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ANALYSIS: Jean-Marie Robine, Jean-Pierre Michel, and François R Herrmann Who will care for the oldest people in our ageing society? BMJ 2007; 334: 570-571 [Full text]

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Oldest old not just passive recipients of care

Desmond O'Neill, Prof Hannah McGee, Dept Health Services Research, Royal College of Surgeons in Ireland   (20 March 2007)

Caring for the Oldest Old: "Mixing and matching" informal and formal caregiving

PH Chau, Edwina Yen , and Jean Woo   (30 April 2007)

Oldest old not just passive recipients of care 20 March 2007
Desmond O'Neill, Associate Professor Dept Medical Gerontology, Adelaide and Meath Hospital, Dublin 24, Ireland, Prof Hannah McGee, Dept Health Services Research, Royal College of Surgeons in Ireland Send response to journal: Re: Oldest old not just passive recipients of care	Robine and his colleagues have performed a useful service in giving clinical expression and significance to a phrase and concept that is well- recognized in Francophone countries, that of the ‘fourth age’ – le quatrième âge (1). Indeed, there is evidence that since ancient times that division of the life- span has been divided into four by many cultures (2), but the elegance of the phrasing, as well as the concept of oldest old/younger old ratio is very helpful. However, while they raise serious points about future trends in ageing, dependency and care provision in later life, it is also worth noting that older people are also creative in their stratagems for later life and are not just passive recipients of care. Of particular significance is the contribution that they themselves bring to their own care. In the first longitudinal study of ageing in Ireland (3), it was notable that over a four-year sampling period that there was a marked increase in the amount that older people spend on provision of health and social care, despite increases in access to services such as free general practitioner care. Over eight percent of older people in this study were themselves the primary carer for another family member. Therefore, even in advanced old age, a sense of partnership between services and all older people needs to be developed. Enabling this partnership, and responding to the changing demands of health and social care services, will require increased emphasis on effective care for older people, whether through acute geriatric medicine (which can reduce death and disability by 25%) (4) or by improved chronic disease management (5). It will also require some thought to ensuring that the societal structures, such as housing and transport (6), do not hinder participation of the oldest old in sharing in their own care. 1. Thevenet A. Le quatrième âge. Paris, Presses Universitaires de France, 1989. 2. Wortley J. Four-Age Systems of Human Development. Journal of Aging and Identity 1998;3:213-30. 3. O'Hanlon A, McGee A, Barker M, Garavan R, Hickey A, Conroy R, et al. Health and social services for older people II (HeSSOP II): changing profiles from 2000 to 2004. Dublin: National Council on Ageing and Older People, 2005. 4. Ellis G, Langhorne P. Comprehensive geriatric assessment for older hospital patients. Br Med Bull. 2005;71:45-59. 5. Lorig KR, Ritter PL, Laurent DD, Plant K. Internet-based chronic disease self-management: a randomized trial. Med Care. 2006;44:964-71. 6. O’Neill D, Dobbs B. Age-Related disease, Mobility and Driving. In Transportation in an Aging Society, A Decade of Experience. Transportation Research Board, Washington DC, 2004, 56-68. Competing interests: None declared
Caring for the Oldest Old: "Mixing and matching" informal and formal caregiving 30 April 2007
PH Chau, Research Assistant Professor Hong Kong, Edwina Yen , and Jean Woo Send response to journal: Re: Caring for the Oldest Old: "Mixing and matching" informal and formal caregiving	Robine et al. described an indicator, the Oldest Old Support Ratio (OOSR), to monitor potential informal care resources.1 We found this to be a very useful indicator for analyzing the present and future needs for informal caregiving in a rapidly ageing world. In Hong Kong, calculations based on population statistics showed that the OOSR for Hong Kong dropped sharply from 36.9 in 1991 to 18.4 in 2006 (table).2 The faster growth rate of people aged 85 and over compared to the growth rate of those aged 50-74, which is in line with global trends, likely contributed to the decline in this ratio. If this trend