The Changing Demography of Late-Life Family Caregiving: A Research Agenda to Understand Future Care Networks for an Aging U.S. Population

Navigating a Skilled Nursing Facility Stay Together: A Dyadic Qualitative Study of Dually Eligible Patients and Care Partners

BACKGROUND AND OBJECTIVES

Shared stressors are co-experienced by dyad members and increase each's psychological distress. This study analyzes dyadic qualitative data with dually eligible (i.e., Medicare and Medicaid beneficiaries) residents and their care partners during a subacute/postacute skilled nursing facility (SNF) stay. We aimed to (1) identify shared stressors that affect both dyad members and (2) explore differences between dyad relationship types.

RESEARCH DESIGN AND METHODS

Seventeen dyads (N = 34 individuals) participated in semistructured interviews during a SNF stay, separately. There were no exclusion criteria based on relationship type. The dyadic framework method was used to analyze dyads as a single unit, rather than the sum of separate narratives.

RESULTS

The sample consisted of adult child (n = 9, 53%), friend (n = 6, 35%), sibling (n = 1, 6%), and parent (n = 1, 6%) care partners. Four themes emerged, providing insight into shared stressors: (1) balancing autonomy and support; (2) long-term care decision-making; (3) cognitive concerns requiring attention; and (4) preexisting relationships. Care roles and shared stressors were mostly similar across relationship types; although, some inter-dyad differences were noted in decision-making processes and interpersonal dynamics.

DISCUSSION AND IMPLICATIONS

This study identified multiple shared stressors that occur during SNF stays, as dyads must navigate changes to autonomy-support structures as well as the care environment, caregiving role, and existing relationship, together. We discuss implications for research, practice, and policy, including dyadic psychological intervention; care partner training for psychological, behavioral, and case management; cognitive symptom assessment, education, and management; and support for long-term care decision-making and transitions.

Racial-Ethnic Differences in Care Networks of Older Adults: Empirical Exploration of Possible Explanations

OBJECTIVES

Previous research on eldercare among minority populations often highlights the role of values, beliefs, and social expectations, placing greater emphasis on ideational factors than on sociostructural and health factors in explaining racial-ethnic differences in care arrangements. This study aims to describe the extent to which care received by older adults varies by race-ethnicity and to explore possible explanations for these variations using the behavioral model of health care use.

METHODS

Data were sourced from the 2018 National Health and Aging Trends Study (NHATS), a nationally representative survey of Medicare beneficiaries aged 68 and older. Latent class analyses were used to develop a care network typology with combinations of care from different sources. Multinomial regression models assessed various predisposing, enabling, and need factors associated with racial-ethnic differences in the distribution of constructed care network types. Formal mediation analysis tested potential mediators of these differences.

RESULTS

Black and Hispanic older adults tended to receive care from children and extended kin caregivers, while White older adults were more likely to receive care from their spouses and perform self-care with assistive technologies. Mediation analyses revealed that racial-ethnic differences in care networks were primarily attributable to enabling factors, including family configurations, social networks, and socioeconomic status. Limited evidence was found for the roles of predisposing factors, measured by care preferences, and need factors, measured by health conditions, in explaining these differences.

DISCUSSION

The findings highlight the need for more research and policy interventions to address the diverse challenges faced by socially disadvantaged older adults.

Caregiving Trajectories and Unmet Care Needs in Later Life

BACKGROUND AND OBJECTIVES

The evolution of care networks accompanying older adults' changing care needs-and implications for unmet care needs-are not well described.

RESEARCH DESIGN AND METHODS

Using group-based trajectory models, we identify 4 incident care need patterns ("care need trajectory groups") for 1,038 older adults in the 2012-2018 National Health and Aging Trends Study and 5 caregiving patterns ("caregiving trajectory groups") and a transient group among their 4,106 caregivers. We model associations between care need/caregiving trajectory groups and the rate of (approximating the proportion of rounds with) unmet care needs. We illustrate how predicted rates vary by care need trajectory groups and by network composition for networks with 2 caregivers.

