A Care Paradox: The Relationship Between Older Adults' Caregiving Arrangements and Institutionalization and Mortality

We investigate how the type of caregiving arrangement is associated with older Americans' outcomes. We use the Health and Retirement Study (2004-2018) and discrete-time event history analysis to assess the odds of institutionalization or death over a 14-year period among older adults with limitations in Activities of Daily Living (ADLs; e.g., bathing). We consider caregiving arrangements as conventional (i.e., spouse or adult child), unconventional (e.g., extended family, employee, friend), or self-directed (i.e., no caregiver). We find a "care paradox" in that self-directing one's own care was associated with a lower risk of institutionalization or death compared with having conventional care (spouse/adult caregiver) and unconventional care (employee). Relative to conventional care, having an employee caregiver was associated with increased risk of institutionalization. Findings are still observed when controlling for level of impairment and various health-related factors. More research is needed to understand older adults who self-direct their own care.

What determines informal care need among community-dwelling older adults in China? Results from a longitudinal study

BACKGROUND

With an intensified aging population and an associated upsurge of informal care need in China, there is an ongoing discussion around what factors influence this need among older adults. Most existing studies are cross-sectional and do not focus on older people living in the community. Conversely, this study empirically explores the factors that affect informal care need of Chinese community-dwelling older individuals based on longitudinal data.

METHODS

This study constructed panel data using the China Health and Retirement Longitudinal Research Study (CHARLS) from 2011 to 2018 for analysis. Generalized linear mixed models were used to analyze the factors affecting reception of informal care, and linear mixed models were used to analyze the factors affecting informal care sources and intensity.

RESULTS

During the follow-up period, 7542, 6386, 5087, and 4052 older adults were included in 2011-2018, respectively. The proportion receiving informal care increased from 19.92 to 30.78%, and the proportion receiving high-intensity care increased from 6.42 to 8.42% during this period. Disability (estimate = 4.27, P < 0.001) and living arrangement (estimate = 0.42, P < 0.001) were the critical determinants of informal care need. The rural older adults reported a greater tendency to receive informal care (estimate = 0.14, P < 0.001). However, financial support from children did not affect informal care need (P > 0.05).

CONCLUSIONS

At present, there is a great demand for the manpower and intensity of informal care, and the cost of informal care is on the rise. There are differences in informal care needs of special older groups, such as the oldest-old, living alone and severely disabled. In the future, the region should promote the balance of urban and rural care service resources, rationally tilt economic support resources to rural areas, reduce the inequality of long-term care resources, improve the informal care support system, and provide a strong community guarantee for the local aging of the older adults.

Long-run consequences of informal elderly care and implications of public long-term care insurance

We estimate a dynamic structural model of labor supply, retirement, and informal caregiving to study short and long-term costs of informal caregiving in Germany. Incorporating labor market frictions and the German tax and benefit system, we find that in the absence of Germany's public long-term insurance scheme, informal elderly care has adverse and persistent effects on labor market outcomes and, thus, negatively affects lifetime earnings and future pension benefits. These consequences of caregiving are heterogeneous and depend on age, previous earnings, and institutional regulations. Policy simulations suggest that while public long-term care insurance policies are fiscally costly and induce negative labor market effects, they can largely offset the personal costs of caregiving and increase welfare, especially for low-income individuals.

Functional disability and utilisation of long-term care in the older population in England: a dual trajectory analysis

