Copyright 1999 by
The Cerontological Society of America
The Cerontologist
Vol. 39, No. 2, 159-166
This study explored how characteristics of multigeneration families of patients with
Alzheimer's disease (AD) affected the family's ability to provide help to their ill elder. An
intensive patient and family assessment battery was employed with 211 families with an
elder with AD, and measures of the amount and kind of help offered by the family group
were recorded. Above and beyond control variables, families that used a focused decisionmaking style and positive conflict resolution methods provided more help than families
that did not use these styles and methods. These data suggest the importance of the
family system of care in disease management.
Key Words: Family, Alzheimer's disease, Caregiving
The Effects of Family Conflict Resolution
and Decision Making on the Provision of
Help for an Elder With Alzheimer's Disease
Morton A. Lieberman1 and Lawrence Fisher2
The problems associated with the delivery of care
by offspring to their aging parents increases as parents
become ill and require more care. For example, families
caring for a parent with Alzheimer's disease often experience ongoing conflicts concerning such issues as
what to do about a parent's continued desire to drive
a motor vehicle, how care tasks should be shared
among family members, and when placement into a
nursing home should be considered!. A fuller understanding of the process of family decision making and
care sharing for ill elders has been limited, by and
large, by an often singular focus on the "primary" caregiver that excludes trie contributions of other active
family members. When other family members are studied,
their caregiving is usually described through the use
of "support" nomenclature, which, in our view, provides a restrictive framework for understanding the
underlying processes through which family caregiving
is organized and delivered.
This study adopted a broad view of the caregiving arena by exploring the role of the multigeneration
family, not just the primary caregiver, on the amount
and type of care that is provided to a dementing elder. Specifically, we tested the hypothesis that the
ways in which families successfully address the disagreements and conflicts that inevitably arise over time
affect the amount of help that second generation family
members are willing to provide. Addressing the dynamics of caregiving within the family using this broader
This research was supported by California Department of Health Services grants #94-20353 and #93-18641. Major support was also received
from Alzheimer's Foundation grant #94-043. Appreciation is expressed
to the network of Alzheimer's Disease and Memory Disorders Clinics supported by DHS, State of California.
1
Address correspondence to Morton A. Lieberman, PhD, Center for
Health & Community, 3333 California Avenue, Suite 475, University of
California-San Francisco, San Francisco, CA 94118. E-mail: [email protected]
department of Family and Community Medicine, University of California-San Francisco.
Vol. 39, No. 2, 1999
159
perspective is particularly important for programs of
clinical evaluation and intervention. If the importance
of second generation decision making and conflict resolution can be demonstrated, then justification can be
offered for programs to move beyond the primary caregiver to address the family as a unit (Mittleman, Ferris,
Shulman, Steinberg, & Levin, 1996).
A review of published studies suggests that many
factors affect the amount of help provided by the second generation to ill family members of the first generation. Adult offspring are more likely to provide care
when they are women (Dwyer & Coward, 1992), when
they live near their parent (Finley, Roberts, & Banham,
1988), when they are an only child (Coward & Dwyer,
1990) or the oldest child (Hanson, Sauer, & Seelbach,
1983), and when they are divorced, widowed, or never
married (Stoller, 1983). Competing work roles (Brody
& Schoonover, 1986) and other family obligations
(Stoller & Pugliesi, 1989) reduce the ability of adult
offspring to provide care to their aging parents. Furthermore, changes in elders' health status and function
(Cicirelli, 1981; Stoller, 1983), marital and living arrangements (Horowitz, 1985), age (Soldo & Myllyluoma,
1983), and economic resources (Riley & Foner, 1968)
also are important predictors of the participation of
offspring in parental care. Cicirelli (1992) suggested
that the care of aging parents is a developmental task
of the entire sibling group over the life span.
