minorities grow, their needs, values, and preferences may necessitate fundamental changes in programs and services for the health care of the elderly.

Access to health care is a function of socioeconomic status, but also to some extent, level of acculturation, ranging from family structure, to education, and facility with the language. Such sociocultural barriers could arise because of differences between receivers and givers of care related to health beliefs and behavior or knowledge about medical services. These differences could make patients reluctant to seek care or comply with prescribed treatments, make care givers insensitive to the needs of patients, and strain relationships between the institutions and their communities.

These barriers often are compounded by inadequate command of the English language. Many elderly immigrants speak little or no English. In 1990, 1 in 7 Americans—nearly 32 million people—spoke a language other than English at home, up from 23 million in 1980. Although fluency in multiple languages is an advantage, speaking a language other than English at home is often a marker for families that are not fluent in English. Among those who speak a language other than English at home, 2 persons in 10 either have very limited English skills or do not speak the language at all. Nearly 1 million persons live in "linguistic isolation," that is, in households where no one aged 14 or older spoke English at all (Bureau of the Census, 1990). The implications of these trends are immense for providing culturally sensitive care and interaction between patients and providers at all levels, and for planning the supply and distribution of nursing personnel.

Sociodemographic Characteristics
Gender Distribution

More women survive to old age than men. In 1994, elderly women outnumbered elderly men by a ratio of 3 to 2, and this difference increases markedly with advancing age. After age 75, most elderly men are married and living with their spouse. Women are more than three times as likely as men to be widowed and living alone. Thus, most elderly men have a spouse for assistance when health fails. The likelihood of living alone increases with age, but much more so for women (Bureau of the Census, 1995b).

Living Arrangements

Changing patterns of family formation and composition (late marriages, smaller families, divorce, childlessness) mean that whereas today's elderly generally have children to turn to when in need, the elderly baby-boomer generation will have far fewer family resources, and specifically fewer younger persons to take care of them. As more persons live longer, issues surrounding the care of the elderly will become more prevalent. Increasingly, those who may be consid-



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