Between l985 and 2020 the population 65 years and older is likely to increase by almost 2 percent a year, an average of about 750,000 additional older persons annually. The oldest old--persons 85 years of age and older--are projected to increase at an even faster rate, by about 3 percent a year. In contrast, the total United States population is anticipated to grow less than l percent a year.

The rate of growth of the elderly population is expected to be somewhat greater after the year 2000 than during the next decade or so. The fastest-growing age group also changes. Between l985 and 2000 the group 85 years and older will increase most rapidly, at an average rate of about 4 percent a year. Subsequently, between the years 2000 and 2020, the group aged 65-74 years will increase most rapidly, as the post-World War II baby boom generation enters the elderly category.

Population Projections


The number of persons who will have celebrated their 65th birthday by 2020 is projected to be almost twice the number who have done so in l985. There are likely to be more than 54 million elderly persons in 2020--approximately the total current populations of California, Florida, and New York.

About 60 percent of those persons who will be 65 and older in 2020 were born between l946 and l955, and so were in their thirties in l985. Over 30 million of the elderly population in 2020 will be between 65 and 74 years of age. About 80 percent of individuals in their thirties in l985 are expected to be alive in 2020.

By 2020 about 23 million persons will be more than 75 years of age. This number approximates the over-65 population in l980. This group will increase substantially after 2020; it may equal almost 40 million in 2040.

During the 35-year period between l985 and 2020, the proportion of the total population that is 65 years and older is expected to increase about 50 percent, from about l2 percent to about l8 percent. The proportion age 85 years and older is likely to double--from l.2 percent to 2.4 percent.

The proportion of the elderly population that is female may decline slightly during this period, from over 60 percent in l985 to less than 58 percent in 2020. By 2020 the female and male populations between 65 and 74 years of age may be almost equal; as a result, in future years there are likely to be more intact couples. However, in the oldest age group, 85 and over, almost three quarters are still likely to be female.

The minority population age 65 and over is expected to increase at a faster rate than the total elderly population in the coming decades. For example, the elderly black population is projected to increase from about 8 percent to about l0 percent of the total elderly population between l985 and 2020. The growth of the elderly black population and the black population 85 years and over may be very rapid.

These population projections may be conservative. In actuality, the elderly population may grow at an even faster rate. The projections cited above are based on the assumption that future death rates will decrease at about half the average rate of reduction which occurred between l980 and l983. A more optimistic assumption--that death rates will decline at about the same average rate as in the past--would result in about an additional 4 million elderly persons in 2020, of which about half would be over 85 years of age.

Variations Among the States


There will be large variations in the growth of the elderly population in different parts of the country. The elderly population in the South and West is expected to increase about 20 percent between l990 and 2000, while the elderly population in the Northeast and North Central States may remain nearly constant during that decade. The population 85 years of age and older in the South and West is expected to expand by more than 60 percent during the l990s, while their counterparts in the Northeast and North Central States will increase by about one-third.

During the l990s the largest percentage expansion of persons 65 and over is anticipated in the States of Nevada (70 percent), Arizona (50 percent), and Florida (39 percent). In three States--Alaska, Arizona, and Nevada--the 85-and-over group may more than double.

In contrast, during the l9905, the elderly population is expected to remain almost stable or even decrease slightly in about half the States in the Northeast and North Central regions. In no State, however, is an increase of less than 20 percent anticipated in the 85-and-over population during this period.

The elderly population of California, the Nation's most populous State, is projected to expand about l0 percent between l990 and 2000. The 85-and-over cohort may expand by about 50 percent during the decade. By the end of the century the State may have about 3.5 million residents 65 years of age and older, a number which exceeds the current total population of the State of Arizona.

Health and Functional Status


The potential future needs for health care personnel to serve older persons will depend in large part on the health and functional status of the growing elderly population. Information on recent experiences with respect to health status and conditions is suggestive, though by no means definitive, concerning the types of needs likely to be present in the years 2000 and 2020.

The majority of older individuals in the future are likely to be healthy and able to function independently. In l984 more than 90 percent of persons 65 and over were living in the community, and about two-thirds of that group perceived their health to be good to excellent.

It is probable that chronic diseases--arising from physical or emotional causes or both--will be the most important of disabilities in the future. Chronic diseases, which tend to be managed and controlled rather than cured, often require the continuing attention of physicians and other personnel and may impair abilities to live independently.

