CHAPTER 2 Implications of an Aging Population for Rehabilitation 17 SUCCESSFUL VS.OPTIMAL AGING 1950.he "Successful aging"was a multidimensional concept first ulation in 1970 articulated in the late 1980s and further elaborated in population. ndividuals born between the years 1946 aging and lts w nd and will be y Boom mpassed three elements avoiding disease and 2010 and 2030,when th disability,maintaining high physical and cognitive func- bispredicted to account for nearly 20% activiti d that hiresearc e concep arch w but their rer n within the age aging but ignored the equally important long-term many who iduals older than 100 also continues to mere proportion ofth h encouraging modification of some extrinsic in the proportion of aged in our society are a declining birthrate and a declining death thin the and er ages the age work within the concer of imal which ger individuals at thebas allows an individual to achieve life satisfaction in mul. to a more rectangular distribution of the population by tiple domains- and social age,with a trend over time for a larger proportio spite the pre nce of 6 t200 op,especiall ing the disabling and sto emnants of the traditional tria re as cvcle of“disea disability-new incident disease"to well as the beginning "rectangularization"(Figure 2-2). maintain quality of life. DEMOGRAPHY te8686e8d6e288268 Defining "Older"Adult 100 The first geronrological question is how a particular seg 80 identifving the older adult in America is strictly arbitrary 7 and usually has been set at age 65 years.However,the 0 65 and older only in their 40s.As the mean age of the population in- 20 creases and more individuals live into their ninth and 0 85 and older 19019201940196019802000,20202040 2006 Projected Population Estimates and Age Structure 88 Data for 2010-2050 In 2 FIGURE 2-1 Growth of the population age 65 years and older was 37.3 million.reflecting the maior changes in the population structure of the United States in the past March2008
CHAPTER 2 Implications of an Aging Population for Rehabilitation 17 SUCCESSFUL VS. OPTIMAL AGING “Successful aging” was a multidimensional concept first articulated in the late 1980s and further elaborated in the 1990s to distinguish between individuals with the characteristics of usual aging and those adults who had managed successful aging. The concept of successful aging encompassed three elements: avoiding disease and disability, maintaining high physical and cognitive function, and sustaining engagement in social and productive activities.1,2 The research that supported the concept suggested that biological orientations to aging in gerontological research were biased toward “usual” or “average” aging but ignored the equally important long-term effects of diet, exercise, and lifestyle that characterized the successful aging of many who had escaped the usual decline and disability of average aging. Physical therapists can assist the promotion of successful aging by encouraging modification of some extrinsic factors, particularly in teenagers and young adults, which lead to less disease and disability in the later years. For those with disease and disability, the physical therapist should work within the concept of “optimal aging,” which allows an individual to achieve life satisfaction in multiple domains—physical, psychological, and social— despite the presence of disabling medical conditions. Physical therapists can promote optimal aging by reducing the disabling effects of disease and stopping a vicious cycle of “disease–disability–new incident disease” to maintain quality of life. DEMOGRAPHY Defining “Older” Adult The first gerontological question is how a particular segment of a population comes to be categorized as “older”? The chronological criterion that is presently used for identifying the older adult in America is strictly arbitrary and usually has been set at age 65 years. However, the onset of some of the “geriatric” health problems of older individuals may occur as soon as they enter their early 50s, and, as detailed elsewhere, “older” athletes may be only in their 40s. As the mean age of the population increases and more individuals live into their ninth and tenth decades, we can expect that our notion of who is “older” will change. Population Estimates and Age Structure The number of Americans age 65 years and older continues to grow at an unprecedented rate. In 2007 the best available estimate of persons age 65 years or older was 37.3 million,3 reflecting the major changes in the population structure of the United States in the past century. Individuals who had reached their 65th birthday accounted for only 4% of the total population in 1900. In 1940 they were 6.9% of the population, and by 1950, they were equal to 8.2%. Although they represented just fewer than 10% of the population in 1970, they currently account for almost 13% of the U.S. population.4 Individuals born between the years 1946 and 1964 are frequently referred to as the “Baby Boomers” and will be responsible for a sharp rise in the number of older people between 2010 and 2030, when the