Several studies support the contention that the
organization and effectiveness of adult offspring involvement in caregiving influences the amount and
type of care provided to an ill elder. For example,
Dwyer, Henretta, Coward, and Barton (1992) explored
changes in adult offspring caregiving over time. They
found that 50.7% of those offspring who provided activities of daily living (ADLs) assistance and 29.9% of
those who provided instrumental activities of daily living (lADLs) assistance initially stopped doing so during
the subsequent years. This finding suggests that the
participation of adult offspring in caregiving changes
over time, often independently of the elder's continued, and often increased, needs for assistance. Caregiving behavior of adult offspring is also influenced, at
least in part, by the caregiving behavior of other offspring. Dwyer and colleagues (1992) reported that the
probability of one offspring providing care was directly
related to the probability of their siblings providing
care: if one helped, the others did as well.
Coupled with this apparent unanimity of caregiving
among adult offspring from the same family is the finding that adult sons and daughters provide care in
different ways, and that the roles they play and the
impact caregiving has on their lives differ. Daughters
are more likely than sons to provide high levels of
personal and home-based care (Chang & White-Means,
1991; Dwyer & Coward, 1991; Horowitz, 1985), whereas
sons are more likely than daughters to provide assistance in home repair, financial management, and maintenance (Stoller, 1990). Taken together, sons and daughters who manage their respective care providing roles
well and who develop effective means for dealing with
decision making and conflict resolution provide complementary caregiving behaviors to their aging and at
times ill parents.
A Family Framework
Considerable data suggest that characteristics of the
family unit are linked with its ability to manage a major health care crisis over time, e.g., diabetes (Hauser,
Jacobson, Wertlieb, Brink & Wentworth, 1985), cancer (Soccorsi, Lombardi, & Paglia, 1987), and cardiovascular disease (Medalie & Goldbourt, 1976). For example, family beliefs, structures, and styles have been
associated with compliance with medical regimens
(Rolland, 1994), frequency of hospitalizations (Doane,
Falloon, Goldstein, & Mintz, 1985), use of health care
facilities (Schor, Starfield, Stidley, & Hanks, 1987), reported family member health and well-being (Fisher,
Ransom, & Terry, 1993), display of health risk behavior (Fisher & Feldman, 1998), and post-illness recovery (Medalie & Goldbourt, 1976). In general, the following family variables have received the most attention
and have demonstrated the most consistent links with
poor response to chronic disease: low family cohesion, high family conflict, too rigid or too permeable
family boundaries, low levels of family organization,
distant or hostile family affiliative tone, criticalness,
lack of clear communication, and poor spousal support (Fisher, Ransom, Terry, Lipkin, & Weiss, 1992).
Despite the rapid proliferation of empirical studies
examining the relationships among family members
caring for an elder with Alzheimer's disease, the vast
majority of research has not addressed the family as
an integrated system responding to and being affected
by the presence of disease. There has been an increased interest, however, in the importance of the
family in understanding variations in disease management behavior. Some studies report that emotional support from siblings (Horowitz, 1985) and other relatives (Zarit, Reever, & Bach-Peterson, 1980) mediates
160
caregiver strain. Other studies document the problems
of conflict and disturbed relationships among family
caregivers. For example, Brody (1989) reported that
between 45% and 60% of primary caregivers complained that their siblings failed to help as much as
they should. Matthews and Rosner (1988) found that
sibling conflict is sometimes exacerbated to the point
that responsibilities can no longer be shared.
Overall, the central focus of Family research in caregiving for frail elders has centered on family conflict
(Abel, 1987; Archbald, 1983; Frankfather, Smith, &
Caro, 1981; Haussman, 1979; Smith, Smith, & Toseland,
1991). Stuifburgen (1990) reported that those families she characterized as involving "structured conflict" perceived a greater impact of illness than those
families she characterized as "cohesive." Furthermore,
Strawbridge and Wallhagen (1991) reported that 40
of 100 adult offspring caregivers experienced serious
conflict with other family members and that family
conflict correlated significantly and positively with caregiver burden and poor reported health.
