Bette and Monica are not alone. In the United States, about 70 percent of those who are age 65 will need some sort of long-term care during their lives3—three years on average but five years for one-fifth of this age group.4 Many older adults would like to remain independent and live in their own homes for as long as possible,5 and technological innovations such as remote monitoring, which allows adult children to watch over their parents, and electronic reminders to take medications have made aging in place a realistic goal to some extent. Homes can be remodeled to include shower grab-bars and ample widths for wheelchairs, furnishings can be made more comfortable and accessible, and services such as Meals on Wheels can deliver food. But aging in place is often unaffordable. On average, home health care aides cost $21 per hour,6 and their services are typically not covered by private health insurance. Given such prohibitive costs, older adults often piece together care or forgo it entirely. A recent study found that in the prior month one out of every three older U.S. adults experienced at least one adverse consequence, such as soiling oneself, staying inside, making mistakes with medications, and going without eating, as a result of having an unmet need for care.7
In this brief, we explore factors that exacerbate the unmet need for care among the noninstitutionalized older population and seek to determine who is likely to need care but go without. We find that unmarried individuals and those who live alone are more likely than others to need care but not receive it. These older adults are frail, have difficulty meeting their daily needs, and do not have family members or friends to whom to turn in times of need. This group of vulnerable older adults requires an array of social supports.
There are a number of ways to estimate the proportion of older adults who have an unmet need for care. Researchers often look at limitations in activities of daily living (ADLs, such as bathing and dressing) and instrumental activities of daily living (IADLs, such as shopping for groceries and preparing hot meals). Unmet need for care is defined as needing help with at least one ADL or IADL and not receiving it. We follow this convention but also add a measure of frailty. We characterize someone as having an unmet need if he or she is frail and needs help with an ADL or IADL but does not receive it. We add this criterion so as to focus on those who are deeply and chronically in need of care.
Following previous research, we constructed a frailty index that, by taking into account many facets of health, tells us more about accumulated frailty than individual health measures alone.8 Our index reflects eight separate medical diagnoses (high blood pressure, diabetes, cancer, chronic lung disease except asthma, heart problems, stroke, arthritis, and psychiatric problems); a measure of obesity; twelve separate ADLs and IADLs; eight separate measures of depression that comprise the Center for Epidemiological Studies Depression Scale; and a measure of self-reported health. The individuals discussed in this brief are frail and have difficulty meeting their daily needs.
Nearly One-Fifth of Older U.S. Adults Are Frail and in Need of Care
Approximately 20 percent of women and 16 percent of men over age 65 are frail and have at least one limitation in meeting their daily needs—bathing, dressing, shopping for groceries, taking medications, or some other ADL or IADL (Figure 1). They need care from others, but many do not receive it.
The Unmet Need for Care
Among older U.S. adults who are frail and have at least one functional limitation, 36 percent (38 percent of men and 34 percent of women) receive no care from family members, friends, or paid providers (Figure 2).
Men are somewhat more likely than women to receive care from a spouse (39 percent versus 15 percent). In part this is because older men are more likely than older women to be married and to have a spouse to whom to turn in a time of need. Women who need care are more likely than men to receive care primarily from a daughter (20 percent versus 7 percent), even when the woman’s husband is alive. Figure 2 also shows that women have a more diverse group of care providers. Women may have larger support networks and more people to whom to turn in times of need.
Unmarried Older Adults and Those Who Live Alone Are Particularly Vulnerable
Unmarried men and women are more likely than married men and women to have an unmet need for care. In other words, marriage protects women and men as they move from middle age into old age. Unmarried older individuals who need care must rely on other family members or friends, and they often do not have strong enough ties. As women and men age, their ties to potential caregivers may weaken, and they can become socially isolated.
Unmarried men are particularly vulnerable: 44 percent of unmarried men have an unmet need for care (Figure 3). Living alone is associated with even greater risks. Sixty-nine percent of older unmarried women and men live alone and, of these, nearly half of men and 36 percent of women have an unmet need for care.
A large percentage of older U.S. adults need care but do not receive it. Their needs vary—some need help bathing or dressing, others need help shopping for groceries or preparing meals—and the factors associated with having an unmet need vary as well. Unmarried individuals are more likely than married individuals, and those who live alone are more likely than those who share a living arrangement, to have an unmet need for care. Unmarried men who live alone are highly vulnerable: close to half of all frail older men who live alone need some sort of help but do not receive it.
The graying of the U.S. population foretells a crisis in care. In 2012, about 43.1 million U.S. adults, accounting for 13.7 percent of the population, were ages 65 and older. By 2050, those figures are estimated to climb to 83.7 million and 20.9 percent.9 The aging of the baby boomers accelerates this growth, and its effects ripple across our social institutions and pose challenges to individuals, families, care providers, and policy makers.
The vast majority of older U.S. adults will need some sort of long-term care during their lives, and the number of people using various long-term supports is projected to rise from 15 million in 2000 to 27 million by 2050.10 The 2013 bipartisan federal Commission on Long-Term Care wrote that services are “highly fragmented and difficult for individuals and family caregivers to access: they lack the focus and coordination across agencies and providers necessary to ensure the best outcomes for the person and family.”11 As the population ages, policy makers must contend with the funding, provision, and coordination of long-term care supports for older U.S. adults and their families, especially those who are unmarried and living alone. They must focus on people such as Monica and Bette—people who are socially isolated, frail, and in need of care.
These analyses are based on the 2012 wave of the Health and Retirement Study (HRS), a panel survey of individuals ages 50 and older. Since 1992, the HRS has been fielded biennially by the National Institute on Aging. All differences reported in the text are significant at the p < .05 level.
1. Moira Lynn Greaves, “The Experiences of Socially Isolated Older People as They Access and Navigate the Health System,” unpublished dissertation, University of Southern Queensland (2012), available at https://eprints.usq.edu.au/23456/1/Greaves_2012_whole.pdf.
3. Peter Kemper, Harriet L. Komisar, and Lisa Alecxih, “Long-Term Care Over an Uncertain Future: What Can Current Retirees Expect?” Inquiry 42 (2005/2006): 335–50.
5. Meika Loe, Aging Our Way: Lessons for Living From 85 and Beyond (New York: Oxford University Press, 2011).
6. U.S. Administration on Aging, available at http://longtermcare.gov/costs-how-to-pay/costs-of-care.
7. Vicki A. Freedman and Brenda C. Spillman, “Disability and Care Needs Among Older Americans,” Millbank Quarterly 92, no. 3 (2014): 509–41; Mayur M. Desai, Harold R. Lentzner, and Julie Dawson Weeks, “Unmet Need for Personal Assistance With Activities of Daily Living Among Older Adults,” Gerontologist 41, no. 1 (2001): 82–88.
8. Kara B. Dassel and Dawn C. Carr, “Does Dementia Caregiving Accelerate Frailty? Findings From the Health and Retirement Study,” Gerontologist, published online August 26, 2014, available at http://gerontologist.oxfordjournals.org/content/early/2014/08/25/geront.gnu078.abstract.
9. Jennifer M. Ortman, Victoria A. Velkoff, and Howard Hogan, “An Aging Nation: The Older Population in the United States” (Washington, DC: U.S. Census Bureau, 2014).
10. Joint Center for Housing Studies of Harvard University, “Housing America’s Older Adults: Meeting the Needs of an Aging Population” (2014).
11. United States Senate Commission on Long-Term Care, “Report to the Congress” (2013), available at http://www.gpo.gov/fdsys/pkg/GPO-LTCCOMMISSION/pdf/GPO-LTCCOMMISSION.pdf.