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Figure 4.3 Trends in the relationship status of adults over age 50 in the US from 1990 to 2015.

      Source: Data from trends in relationship status of adults over age 50 in the US, from 1990 to 2015, US Census Bureau (www.census.gov).

The term grey divorce revolution refers to an increase in the divorce rates in adults over 50. From 1990 to 2015, the divorce rate of older adults in the US doubled from 5 to 10 in 1000, and this rate is expected to remain stably high, even as divorce rates decrease in younger generations. Marriage dissolution (through either divorce or widowhood) is one of the most stressful events that can occur in a person's life; providers should be sensitive to potential psychological distress as well as threats to the person's financial and social support systems. Globally, divorced or widowed older women are a vulnerable population, particularly in the developing world, and may be at risk for abuse, forced arranged marriages, abandonment, or extreme poverty.

      The decision to remarry versus cohabit is based on both personal and financial reasons. The economics of cohabitation versus marriage in older adulthood can be complex. Marriage allows couples to share government benefits, tax incentives, and insurance policies. In many settings, the spouse becomes the de facto medical decision‐maker in the event of patient incapacity. However, cohabitation instead of marriage may make sense for many older adults. Cohabitation allows a person to retain their financial autonomy. People who cohabit may continue to qualify for retirement pensions and/or government benefits from a former spouse. In the event of cohabitation, children generally remain the de facto medical decision‐makers and will inherit a person's assets unless otherwise stated in a will. The health effects of cohabitation (versus marriage) remain an area of active research. As in marriage, it seems that men receive greater health benefits from cohabitation than women, but both members seem to benefit financially and psychologically. Unlike younger couples, older adults who cohabit are likely to do so stably without remarriage or ending the relationship.

      The changing family

      The structure of the modern family in the post‐industrialization period has been influenced by increased age at marriage, increased divorce rate, high geographic mobility, more women in the workforce, and fewer children. In Europe, Asia, North America, and Australia, this has created a ‘sandwich generation’, where middle‐aged people need to provide care for both dependent children and parents. The sandwich generation faces a number of financial and logistical constraints in providing care for ageing relatives (see “Caregiver relationships”). Nevertheless, there is no evidence that the modern family cares less for its elders than past families. In the US, approximately 80% of older people have living children, two‐thirds of whom live within 30 minutes of their elderly parent. Furthermore, approximately 75% of those over 65 have daily personal or telephone visits with their children.

In 2017, the UN studied the living arrangements of older adults. Data were available from 143 countries and examined living arrangements at a household level. Institutionalized older adults were excluded from this study but tend to make up only a small proportion of the older adult population (e.g. approximately 5% in the US). Based on the UN global report, 13.3% of older adults over 65 live alone, 27% with their spouses, 50.1% with adult children, and 9.6% in other arrangements. Adults are much more likely to live independently, i.e. either alone or with their spouse, in high‐income, developed countries. In Western Europe, almost 88% of adults over 65 live independently, and in North America, nearly 78% of older adults live independently. In much of Africa and Asia, two‐thirds of older adults live with their children due to various financial reasons and cultural norms. Compared to data from 2005, there seems to be a gradual trend toward more adults living independently worldwide.

      Caregiver relationships

      Many older adults will require the assistance of caregivers due to disability or impairment from cognitive, psychiatric, or medical conditions. Caregivers are friends or family members who provide support to a dependent person. In the US, as of 2017, there were an estimated 65.7 million unpaid caregivers. Approximately 100 million people are estimated to serve as caregivers in Europe (20% of the European population), and there are an estimated 2.7 million caregivers in Australia (just over 10% of the population). Caregivers are most likely to be female, middle‐aged adults.¹⁸

      Caregivers provide various services, depending on their relationship to the patient and the patient's abilities. The vast majority of caregivers are unpaid and receive little to no education or emotional support for their work. A global survey of caregivers found that one in five reported adverse consequences to their career due to their caregiver role, most often due to missed workdays and/or absenteeism. Twelve percent had to give up their jobs entirely. Almost half of caregivers reported symptoms of depression, and over half (54%) reported being unable to manage their own healthcare.

      Caregivers cite several unmet needs: lack of education about their loved one's condition or how to best serve in their own role, lack of available legal and financial resources, need for respite, and need for mental health care.¹⁹ A number of disease‐specific organizations (such as the Alzheimer's Association) and international caregiver alliances can provide education to caregivers and help caregivers identify local resources and community support.

      Providers for older adults should acknowledge the critical role that caregivers play. Patients and caregivers should, in many ways, be treated as dyads: the health and well‐being of the caregiver are essential to the well‐being of the patient for whom they care. Caregivers can be screened for caregiver burden with formal instruments such as the Zarit Burden Scale.²⁰ Whenever possible, caregivers should be referred for support services and provided information to address unmet needs.

      Religiousness and spirituality

      Religion and spirituality play an important role in preserving the psychological and physical health of older people. For example, Koenig, et al. reported that for medical inpatients, religiosity correlated with a lower likelihood of feeling downhearted or experiencing boredom, loss of interest, restlessness, or hopelessness.²¹ Brown and Gary found that fewer depressive symptoms were associated with religious involvement in a group of urban African‐American males.²² In Israel, religious orthodoxy was found to be protective against death from coronary heart disease, independent of lifestyle correlates. In patients with lung cancer, prayer was, in part, responsible for psychological well‐being.²³ However, religion can also be associated with negative health outcomes. Fear or guilt attributed to religion, or interpersonal stressors resulting from failure to conform with a religious community, can lead to negative health outcomes, including weakened immune response, increased depressive symptoms, and increased mortality.²⁴ Additionally, patients occasionally eschew standard medical care in favour of faith‐based healing techniques.

      The most parsimonious model for describing the role of religion and spirituality on health is to assume that it increases coping skills and enhances access to community and support structures. Healthcare professionals should be aware of their patients' religious and spiritual beliefs and be prepared to incorporate them into a holistic model of healthcare. Prayer is a commonly used coping strategy for many older people dealing with disability or life‐threatening illnesses. The involvement of a person's religious leader as part of the team approach to healthcare is essential, particularly in times of health crises and advanced care planning.

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