Shared Care Networks Assisting Older Adults: New Insights From the National Health and Aging Trends Study

Sharing in Caring: Family Caregiving Task-Sharing Patterns for Older Adults in Singapore

OBJECTIVES

Research on family caregiving for older adults has largely focused on primary caregivers. We identify caregiving task-sharing patterns among multiple caregivers, including family members and live-in hired workers. In addition, we investigate caregiver and care-recipient characteristics associated with these patterns.

METHODS

We interviewed 278 primary family caregivers of home-dwelling older adults in Singapore about who provides what assistance across 3 domains: activities of daily living, health and social services use, and socioemotional and other needs. Latent class analysis was used to identify caregiving task-sharing patterns.

RESULTS

Three patterns were identified: (a) "Shared-Diverse" (39%)-multiple caregivers assisting in all 3 domains, (b) "Shared-Domestic" (32%)-multiple caregivers assisting with activities of daily living and socioemotional and other needs, and (c) "Solo-Diverse" (29%)-a sole caregiver assisting in all 3 domains. "Solo-Diverse" caregivers were less likely to be employed and had higher depressive symptoms relative to "Shared-Diverse" primary family caregivers.

DISCUSSION

The predominance of caregiving task-sharing patterns involving multiple caregivers calls for expansion of research, policies, and programs beyond primary caregivers. Greater attention should be given to how families and live-in hired workers share caregiving tasks for older adults, and how this varies across cultural settings, especially in familial Asian societies. The findings further highlight the vulnerabilities of solo caregivers, whose employment capacity and mental health may be adversely affected by their caregiving duties. Policy-makers should ensure that solo caregivers have access to support programs that address their financial and mental health needs.

Confidants and Caregivers: Network Multiplexity and Subjective Well-Being of Older Adults

OBJECTIVES

Older adults rely on personal networks for different types of support. Given shifts in family composition in later adulthood, more work is needed to map network members who can provide multiple aspects of support and the implications for older adults. We explore the phenomenon of having the same network members as both a confidant and a caregiver (multiplexity) and its implications for the well-being of older adults.

METHODS

Using the 2011 National Health and Aging Trends Study, we describe the prevalence of having someone as both a confidant and a caregiver (henceforth "multiplex helper") for older adults and examine its association with subjective well-being. We also investigate the differences by having whom as multiplex helpers.

RESULTS

About three-quarters (76%) of older adults with at least 1 confidant and 1 caregiver have at least 1 multiplex helper. Partnered older adults are more likely to have any multiplex helpers than unpartnered counterparts and usually nominate their partner as a multiplex helper, whereas the unpartnered are more likely to rely on their children to serve multiple roles, especially for widowed older adults. Having a multiplex helper is associated with better subjective well-being.

DISCUSSION

Network multiplexity is prevalent and positively associated with the subjective well-being of older adults who have at least 1 confidant and 1 caregiver, above and beyond having any confidants or caregivers separately. The baseline patterns established in this study lay the groundwork for future research to further explore support dynamics in older adults' networks.

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.

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.

Race/Ethnicity, Nativity, and Gender Disparities in Unmet Care Needs Among Older Adults in the United States

BACKGROUND AND OBJECTIVES

Although disparities in disability and the unequal distribution of care resources are widely discussed in the literature, there has been less research on disparities in experiencing unmet care needs among older adults. This study aims to investigate how unmet care needs are unevenly distributed across social groups with various intersecting identities, such as race/ethnicity, nativity, and gender, although considering their care needs and care networks, drawing on the conceptual framework of the pathway to unmet needs.

RESEARCH DESIGN AND METHODS

The data for this study came from the National Health and Aging Trends Study (2011-2018), and the study sample consisted of 7,061 Medicare beneficiaries who needed assistance with daily activities. Questions about unmet care needs were in the form of consequences related to difficulty or lack of help with daily activities. Mixed-effects negative binomial regression models were used to predict rates of unmet needs.

RESULTS

Older adults of color, especially women, experienced higher rates of unmet care needs compared with their White and male counterparts. Although Black-White and gender differences in unmet needs were mostly explained by unequal exposures to care needs and differential care networks, Hispanic women and foreign-born Hispanic men were still at a disadvantage even after adjusting for these covariates.

DISCUSSION AND IMPLICATIONS

These results emphasize the importance of adopting an intersectional approach to enhance the quality of long-term services and support for older adults facing social disadvantages.

Identifying longitudinal healthcare pathways and subsequent mortality for people living with dementia in England: an observational group-based trajectory analysis

BACKGROUND

The number of people living with dementia (PLWD) continues to increase, particularly those with severe symptomatology. Severe symptoms and greater ill-health result in more acute care need. Early healthcare interventions can prove beneficial. Healthcare use has not been analysed as a holistic set of interlinked events. This study explores different healthcare pathways among PLWD, social or spatial inequalities in healthcare pathways and subsequent mortality risk.

METHODS

Group-based trajectory models (GBTM) were applied to electronic healthcare records. We generated clusters of PLWD with similar five-year, post-diagnosis trajectories in rates of primary and secondary healthcare use. Potential social and spatial variations in healthcare use clusters were examined. Cox Proportional Hazards used to explore variation in subsequent mortality risk between healthcare use clusters.

RESULTS

Four healthcare use clusters were identified in both early- (n = 3732) and late-onset (n = 6224) dementia populations. Healthcare use variations were noted; consistent or diminishing healthcare use was associated with lower subsequent mortality risk. Increasing healthcare use was associated with increased mortality risk. Descriptive analyses indicated social and spatial variation in healthcare use cluster membership.

CONCLUSION

Healthcare pathways can help indicate changing need and variation in need, with differential patterns in initial healthcare use post-diagnosis, producing similar subsequent mortality risk. Care in dementia needs to be more accessible and appropriate, with care catered to specific and changing needs. Better continuity of care and greater awareness of dementia in primary can enhance prospects for PLWD. Research needs to further illuminate holistic care need for PLWD, including health and social care use, inequalities in care, health and outcomes.

Dual Functionality in Later Life

Gerontologists have long shown interest in both longevity and quality of life during later life, but considerable debate has ensued as scholars sought to integrate the two. Drawing from research on the topics of exceptional longevity, successful aging, and active life expectancy, we propose the concept of dual functionality to examine how humans reach advanced ages while maintaining physical and cognitive function. Dual functionality refers to being free of both physical and cognitive impairment. The loss of dual functionality challenges social networks to respond to the functional loss and is a harbinger of additional losses. Evidence of change in the percent of the older population maintaining dual functionality would be helpful for evaluating public health policies to aid quality of life during later life. This article is based on the first author's Robert W. Kleemeier Award Lecture at The Gerontological Society of America 2022 Annual Scientific Meeting.