Surviving social support: Care challenges facing Taiwanese centenarians

Surviving social support:Care challenges facingTaiwanese centenarians

Yang P-S Surviving social support: Care challenges facingTaiwanese centenarians

In Taiwan, centenarians are the fastest growing demographicamong the 65+ population. However, the general populationknows little about the country’s oldest citizens. There is anurgent need for research to focus on the ‘super old’ commu-nity in order to allocate sufficient public and private resourcestowards their care. This study explored the living conditions ofTaiwanese centenarians as well as their care and supportsystems through a quantitative questionnaire and in-depthinterviews with the centenarians or their caregivers. Thetotal sample size of the study was 100. Sample characteristicsregarding age, gender, living arrangement, physical andmental health status, daily functioning and overall life satis-faction are presented. It was found that a much higher per-centage of Taiwanese centenarians lived with family membersin their own homes, while their counterparts in Western soci-eties were institutionalised. This study also identifies theconcept of symbiotic care grounded in a family network.

Pei-Shan Yang1,2

1National Taiwan University Social Policy Research Center,Taipei, Taiwan2Department of Social Work, National Taiwan University,Taipei, Taiwan

Key words: Taiwan Centenarian Study, social support, theoldest old, Asian concept of elder care

Pei-Shan Yang, Department of Social Work, National TaiwanUniversity, no. 1, Sec. 4, Roosevelt Rd., Taipei 106, TaiwanE-mail: [email protected]

Accepted for publication 4 September 2012

Introduction

The Taiwanese population has experienced accelerationin aging due to an increase in life expectancy anda record-breaking low fertility rate. The president ofTaiwan stated recently that the population issue hasbecome one of the top national priorities. People whoare 65 years and older (the 65+ demographic) firstreached 7 per cent of the total population in 1993. Thepercentage was 10.64 per cent in 2010, and it is esti-mated to rise to 25 per cent in 2025. Taiwan’s popula-tion data highlight the fact that the old old (the 85+demographic) is the fastest growing subgroup of theaging population (Ministry of the Interior, 2012). From1993 to 2010, the number of people in the 65+ popu-lation has increased by 67 per cent, but the number inthe 85+ population has increased by 290 per cent. Theincreased rate of people who are 100 years old andolder (often regarded as the ‘super old’) is an alarming456 per cent. There is an urgent need for research tofocus not only on the old, but also on the super old inorder to allocate appropriate and sufficient national,provincial, local community and individual resourcestowards the care of the oldest citizens.

In 2010, the number of centenarians in Taiwanreached 1,399, or approximately 6 in every 100,000.Although centenarians are not a new discovery(Segerberg, 1982), it is alarming how little the general

population knows about these older citizens. Manyquestions remain unanswered: How do they live? Withwhom do they live? How is their health and how do theyfunction? Are they capable of caring for themselves?How do family and communities view these centenar-ians? In Taiwan, the average life expectancy is close to80, but most citizens know little about advanced oldage. Consequently, Taiwanese society is poorly pre-pared to face many challenges related to the well-beingof the 90+ and 100+ demographic. Furthermore, manycitizens have highly biased and often morose andfearful ideas about the final stage of life.

In order to attract more public attention to the phe-nomenon of ‘super old age’, the researcher conductedthe Taiwan Centenarian Study beginning in the summerof 2008. At the end of 2010, the total sample reached100. This article focuses on how the family and com-munity provide care for centenarians, and what it meansto care for centenarians from the families’ and commu-nities’ perspectives. For the purposes of this article,basic socio-demographic and social characteristics ofcentenarians are presented with a special focus on theirsocial support systems. Therefore, this article seeks toanswer three questions:

(1) Who are the Taiwanese centenarians?(2) What are their living conditions?(3) How do their care and support systems function?

