PRB

Today, an estimated 7.2 million Americans ages 65 and older live with dementia. While conversations around dementia often evoke nursing homes, most older Americans living with dementia are actually aging in place in their homes. Home-based care has become more common over the last decade, partly because it is more affordable and aligns with what many people prefer.  

People living with dementia often face both medical and practical barriers to obtaining care, including challenges with memory, decision-making, and mobility. These difficulties make access to effective care at home not just helpful but essential to supporting their ability to remain safely in the community. 

Despite its benefits, home-based care is not without challenges, including the financial burden of paying out-of-pocket for services not covered by Medicare and Medicaid and the emotional toll on family members who often take on day-to-day caregiving responsibilities. Understanding how home-based care works for the growing population of older adults with dementia is critical for improving how dementia is managed in the community and providing better support for older adults and their families. 

Home-based care typically falls into two categories: home health care and home care. Home health care refers to medical services provided by licensed professionals, including skilled nursing care, physical therapy, and medical social services. It is covered by Medicare if prescribed by a doctor or nurse practitioner. Home care refers to non-medical services to assist with housekeeping and the activities of daily living, such as bathing and dressing. Medicare does not cover home care unless it is provided with medical care, but Medicaid covers home care in some states.  

Older Adults With Dementia Are Twice as Likely to Use Home Health Care 

Based on data from the Health and Retirement Study (HRS) and Medicare claims between 2012 and 2018, Julia Burgdorf and her colleagues found that approximately 30% of home health care users had a dementia diagnosis.¹ Older adults with dementia were twice as likely to use home health care compared to those without dementia.  

About half of those with dementia were referred to home health care without a preceding hospitalization, compared to slightly less than a third of those without dementia. This finding highlights the importance of home health care as a key source of clinical care for older adults with dementia, not just for recovery care, Burgdorf and her colleagues said. 

Once enrolled in home health care, people with dementia received care more times (an average of 1.4 times compared to 1 time) and for longer periods (median of 56 versus 40 days) than people without dementia. They were also more likely to receive personal care, medical social work, and speech-language pathology services than those without dementia.  

However, among people who received services, those with dementia had fewer visits for skilled nursing and physical therapy, the researchers found. 

“Existing prospective payment structures incentivize HHC providers to limit the number of visits in order to lower costs and maximize profits,” they wrote. And “the 2020 implementation of a new Medicare HHC payment model, the Patient-Driven Groupings Model (PDGM), may further incentivize limiting visits for people living with dementia.” 

The new payment model aims to reimburse providers based on how sick patients are—but it doesn’t directly account for dementia status, Burgdorf and team note. It also reduces reimbursement for community referrals, though many people with dementia enter care this way. Differences in coverage between Medicare Advantage (private plans) and fee-for-service (the traditional government-run plan), along with workforce shortages and fragmented care systems, may create additional barriers for people with dementia, they explain. 

Burgdorf and colleagues suggest several ways to improve home health care for people with dementia, including: 

• Developing care models tailored to patients’ specific needs. 
• Improving information sharing, especially during the transition from hospital to home, such as identifying a patient’s dementia status in referral documents.  
• Including family caregivers in care planning.  
• Developing better methods to assess and assist caregivers, including providing additional resources and training.  
• Developing new care approaches that bring in services like social work and speech-language pathology earlier in the care process to improve both quality of care for patients and support for caregivers.

Home Care Costs Create Heavy Financial Burden for People With Dementia

Many older adults end up paying for home care out of pocket because long-term care is not included in Medicare, Medicaid coverage is inconsistent across states, and few people have private long-term care insurance, according to another analysis.  

“The financial burden of out-of-pocket payment for home care is significant, particularly among people with dementia and those with limited income and wealth,” conclude Karen Shen and colleagues, who used Health and Retirement Study (HRS) data (2002-2018) to measure the financial burden of home care.  

Home care also often results in ongoing expenses over a long period of time, unlike most other health care costs, they found. 

In recent years, people with dementia made up one-third of an estimated 3 million people who received home care and almost half (45%) of the over 600,000 people who paid for at least some of this care out of pocket, according to the researchers.² Among those with dementia who paid out-of-pocket, half (51%) spent over $1,000 per month, compared to one-fourth (26%) of those without dementia. Additionally, people with dementia were much more likely to pay for full-time help, defined as 40 hours or more per week, compared to those without dementia (46% versus 22%). 

Although higher-income individuals are more likely to pay out-of-pocket, many people with lower incomes also do so, largely because those with fewer financial resources are disproportionately affected by disability and dementia, the authors note. In fact, about half of those paying for home care out of pocket were poor or near-poor, defying the common perception that private home care is used only by individuals with higher incomes. 

Those who are poor and have dementia experienced disproportionate financial burdens, as they spent 87% of their household income on home care, compared to 32% spent by their peers without dementia, and 22% spent by high-income individuals with dementia (See figure). 

These findings suggest that those with dementia and limited financial resources may not be getting the care they need. 

“Policies aimed at easing the financial burden of home care are essential, particularly for low-income individuals with dementia who experience the greatest financial burden,” argue Shen and her colleagues. 

They recommend policies to reduce unmet care needs and financial hardship while also making the system more equitable and responsive to the realities of aging at home with dementia, including: 

• Expanding access to Medicaid home- and community-based services to help more individuals receive support, as many states currently impose strict eligibility rules, asset limits, and waitlists that limit access.  
• Encouraging long-term care savings and expanding the availability of long-term care insurance to help people avoid steep out-of-pocket costs later in life.  
• Adding a home care benefit to Medicare, which currently does not cover non-medical home care—though such a move would be expensive and require careful implementation.  

To make these programs financially sustainable, they recommend targeting benefits to the most vulnerable individuals and incorporating cost-sharing mechanisms so that those with more resources help shoulder the cost of care. 

Figure: The Poorest Americans With Dementia Spent 87% of Their Monthly Household Income on Home Care

Percent of monthly household income spent on home care for older adults, by patient’s dementia status and income level, 2002–2018 

Note: “Poor”: 100% of the Federal Poverty Level (FPL); “Near-poor”: 100-200% of FPL; “Moderate-income”: 200-400% of FPL; and “Upper-income”: >400% of FPL.

