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

Repeated claims that a dwindling supply of potential caregivers is creating a crisis in care for the U.S. aging population have not been well-grounded in empirical research. Concerns about the supply of family care do not adequately recognize factors that may modify the availability and willingness of family and friends to provide care to older persons in need of assistance or the increasing heterogeneity of the older population. In this paper, we set forth a framework that places family caregiving in the context of older adults' care needs, the alternatives available to them, and the outcomes of that care. We focus on care networks, rather than individuals, and discuss the demographic and social changes that may alter the formation of care networks in the future. Last, we identify research areas to prioritize in order to better support planning efforts to care for the aging U.S. population.

Multifamily Group Psychotherapy for Patients With Nonepileptic Seizures and Their Families

OBJECTIVE

Multifamily group (MFG) psychotherapy is widely used for mental and general medical conditions. MFG therapy engages family members in caring for a loved one experiencing illness and helps clarify the impact of illness on family. Use of MFG therapy for patients with nonepileptic seizures (NES) and their families to explore satisfaction with treatment and family functioning is described.

METHODS

MFG therapy for patients with NES and their participating family members was incorporated into an existing interdisciplinary group-based psychotherapy treatment program. The Family Assessment Device and a novel feedback questionnaire were used to understand the effect of MFG therapy on this population.

RESULTS

Patients with NES (N=29) and their corresponding family members (N=29) indicated on the feedback questionnaire their satisfaction with having MFG therapy as part of their treatment; satisfaction was also evidenced by a 79% (N=49 of 62) patient participation rate. Patients and family members reported enhanced understanding of the impact of illness on the family and believed MFG therapy would help them communicate about illness and reduce family conflict. Scores on the Family Assessment Device indicated that family members perceived better family functioning than did patients (average scores of 1.84 and 2.99, respectively).

CONCLUSIONS

The discrepancy in perceived family functioning supports the idea of integrating family members in treatment for patients experiencing NES. The group treatment modality was satisfactory to participants and may prove useful for other kinds of somatic symptom disorders, which are often external manifestations of internal distress. Family members can become treatment allies in psychotherapy when included in treatment.

Family Dynamics in Dementia Caregiving: Development and Validation of the Interpersonal Triggers of Guilt in Dementia Caregiving Questionnaire (ITGDCQ)

The objective was to develop the Interpersonal Triggers of Guilt in Dementia Caregiving Questionnaire (ITGDCQ). An emotion frequently experienced by caregivers is guilt. However, the studies analyzing potential factors that generate guilt are scarce. Guilt may be generated through interpersonal interactions. A total of 201 dementia caregivers were evaluated for frequency of leisure, guilt, anxiety, depression, and a pool of items measuring the frequency, and guilt was derived from different behaviors performed by the care recipient (ITGDCQ-CR) and other relatives (ITGDCQ-OR). Exploratory factor analysis of the ITGDCQ-CR showed a two-factor solution, explaining 56.24% of the variance. The ITGDCQ-OR subscale also showed two factors, explaining 63.24% of the variance. All the factors had acceptable to good reliability indexes. Positive associations were found between both subscales and depression, anxiety, guilt, and stress associated with CR's behavioral problems. ITGDCQ-CR was negatively correlated with frequency of leisure. The interpersonal dynamics assessed with the ITGDCQ generated other emotions such as anger or sadness. Through structural equation modeling, 28% of the variance of caregivers' distress was explained by the assessed variables, including a significant contribution of the interpersonal dynamics assessed with the ITGDCQ. The results provide preliminary support for the use of the ITGDCQ as a valid and reliable measure of care recipients' or other relatives' factors that trigger or facilitate the experience of guilt in the caregivers. The association between these factors and caregiver distress suggests potential clinical implications for the findings.

Cultural differences in the intended use of long-term care services in the United States: The role of family ties

OBJECTIVES

In the light of an increasingly diverse older population in the United States, there is an ongoing discussion how cultural factors contribute to individual long-term care (LTC) needs and service use. This study empirically assesses whether the level of acculturation and cultural differences in the importance of the family shape foreign-born immigrants' intention to use certain LTC services.

