Crisis looms as aging boom, dementia increase demand for care for elderly

At the outset of the COVID-19 pandemic, in early 2020, about 4.5 million Americans were paid to work in eldercare, most at nursing homes, assisted-living facilities or as in-home aides.

Over the next 24 months, more than 240,000 of those workers left the profession, a decline that made eldercare one of the country’s hardest-hit industries, at least in terms of pandemic-related job losses.

Worse, thousands of the people who “left” eldercare did so because they were no longer alive.

Whatever the cause, the worker exodus helped spark a human and economic disaster. Many nursing homes became COVID-19 hot zones, in part because of short staffing. Some operators, particularly in rural areas, closed their doors. And misery became rampant, as thousands of older people died while receiving barebones care and with no family at their side.

But many experts, in and outside the industry, say that crisis was more than a pandemic-era emergency, it was a glimpse of America’s possible future.

By all accounts demand for age-related health care is about to far outstrip supply, particularly with the coming growth of two demographic groups, people 85 and older and people with Alzheimer’s or other forms of dementia. And without big changes to eldercare – an issue that experts note is not yet a national conversation – millions of American lives could be upended.

“It’s about a lot of things,” said Joe Diaz, the Southern California regional director for the California Association of Health Facilities, a trade group that represents about 1,200 nursing homes in the state, when asked about the coming squeeze on eldercare.

“But, mostly, it’s about age.”

And, Diaz, echoing others in the industry, added this:

“It’s going to affect everybody, not just older people.”

Age and Alzheimer’s

The eldercare industry has regrouped a bit since the worst of the pandemic. Federal data shows the number of nursing homes nationally grew by about 2% over the past year, to slightly more than 26,500. (There are about 4,000 nursing homes and assisted living centers in Los Angeles, Orange, Riverside and San Bernardino counties.) Also, the number of Americans living in nursing homes and assisted-living facilities has grown to about 2 million.

But the professional side of eldercare is only a sliver of the actual work done taking care of older people. And it’s not growing anywhere near fast enough to keep pace with a self-explanatory trend that demographers call the aging boom, which is already well underway in the United States and in most other advanced economies.

The coming explosion of older people within the population will create so much need that industry experts believe it could force a collective re-think when it comes to how America handles age-related health care.

Rich Southard president of a Home Instead franchise in Whittier. (Photo by Jeff Gritchen, Orange County Register/SCNG)

“The effects of this will spread,” said Rich Southard, who owns the Whittier-area franchise for Home Instead, a company that provides in-home eldercare services.

“There’s never going to be enough bed space for all of the older people who are going to need it. That’s just the reality.”

Current population trends back him up.

The Census Bureau projects that by 2032 there will be more older Americans (age 65 and up) than children (age 18 and under), a rarity in human history. By 2060, the pool of Americans age 65 and older will account for roughly one-quarter of the country’s population. The demographics of Florida and New Hampshire – states with currently outsized retiree populations – soon will be the norm nationwide.

But from an eldercare perspective, two specific projections could be more important: the expanding population of old people and the rise of people with Alzheimer’s disease and other forms of dementia.

First, within the broader aging boom, the fastest growing cohort is the oldest of the old, people 85 and up. America currently has about 7 million people in that age range; by 2050, the number will be 18.6 million. And, within that group, the number of Americans age 100 and older is forecast to grow from about 90,000 today to nearly 400,000.

Statistically, these are the people most likely to need care. While just 1.1% of people ages 60 to 74 live in a nursing home, that shoots up to 15% when you’re talking about people 85 and older. And a much larger pool – roughly two-thirds of people in the 85-and-up crowd – can still live independently or with family because they get regular help from paid workers or unpaid family members, friends, spouses and others.

A Home Instead caregiver helps a client get dressed. (Courtesy of Home Instead)

A caregiver with Home Instead helps a client into a bathtub (Courtesy of Home Instead)



Numbers suggest the aging boom is already reshaping Southern California. Over the past decade, the number of people ages 65 and up has grown in Los Angeles (up 34%), Orange (up 41.6%), Riverside (up 40%) and San Bernardino (up 45.4%) counties. And by the mid-2030s each of those counties is expected to see the number of people age 75 and older grow between 55% and 65%.

All of this aging, nationally and locally, is creating – or forcing – an explosion in unpaid caregiving.

As of 2020, there were 41.8 million people taking care of somebody 50 years old or older, a 22% increase in such caregivers since 2015, according to a study from AARP. The help provided by this volunteer army ranges from cooking and housekeeping to navigating a loved one’s insurance and medical care, bathing, lifting them in and out of bed, and dressing.

If current trends hold, as many as 85 million Americans could be providing such help by 2050.

The AARP study also pointed out that the professional and volunteer worlds of caregiving are inextricably linked. As beds in nursing homes and other professional settings become tougher to find, the pool of older people living independently becomes frailer. That means more help from – and more strain upon – their caregivers.