DOI: 10.1111/ijsw.12004Int J Soc Welfare 2013: 22: 396–405

INTERNATIONALJ O U R NA L O F

SOCIAL WELFAREISSN 1369-6866

Int J Soc Welfare 2013: 22: 396–405© 2012 The Author(s). International Journal of Social Welfare © 2012 International Journal of Social Welfare and John Wiley & Sons Ltd396

Review of international centenarian studies

Cognisant of the contextual and methodological differ-ences among international centenarian studies, thisresearch reviewed five centenarian studies to help shedlight on the understanding of the super old. The fourcountries covered by the five studies all had a signifi-cant number of the 80+ demographic. Although the80+ demographic in Taiwan is comparatively muchsmaller, it has an alarmingly fast growth rate, which hasexpedited the need to conduct the Taiwan CentenarianStudy (Table 1).

The Japanese government has been collectingcomprehensive data on the Okinawa centenariansthrough the household ‘Koseki’ system since 1975.Published Okinawa studies have focused mainly onhealth and medicine. For example, Willcox et al. (2008)found that genes and lifestyles both play significantroles in determining longevity. Another Japaneseexample is the Tokyo Centenarian Study (Gondo et al.,2006) that sought to detect the centenarians’ quality oflife while forecasting models for the quality of life. Theresults showed that the centenarians’ levels of function-ing were distributed in a U-shape, with some fullyindependent and others entirely dependent. About 30per cent of the centenarians had no severe illnesses.Few centenarians had diabetes. Mini Mental StatusExamination (MMSE) scores ran from 0 to 29. Thegender ratio of the centenarians was one male to fourfemales, but the cognitive function of male centenar-ians was significantly better than that of the femalecentenarians.

The renowned Georgia Centenarian Study in theUSA (Poon et al., 1992; Siegler, Longino, & Johnson,1992), a longitudinal study, targeted three groups ofpeople: one born in the 1880s, one in the 1900s and onein the 1920s. The study found that physical and mentalhealth was highly significant in affecting the centenar-ians’ cognitive performance. Furthermore, centenarianswith higher intelligence might be better able to main-tain instrumental activities of daily living (IADL)functioning. Religious coping mechanisms were alsohighly important.

The Swedish Centenarian Study (Samuelsson et al.,1997) surveyed 100 elders born between 1887 and1891, with 18 male and 82 female subjects. Thestudy found that 78 per cent of subjects were widowed,19 per cent never married, 2 per cent were divorced and1 per cent were still living together as couples. In termsof their living arrangement, 25 per cent lived at home,37 per cent lived in care homes and 38 per cent livedin nursing homes. Centenarians’ levels of educationalattainment were low, with 71 per cent of the subjectshaving had seven years of formal education or less.Common diseases included cardiovascular diseases,hip fractures, pneumonia, strokes, diabetes and cancer.Dementia (27%) was also a fairly common diagnosis.The majority of the centenarians rated their quality oflife as being ‘very good’ or ‘rather good’. With regardto personality, centenarians were deemed normal in alldomains. Additionally, they were seen as more mature,relaxed, easygoing and less anxious than other cohorts.However, the centenarians’ levels of social participationwere low (Samuelsson et al., 1997).

Andersen-Ranberg and Jeune (2006) reportedon a Danish Longitudinal Study that started in 1995.The gender ratio of the centenarians was 1 male to 3.6females. The most cited diseases among the centenar-ians were incontinence, arthritis, high blood pressureand dementia (51%). In terms of activities of dailyliving (ADL) functions, 41 per cent were relativelyindependent and 35 per cent were very independent. InIADL functions, less than 10 per cent could managetheir own finances, go shopping or prepare meals. Only16 per cent could arrange their own transportation,34 per cent lived in their own homes and over half livedin nursing homes. Two per cent of Danish centenarianslived alone and independently. The Danish study pro-posed that the ‘robustness’ genes had a deterring effecton major life-threatening diseases like cancer, diabetesand apoplexy (paralysis).

The previous international centenarian studiesapplied both qualitative and quantitative methods,intending to portray the national or even municipalprofiles of the oldest of the elderly demographic. TheTaiwan Centenarian Study analysed the Taiwanese

Table 1. Population aged 80+ from1985 to 2010.