Studies also suggest that how families care for an
elder with Alzheimer's disease is associated with the
self-reported health and well-being of the patient's
spouse, offspring, and offspring spouses, or in-laws. Fisher
and Lieberman (1994) used 12 indicators of family
functioning grouped into three behavioral domains of
family life, world view, structure/organization, and emotion management, and found that adult offspring and
in-laws displayed variations in anxiety/depression, somatic symptoms, and well-being as a function of these
qualities of the family system. Fisher and Lieberman
(1996) examined the consistency and change in family and health relationships over time. They found that
the use of mechanisms to avoid family conflict and
the use of guilt by family members as a means of control assessed at baseline led to a significant reduction
in offspring health and well-being over a two-year period. Furthermore, family avoidance of conflict was associated with increased adult offspring vulnerability to
the effects of increasing patient-care distress over time.
Lieberman and Fisher (in press) found that characteristics of the family system either contained or exacerbated the stresses of caregiving from affecting other,
non-disease-related family role behaviors, in this case
marital role functioning. Last, Lieberman and Fisher
(in press) showed that characteristics of the family were
linked to the family's use of professional services for
patient care, as recommended by clinic evaluation.
Families that did not follow through had fewer disagreements and reported closer family relationships
over time than families that did follow through on clinic
recommendations. These "closer" families preferred
to undertake caregiving themselves, without the assistance of professional or community services.
These studies suggest that how family members
structure themselves to address the complexities of
caring for an elder with dementia has an impact on
the conditions of care, the follow-through on clinic
recommendations and the subsequent health and
well-being of all family members. The present study
addresses these issues further by examining another
critical behavioral issue in caregiving: the amount and
The Gerontologist
kind of help offered by family members to the ill
elder with dementia. Our primary research question
concerned how the help offered by family members
in the care of an elder with dementia was influenced
by their style of decision management and conflict resolution regarding caregiving issues. We hypothesized
that families that handled decision making well and
that used effective methods of conflict resolution would
work together better and, therefore, would provide
more help to their ill elder than families that did not.
Methods
Sample
Patients and their families were recruited from the
California Alzheimer's and Memory Disorders Clinics
located in San Francisco, Davis, Fresno, Palo Alto, Los
Angeles, San Diego, and Irvine. Each clinic sees an
average of 130 new patients and their families per
year for comprehensive diagnostic and management/
care planning, and most families are followed for reevaluation yearly. The clinics are multidisciplinary; their
diagnostic procedures include neurological, family,
medical, psychiatric, and social evaluation, as well as
advanced diagnostic imaging procedures. The patient's
behavior and environment are evaluated during a home
visit by a clinic staff member. Each patient's medical,
behavioral, and environmental findings are reviewed
in a clinical case conference to arrive at a consensus
diagnosis and care plan. Three to four weeks after
the staff conference, family members attend a feedback meeting in which the diagnostic recommendations and care plan are discussed.
Inclusion criteria for the study were: the patient
met National Institute of Neurological and Communicative Disorders and Stroke (NCCHD) diagnostic criteria for probable or possible Alzheimer's dementia;
at least one adult offspring resided in California; and
the patient lived in the community, either with a spouse,
relative, or alone. All patients and families meeting
these criteria were referred by the respective clinics
to the research team following completion of the family
feedback conference.
Of the 533 families referred by the clinics, 198 did
not fully meet inclusion criteria. Of the remaining 335
families, 100 refused to participate, yielding a 70%
acceptance rate. Twenty families provided partial data
and were dropped from analysis. The total sample included 211 families.
The study included only adult offspring because
previous studies indicated^ that spouses tended to
present their families in a highly favorable light. This
positive bias limited variations among families (Fisher
& Lieberman, 1994). The data from only one offspring
per family was included in analyses to assure independence among respondents (in 13 families the offspring was not available and the clinics designated an
in-law who was most involved in ADLs/IADLs care).