continued, this would lead to a shrinking of the most commonly identified pool of potential informal caregivers for the oldest old (those aged 85 and over). The important role of informal care to community-living seniors, especially the "old old" (those aged 80 and over) had been noted as early as in 1994, in a Hong Kong longitudinal baseline study.3 The study also postulated that reduction of informal care support will place a heavier demand on formal care, implying that if there is a lack of informal caregiving, some seniors may turn to residential care. This was supported by survey data which showed that in 2004, only about 55% of non- institutional population aged 60 and above who needed assistance had caregivers.4 This meant many seniors who needed care did not have it, which could be a reason for seeking placement, initiated either by the seniors themselves or their families. With this conceptual framework in mind, it would be important to revisit the relationship between informal caregiving and formal caregiving for the oldest old in Hong Kong, in light of the new OOSR indicator and current statistics. According to census data, the proportion of seniors aged 65 and over living in non-domestic households, which were mainly residential care institutions, increased sharply within a short period of time, from 6% to 10% between 1991 and 2006.2 5 Furthermore, despite the commonly held belief that seniors would prefer to avoid institutional placement if at all possible, as at end-2006, the number of applicants on the waiting list for government subsidized residential care services totaled 22,924.6 Focusing on data for the oldest old, we found that they accounted for the highest proportion of people living in non-domestic households (35%) compared to all other age groups in the year 2001.5 Taken together, these figures seem to suggest there is an association between the shrinking pool of potential informal caregivers and increased institutionalization, especially for the oldest old group. As suggested by Robine et al., family members and more specifically women in the role of daughters and daughters-in-law are the most frequently relied upon group for informal caregiving.1 Given the fixed nature of the population structure that is already in place, it would be difficult to substantially increase the supply of this resource pool of informal caregivers. Yet it might be possible to increase their impact through public education and training initiatives. Another option would be to diversify the resource pool. When we looked at the profile of non-institutional caregivers for seniors in general, we found three categories of "principal" caregivers--about 37% and 27% of those aged 60 and over had their children and spouse as major caregivers respectively; another 23% received care mainly from domestic helpers or nurses.4 If we projected forward to the time when some of the seniors reached 85 or above, the relative importance of spouses as informal caregivers would be less, due to the shorter life expectancy in males. This would imply the care originally provided by the male partner would have to be shared by the other types of caregiver categories, including both domestic help and nursing care provided under more formal arrangements, and this tendency would be expected to continue till the end of life. In societies where domestic help is readily available and affordable, it can be a valuable and perhaps increasingly necessary resource for the future, when domestic helpers may have to take on a more caring role as an alternative to friends and relatives for seniors who prefer to avoid institutionalization. Public education and training initiatives could also target this supplementary pool of non- institutional caregivers. Researchers in Hong Kong have found that the presence of disability is one of two major factors that influence older peoples' decision to live in an old age home.7 As the elderly move from "young old" to "old old", the risk of chronic disability increases, resulting in greater need for more formal care services, even in the community setting. As noted by Robine et al., informal care cannot be easily replaced by formal care.1 Yet, due to the high risk of burn-out among caregivers and the ongoing need for strong supportive community structures to make informal care sustainable over time, it may be necessary to complement informal care with formal care in more structured and systematic ways. Actually the role of informal caregivers does not need to end even if