Chapter 11

1. Chapter 11 The Oldest-Old and Caregiving

2. The Oldest-Old The very old, the extreme aged, the dependent elderly, the frail elderly Defined as ages 85+ Those 85+ are the fastest growing segment of the population. Robust aging: successful aging, maintaining good mental and physical status Characterized by higher levels of social contact, better vision and health, and fewer stressful life events in the previous 3 years.

3. Old Age Category Distribution

4. Physical Health Physical losses and chronic health issues begin to take their toll after age 85. Greater likelihood of hospitalization or nursing home placement Functional ability tends to decline after 85. Most declines are gradual and adaptable. Less than half of the 85+ need help with ADLs. About 60% need help with IADLs.

5. Chronic Disabling Conditions Bone and joint problems Heart disease Vision and hearing problems Mental impairment Drug intoxication Falls Urinary incontinence

6. Living Arrangements and Marital Status More than 80% of the oldest-old still live at home. 50% of those who do not have family support end up in nursing homes. Many community-dwelling elders utilize a combination of formal and informal support. Widowhood is much more likely, especially for women.

7. Evaluation of Life Between 80 and 90, more people begin to describe themselves as old. Many oldest-old adults feel that they are doing pretty well for their age. “The spirit is willing, but the body refuses to cooperate”. Life satisfaction—sense of well-being experienced and identified by the individual depends on self-efficacy, or a sense of mastery and control over one’s environment.

8. Centenarians Lots of variability in health statuses and lifestyles Genetic makeup, with longevity running in families Lifestyle choices of diet, exercise, non-smoking, moderation Active social lives predict longevity Strong coping skills are important to deal with aging. Personality characteristics—able to enjoy and appreciate life

9. Informal Caregiving The three generation family is more common than in the past. Preferred living arrangement is independence Informal caregiving comes from family, friends, and church groups. Formal caregiving comes from professionals, hospitals, and paraprofessionals.

10. Obligations of Adult Children to Parents • Modified nuclear family—great deal of family interaction and support, but not an extended household • Has become common in the U.S. • Some older adults expect adult children to live nearby, visit often and take care of parents when sick • Few cultural guidelines in the U.S. for adult children’s obligations to aging parents

11. Intergenerational Norms — Standard Behaviors Almost all people feel that emotional support should be provided by children. A majority believe that adult children should provide physical assistance. A small majority believe that adult children should help out financially. Women are more likely to be expected to help.

12. Weakened Family Support System

13. Demography Long-standing trends in mortality and birthrates have consequences for the kin network. Fewer offspring and siblings are available to offer support for aging adults. Adult children without siblings experience a greater level of strain in caregiving. More people are living well into their 80s (the oldest-old), which may leave young-old children as caregivers.

14. Women’s Changing Role Traditionally, women have been expected to help with physical care and social activities as kinkeepers. Men were expected to help with tax completion, medical bookkeeping and household maintenance. The primary predictor of parent-care hours is the number of female siblings. Middle-aged daughters experience more stress in the caregiving role than do wives.

15. Changing Intergenerational Relationships The basis for help now is less for economic reasons and more for psychological reasons, such as affection, gratitude, or guilt. Adult children are more likely to be geographically scattered. Governmental assistance has reduced dependence on children. Adult day programs, Meals on Wheels, and housekeeping services help bridge the gap.

16. Spousal Caregiving About 40% of caregiving is provided by spouses. Wives provide more care than husbands. Caregiving often stresses a relationship. Many women experience “burn-out.” When men are the caregivers, they are often stressed by discussing personal problems.

17. Types of Husband Caregivers (Harris) • The Worker: models managing his wife’s illness as if it were a job, reading about disease, treatments and handling medical paperwork • Labor of Love: caring is out of devotion, not duty, and he spends all the time he can with his ill wife • Sense of Duty: commitment, obligation and responsibility inspire his caregiving • At the Crossroads: husband is new to the role, is in crisis and floundering as to what to do

18. Adult Children as Caregivers Nearly 30% of aging people who need homecare receive it from adult daughters. Middle-age women are often caught in the middle of aging parents, children, and jobs. Typical caregiver is a 46-year-old working mother caring for her 77-year-old widowed mother. Stress is mediated by the relationship with the parent, the extent of social support for the caregiver, coping skills, and self-image.

19. Caregivers Provide Care provision: personally performing instrumental and/or emotional support services Care management: indentifying and obtaining needed services, and supervising the services provided by others Both roles can be financially expensive, but care provision is more stressful.

20. Childlessness • Twenty percent of women over age 44 have no children. • The childless tend to be: • More financially secure and in better health. • More reliant on siblings, nieces, nephews, and hired care providers through the principle of substitution. • No more likely to be lonely, isolated, or unhappy than those with children.

21. Elder Caregiving to Adult Children and Grandchildren The number of older parents who care for dependent adult children and grandchildren is increasing. Elderly care for children, grandchildren with mental and physical disabilities. Physical, emotional health of caregivers can suffer Caring for an adult child seems more stressful than caring for a spouse.

22. Solving Caregiving Problems

23. Stress and Stress Management Role overload is common among caregivers Caregiver distress results from role strain, subjective burden, depression, anxiety, and hostility. Coping — response to the demands of a specific stressful situation which can vary from person to person

24. Problems in Caregiving Strain of responsibility of personal care Caregivers’ personal and health problems Role demands of other work and need for leisure Strained family relationships and conflicts Coping with bureaucracy and finding outside assistance with caregiving

25. Caring for Parents with Dementia • Restructure parent’s former identity and filial relationship • Seek helpful management strategies • Accept assistance and support from family and friends • Seek support from professional caregivers • Grieve for perceived losses in self and others • Positive restructuring of reality

26. Psychosocial Interventions Individual counseling Family counseling Support groups Educational groups Social worker visits

27. Respite Care • Providing alternative care for a short time to give the caregiver a break • Alleviates stress for the caregiver • Improves functioning of the dependent elder • Prevents or delays hospital or nursing home placements due to caregiver burnout

28. The Home Care Crisis • Paraprofessionals include nurses’ aides, personal care attendants, chore workers. • Home health care workers are generally poorly paid, overworked, have high turnover rates and are poorly trained. • They are disproportionately middle-aged ethnic minority women. • Private insurance typically does not cover home care. • Separate long-term care policies are available, but can be expensive • The demand for home care workers will continue to increase with demographic trends.

29. Recommendations for Employers of Family Caregivers Provide part-time job options. Provide flexible work hours. Allow employees to work at home when possible. Provide paid sick and personal leave. Provide long-term care insurance. Provide on-site day care.