Preliminary analysis indicated no differences between
offspring and in-law responses on any of the measures
included in this article. Characteristics of the patient
Vol. 39, No. 2, 1999
161
Table 1. Characteristics of Patients (N = 211)
N
Percent
133
78
63
37
10
7
25
169
4
3
12
81
38
99
17
49
8
18
47
8
23
4
Mean
SD
11.98
15.80
4.87
1.50
2.43
4.68
6.47
2.78
4.1
7.0
5.6
1.9
2.1
1.9
4.8
2.8
Gender
Male
Female
Ethnicity
Asian
African American
Hispanic
Non-Hispanic White
Living arrangements
Alone
With spouse only
With spouse & offspring
With offspring
With non-relatives
Years of education
Mini-Mental Status Exam
Blessed Roth Dementia Rating Scale
Number of neurological signs
Number of other illnesses
Number of dementia-related problems
Number of psychiatric symptoms
Number of services used
and respondent sample are presented in Tables 1 and
2, respectively.
Using the clinics' shared, computerized database,
analysis of data between the 120 Tamilies that refused
or were dropped and the 211 that participated yielded
no significant differences in clinic location, reasons for
seeking evaluation, patient gender, ethnicity, marital
status, living arrangements, income, patient education,
Table 2. Characteristics of Offspring/In-laws (/V = 211)
Gender
Male
Female
Marital status
Single
Married
Divorced or separated
Widowed
Education
>11 years
High school
Some college
College graduate
Post-college
Work status
>50% Time
<50% Time
Number of children
Care hours per week
Nuclear family size
N
Percent
80
131
38
62
32
153
23
3
15
73
11
1
44
21
41
73
32
21
10
19
35
15
173
38
82
18
Mean
SD
2.2
2.7
2.5
1.9
3.3
.7
number of primary and secondary caregivers, or scores
from the Mini-Mental State Exam, Blessed Roth Dementia Rating Scale, Blessed Orientation Cognitive Test,
diagnosis, or number of patient problems. Hence, the
sample appears representative of the population served
by trie California clinics.
fied by Pearlin, Lieberman, Menaghan, & Mullan, 1981,
alpha = .92).
Family Characteristics.—Family decision making and
conflict resolution were assessed by four sets of interviewer ratings based on a tape-recorded, semistructured
telephone interview. These scales assessed how offspring and in-laws made decisions and how they adProcedure
dressed the disagreements they experienced regarding the ill family member's care. Interrater reliability
Family members were contacted by the research
(kappa) was established using a separate set of 20
team after the clinic feedback conference. The patient's
pilot interviews and internal consistency (alpha) was
spouse was called first to determine if the family met
based on scores from the entire sample.
the inclusion criteria. If so, the offspring (or in-law)
The telephone interview began with the following
was contacted, and she or he became the primary
question: "I would like you to tell me about a situafamily respondent. Agreement to participate involved
tion in which your family has had to make a decision
the offspring completing a 197-item questionnaire and
regarding Mr./Mrs. X's care or about arrangements
a 45-minute tape-recorded telephone interview (we
that had to be made for him/her. Please tell me about
were unable to complete the inverview for nine suba situation like this and how you went about making
jects, and these were included among the 20 families
a decision." The respondent defined for her/himseff
dropped from analysis because of incomplete data).
the problem area. Two sets of interviewer questions
followed the respondent's presentation of the decision-making situation. Positive decision making techMeasures
niques was based on a 9-item, yes/no scale that asked
Patient Characteristics.—Six patient measures, asthe respondent to state how the family came to
sessed by the clinics using uniform criteria, were used
their decision. Items included: did your family consult
to measure severity of patient problems: level of cogan expert in the field, ask an advisor (clergy, friend),
nitive disturbance (Mini-Mental State Exam; Folstein,
list alternatives, go around and around, not deal
Folstein, & McHugh, 1975), level of functioning (Blessed
with it, divide up the tasks, reach a stalemate (dead
Roth Dementia Rating Scale; Blessed, Tomnnson, &
end), feel you worked too hard for too little results,
Roth, 1968), number of psychiatric symptoms (psychiaand read books or literature. The number of positive
trist's rating of nine symptoms using DSM—III criteria),
methods was used as the indicator score (alpha = .72).
