Living With Family At Old Age

Ashok Kumar Biswas; Kelvin Leshabari; Edward P.A. Gebuis

Living With Family At Old Age

Ashok Kumar Biswas, Kelvin Leshabari, Edward P.A. Gebuis

Ashok Kumar Biswas^1*, Kelvin Leshabari² and Edward P.A. Gebuis³

MBBS, DPH, MSc.; Geriatrician, Gerontologist and Public Health Adviser, Leiden University, Netherlands
MD, MSc; Head, Department of Medicine, Walter Hospital Dar es Salaam, Tanzania
MD, MSc; Hospitalist, Medical Centre Haaglanden, The Hague, Netherlands

Corresponding Author: Dr. Ashok Kumar Biswas, MBBS, DPH, MSc.; Geriatrician, Gerontologist and Public Health Adviser, Leiden University, Netherlands, Email: drkbashok@ymail.com, Tel: +31627381003, Address: Kennedylaan 51, Leiden, 2324 ET, Netherlands

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Abstract

The quality of life (QoL) depends on several elemen ts that are studied in detail in different populations. However, little is known about the liv ing arrangements and how these affect the QoL, especially in the elderly. Although multiple v ariations can be thought of, in essence, elderly can be living with family members or without. Posit ive and negative aspects of both types of living conditions need to be addressed in order to answer the question whether elderly should or should not be living with family members. Due to la ck of scientific evidence and personal opinions the older generation might have on this su bject, this question cannot be answered at this time. Specific research on this topic is required t o gain more certainty.

Keywords

Quality of life (QoL), Old age, Household, Family, Life and Age

Introduction

“One who always serves and respects elderly is blessed with four things:

Long Life, Wisdom, Fame and Power”- Manusmriti 2:121

The quality of life (QoL) is an increasingly important element in many research areas, including medical research. Nowadays, the effect of treatment is in general no longer appreciated unless improvement of QoL is involved.Several tools have been developed to measure QoL, such as WHOQOL-100 or WHOQOL-BREF by the World Health Organization (WHO), which are considered accurate instruments in science.1 However; the general public understands QoL best in its crude description of “general well-being” that sometimes confuses the discussion with scholars.2

QoL is dependent on several parameters, including physical health, mental health, economic prosperity and a sense of purpose in life.1,2 Hence, illness, financial insecurity or loss of purpose in life will decrease QoL. Since elderly are prone to physical or mental disabilities due to ageing3 one would expect a decline in QoL among the older population. However, research suggests the overall QoL does not change with age.4 Therefore, one might conclude the decline in one parameter determining QoLneeds to be compensated by other elements to maintain the same QoL at older age; for example, an increased sense of purpose to compensate the decrease in financial means. In addition, QoL is also influenced by the quality of care (QoC),5 either from professional caregivers (formal care) or family members and friends (informal care). Therefore, a decrease of QoL can also be compensated by increasing QoC.

The concept of QoL, although at first sight simple, proves to be more eluding than one might think.2 Especially in the elderly population, questions remain regarding variables influencing QoL. One of the questions I have is whether living arrangements and different types of households influence QoL in elderly. In essence the question is: what is better for the elderly, living with or without their (direct) relatives?

Living with family and quality of life

Since QoL is influenced by QoC the first positive point, and perhaps the most important one, of living with relatives is having someone to take care of you. In a time of budget cuts and a constant decrease of access to formal care systems, informal caregivers become more important to the elderly population.6 Another issue is trusting the person who takes care of you. Recently the professional home care system in the Netherlands was changed, removing the certainty that elderly would be taken care of by the same caregiver or a small team of caregivers. Nowadays, older people have to accept whoever is available to provide care, putting them in a vulnerable position. They need to trust their formal caregivers but how do you trust someone new every single day, especially when you are older and dependent? This issue does not arise as strongly when you have your family to take care of you, although certain things elderly people may not feel comfortable of to ask from family members either.

Not only physically family members can take care of the elderly to improve QoL, but also mentally the elderly need to be supported. Loneliness is a terrible threat to elderly, especially in the oldest age groups where friends and loved ones are no longer there.7 Living with family means less chance to become lonely because you will have people around, though probably from a different generation(s).The age differences, however, do not have to be an issue. After all, most elderly who interact with younger generations state spending time with younger people maintains their (inner) youth as well.

