Who Receives Care

To be distinguished from who needs care is who receives care. Whether some older people are more likely than others to receive informal care at all, or to receive greater amounts of assistance, has implications for appropriate targeting of services to subgroups with unmet need, or with patterns for service delivery to certain subgroups. Looking first at the likelihood of receiving informal care, noteworthy differences emerged when those people who rely on formal services for most of their care are compared with those who receive all of their help from informal caregivers. We have found that those who were not married, lived alone, and lived in public housing were less likely to have informal caregivers available for assistance and therefore more likely to rely on formal services for assistance. This describes the typical senior housing resident (McKinlay and Tennstedt, 1986).

Turning to variations in the levels or amounts of informal care provided, differences have been associated with the degree of disability, the gender of the elder, as well as with the elder’s living arrangement. Most studies report a direct relationship between the elder’s degree of functional disability and receipt of informal care (Sherwood et al., 1981; Horowitz and Dobrof, 1982; Branch and Jette, 1983). That is, those elders with the most impairment receive significantly more informal care than those who are minimally or moderately impaired (McKinlay and Tennstedt, 1986). It is interesting, however, that an expected simple linear relationship between level of frailty and receipt of care, where moderately impaired elders receive more care than minimally impaired elders, was not apparent in this study conducted in Massachusetts (Figure 1). Minimally and moderately impaired elders received similar amounts of informal care, indicating a possible threshold of impairment, at which the amount of such care increases substantially. This apparent threshold may be related to: a) an increase in the number and scope of needs, necessitating a wider variety of help and more intensive care; b) a preference by elders for care by their families; c) the family’s sense of responsibility for providing care; d) the greater ability of informal care to meet specific needs (e.g., flexibility in response, intimate knowledge of elder); and/or e) problems with access, availability, or limitations of formal services (e.g., restricted hours/functions, staff shortages, reimbursement issues). Further, the receipt of informal care increases far more dramatically than the use of formal services with an increase in disability. These data underscore the predominance of informal care even at a point when use of more formal services might be expected.

Gender clearly influences the type and amount of informal care received. While women are more likely than men to receive help from informal caregivers, it does not appear that they also receive more such care. Consistent with other findings (Branch and Jette, 1983), our Massachusetts data indicate that, controlling for functional status, men receive more care than women (Tennstedt and McKinlay, 1989). This finding may be a function of the time required to perform gender specific types of care received. Older men are more likely to receive help with personal care, housekeeping tasks, and meals, activities which may require more time than the assistance with transportation, shopping, and home repairs which were more frequently received by women. In addition, while men receive more care, on average they are likely to get that help from only one person, usually their spouse. Older women, on the other hand, have larger numbers of caregivers, typically two to four.

These differences in types and related amounts of assistance received are probably related to both traditional gender/social role behavior, as well as the influence of gender/social role stereotypes on perception of need for help. Older people most likely continue to do those tasks of daily living with which they feel familiar, and for which they have skills, and to receive help in those areas with which they are unfamiliar or less skilled. Conceptual models of utilization behavior (e.g., Anderson and Newman, 1973; Mechanic, 1962) have often related use of services to perceived need, as distinguished from objective need determined by functional assessment of health indicators. Older men and women appear to perceive their need for assistance differently. One male respondent who was physically able to perform household tasks, yet received substantial help, told us that he would rather starve than learn to cook his own meals! Similarly, caregivers’ expectations of the elder may differ according to the elder’s gender, and therefore be an additional determinant of the type of informal care provided. For example, caregivers may be more likely to provide meals for older men because they do not expect them to cook for themselves.

Finally, our data and that of others indicate that an elder’s living arrangement is an important predictor of the level of care received (Tennstedt and McKinlay, 1989). Elders living with a spouse (78 hours/week) or others (66 hours/week) were likely to receive substantially more care than those who lived alone (9 hours/week). Our data also indicate that those living alone are nearly twice as likely to use paid formal help (Tennstedt et al., 1993a). It should be noted that living alone has consistently emerged in studies as a major predictor of institutionalization of the elderly (Shanas, 1979; Kahana and Kiyak, 1980; Prohaska and McAuley, 1983), having important implications for identification of subgroups most in need of community services.