number of neurological signs and symptoms (neuroFocused decision making was based on a summed
logist's rating), number of other health problems (phycomposite of two interviewer ratings. The first was
sician's rating based on a history and physical exam),
a rating of who made the final decision. Options
and number of patient problem behaviors (clinical
included: one person with little or no input from
nurse's rating of ten areas assessed at a home visit). A
others, one person with some discussion with others,
principal components analysis of the six patient charactive discussion by all family members with one peracteristics yielded one factor, accounting for 67% of
son deciding, and shared or democratic decision makscore variance. A factor score from this single compoing (reverse coded, kappa = .78). The second was
nent was used as an index of patient severity.
a rating of how much verbal discussion occurred
among family members, using a 5-point scale from
Each patient's living arrangements was classified
"minimal or not at all" to "a great deal" (kappa =
into a three-way categorical variable: living with spouse,
.73).
living with an offspring (with or without a spouse), or
living alone. Last, we asked each family member
The conflict resolution scales were based on the
to rate the patient on a scale of "troublesomeness"
respondent's answer to the following telephone interbased on a list of 17 patient problem behaviors
view question: "I'd like you to tell me about a dis(alpha = .83). Examples included: wandering or getagreement or difference of opinion that is occurring
ting lost, asking the same question over and over, hidin your family now about caring for Mr./Mrs. X. Someing things (money, jewelry), or being suspicious or
thing that is important to the family and about which
accusative.
you do not agree." Positive conflict resolution was
based on a 6-item scale that asked the respondent
Offspring/ln-law Characteristics.—Data were collected how often the following occurred regarding the disagreement: a person or group of family members gave
on offspring (or in-law) gender, distance in miles bein; a compromise occurred; the conflict was avoided;
tween the residence and the ill parent, offspring work
the family worked hard to resolve it; we handled it
status (50% or more time vs less than 50% time), age
positively; members felt pressured or coerced. A 5of youngest child, and minority ethnic group status. In
point scale from "always" to "rarely or never" was used
addition, two measures of the respondent's health and
for each item (reverse coded, alpha = .61). Task fowell-being were included: number of 13 somatic sympcus was based on a 5-po/nt rating from "a/ways task
toms occurring regu/ar/y over the fast three montns
focused" to "very often off task" in response to: "When
(Ware et al., 1984), alpha =.93, and anxiety/depresyou have a disagreement in your family, how hard is
sion (combined anxiety and depression scales from the
it for the family to stay on the topic? Do you tend to
Hopkins Symptoms Checklist; Derogatis, 1974; modi162
The Gerontologist
get diverted or lose track easily, or can you generally
stay on the topic" (kappa = .90).
Dependent Variable.—The respondent was then
asked about the "things you did to help care for Mr./
Mrs. X" during the last six months. Responses were
coded into eight content areas: shopping, finances,
errands, transportation, personal care, food preparation, laundry, and home maintenance. If help was provided in a particular content area, frequency of help
was also recorded (daily, 2-6 times per week, once
per week, 1-3 times a month, occasionally). Similarly,
each respondent was asked if care was provided by
other family members in each content area, and if so,
frequency of help was recorded. Adding the respondent's help score to the "other family member" help
score created the total family help score used in the
analyses reported below. The total family help score
was used in all analyses because we were interested
in how much help trie family as a group provided to
the patient. This score was unrelated to family size
(r = .09) and was significantly related to estimates of
total family help provided by other family members
(r = .54).
Data Analysis
Our primary question was whether the four family
decision-making and conflict resolution variables predicted the quantity of help provided by the family to
the ill elder, after controlling for the effects of the
other variables most often studied (for purposes of this
article we label these "control variables"). Because of
the number of control variables assessed, relative to
the size of the sample, two sets of multiple regression
equations were constructed.
In the first equation, 13 control variables were entered into a simultaneous regression equation, with
total family help as the dependent variable, to explore
the quantity of nelp provided. Significant, independent
predictors from this equation were then identified.
Next, three equations were created to assess the
role of the family variables in predicting help provided.
Three equations were required because the number
of potential interaction terms between the family variables and the control variables was too large, relative
to sample size, to be included in a single equation.
