Health and care-receiving profiles and unmet home care needs among community-dwelling Canadians aged 85 years and older (2025)

Release date: May 21, 2025

Abstract

Background

The population aged 85 and older is one of the fastest-growing age groups. Identifying distinct health status and care-receiving profiles can improve the understanding of the heterogeneity in this age group. Unmet home care needs are associated with negative health consequences and can challenge the ability of those 85 and older to age in the community.

Data and methods

A representative sample of 4,083 community-dwelling Canadians aged 85 years and older from the 2019/2020 Canadian Health Survey on Seniors (CHSS) was used to identify health and care-receiving profiles applying latent class analysis. Multinomial logistic regression was used to examine factors associated with the profiles. Multivariable logistic regression was applied to evaluate the association between the profiles and unmet home care needs.

Results

An estimated 201,000 Canadians aged 85 years and older (28.2%) were classified as “healthiest–low care receiving”, 180,000 (25.3%) as “moderately healthy–moderate care receiving,” 194,000 (27.2%) as “moderately unhealthy–low care receiving,” and 137,000 (19.2%) as “poor health–high care receiving.” Increasing age and being an immigrant were associated with poorer health status and a higher likelihood of receiving care. An estimated 46,000 Canadians aged 85 years and older (6.5%) reported having unmet home care needs. Individuals with the profiles characterized by poorer health and a higher likelihood of receiving care were more likely to have unmet home care needs.

Interpretation

The findings of this study highlight the importance of considering multiple health and care-receiving factors to better illuminate unmet home care needs among community-dwelling Canadians aged 85 years and older.

Keywords

Health status, care receiving, unmet home care needs, Canadians aged 85 years and older.

Authors

Md Kamrul Islam and Heather Gilmour are with the Health Analysis Division at Statistics Canada.

Introduction

Among the older population, those aged 85 and older, sometimes referred to as the “oldest old”^Note1 is one of the fastest-growing age groups. In 2023, there were 896,600 Canadians aged 85 and older, comprising 2.2% of the population, an increase of 16.3% from 2016,^Note2 mostly driven by increasing life expectancy, improved screening, and treatment advances.^Note1 The population aged 85 and older is projected to reach 2.2million by 2043 under a medium-growth scenario,^Note3 and could triple by 2073, reaching between3.3million (low-growth scenario) and4.3million (high-growth scenario). The increase in the population aged 85 and older will be particularly rapid from2031to2050, when the large baby boom cohort will reach this age group.^Note4 Societal implications of the increasing number of oldest-old Canadians include higher need for caregiving and support services for long-term care, health care, and home care.

While most older Canadians indicate a preference for aging in their homes,^Note5 the proportion who live in institutions increases with age. Based on 2021 Census data, 1.0% of those aged 65 to 69 lived in health care and related facilities (hospitals, nursing homes, residences for senior citizens, residential care facilities), while 27.1% of those aged 85 and older did so.^Note6, ^Note7 Nonetheless, the majority of individuals aged 85 and older live in the community but are unlikely to be a homogenous group in terms of their health status and the care they receive.^Note8 They will differ in terms of physical and mental health, social supports available to them, and the support services they need to remain living outside an institutional setting. Therefore, a better understanding of this group could help programs that aim to assist them to continue to do so.

Previous studies that have focused on Canadians aged 85 years and older have mostly looked at singular dimensions of health, such as general health,^Note9 oral health,^Note10 dementia,^Note11 and other chronic conditions^Note1, ^Note12—with few exceptions. A high prevalence of chronic conditions is documented in this age group, including hypertension (83.4%), osteoarthritis (54.0%), heart disease (42.0%), osteoporosis (36.9%), and chronic obstructive pulmonary disease (COPD) (27.3%).^Note12 Despite the higher prevalence of chronic conditions, the majority of the oldest-old Canadians rated their health status as good, very good, or excellent. For example, in the 2019/2020 CHSS, 71.5% of people in this age group rated their general health as good, very good, or excellent, and 95.3% did so for mental health—even though 93.6% were living with at least one chronic condition and 80.8% were living with two or more chronic conditions.^Note13 This apparent paradox suggests that individuals’ perception about their health status is influenced by many other factors, including economic security, physical environments, social connectedness, and psychosocial well-being.^Note12 Hence, research examining individuals’ health status should consider multiple indicators related to the intrinsic capacity of individuals and their social and physical environment.