As discussed before, sense of purpose in life also influences QoL in a positive way. Living with relatives and having responsibilities in the household themselves will increase the sense of purpose in elderly; they feel needed and appreciated, no matter how big or small their contribution might be.2 These responsibilities may vary from a mental support (e.g. listening to problems other members of the household might have), supporting by financial means or merely performing small chores in the household, such as cutting food for cooking or small tasks in cleaning. Ultimately, elderly want to feel useful instead of outdated and returning the support they receive from the family, is ideal for that purpose.8

Elderly, especially the oldest among them, were raised in a different time with a different set of moral values. Those values are often the result of traditions going back generations or are part of the religion a person values. Although most elderly understand times have changed, being forced to let go of those traditions can cause distress, resulting in a loss of QoL.9 One such tradition is spending the winter days of your life in the care and company of your (grand)children. In Europe, people let go of those traditions over the past century while rebuilding Europe after the German occupation.10-13 People in other countries are still reluctant to accept this new way of life. Therefore, it is logical to conclude elderly in industrialized countries will suffer less decrease in QoL when not living with their family compared to people still living with strong cultural traditions.

Life is a series of experiences and from those experiences we humans learn. During our lives, we do not only learn but we also teach; we teach our children the things we usually learned from our parents.When elderly are living with the youngest generation, the children do not only benefit from their parent’s knowledge but also their grandparents. This extended process of handing down teachings increases the sense of purpose in life elderly experience, therefore increasing QoL of elderly, and all other members of the household.

However, negative aspects of living with family members in relation to QoL cannot be overlooked either. Living with family members can result in a lack of privacy for all the members of the household, which can actually reduce the QoL by reducing mental health. Even though humans are social creatures by nature, people need their personal time and space as well. Also, the generation gap between the oldest and youngest generation can cause a different view on life with potential controversies. In order to avoid arguments between family members in the same household sometimes it can be necessary to avoid each other for a while. Living in the same house does not allow to have personal space or to avoid each other when required and potentially reduces the QoL.2

Loss of privacy is subjective, and not all people (both elderly and younger generations) consider a reduced personal space to be a significant sacrifice, compared to all that can be gained by living with family. The presence of elderly family members can even increase the privacy for parents; grandparents living with the family can be asked to babysit, so the parents are free to work on their own relationship. Elderly will experience an increase of purpose in life by this, which balances out the loss of QoL by the loss of privacy. Furthermore, it is quite common for the elderly to at least have their own room in the house so whenever privacy or rest is required they can withdraw to their private space.

Elderly can feel like they are a burden to the household they share with the younger generations, especially if they are suffering from disabilities preventing them from active participation in the household. Other elements potentially contributing to this feeling include but are not limited to a financial burden (e.g. in case of expensive medicine), occupying space in a small living area (in case of a small house) or requiring a lot of time and effort (in case of long time care).14 The feeling of being a burden on family members causes stress as well as feelings of unhappiness. When not addressed properly, this could lead to depression as described in the DSM-V15, severely limiting the mental health of the elderly and thus reducing QoL. Of all the potential negative aspects of living with relatives, this is perhaps one of the most serious issues.

The feeling of being a burden on others is a feeling that is hard to counter and easy to give. Especially when (grand)children live a busy life, elderly might feel the care they require is too much to ask. If the (grand)children comment in a negative way on the time and effort they put in the custody for the elderly, this will confirm and reinforce the feeling of being a burden. However, even without negative comments and only positive reinforcements elderly can still feel they are asking too much from their younger relatives, afraid of reducing the younger relatives’ QoL, which in turn reduces their own QoL. The elderly cannot take action to reduce this feeling, meaning the effort needs to come from the informal caregivers. If shown enough love and willingness to take care of the elderly without reinforcing the sense of burden, this feeling might be reduced over time, eliminating the decrease of QoL. However, the feeling of being a burden can also be the result of high levels of expectations. If those expectations are not met by the informal caregivers, elderly might (mis)interpret this as a sign they are being a burden, while the family members might simply be unaware of the high expectations in the first place.