The three significant predictors identified in the first
regression equation were entered into Step 1 and the
four family variables were entered into Step 2 of all
three equations. Step 3 included interaction terms between all four family variables and one of the three
traditional variables entered into Step 1, thus yielding
three separate equations.
Beta
Patient living with spouse
Patient living alone
Severity of dementia
Ethnic minority membership
Gender of offspring/in-laws
Number of children (third generation)
Offspring miles from patient
Nuclear family size
Offspring education
Offspring physical symptoms
Offspring carestrain
Troubling behaviors
Offspring anxiety/depression
-.17
-.02
-.01
-.03
.04
.09
.02
-.02
.16
-.03
-.09
.13
.01
2.14
.23
.02
.56
.60
1.48
.28
.24
2.28
.35
1.29
1.74
.39
.03
.82
.98
.58
.55
.15
.78
.81
.02
.72
.20
.08
.70
Final model: R = .30, F (12/198) = 3.50, p = .08.
statistical significance: patient living with a spouse
was negatively correlated with total family help (|3 =
-.17, t = -2.14, p = .03); and respondent education was positively correlated with total family help
(P = .16, t = 2.27, p = .02). Troubling behaviors
approached statistical significance (P = .13, t = 1.74,
p = .08), suggesting a positive relationship with the
provision of family help.
Analysis of Family Factors
The three step-wise multiple regression equations
indicated that none of the family by conrol variable
interaction terms in Step 3 or the R2 change for Step
3 approached or reached statistical significance {R2
change for Step 3 = .005, .021, and .008). For ease
of presentation, the results of only the first two steps
are presented in Table 4. The two-step equation with
Table 4. Hierarchical Multiple Regression Model of Control
and Family Variables to Predict Total Family Help
Step 1. Control variables:
Living arrangements:
Spouse vs offspring
Alone vs spouse and offspring
Troubling behaviors
Education
Step 2. Family variables:
Positive decision making
Focused decision making
Task focus
Positive conflict resolution
Step 3. Interaction terms:
(all nonsignificant)
Step 1 Beta
Step 2 Beta
-.19**
.04
.12*
.16***
-.14**
.05
.13*
.16***
.07
.14**
.05
.18***
Step 1 : R = .28, F = 4.30, p = .002. Step 2: R = .37, F =
3.70, p = .0001.
Results
* = p < .10; ** = p < .05; *** = p < .01.
Analysis of Traditional Factors
Note: Three separate regression equations were run. Step 3
included the interaction terms between the family variables in
Step 2 and one of the control variables in Step 1. For ease of
viewing, the betas for Step 3 are not presented, because the step
was not significant in any equation and no interaction term reached
or approached significance.
The results of the simultaneous regression equation
are presented in Table 3. The equation approached
significance {R = .30, df = 12/198, F = 3.50, p =
.08). Of the 13 traditional variables, two reached
Vol. 39, No. 2, 1999
Table 3. Simultaneous Regression Model of Traditional
Variables to Predict Total Family Help
163
all variables entered reached statistical significance
(R = .37, df =8/202, F = 3.70, p = .0001). After
controlling for the effects of living arrangements, education, and patient troubling behavior, a significant
main effect occurred for positive conflict resolution
({3 = .18, t = 2.6, p = .01) and focused decision
making (p = .14, t = 2.00, p = .04). The greater the
family's positive conflict resolution skills and the more
focused their decision-making style, the more help the
family provided.
narrow body of research, in our view. By and large,
research has focused on the care provided by the "primary" caregiver, examining the motives and costs of
caregiving. Caregiving within the context of the larger
family system has been relatively less well studied
(Dwyer & Coward, 1992).
me present study took as its central theme the view
that every family has certain caregiving values, traditions and practices that account, in part, for the variations that families display when caring for ill elders
(Brubaker & Brubaker, 1989; Gubrium, 1991). We addressed one aspect of the family's style of management that shapes its response to elder care needs.
We find that three control variables are linked to
the provision of family help: less family help is provided when the ill family member lives with his or
her spouse than when they live alone or with offspring;
more family help is provided when elders display
troublesome behavior than when they do not; and
more family help is provided when the adult offspring
are educated than when they are not. All three findings were expected, given previous research.