Denmark Japan Sweden USA Taiwan

Population bythousands

% Population bythousands




%

1985 166 3.3 2,160 1.8 309 3.7 6,117 2.5 111 0.61990 191 3.7 2,872 2.3 364 4.3 7,024 2.8 152 0.71995 205 3.9 3,765 3.0 411 4.7 7,991 3.0 226 1.12000 211 4.0 4,669 3.7 442 5.0 9,123 3.2 301 1.42005 222 4.1 6,123 4.8 484 5.4 10,507 3.5 434 1.92010 228 4.1 7,996 6.3 494 5.3 11,822 3.8 364 1.6

Sources: Ministry of the Interior (2012) and United Nations Department of Economic and Social Affairs (2012).

Care challenges facing Taiwanese centenarians

Int J Soc Welfare 2013: 22: 396–405© 2012 The Author(s). International Journal of Social Welfare © 2012 International Journal of Social Welfare and John Wiley & Sons Ltd 397

centenarian data with the help of international researchfindings, hoping to portray a national profile as well.

Social support

Kropf and Pugh (1995) analysed the American CensusData and found that more centenarians lived in institu-tions or with their children than did the younger ofthe elderly demographic (the ‘younger old’). Evenwhen not living with family members, this group ofelders maintained regular contact with their families.Centenarians placed high priority on maintainingfamily relationships and considered them to be a keysource of social support. Kropf and Pugh (1995)also cited Segerberg’s (1982) report that the supportbetween centenarians and their family is reciprocal.While receiving care and support, centenarians havebeen found to provide the family with advice, memo-ries and information, and sometimes even help withtasks around the house.

Social support for the oldest old was operationalisedin previous studies as family living arrangements,availability of caregivers, caregiving activities, caregiv-ing functions and frequency of social interactionssuch as telephoning or visits (Leea & Dunkleb, 2010;MacDonald, 2007; Poon et al., 1992, 2000; Zhou &Qian, 2009). These studies clearly indicate that socialsupport is very important for the oldest old, especiallybecause of their eventual dependency and sometimeshomebound status. Poon et al. (2000) showed thatsocial support not only enhances quality of life, but alsohas a significant relationship with the successful sur-vival of centenarians.

Kahn and Antonucci (1980) presented the socialconvoy model in predicting how and with whom an olderperson will choose to interact and to obtain convoy orprotection from expected declines in later life. Berges,Dallo, DiNuzzo, Lackan, and Weller (2006) examinedthe cultural aspect of a social convoy and found thatminorities relied more on support from kin than non-kin.Leea and Dunkleb (2010) studied the oldest old in SouthKorea and proposed that support from children wasconsistently the main source of support for the oldestKoreans. Having filial support could buffer psychologi-cal distress and help treat depressive symptoms of theoldest old. However, MacDonald (2007, p. 115) positeda question related to the social convoy of centenariansbeing ‘what kind of convoy, if any, remains’.

Fiori, Smith, and Antonucci (2007) applied thesocial convoy theory in explaining the typology andfunctions of the elders’ social support networks. Theauthors stated that objective factors such as networksizes, accessibility of network members, frequency ofcontacts, marital status and level of social participationand subjective factors such as self-perceived quality ofcontacts and benefits of emotional or functional support

could affect physical and mental health in older adultlife. In a different cultural and social context, Zhou andQian (2009) studied the quality of life of 7,871 Chineseelders aged 80–110 years. These researchers foundsimilar results. Objective indicators such as living withfamily members and having regular social interactionswith the family may have enhanced the quality of life,often because family members provide physical andemotional support. Subjective indicators such as thebelief that family members cared for them may havehelped the elders to construct a positive attitude towardlife, even when they lived alone without family around.Furthermore, regular visits by relatives and friendswere a key to self-perceived quality of life of institu-tionalised elders. Elders could attain higher status andmore respect among peers by having regular visitors.Zhou and Qian (2009) also found that the oldestold living in institutions ranked the highest in self-perceived quality of life, followed by those living withchildren and spouses, whereas those who lived aloneranked the lowest. Support and care provided by formalcaregivers may have had a positive effect on the qualityof life of the oldest old. Elders could also have ben-efited from having common concerns and shared inter-ests with their co-residents. Good social interactionamong peers may be a positive factor for quality of lifeby enhancing the sense of belonging and self-worth.