older population is predicted to account for nearly 20% of the total U.S. population.4 Individuals older than age 85 years currently represent just under 10% of people older than age 65 years (5.3 million people in 2006), but their representation within the general populace is likely to quadruple by 2050 (Figure 2-1).4 The number of individuals older than 100 also continues to increase, even though the actual proportion of the total population (1 of every 10,000) is relatively small.5 Two concurrent factors that have affected the increase in the proportion of aged in our society are a declining birthrate and a declining death rate. With fewer births overall and more survivors at older ages, the age structure of the population changes from a triangular shape, with a larger number of younger individuals at the base, to a more rectangular distribution of the population by age, with a trend over time for a larger proportion of older individuals at the top, especially among the oldest old.6 In 1990 and 2000, the shape of the age pyramid shows remnants of the traditional triangular structure as well as the beginning “rectangularization” (Figure 2-2). Projected 100 90 80 70 60 50 40 30 20 10 0 Millions 1900 1920 1940 1960 1980 2000 2006 2020 2040 65 and older 85 and older Number of people age 65 and older, by age group, selected years 1900-2006 and projected 2010-2050 Note: Data for 2010-2050 are projections of the population. Reference population: These data refer to the resident population. Source: U.S. Census Bureau, Decennial Census, Population Estimates and Projections. FIGURE 2-1 Growth of the population age 65 years and older, past and projected, with projected growth of adults age 85 years and older to midcentury. (From Federal Interagency Forum on Aging-Related Statistics: Older Americans 2008: key indicators of well-being. Washington, DC: U.S. Government Printing Office, March 2008.)
18 CHAPTER 2 Implications of an Aging Population for Rehabilitation (NP-P1)F the Unite ates as of July 1.1990. 00 and 98 5 to 5 10o1 645435325215150511522.533 53252151505115225335 Female Female 10a 00 200 0 Und 5454353252155051152253354455 54543532521515051152253354455 Percen Male Male By 2050,the age struct changes in life expectancy were primarily the result of ne lea lived to age &s vearss in 1900.a person who lived until Life Expectancy age 65 years might expect another 12 years of life. States was s years.whereas th e median age o first half of the 20th centur for both although the gap has begun ily as a result of advances in health at birth and younge to decrease.Racial differences in life expectancy have ages,especially infant mortality.However,by 2000 the also been demonstrated,as white women generally live
18 CHAPTER 2 Implications of an Aging Population for Rehabilitation FIGURE 2-2 Change in the population age structure by age and sex from 1990 to 2050 showing shifts in proportions of younger individuals to older individuals. (Source: National Estimates Program, Population Division, U.S. Census Bureau, Washington, DC, 20233. From U.S. Census Bureau: U.S. population projects: population pyramids [website]: http://www.census.gov/population/www/projections/natchart.html; Accessed February 27, 2010.) 5 4.5 4 3.5 3 2.5 2 1.5 1 .5 .0 .5 1 1.5 2 2.5 3 3.5 4 4.5 5 Percent Male Female 100 and over 95 to 99 90 to 94 85 to 89 80 to 84 75 to 79 70 to 74 65 to 69 60 to 64 55 to 59 50 to 54 45 to 49 40 to 44 35 to 39 30 to 34 25 to 29 20 to 24 15 to 19 10 to 14 5 to 9 Under 5 Age (NP-P1) Resident Population of the United States as of July 1, 1990. 5 4.5 4 3.5 3 2.5 2 1.5 1 .5 .0 .5 1 1.5 2 2.5 3 3.5 4 4.5 5 Percent Male Female 100 and over 95 to 99 90 to 94 85 to 89 80 to 84 75 to 79 70 to 74 65 to 69 60 to 64 55 to 59 50 to 54 45 to 49 40 to 44 35 to 39 30 to 34 25 to 29 20 to 24 15 to 19 10 to 14 5 to 9 Under 5 Age (NP-P2) Projected Resident Population of the United States as of July 1, 2000, Middle Series. 5 4.5 4 3.5 3 2.5 2 1.5 1 .5 .0 .5 1 1.5 2 2.5 3 3.5 4 4.5 5 Percent Male Female 100 and over 95 to 99 90 to 94 85 to 89 80 to 84 75 to 79 70 to 74 65 to 69 60 to 64 55 to 59 50 to 54 45 to 49 40 to 44 35 to 39 30 to 34 25 to 29 20 to 24 15 to 19 10 to 14 5 to 9 Under 5 Age (NP-P3) Projected Resident Population of the United States as of July 1, 2025, Middle Series. 5 4.5 4 3.5 3 2.5 2 1.5 1 .5 .0 .5 1 1.5 2 2.5 3 3.5 4 4.5 5 Percent Male Female 100 and over 95 to 99 90 to 94 85 to 89 80 to 84 75 to 79 70 to 74 65 to 69 60 to 64 55 to 59 50 to 54 45 to 49 40 to 44 35 to 39 30 to 34 25 to 29 20 to 24 15 to 19 10 to 14 5 to 9 Under 5 Age (NP-P4) Projected Resident Population of the United States as of July 1, 2050, Middle Series. By 2050, the age structure “pyramid” is relatively rectangular except among the older age groups. Life Expectancy In 2007, the median age of the total population of the United States was 36.4 years, whereas the median age of individuals 65 years and older was 74.8 years.3 In the first half of the 20th century, mortality declined primarily as a result of advances in health at birth and younger ages, especially infant mortality. However, by 2000 the changes in life expectancy were primarily the result of reduced mortality at older ages, not the least of which was the dramatic increase in the number of adults who lived to age 85 years.6 In 1900, a person who lived until age 65 years might expect another 12 years of life. Additional life expectancy for individuals age 65 years in 2000 had grown to 18 years. However, female life expectancy continues to outpace male life expectancy, despite gains made for both sexes, although the gap has begun to decrease. Racial differences in life expectancy have also been demonstrated, as white women generally live