METHODS

We correlated immigrants' intention to use certain LTC services to the cultural strength of family ties that prevails in their region of origin. We used data from the National Health Interview Survey and the World Values Survey/European Values Study for analysis. Multinomial logit models were estimated and predisposing, enabling, and need factors were controlled for. Estimations were weighted to account for the sampling structure and sensitivity analyses were conducted.

RESULTS

Immigrants from cultures with stronger family ties are significantly more likely to intend the use of LTC options that include the family. Furthermore, immigrants are less likely to intend the use of exclusively family care when having lived in the United States for a longer time.

DISCUSSION

We conclude that cultural differences in family ties shape immigrants' intention to use certain LTC services. If policy makers aim at increasing the provision of specific LTC services or support to family caregivers, there should be a careful evaluation of demand-side factors in an increasingly culturally diverse society.

Well-Being and Stability among Low-income Families: A 10-Year Review of Research

Scholarship on families in poverty, in the last decade, documented various struggles and challenges faced by low-income families and expanded our understanding of their complicated life circumstances embedded within the contexts of community, culture, and policies. The research articles published in the Journal of Family and Economic Issues during this time, that highlighted poverty, focused primarily on three topic areas: economic security, family life issues, and food security. Overall, findings conclude that family well-being and stability cannot be promoted without the consideration of environmental factors. They depend on the interaction among individual (e.g., increased human capital), family (e.g., positive co-parental relationship), community (e.g., affordable childcare), and policy changes (e.g., realistic welfare-to-work programs). Collectively, the articles have provided a road map for future research directions.

A Scoping Review: Characteristics and Outcomes of Residents Who Experience Involuntary Relocation

BACKGROUND AND OBJECTIVES

Relocation to a residential care facility has been described as the most significant relocation affecting older adults, yet subsequent relocations, like in the case of a facility closure, have received minimal attention in the scholarly research literature. This paper reviews the published literature on involuntary relocation, focusing on the experiences of residents, families, and staff and the effects of involuntary relocation on nursing home residents' health.

RESEARCH DESIGN AND METHODS

We conducted a scoping review to identify peer-reviewed studies reporting on involuntary relocation of nursing home residents. A total of 28 quantitative, qualitative, and mixed-method articles met inclusion criteria.

RESULTS

Researchers mostly relied on longitudinal designs and quantitative indicators of functional health, cognitive status, psychological and emotional well-being, environment, and relocation context to examine residents' mortality risk and health outcomes associated with involuntary relocation. Inclusion of qualitative and mixed-method approaches was infrequent, as were indicators of social engagement and perceptions of relocation. Residents' awareness of and preparation for involuntary relocation positively influenced their health and well-being. Family involvement was frequently hindered by communication challenges with facilities. Staff expressed concern about residents, experienced increased workload demands, and acknowledged challenges with planning and communication.

DISCUSSION AND IMPLICATIONS

Based on the collective findings, we propose a conceptual model of critical factors at play during relocation for consideration for guiding future research and developing provisions to current policies guiding relocation processes. Facilities and policymakers need to consider procedures that enhance planning efforts and decision-making among this vulnerable population and their families.

Stressors and Resources Related to Medication Management: Associations With Spousal Caregivers' Role Overload

BACKGROUND AND OBJECTIVES

Managing medications can be stressful for spousal caregivers, but little is known about particular aspects of medication management that are most consequential for caregiving outcomes. We examined care stressors and resources related to medication management, their associations with role overload among spousal caregivers, and whether these links vary by care recipients' number of chronic health conditions and dementia status.

RESEARCH DESIGN AND METHODS

This cross-sectional study included 377 spousal caregivers of adults aged 65 and older from the 2011 National Health and Aging Trends Study and National Study of Caregiving. Linear regressions were estimated to evaluate how medication-related stressors (ordering medication, keeping track of medications, giving injections) and resources (medication reminder systems, shared medication management within the spousal dyad) are associated with caregivers' role overload. Care recipients' number of chronic health conditions and dementia status were considered as moderators. Models controlled for caregivers' sociodemographic characteristics, chronic health conditions, and other care tasks.

