Older disabled adults in the United States most often rely on spousal support for the provision of care. Unmarried individuals who cannot rely on this informal source of care provision are forced to navigate more fragmented and less reliable sources of care. Government initiatives in the United States have aimed to further expand the role of family provided support through: 1) tax deductions, 2) respite programs and, 3) public policy to restrain growth in public spending for home based care. The analysis demonstrates that functional capacity is not unidirectional in old age: care recipient functioning improves and declines dynamically, and care hours should respond accordingly. While unpaid care hours respond to both increases and decreases in care recipient functioning, paid care hours only respond to increasing impairment. In the future, home care for both married and unmarried individuals will have to be considered in the context of effective targeting, and considering both paid and unpaid care simultaneously.

Background: Older disabled adults in the United States most often rely on spousal support for the provision of care. Unmarried individuals who cannot rely on this informal source of care provision are forced to navigate more fragmented and less reliable sources of care. Government initiatives in the United States have aimed to further expand the role of family provided support through: 1) tax deductions, 2) respite programs and, 3) public policy to restrain growth in public spending for home based care. While there is a growing literature on disability trajectories, only a select few use measures of changes in disability status to predict care use. The studies do highlight that increases in limitations in activities of daily living (ADLs) and in instrumental ADLs (IADLs) result in a greater occurrence of individuals living with others and using paid care or a mixed network of care, paid and unpaid. This study explores the relationship between home care recipients' level of disability and intensity of home care service provision in the United States. It examines the interrelationship between paid, unpaid, and total hours of service provision in response to a change in care recipients' functional capacity. The study is limited to unmarried older Americans, as this group is perceived to be more vulnerable than disabled adults who may rely on unpaid spousal assistance.

Methods: The study utilizes a national sample of 746 older unmarried Americans with functional limitations, living in the community between 1993 and 1998. The study uses three waves of the AHEAD dataset, a survey which collected information from the same respondents in 1993, 1995,and 1998. Functional limitations were defined as having one or more restrictions in ADLs or IADLs. The authors modeled changes in the total hours of care received in the past month, and considered changes to both unpaid and paid hours in response to declines and improvements in functional capacity. The main predictors of interest were care recipient demographic characteristics, existence of family support, and changes in the disability level of respondents.

Findings: Between 1995 and 1998, disability levels increased among most respondents, resulting in an increase in total average hours of care from 77 hours/month in 1995 to 106 hours/month in 1998. When ADL limitations decreased, hours of unpaid care decreased significantly, whereas the effect on paid care hours was insignificant. In contrast, when ADL limitations increased, unpaid care hours did not increase significantly, whereas paid care hours did. When IADL limitations decreased, there was no significant change to unpaid or paid service provision. However, when IADL limitations increased, both paid and unpaid care hours increased significantly. The regression model revealed that having only one son and having increasing ADL/IADL limitations increased total hours of service provision. Being over 85 years, having increasing IADL limitations, and having only one daughter significantly increased hours of unpaid care. Having higher education, higher income, higher ADL/IADL restrictions, and only one son significantly increased hours of paid care.

Conclusions: The analysis demonstrates that functional capacity is not unidirectional in old age: care recipient functioning improves and declines dynamically, and care hours should respond accordingly. While unpaid care hours respond to both increases and decreases in care recipient functioning, paid care hours only respond to increasing impairment. The authors conclude that once paid care arrangements are put in place, this care remains constant. As such, some older adults may be receiving assistance, which they do not require. The study did not control for state-funded paid care (Medicaid or Medicare) versus privately insured, or privately purchased by care recipients themselves.

Reference: Freedman, V.A., Aykan, H., Wolf, D.A. and Marcotte, J.E. "Disability and Home Care Dynamics Among Older Unmarried Americans". Journal of Gerontology: Social Sciences. 2004. 59B/ 1, S25-33.

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