1. GENERAL ASPECTS OF CARE AND SUPPORT OF THE ELDERLY
Care in the broad meaning would include also public economic support of the aged. As this is now changing, it deserves attention. The indications are that historically the aged are given a constant fraction of the resources available in society. In the Swedish past, many elderly were poorly provided, because the providers were poor, too. In the years after World War II national income was rising. Pensions were raised substantially as well, and housing allowances were introduced. This rise continued for the elderly and the general population in the 1960s and 1970s, but in the 1980s incomes of the aged no longer rise in real terms. Their position relative to the middle-aged is also weaker now than before. Relatively many women and old-old (80+) persons still have quite small pensions and live near (but not in) poverty: see Table 1.

Table 1 The elderly in 1988, classified by types of pensions, average incomes (from pensions and total) and sex

Another illustration of this is given in Fig. 1 : after the early 1980s there is no increase in spending on the aged at the national level or per capita.

Fig. 1 Costs of old-age care in Sweden 1960-1985, 1975 prices

Yet, there are great variations in this spending at the local, municipal, level that I will describe later.

2. HOUSING AND LIVING ARRANGEMENTS IN GENERAL
Rising incomes have permitted many of the elderly to live with only their wife/husband or alone, rather than to live together with children or other family. In 1954 27% lived alone (67+), today about 36% (65+). Only in Denmark the figure is higher (53% of the non-institutionalized elderly 70+, in Sweden about 44%). The figure for Japan seems to be about 10%, which is slowly increasing. In the Mediterranean countries the percentage is about 20%. Living with one's children is very unusual in Sweden today for the aged: 6% do so (in Japan about 60%). The proportion was higher before, as can be seen from Fig. 2, but most of the children were and are non-married (in Japan about a quarter) and sons, not daughters. Today both generations can live on their own.

Fig. 2 Percentage of people aged 65 and over who live with their children, selected countries, 1950-1988

From these general considerations one may conclude that rising material standards have permitted an increasing freedom of both the elderly and their children to live on their own, be they married or not. We know from surveys that very few of the aged want to live together with their families. They want to live rather near, and that is what many are doing. Most see their children frequently, and there seems to be no decrease in contacts or in personal care.

3. FAMILY SITUATIONS OF THE ELDERLY
Every 8th of the elderly (13%) have never been married (nor have they lived with a man/woman without being formally married). More people get married among younger persons, but still (40-44 year old women) some 8% never marry and 5% never live with a man/woman. Compared to e.g. Japan (about l%) these are high figures. Among the aged, 24% do not have any children, and among the future elderly the percentage will be about 14%, again high compared to Japan. In other words, there will at least for the nearest 50 years be a need for public or other non-family support of the aged !

4. SOCIAL ISOLATION AND LONELINESS? EXPELLED ALSO FROM WORK?
Many Swedes, especially those who work with the aged, believe that old people are generally lonely and feel undesired. Yet, in no survey is the proportion reporting these feelings very high, and not higher now than before (when more of the aged lived with family), and not higher than in other countries. Of course it has to be considered that people adapt to their conditions and that in the long run more people have these feelings than indicated by cross-sectional data.
The proportion that has a paid job is very low among the elderly. It was comparatively low already in the 1950s, and it seems that most of the aged retreat voluntarily from work. They want to leave and they have had the economic means to do so. Already before 65 more than half have stopped working.

