The aging of the population is expected to result in substantial increases in the costs of maintaining health care and pension programs, and that is a source of widespread concern. However, a proper assessment requires that attention be given to all categories of government expenditure, including education and others associated with younger age groups, and not just those associated with the older population. It requires also that privately provided goods and services be considered, since their costs must be charged against the same national income as publicly provided ones. Beyond that, it is important to recognize that population change affects not only the demand side of the economy, but also the supply side — the economy's productive capacity. An important conclusion is that while other influences will no doubt play a role, demographic effects by themselves are likely to cause government expenditure (all categories, all levels of government combined) to increase by no more than the rate of growth of the population, and by less than the rate of growth of the gross domestic product. Taking public and private costs together, and assigning appropriate weights to different age groups, the overall “dependency ratio” can be expected to remain at its current low level for another decade and a half or two decades, and then to rise as the baby boom generation retires in large numbers. However, the projected future ratio never reaches the levels of the 1950s and 1960s. Although the overall “burden” of population aging is manageable, major adjustments will be required in the coming decades, especially in the area of federal/provincial cost sharing. For the most part, though, the effects of population aging are predictable, slow, and some time off.

This review and synthesis of the literature on the topic of self-care among older adults defines the construct in terms of preventive behaviours and responses to illness that are performed by lay people on their own behalf. After placing self-care in a historical context, theoretical perspectives and key findings concerning its incidence, correlates, and barriers are reviewed. This is followed by a review of the process and outcomes of interventions designed to promote self-care. The paper concludes with recommendations for future research, policy, and practice.

This review of the literature on the subject of health-related self-help and support groups for older adults begins by defining these two small group helping arrangements, and proceeds with a discussion of the extent of their utilization by older adults, barriers to participation, and ways of tailoring the groups to the needs and circumstances of older adults. The process and outcomes of these groups are also reviewed, and recommendations are offered regarding future research directions and ways of optimizing both the appeal and impact of these two types of mutual aid groups.

Increasing emphasis is being placed on the need to have older adults, their families and formal service providers work together collaboratively or “in partnerships” to provide long-term care, both in community and residential care settings. There is therefore a need to determine how such relationships are currently structured. This paper systematically reviews the results of studies published from 1985 through 1998 on relationships involving self-, informal and formal care within these settings. The findings suggest that formal services are not used to displace or substitute for informal care but rather, that formal services tend to be used to supplement and complement the care provided by the informal network. This is true both in community and residential care settings. Exactly how these partnerships are structured and the relationships between self-care and both informal and formal systems of care are less clear. The findings point to a need to refocus attention away from the creation of partnerships and protecting against unnecessary substitution, towards broader concerns with supporting the partnerships that already exist.

Fostering independence amongst people over 65 years of age, over 80 per cent of whom have medical conditions, presents many challenges to policy personnel, program planners, and service providers, as physical, social, and psychological dimensions of independence must all be considered. This paper presents a systematic literature review and synthesis of 65 rigorous, comprehensive research papers selected from 238 published studies on care delivery approaches relevant to promoting the independence of older persons. This evidence suggests the merits of exercise and health promotion programs for all seniors, and in-home geriatric health care management and fall prevention programs for frail older persons. Findings also indicate the need for more attention to policy on assistive devices, and the need for more research on the effectiveness of public health programming, on strategies to enhance preventive medical care, and onpsychosocial factors which affect seniors' self-efficacy.

The goal of this literature review is to identify key issues in the patterns of medical care utilization of services for seniors as a contribution to the National Consensus process on designing and delivering health care reforms which foster seniors' independence (Shapiro & Havens, 2000). A search strategy used to identify the relevant literature since 1985 focussing mainly on peer-reviewed journal articles is described and the results of the search strategy are summarized. Key articles are identified, analysed and synthesized based on Canadian and American evidence covering patterns of institutional care, physician use, ambulatory care and the determinants of utilization of these services.

Increasing expenditures for prescription drugs have placed seniors in the spotlight of health reforms because they are the main users of prescription drugs. Substantial improvements could be made in the utilization of prescription drugs that would enhance the benefits of therapy, and minimize adverse effects, particularly for seniors. A variety of problems have been documented, including the over- and under-use of drug therapy, prescribing errors, treatment compliance, and cost-ineffective prescribing. Health care system policies, selected physician and hospital-based pharmacist interventions, and decision-aids and compliance aids have been shown to be effective for components of the problem. Integration of key policies and interventions into a comprehensive solution for optimal drug use is needed. This will include: (1) revision of policies guiding the relationship between the drug industry and health sector, (2) regulations requiring adequate drug testing in seniors for drug approval, (3) a Consumer Health Institute to provide a central objective resource for patient information and decision support systems, (4) integrated clinical information systems to support prescribing, dispensing and drug and disease management systems for pharmacists and primary care physicians, and (5) reforms in medical training and licensure.

The objectives of this synthesis are to highlight some of the evidence presented by the other articles in this issue and to discuss how this evidence can be used to design policies and deliver health care services which foster seniors' independence within a health reform context. This paper, therefore, first examines health reform and proceeds from there to discuss the key findings of the studies reported in this journal issue. The discussion then focusses on the importance of the evidence presented for policy making, planning and practice within the current context. Each section concludes by identifying the specific gaps in knowledge that require either additional literature reviews or further research.