Formal services are used infrequently.

Although economic constraints have limited service availability in recent years, even when services were more widely available in the early 1980s, they were not widely used. In general, services are targeted on the basis of extent of need for care and availability of informal sources of care. Assessments typically are care recipient focused. Research data support more attention to assessment of the caregiver’s status. Again, assessment is better directed at the caregiver’s appraisal of the care giving arrangement rather than at the caregiver’s availability and physical ability to provide care.

In the case of dementia care, use of formal services is not only appropriate but also clinically indicated as severity increases. From a practice perspective, it is important to determine the optimal mix of formal services and informal care in order to ensure the well being of both care recipient and caregiver. Transition to a special care environment is another important juncture in this regard. Assistance with appropriate timing and with negotiating a role for continued involvement of the caregiver(s) will facilitate what might be interpreted as another in a series of losses by a caregiver who sees this transition as loss of an important role.

From a policy perspective, the issue of eligibility criteria for services is important. For both publicly and privately (i.e., third party payer) funded services, eligibility typically is based on functional disability in the performance of specified ADLs. The Advisory Panel on Alzheimer’s Disease (1989) has advocated for the expansion of eligibility criteria to provide services in situations where the degree of cognitive impairment interferes with the person’s ability to complete either IADLs or ADLs without substantial supervision. The cost analyses performed by Paveza et al. (1998) "suggest that changes in cognitive impairment are independent factors affecting cost regardless of the magnitude of ADL/IADL impairment" (p. 79). Similar findings from the National Long-Term Care Channeling Demonstration Project in the 1980s were reported by Liu et al. (1990). These findings support the notion of applying a cognitive weighting factor to the degree of ADL/IADL impairment in establishing eligibility for services.

Most caregivers do not plan for the future. Unexpected acute events are stressful.

Not only do most adults not plan how they will provide care for their parents or other relatives, most caregivers also do not plan for changes in caregiving needs. A common coping strategy is to "take one day at a time." This works as long as the situation is stable, or changes gradually. A major acute health event which suddenly increases the need for care is an appropriate time for formal intervention. This may be organizationally challenging for service providers since services might be needed quickly and at times when services are not normally provided. However, all the research data on well-being of both care recipient and caregiver indicate that these services are needed and will likely have a beneficial effect.

An alternative approach is to engage a caregiver in mutual planning for handling of such situations. This is challenging, as most people will not seek out information until they need it. General information sessions about community services are frequently not well attended. The most effective strategy might be to engage a caregiver in planning shortly after experiencing an acute event. The recent experience might sensitize them to the need and increase their receptivity to new information.

Finally, the challenges we face as we approach the millenium include:

The widely recognized changing sociodemographics of the older population – the aging baby boomers;
Projected changes in active life expectancy and the compression of disability, meaning higher needs for care but perhaps for shorter periods of time at advanced ages;
The availability and ability of families – which will be smaller and older – to care for very old and perhaps severely disabled elders; and
The increased ethnic diversity of the population, underscoring the need for culturally sensitive and appropriate services and service delivery mechanisms.
In closing, we should not lose sight of the fact that caregiving is imbedded in the family experience, history, and values. How caregivers respond to the presenting needs for care, how they perceive the personal impact of that care, and how they interface with the formal service system will be shaped by their personal situation. As we have argued for recognition of the heterogeneity of older adults, in all that we do as researchers, practitioners, and policy makers, we must recognize the heterogeneity of their caregivers.