This study investigates the developmental trajectories of long-term care needs and utilisation in older people aged 65 years and over in England. The data came from the English Longitudinal Survey of Ageing (ELSA, waves 6-9, 2012-2018, N = 13,425). We conducted dual trajectory analyses to cluster people's trajectories of care needs (measured by functional disability) and utilisation into distinct groups. We conducted logistic regression analyses to identify the factors associated with trajectory memberships. We identified three trajectories of long-term needs (low, medium, and high) and three trajectories of care utilisation (low, medium, and high). Both care needs and care hours increased with age, but the speed of increase varied by trajectory. Females, minority ethnic groups, people with low wealth, and those experiencing housing problems were more likely to follow the joint trajectories characterised by higher care needs and higher care intensity. People with low or medium care needs stayed in the same trajectories of care utilisation. In contrast, people in the high-needs trajectory followed divergent trajectories of care utilisation: 63% of them followed the trajectory of high care intensity and the rest (37%) followed the trajectory of medium care intensity. Lack of spouse care was the leading predictor of trajectory divergence (OR = 3.57, p < 0.001). Trajectories of care needs and utilisation are highly heterogeneous in later life, which indicates persistent inequalities over time. Single people with multiple functional limitations face an acute and enduring risk of inadequate care and unmet needs. The amount of support is as important as the availability of support.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10433-022-00723-0.

Do oldest old individuals perceive receipt of informal care as a restriction or support of their autonomy?

OBJECTIVES

Autonomy (defined as self-governance; not equivalent to independence) is relevant to well-being and psychological functioning. However, there is a lack of research on individuals aged >85 years and their perception of autonomy when receiving informal care. This study aims to answer the question if and how the receipt of informal care is associated with perceived autonomy of individuals aged over 85 years.

METHOD

A cross-sectional study was conducted with data from follow-up 9 of the AgeQualiDe study (2015/2016), which is a multi-centric prospective cohort study in Germany. The analytical sample included 570 participants aged >85 years and with a score of ≥ 19 on the Mini-Mental-State-Examination. Perceived autonomy was assessed with the Perceived Autonomy in Old Age Scale. Receipt of care was assessed as performance of at least one care task (help with basic and instrumental activities of daily living, and supervision) by relatives or friends. Sociodemographic information, mental health, functional level and receipt of professional ambulatory care were controlled for.

RESULTS

Unadjusted and adjusted linear regression analyses indicated a significant negative association between receipt of informal care and perceived autonomy. The results remained stable in sensitivity analyses; no significant interaction effect was found for gender or education.

CONCLUSION

Findings indicate that informal care recipients aged >85 years perceive lower autonomy compared to those not receiving care. Additional or other forms of support, and improving the care relationship and communication might be considered to support autonomy of care recipients aged >85 years.

Does Receiving Informal Care Lead to Better Health Outcomes? Evidence From China Longitudinal Healthy Longevity Survey

Population aging has become a global challenge. Drawing data from Chinese Longitudinal Healthy Longevity Survey 2008, 2011, and 2014, this study examines the effect of informal care receipt on functional limitations and depressive symptoms among older people in China using lagged fixed effects model. Our findings suggest that receiving informal care is significantly associated with a slower functional decline. We also find that this effect varies across different income groups. The protective effect of informal care is more pronounced among older people with higher income compared to those with lower income. We do not observe any significant associations between receiving informal care and depressive symptoms of older people. This study highlights a pressing need for the Chinese government to establish a comprehensive long-term care system.

Socioeconomic inequality of long-term care for older people with and without dementia in England

Ensuring distributive fairness in the long-term care sector is vitally important in the context of global population ageing and rising care needs. This study, part of the DETERMIND (DETERMinants of quality of life, care and costs, and consequences of INequalities in people with Dementia and their carers) programme, investigates socioeconomic inequality and inequity in the utilisation of long-term care for older people with and without dementia in England. The data come from three waves of the English Longitudinal Study of Ageing (ELSA, Waves 6–8, N = 16,458). We find that older people with dementia have higher levels of care needs and a lower socioeconomic status than those without dementia. The distribution of formal and informal care is strongly pro-poor. When care needs are controlled for, there is no significant inequality of formal or informal care among people with dementia, nor of informal care among people without dementia, but there is a significant pro-rich distribution of formal care among people without dementia. Unmet care needs are significantly concentrated among poorer people, both with and without dementia. We argue that the long-term care system in England plays a constructive role in promoting socioeconomic equality of long-term care for people with dementia, but support for older people with lower financial means and substantial care needs remains insufficient. Increased government support for older people is needed to break the circle between care inequality and health inequality.