While health status is an important factor in determining whether an older adult continues living in the community,^Note14 an individual’s use of caregiving services such as informal care or public or private home care, and community supports are also important. These supports can improve quality of life, and allow older adults to age outside institutions safely and with dignity.

When profiling the characteristics of the oldest-old population living in the community, it is important to consider both health status and care-receiving variables. Previous studies that identified distinct profiles among older individuals have focused solely on environmental factors^Note15 or health status characteristics^Note8, ^Note16, ^Note17 without considering the care received. These studies have shown that examining multiple indicators can better illuminate the complexity and heterogeneity of health among older adults and recognized that individual factors do not necessarily occur in isolation from one another. The current study builds on this previous work by including care-receiving variables, along with health status, in the identification of distinct profiles. Identifying these profiles can help to understand the heterogeneity of the oldest old living in the community and inform policies and programs related to support services.

Unmet home care needs may challenge the ability of the oldest old to age in the community. Home care services help people remain at home and cost less than more expensive institutional options.^Note18 Unmet home care needs have been associated with negative consequences, such as poorer health and an increased use of other health services,^Note19, ^Note20 admission to nursing homes,^Note21, ^Note22 and reduced emotional well-being.^Note23, ^Note24 Therefore, meeting home care needs is relevant to the well-being of the individual and the health care system. In 2021, 3.0% of households reported having unmet home care needs.^Note25 Earlier studies found that unmet home care needs were more common among those aged 85 years and older, compared with younger age groups.^Note26, ^Note27 Previous studies have identified several factors associated with unmet home care needs, including living arrangements, education, income, access to a regular medical doctor, chronic conditions, health status, and functional limitations.^Note26, ^Note27, ^Note28 However, less is known about the extent to which unmet home care needs vary across the health and care-receiving profiles of the oldest-old Canadians.

This study aims to enhance the understanding of the heterogeneity among the community-dwelling population aged 85 years and older in Canada by identifying distinct profiles, where individuals within each group are similar to one another but distinct from those in other groups. More specifically, the study had three objectives. The first was to identify the distinct health and care-receiving profiles among the oldest-old population by applying latent class analysis (LCA) with multiple measures from the 2019/2020 CHSS. The LCA included measures of physical, mental, and psychosocial health, as well as the use of home care, informal care, and community support services. Drawing on the World Health Organization’s framework on the social determinants of health,^Note29 the second objective was to identify demographic, socioeconomic, and geographic factors associated with the distinct health status and care-receiving profiles among the community-dwelling oldest-old Canadians. The final objective was to assess the association between the distinct profiles and unmet home care needs while controlling for the demographic, socioeconomic, and geographic factors.

Methods

Data source

The CHSS—2019/2020, a cross-sectional supplement to the Canadian Community Health Survey (CCHS), collected information from 41,635 respondents aged 65 years and older living in the 10 provinces. The survey excluded people living on reserves and other Indigenous settlements in the provinces, full-time members of the Canadian Forces, the institutionalized population, and people living in certain health regions. Data were collected from January 2019 to December 2020, with a pause from April to August 2020 because of the COVID-19 pandemic. The response rate for the 2019/2020 CHSS was 40.1%, and 90.8% of respondents agreed to link their answers to the CCHS. Detailed documentation for the 2019/2020 CHSS is available at https://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SDDS=5267.

Study sample

The analytical sample for this study was 4,083 individuals (1,524 men and 2,559 women), representing 712,000 Canadians aged 85 years and older living in the community. The demographic and socioeconomic distribution of the study sample is shown in Appendix TableA.1.

