摘要：Objectives . To examine changes in active life expectancy in the United States over 30 years for older men and women (aged ≥ 65 years). Methods . We used the 1982 and 2004 National Long Term Care Survey and the 2011 National Health and Aging Trends Study to estimate age-specific mortality and disability rates, the overall chances of survival and of surviving without disability, and years of active life for men and women. Results . For older men, longevity has increased, disability has been postponed to older ages, disability prevalence has fallen, and the percentage of remaining life spent active has increased. However, for older women, small longevity increases have been accompanied by even smaller postponements in disability, a reversal of a downward trend in moderate disability, and stagnation of active life as a percentage of life expectancy. As a consequence, older women no longer live more active years than men, despite their longer lives. Conclusions . Neither a compression nor expansion of late-life disability is inevitable. Public health measures directed at older women to postpone disability may be needed to offset impending long-term care pressures related to population aging. As the US population has aged, concerns about meeting the nation’s late-life disability and care needs have grown. 1 Questions about just how pressing needs will be are magnified by statistics about the large baby boom generation, whose long-term care demands are expected to peak around 2030. In that year, 1 in 5 persons in the United States will be aged 65 years or older, compared with 15% in 2015. 2 The future long-term care needs of older men and women will depend in part on longevity increases and on whether they are accompanied by an expansion or compression of end-of-life disability and dependency. More than 3 decades ago, competing theories about the implications of population aging for late-life functioning were proposed. 3–5 The first posited that medical advances would necessarily lead to increased survival of persons with chronic morbidity and would expand the proportion of life spent in ill health. 3 Another suggested that health promotion and disease prevention would increase the age at onset of disease and disability and yield a shorter period of infirmity before death. 4 A third perspective recognized that mortality and disability were dynamic interrelated processes and that population-level changes in disability would depend on the particular combination of factors driving mortality decline (e.g., postponement of onset and reductions in severity and progression of chronic disease). 5 Implicit in the latter theory is the possibility that different subgroups, such as men and women, might experience different outcomes, and that episodes of disability that were longer on average but also milder could materialize. Implications of mortality shifts for disability in later life are challenging to assess. Because population-level changes in health and longevity tend to occur slowly, long-term data are ideal for investigating such shifts, yet population-based measures of disability were not consistently collected in the United States until the early 1980s. Nevertheless, several studies have pointed to a pattern consistent with an overall compression of morbidity through the 1980s and 1990s. 6–10 More recent analysis focusing on the 2000s raises the question of whether such a compression has continued. For example, small increases in remaining years free from activity limitations were found for men but not women at age 65 years for the 1999-to-2008 period, 11 and declines in years remaining free from mobility impairments were found for both men and women for a similar time period. 12 Despite well-established evidence that women are more likely than men to have activity restrictions in later life, 13,14 little attention has focused on gender differences in long-term trends. Whether women’s disadvantage has grown with respect to late-life disability, and, if so, why, are important questions, as women make up a substantial share—57%—of the population aged 65 years or older in the United States and an even larger share—68%—of those receiving assistance with daily tasks. 1 Several factors have changed in recent years that suggest that men and women may be experiencing different long-term patterns. First, demographers have long recognized that women in the United States outlive men, as they do in most countries, 15 yet men in the United States have gained substantial ground in life expectancy relative to women over the past few decades as cardiovascular-related deaths have declined. 16 Some of this narrowing has been attributed to shifts in smoking histories of US women, which now more closely mirror those of men. 17 Second, causes of death have also shifted; US women are now as likely as men to die from chronic respiratory disease and 30% more likely than men to die from Alzheimer’s disease. 18,19 Third, a substantial decline in late-life disability prevalence has been documented for this country for the 1980s and 1990s, 20–23 but a recent flattening suggestive of an impending reversal has been identified, along with increased prevalence relative to earlier decades among those approaching later life. 24,25 Others have noted recent increases in more moderate disability among older adults. 26 Our interest is in highlighting gender differences in mortality and disability linkages in the United States since the early 1980s. We examined changes over 3 decades in the chances of survival beyond age 65 years overall and without disability, mortality rates by age and disability status, the prevalence of disability, and the number and percentage of remaining years expected to be lived free from disability. For the latter, we considered both severe and more moderate forms of disability.
