Does Informal Care Break the Cycle of Functional
Disability and Depressive Symptoms in Late Life?
I-Fen Lin (林一芬)
Bowling Green State University
Department of Sociology
Background
• Functional disability and depressive
symptoms increase with age
– Disability: 9% young-old, 22% old-old,
and 50% oldest-old
– Depression: 8% young-old, 10% old-old,
and 12% oldest-old
• Both reduce quality of life and contribute to
suicides among older adults
Feedback Cycle
+
Disability
Depression
+
Background
• More than three quarters of disabled older
adults reside in the community
• Two thirds of community-dwelling older
adults rely on informal care
• Informal care is usually mobilized in a
hierarchical order: spouses, adult children,
other family members, and nonfamily
members
Breaking Feedback Cycle
+
Disability
Care
-
Depression
+
But Informal Care May Fail…
• Caregiving strains (time, finance, health)
• Interpersonal theory of depression
• Negative interaction between caregiver
and care recipient may exhaust informal
care and increase older adults’ disability
and depression
Research Questions
• Do disability and depression mobilize
informal care?
• Does informal care, once mobilized,
reduce disability and depression?
• How long does informal care maintain its
intervening effect?
Analytic Strategy: Cross-Sectional Data
Time 1
Disability
Care
Depression
Time 1
Disability
OR
Care
Depression
Concurrent Association
• Disability
+
Depression
(Black et al., 1998; Prince et al., 1997; West, 1998)
• Depression
+
Disability
(Barberger-Gateau et al., 1992; Grigsby et al., 1998; Guccione et al., 1994)
• Disability/Depression
+
Informal care
(McGarry, 1998, Wolff & Kasper, 2006)
• Informal care
-
Disability/Depression
+
Disability/Depression
(Greenglass et al., 2006)
• Informal care
(Lee et al., 1995; Liang et al., 2001; Seeman, et al., 1996)
Analytic Strategy: Two-Wave Data
Time 1
Disability
Time 2
Disability
Care
Care
Depression
Depression
Analytic Strategy: Two-Wave Data
Time 1
Disability
Care
Depression
Time 2
Disability
Care
Depression
Autoregressive Effect
• Disability
+
Disability
(Gayman et al., 2008; Ormel et al., 2002)
• Depression
+
Depression
(Gayman et al., 2008; Ormel et al., 2002)
• Informal care
(Silverstein et al., 2006)
+
Informal care
Cross-Lagged Effect
• Disability/Depression
+
Informal care
(Silverstein et al., 2006)
• Informal care
-
Disability/Depression
(Hays et al., 2001; Roberts et al., 1997; Wilcox et al., 1994)
• Informal care
+
(Davey & Eggebeen, 1998)
Disability/Depression
Direct Effect
• Disability | Informal care
+
Depression
(Turner & Noh, 1988)
• Depression | Informal care
(Greemglass et al., 2006; Penninx et al., 1999)
+
Disability
Analytic Strategy: Three-Wave Data
Time 1
Disability
Time 2
Disability
Care
Care
Care
Depression
Depression
Depression
Time 3
Disability
If More Waves of Data Are Used…
Time 1
Time 2
Time 3
Time 4
Time 5
Disability
Disability
Disability
Disability
Disability
Care
Care
Care
Care
Depression
Depression
Depression
Depression
Care
Depression
If More Waves of Data Are Used…
Time 1
Time 2
Time 3
Time 4
Time 5
Disability
Disability
Disability
Disability
Disability
Care
Care
Care
Care
Depression
Depression
Depression
Depression
Care
Depression
If More Waves of Data Are Used…
Time 1
Time 2
Time 3
Time 4
Time 5
Disability
Disability
Disability
Disability
Disability
Care
Care
Care
Care
Depression
Depression
Depression
Depression
Care
Depression
If More Waves of Data Are Used…
Time 1
Time 2
Time 3
Time 4
Time 5
Disability
Disability
Disability
Disability
Disability
Care
Care
Care
Care
Depression
Depression
Depression
Depression
Care
Depression
Data
• 5 waves of Health and Retirement Study
(1998, 2000, 2002, 2004, & 2006)
• 65+ years old in 1998
• Exclude respondents who died, who were
lost to follow up, and who moved into
nursing homes during 1998-2006
• 6,359 older adults