RESULTS

Caregivers who administered injections reported more role overload, whereas those who worked with care recipients to jointly manage medications reported less role overload. Keeping track of medications was linked to caregivers' greater role overload when care recipients had 5 or more chronic health conditions. Finally, care recipients' use of medication reminder systems was linked to less role overload for caregivers of a partner with dementia.

DISCUSSION AND IMPLICATIONS

Devising strategies to assist spousal caregivers in the more onerous components of medication management and promote resources that mitigate medication-related stress may improve caregiver well-being.

The Burden and Benefits of Caregiving: A Latent Class Analysis

BACKGROUND AND OBJECTIVES

Informal caregiving to older adults is a key part of the U.S. long-term care system. Caregivers' experiences consist of burden and benefits, but traditional analytic approaches typically consider dimensions independently, or cannot account for burden and benefit levels and combinations that co-occur. This study explores how benefits and burden simultaneously shape experiences of caregiving to older adults, and factors associated with experience types.

RESEARCH DESIGN AND METHODS

2015 National Health and Aging Trends Study (NHATS) and National Study of Caregiving (NSOC) data were linked to obtain reports from caregivers and recipients. Latent class and regression analysis were conducted on a nationally representative sample of U.S. informal caregivers to older persons.

RESULTS

Five distinguishable caregiving experiences types and their population prevalence were identified. Subjective burden and benefits level and combination uniquely characterize each group. Primary stressors (recipient depression, medical diagnoses), primary appraisal (activities of daily living, instrumental activities of daily living, medical task assistance, hours caregiving), and background/contextual factors (caregiver age, race, relationship to recipient, mental health, coresidence, long-term caregiving) are associated with experience types.

DISCUSSION AND IMPLICATIONS

Findings highlight caregivers' experience multiplicity and ambivalence, and identify groups that may benefit most from support services. In cases where it is not possible to reduce burden, assistance programs may focus on increasing the benefits perceptions.

Transition in Older Parent-Adult Child Relations in U.S. Chinese Immigrant Families

BACKGROUND AND OBJECTIVES

The family fundamentally underpins the immigration and acculturation processes. But most existing research on acculturation focuses on individual instead of family experience. Guided by Berry's acculturation theory and Intergenerational Solidarity Theory, this study examined continuity and changes in parent-adult child relations of older Chinese immigrants over a 2-year period, and their implications for older adults' depression and quality of life (QoL).

RESEARCH DESIGN AND METHODS

Participants included 2,605 older Chinese immigrants from the Population Study of Chinese Elderly in Chicago (PINE). Latent Transition Analysis (LTA) was used to identify transitions in multidimensional parent-child relations over time. Negative binomial and logistic regressions were used to examine the influence of family transitions on depression and QoL, respectively.

RESULTS

LTA revealed five types of family relations: traditional, modified traditional, coresiding-unobligated, independent, and detached. Over 40% of the respondents shifted to a different relation type, with more families classified as modified traditional or independent over time. Transitioning into modified traditional relations or out of detached relations was associated with fewer depressive symptoms and better QoL at the follow-up. Transitioning into independent relation was associated with more depressive symptoms over time.

DISCUSSION AND IMPLICATIONS

Parent-child relations among Chinese older immigrants demonstrate significant complexity, including both heterogeneity and fluidity. Better well-being of these older adults seems to stem from the optimal combination of retaining the supportive heritage culture and embracing the host society's instrumental cultural elements. Services to this population need to include the family context in assessment and interventions.

Predictors of Secondary Role Strains Among Spousal Caregivers of Older Adults With Functional Disability

BACKGROUND AND OBJECTIVES

Aging spouses commonly care for a partner with functional disability, but little is known about how spousal caregiving may impact different life domains. This study evaluated how caregiving characteristics are associated with secondary role strains among spousal caregivers.