Noteworthy are our findings concerning the linkages between characteristics of caregiving families and
the provision of help. Families that use positive conflict resolution methods provide significantly more help
than families that do not. Families that assign decision-making responsibilities to a single family member
with at least some input from others provide more
help than families that use more democratic but potentially more disorganized methods. Taken together,
these findings suggest that the provision of family help
is greatest when there is a family ethos of using effective methods for resolving conflicts among family
members regarding caregiving and decisions about
caregiving, and when the responsibilities for decision
making are focused and concentrated on a single family
member.
The absence of a significant interaction term in all
three multiple regression equations and the very low
R2 change between Steps 2 and 3 suggests that the
family effects on the provision of family help are not
qualified by patient living arrangements, troubling behaviors, or offspring education, a surrogate for social
class. This finding enhances the generalizability of
the family effects to a broad range of multigeneration
families.
These findings echo a recent study by Pyke and
Bengston (1996) on variations in family caregiving among
multigeneration families. They found that families organize their response to the caregiving needs of elders in one of two ways: one corresponds with the
idea of individualism and the other with collectivism
or familism. Collectivist families are more likely than
individualist families to emphasize the emotional needs
of the family, which provides a sense of continuity,
belongingness, and family identity. In these families,
emphasis is placed on kinship ties and familial responsibilities, which take precedence over other personal
roles and obligations. Individualistic families, on the
other hand, emphasize personal independence, selfreliance, autonomy, and loose kinship ties. Individualistic families minimize hands-on caregiving and rely
Supplementary Analyses
Given the significant findings, we asked whether the
provision of family help, and by implication the way
the family structured itself for decision making and conflict resolution, affected a family's decision to place
their ill elder in a care facility during the two years
subsequent to clinic evaluation. Our rationale was that
the provision of family help, and the family-related
factors that influence it, have important implications
for family decisions to institutionalize: the less able
the family was to provide help to their ill elder in the
community, the greater the probability that the family
might choose to institutionalize over time.
We had available follow-up data on this sample as
part of a larger study. Data on placement were gathered from a brief, telephone interview administered
every six months for two years following clinic evaluation. The sample of 211 families was reduced for this
analysis by ten deaths and 25 drop-outs during the
ensuing two-year period, leaving 176 families. Of these,
87 (49.4%) had been institutionalized during the two
years following clinic evaluation.
A simultaneous logistic regression equation was
constructed with institutionalization as the dependent
variable. Three predictors were included: total family
help, troubling patient behaviors, and patient severity
(the correlation between patient severity, based on
clinic evaluation, and troubled behavior, based on respondent perceptions is .27). The latter two variables
were included to control for other indicators that might
directly contribute to institutionalization, thus allowing the role of family help to be assessed more independently. The logistic regression equation reached
statistical significance (%2 = 13.70, df = 3/172, p =
.003), with two of the three odds ratios reaching
statistical significance: troubling behavior (OR = 1.39,
p = .01); patient severity (OR = 1.09, p = .52); and
family help (OR = .69, p = .01). As expected, family
members who reported high levels of patient troubling behaviors more frequently institutionalized their
ill elders than family members who reported low
levels of patient troubling behaviors. After controlling
for troubling behavior, families that provided high levels of help were less likely to institutionalize their ill
elders than family members who reported providing
low levels of family help.
Discussion
The increased national awareness of the need for
family elder care is reflected by a large but somewhat
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instead on formal supports. They do not abandon their
elderly parents, however, but instead serve as managers of the parents' needs and maintain regular social
contact. Collectivistic families personally assume care
of frail elders, even when the demands for care are
high.
The results of the supplementary analyses expand
the primary findings concerning the provision of family help. Controlling for patient troublesomeness and
severity, the more help provided by the family, the
lower the probability that the family will institutionalize the ill parent during the ensuing two years. Characteristics of the caregiving family, therefore, may be
indirectly linked with the timing of institutionalization.