Measures

Health status and care-receiving variables

Drawing on the healthy aging lens^Note30 and a review of the literature on health status and care receiving,^Note16, ^Note17, ^Note18 13 indicators were included to identify the health and care-receiving profiles of the community-dwelling Canadian population aged 85 years and older: self-perceived general health, self-perceived mental health, multimorbidity, perceived stress in life, loneliness, cognition health, emotional health, hearing status, mobility, pain status, home care, informal care, and community services.

Self-perceived general health and self-perceived mental health were categorized as excellent or very good, or as good, fair, or poor.

Multimorbidity, i.e., two or more chronic conditions diagnosed by a health professional, included the following 26 conditions: asthma, COPD, sleep apnea, fibromyalgia, arthritis, osteoporosis, high blood pressure, high blood cholesterol or lipids, heart disease, stroke, diabetes, cancer, Alzheimer’s disease, chronic fatigue syndrome, mood disorder, anxiety disorder, back problems, chronic kidney disease, bowel disorder, urinary incontinence, Parkinson’s disease, cataracts, glaucoma, diabetic retinopathy, age-related macular degeneration, and post-traumatic stress disorder.

Perceived life stress was based on the question “Thinking about the amount of stress in your life, would you say that most of your days are: not at all stressful, not very stressful, a bit stressful, quite a bit stressful, extremely stressful?” It was categorized as dichotomous: stressful (a bit stressful, quite a bit stressful, or extremely stressful) versus not very stressful or not at all stressful.

Loneliness was based on a three-point Likert scale (hardly ever, some of the time, and often). The survey respondents were asked three questions:

• “How often do you feel that you lack companionship?”
• “How often do you feel left out?”
• “How often do you feel isolated from others?”

A higher score indicated greater loneliness. Therefore, participants who responded “some of the time” to two or more questions or “often” to one or more questions—resulting in a score of at least 5—were labelled as “lonely.”^Note31, ^Note32

Levels of functional impairment for cognition, emotion, hearing, mobility, and pain were based on the Health Utilities Index Mark3 (HUI3).^Note33, ^Note34 Each HUI3 attribute has five or six levels, with corresponding utility-based scores ranging from 0.00 (most impaired) to 1.00 (no impairment). HUI3 domains for vision, speech, and dexterity were excluded from the analysis because of the small number of cases with scores below 1.0. The remaining HUI3 attributes were categorized as no impairment (level1) and impairment (levels2 to 5 or 6).^Note35

Home care refers to services received in the home because of a health condition or a limitation in daily activities, and it excludes help from family, friends, or neighbours. If the respondent indicated that they had received any of the following types of home care in the past 12 months, they were considered to have received home care:

• nursing care (e.g., dressing changes, preparing medications, visits from the Victorian Order of Nurses for Canada)
• other health care services (e.g., physiotherapy, occupational or speech therapy, nutrition counselling)
• medical equipment or supplies (e.g., wheelchairs, pads for incontinence, help with using a ventilator or oxygen equipment)
• personal or home support (e.g., support with bathing, housekeeping, meal preparation)
• palliative or end-of-life care
• other services (e.g., transportation, Meals on Wheels).

Respondents were considered to have received informal care if they indicated that, during the past 12 months, they had received short-term or long-term assistance from family, friends, or neighbours because of a health condition or limitation that affected their daily life for any of the following activities:

• personal care, such as assistance with eating, dressing, bathing, or toileting
• medical care, such as help taking medicine or help with nursing care (e.g., dressing changes or foot care)
• managing care such as making appointments
• transportation, including trips to the doctor or for shopping
• meal preparation or delivery
• other assistance.

Receipt of community services was based on the question “In the past 12 months, did you receive any of the following community support services?” Responses included

• friendly visiting (e.g., regular visits from a companion, providing friendship and company)
• adult day program (e.g., specialized programs of therapeutic, social, and recreational activities)
• grounds maintenance services (e.g., snow removal or lawn mowing)
• faith outreach services
• transportation, including trips to the doctor or for shopping
• foot care
• food bank
• support groups (e.g., grief support group)
• other services.