5. THE SITUATION OF PUBLIC CARE FOR THE AGED IN SWEDEN
Sweden has at present the oldest population (19% 65+, 7% 80+) of any nation, which of course makes heavy demands on care of all kinds and on health care. Sweden has 8 mill. people with 1.5 mill. 65+ and 360,000 80+. Compared to other countries in the Western world, our problems and solutions are not so different. For example, we spend about the same proportion of our GNP on health care as do other Western nations. Like the other Nordic countries, nearly all non-family care is publicly provided. About 5% of the 65+ suffer from dementia. because the aged get older on average - though their absolute numbers increase very little - the number of dementia victims increase considerably, from 70,000 today to about 100,000 in year 2000.
Comparisons between countries are always difficult. I will give you one example. In Sweden about 6% of the elderly (65+) are in institutions, in Japan officially about 1.6%. But when I was in Japan 1988 I learned (from Prof. Ryu Niki) that there are also some 4.4% of the aged (70+) who have been more than 6 months in medical wards of hospitals and for whom doctors can do no more. This is much same group that in Sweden would be in an institution. Sometimes they do not have a family, or do not want to live with it or their family refuses to take them in or to keep them. Adding these percentages together makes the needs for institutional care in the two countries seem quite alike!
In one respect Sweden and Denmark are different from other countries: we provide more help to the aged in their own homes than do other countries (below). But we still have institutional care. Among the old-old (80+), 25% are institutionalized. In other words, a fifth of all the aged (65+) and two thirds of the very elderly receive some kind of public care and attention. In Figs. 3 and 4 I describe how the supply of institutional care and support at home (Home Help) has changed over the last decades.

Fig. 3 Institutional places per 1000 elderly (80+) persons in the population, Sweden and the United States, 195-1985, and projected for Sweden to the year 2000

Fig. 4 Elderly receiving Home Help per 1000 elderly in the population, Sweden 1965-1989, by age groups

Institutional care in Sweden is old age homes and long term care hospitals (about 50,000 places of each). In the former, residents have a room of their own but eat together in a dining room. The latter are built much like ordinary hospitals (usually 2-4 or even 6 persons per room) and provide very little integrity and privacy. Several old age homes were built in the 1950s and 1960s, and many long term care wards in the 1970s. The ideology now is that old people should stay at home. Supposedly that is better for them and also more economical. The whole issue of who is responsible for the care of the elderly is now debated, and little is done before this has been solved. The prediction of Fig. 3 that it will be about three timed as difficult to find an institutional bed in year 2000 as it was in 1985 is therefore unavoidable. There are also so-called service apartments (35,000) that are not institutions, officially. These look like ordinary high-standard apartments (1-3 rooms), usually in a unit (house) with home help personnel on duty round- the-clock. Few of these have been built in the last years.
Considering the demands it may not be surprising that several private and cooperative companies now build non-public service-apartments that older people (55 or more) may buy. The demand for these is great!
At the same time Fig. 4 shows that provision of Home Help has decreased from 1977-78 in absolute and relative terms. The typical Home Help user gets 4-6 hours/week, a few get many hours (there is no upper limit) and visits evenings and nights. There is no economic means test! The Home Helper primarily does cleaning, shopping, cooking and laundry (80% of the time worked). Employed by the municipality, she/he and works 20-38 hours per week. In a sense this is a substitute for what families can do or what maid servants did in the old days. Yet, most users live alone and some do not have families (nearby). Maid servants were an option only for the more well-to-do in the past. Therefore, Home Help sometimes helps instead of families, but often users might get no or unsatisfactory help if there was no Home Help. We know that in "the good old days" some old people did not at all get the help they needed. What was acceptable standards of care in the past no longer is acceptable! It is noteworthy that most users of Home Help (85%) live alone.
Municipalities where many elderly live alone (which varies a lot) often also provide more Home Help. Elderly persons who move into institutions usually also live alone before that, and today most have had Home Help before moving. But, still they receive relatively little Home Help relative to the need before moving.
In other words, families protect the elderly against using public services and institutions, in Sweden as well as in other countries. What is different here is that more people live alone. Never-the-less, most help to the aged is given by their family also in Sweden! The most important family member is simply the person you are married to (if you are married-above). Often this means a wife, but may men care for their wives as well. (Among 87-year olds, 14% of the women and 8% of the men have cared extensively for a spouse.) If there is no spouse, children are the next to help. Often old people get both family help and Home Help, and they usually get a lot of help from families before moving to institutions. The more help they need, the more they get, from both their families (if they have) and from the Home Help.
Public support for the elderly is decreasing. For a number of years, old age homes were closed or rebuilt into so-called service-apartments, youth hostels (!), etc. Today some municipalities have no old age home left, some have no long-term care and quite a few (20%) have no service-apartments at all. Institutional care has been a political issue: the Social democratic government wished to close all old age homes, the opposition parties wanted to keep them. After realizing the popular support for institutional care, the government has reversed its position. Surveys indicate that rather few of the aged on average want to move to institutions. But asking the oldest old and frail elderly show that about half of them see this as a realistic and attractive alternative. And it is they who may move there! Today most sensible observers think that we need a reasonable number of beds in institutions. The problem is the decreasing supply relative to needs (above), and that care in these places not always is as good as it should be. With the controversies of the last few years, few people have taken initiatives to renew routines and practices in institutions. Especially long-term care hospitals sometimes provide little stimulation for their residents, little privacy, and much too strict and uniform practices.
A large and increasing proportion of those who move into institutions are demented and their presence in service-apartments increases as well. Neither these or old-age homes are staffed and prepared to give them adequate attention. In a study in Southern Sweden we have followed all those who retired in 1969-70 with interviews, medical tests etc. Today a few are still alive. About 30% sooner or later move to institutions, and about 20-25% end their lives in dementia (to compare with 5% on average for both phenomena). Many of them get much help from spouses and other family for many years, but Home Help is unable to keep them at home for any longer time. The same we have seen in local studies in Jokoping: Home Help receivers with memory problems etc. rather soon are moved to institutions, in spite of the official ideology that the aged should stay at home and official statements like "any dwelling can be made into a service-apartment" thanks to Home Help and Visiting Nurses, technical gadgets, etc.
Another example: in a Jokoping survey in 1987 of all the elderly 84-90 years old, regardless of where they lived, we found that those with dementia symptoms quite often live in institutions: Fig. 5.

