Familial support and caregiving among generations typically run in both directions. Older people often provide care for a variety of others (spouses, older parents, children, grandchildren, and nonfamily members), while families, and especially adult children, are the primary source of support and care for their older relatives. Most older people today have children, and many have grandchildren and living siblings. However, in countries with very low birth rates, future generations will have few if any siblings. The global trend toward having fewer children assures that there will be less potential care and support for older people from their families in the future.
As life expectancy increases in most nations, so do the odds that several generations are alive at the same time. In more developed countries, this is manifested as a “beanpole family,” a vertical extension of family structure characterized by more but smaller generations. As mortality rates continue to improve, more people in their 50s and 60s are likely to have surviving parents, aunts, and uncles. Consequently, more children will know their grandparents and even their great-grandparents, especially their great- grandmothers. There is no historical precedent for a majority of middle-aged and older adults having living parents.
However, while the number of surviving generations in a family may have increased, today these generations are more likely to live separately. In many countries, the shape of the family unit reflects changing social norms; economic security; rising rates of migration, divorce, and remarriage; and blended and stepfamily relations. In addition, more adults are choosing not to marry or have children at all. In parts of sub-Saharan Africa, the skipped- generation family household—in which an older person or couple resides with at least one grandchild but no middle-generation family members—has become increasingly common because of high mortality from HIV/AIDS. In Zambia, for example, 30 percent of older women head such households. In developed countries, couples and single mothers often delay childbearing until their 30s and 40s, households increasingly have both adults working, and more children are being raised in single-parent households.
The number, and often the percentage, of older people living alone is rising in most countries. In some European countries, more than 40 percent of women aged 65 or older live alone. Even in societies with strong traditions of older parents living with children, such as in Japan, traditional living arrangements are becoming less common (Figure 14).
In the past, living alone in older age often was equated with social isolation or family abandonment. However, research in many cultural settings shows that older people prefer to be in their own homes and communities, even if that means living alone. This preference is reinforced by greater longevity, expanded social benefits, increased home ownership, elder- friendly housing, and an emphasis in many nations on community care.
The ultimate impact of these changing family patterns on health is unknown. Older people who live alone are less likely to benefit from sharing goods that might be available in a larger family, and the risk of falling into poverty in older age may increase as family size falls. On the other hand, older people are also a resource for younger generations, and their absence may create an additional burden for younger family members.
Figure 14. Living Arrangements of People Aged 65 and Over in Japan: 1960 to 2005
Note: Percentages living with child(ren) include small numbers of people living in unspecified arrangements.
Sources: Japan National Institute of Population and Social Security Research. Population Statistics of Japan 2008.
Available at: http://www.ipss.go.jp/p-info/e/psj2008/PSJ2008-07.xls  (MS Excel, 291K).
Many of the oldest-old lose their ability to live independently because of limited mobility, frailty, or other declines in physical or cognitive functioning. Many require some form of long- term care, which can include home nursing, community care and assisted living, residential care, and long-stay hospitals. The significant costs associated with providing this support may need to be borne by families and society. In less developed countries that do not have an established and affordable long-term care infrastructure, this cost may take the form of other family members withdrawing from employment or school to care for older relatives. And, as more developing country residents seek jobs in cities or other areas, their older relatives back home will have less access to informal family care.
The future need for long-term care services (both formal and informal) will largely be determined by changes in the absolute number of people in the oldest age groups coupled with trends in disability rates. Given the increases in life expectancy and the sheer numeric growth of older populations, demographic momentum will likely raise the demand for care. This growth could, however, be alleviated by declines in disability among older people. Further, the narrowing gap between female and male life expectancy reduces widowhood and could mean a higher potential supply of informal care by older spouses. The great opportunity for public health programs in the first half of the 21st century is to keep older people healthy longer, delaying or avoiding disability and dependence.