Social support may be affected by micro-level vari-ables, such as age and gender, as well as macro-levelvariables, such as history and economy. Nauck (2009),while conducting a comparative study on Germany,Russia and China, sought to synthesise the institutionalhypothesis and functional hypothesis of kinship rela-tionships. Results showed that the institutional struc-ture of a kinship system, such as the current economyand social policy and regulations in mate selec-tion, household formation, lineage and allocation ofcontrol rights and generative decisions of precedinggenerations had a much stronger effect on kinshiprelationships than did individual attitudes or individualsocial-economic positions. In studying social supportprovided by friends, Matt and Dean (1993), in NewYork, found that the effects of gender on psychologicaldistress and support over time were greater for theoldest old than for the younger old. In general, olderwomen had a higher risk of experiencing psychologicaldistress than did men. However, the oldest old menexperienced higher distress when losing the supportof a friend and also had a higher risk of losing suchsupport when under distress. In a comparative studyon the sense of loneliness between American andSwedish centenarians, Martin, Hagberg, and Poon(2004) reported that social support was a significantpredictor of loneliness. However, the direction of cor-relation was different for the two groups of centenar-ians. More social support predicted less loneliness for

Yang

398Int J Soc Welfare 2013: 22: 396–405

© 2012 The Author(s). International Journal of Social Welfare © 2012 International Journal of Social Welfare and John Wiley & Sons Ltd

the American centenarians, but more loneliness for theSwedish centenarians. The authors suspected that thehomogeneity of the Swedish society led elders who hadreceived more social support to feel lonelier by beingsingled out. However, more cross-cultural comparativestudies were called for to test this hypothesis.

In sum, social support plays an important role inexplaining the survival, physical and mental health,sense of loneliness and the quality of life of elderlypeople. However, when people are approaching cente-narian status, changes in the objective conditions andsubjective evaluation of their social support may haveoccurred. Centenarians may have lost their spouses,even children, their functional levels may have deterio-rated and the level of their social participation may havedecreased. As the kinship network evolves and changes,social support provided by society or institutionsmay be of greater significance to centenarians than toyounger generations of elders. As MacDonald (2007)pointed out, centenarians were in the greatest needof help for household chores and IADL assistance.Without public resources and support services, familycaregivers of centenarians may carry high levels ofburden by themselves.

Research methodology

The Taiwan Centenarian Study applied both quan-titative and qualitative methods to understand theTaiwanese centenarians’ lives and care. Centenariansare a population group highly difficult to contact due tothe high rate of illiteracy, high rate of functional disabil-ity and extreme lack of social participation. The studymade many efforts to reach the centenarians, includingseeking county governments or local leaders as liaisons.During the period from the summer of 2008 to the fall of2010, the researcher finally accrued a sample consistingof 100 centenarians. Each centenarian in the studyreceived an interview request letter and a questionnaireby mail. Upon permission of the centenarians or theirfamilies, each centenarian was personally visited intheir chosen venue, most often in their own homes,and interview data were collected. The researcher andresearch assistants entered the everyday environmentsof the centenarians to observe their lives and care situ-ations. Quantitative data were collected by using a shortquestionnaire including the centenarians’ demographicand social-economic characteristics, living arrange-ments, physical and mental health and functioningcapacities measured by ADL and IADL indexes. Quali-tative data were collected by using a semi-structuredinterview guide. In those cases when the centenarianswere unable to participate in the interviews, their proxyfamily members/caregivers/care workers or closefriends were interviewed. The interview exploredthemes related to the meaning of longevity, centenar-

ians’ families and community roles, family values, carearrangements and social support. An average visit to acentenarian took about an hour to an hour and a half.Because of the frailty of centenarians, the interviewswere kept focused and short, and care routines weregiven priority over the interviews. When the centenar-ians needed to be cared for, fed or taken to the toilet, theresearcher suspended the interview and waited until theinterviewee returned. A red envelope containing cashwas given to each interviewee as a token of appreciationfor participating in the interview.