Although most older adults develop one or more chronic health problems, these conditions vary from relatively minor difficulties to severe disabilities. In many cases only relatively modest changes in lifestyle ensue, requiring little or no assistance from others. In other cases increasing amounts of care and professional health services are required. Because chronic conditions tend to accumulate, many elderly persons--especially the oldest old--often experience multiple health problems at the same time. Persons with multiple problems tend to utilize a substantial share of available services.

The relationships among chronic disease morbidity, disability, and mortality are illustrated in Figure 3. The morbidity and disability curves indicate the age-specific probabilities of surviving to different ages without serious chronic diseases and disabilities. The mortality curve describes how deaths reduce the proportions living at various ages. Consistent with World Health Organization concepts, it is assumed that some chronic disease process must precede the emergence of serious chronic disability, although the disease processes producing most disabilities may not be the same as those leading to death.

The areas identified by the curves have important implications for the need for services. They represent the average number of years that a person in the group described by the curves will be in a particular health condition. Thus, the area under the morbidity curve represents the "healthy" life expectancy while the total area under the disability curve indicates the "active" life expectancy. The area between the mortality and morbidity curves is the period during which individuals are more likely to require substantial health care services. If community-based services can be designed to respond to the service needs of persons at higher disability levels, then the threshold for institutional care can be raised and more persons successfully maintained at home.

In l984, almost 9 million persons 65 years of age and older living in the community, about one-third of the total, were estimated to have one or more functional deficiencies (with respect to activities of daily living or instrumental activities of daily living). More than 2 million, about l0 percent, had difficulties with three or more activities of daily living. However, only about half of the latter group reported that they were receiving the help of another person.

The impact of chronic health problems increases with age. Of those 85 and older, more than 60 percent had one or more functional deficiencies. About one-quarter had difficulties with three or more activities of daily living, and almost 60 percent of this group were receiving assistance from another person.

The l0 most prevalent chronic health problems reported from a survey among the elderly non-institutionalized population in l984 are indicated in Figure 4. Arthritis and hypertensive disease are the most common. For most chronic conditions, rates tend to increase markedly after 75 years of age.

Mental impairments have serious impact on the functioning of many older persons. Mental impairments include acute and chronic mental illness, mental retardation, and reactive psychological distress; the most debilitating is chronic mental illness (e.g., schizophrenia and depression). Epidemiological studies indicate that l8-28 percent of the elderly population have significant psychiatric symptoms. Depression occurs commonly in older patients who have a considerable burden of physical illness.

Not only are mental impairments handicapping conditions in themselves, they also often affect how well an individual can handle a physical problem and whether he or she can remain living in the community. Moreover, family stability and stress are two important factors in determining the strength and continuity of informal support arrangements, which are often key to deterring institutional admission.

The prevalence of mental impairment due to acute or chronic mental illness increases with age, primarily because of the increasing incidence of dementias. Further, because of increased longevity among chronically mentally impaired individuals (such as those persons with mental illness or mental retardation), the prevalence of persons with all types of mental impairment will be greater in the years to come.

Dental needs among older adults are often serious. For example, surveys have found that more than 80 percent of elderly persons living in the community have one or more dental-related problems.

The most debilitating conditions, in terms of producing functional impairment among healthy older persons, are dementia, stroke, and hip fractures, according to the l982 National Long Term Care Survey. As older persons live longer, the prevalence of non-lethal disability may increase. For example, it is estimated that one of every three elderly persons experiences serious falls each year.

The number of hip fractures doubles every 5 years of aging; by 2020 there may be about 4 million such cases annually, compared to about 2 million in l980. Similarly the number of persons with dementia may increase from fewer than 2.5 million to more than 5 million persons between l980 and 2020.

An important indicator of potential needs for health services is the number of elderly persons receiving the help of another person. As indicated in Table 8, in l984 about l0 percent of older persons living in the community received help due to difficulties in activities of daily living; almost one third of those 85 years of age and older needed some such assistance. More than 20 percent of older persons living in the community received help due to difficulties in instrumental activities of daily living; this ratio exceeded one half for the oldest old group. (An individual may be included in both of these groups.)

However, most of the help received by older persons is on an informal basis, given by spouses, relatives, neighbors, and other friends. As indicated in Table 9, about 80 percent of those giving care to elderly persons in l982 were in these categories. About 70 percent of older disabled persons living in the community received all their care on an informal basis. The mean age of family caregivers was about 57 years. About three quarters lived with the disabled older person. The most frequent voluntary services were assistance with transportation, shopping, and housekeeping.

