have been studied by a number of researchers to estimate the size of the population outside of institutions in need of long-term care. According to a recent synopsis of these studies, estimates for functional limitations range from 2.8 million to 7 million. 14

For our purposes, we will report the results of a special Supplement on Aging which was added to the National Health Interview Survey in 1984 to collect information about the physical limitations of older people living in the community. Data from the supplement show that about one-quarter (23 percent) of the population 65 and over living in the community has difficulty with one or more of the seven personal care activities (ADL's) inventoried, and about the same proportion (27 percent) has difficulty with at least one of the six home management activities (IADL's) (tables 4-5, 4-6). Not surprisingly, the proportion of persons experiencing difficulty with daily life activities-personal care or home management-increases with age. For example, the proportion reporting difficulty with one or more personal care activities rises from 15 percent for people 65-69 years of age to 49 percent for people 85 years or older.

A greater proportion of women than men 65 and over reported difficulty with personal care activities, which may reflect the older age, on average, of women in this population group. When home management activities were considered, women were significantly more likely than men in this age range to have difficulties in performance. These differences may again reflect the older age distribution of women, but also, in part, the cultural phenomenon that many older men do not routinely perform home management tasks and are thus at reduced risk of experiencing health-related difficulties with them. 15

14 Stone, Robyn I. and Christopher M. Murtaugh. "The Elderly Population with Chronic Functional Limitations: Implications for Home Care Eligibility," December 1988.

15 Dawson Deborah; Gerry Hendershot; and John Fulton. "Aging in the Eighties: Functional Limitations of Individuals 65 and Over." Advance Data Number 133, National Center for Health Statistics (June 10, 1987).

TABLE 4-5. PERCENT DISTRIBUTION OF PERSONS 65 YEARS OF AGE AND OVER BY NUMBER OF PERSONAL CARE ACTIVITIES THAT ARE DIFFICULT, ACCORDING TO SEX AND AGE: 1984

Source: Dawson, Deborah, Gerry Hendershot, and John Fulton. "Aging in the Eighties: Functional Limitations of Individuals Age 65 Years and Over." Advance Data No. 133, National Center for Health Statistics (June 10, 1987).

TABLE 4—6.—PERCENT DISTRIBUTION OF PERSONS 65 YEARS OF AGE AND OVER BY NUMBER OF HOME MANAGEMENT ACTIVITIES THAT ARE DIFFICULT, ACCORDING TO SEX AND AGE: 1984

Note.-Figures may not add to 100.0 because of rounding.
Source: Dawson, Deborah, Gerry Hendershot, and John Fulton. "Aging in the Eighties: Functional Limitations of Individuals Age 65 Years and
Over." Advance Data No. 133, National Center for Health Statistics (June 10, 1987).

Not everyone with limitations in personal care or home management receives assistance with ADL's or IADL's. According to the 1984 Supplement on Aging, about 23 percent (6 million) of Americans 65 years and over who lived in the community reported difficulty in performing a personal care activity, but only 10 percent (about 2.5 million) reported receiving help with one or more such activities. Similarly, about 27 percent (7.1 million) of noninstitutionalized elderly in the United States experienced any difficulty in home management tasks, while 22 percent (or approximately 5.9 million) received help with these activities.16

Another measure of activity limitation is the number of days a person is confined to bed. Again, we find differences in this health indicator within the 65 and over population. For those age 85 and over living in the community, 3.4 percent are always confined to bed. In contrast, only 1 percent of the 65 to 74 age group was similarly limited. Sixty-two percent of the total older population spent no days confined to bed in 1984 (table 4-7).

16 Ibid.

TABLE 4-7.-PERCENT OF THE 65-PLUS POPULATION IN THE COMMUNITY CONFINED TO BED: 1984

Source: National Center for Health Statistics. Other data from the National Health Interview Survey, Supplement on Aging, 1984.

MORTALITY

DEATH RATES FOR THE ELDERLY HAVE IMPROVED DRAMATICALLY IN THE LAST SEVERAL DECADES

The last several decades have seen tremendous improvement in life expectancy (see chapter 1). Significant declines in death rates have occurred in the older age groups, although the pace and timing of these declines have varied for individual age-sex-race groups within the older population (table 4-8). For example, declines in death rates for people 85 years or older have not been quite as dramatic as those for people 65-84 years of age. Likewise, the declines for older females are greater than those for older males; and the declines for older whites, regardless of gender, have been considerably larger than the declines for older blacks.

TABLE 4-8.-DEATH RATES FOR OLDER PERSONS, BY AGE, SEX AND RACE: SELECTED YEARS,

TABLE 4-8.—DEATH RATES FOR OLDER PERSONS, BY AGE, SEX AND RACE: SELECTED YEARS,

Source: 1987 data: National Center for Heath Statistics, "Annual Summary of Births, Marriages, Divorces, and Deaths: United States, 1987." Monthly Vital Statistics Report, vol. 36, No. 13 (July 23, 1988).

1950-80 data: National Center for Health Statistics, Health, United States, 1987. DHHS Pub. No. (PHS) 88-1232, Washington: Department of Health and Human Services, March 1988.

HEART DISEASE, CANCER, AND STROKE ARE THE LEADING CAUSES OF DEATH FOR THE ELDERLY

As previously noted, in the United States three out of four elderly persons die from heart disease, cancer, or stroke (chart 4-3). Heart disease was the major cause of death in 1950, and remains so today even though there have been rapid declines in death rates from heart disease since 1968, especially among females. Death rates from cancer continue to rise in comparison to heart disease, especially deaths caused by lung cancer. In 1986 and 1987, however, heart disease accounted for 41 percent of all deaths among 65plus persons, while cancer accounted for 21 percent of all deaths in this age group. Even if cancer were eliminated as a cause of death, the average life span would be extended by less than 2 years because of the prevalence of heart disease. Eliminating deaths due to heart disease, on the other hand, would add an average of 5 years to life expectancy at age 65, and would lead to a sharp increase in the proportion of older persons in the total population.17

The third leading cause of death among the elderly-stroke (cerebrovascular disease)-has been decreasing over the past 30 years. Reasons for this dramatic decline are not fully understood. Part of the decline may be attributable to better control of hypertension. Better diagnosis and improved management and rehabilitation of stroke victims may also be related factors. 18 In 1986 and 1987, cerebrovascular disease accounted for only 9 percent of all deaths in the 65-plus age group.

Table 4-9 shows the 10 leading causes of death for three subgroups of the older population.

17 Natioral Center for Health Statistics. "United States Life Tables Eliminating Certain Causes of Death." U.S. Decennial Life Tables for 1979-1981, Vol. 1, No. 2 (forthcoming).

18 National Center for Health Statistics. Health, United States, 1985. DHHS Pub. No. (PHS) 86-1232, Washington: Department of Health and Human Services, December 1985.