To obtain a sample as close as possible to the cente-narian population, sample areas were designed to coverdifferent geographic parts of Taiwan and include bothurban and rural areas.Three counties and one metropoli-tan city were selected for the study: Tai-nan County(southern), Taipei City (northern), I-lan County (north-eastern) and Hua-lien County (eastern). The fourmunicipalities were selected for their higher rates ofolder populations aged 65 and over and the availabilityof municipal administrative support for the study. Thepercentages of older adults over the total populations ofTai-nan County, Taipei City, I-lan County and Hua-lienCounty were 12.94, 12.60, 13.10 and 12.41 per cent,respectively, which were well above the national averageof 10.74 per cent (Ministry of the Interior, 2011). Higherpercentages of older adults were considered a facilitat-ing factor in finding centenarians.

Data analysis was performed using SPSS 15.0 forWindows. Descriptive statistics were used to present theprofile of Taiwanese centenarians. Although randomsampling was not possible for the Taiwan CentenarianStudy due to the unavailability of the complete listing ofcentenarians in the selected municipalities, this studyused the other three surveys on younger Taiwaneseelders, that is, the Report of the Senior Citizen ConditionSurvey 2009 (Ministry of the Interior, 2009), the 2009Survey of the Living Condition of Senior Citizens inTaipei City (Taipei City Government, 2009) and the2004 National Survey on People Aged 90 and Above(Ministry of the Interior, 2004), to build a comparativebasis for the study. Percentage distributions of centenar-ians’ genders, educational status, marital status, livingarrangements, religious affiliations and subjective well-being were compared with that of younger cohorts ofelders. In-depth interviews were taped and transcribedverbatim. Theme analysis was performed against thebackground information of Taiwanese centenarians toexplore the distinguishing features of centenarian careand social support in Taiwan.

Results

A profile of Taiwanese centenarians

The total sample size of the study was 100. Samplecharacteristics included the following. The average age



of the study sample was 102.54, ranging from 100 to110 years old, with 11 centenarians aged 106 years orolder. The respondents were predominantly women(73%), roughly 1 male to 3.7 females. Ninety-threeper cent were widowed, 5 per cent were never marriedand only two male respondents had living spouses atthe time of the interviews. Compared with youngerTaiwanese elders, this study showed that the centenar-ians are a subgroup with distinctively different charac-teristics. The subgroup of centenarians was highlygender-biased, widowed and had a generally low edu-cation level. Only 17 per cent reported no religiousaffiliation, with the majority believing in Buddhism(35%) or Taoism (30%). There was no significant dif-ference in religious affiliation between the centenariansand the younger group of elders (Table 2).

Among 93 reports, only 14 per cent of the respond-ents perceived the health status of the centenarians aspoor or very poor. Twenty per cent of the total 100centenarians had not visited a doctor in the past yearand another 74 per cent visited a doctor. But 26 per centhad been hospitalised at least once in the past year.An amazing 12 per cent of the centenarians hadno diagnosis of chronic disease at all. The three mostcommon chronic diseases were cataracts (43%), highblood pressure (31%) and dementia (22%), followed

by presbyopia (17%), bone fractures (16%), heartdisease (15%) and arthritis (10%). One centenarian hadstomach cancer in his 80s, but he was treated success-fully and has been well ever since (Table 3).