RESULTS

The percentage of rounds with unmet care needs varies from 13% among older adults with few, stable needs to 62% among those with many, stable needs (p < .01). In models, care need trajectory group is strongly associated with the rate of unmet care needs; among those with steep increasing care needs, network composition is also predictive. For older adults with steep increasing care needs, when 1 caregiver provides high, variable, and another medium, stable care hours, the predicted rate of unmet care needs is low (0.16) and similar to those with few, stable care needs (0.12).

DISCUSSION AND IMPLICATIONS

The findings highlight the complexity and heterogeneity of older adults' care needs and caregiving patterns over time. For those with rapidly increasing needs, identifying and assessing the evolving care network may be a fruitful direction for forestalling unmet care needs.

Stressors and Resources Among Adult Child Caregivers in the Presence or Absence of Siblings

BACKGROUND AND OBJECTIVES

Recent attention has focused on understanding later-life caregiving networks, emphasizing how multiple adult children within the same family navigate parental care. However, families with one child are increasingly common, and we know little about how adult only children experience caregiving and whether their experiences differ from those with siblings. Therefore, this study assessed differences in caregiving experiences between adult child caregivers with and without siblings and whether associations between caregiving experiences and mental health (i.e., psychological well-being and distress) vary by sibling presence.

RESEARCH DESIGN AND METHODS

We used cross-sectional data from 1,773 adult child caregivers (12% without siblings; Mage = 56.75 [9.23]) in the National Health and Aging Trends Study and National Study of Caregiving. We conducted t tests and a series of multivariate regressions with interactions to test hypotheses.

RESULTS

Adult only child caregivers reported more financial difficulty with care than respondents with siblings. The negative association between emotional difficulty of care and psychological well-being was stronger among adult children without siblings. Informal support was positively associated with psychological well-being only for adult children with siblings, although this may be accounted for by race and ethnicity.

DISCUSSION AND IMPLICATIONS

Findings suggest that adult only children may be at elevated risks of the financial difficulties and the emotional consequences of parental care provision. Further, informal support may be less protective for adult only children's well-being. Given the increasing prevalence of single-child families, more research is needed to better understand and support adult only children caring for parents.

Racial-Ethnic Stratification in Work-Family Arrangements among Black, Hispanic, and White Couples

Objective

This article builds on work-family scholarship to document racial-ethnic variation in couples' work-family arrangements, i.e., how couples respond to their work and family demands.

Background

Existing research on the division of labor finds traditional gender norms continue to dictate how couples share paid and unpaid work in the United States. Yet, this narrative relies primarily on the structural conditions and cultural expectations of white and middle-class women. Black and Hispanic women and men face different labor market opportunities and hold different cultural expectations about gendered responsibilities in families.

Method

The authors use the 2017-2019 Panel Study of Income Dynamics (https://psidonline.isr.umich.edu) and multi-group latent-class analysis to determine typical work-family arrangements for paid work, housework, and care work among U.S. different-sex racially homogamous Black, Hispanic, and white couples, as well as how the prevalence of these arrangements vary across race-ethnicity and life-course stage.

Results

Black, Hispanic, and white couples respond to their work-family demands through one of six work-family arrangements depending on how partners spend time in adult care, childcare, housework, and paid work. Childcare and paid work emerge as stratifying mechanisms of how couples spend their time. Specifically, racial-ethnic differences in distribution across work-family arrangement are large and greatest when couples have young children.

Implications

This article provides support for a couple-level and life-course approach to explaining how couples spend their time in work and family domains across racial-ethnic lines.