The weighted percentage distribution of the variables used in the LCA to identify health and care-receiving profiles is shown in Appendix TableB.1.

Covariates and outcome

Based on the review of literature and available data, eight control covariates were included for multivariable analysis: gender, age, marital status, education, household income, access to a regular health care provider, place of residence, and timing of the survey. Two categories of gender (men and women) were used in the study, based on the question “What is your gender?” The age groups were 85 to 89 years, and 90 years and older. Marital status was classified as dichotomous: married or common law, and divorced, separated, widowed, or single (never married). Immigrant status was categorized as immigrants or Canadian-born population.

The highest level of education was classified as less than postsecondary or postsecondary. Household income was categorized as low (deciles1 to 4), middle (deciles5 to 6), or high (deciles7 to 10). It was not possible to include additional categories of education and household income because of the small number of cases.

Having a regular health care provider (yes or no) was based on the question “Do you have a regular health care provider? By this, we mean one health professional that you regularly see or talk to when you need care or advice for your health.”

Defining urban and rural geography based on population size has been used in the CCHS and the literature. The place of residence was coded as urban (population centre with 1,000 or more people) or rural (fewer than 1,000 people). Additional categories of urban and rural geography could not be included because of inadequate sample size.

The timing of the survey was classified as before the COVID-19 pandemic restrictions (January to December 2019, and January to March 2020) and during the COVID-19 pandemic (September to December 2020).

Respondents were considered to have unmet home care needs if they indicated that, during the past 12 months, there was ever a time when they felt that formal home care services were needed but were not received. In measuring unmet home care needs, informal care and community services were not considered.

Analytical approach

LCA was used to identify distinct groups based on 13 health status and care-receiving factors. The objective was to categorize individuals into groups such that those within each group were similar to each other while being distinct from individuals in other groups. LCA can identify the most common patterns of characteristics that frequently appear together and recognizes the heterogeneity of health status and care received among older Canadians. It also recognizes that individual factors do not necessarily occur in isolation and may have a synergistic effect on each other. The optimal number of groups, in this case four, was determined by the Akaike information criterion, the Bayesian information criterion (BIC), and the sample-adjusted BIC, whereby lower values indicate better model fit.^Note36 The entropy value of 0.94 in the four-class model indicates a very good separation of classes. The percentage of respondents in the smallest class was 17.6% (Table1), indicating enough respondents for calibrating regression analysis. The LCA was implemented in Stata17.0, and individual sampling weights were used. Each respondent was assigned to a class based on the highest probability of class membership.



The four mutually exclusive classes were labelled as (1) “healthiest–low care receiving,” (2) “moderately healthy–moderate care receiving,” (3) “moderately unhealthy–low care receiving,” and (4) “poor health–high care receiving.” The four groups had probabilities of comprising 27.8%, 25.2%, 27.3%, and 19.6%, respectively, of the study population. Those in the class characterized as healthiest–low care receiving had the highest probabilities of good health and the lowest probabilities of receiving care, while those in the class characterized as poor health–high care receiving had the lowest probabilities of good health and the highest probabilities of receiving care (Table2).



Weighted percentages and cross-tabulations of health and care-receiving profiles were estimated. Multinomial logistic regression was used to evaluate factors associated with the health and care-receiving profiles. Multivariable logistic regression was used to examine the association between unmet home care needs and health and care-receiving profiles after adjusting for relevant covariates. Missing cases were very low, ranging from 0.01% (access to a regular medical health care professional) to 2.2% (education). Listwise deletion of missing cases was applied to calibrate the regression models.

Sampling weights were used to account for the survey design and non-response. Bootstrap weights were applied using SAS-callable SUDAAN 11.0.3 to account for the underestimation of standard errors caused by the complex survey design.^Note37 The significance level was set at p < 0.05.