Functional Disability
• Difficulty in walking, dressing, bathing,
eating, getting in/out of bed, using toilet
(ADL) for 3+ months
• Difficulty in preparing meals, shopping for
groceries, making phone calls, taking
medicines, managing money (IADL) for 3+
months
• Yes/No; KR-20 = 0.80 - 0.87; 0-11
Average Number of ADL/IADL Difficulties
1.2
Number of Difficulties
1
0.8
0.6
0.4
0.2
0
1998
2000
2002
Year
2004
2006
Depression
• Feeling depressed, feeling that everything
was an effort, having restless sleep, being
unhappy, feeling lonely, not enjoying life,
feeling sad, being unable to get going, not
having a lot of energy
• Yes/No; KR-20 = 0.74 – 0.76; 0-9
Average Number of Depressive Symptoms
Number of Symptoms
2.5
2
1.5
1
0.5
0
1998
2000
2002
Year
2004
2006
Informal Care
• Four sources of informal care
– Spouse
– Children
– Other kin (grandchildren, parents, parents-inlaw, siblings, other relatives)
– Unrelated others
• Yes/No, 0/1, 4 dichotomous variables
(reference group: receiving no care)
Percentage of Older Adults Receiving Help
from Four Sources of Informal Care
14
12
10
8
Spouse
Child
Kin
Other
6
4
2
0
1998
2000
2002
2004
2006
Control Variables
Women
58.64%
Age in 1998
72.26
Education
11.78
White
80.58%
African American
11.84%
Hispanic
7.58%
Married in 1998
65.81%
Widowed in 1998
24.47%
Divorced in 1998
7.30%
Never married in 1998
2.42%
Health in 1998 (1:poor, 5:excellent)
3.22
Income in 1998
42,011.63
Number of children in 1998
3.28
Analytic Strategy
• Autoregressive, cross-lagged model using
structural equation modeling framework
• Model trimming approach
• Final model:
Comparative fit index (CFI) = 0.990
Tucker-Lewis index (TLI) = 0.989
Root mean square error of approximation (RMSEA)
= 0.015
χ2 = 503.961, df = 214, p < 0.001
Autoregressive, Cross-Lagged Model
1998
2000
2002
2004
2006
Disability
Disability
Disability
Disability
Disability
Care
Care
Care
Care
Depression
Depression
Depression
Depression
Care
Depression
*Concurrent associations, higher-order autoregressive effects, and control
variables are not shown in the graph.
Spouse: Mobilizing Care?
1998
Disability
Spouse
Depression
2000
Disability
.137
Spouse
.043
Depression
2002
Disability
0
2004
Disability
-.093
Spouse
Spouse
0
Depression
-.048
Depression
2006
Disability
-.071
Spouse
0
Depression
Spouse: Protective Effect of Care?
1998
2000
Disability
.104
Spouse
-.292
Depression
Disability
.113
2002
Disability
.096
2004
2006
Disability
Disability
.165
Spouse
Spouse
Spouse
Spouse
.114
Depression
.045
Depression
.086
Depression
Depression
Spouse: Breaking Cycle 1?
1998
2000
2002
2004
2006
Disability
Disability
Disability
Disability
Disability
.137
Spouse
.113
Spouse
.043
Depression
Spouse
Spouse
Depression
Depression
Spouse
.114
Depression
Depression
Spouse: Breaking Cycle 2?
1998
2000
2002
2004
2006
Disability
Disability
Disability
Disability
Disability
0
Spouse
Spouse
.096
Spouse
0
Depression
Depression
Spouse
Spouse
.045
Depression
Depression
Depression
Spouse: Breaking Cycle 3?
1998
2000
2002
2004
2006
Disability
Disability
Disability
Disability
Disability
Spouse
Depression
Spouse
Depression
-.093
Spouse
-.048
Depression
.165
Spouse
Spouse
.086
Depression
Depression
Children: Mobilizing Care?
1998
Disability
Child
Depression
2000
Disability
.129
Child
.041
Depression
2002
2004
2006
Disability
Disability
Disability
0
0
Child
0
Depression
0
Child
0
Depression
Child
0
Depression
Children: Protective Effect of Care?
1998
2000
Disability
.357
Child
Disability
.096
Child
0
Depression
2002
Disability
.078
Child
0
Depression
2006
Disability
Disability
.114
Child
0
Depression
2004
.088
Depression
Child
Depression
Children: Breaking Cycle 1?
1998
2000
2002
2004
2006
Disability
Disability
Disability
Disability
Disability
.129
Child
.096
Child
.041
Depression
Child
Child
Depression
Depression
Child
0
Depression
Depression
Children: Breaking Cycle 2?
