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More highly dependent older people with complex care needs – the future for social care

Carol Jagger is AXA Professor of Epidemiology of Ageing

What did we do?

New research in the Lancet Public Health1 forecasts how dependency levels of the older population (aged ≥65 years) will change between 2015 and 2035. Our model, the Population Ageing and Care Simulation (PACSim) is based on data from three large longitudinal studies. PACSim takes men and women aged 35 years and over, with their diseases and health conditions, lifestyles (smoking, obesity, physical inactivity), socio-economic factors (education, social class), and levels of dependency, and models how these inter-related factors will change as they age over the next two decades.

What did we find?

The number of older people as a whole who require 24-hr care will increase by around a third, but the number of people aged 85 years and over who require this level of care will almost double. This is important because the very old, those aged 85 years and over, are much more likely to have not just one condition, but multiple ones – multi-morbidity. Therefore the composition of the older population having substantial care needs (requiring care at multiple times a day or 24-hr care) will be very different in the future. In 2015 under half (39%) of those with substantial dependency had three or more diseases but by 2035 almost three-quarters (74%) will have, and the majority of these will have dementia and at least 2 other diseases.

Though much of this increase in multi-morbidity is a result of the growing numbers of very old people – this section of the population is the one that is growing the fastest – PACSim also suggests that there is a contribution from the young-old, aged 65-69 years, who are less likely to be free of disease as they enter the older population in the future. This will mean that they may well become multi-morbid more rapidly.

What are the implications of our research?

Our findings have considerable implications for those who care for older people with substantial dependency since their needs will be much more complex than now. Much care is provided by families, often a daughter or, as men’s mortality rates have declined faster than women’s, increasingly a spouse. Spouses may well have health problems themselves. Daughters of those aged 85 years and over are likely to be around 60 years of age and these are the cohorts whose retirement age has been deferred and who may need to continue working to maximise pension contributions. We will need to provide better support, and training, for families in the future, and employers will need to recognise the uncertainty that occurs when caring for such dependent family members. In addition we will need to ensure the care workforce is adequately trained to meet the needs of this growing older population with complex health and care needs.

In addition, if this picture is to change, we need to put prevention of dependency higher on the health agenda, both as individuals and as a society. It is much easier to reverse the dependency process early on – regaining independence from low levels of dependency. Many of us are well aware of the things we should be doing to keep active and healthy and maintain independence: being physically active, socially engaged, eating healthily, not being obese, drinking in moderation and not smoking. But few recognise the importance of strength and balance. Strength is perhaps one of the reasons why women become limited in their daily activities earlier than men, since women start from a lower level than men and therefore hit the threshold to perform activities faster. There is good evidence that resistance training is beneficial, even for those in care homes.


There is little doubt that the public health and medical advances that have helped us to live longer lives bring considerable benefits to individuals, families and society. However without a full recognition of the challenges it also brings, and solutions, these extra years are unlikely to be good quality ones.



  1. Kingston A, Comas A, Jagger C, for the Mp. Forecasting the care needs of the older population in England over the next 20 years: estimates from the Population Ageing and Care Simulation (PACSim) modelling study. Lancet Public Health 2018;

Edel Harris





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