Source: Karen Shen et al., “Paying for Home Care Out-of-Pocket Is Common and Costly Across the Income Spectrum Among Older Adults,” Health Affairs Scholar 3, no. 1 (2025). 

Caregivers Are Underusing Respite Care—Which Could Shoulder Some of the Burden 

Even with paid home care, most dementia care still falls on family and friends. In the United States, over 11 million unpaid caregivers provide over 15 billion hours of dementia care every year, according to Yeunkyung Kim and his colleagues.³ One way to give caregivers a break is through respite care—short-term care that lets family members step away for a few hours or days. Ultimately, respite care aims to help sustain caregiver health and delay the institutionalization of the people in their care.  

Yet its use remains limited. Only 16% of Black caregivers used respite services compared to 32% of white caregivers in 2015, representing a significant gap of 12 percentage points, Kim and team found. Although this racial gap had been reduced or eliminated by 2017, respite care use remained low among both Black and white caregivers. Data are from the National Health and Aging Trends Study (NHATS) and the National Study of Caregiving (NSOC) from 2015, 2017, and 2021. 

Even though there have been efforts to expand access, too many caregivers are still doing this difficult work without enough support. This highlights the persistence of structural and informational barriers to care—including financial cost, lack of awareness, cultural expectations, and insufficient supply of respite providers.  

The underuse of respite care represents a missed opportunity to support the mental and physical health of caregivers, and thereby also the stability of dementia care at home. 

Kim and colleagues recommend several strategies to improve access to respite care for families supporting older adults with dementia, including integrating respite services more fully into long-term care systems, particularly through expanded support in Medicaid-funded programs like home- and community-based services waivers.  

Better outreach and clearer communication could also raise awareness of available services, since many caregivers remain uninformed or face fragmented information, the researchers note. There is a clear need for more flexible respite options that can accommodate the diverse cultural, financial, and scheduling needs of caregivers. For example, offering evening or weekend respite hours for those who work during the day, or providing in-home options for caregivers who are uncomfortable with facility-based care, could make a meaningful difference. 

Simplifying program design, reducing waitlists, and ensuring consistent availability are also key to increasing use of these services, they said. 

Early onset chronic disease, a growing caregiving gap, and climate change are among the major trends affecting the health and well-being of older Americans and their families, according to leading scholars from across the country.

Before a standing-room-only crowd at the 2025 meeting of the Population Association of America in Washington, D.C., experts identified seven key themes that are challenging policymakers, planners, and families as the U.S. population rapidly ages.

1. U.S. Life Expectancy Gains Have Stalled, Lagging Behind Other Higher-Income Countries 

The United States has experienced the earliest and greatest slowdown in life expectancy improvements among higher-income countries, reported Eileen Crimmins of the University of Southern California/University of California-Los Angeles Center on Biodemography and Population Health.

“We have horrible life expectancy—and it’s getting worse and worse,” she said, pointing to the diverging line for the United States in Figure 1. Though premature deaths from heart disease and stroke have declined, Americans today are unhealthy for a longer portion of their lives, coping with chronic diseases and conditions such as diabetes, hypertension, arthritis, cancer, and heart problems.

While we “have a long way to go” to improve the health of the U.S. population, Crimmins said, new research into biomarkers gathered through blood and other medical tests is offering clues into what speeds up or slows down the aging process, including stress levels, income, and social connections over a lifetime.

Figure 1: The United States Experienced the Earliest and Greatest Slowdown in Life Expectancy Improvements Among Higher-Income Countries

Trends in Life Expectancy Among 23 Higher-Income Countries, 1980-2024

Source: United Nations, World Population Prospects.

2. Americans Are Spending More of Their Later Years With Chronic Diseases Rooted in Their Early Lives

While advances in health care have succeeded in preventing many early deaths, older people are spending more time living with chronic diseases today than two decades ago, Crimmins’ forthcoming research shows. Americans spent more years after age 65 living with diabetes, cancer, heart disease, arthritis, and high blood pressure in 2018 than in 1998, she has found.

Scott Lynch of the Duke Center for Population Health and Aging agrees. Over the past century, complex chronic conditions like cardiovascular disease and cancer have replaced infectious diseases like pneumonia and tuberculosis as the leading causes of death, he noted. In addition to biomarker research, longitudinal studies that follow individuals over decades have contributed to a growing understanding that events and conditions in childhood and adolescence shape health and lifespans in adulthood and old age, he said.

Improving the health of children and young people has profound effects later in life, argued William Dow of the Center on the Economics and Demography of Aging at the University of California, Berkeley. He pointed to new research showing that people with Medicaid insurance in childhood have better health as adults. “By reducing disability and keeping people in the labor force, Medicaid is actually paying for itself,” Dow said.

3. The United States Faces a Caregiving Crisis As the Cadre of Traditional Caregivers Shrinks

Family members provide most of the care that enables older people to live safely in their own homes, said V. Joseph Hotz of the Center for Healthy Aging Behaviors and Longitudinal Investigations at the University of Chicago. Among care recipients ages 65 and older, 69% receive only informal home care from friends and relatives, whereas just 5% receive only formal paid home care  (Figure 2).

But a care gap is emerging as the baby boom generation ages. The traditional caregiver population (ages 45 to 64) is shrinking while the number of oldest-old Americans—those most likely to need care—is growing. By 2040, there are expected to be just three traditional caregivers per person ages 80 or older—down from a 6:1 ratio in 2025, according to Census Bureau projections.

But there is some good news, Hotz adds. While research finds that adult children feel less obliged to care for stepparents, new evidence suggests that an increasing share of adult children are stepping up when older parents are in need (for example, having trouble buying food). His own analysis shows that childless older people received as much help from their siblings, other relatives, and friends as their peers received from their adult children.

Figure 2: Most Older Americans Receive Only Unpaid Help From Family and Friends

Type of Care Received by Adults Ages 65+ and 85+

Source: Jonathan Gruber and Kathleen M. McGarry, “Long-term Care in the United States,” National Bureau of Economic Research, Working Paper 31881, November 2023, DOI 10.3386/w31881.

4. Older Adults’ Social Ties Are More Important to Health and Longevity Than Many Realize

Compared with their peers who have supportive families and robust social networks, socially isolated older people face a greater risk of early death, dementia, heart disease, diabetes, and a host of other conditions, explained Debra Umberson of the Center on Aging and Population Sciences at the University of Texas at Austin. “The evidence is increasingly convincing, overwhelmingly persuasive,” she said.