Significant opportunities exist for persons with serious limitations in daily activities to increase their capabilities so that they can function more effectively and independently. The potentialities are illustrated in Table l0, which compares data from the l982 and l984 National Long Term Care Surveys. Approximately 25 percent of the non-institutionalized individuals 65 years and over with numerous limitations in daily activities in l982 were reported to have fewer problems 2 years later; for those between 65 and 74 years of age, over one-third improved. These gains might be extended if added knowledge were available concerning risk factors and additional rehabilitation and other support services were more widely available and used.

Heterogeneity of the Elderly Population


The heterogeneity of the older population is a critical fact. Individuals traditionally classified as "elderly" cover an age span of 35 years or even longer. In addition, within specific age groups, variations and diversities among individuals are extreme. For example, among older persons living in the community in l984, for more than 60 percent no limitations in daily activities were reported, while about l0 percent reported they spent 28 days or longer in bed during a year.

Very important differences among older persons are related to the nature of their living arrangements. In l984 about 30 percent of persons age 65 and over lived alone. About 40 percent of elderly women lived alone but only l5 percent of elderly men. Living alone can indicate capacities for independence but it can also mean greater difficulties in arranging assistance when needed, particularly informal support.

An analysis of the non-institutionalized elderly population in l982 identified four significant groups, each of which was made up of persons with generally similar socio-demographic characteristics and functional limitations:

1. Relatively young (mean age 75), generally intact couples with comparatively few functional problems;
2. Elderly unmarried women (mean age 86) with few physical limitations but with difficulties suggestive of serious cognitive problems;
3. A group (mean age 76) with physical limitations with respect to activities of daily living but few cognitive problems; and
4. Seriously disabled persons (mean age 78) living in the community, primarily because of the presence of a caregiving spouse.

These groupings highlight the importance of living arrangements and the availability of informal and other care providers, especially for personal care services. It appears that the needs of the second group required more personal care support while those of the third group might be alleviated by special equipment. The second group was at higher risk of nursing home placement because of deficiencies in informal support arrangements.

Other important differences among older persons are related to income and education. While about l2 percent of persons age 65 years and older were below the poverty level in l984, the rate for women was about twice the rate for men (l5 percent compared to about 8 percent) .The poverty rate for the black aged was about 32 percent and for Hispanic aged about 22 percent. For older black women living alone, the rate exceeded 50 percent.

A recent report of the U.S. General Accounting Office pointed out that, while the income status of elderly persons has improved significantly over the last two decades, much of this gain is due to growth in Social Security and public and private retirement benefits. Any reduction in this support could jeopardize their improved economic status. In addition, many older persons continue to have low incomes or incomes just above the poverty line. Further, the rising costs of health care--including greater out-of-pocket costs--pose a major threat to the retirement income status of elderly persons. For some older persons, the cost of long-term care causes financial catastrophe.

About half of older adults have completed high school. About one fifth have some college education. These percentages will increase in the future; for example, among persons born between l945 and l949, more than 80 percent have graduated from high school and almost half have had some college education.

There are other groups within the older population that require special attention in light of their extraordinary circumstances or conditions. For example, there will be a sizeable increase in the number of elderly persons with life-long handicapping conditions such as mental retardation and other developmental and physical disabilities, due to decreasing rates of mortality in the group and improved living conditions during adulthood.

The Oldest Old


Individuals 85 years of age and over are another noteworthy group. In recent years they have been the fastest-growing portion of the u.s. population; furthermore, life expectancy at advanced age has been increasing. This group is predominantly female (about 70 percent in l980) and widowed (over 70 percent).

In l980, almost one-quarter of the oldest old were living in institutions--compared to less than 2 percent of the young old (65-74 years of age). Among the non-institutionalized, about half required the help of another person to carry out daily activities. The most common primary causes of disabilities in this group are dementia, arthritis, peripheral vascular disease, cerebral vascular disease, and hip fractures.

The age group 85 years and older accounted for more than 40 percent of nursing home residents, many of whom have serious cognitive impairments. The presence of Alzheimer disease in this population is estimated to exceed 20 percent; these problems are present in a large percentage of long-stay nursing home patients.

Nonetheless, among the oldest old living in the community in l984 (more than 70 percent of the total age group), about 40 percent did not report any limits in their daily activities. Over 60 percent of this group perceived their health to be good to excellent.

It is noteworthy that the rate of physician visits is not much higher among those over 85 years of age than among those aged 65 to 74--an average of 8.5 visits per year compared to 7.7 visits per year in l985. However, hospital days of care are much higher--an average of 3.3 days compared to 2.l days. Rates of nursing home residents are ll times higher for men and l6 times higher for women aged 85 and over than among the young old population.