CHAPTER 2 Implications of an Aging Population for Rehabilitation 19 gon social ship.There has been a long-standing con rsy in the marriage or partnered relationships defy easy character literature regarding whether there is a racial crossover at izations,suggesting that one must look at the specific the oldest ages,wh ere black survivorship may improve attributes of a particular relationship before drawing at 6 cies,or not accounting for confounding variables:othe regiving burdens and socio of a significant researchers have drawn conclusions about "survival of the fittest,"arguing tha one.This dis ion the Race and Ethnicity search for self-validation through the recognition,esteem. and affection of another that may have been present in a Racial and nonwhite marital or partered relationship. 。 Living Arrangements fo r was non-Hispanic wherea n age 65 years and older 7o Asian alon oting that non-Hispani whit owth rate of any sub pop than other racial or ethnic older black.Asian likely to surpass the black subr nearly eight ti D and ingof help s e in funs 1 million)of older Asians in the United States to a pro jected 7 million by 2050.* adult living alone will seek other arrangements. he fut rsing hom ation has changed sid since nd cul h est thos patients currently served,and culturally competent care short-term admissions and return to their premorbid will literally require a global appreciation of diversity. n2004,ol Sex Distribution and Marital Status 829% e age years and e,non Simply put,there is a marked sex differential in mortal- Family Roles and Relationships.Despite many social ity,and a number of social and life factors beyond bio advances for younger generations of we omen,the degree logic for me to which female older adults are still bound by society ave a lower mo ty at an the: oles such as ho and woman is more likely to live alone when compared to women.However,because women typically live longer a male counterpart and must continue to function inde- than men,th pendently,w atever her lev of 1 omen are ther men to repor availability of assistance with home chores in compari are more likely to be married than older women and son with other social support services may be a subtle haedm expectancy by virtue of thsire although the level have a grea of unmet need in this are ente and oder are three times more likely to be widowed as lowing an older adult to remain living independentl at comparably aged men,with the proportion growing home when functional abilities are compromised.Physi- with each de ade of aging.I here have been many theo erapists will need to continue working with othe ries proposed to explain the salutary effects of marriage
CHAPTER 2 Implications of an Aging Population for Rehabilitation 19 on longevity, generally focusing on social support and shared resources. However, like most social institutions, marriage or partnered relationships defy easy characterizations, suggesting that one must look at the specific attributes of a particular relationship before drawing conclusions. In addition to the caregiving burdens and socioeconomic implications of being partnered, loss of a significant other brings its own set of psychosocial challenges to the individual in contemporary society. Any individual whose identity is linked to being a couple or part of a long-term relationship may experience a severe disruption of social roles when left alone. This disruption complicates the search for self-validation through the recognition, esteem, and affection of another that may have been present in a marital or partnered relationship. Living Arrangements In 2000, 28% of the population age 65 years and older lived alone,9 noting that older non-Hispanic white women and black women were more likely to live alone than other racial or ethnic groups.4 Older black, Asian, and Hispanic women are more likely than non-Hispanic white women to live with nonspousal relatives.4 When older adults need assistance in basic and instrumental activities of daily living (ADLs), spouses and children often provide the majority of help. Decline in functional abilities strongly predicts the likelihood that an older adult living alone will seek other arrangements. Nursing home utilization has changed since the mid-1980s, especially with respect to racial and ethnic diversity.10 Many more of these individuals now have short-term admissions and return to their premorbid living arrangements compared with 20 years