More Caregivers Needed Worldwide for the 'Oldest Old'

The Population Reference Bureau’s 2010 World Population Data Sheet focuses on a rapidly aging world, highlighting many countries’ pressures to care for their elderly citizens. According to the data sheet, the elderly support ratio—the number of working-age people ages 15 to 64 divided by the number of people 65 or older—is declining in many countries, most notably in developed countries. According to PRB estimates, by 2050 Japan will have the lowest ratio of one working-age adult per elderly person, while Niger, a developing country, will still have a ratio of only 19. No country will have an elderly support ratio above 20 by 2050.

While the elderly support ratio is significant in indicating levels of potential support from society available for the elderly, and has implications for public programs, it does not incorporate informal care. The elderly support ratio does not capture the number of people ages 85 and older who may require the most resources of care, for longer periods of time. Researcher Jean-Marie Robine and his colleagues have refined the elderly support ratio, and have introduced the “oldest-old support ratio,” the number of people ages 50 to 74 to the number of people ages 85 and older. This measurement is more specific and provides information on the number of middle-aged people available to care for one person in the oldest age group.1

Longevity is a societal success story but also a strain on health resources in developed countries; one study states that “caring for the oldest old is the price of affluence.”2 In 2010, France, Italy, and Sweden have the lowest oldest-old support ratio, with 10 middle-aged people available to care for one elderly person, followed by Guadeloupe, Japan, Switzerland, Spain, and Norway with 11; the United Kingdom with 12; and Austria, Belgium, and the United States with 13 (see table).

Top Countries With the Lowest Oldest-Old Support Ratios

2010 2050





Italy 10 United States Virgin Islands 4
Sweden 10  Hong Kong 4
Guadeloupe 11 France 4
Japan 11 Singapore 4
Switzerland 11 Italy 4
Spain 11 Germany 4
Norway 11 Switzerland 4
United Kingdom 12 Martinique 4
Austria 13 Belgium 4
Belgium 13
United States 13

Source: Toshiko Kaneda, using data from World Population Prospects: The 2008 Revision Population Database
(New York: United Nations Population Division, 2009).

In 2050, Japan will have the lowest oldest old support ratio with three middle-aged people available to care for one elderly person, followed by the United States, Virgin Islands, Hong Kong, France, Singapore, Italy, Germany, Switzerland, Martinique, and Belgium (all at 4). It is unclear how aging will affect health, but it is possible that people will live longer, but with one or more chronic conditions. The World Health Organization estimates a doubling of chronic disease in the 65 and older population by 2030. 

These potential caregivers are aging as well and are possibly unavailable or physically unable to care for anyone except their relatives, placing an increasing burden on health care systems. The oldest-old ratio can encourage more policies that provide more research and resources, helping policymakers and health officials meet the challenge of population aging.

Family and Informal Care

If family members give the elderly less informal care, formal care provided at home or nursing home care might increase in demand; however, there is no standard of tracking informal care. This responsibility traditionally falls to families of the elderly (in particular, to a daughter or daughter-in-law). Middle-aged women are especially in caretaker roles.

Household restructuring and physical distance between family members makes family caregiving trends difficult to predict. The rising participation of women in the labor force may also reduce the ability to provide informal care, and it is unclear whether men will fill this gap. The availability of family caregivers may decline over time because of rising divorce rates, increasing childlessness, and declining family size.3

In England, an estimated 8.5 million people provided informal care in 2000, 3.4 million of whom cared for people over age 65. In the United Kingdom, an estimated 3.5 million more caregivers will be needed by 2037 to care for those 75 and older. China is considering relaxing their decades-old one-child policy due to unexpectedly rapid intergenerational changes. Media reports China’s population may well be aging at the fastest rates ever recorded, so there is a need for more children to care for their parents.4

Aging Alone

Because of the shortage of potential caregivers and the high cost of formal care, alternatives are needed to maintain the independence of the oldest old. Home modification and technology such as personal helper robots (which have been introduced in Japan) were once seen as the solution to a rapidly aging population, but little is known about the elderly’s daily use of technology.

Use of technology such as sensors to monitor the safety and well-being of the elderly in their homes can improve the quality of life for homebound elderly and increase the amount of time they can live independently. Technology can increase communication between caregivers or clinicians and homebound elderly, relieving the strain on caregivers and allowing them more time for themselves or other patients.

Technology could also be used to remind homebound elderly to take medication or monitor vital signs. There is evidence that use of technology in the home of elderly persons can be cost-effective, reducing clinic visits and other health costs.5 New devices designed for the elderly may be easier to use and more effective if they are familiar. A survey of men and women ages 65 and older in Portland, Oregon, found that they are most likely to use devices that have been available the longest: TVs, microwaves, and answering machines. More-recent technologies such as cell phones and computers are least used. The more complex the device, the less frequent the use; only 18 percent of those surveyed used a computer with any frequency.

People Need People

Helper robots and other technology would only solve part of the problem of long-term care. A study of 80-year-old residents in Jyvaskyla, Finland, showed a strong association between nonassistance-related perceived social support (consisting of feelings of worth, emotional closeness, belonging, and an opportunity for nurturance) and survival in older women.6 Those who are alone and neglected, despite having formal support, are at a higher risk for death.

Studies show no significant association with mortality in any of the dimensions of social support among men (most of them were married, whereas most of the women were widowed and lived alone); previous studies with exclusively older samples have found social support to be beneficial for health in both genders. The results of the Finland study challenge society to find and develop new social innovations and interventions in order to promote a sense of emotional social support in older people that would support their health and welfare and prevent their neglect.


  1. Jean-Marie Robine, Jean-Pierre Michel, and Francois R. Hermann, “Who Will Care for the Oldest People in Our Aging Society?”, BMJ 334 (2007): 570-71.
  2. Domhnall MacAuley and Zoe Slote Morris, “Caring for the Oldest Old,” BMJ 334 (2007): 546-47.
  3. Richard W. Johnson, Desmond Toohey, and Joshua M. Wiener, “Meeting the Long-Term Care Needs of the Baby Boomers: How Changing Families Will Affect Paid Helpers and Institutions,” The Retirement Project Discussion Paper (May 2007), accessed at, on Sept. 13, 2010.
  4. Calum MacLeod, “China May Relax its One-Child Rule,” USA Today, Sept. 9, 2010, accessed at, on Sept. 13, 2010.
  5. James F. Calvert, Jr. et al., “Technology Use by Rural and Urban Oldest Old,” Technology and Health Care 17 (2009): 1-11, accessed at, on Sept. 13, 2010.
  6. Tiina-Mari Lyyra and Riitta-Liisa Heikinen, “Perceived Social Support and Mortality in Older People,” Journal of Gerontology 61B, no. 3 (2006): S147-52, accessed at, on Sept. 7, 2010.