Health Service Needs


A very broad range of services is required to address the health care needs of the older population. Services include activities focused on prevention, primary care, acute care, postacute care, rehabilitation, long-term, and hospice care. Different services are more important to older adults at various stages of their lives.

The oldest-old population will be increasing most rapidly in the next decade or so. This group will require more services that help maintain the functional capacities of persons at advanced ages and that provide long-term care to an increasing number of frail elderly individuals. After the year 2000, although the oldest-old population continues to grow, there will be a more rapid expansion in the young-old group. This group will need more prevention, primary care, and acute care services.

The scope and diversity of services needed by older persons is illustrated in Table ll. Some services are provided primarily in the community and others through various institutions. Future developments, which are discussed below, may call for the further expansion of many of these activities and the initiation of new ones, with related extensions of personnel and training needs.

Individuals with similar health problems may require very different types and combinations of service. The availability of informal support systems and the nature of living arrangements can make critical differences in older persons' service requirements. For example, it has been estimated that for every nursing home resident there are two other older individuals with generally similar conditions living in the community.

The vast majority of disabled older persons receive all their care in the community. An elderly disabled person living alone has almost twice the likelihood of requiring formal health care services than an individual living with others. About l0 percent of disabled older persons live alone, while 40 percent live with their spouses only and 36 percent with children, according to the l982 National Long Term Care Survey.

Older persons are already the major utilizers of health care services. As noted in Figure 5, they account for about l0 percent of dentist office visits, about 20 percent of physician office visits, 25 percent of prescription drugs, more than 40 percent of short-stay hospital days, 75 percent of home health visits, and almost 90 percent of nursing home occupancy. Expenditures for aged persons in l984 accounted for about 35 percent of national expenditures for health care. As the elderly share of the population increases, older persons may soon be involved in over half of the Nation's medical care services.

More than 80 percent of persons 65 years of age and older visit a physician during a year and 40 percent visit a dentist. However, only about 20 percent are hospitalized during a year and 8 percent are in a nursing home.

The use of certain services has been shifting in recent years. For example, admissions to short-stay hospitals by older persons (as well as by younger persons) has been declining and the number of days of care has declined by about l5 percent. However, as discussed in Chapters III and IV, there have been even greater increases in the use of ambulatory physician visits and home health services during these years.

Projections of Health Service Needs


Projections of health service needs depend upon assumptions about the future. Such assumptions necessarily involve many uncertainties. Uncertainties concerning the extent of chronic disabilities among the older population in the future and the potential impact of possible changes in various societal and health conditions are considered below.

Critical assumptions affecting needs for health services concern the nature and scope of disease and disability among older concerns that require the attention of health personnel. A common approach is to assume that morbidity, disability, mortality, and health service utilization rates at different ages will remain essentially the same as current levels and to project the effects of changes in the composition of the population. This method provides a baseline for considering the potential effects of changes in these and other important factors.

An analysis using this approach was reported in l983 by Rice and Feldman. They projected future utilization of certain health services by persons 65 years and older on the basis of current information on age-specific rates concerning health status and health service utilization and estimates of future population increases. The projections identified the following potential levels of services to be required by elderly persons, if current rates of disabilities and needs for care are not modified through improved health care, research advances, and the application of knowledge:

• More than 230 million physicians visits in the year 2000 and 330 million in 2020 (compared to l55 million in l980);
• About l60 million short-stay hospital days in 2000 and 220 million in 2020 (compared to l05 million in l980) ; and
• More than 2.3 million nursing home residents in 2000 and 3.2 million in 2020 (compared to about l.3 million in l980).

These projections indicate that persons 65 years of age and older may account for about half of all hospital days in 2020, as well as about 25 percent of physician visits and more than 90 percent of nursing home occupancy. Individuals 85 years and over may make up half of all nursing home residents.

The projected percentage increases in the utilization of certain health services between l980-2000 and l980-2020 are shown in Figure 7. The possible increases are most dramatic for nursing home residents. In all three cases, however, the potential utilization of services by the elderly population in 2020 is more than twice the l980 volume.

Projections of Health Service Needs by State


A similar analysis of projected utilization of certain health services by older persons in the years l990 and 2000 on a State-by-State basis was reported in l986 by the Institute for Health and Aging. Potential levels of physician visits, short-stay hospital days of care, nursing home residency, and home health services were estimated.