ago.10 In 2004, older adults in nursing homes were predominately female; age 75 years and older (82%); white, nonHispanic, and not married.11 Family Roles and Relationships. Despite many social advances for younger generations of women, the degree to which female older adults are still bound by society to traditional roles such as homemaking and caretaking should not be underestimated. Furthermore, an older woman is more likely to live alone when compared to a male counterpart and must continue to function independently, whatever her level of physical function. Women are therefore more likely than men to report disability with respect to social roles. The relative unavailability of assistance with home chores in comparison with other social support services may be a subtle discrimination against older women, although the level of unmet need in this area is not well documented. These home services can often be the essential element in allowing an older adult to remain living independently at home when functional abilities are compromised. Physical therapists will need to continue working with other health professionals to advocate for access to a wide the longest, whereas black women and white men live about the same and black men have the lowest survivorship.6 There has been a long-standing controversy in the literature regarding whether there is a racial crossover at the oldest ages, where black survivorship may improve. Some have argued that the phenomenon is actually a statistical artifact of misreporting and data inconsistencies, or not accounting for confounding variables; other researchers have drawn conclusions about “survival of the fittest,” arguing that individuals who surmount racial, socioeconomic, and health disadvantages early in life represent the most “fit” to survive into old age. Race and Ethnicity Racial and nonwhite ethnic minorities are currently underrepresented among the nation’s older adults relative to the distribution of these subgroups in the general population. In 2006, approximately 81% of the population age 65 years and older was non-Hispanic white, whereas blacks accounted for 9%, Asians 3%, and Hispanics of any race 6%.4 Hispanic representation in the older population has the fastest overall growth rate of any subgroup, likely to surpass the black subpopulation of older adults by 2028, and anticipated to be 15 million in 2050, or nearly eight times as large as it was in 2005.4 More recent immigrations in the 1990s of peoples from Southeast Asia will likely add to the relatively small number (about 1 million) of older Asians in the United States to a projected 7 million by 2050.4 Clearly, the geriatric physical therapist must recognize that the older adult of the future, especially those who will be considered the “oldest old,” will be more racially and culturally diverse than those patients currently served, and culturally competent care will literally require a global appreciation of diversity. Sex Distribution and Marital Status Simply put, there is a marked sex differential in mortality, and a number of social and life factors beyond biologic predisposition may lead to shorter lives for men overall.6,7 Married people have a lower mortality at all ages than their unmarried peers, and married men appear to derive a greater survival advantage than married women.6 However, because women typically live longer than men, the problems of America’s older adults are largely the problems of women, of whom fewer will have a living spouse at the age of 65 years and older in contrast to their male counterparts (Figure 2-3).8 Older men are more likely to be married than older women and married men are generally older than their wives, who have a greater life expectancy by virtue of their sex across all racial and ethnic groups.6 Women age 65 years and older are three times more likely to be widowed as comparably aged men, with the proportion growing with each decade of aging.3 There have been many theories proposed to explain the salutary effects of marriage
20 CHAPTER 2 Implications of an Aging Population for Rehabilitation Marital status of the population age 65 and older,by age group and sex.2007 ☐65-74☐75-84■85 and older 100 100 90 90 80 78 80 70 70 60 号50 30 20 10 434 Divorced Widowed Married Divorced Widow Mar ence p Cens nd Economic Supplemen range of services that support the highest level of inde- exclusion of men as subjects in many studies.Recom per the aged e tasks of a number of studies duri aregiving among the past 20 vears have been treated as "common wis. aseither a burden dom"about families and aging,the simple fact is that or as an opportunity thus evaluation of caregiving family' ”as a social con impact of rehabilitation interventions may bere struct cannot ea an families,the influenc nder-specifo clusion that one up is sed"to offer roles in caring for older family members.Fertility rates assistance.Physical therapists must evaluate each fam- ily situation for its unique characteristics y members to suppo aging eo s or g o contin themselyes in multigenerational families old e bein nt It is with their children.Spouses are the most likely indi- moveme's ad the life rse nes 100 for an aging pa ent in need The actual childre randparents find themselves takin direct care to older parents has traditionally been de- additional babysitting and child-rearing responsibilities. scribed as on of trad omen'swork,which is as much a func. Therefore,an exami 10 ores as a ence e per on s sid lona fun abil and evaluation of an olde ities in t ch context mig of men in c aring for older rente ac to char have often assumed that the responsibility of caregiving the stamina to walk young children home from the falls to daughters and daughters-in-law,often to the school bus