RESEARCH DESIGN AND METHODS

This cross-sectional study examined 367 spousal caregivers and their partners from the 2011 National Health and Aging Trends Study and National Study of Caregiving. Hierarchical regressions were estimated to determine how caregiver background factors (sociodemographics, health conditions) along with primary objective (care activities, care recipient health conditions, and dementia status) and subjective (emotional caregiving difficulties, role overload) stressors are linked to care-related valued activity restriction, negative caregiving relationship quality, and care-related family disagreements. Gender differences were considered.

RESULTS

After accounting for all predictors, older caregivers and caregivers providing more help with activities of daily living and health system interactions (e.g., scheduling appointments) were more likely to report activity restriction, whereas caregivers with more emotional difficulties reported higher negative caregiving relationship quality. Role overload was positively associated with all three secondary strains. For husbands only, caring for a partner with more chronic conditions was linked to higher negative caregiving relationship quality and caring for a partner with dementia was associated with a greater likelihood of family disagreements.

DISCUSSION AND IMPLICATIONS

Secondary role strains may develop through similar and unique pathways for caregiving wives and husbands. Further research is needed to identify those who could benefit from support in managing their care responsibilities alongside other life areas.

Care Values in Dementia: Patterns of Perception and Incongruence Among Family Care Dyads

BACKGROUND AND OBJECTIVES

Persons with dementia (PWDs) often place greater importance on their care values (i.e., maintaining autonomy and social relations, choosing caregivers, avoiding being a burden) than family caregivers (CGs) perceive, which can detract from dementia care planning (e.g., care arrangements or surrogate decisions). Notable variability has been found across family care dyads (PWD and CG) in their perceptions of care values, suggesting that there may be multiple patterns of perception. The purpose of this study was to characterize distinct patterns of perception of care values in family care dyads.

DESIGN AND METHODS

Using cross-sectional data from 228 community-dwelling family care dyads, we quantified dyads' average perceptions and incongruence in perceptions of the importance of everyday care values using multilevel modeling. These scores were then used in a latent class analysis to identify distinct patterns of perception, with the dyad as the unit of analysis.

RESULTS

Two distinct patterns of care value perception were identified. 25% of dyads were labeled as "CG underestimating" due to lower average estimations of the importance of PWDs' care values, and a significant amount of dyadic incongruence. Underestimating dyads were characterized by a confirmed diagnosis of dementia, lower cognitive function, and younger age in PWDs, and higher relationship strain in the dyad.

IMPLICATIONS

Care dyads that fall into an underestimating pattern may be at greater risk for inadequate dementia care planning. Interventions to improve care planning in this higher-risk group may include care values identification with the PWD, strategies for alleviating relationship strain, early-stage planning, and disease education.

Purpose in Life Among Family Care Partners Managing Dementia: Links to Caregiving Gains

BACKGROUND AND OBJECTIVES

Purpose in life is associated with better health and has been found to minimize caregiving stress. Greater purpose may also promote caregiving gains (i.e., rewards or uplifts from providing care), yet the implications of purpose for positive aspects of the care role are largely unknown. The present study determined how perceptions of purpose in life among persons with dementia (PWDs) and their family caregivers are linked to caregiving gains.

RESEARCH DESIGN AND METHODS

This cross-sectional study examined 153 co-resident family caregivers drawn from the 2011 National Health and Aging Trends Study and National Study of Caregiving. Linear regressions were estimated to evaluate associations between caregivers' and PWDs' reports of their own purpose in life and caregivers' perceived caregiving gains, along with whether these associations vary by caregiver gender. Models controlled for caregivers' sociodemographic characteristics, relationship to the PWD, care tasks, role overload, negative caregiving relationship quality, and both care partners' chronic health conditions.

RESULTS

Caregivers' higher purpose in life was significantly linked to greater caregiving gains. Beyond this association, PWDs' higher purpose in life was significantly associated with greater caregiving gains for women but not for men.