Fig. 5 Living arrangements for representative 84-90 year old persons in Jonkoping 1987, by mental status (dementia symptoms or not)*

Of special interest are those living alone at home with dementia symptoms: 10 out of these 12 persons had Home Help in 1987, the other two had extensive help from family (like most of the others). When followed up in 1989, only 3 out of the 12 were still at home, 2 were dead and the nest in institutional care. The 3 who remained at home had relatively mild dementia symptoms and family members available who cared a lot for them.
The official policy is to build so-called group-living units for the severely demented elderly. These are small houses or wards with ideally 6-8 patients and round-the-clock staff. Typically each patient has a room (sometimes two rooms), with kitchenette and there is a central kitchen where supposedly patients help cook and a combined dining- and living-room. In a sense, it is like the old-age home of the past, but of much higher standard. These are officially not institutions. Like so-called service-apartments they keep high standard and are rented on a formal lease (to give government grants for construction and housing subsidies for renters). Yet, municipalities have been very slow to plan and build these new settings. Today there are about 900 places in this kind of care for the demented elderly in all of Sweden, which is clearly insufficient.
All the above figures are national averages and changes in these measures. Yet, spending on the elderly varies a great deal between the 284 Swedish municipalities, as does the amount of Home Help and institutional care supplied. We have analyzed this in a special study for year 1985. In Figs. 6 and 7 we show the situation for the old-old (80+).

Fig. 6 Proportion elderly (80+) who receive Home Help, municipal distribution, Sweden 1985

Fig. 7 Proportion elderly (80+) who reside in institutions, municipal distribution, Sweden 1985