1998
2000
2002
2004
2006
Disability
Disability
Disability
Disability
Disability
0
Child
Child
.078
Child
0
Depression
Depression
Child
Child
0
Depression
Depression
Depression
Children: Breaking Cycle 3?
1998
2000
2002
2004
2006
Disability
Disability
Disability
Disability
Disability
0
Child
Child
Child
.114
Child
0
Depression
Depression
Depression
Child
.088
Depression
Depression
Other Kin: Mobilizing Care?
1998
2000
2002
2004
2006
Disability
Disability
Disability
Disability
Disability
0
Other Kin
0
Other Kin
0
Depression
Depression
0
Other Kin
0
Depression
0
Other Kin
0
Depression
Other Kin
0
Depression
Other Kin: Protective Effect of Care?
1998
2000
2002
Disability
Disability
Disability
.839
Other Kin
0
Other Kin
0
Depression
0
Other Kin
0
Depression
2004
.125
Depression
2006
Disability
Disability
.148
Other Kin
Other Kin
0
Depression
Depression
Other Kin: Breaking Cycle 1?
1998
2000
2002
2004
2006
Disability
Disability
Disability
Disability
Disability
0
Other Kin
0
Other Kin
0
Depression
Other Kin
Other Kin
Other Kin
Depression
Depression
Depression
0
Depression
Other Kin: Breaking Cycle 2?
1998
2000
2002
2004
2006
Disability
Disability
Disability
Disability
Disability
0
Other Kin
Other Kin
0
Other Kin
Other Kin
.125
Other Kin
Depression
Depression
Depression
0
Depression
Depression
Other Kin: Breaking Cycle 3?
1998
2000
2002
2004
2006
Disability
Disability
Disability
Disability
Disability
0
Other Kin
Other Kin
Other Kin
Other Kin
0
Depression
Depression
Depression
Depression
.148
Other Kin
0
Depression
Unrelated Others: Mobilizing Care?
1998
Disability
2000
Disability
.150
Others
Others
0
Depression
Depression
2002
Disability
0
2004
Disability
.063
Others
Others
0
Depression
0
Depression
2006
Disability
.061
Others
0
Depression
Unrelated Others: Protective Effect of Care?
1998
2000
2002
2004
2006
Disability
Disability
Disability
Disability
Disability
.640
Others
Others
0
Depression
0
.149
Depression
0
Others
0
Others
0
Depression
Others
0
Depression
Depression
Unrelated Others: Breaking Cycle 1?
1998
2000
2002
2004
2006
Disability
Disability
Disability
Disability
Disability
Others
Others
Others
Depression
Depression
0
Others
0
Others
0
Depression
.149
Depression
Depression
Unrelated Others: Breaking Cycle 2?
1998
2000
2002
2004
2006
Disability
Disability
Disability
Disability
Disability
Others
Others
.063
Others
Others
0
Others
0
Depression
Depression
0
Depression
Depression
Depression
Unrelated Others: Breaking Cycle 3?
1998
2000
2002
2004
2006
Disability
Disability
Disability
Disability
Disability
.061
Others
Others
Others
0
Others
0
Depression
Depression
Depression
Others
0
Depression
Depression
Direct Effect: Disability to Depression
Time 1
Time 2
Time 3
Time 4
Time 5
Disability
Disability
Disability
Disability
Disability
.038
Care
Care
Care
Depression
.188
Care
.056
Care
Depression
Depression
Depression
Depression
Direct Effect: Depression to Disability
Time 1
Time 2
Time 3
Time 4
Time 5
Disability
Disability
Disability
Disability
Disability
0
Care
.022
Care
Care
Depression
Depression
Depression
Care
Depression
.023
Care
Depression
Conclusions
• Although older adults’ disability and
depression mobilize informal care, sources of
support are likely to be exhausted over time.
• Receipt of support does not reduce, but
increase, the progression of older adults’
disability and depression
• Informal care does not break the cycle of
disability and depression.
Limitations
• Select sample: older adults residing in the
community during the study period
• Equal time interval across waves: HRS
interviewed respondents every other year
• Time-invariant control variables
Contributions to the Literature
• Comprehensively examine concurrent,
autoregressive, cross-lagged, and direct
effect
• Establish temporal order
• Examine mediating effects across three
consecutive cycles
Future Research
• Better understand the mechanisms by which
informal care worsens disability and
depression
• Evaluate the National Family Caregiver
Support Programs
• Explore subpopulation differences and other
ways to break the cycle of disability and
depression