That, too, is already happening.

“Not only are more American adults taking on the role of unpaid caregiver, but they are doing so for adult recipients who may have increasingly complex medical or support needs,” the AARP report found.

The report also found that while most (60%) caregivers say taking care of elders is “difficult but rewarding,” there are myriad downsides, ranging from lost income to frustration to depression. About 1 in 4 (23%) said caregiving has made their own health go downhill.

Local caregivers say the experience, good and bad, is life-changing.

“There’s no way every family can do this. No way,” said Lia Alvarez, a 58-year-old former librarian in Long Beach who left her job three years ago to care for her aging mother (also in Long Beach) and her mother-in-law (in Downey).

“I’m at capacity. And the people I help are both really sweet, and their needs aren’t that intense yet. And I’m not the only person in the family who does it; my husband and our kids and my sister, everybody pitches in.

“But it’s pretty crazy,” she added. “I can’t imagine what it will be like when this is happening in every family.”

The second Census projection that figures to reshape American life is this: The number of people with Alzheimer’s disease or some other form of dementia is growing even faster than the broader aging boom.

Between now and 2060 the number of Americans with Alzheimer’s is expected to grow from 6 million to about 13.8 million, or slightly more than the current population of Pennsylvania, according to federal data and studies by the national Alzheimer’s Association. In Southern California, the number of Alzheimer’s and other dementia patients figures to jump from about 710,000 today to about 1.5 million.

And while Alzheimer’s and other forms of dementia are tragic – the disease is a key cause of death, particularly for older women and people of color – it also eats up a lot of money. In 2021, the cost of medical care for Alzheimer’s and other dementia ran to about $321 billion nationally, a number that’s expected to reach $1 trillion a year by 2050.

The dementia boom is leading its own world of unpaid caregiving. About 11 million Americans currently provide volunteer care for people with some form of dementia, labor that two years ago would have been valued at $271.6 billion. (In Southern California, about 670,000 people provided unpaid dementia-related care that would have been worth about $13.7 billion.)

Even within the many ominous projections related to eldercare, experts and caregivers view the dementia boom as a potential time bomb.

“I watch every day to see if my two moms are showing any signs. So far, nothing,” said Long Beach caregiver Alvarez.

“But if that happens, I don’t know what we’ll all do.”

Machines, people, money

Even as the age- and dementia-related forecasts begin to play out, the staffing crisis is clouding the eldercare industry.

A survey released last summer by the American Health Care Association/National Center for Assisted Living found that 3 in 5 nursing homes have limited new admissions because they don’t have enough workers. And the survey, which tracked 759 nursing home providers, found that 3 in 4 believe the lack of workers might eventually push them out of business.

“I had way more service calls this week than I did from job applicants,” said Whittier-based in-home caregiver employer Southard.

Like many in the industry, Southard noted that a lot of ideas are being floated to boost staffing and to fix eldercare in ways that could stave off some of the changes that figure to happen as America ages up. Few, so far, are close to becoming reality.

Technology is often part of that discussion. Some devices (blankets that can read a person’s temperature and sleep patterns; sensors that can tell if a person is becoming frailer by tracking their movement, or even the sound of their voice) are already hitting the market. Others (robots to lift people in and out of beds) are in development.

But Southard, like others, said that while he welcomes new tech that will help his clients, he’s doubtful we’re close to anything that will supplant his workforce.

“I don’t think you can replace touch,” he said. “It really matters.”

Another key to the eldercare solution is immigration.

The staffing shortage in nursing homes (which is pushing more eldercare back to families) has grown worse as American immigration policies have hardened and the number of new arrivals, overall, has slowed. Eldercare has traditionally employed many of those people, from physicians and trained nurses to lower-skilled aides. The Eldercare Workforce Alliance notes that as many as 80% of hands-on workers in nursing homes and assisted living centers were born in another country.

Though the group doesn’t offer specific proposals, it does urge lawmakers to “review carefully all immigration-related legislation and regulations for their potential impact on the health care workforce.”

But two basics – pay and respect – are essential.

Though people who are good at caring for older people possess a variety of positive human traits – patience, respect, communication – those traits don’t qualify as official job “skills,” and unskilled labor in eldercare typically earns minimum wage. Southard’s company stays slightly ahead of minimum, currently paying $16 to $20 an hour, but he noted that he also offers health care, 401 (k) options and other benefits aimed at keeping good employees.

“We’re trying to make it a possible career for people,” Southard said.

But Southard also said higher pay alone isn’t going to fix the long-term problem. Rising costs, he noted, will price out a lot of older people on fixed income, shifting eldercare back to families that can afford it the least.

“The state report on workforce said we will need 600,000 new caregivers in California in the next few years. Where are we going to get them? How are we going to train them? Those are a couple of the questions we have to answer,” Southard said.

“But, really, there are a lot of questions like that.”

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