Inflammation, depression, hypervigilance, alcohol consumption, and the disadvantages of lower levels of education all play a role in poorer outcomes among older adults, Umberson said. Social isolation is a modifiable risk factor; the challenge is “identifying who is most at risk, why, and what can be done.”

Research suggests that “isolation begins to increase as early as adolescence and continues steadily through the life course,” she reported. Black Americans, people living in poverty, and sexual and gender minority populations tend to experience higher levels of isolation than other groups. Experiencing the death of a family member, extreme weather events (like Hurricane Katrina, which dispersed community members), pandemics (as we saw with COVID-19), incarceration, and deportation can also disrupt families and communities.

5. Medicare Advantage Plans Could Lead to Cost Savings and More Home-Based Services, But May Shift More Caregiving to Families

In 2024, more than half of Americans ages 65 and older (54%) were enrolled in the Medicare Advantage program, up from just 19% in 2007. The dramatic change from a fee-for-service model to a privately run managed care model has vast implication for aging Americans, said Dan Polsky of the Johns Hopkins’ Economics of Alzheimer’s Disease and Services (HEADS) Center. Medicare Advantage plans may offer efficiency and flexibility that can lower recipients’ costs and increase access to home-based care, which most Americans say they prefer, according to Polsky. But new findings by Lauren Nicholas suggest that unpaid family caregivers may be providing more end-of-life home care for people with dementia, essentially moving costs from the formal system of payment to unpaid family members, he reported.

At the same time, traditional Medicare is not without innovations: A new program is exploring ways to meet the health care needs of both people with dementia and their caregivers, Polsky noted.

In the pipeline are new disease-modifying pharmaceutical treatments for dementia, but they require an early diagnosis, which only a fraction of people receive. Should these treatments scale, it could cost the Medicare program tens of billion dollars a year, presenting an additional challenge to the already-strained Medicare budget. Implementing new early diagnosis techniques and providing cost-effective new treatments will present complicated hurdles for the health-care delivery system, Polsky suggested.

6. Americans Caring for Relatives With Dementia See Increasing Demands on Their Time and Constraints on Their Employment

The more than 5 million family members and friends who provide unpaid care for older adults with dementia have high—and increasing—demands on their time, reported Jennifer Wolff of the HEADS Center, based on her team’s research using nationally representative data.

On average, the time that family caregivers spent helping older adults with dementia grew by almost 50% between 2011 and 2022, going from 21 hours per week to 31 hours (Figure 3). By contrast, time spent assisting older adults without dementia fell during the same period.

Wolff and team show that more than half (52%) of dementia caregivers lived with the person they were caring for in 2022, up from 39% in 2011. And the share able to hold jobs—outside their caregiving work—dropped from 43% to 35% during the same period.

Noting that the number of individuals affected by dementia is projected to triple in the next 30 years, Wolff underscored the importance of monitoring unpaid caregivers and developing interventions to support them. Some strategies could include providing direct financial assistance and tax relief, supporting flexible work arrangements and paid family leave, and using digital tools and remote monitoring technologies to help caregivers manage care more efficiently and connect with support networks.

Figure 3: Family Caregivers Are Spending 50% More Time Caring for Older Adults With Dementia

Average Weekly Family Caregiving Hours, by the Dementia Status of Older Adults (65+), 2011 and 2022

Source: Jennifer L. Wolff, Jennifer C. Cornman, and Vicki A. Freedman, “The Number of Family Caregivers Helping Older US Adults Increased From 18 Million to 24 Million, 2011–22,” Health Affairs 44, no. 2 (2025): 189-95.

7. Extreme Weather Events and Warmer Temperatures Pose Unique Challenges for Older People

More devastating fires, storms, and hurricanes, along with greater climate variability are the “new normal,” said Elizabeth Frankenberg of the Carolina Population Center at the University of North Carolina at Chapel Hill.

People who experience these events not only face an increased risk of death and disease but also lost livelihoods, diminished assets, and poor quality of life for months, years, and even decades to come, she noted.

Older people can be uniquely vulnerable due to reduced physical mobility, cognitive decline, diminished temperature regulation, and changes in economic resources, access to safety net programs, and the availability of social and family networks. Further, their ability to cope with change may be influenced by anxiety around uncertainty, a deep attachment to where they live, and difficulty making life-changing decisions.

To effectively plan for, mitigate, and adapt to severe weather events and temperature changes, demographers should team up with engineers to better understand the level of vulnerability in specific risky locations, Frankenberg said. For example, older people with lower incomes and limited mobility may need emergency support in places with rising sea levels or that are prone to wildfires.

How Future Research Can Address Unanswered Questions About Population Aging

The experts noted several promising areas for future research that can improve the health and well-being of older adults, including:

• Advanced data collection: Expand the use of wearables, MRIs, sound files, and other innovative data collection methods to better understand social interactions and biological processes.
• Macro-level demographic analysis: Better integrate micro-level research on households and individuals with population-level questions and policy implications.
• Biological mechanisms of aging: Focus on understanding physiological dysregulation, molecular and cellular changes, and other factors that determine fast versus slow aging trajectories.
• Early-life interventions: Evaluate social and economic interventions earlier in the life course to prevent later health problems.
• Real-world care delivery for people with dementia: Study how new diagnostic technologies and treatments can be effectively integrated into primary care systems.
• Measurement harmonization: Develop better methods to harmonize measures of dementia across different surveys and data sources.
• Root causes of isolation: Better understand why people become isolated, focusing on people, place, climate, and social disruption factors.
• Caregiving workforce: Better quantify and understand the economic value of unpaid family caregiving as the care-to-support ratio declines.
• Medicare Advantage impacts: Study how the shift to private Medicare plans affects care quality and costs, especially for vulnerable populations.

The researchers emphasized that many of these priorities require sustained investment in longitudinal data collection and interdisciplinary collaboration across aging research centers.

The scholars featured above lead many of the 15 research centers on the demography and economics of aging and Alzheimer’s disease and Alzheimer’s related dementias supported by the National Institute on Aging (NIA) of the National Institutes of Health for the past 30 years.

A coordinating center based at the University of Michigan supports the dissemination of findings from the centers in partnership with PRB.