The Number Of Family Caregivers Helping Older US Adults Increased From 18 Million To 24 Million, 2011-22

The evolving composition and experiences of the family caregiver workforce have profound ramifications for public policy but are not well understood. Drawing on the linked National Health and Aging Trends Study and National Study of Caregiving, we found that the numbers of family caregivers providing help to older adults increased by nearly six million between 2011 and 2022, rising from 18.2 million to 24.1 million. Among older adults receiving care, network size was stable, at about two caregivers per older adult at both points in time. However, in 2022, family caregivers were assisting older adults who were younger, more likely to be male and better educated, and less likely to have dementia. We found few changes in competing work and child care responsibilities, weekly care hours, and caregiving-related difficulty. A smaller number of family caregivers were assisting fewer older adults with dementia, but in this group, co-residence increased by 25 percent, average care hours increased by 50 percent, and employment decreased. For family caregivers as a whole, challenges persist, and for those assisting people with dementia, tailored surveillance and effective support programs are needed.

Impact of Older Adults' Internet Use on Economic Burden of Informal Caregiving

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Young Adult Caregivers for Older Family Members: Setting a New Research Agenda

Young adults (approximately aged 18 to 29) are frequently involved in caring for older relatives, potentially filling gaps and playing key roles in the network of caregivers. The time is ripe to synthesize the emerging literature on this topic and propose an agenda for future research. This article identifies key questions for research that will propel the field forward, including: (a) why young adult caregiving warrants distinct consideration from caregiving in midlife or later life, (b) young adult caregivers' position in the caregiving network and tasks they perform, and (c) factors that help determine who becomes a caregiver at this stage of life and who does not, with attention to race/ethnicity, and beliefs about family interdependency. We then address appraisals of caregiving stress, rewards, and potential factors that may buffer the negative impact of caregiving at this stage of life. We extend this discussion to the detriments and benefits of caregiving for well-being. We consider longer-term enduring positive and negative consequences of caregiving at this potentially transformative stage of adulthood. Throughout this article, we review many of the founding studies and scholars who have laid the groundwork in this emerging field and point out the components of existing models of caregiving that particularly apply to young adult caregivers. We conclude with suggestions for potential policies and programs to allow for young adults to engage in caregiving while also pursuing the roles and activities that align with their values and set them up for a successful adulthood.

Including Families in a Response to the Unregulated Toxic Drug Crisis: A Call to Action

The unregulated toxic drug crisis continues to be an urgent health issue in North America. Many families of people who use drugs have been significantly impacted by this issue. In addition to the thousands of North Americans who have been bereaved by drug mortality, many families are providing unpaid care to bridge gaps in services while navigating the grief and stress associated with caring for a loved one amidst a heavily politicized and rapidly changing context. Despite the impact on families, few interventions are in place to lessen the burden of the crisis. This commentary presents a call to action to include families of people who use drugs in a public health response to the toxic drug crisis. We emphasize the need for (1) the consideration and involvement of families in all aspects of policy and program decision making, (2) the recognition of families of people who use drugs within national caregiving and bereavement strategies; (3) increased supports and services for families; and (4) additional research and public health monitoring on the impact of the toxic drug crisis on families.

Kinship and Care: Racial Disparities in Potential Dementia Caregiving in the United States From 2000 to 2060

BACKGROUND

Although the family plays a pivotal role in older adults' care, there is limited research on how evolving demographic trends affect older adults' support networks and how the trends vary by race. To fill this gap, we examine the influence of shifting family demographics on future care needs for older adults with dementia, emphasizing the unequal health and potential caregiving burdens by race in the United States.

METHODS

Using demographic models of kinship, we estimate the availability of potential caregivers, and dementia prevalence among one's kin by race, kin type, and the age of a focal person from 2000 to 2060. We introduce an index called the Dementia Dependency Ratio to assess dementia caregiving demands at the population level, taking into account the age and kinship structure of the population.

RESULTS

Our findings suggest that Black individuals tend to have more children, grandchildren, and nieces/nephews as they age. However, Black individuals also tend to have more kin with dementia compared to their White counterparts. This elevated prevalence of dementia among Black kinship networks counterbalances the advantage of having more kin as potential caregivers. A further projection analysis suggests that the racial gap in caregiving demand within the kinship network will widen in the next 4 decades if the racial gap in dementia prevalence remains unchanged.