20 CHAPTER 2 Implications of an Aging Population for Rehabilitation 100 90 80 70 60 50 40 30 20 10 0 Percent Men 4 4 3 10 6 2 8 17 34 78 74 60 Never married Divorced Widowed Married 100 90 80 70 60 50 40 30 20 10 0 Percent Women 4 3 4 13 7 4 26 52 76 57 38 15 Never married Divorced Widowed Married Marital status of the population age 65 and older, by age group and sex, 2007 65-74 75-84 85 and older Note: Married includes married, spouse present; married, spouse absent; and separated. Reference population: These data refer to the civilian noninstitutionalized population. Source: U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplement. FIGURE 2-3 Marital status by age and sex of adults age 65 years and older. (From Federal Interagency Forum on Aging-Related Statistics: Older Americans 2008: key indicators of well-being. Washington, DC: U.S. Government Printing Office, March 2008.) range of services that support the highest level of independent living for the aged. Although findings from a number of studies during the past 20 years have been treated as “common wisdom” about families and aging, the simple fact is that the magnitude of variation in “family” as a social construct is very great and cannot easily be generalized into evidence-based statements about the nature of families, the influence of ethnicity, or gender-specific roles in caring for older family members. Fertility rates and immigration patterns also influence the proportion of family members able to support aging parents.6 Older adults who do live with family can often find themselves in multigenerational families, growing old with their children. Spouses are the most likely individuals to care for their partners in old age and sickness. When a spouse is unable or unavailable to provide assistance, it is not easily determined who will do what for an aging parent in need. The actual provision of direct care to older parents has traditionally been described as “women’s work,” which is as much a function of traditional social mores as a lack of evidence to the contrary. Research has not elucidated the role of men in caring for older parents as investigators have often assumed that the responsibility of caregiving falls to daughters and daughters-in-law, often to the exclusion of men as subjects in many studies. Recommendations that increase the tasks of caregiving among selected family members (e.g., assisting with a home exercise program) may be perceived as either a burden or as an opportunity12,13; thus evaluation of caregiving impact of rehabilitation interventions may be required. Many stereotypes exist about different racial and ethnic groups, but the data do not support a facile conclusion that one group is more “predisposed” to offer assistance. Physical therapists must evaluate each family situation for its unique characteristics. The societal roles of grandparenting also continue to evolve. Increased longevity increases the amount of one’s life that might be spent being a grandparent. It is not unusual for an aging individual to witness a grandchild’s movement through the life course from birth up to the grandchild’s adulthood. Healthy older adults still provide substantial financial and emotional support to their children. Many grandparents find themselves taking on additional babysitting and child-rearing responsibilities. Therefore, an examination and evaluation of an older person’s functional abilities in this social context might need to consider whether a grandparent has the dexterity to change a diaper, the strength to lift a toddler, and the stamina to walk young children home from the school bus
CHAPTER 2 Implications of an Aging Population for Rehabilitation 21 Economic Status The tendency to regard older adults as a homogeneous 90 19 20 20 19 80 heterogene 70 adults overall the entrance of the vo stratum of older adults,who benefit from private and workers'pen 32 50 40 im200p 4141m with than year 30 among childre 18 6 17 20 stead 7 group howeve 10 11 12 5 noverty increases with a e women are more 0 7 poverty than men;and older Hispanics and older blacks 55-64 65-74 economic Furthe hereennre5hdbeaaraersondraraeaietane 2oiaef ad data reter to the resident noninstiutor ger than age 18 veare 65 and older who do enter poverty are less likely to transition out than their young FIGURE 2-5 Total household exp ditures by ory and accoun nditures for housing food and r tation remain