As the large Baby Boom generation enters advanced ages, more family members and other unpaid helpers are stepping in as caregivers. In just over a decade, the number of family caregivers regularly assisting older adults with daily activities at home grew by 32%, increasing from 18.2 million to 24.1 million between 2011 and 2022.¹

While the caregiving cadre has grown, who’s getting care has also changed. Older Americans receiving family care are younger, better educated, and less likely to have dementia than they were in 2011, report Jennifer L. Wolff of Johns Hopkins University, independent consultant Jennifer C. Cornman, and Vicki A. Freedman of the University of Michigan.

The increase in family caregiving partly reflects the rising share of older adults with multiple chronic conditions, such as heart disease, hypertension, stroke, and cancer. And while the share of older adults with dementia has declined, unpaid caregivers average twice as many hours each week caring for people with dementia than without dementia (about 31 hours versus 14), Wolff and team found (see Figure 1).

In addition, a new study estimates that the number of new dementia cases will double over the next 40 years as the population ages—setting the stage for more demands on dementia caregivers and more changes to the caregiving landscape.

“Understanding the changing composition and experiences of family caregiving has never been more important, but it is challenging to assess,” the researchers write. “[It] requires consistent measurement for well-characterized, generalizable samples of people who receive and provide help.”

The nationally representative National Study of Caregiving and the National Health and Aging Trends Study offer important insights. The two studies provide a snapshot of the family caregivers that help Americans ages 65+ who live in the community (i.e., at home or with a relative) or in a residential care setting other than a skilled nursing facility, such as an assisted or independent living facility, a personal care home, or a continuing care retirement community.

Family caregivers include relatives and unpaid helpers, like neighbors and friends, who assist with personal care tasks like bathing and dressing; mobility tasks like getting out of bed and getting around the house; and household activities such as laundry, food preparation, shopping, and managing money.

Dementia Caregivers See Increasing Demands on Their Time, Employment Woes

On average, the time that family caregivers spent helping older adults with dementia increased by almost 50% over the decade, rising from 21.4 hours per week in 2011 to 31.0 hours in 2022. By contrast, time spent assisting older adults without dementia fell from 15.3 hours a week in 2011 to 13.9 hours in 2022 (Figure 1).

Figure 1: Family Caregivers Are Spending 50% More Time Caring for Older Adults With Dementia

Average Weekly Family Caregiving Hours, by the Dementia Status of Older Adults (65+), 2011 and 2022

Source: Jennifer L. Wolff, Jennifer C. Cornman, and Vicki A. Freedman, “The Number of Family Caregivers Helping Older US Adults Increased From 18 Million to 24 Million, 2011–22,” Health Affairs 44, no. 2 (2025): 189-95.

People caring for older adults with dementia have high—and increasing—demands on their time. More than half (51.7%) of dementia caregivers lived with the person they were caring for in 2022, up from 39.4% in 2011, Wolff and team report. And the share able to hold jobs—outside their caregiving work—dropped from 42.5% to 34.6% during the same period.

Among caregivers with formal jobs, the share who reported challenges with their employment—including working fewer hours or being less productive—increased over the decade, regardless of whether they cared for someone for dementia.

“Challenges are exacerbated when caregivers are in poor health themselves; have a lack of choice in assuming the caregiving role; and, for the substantial proportion of family caregivers who are employed, work in low-wage jobs with limited flexibility,” the researchers note.

Care Recipients Are Mainly Older Women, but the Share of Men Receiving Care Is Growing

Which older Americans get family care? As in the past, they tend to be female, non-Hispanic white women who are married or widowed. But growing numbers of family care recipients are male and have some college education. More are also separated and divorced compared to 2011, reflecting national trends.

Adult Children Continue to Care for Their Parents

Who’s providing care? Family caregivers continue to be largely female and married, and most report being in good health. In 2022, adult children still made up the largest share of family caregivers for older adults, at 40.7%, but this represents a significant decline since 2011 (Figure 2).

Figure 2: The Share of Adult Children Caring for Older Relatives Has Declined

Relationship of Family Caregivers to Adults Ages 65 and Older Receiving Care, 2011 and 2022

Source: Jennifer L. Wolff, Jennifer C. Cornman, and Vicki A. Freedman, “The Number of Family Caregivers Helping Older US Adults Increased From 18 Million to 24 Million, 2011–22,” Health Affairs 44, no. 2 (2025): 189-95.

In 2022, adult children accounted for about half (49.1%) of family caregivers for older adults with dementia, compared with 38.4% of caregivers for those without dementia. Just 17.7% of family caregivers for older adults with dementia were spouses, compared with 24.5% of family caregivers for people without dementia.

A sizeable share of family caregivers (17.0%) had children under age 18 at home in 2022, and 6% to 13% viewed their care responsibilities for older adults as a source of financial, physical, or emotional difficulty.

Despite these challenges, the researchers report a decline in the use of support groups (4.1% to 2.5%) and respite services (12.9% to 9.3%) between 2011 and 2022.

Trends and Policy Implications

Many caregivers face extraordinary demands and should be the focus of support services, Wolff and colleagues say. They single out those caring for older adults with dementia or nearing the end of life, as well as caregivers “from racial and ethnic minority groups who are more likely to assist people who have extensive care needs in circumstances that involve scare economic resources.”

Family care needs are likely to rise as the number of U.S. adults ages 85 and older is  projected to triple by 2050. The researchers note that the number of family caregivers rose even as the long-term use of skilled nursing facilities among older Americans dropped and community living increased. The challenges these caregivers continue to face is “sobering,” they write, including competing time demands from work and child care while spending an average of 17 hours per week on care. In addition, about 1 in 8 family caregivers report financial, physical, or emotional difficulties related to their caregiving roles, percentages that were largely unchanged over the 11 years examined.

Policies and programs to help reduce the financial, physical, and emotional burden of caregiving exist, but do not represent a coherent strategy, the researchers say. “Local, state, and federal policies are a patchwork that is uneven in availability and largely symbolic in magnitude,” they argue. Addressing the needs of family caregivers will require a “cohesive framework in support of the care economy.”

In this March 4, 2025 webinar, three researchers discussed how social media and new technologies may enhance—or limit—social connectedness and emotional well-being among older adults.