CONCLUSIONS

These findings emphasize the urgency of reducing racial inequality in dementia prevalence rates and increasing public support for families with extended members affected by dementia. With the shrinkage of nuclear families and population aging in the next few decades, extended family members may undertake more caregiving responsibilities for dementia. We call for a kinship perspective in understanding dementia care in future research.

Changes in Family Structure and Increasing Care Gaps in the United States, 2015-2050

Research on caregiving in the United States has not clearly identified the scope of the gap between care needed and care received and the changes implied by ongoing and anticipated shifts in family structure. This article examines the magnitude of contemporary gaps in care among older adults in the United States and how they are likely to evolve through 2050. We use data from the Health and Retirement Study (1998-2014) to estimate care gaps, operationalized as having difficulties with activities of daily living (ADLs) or instrumental activities of daily living (IADLs) but not receiving care. We also estimate variation in care gaps by family structure. Then, we use data from demographic microsimulation to explore the implications of demographic and family changes for the evolution of care gaps. We establish that care gaps are common, with 13% and 5% of adults aged 50 or older reporting a care gap for ADLs and IADLs, respectively. Next, we find that adults with neither partners nor children have the highest care gap rates. Last, we project that the number of older adults with care gaps will increase by more than 30% between 2015 and 2050-twice the rate of population growth. These results provide a benchmark for understanding the scope of the potential problem and considering how care gaps can be filled.

Examining Care Network Characteristics in Older Adults' Relocation to Residential Care Settings

Background and Objectives

When older adults face increasing care needs or limited support, remaining safely and comfortably at home becomes challenging. Extant research has primarily concentrated on characteristics of the older adult or their primary caregiver on nursing home admission. This study examines the risk of older adults transitioning to residential care (e.g., assisted living, nursing home), focusing on the influence of their care network or involvement of multiple helpers.

Research Design and Methods

Using the National Health and Aging Trends Study, we conducted competing risk regression models that account for mortality, following 7,085 initially community-dwelling older adults across Rounds 1-9 (2011-2019). We assessed network composition, size, shared tasks, and the number of in-network specialists or generalists while controlling for individual sociodemographic and health factors.

Results

Individuals with care networks that shared medical tasks had the highest risk of moving to a residential care setting, followed by those sharing household tasks. Conversely, shared mobility or self-care and transportation responsibilities were associated with lower risks. Having more generalists, but not specialists, increased the risk. Larger networks were associated with heightened risk, although having close family members like a spouse was protective.

Discussion and Implications

The findings underscore that care network characteristics are critical to older adults' ability to age in place. Specifically, older adults with larger networks, lacking a spouse or child, and providing complex care are at greater risk for relocating. Understanding care networks can guide interventions related to care network coordination and resource allocation to help avoid or postpone a residential care move.

The care of non-institutionalized ADL-dependent people in the Orcasitas neighborhood of Madrid (Spain) during the Covid-19 pandemic and its relationship with social inequalities, intergenerational dependency and survival

Background

Mortality among people with dependency to perform basic activities of daily living (ADL) is higher than that of non-dependent people of the same age. Understanding the evolutionary course and factors involved in non-institutionalized ADL dependency, including the influence of the family structure that supports this population, would contribute to improved health planning.

Methods

A longitudinal study carried out in the ADL-dependent population of the Orcasitas neighborhood, Madrid (Spain), between June 2020, when the nationwide COVID-19 lockdown ended, and June 2023. A total of 127 patients participated in the study, 78.7% of whom were women and 21.3% were men. Risk analysis was performed via odds ratios (OR) and hazard ratios (HR). Survival analysis was performed using Cox regression.