Vision impairment, vision correction, and cognitive decline among middle-aged and older Chinese: results from the China health and retirement longitudinal study

OBJECTIVES

To investigate the associations between vision impairment (VI), vision correction (VC), and cognitive function.

METHOD

We included 20,677 participants aged ≥45 years from the China Health and Retirement Longitudinal Study (2011-2015). Participants were grouped into no VI, distance VI (DVI) only, near VI (NVI) only, or both distance and near VI (DNVI), and VI(+)/VC(-), VI(+)/VC(+), VI(-)/VC(-), or VI(-)/VC(+) further at baseline. Cognitive function at baseline and subsequently every two years was applied as a dependent variable in a generalized estimating equation model.

RESULTS

DVI only, NVI only, and DNVI had significantly worse cognitive function over time than no VI (all p < .05). DNVI had significantly worse cognitive function over time than DVI only and NVI only (all p < .001). VI(+)/VC(+), VI(-)/VC(-), and VI(-)/VC(+) had significantly better cognitive function over time than VI(+)/VC(-) (all p < .05). VI(-)/VC(+) had significantly better cognitive function over time than VI(+)/VC(+) and VI(-)/VC(-) (all p < .05).

CONCLUSION

Cognitive function was worse in middle-aged and older Chinese with VI, especially in those with DNVI. VC was associated with better cognitive function over time regardless of the status of vision.

Childhood Adversities and Unmet Needs of Older Chinese Adults: The Mediation Effects of Family Relationships

Ensuring equality and adequacy of care for older adults is vitally important. This study investigates the relationships between childhood adversities and unmet long-term care needs of older adults in China and the mediation effects of family relationships. The data came from a nationally representative sample of older Chinese adults aged 60 and over with long-term care needs (N = 2186). We conducted mediation analyses and decomposed the total effects of childhood adversities on unmet needs into direct and indirect effects. The probability of unmet needs is significantly higher among older adults experiencing childhood adversities. Satisfaction with marriage mediates the association between childhood adversities and unmet personal care needs. Relationships with children mediate the association between childhood adversities and unmet domestic care needs. The causes of unmet needs can be traced back to early life, which underscores the importance of concerted efforts in family, education and long-term care policies to tackle unmet needs.

A Longitudinal Study of Functional Unmet Need Among People with Dementia

BACKGROUND

Understanding the changes of unmet need in dementia may enable effective targeting of help and allow people to stay in their homes longer.

OBJECTIVE

We investigated changes in unmet need and functioning over a 4-year period and the role of socio-demographic factors in these changes among people with dementia.

METHODS

234 community-dwelling people with dementia at baseline were studied in three consecutive waves (four years) of the English Longitudinal Study of Ageing (ELSA). Unmet needs (self/informant-reported limitations for which no help was received) and functional limitations (self/informant-reported difficulties in activities/instrumental activities of daily living and mobility) were modelled with latent growth curves. Sex, age, partnership, and socioeconomic status at baseline were used as predictors. Admission to a care home was an additional outcome.

RESULTS

Unmet needs increased over time, especially among those who initially had more functional limitations. Unmet needs contributed to faster decline in functional capability, except among those with many limitations initially. The major driver of increased unmet needs was not having a partner (direct effect). Age, sex, and wealth contributed indirectly via the initial level of functional limitations and/or unmet need. Those with several functional limitations but few unmet needs were most likely to move to a care home.

CONCLUSION

Unmet need increases over time in those with dementia with mitigating effects of having a partner and initial levels of functioning. Meeting needs at early stages of dementia, especially for those living alone and when functional limitations are low may help slow functional decline.

Extending the analysis of functional ability trajectories to unexplored national contexts: The case of Chile

OBJECTIVES

Despite the enormous advances in the field, most evidence about functional ability trajectories in old age comes from studies conducted in developed and high-income countries. This research aims to build on these previous advances to examine functional ability trajectories in Chile.