• Karen L. Fingerman (University of Texas at Austin) focused on the relationships between social media use, social ties, and emotional well-being in later life.
• Ellen L. Compernolle (NORC at the University of Chicago) summarized research on loneliness among older adults from Chicago during and before the COVID-19 Pandemic.
• Steven W. Cole (University of California at Los Angeles) described how in-person and virtual social environments influenced gene expression during the COVID-19 Pandemic.

This webinar was hosted by PRB and the Coordinating Center for the Centers on the Demography and Economics of Aging and Alzheimer’s Disease and Related Dementias, with funding from the National Institute on Aging.

Like this event?

Support our work

Stay up to date on future PRB events.

Subscribe to our newsletter

In this Nov. 14, 2024 webinar, two distinguished researchers discussed how U.S. state policies and systems can affect racial and regional inequities in health and longevity.

• Tyson H. Brown (Duke University) focused on innovative and best practices for measuring and modeling state-level structural racism to advance aging health research.
• Jennifer Karas Montez (Syracuse University) summarized findings from recent studies that have connected the dots between changes in states’ policy contexts in recent decades and changes in population health.

This webinar was hosted by PRB and the Coordinating Center for the Centers on the Demography and Economics of Aging and Alzheimer’s Disease and Related Dementias, with funding from the National Institute on Aging.

Like this event?

Support our work

Stay up to date on future PRB events.

Subscribe to our newsletter

Older Americans with strong social connections are healthier and live longer than their socially isolated peers. Increasingly, researchers are finding that the components of good health are not only the absence of mental disorders and physical disease but also the presence of robust social relationships.

This brief explores recent research probing the dynamics of social connection and health supported by the National Institute on Aging. The findings point to myriad ways in which social ties bolster health—from slowing aging and boosting cancer-fighting hormones to preventing depression and protecting memory. Health policymakers and program planners can use this evidence to inform a variety of interventions—particularly those aimed at reducing social isolation in vulnerable groups—to support longer and healthier lives for older Americans.

Strong Social Ties Slow Aging, Lower Risk of Death

Studies have shown that both the quality and quantity of our social ties shape our mental and physical health, health behaviors, and mortality risk. Researchers are studying multiple aspects of our social lives—from the levels of social support we receive to our activities and the strength of our social networks—to understand how they link to health outcomes.

Healthy, supportive relationships with family and friends may slow aging, concluded a research team from the University of California, Los Angeles (UCLA) and the University of Southern California (USC).¹ According to their DNA, older adults with the most supportive relationships with spouses, adult children, other family members, and friends were aging one to two years slower than those who lacked such ties, they found. The pace of such aging is important—rapid epigenetic aging at younger chronological ages can contribute to the early onset of chronic disease and disability and premature death.

The authors, led by Kelly E. Rentscher, based their analysis on aging-related molecular changes in DNA among older adults participating in the nationally representative Health and Retirement Study (HRS). Even after factoring in smoking, alcohol use, and other lifestyle factors known to accelerate aging, the protective role of strong social relationships persisted, they reported.

Supportive relationships with spouses and children helped slow the pace of aging by more than three weeks per year, they found. Having support from other family members and friends also helped slow the pace of aging, by about three weeks per year and more than two weeks per year, respectively.

Overall, the findings affirm that both the presence of relationships and their quality mattered for longevity. The new study may support interventions with the potential to “prevent, slow, or reverse accelerated aging and extend the healthspan and lifespan,” the authors wrote.

Other ongoing research underscores the important role of social factors in the overall health of older adults. Linda Waite and Yiang Li from the University of Chicago found that the healthiest older adults had strong social connections and just a 4% risk of dying within five years, while those with the poorest health had weaker social connections and a 57% risk of dying within five years.² Key factors linked to longevity included robust social networks and partnered sexual activity, highlighting the importance of social integration in maintaining health in later life. Their preliminary findings are based on nationally representative data from the National Social Life, Health, and Aging Project (NSHAP).

Social Connections May Improve the Well-Being of Patients With Cancer and Other Health Conditions

More new research poses that social connections may also improve the well-being of cancer patients by boosting protective hormones.

A research team from six major universities found that in ovarian cancer patients, social support was associated with higher levels of oxytocin—a hormone linked to some protection against cancer.³ Specifically, having a more positive outlook, a sense of purpose, and a role in caring for others at the time of cancer surgery were associated with higher oxytocin levels. (However, a person’s perceived closeness with others was not related to higher oxytocin levels.)

“Nurturance is consistent with the oxytocin-focused ‘tend and befriend’ hypothesis of female coping and stress response,” wrote the team, led by Michaela G. Cuneo at the University of Iowa. Thus, even though this research is in the early stages, feeling needed by others could have protective health effects for women with ovarian cancer.

Similarly, another team of researchers at the National Cancer Institute and the University of Wisconsin–Madison found that strong, supportive relationships between cancer patients and their caregivers were associated with better self-reported health for both parties.⁴ This was especially the case for those dealing with lung cancer, where social support was linked to better self-reported health 12 months after diagnosis. Dannielle E. Kelley and coauthors speculate that there may be a beneficial “partner effect” for lung cancer that can counter internalized and social stigmas associated with the disease for former smokers.

Social connections might also help a patient adopt more healthful behaviors after diagnosis—but the benefits could depend on their education level. According to Won-tak Joo of the University of Florida, college graduates have more robust health conversations with people in their social networks at the time of diagnosis, which may help explain why they are more successful at improving their health behaviors and show a better prognosis than those with lower education levels.⁵

“The cultivation of health discussion may be more active in earlier stages of illness when patients require external support to adapt to new lives with diseases,” writes Joo. For older adults with lower levels of education, Joo finds that both social networks and health conversations decline with disease diagnosis, suggesting a need for interventions to help this group.

Researchers are also studying how social ties affect the health of older people with disabilities. Karen L. Fingerman of the University of Texas at Austin and colleagues find that those with limiting disabilities were more likely to attend medical appointments when spending time with friends and family.⁶ And Sophie Mitra of Fordham University and coauthors report that older adults with disabilities have as much close, regular contact with partners, family, and friends as those without disabilities.⁷ For those with disabilities and others with serious medical conditions, social connectedness may lead to help with activities that improve their health and well-being.