Home Help varies from 17% to 80% of potential recipients, around the national average 43%. Institutional care in the same way varies between 9% and 37%. One might think that when a municipality has little of Home Help it instead provides more of institutional care, and vice versa. But we can not find that there is much substitution of that kind. Several municipalities give much of all kinds of care, others provide little of everything! Variation for these two together is from 31% to 100% (!), with an average of 67% (above). In Sweden old age care is largely a municipal responsibility, and municipalities have constitutional autonomy. Home Help is not everywhere the "same". Fig. 8 shows that the number of hours provided varies considerably. In some municipalities, few get Home Help and few hours, in others many get it and more hours per client! It surprises foreign visitors to learn that variations are this great in the welfare state. I want to mention that the same pattern can be seen in Denmark and Norway. Maybe it is true everywhere. We have tried to find the explanations for these Swedish variations, but I have to confess that they are hard to explain. Rural areas provide better than urban districts, and poor areas (usually rural) better. This is possible thanks to the system for tax redistribution that operates in Sweden between municipalities. This is not popular with (the rich) municipalities and it is likely that differences will continue to exist. We know that the elderly in all kinds of municipalities usually get the help that they need, or think they need. Probably families intervene when there is little public help and the elderly also adapt their expectations to what is available (above). Protests have also been heard that the new directions in old age care, especially the shortage of institutions and the stress on living at home, will lay a heavy burden on families, that is on wives, daughters and daughters-in-law.

Fig. 8 Average number of Home Help hours provided by year and client (65+), Swedish municipalities 1985

Many Swedes entertain the idea that we today provide less personally for our parents than was the case in "the old days" and that we have the "State" do it for us instead. This is both true and untrue. In the total "budget" of care for an elderly person children may play a smaller role today than before. In particular, the Home Help has lifted off shopping and cleaning (above). It seems that both the elderly and their off-spring like this arrangement: after all, Home Help is something that has been demanded in the political process. Now the elderly do not have to ask their children for help with that and they may spend time together with more pleasant tasks. We know from surveys that Home Help is much preferred above any other helper (except spouse) by needy elderly people. We have also asked 87-year olds about who cared for their parents once, and compared this to figures on who provides for the aged today. The indications are that 20-25% sooner or later help their aging parents, earlier and today. The figure was rather low in the old days as well, because many parents never reached old age, or sisters/brother did the caring instead, the parents lived too far away etc. In the past quite a few of the elderly did not get the help they needed! (above). In other words, personal care of parents has not changed as much as we believe. And elderly women who have themselves taken care of their parents seldom want their own daughters do it for them...

6. CONCLUSIONS
Over the years and up till the 1980s, resources spent on the elderly have grown in real terms. Now public providers of services for the elderly try to economize and make priorities among their clients. The real value of pensions is no longer increasing (O% change 1981-87 for individual elderly), fewer get housing allowances, Home Help and institutional care. The Golden Days are over!
Into the institutions are taken elderly people who are older and frailer by every year, and also more confused/demented. Clients in the Home Help grow older, and administrations try to cut down on shopping-cleaning (and cooking) and to concentrate on personal care. Those who have family near tend to get less. This means that those living at home become frailer and need more help and probably families do have to help more. New legislation (July 1989) gives the right to 30 days leave with sick pay to care for a relative. The first half year 2,500 persons have received money (on average 6 days per case and totaling 15 million Sw Cr/year). Doctors have to certify the need for these allowances, and it seems safe to say that most people help their parents without economic compensation.
Some family members (about 7,000) are also employed as "Home Helpers" for frail elderly persons. There are municipalities where this is common (e.g. Jonkoping), but most municipalities use it little or not at all. In spite of official recommendations to support families in this way, the program is less　common now than before (in the early 1970s 25% of the Home Help staff were employed family members). It seems that there is an inherent contradiction between professional social services and families that makes it hard to unite them in one system.
I have mentioned that Swedes help their parents about as much now as before. As there are so many more elderly today (1.5 mill., in 1900 240,000) this means that never before have so many elderly been helped by their families. As we have seen, they also receive more non-family help. In other words, the aged totally get more help of all kinds than ever before. In a sense,　this is not surprising but exactly what to expect: the welfare society provides more of everything (nearly) for everyone. The new prospects - above - is that this growth may have come to a halt. This may be the real challenge, for the old and the young: to economize better with the resources that we have, and to distribute them more equitably to the needy elderly.