This finding suggests an important hypothesis for future research, namely that specific characteristics of
the social context of care may significantly increase
our ability to predict which families may institutionalize early in trie disease process and which families
may be unable to institutionalize even when the emotional and instrumental costs become high. Such data
would have substantive implications for programs of
intervention.
Several limitations of these findings need to be considered. First, the analyses of the primary research questions were based on cross-sectional, retrospective data
supplied by family members. The predictive linkages
among these variables were not assessed.
Second, we did not include variations in family
appraisals by members of the same family in these
analyses. This might have influenced the findings insofar as we selected the offspring most involved in
care as the family respondent. However, other research
suggests that correlations on family appraisals between
offspring and in-laws are generally moderate (Fisher &
Lieberman, 1996) suggesting that the linkages between family conflict resolution and decision making,
and the provision of family help are relatively stable.
Third, our sample was predominately non-Hispanic
White. Because family structures, beliefs, and styles of
management vary by culture and ethnicity, these data
cannot be directly generalized to ethnic minority families. Although we hypothesize that characteristics of
the family context of care are linked to the provision
of help and other management issues among ethnic
minority families, we suspect that qualitative aspects
of these patterns may vary from culture to culture.
The present study suggests the importance of addressing characteristics of the multigeneration family
caregiving system in studies of clinical care for patients
with dementia. Addressing family organizational patterns, world views, problem-solving skills, and emotion management styles may provide important new
vehicles for intervention, mis approach suggests an
expansion of the perspective often used to observe
caregiving, from the so-called primary caregiver to the
broader social context in which decisions are made
and care is delivered.
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Received May 18, 1998
Accepted December 10, 1998
Serono Symposia USA, Inc.
Endocrinology of Aging
October 27-30, 1999, Tempe, Arizona
Scientific Committee
Barry B. Bercu, M.D., Richard F. Walker, Ph.D., Chairs
Marc R. Blackman, M.D., Michael Fossel, M.D., Ph.D.
Steven W.J. Lamberts, M.D.
The objective of this meeting is to review contemporary
knowledge of basic and clinical aspects of aging as it impacts
upon the endocrine system. Accordingly, part of the meeting will
be devoted to understanding the pathophysiological causes of
decay and dysfunction of endocrine tissues, of integration among
the different neuroendocrine axes and of the cellular and
molecular processes underlying endocrine senescence. This
information is derived primarily from research in animals and
will represent much of the preclinical logic for clinical interventions into the aging process. Current clinical interventions
such as those involving hormone replacement therapy will be
described, and more hypothetical approaches involving gene
therapy will be discussed. The symposium will present "state of
the art" applications of basic research to the human condition, as
well as insight into future trends of endocrine aging research.
COASTAL CAROLINA
UNIVERSITY
The Sociology Program at Coastal Carolina
University invites applications for an Assistant
Professor, tenure track position beginning August
1999. The successful candidate will have a Ph.D. in
Sociology, research expertise in Social Gerontology,
a demonstrated interest in undergraduate teaching
and research, and will assist in helping to promote
the Department's Gerontology Certificate Program.
Applicants should send vitae, statements of teaching
and research interests, copies of transcripts, and three
(3) letters of reference. Coastal Carolina University
is a growing, state-assisted institution located 10
miles from Myrtle Beach. Consult our web page at
http://www.coastal.edu. Send application to Chair,
Sociology Search Committee, Coastal Carolina
University, P.O. Box 261954, Conway, SC 29528.
This symposium is designed for physicians, scientists, and
other health professionals interested or trained in endocrinology,
gerontology and geriatric, internal and family medicine.
AMA Category I credit hours will be awarded.
For further information, please contact:
Leslie Nies, President, Serono Symposia USA, Inc.
100 Longwater Circle, Norwell, MA 02061 USA
Telephone 800-283-8088 or 781-982-9000
Fax 781-982-9481
Review of candidates will begin immediately and continue
until the position is filled. Coastal Carolina University is
committed to Equal Employment Opportunity and is eager
to identify minority persons and/or women with
appropriate qualifications.
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