1As people grow older, they face an increasing risk of loss of autonomy. When assistance with the activities of daily living becomes indispensable, this leads to dependence, a growing challenge to our ageing society. Women live for longer than men, and outnumber them at advanced ages, so they currently represent the majority of elderly dependent persons receiving home care. Women are also the main care providers in the family. But ongoing demographic and social trends may well alter this situation, prompting a new approach to dependent elder care.

Women are the main beneficiaries of elder home care…

2In France, based on the mortality observed in 2010, women aged 65 can expect to live a further 23.0 years and men 18.5 years. Male excess mortality results in an over-representation of women in the elder population which becomes more marked as age increases: in 2010 they represented 60% of persons aged 75-84, 70% of persons aged 85-94, and almost 85% of the over-95 age group.

3Women are also more frequently affected by health problems and disabilities defined as difficulties in performing the activities of daily living without assistance. As their life expectancy is longer, they spend more years than men in poor health, with difficulties, but also in a situation of dependence, i.e. in need of assistance for activities of daily living. In France, in 2008, men and women aged 65 could expect to live just under 10 years with activity limitations. However, women live for 3 or 4 years longer than men on average, with difficulties in several areas, notably in performing household chores, and 2 years longer with limitations in personal care activities (Figure 1) [1]. Also in 2008, 35% of women aged 60 or above reported receiving regular help, compared with 19% of men of the same age, and there are more women at each level of dependence [2]. The notion of regular family and professional help covers various types of activities that range from moral support or assistance with medical visits to daily help with basic activities (household chores, meals, personal care such as washing or dressing).

Figure 1

Life expectancy at age 65 with and without disabilities^(a) (in 2008)

Life expectancy at age 65 with and without disabilities^(a) (in 2008)

^(a) Difficulties in activities of daily living and physical or sensory functional limitations.

4Men and women also have unequal risks of finding themselves alone at an advanced age: male excess mortality combined with the age difference between spouses (on average, men have a partner who is 3 years younger) mean that there are more widows than widowers. Moreover, men find a new partner more easily than women. In the 2008 census, 76% of men aged 60 or above lived with a partner, compared with 43% of women, and the contrast is even greater after age 80 (66% versus 21%).

5As a consequence, women who need assistance or who become dependent are more frequently alone than men, and more often rely on external support.

6For all these reasons, three-quarters (74% in 2007) of the beneficiaries of the dependence allowance (allocation personnalisée d’autonomie, APA) [1], whether they live at home or in an institution, are women, and among those living at home the proportion increases with age [3] (Figure 2).

… but also the main caregivers

7As is the case throughout Europe, caregivers in France are more often women than men. For 80% of older adults living in their own home, assistance is provided by their family (for 48% by the family alone and for 32% with the help of a professional caregiver). When just one family member provides help, this caregiver is a woman in the majority of cases: in 2000, three-quarters of caregivers looking after an elderly parent were daughters, and 70% looking after a spouse were wives. Within couples, women more often assume the caregiver role than their spouses: for an equivalent dependence level, wives are more often institutionalized than husbands [7]. More generally, men more often seek professional assistance to help with care duties.

8Male and female caregivers do not provide the same type of support. Women devote more time to the task – around 2 hours more per day when they are the sole caregiver of a parent or spouse. In the latter case, their care duties represent an almost full-time occupation: 9 hours and 45 minutes on average (7 hours 20 minutes for husbands), compared with 4 hours 30 minutes spent by daughters and 2 hours 40 minutes by sons [5]. Family support mainly takes the form of help with shopping, household chores, providing company and moral support, help with paperwork, medical visits and personal care [2]. While spouses – both husbands and wives – and daughters of APA beneficiaries are involved in all areas of their daily life, sons devote most time to helping with paperwork and shopping.

Figure 2

Beneficiaries of the dependence allowance (APA) living at home in 2007. Numbers and gender distribution

Beneficiaries of the dependence allowance (APA) living at home in 2007. Numbers and gender distribution

Population: Mainland France and Corsica, extrapolation from data for 33 départements.

Impact on caregivers’ health and professional life

9In around 40% of cases, elder caregivers also have a job [2]. Among these working caregivers, 90% of the men worked full time in 2003 versus 75% of the women [5]. Providing care tends to have a negative effect on caregivers’ working careers, although the repercussions vary, with substantial differences between countries [9]. In France, 11% of working caregivers report making adjustments to their professional lives, involving shorter working hours in more than two-thirds of cases [2]. This could affect the caregivers’ pension entitlements, those of women especially, thereby reducing their capacity to finance their own future care needs. In addition, their dual burden gives working caregivers less time for family and leisure [8].

10Looking after an elderly person may also affect the caregiver’s health, although the effects are complex: the constraints of care responsibilities are closely intertwined with the satisfaction of devoting oneself to a close relative [2, 4, 8]. The resulting stress and strain lead to higher risks of psychological problems, especially depression. Stress and risk of depression also appear to be more frequent for caregivers of patients with dementia, probably because of their closer involvement in daily care [10]. Caregivers – spouses especially – may neglect their own health and delay necessary treatment, at the risk of accelerating their own loss of autonomy.