METHODS

Drawing on a robust, publicly available 15-years panel dataset (2004-2018), and using sequence analysis, we examine functional ability trajectories types among four age groups (people aged 46-50, 51-55, 56-60, and 61-64 at baseline). Then, we analyze trajectories' dynamics looking at intra-individual health-declining and health-recovery transitions between functional ability statuses, within each trajectory type. Finally, we assess how multiple baseline individual characteristics predict the likelihood of following a functional ability trajectory type, using multinomial regression models.

RESULTS

Across all age groups, an important fraction (between 26%-50%) reports stable healthy trajectories, and between 10%-20% follow equivocal-declining trajectories (i.e., exhibiting both health-declining and health-recovery intra-individual transitions), suggesting that age might not be the main source of heterogeneity in functional ability trajectories. Overall, women, lower educated people, nonworking individuals, and people with a higher burden of chronic conditions at baseline, are more prevalent among health-declining trajectory types; however, these results are not constant across the age groups analyzed.

DISCUSSION

This nationally focused study reinforces the feasibility and usefulness of an in-depth analysis of functional ability trajectories in old age. The study findings can be crucial to define different prevention strategies according to the functional ability path that an individual might follow, especially in countries like Chile that currently navigates the challenges of population aging.

Self-reported vision impairment, vision correction, and depressive symptoms among middle-aged and older Chinese: Findings from the China health and retirement longitudinal study

OBJECTIVE

To investigate associations between vision impairment (VI), vision correction (VC) and depressive symptoms among middle-aged and older Chinese.

METHODS

22 203 participants aged ≥45 years from China Health and Retirement Longitudinal Study 2011 to 2015 were divided into four self-reported VI categories: no VI, distance VI (DVI) only, near VI (NVI) only, and both distance and near VI (DNVI); and four self-reported VI/VC subgroups: VI(+)/VC(-), VI(+)/VC(+), VI(-)/VC(-) and VI(-)/VC(+). Depressive symptoms were evaluated by 10-item Center for Epidemiological Studies Depression Scale (CESD-10).

RESULTS

Compared with no VI, DVI only (OR = 2.12, 95% CI: 1.95, 2.31), NVI only (OR = 1.51, 95% CI: 1.39, 1.63) and DNVI (OR = 2.75, 95% CI: 2.47, 3.07) were associated with higher odds of depressive symptoms. Compared with VI(+)/VC(-), VI(+)/VC(+) (OR = 0.91, 95% CI: 0.83, 0.98), VI (-)/VC(-) (OR = 0.50, 95% CI: 0.48, 0.53) and VI(-)/VC(+) (OR = 0.49, 95% CI: 0.47, 0.54) were associated with lower odds of depressive symptoms. Compared with no VI at baseline, baseline DNVI was significantly associated with higher odds of depressive symptoms after two (OR = 1.48, 95% CI: 1.16, 1.88) and four (OR = 1.32, 95% CI: 1.04, 1.68) years. Baseline depressive symptoms were significantly associated with higher odds of VI after two (OR = 1.53, 95% CI: 1.34, 1.74) and four (OR = 1.54, 95% CI: 1.34, 1.76) years.

CONCLUSION

Adults with DNVI were more likely to report depressive symptoms in the future and those with depressive symptoms were more likely to report VI in the future. VC might be a protective factor for preventing depressive symptoms among adults with VI.

Time to care? The effects of retirement on informal care provision

This paper analyzes the impact of women's retirement on their informal care provision. Using SOEP data, we address fundamental endogeneity problems by exploiting variation in the German pension system in two complementary ways. We find a significant effect of retirement on informal care provision, when using early retirement age thresholds as instruments. Heterogeneity analyses confirm the underlying behavioral mechanism, a time conflict between labor supply and informal care. We further exploit a sizable increase in the early retirement age for German women and find that affected women provide less non-intensive care. High intensity care is not impacted, which leads to a double burden and potentially negative health effects for caregivers. Exploiting the policy reform, we find evidence supporting the notion that formal care is no substitute for informal care. This implies that less overall care is received, which can be damaging to the health of the recipients of care.