurs in an environment where, according to the 199 National Hospital Discharge Survey, patients over 65 years of age accounted for 48% of discharges and 48% of hospital care days.
A crime is a crime, whether in or outside of a nursing home, where residents should not spend their days living in fear," Sen. John Breaux (D-La.), the chair of the committee, said (AP/Washington Times, 3/5). The GAO report, based on interviews and records in GeorgiaIllinois and Pennsylvania, found that more than 30% of nursing homes have been cited by state inspectors for violations that "harmed residents or placed them in immediate jeopardy." And in half of the 111 abuse cases the report studied, nursing homes reported the incidents "days or weeks" after it occurred, despite a law requiring such instances to be reported within 24 hours (Kaiser Daily Health Policy Report, 3/4). Barbara Becker, an Indiana woman, told committee members how her 83-year-old mother died in a nursing home after being assaulted by an unstable patient, saying that nursing home crimes are treated "far more lightly" than others. "The biggest insult of the whole experience has been that had this happened in my own house, I would have been investigated. I would have been prosecuted, and I probably would have been put in prison.
 The nursing home industry is in a "state of near crisis" in the United States, but PBS' "NewsHour with Jim Lehrer" reports that "Eden Alternative" nursing homes, which provide improved living conditions for residents, may help address the problem. The industry faces a staffing shortage and low Medicare and Medicaid reimbursement rates, and a number of nursing homes in many states have closed or filed for bankruptcy. In addition, some nursing home residents suffer neglect or abuse by employees. A congressional report released last July found that state inspectors cited cases of "serious abuse" at one in 10 nursing homes. According to a new survey conducted by "NewsHour," the Kaiser Family Foundation and the Harvard School of Public Health, 45% of respondents said that patients who move into nursing home are "worse off" than before they entered, and 43% "would find it totally unacceptable" to move into a nursing home. Eden Alternative homes aim to improve the nursing home experience, featuring widespread plants, animals and onsite day care for children. About 240 nursing homes nationwide -- including St. Luke's Home in Utica, N.Y. -- have adopted the Eden Alternative approach (Dentzer, "NewsHour with Jim Lehrer," PBS, 2/27).
African Americans are four times more likely than their white counterparts to reside in substandard nursing homes. The study reviewed over 140,000 non-hospital based Medicare and Medicaid certified nursing homes and found that 40 percent of African Americans live in a lower-tier nursing home compared to just 9 percent of white nursing home residents. Nursing homes are defined as lower-tier if they have high turnover rates, substandard care, a high concentration of Medicaid residents, limited resources and poor programming.
Nursing care: A study by University of Pennsylvania researchers showed that when a nurse is assigned more than four post-surgery patients, the risk of death goes up 7% for each additional patient.
(A study published last year by University of California researchers found among more than 1.3 million nursing home residents, half needed help with five activities of daily living and 24% with four ADLs. About 95% required help with bathing, 87% with dressing and 51% with eating. Over 44% were diagnosed with dementia.)


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