As indicated in Table l3, substantial differences in the potential needs for services by older persons are likely among the different States. For example, while an overall increase in physician visits of about l0 percent was projected, the estimated changes among the States vary from increases exceeding 50 percent to decreases of about 5 percent.

Similarly, the projected percentage increases in the number of nursing home residents during the l9905 varies from about l0 percent in some States to more than 80 percent in others. The projected growth in the number of persons receiving home health services ranges from less than 5 percent to more than 70 percent.

Uncertainties Concerning Projections Relating to Health Status


The foregoing projections of potential service levels may be conservative. For example, more organized services may be needed if there are increases in the proportion of elderly persons living alone, particularly those 75 years of age and over. If the elderly population increases at a faster rate or if health services are used more often, the estimates may need to be increased by l0-20 percent or more.

Conversely, future conditions may render the projected estimates too high. The burden of chronic diseases may be reduced by effective preventive actions and by research advances. For example, if age-specific disability rates were to decline in proportion to projected declines in mortality among the aged, the estimates may exceed future needs by 20-30 percent or more.

There are significant differences of view with respect to the future extent and impact of chronic disease among the elderly population. The differing concepts have important implications for estimates of the related needs for both informal and formal organized health care services.

One view is that as the average life span grows longer, the prevalence of chronic disease and mental illness will increase greatly. This concept anticipates that the average period of disability for older adults is likely to increase substantially. Accordingly, needs for medical care in later life would expand greatly.

Another view is that the future elderly population is to be healthier, reflecting the results of greater lifestyles and behavior in earlier years and the benefits of advances from research in treatment and rehabilitation. In this case, significant increases in the length of life are not anticipated and, thus, declines in the average period of diminished capacity are anticipated. As a result, needs for medical care by the elderly would decrease.

A third perspective emphasizes the potential importance of declines in the severity and rate of progression of chronic diseases among the elderly in line with related decreases in mortality. While life spans and the numbers of chronic conditions may increase progressively, so may the capacities of older persons to manage disabilities and to maintain extended periods of independent living.

Another approach suggests that there may be both an increasing proportion of elderly individuals in relatively good health up to the time of death and an increasing proportion with prolonged severe functional limitations. In such a case, the group with moderate degrees of infirmity would be relatively smaller. The effects on the prevalence of disability and the needs for care would depend on the relative magnitudes of the various changes.

Research, including longitudinal studies, is under way to help clarify relationships among changes in mortality, morbidity, and disability, and related needs for medical and other services among older persons. Findings from these efforts can help clarify these issues in the next few years and enhance capacities for projecting future needs. The concept of "active life expectancy," for example, a measure of the expected duration of independent living, can provide important insights with respect to the quality of life of older persons and the potential periods of disability requiring support from family members, other caregivers, and health care professionals.

Other Uncertainties Affecting Potential Needs


Increased demand for health services by the elderly population is a virtual certainty in light of what can reasonably be anticipated about population growth, health status, and patterns of service utilization. However, these factors do not entirely govern demand for health services.

Attitudes towards use of health care services affect demand, for example, and these may change significantly in the future in many respects. Persons 65 years and over in the l980s, who were born in the l920s and earlier, were usually significantly influenced by the experiences of the Great Depression of the l930s and the wartime events of the l940s. The life experiences and expectations of persons who will be 65 in 2020, coming from a generation born in the l950s and maturing in the l970s and l980s, are very different. Not only are many more future older persons likely to be better educated and more affluent, but many may have developed more positive attitudes towards the use of health services, such as mental health programs and health promotion and disease prevention activities.

Projecting personnel needs for long-term care is particularly complicated. A suitable array of health and social services can be provided through a wide variety of organizational arrangements and with different mixes of formal and informal caregiving. Predicting the numbers and kinds of health personnel needed to address the long-term care needs of older persons requires assumptions, first, about the mix of formal vs. informal caregiving, and secondly about the future mix of institutional vs. community-based long-term care arrangements. Further, the levels and sources of funding for long-term care over the next 35 years are unknown. However, regardless of further developments in formal long-term care, the need to support and sustain the efforts of family caregivers and volunteers will continue to be very important.

Another reason for uncertainty in projecting health personnel requirements has to do with the rapidly changing structure of the health services industry. Organizational arrangements in the year 2020 will probably differ in many ways from current patterns. The shifts now underway have implications for personnel projections, since staffing patterns differ by setting. Moreover, education and training needs change as the delivery system changes. The shift from institutional to community-based health care, for instance, is already a pressing issue for health professions educators.