Results

Characteristics of the study population

The study population represents 712,000 Canadians aged 85 years and older (38.9% men and 61.1% women) living in private households in the 10 provinces. The majority were aged 85 to 89 years old; divorced, separated, widowed, or single (never married); and born in Canada. About two-thirds of the study population (61.6%) had less than a postsecondary education. More than half of the study population (56.4%) were from low-income households. Most had a regular health care professional (94.8%) and were living in urban areas (84.3%). The majority were interviewed before COVID-19 restrictions were put in place (Appendix TableA.1).

Prevalence of health and care-receiving profiles

Based on the CHSS—2019/2020, an estimated 201,000 oldest-old Canadians (28.2%) were classified as healthiest–low care receiving, 180,000 (25.3%) as moderately healthy–moderate care receiving, 194,000 (27.2%) as moderately unhealthy–low care receiving, and 137,000 (19.2%) as poor health–high care receiving. Compared with those aged 85 to 89 years, those aged 90 years and older were more likely to be classified as poor health–high care receiving and less likely to be classified as healthiest–low care receiving (Table3).



Those who were married or living in a common-law relationship had a lower percentage in the moderately healthy-moderate care receiving, but a higher percentage in the moderately unhealthy-low care receiving classes than those who were divorced, separated, widowed, or single-never married. Immigrants, those with less than postsecondary education, and with a regular medical doctor had lower percentages in the healthiest-low care receiving class but higher percentages in the poor health-high care receiving class.

Factors associated with health and care-receiving profiles

In the multivariable analysis that accounted for demographic, socioeconomic, and geographic factors, increasing age was associated with a poorer health status and a higher likelihood of receiving care. For example, compared with individuals aged 85 to 89 years, those aged 90 years and older were 1.8 times more likely to be classified as moderately healthy–moderate care receiving, and 2.6 times more likely to be classified as poor health–high care receiving than to be classified as healthiest–low care receiving (Table4).



Similarly, compared with Canadian-born populations, immigrants were more likely to be classified as poor health–high care receiving (2.6 times) than to be classified as healthiest–low care receiving. In addition, having a lower level of education was consistently found to be associated with poorer health status and a higher likelihood of receiving care. For instance, compared with individuals with a postsecondary education, those with less than a postsecondary education had 2.1 times higher odds of being classified as moderately unhealthy–low care receivingand 2.4 times higher odds of being classified as poor health–high care receiving thanto be classified as healthiest–low care receiving.

Unmet home care needs

Based on the CHSS—2019/2020, an estimated 46,000 Canadians aged 85 years and older (6.5%, 95% confidence interval: 5.3 to 8.0) reported having unmet home care needs. Unmet home care needs were more likely for those classified as moderately healthy–moderate care receiving (7.0%), moderately unhealthy–low care receiving (4.1%), and poor health–high care receiving (17.2%) than for those classified as healthiest–low care receiving (1.0%) (Table5).



In relation to the class characterized as healthiest–low care receiving, the higher likelihood of having unmet home care needs across the three other health and care-receiving profiles persisted even after accounting for the selected demographic, socioeconomic, and geographic factors in the multivariable regression analysis.

Discussion

This study classified the oldest old living in the community according to their multidimensional health status and care-receiving characteristics—defined by physical, mental, and psychosocial health and the use of home care, informal care, and community services. Findings of this study are generalizable to Canadians aged 85 years and older living in the community. As with many population health surveys, the CHSS 2019/2020 excludes those living in institutional settings (e.g., long-term care homes). However, because the focus of the analysis is to profile those who remain living in the community, this exclusion is not a limitation.

More than half of the community-living oldest-old Canadians were relatively healthy and low care receiving. However, about half were classified as moderately unhealthy–low care receiving or poor health–high care receiving. The likelihood of being classified as poor health–high care receiving was higher among those aged 90 years and older. Having a poorer health status with increasing age among the oldest-old Canadians—which includes a higher concentration of chronic conditions, functional limitations, and poor psychosocial health—is consistent with previous research.^Note12, ^Note38

Having a lower level of education was associated with a higher likelihood of being in the classes characterized by relatively poorer health and higher care receiving. The long-term effect of education on health status and care receiving among the oldest-old Canadians aligns with findings from previous studies.^Note39, ^Note40, ^Note41 The influence of education on health and well-being in later life has been explained relying on the cumulative (dis)advantage hypothesis, which suggests that education reproduces and augments health-related (dis)advantages that become more noticeable with increasing age.^Note39 The positive influence of education on health status may also be mediated through a healthy lifestyle and greater financial security from mid- to later life.