The tradition of taking care of elderly at the last stage of their lives is reduced in importance by outside forces. In strongly industrialized countries or countries in the process of industrialization, it simply was no longer possible for children to take care of their parents since children were no longer bound to the area they were born. An obvious example is a development in Japan. Originally an agricultural society Japan was the first Asian country to industrialize, concentrating the Japanese population in cities.16 Having a choice in a different lifestyle and profession children broke with tradition and moved to the cities, therefore not being able to care for elderly parents any longer.17In Japan, being a country with strong traditional values, this social development has increased uncertainty for elderly. Japanese elderly can no longer count on their children, causing a decrease of QoL.

Society is not static but evolves continuously. This evolution cannot be stopped and can conflict with traditional values. With traditions being less strict adhered to, elderly who are taken care of by their (grand)children know it is based on a genuine willingness to care for them instead of avoiding a social stigma. However, attention is required to safeguard the most vulnerable, including our elderly, in our changing world.

As described earlier, the generation gap between the youngest generation (children, teens and young adults) and the older members of the family can cause misunderstanding and difficulties between these two generations. Unless an effort is made by both, the constant disagreement between young and old can result in severe loss of mental peace on both sides and eventually the QoL.

Even though most of the elderly might not understand modern technology and have very little understanding about modern communication, they can be helpful in only listening and assisting the younger generation in considering both sides of a discussion. Doing so, the elderly can experience an increased sense of purpose in life and, therefore, an increased QoL instead of a decrease due to tension or feelings of uselessness. At the same time, the younger generation should not forget elderly had to fight for their place in society just as much as the younger generations need to do in present time. Sometimes “new” problems prove to be older than one thought they were, meaning elderly can relate better than young people often think.

Living without family and quality of life

As we have discussed the merits and demerits of living with the family at old age critically, discussion of elderly living without family members will involve some of the arguments already made. However, addressing similar insights from the opposite aspect of the question at hand requires revisiting some of the arguments.

Personal freedom, or independence, is trait treasured by most of us.18After a long professional life in which their freedom was limited due to work, the elderly usually enjoy the time they have to travel, read, remodel their house and do all the things they could not do before retirement. Also, not having to consider children in their decision making elderly can act according to their wishes, increasing the QoL by increasing their mental health. Living with relatives, especially younger generations, including working hours, raising children and other responsibilities, would hold them back too much, decreasing QoL as a result. Of course, such a life is only available for those who are fit and do not suffer from chronic illnesses.Moreover, the financial means to support a carefree life are not available to everyone.

Self-sufficiency is another important trait elderly people cherish. Self-sufficiency, or being able to take care of one’s own affairs with minimal help from others, means living with relatives (or other informal caregivers) is not essential. Self-sufficiency will, in time, give an elderly person self-confidence while self-confidence leads to an increased feeling of self-worth. Self-worth is being defined as: “the sense of one’s own value or worth as a person”19, leading towards an increased mental health and greater sense of purpose in life. We already described an increased sense of purpose in life as well as increased mental health increases Qol. Therefore, we can conclude self-sufficiency increases QoL in elderly.

In the end, all of the mentioned positive sides of not living with family comes down not being a burden as discussed before. Being a burden weighs heavily on people, decreases mental health and self-worth and, therefore, decreases QoL. Being a burden is a feeling everyone wants to avoid, not only the elderly.17However, the elderly population seems to be willing to go furthest to avoid being a burden to the level where they actively deny the need for help. For many older turning towards family for help is the actual last resort. In order to maintain as much as their independence as possible, some elderly actually prefer living in retirement or nursing homes instead of turning towards family and friends for support, which is quite a paradox. Some members of the older generation are more comfortable with formal caregivers than with informal caregivers that might increase their QoL.

The personal freedom elderly cherish so much has a few dark opposite sides. Especially people in the United States and parts of Europe society is known to have become increasingly individualistic and, as a result, they seem to care less about each other. Especially elderly living alone are at risk of getting lonely, even more so when they suffer from more serious disabilities. However, more severe situations can also occur. In major cities in the Netherlands,cases were reported of elderly not being missed after they died for weeks, months and, on rare occasions, even years, leaving them in their homes without proper burial arrangements.20,21If you are not missed for such a long time after death, how much QoL do you have?