Results

A total of 54.33% of the ADL-dependent persons did not live with their adult children and 45.67% did, being associated living independently with economic capacity and the married marital status but not with the dependency level. In women, being married increased the probability of living independently of their adult children (OR = 12.632; 95% CI = 3.312-48.178). Loss of mobility (OR = 0.398; 95% CI = 0.186-0.853), economic capacity of the dependent (HR = 0.596; 95% CI = 0.459-0.774), and living independently and having better economic capacity (HR = 0.471; 95% CI = 0.234-0.935) were associated with 3-year survival. Those who lived with their adult children had a worse autonomy profile and higher mortality (HR = 1.473; 95% CI = 1.072-2.024). Not being employed, not being married, and not owning a home were significantly associated with being an essential family caregiver. Caregivers were mostly women (OR = 1.794; 95% CI = 1.011-3.182).

Conclusion

Among ADL-dependent persons, economic capacity influenced the ability to living independently and affected survival after 3 years. Loss of mobility (wheelchair use) was a predictor of mortality. Social inequalities promote that adult children end up as essential family caregivers. This generates reverse dependency and maintains a vulnerability that is transmitted from generation to generation, perpetuating social and gender inequalities. Dependent parent care in this cohort maintained an archaic pattern in which the eldest daughter cared for her parents. This study made it possible to show that ADL dependence is accompanied by complex interrelationships that must be considered in socio-health planning.

Mental and physical health among 'sandwich' generation working-age adults in the United States: Not all sandwiches are made equal

Objective

This research examined mental and physical health differences by (1) potential upward and downward care recipients and (2) heterogenous time and money transfer arrangements among working-age adults aged 35-64 in the U.S. who are considered to belong to the 'sandwich generation'.

Methods

Data for this study came from the Panel Study of Income Dynamics 2013 Family File and Rosters and Transfers module (n = 4609). For the second study objective, we restricted the analytic sample to individuals with at least one living parent/parent-in-law and at least one child (n = 2228). We varied the sandwich generation experience by whether upward (i.e., to parent), downward (i.e., to children), or transfers at both directions occurred. We then fit a series of logistic regression models to study psychological distress and self-rated health status differences among various classifications of sandwich generation, controlling for basic sociodemographic factors and living arrangements. For both samples, we ran separate models for those without underaged coresident children.

Results

Compared to respondents without potential care recipients, sandwiched individuals do not differ concerning severe psychological distress or poor/fair health. Conditional on being sandwiched between parents/parents-in-law and adult children, providers of both upward and downward time transfers have almost twice the odds of having severe psychological distress while money providers to parents/parents-in-law have about 1.6 times higher odds of reporting poor/fair health status.

Conclusion

This study dispels the notion that being part of the sandwich generation is automatically deleterious to mental and physical health. Rather, it is the provision of certain transfers whilst being sandwiched that is associated with worse health outcomes.

Unpaid caregiving and stress among older working-age men and women in Sweden

Many individuals are experiencing the potentially stressful combination of providing care while still employed. In this study, the association between unpaid caregiving to another adult and self-reported stress among men and women aged 45-74 is investigated, using nationally representative time use diary data for Sweden (2000-01 and 2010-11, N = 6689). Multivariate regression analyses established that women were overall more stressed than men with the largest gender stress gap observed among intensive caregivers, providing >60 min of daily care and employed caregivers. The association between unpaid caregiving, employment, and self-reported stress is gendered. Among men, there is no caregiver effect regarding stress, but for women there is a net effect of 6-9%. Combining employment and unpaid caregiving (especially if intensive) is stressful for women but not for men. There are two potential mechanisms for this: less time for leisure and sleep. Unpaid caregiving is positively associated with stress among women when seen in relation to the way caregivers trade off time, not least to aid their recovery. These findings provide a more nuanced understanding of the time trade-offs carers make and uncover gender differences in the association between caregiving and stress that add to an existing gender stress gap. Given that unpaid caregivers are an important source of long-term care services, policymakers should consider that caregiving may be stressful and that stress impacts are gendered when designing and evaluating policies for longer working lives.