seniors have to turn to residential care. According to survey data, in 2004, about 40% of the institutional population aged 60 and above were visited by their children, family members and/or friends at least once a week and another 16% were visited two to three times a month.4 These individuals represent a potential pool for providing informal care support to institutionalized seniors. As pointed out by Robine et al., the supply of formal care itself is also in jeopardy,1 so this group of traditional family type of informal caregivers can be encouraged to learn more skills to help out while at the same time bring a more personal relationship to the care received in formal settings. Thus, for at least the Hong Kong situation, it could be advantageous to incorporate formal caregiving into a predominantly informal care environment as well as incorporate informal caregiving into a predominantly formal care environment. Therefore, in response to Robine et al.'s call on starting the debate, we would suggest exploring further the perspective of ¡§mixing and matching¡¨ informal and formal care as a more integrated way to address the issue of caring for our oldest old, especially those with increasing frailty. Ultimately, whether the oldest old are residing in the community or institutional setting or may have to shuffle between the two, society faces a growing challenge in having to share shrinking caregiving resources. We believe an expanded model integrating informal and formal caregiving may be the direction to go to maximize the possibilities for continuum of care till the end of life. By advocating for policies that can facilitate the "complementation" of informal and formal care systems, we hope to optimize quality in care provision to this population group. PH Chau research assistant professor, Faculty of Social Sciences, The University of Hong Kong, Hong Kong SAR Edwina Yen assistant professor, Department of Medicine & Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR Jean Woo professor, Department of Medicine & Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR References 1. Robine J-M, Michel J-P, Herrmann FR. Who will care for the oldest people in our ageing society? BMJ 2007; 334: 570-1. 2. Census and Statistics Department of Hong Kong Special Administrative Region. (2004). Hong Kong Statistics--Population. Available at http://www.censtatd.gov.hk/showtableexcel2.jsp?tableID=002 Accessed on 27 Apr 2007. 3. Ho SC, Woo J. Social and Health Profile of the Hong Kong Old-Old Population. Hong Kong: The Chinese University of Hong Kong, 1994. 4. Census and Statistics Department of Hong Kong Special Administrative Region. Thematic Household Survey Report No. 21: Social- demographic Profile, Health Status and Long-term Care Needs of Older Persons. Hong Kong: Government Logistics Department, 2005. 5. Census and Statistics Department of Hong Kong Special Administrative Region. 2001 Population Census: Thematic Report ¡V Older Persons. Hong Kong Special Administrative Region: Government Logistics Department, 2002. 6. Social Welfare Department of Hong Kong Special Administrative Region (2007). Waiting List for Residential Care Services. Available at: http://www.swd.gov.hk/doc/elderly/Overview%20Item(f)English(3-2007).pdf Accessed on 27 Apr 2007. 7. Woo J, Ho SC, Lau E. Care of the older Hong Kong Chinese population. Age Ageing1998; 27(4): 423-6. --Table-- Hong Kong Population Aged 50-74 and 85+; and Oldest Old Support Ratio, 1991-2006 Age Group 50-74 85+ Year Number Annual growth rate Number Annual growth rate Oldest Old Support Ratio (OOSR) 1991 1094500 -- 29700 -- 36.9 1992 1100300 0.5% 32100 8.1% 34.3 1993 1108500 0.7% 34700 8.1% 31.9 1994 1121600 1.2% 37200 7.2% 30.2 1995 1138600 1.5% 40300 8.3% 28.3 1996 1210600 6.3% 43800 8.7% 27.6 1997 1240900 2.5% 47000 7.3% 26.4 1998 1270300 2.4% 48200 2.6% 26.4 1999 1306000 2.8% 50500 4.8% 25.9 2000 1354400 3.7% 55000 8.9% 24.6 2001 1400900 3.4% 62600 13.8% 22.4 2002 1447600 3.3% 67700 8.1% 21.4 2003 1486300 2.7% 71900 6.2% 20.7 2004 1543800 3.9% 76800 6.8% 20.1 2005 1607600 4.1% 82700 7.7% 19.4 2006 1668100 3.8% 90700 9.7% 18.4 Note : The figures from 1991 to 1995 are compiled based on the "extended de facto" method and those from 1996 onwards are compiled based on the "resident population" method. Source: Census and Statistics Department of Hong Kong Special Administrative Region (2007). Hong Kong Statistics¡XPopulation. Available at http://www.censtatd.gov.hk/ Accessed on 27 Apr 2007. Competing interests: None declared