Connectedness also affects our health in ways that ultimately impact our sleep. A recent study from China’s Xi’an Jiaotong University, the University of Texas at Austin, and the University of Maryland found that socially isolated older adults—those with smaller and less intimate relationships—had more depressive symptoms, were lonelier, and had more chronic diseases and pain, all of which contributed to greater sleep difficulty.⁸ Dan Zhang and coauthors argue that improving older adults’ social connections could enhance their mental, physical, and sleep health.

A Lifetime of Experiences Shape Social Connections at Older Ages

Some groups of people are more likely to be socially isolated than others, report Debra Umberson of the University of Texas at Austin and Rachel Donnelly of Vanderbilt University.⁹ Older married women may become socially isolated when a spouse needs round-the-clock care, while men who either never marry or divorce may begin experiencing social isolation in young adulthood.

In addition, non-Hispanic Black and Hispanic older adults are more likely to experience social isolation than non-Hispanic older white adults, they found (see Figure 1). Black and Hispanic Americans’ social isolation could be related to the impact of lifetime discrimination and financial stress, the researchers suggest. Using HRS data, the study measured isolation among adults ages 50 and older based on whether they are married or cohabiting, participate in volunteer activities, and have contact with parents, children, and neighbors.

Figure 1. Older Non-Hispanic Black Americans Experience Higher Levels of Social Isolation Than Other Groups

Mean Levels of Social Isolation Among U.S. Adults Ages 50 and Older in the Health and Retirement Study, by Race/Ethnicity

Source: Debra Umberson and Rachel Donnelly, “Social Isolation: An Unequally Distributed Health Hazard,” Annual Review of Sociology 49, no. 1 (2023): 379-99. 

Another study out of Johns Hopkins University estimated that nearly one in four (24%) of older Americans living in the community are socially isolated, and one in 25 (4%) are severely isolated.¹⁰ To measure isolation, they examined participants’ living arrangements, religious attendance, social activities, and the number of people they spoke with about important matters. The study used data from the National Health and Aging Trends Study, which includes a nationally representative sample of Medicare beneficiaries ages 65 and older.

Being unmarried, male, and having low education and income levels increased the odds of being socially isolated, according to the analysis, led by Thomas Cudjoe. Specifically, men were four times as likely as women to be severely isolated, while people with annual incomes below $30,000 were twice as likely as people with incomes over $60,000 to be severely isolated. These findings offer “easily identifiable” factors to help program planners target those most at risk, the researchers wrote, noting that living arrangements, discussion networks, and social activities can all be modified to improve social connections.

Calling social isolation “an unequally distributed health hazard,” Umberson and Donnelly urge future researchers to undertake “a systematic assessment of social conditions that foster isolation over the life course” to better understand the root causes and identify ways to reduce isolation among those most at risk.

“We need to understand why people become more isolated over their lives, because social isolation is a public health issue,” Umberson said. “People became more concerned about isolation in the wake of Covid-19 because we were all more isolated for several years, but this is a problem that’s likely to become more serious, not less.”¹¹

The stability of older adults’ lives may also contribute to richer social networks. While younger adults experienced turnover in social networks after a major life transition, such as getting married or having children, older adults maintained relatively stable social networks after such changes, including retirement, changes in marital status, or becoming empty nesters, found Jordan Weiss and team at the University of California, Berkeley.¹² The authors suggest that for older adults, having stable, long-term (often decades-old) relationships make for more reliable networks.

A person’s temperament also may influence their lifelong social ties. Using NSHAP data, James Iveniuk at the University of Toronto finds that among older Americans, personality traits such as extraversion and agreeableness were associated with stronger social ties than openness, conscientiousness, or neuroticism.¹³ Thus, certain personality traits may strengthen the social connections linked to health benefits.

Social Networks May Protect Mental Health and Prevent Cognitive Decline

Older adults’ social networks may protect both their mental health and cognitive abilities. Getting help with daily activities may be an important reason why—since many older adults need assistance bathing, getting in and out of bed, and doing other tasks, some built-in social interaction can accompany aging. But feelings of closeness and companionship may also help stave off memory loss, loneliness, and depression—and may matter as much or more than geographic proximity or number of family or friends, new research shows.

To try to understand the importance of relationship quality, Sarah Patterson of the University of Michigan and Rachel Margolis of the University of Western Ontario looked at four groups of older adults with different types of family connections: those who were geographically and emotionally close with family; those who were kinless and without a partner or children; those who were distanced and lived far from family; and those who were disconnected and had no family members in their social network or did not know where they lived.¹⁴

“We were interested in understanding how much the presence of family ties matters for older adults’ well-being but also in measuring the quality of those relationship ties,” said Patterson.¹⁵

They found that older adults who lived near family members and discussed important concerns with them were less likely to report unmet need for help with daily activities than the other groups (see Figure 2). Meanwhile, those who reported no partner or family or disconnection had the poorest mental health and socialized less often—even less than those who lived far away from their family.

Figure 2. Older Adults Who Are Close to Family Get More Help With Activities

Share of adults ages 70 and older reporting unmet need for help with activities by type of family connections, 2015–2019

Source: Sarah E Patterson and Rachel Margolis, “Family Ties and Older Adult Well-Being: Incorporating Social Networks and Proximity,” The Journals of Gerontology: Series B, Volume 78, no. 12 (December 2023): 2080–89.

The findings suggest that the presence and strength of family ties matter for older adults’ mental health. “As families continue to evolve, researchers should strive to capture the size and shape of family networks, as well as the level of connection that older adults have with those kin,” the authors note.

In fact, social connections can also produce distress. Stephanie T. Child and Leora E. Lawton of UC Berkeley found that social companionship and emergency help mattered most to older adults, whereas having more people from whom they sought advice was related to more psychological distress.¹⁶ The findings suggest that mental well-being may be enhanced by enjoyable and helpful relationships, while those that are more demanding may detract from it. Data are from the UC Berkeley Social Networks Study (UCNets), which includes a locally representative sample from across the San Francisco Bay Area in California.

In a similar study, the Berkeley authors found that those who were more dissatisfied with their social networks also experienced more loneliness and isolation.¹⁷ Interestingly, it wasn’t the number of connections but the closeness of the relationships—especially with family—that buffered loneliness. Further, having a romantic partner helped older adults feel less isolated.