As said, situations, as described above, are rare and will be even more so in the future. Due to modern means of communication people can monitor elderly better, if elderly are trained better in the use of modern communication. In community centers elderly can be taught how to use the basics of a computer or smartphone, creating not only more knowledge but also improves the social network outside of Facebook, therefore improving QoL. But also passive monitoring has been suggested more than once over the last decades, going from a social alarm system (elderly wear a unit as a necklace or bracelet, which they can activate if something is wrong or, in more modern version, the system will activate itself as soon as vital parameters are outside preset conditions, to camera monitoring or even a Japanese health care robot.22,23It is, however, debatable if those modern, passive monitoring strategies will improve QoL or will push elderly even deeper in social isolation.

Finances are another limiting factor in the life of the elderly. Finances decrease after reaching the age of retirement, increasing financial insecurity. In some countries, men or women without a paid job will not receive pension or financial assistance of government at an older age at all, putting their QoL in severe jeopardy. This increases their dependency which in turn also decrease QoL. Furthermore, some people might choose to live without family but cannot do so due to financial dependency, decreasing their QoL even more.

Elderly may value self-sufficiency but isn’t self-sufficiency an illusion at any age? No person is able to function completely independent from other human beings, sometimes due to lack of knowledge and sometimes due to lack of physical strength. Elderly are no different in that regard, although can be less self-sufficient due to decreased physical strength or mental capacities, even more when living without family members. The loss of self-sufficiency can reduce the QoL due to the described mechanism above.3,4

The loss of self-sufficiency does not have the same effect on all people. It is generally accepted that a gradual decline of self-sufficiency is experienced as less troublesome as an acute loss.4Also, the level of (physical) activity prior to loss of self-sufficiency plays a role when considering the loss of QoL; for example, the limitations due to arthrosis will hamper a former athlete more, both physically and mentally, compared to someone who led a sedentary life. Therefore, stating loss of self-sufficiency will automatically lead to a loss of QoL, is too simple; an individual’s need has to be taken into account. Besides, an adjustment period to grief for a loss of self-sufficiency is warranted. The loss of anything valuable to a person (including selfsufficiency) might lead to decrease in QoL at the acute moment while this loss of QoL is no longer felt (as strongly) after having adjusted to the new situation. Thirdly, a loss of selfsufficiency can be countered by investments, either by physical therapy, adjustments made in the home or using assisting-devices for mobility. Therefore, loss of self-sufficiency also depends on the investments elderly can and are willing to make. Willing to make such an investment does not mean elderly are able to do so. In those cases, mental support is required to prevent further loss of QoL due to negative social interaction.

As described before, no person wants to be a burden on another. However, a thin line needs to be walked between not feeling a burden and loneliness. Whenever a person desperately tries to avoid being taken care off, he endangers himself since loneliness is considered more lifethreatening than smoking.7

It is the human nature to be willing to help, just as it is human nature not to be prepared to ask for help. This discrepancy in human nature causes many people, especially elderly, to feel a burden on others while they are actually not. Loss of QoL tends to increase when an imbalance exists between the care needed or expected and the ability to give care. This loss is experienced by both the elderly as the informal caregiver; the elderly feels like a burden to the caregiver while the caregiver feels inadequate in their duties towards the elderly. Proper empathic communication between care giver and the elderly can reduce this problem so that they can understand each other’s limitations.

Conclusion

In science, we strive to find answers usable for large groups of people. However, in this essay I have been unable to come to such a conclusion. Although QoL is well measurable in science, not every person values the same aspects of QoL the same. As an Indian upholding, the traditions of my culture is important to me, traditions that were also present in the Netherlands in the first half of the previous century. However, during my interactions with elderly in the Netherlands, but also in the United States, I have found elderly nowadays value their personal freedom most and do not want to burden their (grand) children.

To the best of my knowledge, no research has ever been performed to compare QoL in elderly living with or without their family members. Although the arguments made in this essay are substantiated with (scientific) evidence the available evidence is circumstantial and derived from populations that might not be entirely comparable with the average elderly. In order to truly answer the question, I started this essay with, a well set up cohort study is needed in order to compare the QoL in elderly living with family members and those living without them. Perhaps in the future we can answer with certainty what is better for the elderly, living with or without their (direct) relatives.

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