In terms of functioning, 21 per cent were fairlyindependent in such ADL functions as eating, movingabout, toileting, bathing, walking and continence, witha Barthel’s score of 90–100. Only 3 per cent were fairlyindependent in IADL functions, such as grocery shop-ping, meal preparation, house cleaning, laundry, takingmedicine, telephoning and handling finances. Withregard to mental functioning, there were four centenar-ians who obtained a perfect score or a nearly perfectscore on the MMSE, but the rest, all had minor tosevere cognitive impairments. Among the 41 centenar-ians who responded to the Geriatric Depression Scale,all scored less than 10, which indicated fairly low levelsof depressive symptoms (Table 4).

Most of the centenarians (72%) lived in their privateresidences, while the rest lived in institutions such ashospitals, care homes or nursing homes. Except forfour centenarians who lived alone and two who livedonly with their spouse, the centenarians usually hadsomeone else living with them and providing 24-hourmonitoring. This live-in companion was most likely achild (54%) or a grandchild (26%), a hired care worker(33%) or a co-resident in a care institution (25%).

Table 2. Personal characteristics of the Taiwan centenarianscompared with other studies.

Personal characteristics (%)

2008–2010 2004 2009 2009Centenarian 90+ National

65+Taipei65+

GenderMale 27 39.2 48.32 48.14Female 73 60.8 51.68 51.86

MarriageMarried 2 15.76 57.13 63.2Widowed 93 80.75 37.64 30.7Never married 5 2.93 1.69 2.5Divorced/separated 0.55 3.53 3.3

EducationNo qualification 63 64.47 22.04 17.3Primary 19 24.03 40.10 33.6Secondary 6 3.32 10.79 13.3High school 7 3.69 13.01 15.7Junior college 3 1.34 5.64 5.0College 2 3.15 7.33 14.7No response 1.10

ReligionNone 17 18.38 19.09Buddhism 35 24.05 11.55Taoism 30 7.18 2.04Christian 8 4.56 5.40Catholic 2 1.45 1.38I-Kuan-Tao 4 0.61 1.49Other 4 43.77 58.8No response 0.26

Table 3. Health status of the Taiwan centenarians.

Health status (%)


65+Taipei65+

Self-perceived health statusVery good 32.3 9.08 13.90 6.9Good 35.5 36.79 38.31 38.4So-so 18.3 26.33 19.02 22.2Not poor 9.7 22.86 21.82 24.3Very poor 4.3 4.95 5.33 7.4No response 2.42 0.8

Doctor visits in past yearNever 20 5.83Occasionally 74 66.39Once times a week 2 12.082 times a week 2 3.493 times a week 1 1.72Above 4 times a week 1.48Long-term hospitalisation 4.67No response 4.34

Doctor visits in past monthNone 31.09 31.2Yes 68.91 31.21 56.91 57.82 17.98 19.53 17.26 22.7

Hospitalised in past yearYes 26 19.98 20.0No 74 80.02 80.0

Yang

400Int J Soc Welfare 2013: 22: 396–405


However, even with the family living together, the dailycare of centenarians was most likely provided by hiredcare workers. Thirty-nine per cent of the centenarianshad hired care workers as their primary caregivers withan additional 7 per cent as secondary caregivers. Theroles of sons, daughters-in-law and daughters, inrespective ordering, were more important as secondarycaregivers than primary caregivers in providingdaily care for centenarians. Grandchildren were morelikely the third-tier caregivers. It is worth noting that13 per cent of centenarians reported themselves as theprimary caregivers, meaning they could provide suffi-cient self-help. However, children were the most impor-tant source of income and financial support, and thegovernment ranked second through elder allowance andpublic assistance payments. Compared with data on theyounger elders, a much higher percentage of centenar-ians reported positively regarding general life satisfac-tion and economic well-being (Tables 5 and 6).

