Who will care for the oldest people in our ageing society?
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39129.397373.BE (Published 15 March 2007) Cite this as: BMJ 2007;334:570
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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
Competing interests: No competing interests
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.
Competing interests:
None declared
Competing interests: --Table--Hong Kong Population Aged 50-74 and 85+; and Oldest Old Support Ratio, 1991-2006Age Group 50-74 85+ Year Number Annual growth rate Number Annual growth rate Oldest Old Support Ratio (OOSR) 1991 1094500 -- 29700 -- 36.91992 1100300 0.5% 32100 8.1% 34.31993 1108500 0.7% 34700 8.1% 31.91994 1121600 1.2% 37200 7.2% 30.21995 1138600 1.5% 40300 8.3% 28.31996 1210600 6.3% 43800 8.7% 27.61997 1240900 2.5% 47000 7.3% 26.41998 1270300 2.4% 48200 2.6% 26.41999 1306000 2.8% 50500 4.8% 25.92000 1354400 3.7% 55000 8.9% 24.62001 1400900 3.4% 62600 13.8% 22.42002 1447600 3.3% 67700 8.1% 21.42003 1486300 2.7% 71900 6.2% 20.72004 1543800 3.9% 76800 6.8% 20.12005 1607600 4.1% 82700 7.7% 19.42006 1668100 3.8% 90700 9.7% 18.4Note :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.