aid assistance discourage some elderly from the use of nursing home care when it is needed (O'Shaunessy and Price, 1987).

Future Demand for Institutional Long-Term Care
Effect of Demographic Trends

As mentioned earlier, the population of older adults with complex and chronic conditions that require long-term care is growing. In 1985 there were about 1.4 million elders (people over age 65) residing in nursing homes; by the year 2050 this number is expected to increase fourfold (Andreoli and Musser, 1991). Current demographic predictions suggest that although the proportion of the U.S. population aged 65 and older will remain fairly constant, the proportion aged 85 and older will continue to rise in the next 30 years to about 2.1 percent of the population. With a stable population, these increases in proportion reflect the increase in the absolute numbers of elderly persons, particularly those 85 and older, who will increase in number from about 200,000 in 1951 to an estimated 1.2 million in 2011 (Bond and Bond, 1987). Over the next several decades, the proportion of nursing residents who are "old-old" (i.e., over age 85) is also expected to increase to somewhere around 50 percent.

Recent estimates indicate that one-half of the women and almost one-third of the men who turned 65 in 1990 will require nursing home care during their life. By the year 2010, an estimated 76 percent of the elderly are expected to be completely independent, but 24 percent of the elderly—about 7 million elderly persons—are projected to have some impairment that requires them to seek assistance with one or more activities of daily living (Scanlon, 1988; Kane and Kane, 1991). The number of dependent elders is expected to grow as the proportion of elderly in the population, especially those over age 75, increases (Griffin et al., 1989; Strumpf and Knibbe, 1990). Dependencies for assistance range from instrumental activities of daily living (IADL), such as cooking, shopping, and cleaning, to personal care activities of daily living (ADL), such as toileting, dressing, bathing, transfer and ambulation, and eating. Of the 7 million elderly needing long-term care by the year 2010, 1.75 million will be in nursing homes or other institutions; 1.4 million out of the total 7 million will need assistance with almost every ADL and IADL. Further, as a result of the aging population and increasing life expectancy, by the year 2020 the number of elderly residents in nursing homes could nearly double (Kemper and Murtaugh, 1991).

Trends in Case-Mix and Characteristics of Nursing Homes

By 2030, the elderly will comprise 20 percent of the population and use 30 percent of health care resources (Select Committee on Aging, 1992). The majority of residents in nursing homes will be 80 years and older, functionally depen-

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