relatively constant for noninstitutionalized older adults,health care expenses continue to rise after age 65 years (Figure 2-5). MORTALITY Causes of Death Poverty rate of the population,by age group,1959-2006 The five most common causes of death for all individu- 100- als heart diseases,malignant rovand disease,ch wer re 70 adjusted death rates in the United States from hear 60 the in the past 30 years. use of ngolder well as improvements in emergency and critical care. Under 18 However,age-adjusted death rates for both diabetes and ases increased marke dly in the same pe 1864 959796470691o7470701941980199109202g 、e in th 之二s包清6 conditions,physical therap sts are able to make a major contribution to the well-being of the geriatric These n noninstitutionalize population. 8oieesugpemsnRueg0.80o7entPopulaiansunvoyAnmualsocaland Active Life Expectancy FIGURE 2-4 Poverty rates by age Adults who survive to age 65 years can expect to live r,which is a nting Office.March00
CHAPTER 2 Implications of an Aging Population for Rehabilitation 21 Economic Status The tendency to regard older adults as a homogeneous group biases any understanding of their economic status. The heterogeneity of this population group is perhaps best illustrated by considering who is financially well-off and who is economically disadvantaged among older adults. Overall, the entrance of the youngest stratum of older adults, who benefit from private and workers’ pension programs, has improved the economic well-being of older adults as a whole, as the proportion of older adults living in poverty has shrunk from 35% in 1959 to 9% in 2006 (Figure 2-4).4 In comparison with poverty among children younger than age 18 years, people age 65 years and older have experienced a relatively steady decline in poverty.4 These group figures, however, do obscure the realities of poverty among older people; poverty increases with age; women are more often in poverty than men; and older Hispanics and older blacks experience greater economic deprivation than nonHispanic whites.4 Furthermore, although older adults may be less likely to enter into poverty than individuals younger than age 18 years, people age 65 years and older who do enter poverty are less likely to transition out than their younger counterparts.6 Housing expenditures account for about 33% of expenses, whereas health care and food each account for about 13%.4 Although expenditures for housing, food, and transportation remain relatively constant for noninstitutionalized older adults, health care expenses continue to rise after age 65 years (Figure 2-5). MORTALITY Causes of Death The five most common causes of death for all individuals age 65 years or older are heart diseases, malignant neoplasms, cerebrovascular disease, chronic lower respiratory diseases, and pneumonia and influenza.4,6 Despite its position as the leading cause of death, ageadjusted death rates in the United States from heart disease and stroke mortality have declined remarkably in the past 30 years, most likely because of improvements in the detection and treatment of hypertension as well as improvements in emergency and critical care.4 However, age-adjusted death rates for both diabetes and respiratory diseases increased markedly in the same period. Given the role of exercise in the primary and secondary prevention as well as rehabilitation of all of these conditions, physical therapists are able to make a major contribution to the well-being of the geriatric population. Active Life Expectancy Adults who survive to age 65 years can expect to live almost 19 years longer, which is about 7 years longer than what would have been expected in 1900.4 Although 100 90 80 70 60 50 40 30 20 10 0 Percent 1959 1964 1969 1974 1979 1984 1989 1994 1999 2004 2006 65 and older Poverty rate of the population, by age group, 1959-2006 Under 18 18-64 Data are not available from 1960 to 1965 for the 18 to 64 and 65 and older age groups. Reference population: These data refer to the civilian noninstitutionalized population. Source: U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplement, 1960-2007. FIGURE 2-4 Poverty rates by age group. (From Federal Interagency Forum on Aging-Related Statistics: Older Americans 2008: key indicators of well-being. Washington, DC: U.S. Government Printing Office, March 2008.) 55-64 65 and older 65-74 75 and older Other Food Housing Transportation Healthcare Personal insurance and pensions 100 90 80 70 60 50 40 30 20 10 0 Percent 19 13 32 18 7 12 20 13 34 16 13 5 19 13 36 14 16 4 20 13 32 17 11 7 Note: Other expenditures include apparel, personal care, entertainment, reading, education, alcohol, tobacco, cash contribtions, and miscellaneous expenditures. Reference population: These data refer to the resident noninstiutionalized population. Source: Bureau of Labor Statistics, Consumer Expenditure Survey. FIGURE 2-5 Total household expenditures by category and age group. (From Federal Interagency Forum on Aging-Related Statistics: Older Americans 2008: key indicators of well-being. Washington, DC: U.S. Government Printing Office, March 2008.)