DISCUSSION AND IMPLICATIONS

Purpose in life is a psychological resource that contributes to positive caregiving outcomes. Interventions to improve caregiver well-being could benefit from strategies that strengthen and maintain feelings of purpose among caregivers and PWDs.

Negotiating a Place in the Family-A Grounded Theory Exploration of Stepgrandmothers' Enactment of Roles

Purpose

Stepgrandparents are becoming more common, and they can, and often do, provide affective and instrumental support to families. Little is known, however, about how they negotiate and enact their roles within families, especially with stepgrandchildren. Stepgrandmothers warrant special attention because researchers have found that women experience more challenges than men in stepfamilies. Guided by symbolic interactionism, the purposes of our study were: (a) to explore stepgrandmothers' role enactment and (b) to explore the intrapersonal, interpersonal, and contextual factors that contribute to role enactment in intergenerational steprelationships.

Design and Methods

Eighteen stepgrandmothers participated in semi-structured interviews, discussing their relationships with 94 stepgrandchildren. Consistent with grounded theory methods, data collection and analysis occurred simultaneously.

Results

Interviews with stepgrandmothers revealed that they spend considerable time and energy defining their roles with stepgrandchildren. Stepgrandmothers' role enactment is a complex, reflexive process. A few perceived that their roles were shaped by their own dispositions, desires, and expectations (evidence for role-making), but most stepgrandmothers described their roles as reflecting the dispositions, desires, and expectations of others (evidence for role-taking). Stepgrandmothers reflected on their roles as a delicate balance of intra- and inter-personal negotiations, operating within cultural expectations.

Implications

Findings draw attention to the complex nature of role-taking, role-making, and gendered, relational processes in multigenerational stepfamilies. We discuss implications for research and theory related to stepgrandmotherhood as an incomplete institution.

Adult Children's Serious Health Conditions and the Flow of Support Between the Generations

Purpose

The life course perspective suggests that serious physical or mental health conditions that limit the daily activities of any one family member are likely to be consequential for other family members as well. In this article, we explored whether adult children's serious health conditions affected the flow of expressive and instrumental support between mothers and both the offspring with health conditions and other offspring in the family.

Design and Methods

We used data collected from 369 older mothers (M = 78 years) regarding 1,338 of their adult children (M = 49 years), as part of the Within-Family Differences Study-II.

Results

Adult children with serious health conditions were more likely than their siblings to be given support by their mothers. The presence of adult children with health issues did not reduce mothers' provision of expressive or instrumental support to their children without health conditions. However, in families in which a higher proportion of children had serious health conditions, mothers received expressive support from a greater proportion of their healthy adult children than in families with a smaller proportion of adult children with health conditions.

Implications

These findings contribute to a growing body of research demonstrating the ways in which conditions in adult children's lives affect their mothers.

Filial Obligation and Marital Satisfaction in Middle-aged Couples

Purpose of the Study

Although prior research suggests that high filial obligation has an adverse impact on psychological well-being, little is known about the implications of these beliefs for marital quality during midlife. Therefore, the purpose of this study was to examine dyadic associations between middle-aged husbands' and wives' filial obligation beliefs and their marital satisfaction.

Design and Methods

Using a sample of 132 middle-aged husbands (M = 51.45 years) and wives (M = 49.75 years) drawn from Wave 1 of the Family Exchanges Study, we tested actor-partner interdependence models to determine associations between husbands' and wives' filial obligation beliefs and marital satisfaction in both spouses. We also examined associations between spousal dissimilarity in filial obligation and marital satisfaction.

Results

Wives' greater filial obligation was associated with their own lower marital satisfaction. Conversely, husbands' greater filial obligation was associated with their own higher marital satisfaction. Greater spousal dissimilarity in filial obligation was associated with lower levels of marital satisfaction for husbands but not for wives.

Implications

Given that support provided to aging parents most often occurs within the context of marriage, findings highlight the importance of examining dyadic associations between filial obligation beliefs and marital quality among middle-aged couples.