This study found that immigrants were more likely than individuals born in Canada to be in the class characterized by the poorest health status, greater functional limitations, and high care receiving. This finding is consistent with previous studies that have documented health disadvantages among immigrants—particularly among long-term immigrants (those living in Canada for 10 years or more)—compared with individuals born in Canada.^Note42, ^Note43, ^Note44, ^Note45 The health disadvantage among long-term immigrants has been attributed to various factors, including challenges associated with getting established in the new country, language barriers, inadequate social networks, and perceived discrimination in the host society.^Note46, ^Note47 It is worth mentioning that 99.2% of immigrants in this study population were long-term immigrants.

Among the four health and care-receiving profiles, unmet home care needs were highest among those classified as poor health–high care receiving. While not directly comparable because of differences in the study population and the key predictor variable of interest, previous studies have also documented higher unmet home care needs among older adults living with functional limitations, such as difficulties in mobility, pain, hearing impairment, and poor cognitive health.^Note48, ^Note49, ^Note50, ^Note51 In addition, unmet home care needs were higher among households with low socioeconomic status (SES). The higher unmet home care needs among households with low SES may be attributable to several factors, such as higher rates of chronic conditions and fewer available resources.^Note25

In this study one fifth of the oldest old people were classified as moderately unhealthy yet they were also low care receiving. Their health problems may not be severe enough to require high levels of care, or they may be facing barriers to accessing needed home care that could help them maintain their independence. Although reasons for unmet home care needs cannot be assessed in this study, potential factors include complex care needs, limited services in the area, financial constraints, and physical or cognitive barriers to accessing care.

Strengths and limitations

To the best of the authors’ knowledge, this is the first study that identified the health and care-receiving profiles of community-dwelling Canadians aged 85 years and older while examining a host of sociodemographic, geographic, and enabling factors associated with the profiles. In addition, this study evaluated the extent to which unmet home care needs varied across the profiles.

However, this study has some limitations. Stratifying analyses by gender was impossible because of inadequate sample size. The sample size also precluded the inclusion of separate categories for recent immigrants (those living in Canada for less than 10 years) and long-term immigrants. In addition, because of the inadequate sample size, the extent to which various types of unmet home care needs (e.g., home health care, support services) varied across the health status and care-receiving profiles could not be examined. Data collection for the 2020 CHSS was interrupted by the COVID-19 pandemic, and the inability to conduct in-person interviews during the pandemic resulted in lower response rates. Survey weights were used in the analyses to minimize any potential bias that could arise because of low response rates. A bias could result if people with a poorer health status or with high needs for support and services to assist them in living in the community were less likely to participate in the survey. Finally, the CHSS—2019/2020 is a cross-sectional dataset, and causality cannot be inferred.

Conclusion

Using a representative sample of Canadians aged 85 years and older, this study identified four distinct health and care-receiving profiles of the oldest-old Canadians who were living independently. More than half were relatively healthy and receiving low care. But being older, having a lower education, and being an immigrant were associated with a higher risk of poor health and greater needs for care and support for those living in the community. Those classified as moderately healthy–moderate care receiving, moderately unhealthy–low care receiving, and poor health–high care receiving were more likely than those classified as healthiest–low care receiving to have unmet home care needs.

Identifying the different health and care-receiving profiles among community-dwelling Canadians aged 85 years and older enhances the knowledge of heterogeneity among this group. Specifically, an understanding of the association between distinct profiles and unmet home care needs will help target home care services to the specific needs of the oldest-old Canadians. Future research could focus on examining the types of home care services received by the oldest-old Canadians and identifying their barriers to accessing home care services.





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