As Child and Lawton write, “evaluations about one’s own social network, including whether someone feels satisfied in the number or quality of connections they have to call on for social engagement or support, may be a more meaningful precursor of loneliness.”

Similarly, social engagement may be connected to cognitive benefits. Using Michigan Cognitive Aging Project data, Abbey M. Hamlin at the University of Michigan and colleagues find important differences by race in both social engagement and its connection to cognition.¹⁸ Older white, non-Hispanic adults engaged in more social activities than their Black peers, and those activities were linked to better episodic memory—or the recall of information from the past—and thus better cognitive health. The findings suggest that social isolation is not only more prevalent among older non-Hispanic Black adults, but also that it may be taking a toll on their cognitive well-being.

Marriage Has Diverse Effects on Older Adults’ Health

Several recent studies build on the well-established link between marriage and better physical and psychological health in old age, particularly for men. They examine some of the ways marriage may benefit health as well as the connections between marriage and other forms of social interaction.

New research finds that marriage can help men be less socially isolated throughout their lives. Umberson of University of Texas at Austin, Zhiyong Lin of University of Texas at San Antonio, and Hyungmin Cha of USC show that men tend to be more isolated in adolescence and young adulthood, while women tend to experience isolation in later life.¹⁹ Their analysis of HRS data shows that levels of social isolation increase with age for both men and women.

But gender patterns differ by marital history (see Figure 3). Among older adults in stable marriages, women are less isolated than men until age 60, but by age 68, men are slightly less isolated than women. This gender gap shrinks at older ages for those who have experienced marital disruptions, possibly because chronic health issues contribute more to social isolation among women, the authors note.

Figure 3. Social Isolation Increases With Age, but Gender Patterns Differ by Marital History

Age Trajectories of Social Isolation Among Adults Ages 50 and Older, by Gender and Relationship History, 1998-2012

Source: Debra Umberson, Zhiyong Lin, and Hyungmin Cha, “Gender and Social Isolation Across the Life Course,” Journal of Health and Social Behavior 63, no. 3 (2022): 319-35. 

There may be an unexpected physiological explanation for some of marriage’s health benefits. Drawing on lessons from primate research and using stool samples from a subset of participants in the long-running Wisconsin Longitudinal Study, researchers affiliated with the University of Wisconsin-Madison find that spouses in self-described close marriages tend to have more diverse and healthful gut microbiota compared with siblings, people without a partner, or married couples in less close relationships.²⁰ Less diverse gut microbiota is related to obesity, cardiac disease, type 2 diabetes, and other inflammatory disorders, Kimberly Dill-McFarland and coauthors note.

Not all marriages are equal when it comes to social support and its potential health effects. Both men and women in same-sex marriages are more likely than those in different-sex marriages to offer concrete support to a spouse in distress, such as taking over chores or giving extra personal time, found Mieke Thomeer of the University of Alabama at Birmingham, Amanda Pollitt of Northern Arizona University, and Umberson.²¹ The team used a survey of 378 midlife couples ages 35 to 65.

Relationships can be a source of stress as well as support, and individuals in a marriage with a difficult or demanding partner experience a similar degree of loneliness as single people and more loneliness than other married people, another study finds.²² Shira Offer’s research at UC  Berkeley draws on UCNets data to identify these differences and finds that the same is true for tough relationships with adult children.

Two other studies offer new insights into the mental health toll of the loss of a spouse due to death, separation, or divorce. People with less than a high school education face a higher risk of losing a spouse than people with more education, research using HRS data shows. But higher education levels do not lessen symptoms of depression when divorce, separation, or death does occur, find Claudia Recksiedler of the German Youth Institute and Robert S. Stawski of Oregon State University.²³

People who lose a spouse often receive helpful support from social networks. Using NSHAP data, James Iveniuk of the Wellesley Institute and coauthors find that friends and family of older adults respond with social support after the death of a spouse, but less so when a close friend or other confidant dies.²⁴

Good Neighbors (and Neighborhoods) Are Good for Well-Being

Multiple studies have shown that a neighborhood’s physical features—from broken sidewalks and high crime to plentiful parks and low air pollution—are related to older residents’ health and quality of life.²⁵ Not surprisingly, the places older people call home also shape their social connections, thereby influencing both their physical and mental health.

Neighborhood social ties may promote sensory health, a study using NSHAP data shows. Older adults who have more social connections in their neighborhoods report better self-rated vision than those who have fewer connections, find Alyssa Goldman of Boston College and Jayant Pinto of the University of Chicago.²⁶ More social ties may lead to more time spent engaging with people and places outside of the home, protecting visual abilities, the researchers suggest. Good vision is key to older adults’ ability to safely navigate their environment, they add.

For caregivers, social support can counteract the negative effects of living in less-connected neighborhoods. Researchers at the University of California, Davis and the University of Michigan show that neighborhoods with low social cohesion—lacking a sense of community and trust among neighbors—can take a toll on mental health in the absence of social support.²⁷ This is particularly true for dementia caregivers, who face a high risk of depression related to the emotional and physical burden of their work. But dementia caregivers living in neighborhoods with low social cohesion had fewer symptoms of depression if they had family and friends to talk to and help with daily tasks, Oanh Meyer and team found.

Community-level interventions focused on increasing neighborhood connections—such as caregiver support groups in disadvantaged neighborhoods—could be important for maintaining caregiver health, the research team suggests.

The proximity of one’s close friends also makes a difference for mental health, reports Keunbok Lee of UCLA.²⁸ Older adults with fewer confidants who live nearby show more severe depression symptoms when faced with traumatic events than those with more close friends in their neighborhood, according to Lee’s study of UCNets data.

Local opportunities for social connection may strengthen social ties and help prevent suicide. A new study finds that suicide rates are much lower among working-age adults, including people ages 51 to 64, in counties with more places for people to connect, such as public libraries, community centers, religious groups, coffee shops, diners, and entertainment and sports venues.²⁹ These findings held true even when the researchers accounted for differences in health care availability, age, education, race/ethnicity, and proximity to metropolitan areas.