Interconnections Between My Research and Experience as a Caregiver: Impacts on Empirical and Personal Perspectives

Shortly after I received my first R01 grant to study the health effects of caregiving, my sister and I became caregivers to our father. For the next 13 years, we helped him with activities of daily living (ADLs), accompanied him to doctors' appointments, arranged for home health care, and finally for home hospice. At first, I was able to connect our assistance with ADLs, frustration with coordinating his care, and our psychological stress with my epidemiologic studies. My familiarity with the language of caregiving and long-term care helped us to navigate the medical and home care systems, and to be advocates for my father. However, as my father's health declined, I felt an increasing disconnect between my research and my experience: communicating with physicians and other care providers, responding to crises and conversations with my sister about placing our father in a nursing home were greater sources of stress than my father's dementia. These discrepancies made me realize that I could help caregivers more by helping them to negotiate these challenges than through performing quantitative research. So I enrolled in a counseling psychology program. My manuscript will chronicle the ways that caregiving changed me; how my professional work did and did not help me as a caregiver; how the developmental and family theories that I am learning in my psychology classes have expanded my understanding of stressors facing adult child caregivers, and how this entire experience ties into generativity and Third Chapter careers that build on midlife experiences.

"It Can't Happen Soon Enough." The Role of Readiness in Residential Moves by Older Parents

My father moved from his home of 92 years to a care community in a distant location. This is the story of his move, from the perspective of a gerontologist and soon-to-be young-old daughter. I describe the events that prompted my father's decision to make the move, how I chose the care community, the transition arrangements, and the outcomes. I discuss key factors that contributed to the successful transition, all with a focus on readiness. Other factors included drawing on my knowledge as a gerontologist, using informal networks to identify a care community, visiting the care community repeatedly, and communicating openly and often with family. I briefly describe my father's quality of life after the move. I examine my experiences in the context of relevant research in gerontology, recommend how gerontologists can manage transitions to care communities for their aging parents, and offer suggestions for research.

Who provides care? A prospective study of caregiving among adult siblings

PURPOSE

We use data from a longitudinal, within-family study to identify factors that predict which adult siblings assumed caregiving responsibilities to older mothers over a 7-year period.

DESIGN AND METHODS

Data for the study were collected from 139 older mothers at 2 points 7 years apart regarding their expectations and experiences of care from 537 adult children.

RESULTS

Children whom mothers identified at T1 as their expected future caregivers were much more likely to provide care when a serious illness occurred. Caregiving offspring were also more likely at T1 to have shared their mothers' values, lived in proximity, and to be daughters.

IMPLICATIONS

The findings indicate the degree to which a mother's expectations for care predict actual caregiving by that child. Practitioners working with older adults should explore parents' expectations for future care that involves their adult children.

The experiences of grandparents who have limited or no contact with their grandchildren

PURPOSE OF THE STUDY

The matrilineal advantage theory suggests that paternal grandparents are more at risk of having little or no contact with their grandchildren. However, there is significant family diversity within Australia and we wished to understand the experiences of a wide range of grandparents in order to determine if the matrilineal theory can be effectively used in practice to identify those grandparents most at risk for estrangement.

DESIGN AND METHODS

A convenience group of grandparents with little or no contact with grandchildren (n=38) told their stories in their own words using narratives obtained through interview or writing.

RESULTS AND IMPLICATIONS

We found that paternal grandparents, as per the matrilineal advantage theory, were more likely to be estranged from their grandchildren when their son divorced, particularly when he was not the resident parent or when he re-partnered. However, in contrast, we found that maternal grandparents who experienced conflict in their relationship with their daughter were also at risk for estrangement. This occurred even when grandparents had previously been highly involved in the lives of their grandchildren. Some estrangements appeared to result from a cultural bias towards the nuclear family form. We argue that practitioners need not only to expand their understanding of the risk categories for estrangement, they also need to actively support parents and grandparents in creating and maintaining wider family support networks in order to improve family resilience.