Personnel projections are subject to error with respect to supply as well as demand. Projections of supply generally begin with enrollment and earned degree data; estimates of the college-age population are used as starting points. Past experience suggests that the ability to project long-term enrollment trends with reasonable accuracy varies by discipline. Beyond that, supply projections must incorporate assumptions about likely patterns of re-entry by experienced workers who leave the occupation and subsequently return.

Underlying the uncertainties about the future size and shape of the health care delivery system is an array of social, economic, and political factors. Some changes are likely to increase the use of organized services while others would probably decrease such use. In some cases the effects may involve both increases and decreases, the overall impact being unpredictable.

Societal changes likely to increase use of organized services include the following:

• Increased availability of resources for health and human services due to the growth of the economy;
• Larger incomes available to many older persons;
• Higher expectations concerning the availability of services and quality of life;
• Rise in education attainment;
• Greater workplace participation by middle-aged women;
• Increase in childlessness, especially after 2000; and
• Larger number of older persons living alone.

Societal changes likely to decrease use of organized services:

• New residential and living arrangements;
• Limited financial resources among some older groups, especially some minorities and women;
• Increasing interests among the young old in working with the oldest old; and
• Expansion of volunteer efforts to serve elderly people.

Other important prospective changes specifically in the health field include the following, which are likely to increase use of organized services:

• Greater technological capabilities to detect, diagnose, and treat diseases and extend rehabilitation;
• Increased availability of health insurance benefits, including long-term care insurance;
• Larger supply of physicians and other health care personnel;
• Concentration of sickest patients in hospitals;
• Increased levels of illness among discharged hospital patients;
• More professional and public interest in community-based services;
• New health programs for low-income groups.

Changes in the health field likely to decrease use of organized services:

• New knowledge and practices from research that extend prevention and management capacities;
• Greater technological capabilities to identify high-risk groups so that preventive interventions may be initiated;
• Greater technological capabilities to alleviate disabilities and extend independent living;
• Development of professional standards to reduce variations in care practices and patterns;
• Increasing interests in health promotion and disease prevention;
• More emphasis on rehabilitation and greater capacities for self-care;
• Expansion of integrated systems of care, involving institutional and community facilities as well as case management activities, that strengthen continuity of care arrangements;
• Closer coordination of health, social, and other human services; and
• Continuing cost-containment activities in both the private and public sectors, including more cost-sharing arrangements.

Conclusion


Needs for health services among the elderly population will increase dramatically in future decades, although the exact nature and scope of the expansion are uncertain. Changes in the structure of the health care system that are currently underway, together with uncertainties about future directions in health care financing, make it extremely difficult to project specific service needs and utilization. The projections cited above illustrate the potential dimensions of these changes, however. Under any conditions, these trends indicate needs for substantial increases in the number of health personnel specifically prepared to provide services to older persons in the future.

Further, the total use of health services in the future will be increasingly concentrated among older and very old persons. This fact has important implications for the education and training of all health care personnel. The impact of these changes on the number and preparation of health personnel to serve elderly persons is considered in the next chapter.

References


Bureau of the Census. Projections of the Population of the United States: 1983 to 2020. Series p-25, No. 952. May 1984. US Department of Commerce, Washington, DC.

Institute for Health and Aging. Impact on an Aging Population on Health Care Needs: State Projections. University of California, 1985. San Francisco, CA.

K Manton. Report for a working conference sponsored by the National Institute on Aging, December 1986.

K Manton and B Soldo. Dynamics of Health Changes in the Oldest Old: New Perspectives and Evidence. Millbank Memorial Fund Quarterly, Health and Society. Vol. 63, No. 2, Spring 1985, pp 206-285.

National Center for Health Statistics. Current Estimates from the National Health Interview Survey. DHHS Pub No. (PHS) 86-1588. September 1986. Hyattsville, MD.

D Rice and H Feldman. Living longer in the United States: Demographic changes and health needs of the elderly. Millbank Memorial Fund Quarterly, Health and Society. Vol. 61, No. 3, 1983. pp 362-396.

Social Security Area Population Projections, 1985, Actuarial Study No. 95. SSA Publication No. 11-11542. Social Security Administration, Baltimore, MD.

US General Accounting Office. An Aging Society. Meeting the Needs of the Elderly While Responding to Rising Federal Costs. GAO/HRD-86-135, September 1986. Washington, DC.

DR Waldo and HC Lazenby. Demographic Characteristics and Health Care Use and Expenditures by the Aged in the United States: 1977-1984. Health Care Financing Review, Vol. 6, No. 1, Fall 1984.