Gathering places, part of the social infrastructure, may buffer suicide risk and improve mental health by boosting social connections, reducing social isolation, and facilitating social support, trust, and information and resource sharing, report Xue Zhang and Danielle Rhubart of Penn State University and Shannon Monnat of Syracuse University. Local governments should consider partnering “with market-based services and social service agencies to increase the availability, access, and use of spaces that promote social interaction,” they write. In addition to helping to lower suicide rates, building more robust social infrastructure may also support overall health, they suggest.

Living Alone Linked to Social Isolation and a Variety of Health Risks

Research has established that living alone at older ages raises the risk of poor health, early death, and dementia. New evidence demonstrates that living alone for extended periods increases the risk of dementia more strongly than previously thought.³⁰ Every two years of living alone is linked to about a 10% increase in the risk of dementia, according to study authors Benjamin A. Shaw of the University of Illinois Chicago, Tse-Chuan Yang of the University of Albany, and Seulki Kim of the University of Nebraska.

Social isolation may explain this dynamic. Their analysis, based on HRS data that tracked more than 18,000 older Americans for 18 years (2000 to 2018), suggests that a lack of mental stimulation combined with limited day-to-day companionship may increase stress “that, over time, could accumulate and eventually lead to cognitive impairment.”

Another recent study shows that the impact of social isolation extends to diet and nutrition. Analysis of data from an HRS nutrition survey shows that older adults—particularly men—living alone with no adult children or friends in their neighborhood had the lowest fruit and vegetable intake.³¹ Lack of motivation to cook and eat healthy may explain this pattern, according to Yeon Jin Choi, Jennifer A. Ailshire, and Eileen M. Crimmins of USC.

Because fruits and vegetables provide key nutrients for maintaining health and protecting against age-related diseases, the researchers recommend local agencies consider ways to improve social engagement among older adults who live alone to boost health outcomes. They also suggest providing help with grocery shopping (such as transportation) and meal preparation (including home-delivered meals).

Virtual Interaction Cannot Fully Replace the Health Benefits of Face-to-Face Contact

Phone calls and Zoom or FaceTime gatherings replaced in-person get-togethers for many people during the COVID-19 pandemic shutdowns, but a growing body of research suggests virtual interaction cannot fully replace face-to-face contact. Two recent studies, one led by Namkee Choi at the University of Texas at Austin and the other by Louise Hawkley at NORC at the University of Chicago, show that older adults who had less in-person time with family and friends and more phone calls during the first year of the pandemic were more likely to experience loneliness.³²

Older people with impaired hearing or vision may be an exception—phone and video chats appear to have protected them in 2020 from depressive symptoms, find Amanda Zhang and colleagues at the University of Chicago.³³ One reason may be that phone calls are important for the mental health and mood of people with small social networks, replacing some of the day-to-day interactions that shrink with age and physical impairment, report Yijung K. Kim and Karen L. Fingerman of the University of Texas at Austin, based on another study.³⁴

At the root of these mixed findings on digital versus in-person interaction may be the immune system. A team of researchers from Colorado State University and UCLA show that face-to-face interaction protects health-promoting immune functions in ways that digital contact does not.³⁵ They examined the gene activity that stimulates inflammation and inhibits antiviral responses in the blood of adult study participants during the COVID-19 social distancing period. Participants who had mainly online social contact had higher levels of such unhealthy gene activity than those who had more in-person social contact.

“Digitally mediated social relations do not appear to substantially offset the absence of in-person/offline social connection,” the research team concluded.

Policy Implications

As many as one in four older Americans are socially isolated and face an increased risk of poor health and early death. The research documented in this report underscores the links between strong social ties and longer, healthier lives. U.S. Surgeon General Vivek H. Murthy has called for making social connectedness a national priority, “the same way we have prioritized other critical public health issues such as tobacco, obesity, and substance use disorders.”³⁶ His recent advisory, Our Epidemic of Loneliness and Isolation, identifies multiple actions based on growing research evidence, including:  

• Strengthening social infrastructure: Social ties are not just built by person-to-person interactions, but by the physical elements (parks, libraries, sidewalks, and benches) and the programs and policies in place. Communities can design environments, establish and expand programs, and invest in institutions that bring people together.
• Enacting pro-connection public policies: National, state, local, and tribal governments can play a role in establishing policies for accessible public transportation, paid family leave, and other supports that can enable more connection among communities and families.

Social Isolation and Loneliness Among Older Adults: Opportunities for the Health Care System, a recent report from the National Academies of Sciences, Engineering, and Medicine, details ways health care organizations can address social isolation among older people by better educating their staff to intervene and aligning with other community agencies. Specific recommendations include:

• Partnering directly with ride-sharing programs to help older adults’ get to medical appointments and community events.
• Working with community organizations to integrate social activities and in-person interaction into hospital discharge planning, care coordination, and transitional care planning.

“Our relationships are a source of healing and well-being hiding in plain sight,” Murthy said, “one that can help us live healthier, more fulfilled, and more productive lives.”³⁷

With current data on more than 200 countries and territories, PRB’s World Population Data Sheet offers essential context for journalists reporting on policy, public services, health, climate, and other critical issues shaped by population shifts. The Data Sheet provides a comprehensive view of where and how populations live, projecting trends in growth, decline, and factors affecting population change. Each year’s special focus takes an in-depth look at a topic like climate adaptation so we can better understand what the data show and why it matters. PRB provides media resources that guide journalists on how to report on these complex topics for their communities.

This media brief on primary health care (PHC), a special focus of the 2024 World Population Data Sheet, identifies the components, actors, and systems of this holistic step toward universal health coverage. It includes definitions and highlights data that can be used to report stories about how PHC touches every part of our society.

With current data on more than 200 countries and territories, PRB’s World Population Data Sheet offers essential context for journalists reporting on policy, public services, health, climate, and other critical issues shaped by population shifts. The Data Sheet provides a comprehensive view of where and how populations live, projecting trends in growth, decline, and factors affecting population change. Each year’s special focus takes an in-depth look at a topic like climate adaptation so we can better understand what the data show and why it matters. PRB provides media resources that guide journalists on how to report on these complex topics for their communities.

Two media briefs explore climate adaptation and resilience, a special focus of the 2023 World Population Data Sheet. They demystify key concepts and provide journalists with causes, consequences, and examples of this issue.

• Brief 1 explains climate change, adaptation, and resilience; and defines these often-misunderstood terms.
• Brief 2 unpacks how to use climate and demographic data to report on climate change and adaptation.