More men among potential future caregivers

11Whatever the methods and scenarios used, demographic projections predict a substantial increase in the number of dependent persons over the coming decades [6, 7]. The proportion of dependent men is forecast to increase only slightly (from 26% in 2010 to 27-30% in 2060 depending on the scenarios) with women continuing to represent a large majority. If the dependence rate at each age declines thanks to medical progress and improved health management, the dependent population will be older on average.

12The conjugal situations of older adults – dependent or otherwise – are also set to change. In the future, women will more often grow old with a partner. The sharp decline in widowhood, due to lower mortality and a convergence between male and female life expectancies, will largely offset the increase in divorce up to 2030. Today, among dependent elders aged 75 and above living in a couple, only 38% are women, but in 30 years this proportion could rise to 47% [7]. Among the over-85s, for whom the contrasts in conjugal situation are strongest, the proportion of men living in a couple was 5 times higher than that of women (43% versus 8%) in 2000, but the ratio could fall to 2.5 (55% versus 21%, Figure 3) by 2030. Men in the future will more often have a spouse in need of assistance and in a situation of dependence. Another category is also likely to increase in size: that of couples where both partners are dependent, for whom specific solutions will be needed.

13Last, among the over-60s, the share of dependent men with a spouse will tend to decrease up to 2050, while for women it will increase. This decrease concerns the 60-74 age group especially. Beyond age 75, the trend is upward, but remains less favourable than for women [6]. With a broader definition of dependence, the share of men aged 75-84 with a spouse may even decrease [7] (Figure 3). The growth in the number of divorcees in this age group will cancel out the effect of fewer widows and widowers.

14The proportion of men in the partnerless dependent population is thus set to increase, rising from 24% in 2000 to an estimated 31% in 2030 (Figure 4). Indeed, the number of divorced men with disabilities who live alone will increase dramatically: under the most optimistic scenario of health improvement, they could increase 6-fold in France [7]. These changes will certainly generate increased demand for professional care. In the 2000s, divorced men – be they parents or children – received and provided less assistance. It is possible, however, that intergenerational solidarity will take a new form among future generations of divorcees.

Figure 3

Proportion of dependent persons living in a couple, by age and sex in France (%). Situation in 2000 and projection for 2030

Proportion of dependent persons living in a couple, by age and sex in France (%). Situation in 2000 and projection for 2030

Figure 4

Gender distribution of the dependent population by presence or not of a partner. Situation in 2000 and projection for 2030

Gender distribution of the dependent population by presence or not of a partner. Situation in 2000 and projection for 2030

A more equal gender division of caregiver roles in the future?

15The professional situation of women caregivers is changing. They are more present in the labour force and recent changes in the legal retirement age will oblige them to continue working for longer. The probable increase in age of the most heavily dependent elders raises the question of the future availability of female caregivers who will themselves be reaching old age – and hence more exposed to health problems – while continuing to work in paid employment. Will they still be willing to accept the workload assumed by women caregivers today? Will they be able to change the way in which support is provided? Will they receive more help from male family members or, as is the case for men today, will they rely more heavily on professional help?

16The ongoing demographic and social changes will more often place men in a position of potential caregiver. Will the transformation of male social roles encourage sons and sons-in-law to play a greater role in the care of their parents, and husbands in the care of their wives? Will they continue to rely to the same degree on professional help for certain tasks?

17More broadly, to what extent will the higher frequency of separations and new forms of union among potential caregivers change the nature of solidarity between couples and between generations?

18Older adults, and especially those with personal experience as caregivers, may themselves initiate changes in the way their care needs are met. Perhaps they will be more reluctant to see themselves as a burden on their family and to see their daughters in the role of caregiver. Today, in countries where professional services are most widely available, older people show a strong preference for non-family support, especially when they require personal or long-term care. Elsewhere, it would appear that the wishes of older people have not been satisfied, and in all countries, most of them agree that the future needs of dependent elders should be met primarily by professional caregivers [7].

19In coming years, demographic and social changes will increase the continuing burden of family support. As a consequence, the development of professional care provision, offering attractive working conditions for caregivers and providing accessible services to users, is a key issue in the social debate on dependence. The affordability of this support (including institutionalization) will depend on the individual resources of the persons concerned and on future public welfare policies targeting dependent elders. The future level of retirement pensions and their indexing rules are thus a crucial question. Current pensions are price-indexed, while the costs of services and professional support evolve with wages. As needs tend to occur well after entry into retirement, and as demand for care services is likely to increase over time, the gap between pensions and care costs is set to widen.

20An increase in the supply and accessibility of care services for dependent elders is key to restoring a balance between family and professional caregiving roles. In view of the trends we have described, the continued existence of support systems enabling older adults to remain in their own homes will inevitably place additional pressure on families, women especially, if the burden of care is not shared more equally.