Chi-square analysis was performed to test ifthere were differences between centenarians living inMetropolitan Taipei (the capital) and the other lessdeveloped areas. Results showed that urban and ruralcentenarians differed significantly only in their educa-tional attainment and the number of hospitalisa-tions in the previous year. Otherwise, urban and ruralTaiwanese centenarians were fairly alike with regard totheirADL and IADL functioning, cognitive functioning,self-rated health, depressive symptoms, economic satis-faction and general life satisfaction. There was littlegender difference as well. Female centenarians fairedless well than male only in educational attainment(Tables 7 and 8).

Qualitative analysis

Centenarians in Taiwan are distinctively different fromcentenarians in Western countries. Only 5 per cent in

the study sample had never married, and the majority ofthem had many children. In a Taiwanese macro-systemwith a very low level of public old-age support andservices, the care of the current Taiwan centenarians isprimarily dependent on an extensive reservoir of familyresources. Only low-income centenarians with no closefamily ties are cared for in public care institutions. Theappearance of care may seem to resemble Cantor’s(1991) model of multiple layers of support: first, theimmediate family, then extended family, friends, dis-tant relatives, neighbours and, lastly, the outer layer offormal services. However, in reality, the textures of thevarious layers have changed.

Table 4. ADL score of the Taiwan centenarians.

ADL, IADL, MMSE, Depression Scale (%)

ADL score 2008–2010 2009 2009Centenarian(N = 100)

National 65+(N = 3,158)

Taipei 65+(N = 2,655)

0~10 29 2.21 3.011~20 7 0.77 0.821~30 4 0.66 0.831~40 3 0.67 0.441~50 3 0.70 0.651~60 4 0.64 1.061~70 2 0.64 0.971~80 10 1.63 1.581~90 17 3.64 3.391~100 21 88.01 87.6

Loss 0.42

Table 5. Family and support of the Taiwan centenarians.

Family and support (%)


65+Taipei65+

Main caregiversMy self 13 26.75 12.12 42.9Spouse (cohabitant) 0 5.14 14.25 21.7Son 19 38.31 22.30 21.1Daughter 7 7.36 11.32 15.2Daughter-in-law 11 16.35 14.62 6.8Son-in-law 0 0.23 0.23 0.3Brothers and sisters 0 0.13 0.51 0.6Grandchildren 4 1.98 3.00 1.7Granddaughter/grandson 4 0.98Friend 0 0.42 0.39 0.6Caregivers 39 1.62 20.51Relatives 1 0.30 0.23 0.3Other 2 0.43 0.4

ResidenceHome 72 89.52 97.21 99Hospital 1 2.45Care facilities 27 7.78 2.79 1Temple 0.26

Family populationAlone 4 6.72Spouse (cohabitant) 2 9.33Children (daughter-in-law/

son-in-law)54 74.08

Grandchildren 26 16.74Relatives 4 0.55Friends 0 0.49Hired caregivers 33 6.04Institution resident 25 6.11Other 2

Household sizeLive alone 9.16With spouse 18.76Household of 2

generations29.83

Household 0f 3generations

37.86

Household of 4generations

0.78

Live with friends or otherrelatives

0.82

Institution 2.79



The fact that the centenarians have survived thesame generation and even the succeeding generation oftheir family members, such as spouses, siblings andchildren, manifested a declining or ‘draining’ socialconvoy phenomenon provided by the family. Membersof the extended family had to be called in to help;otherwise, the centenarians might not have had anyoneupon whom to rely. Aging in general and depopulationin some rural and remote communities furtherprompted the weakening of the care capacities offriends and neighbours in the localities and villages.

Many family caregivers of centenarians expressedserious concerns about their own super old age whileconsidering the factors of the changing family compo-sition and social values. They made comments such as:‘I am worried about my own age. The younger genera-tions in the neighbours don’t care much about us’.

For the majority of centenarians who remainedliving with their family members, the responsibility forthe everyday care of the centenarians and the mainte-nance of household chores had shifted to consumer-paid, live-in maids. Only in a handful of cases were themaids hired locally, and in the other cases, they were allforeign care workers. In care institutions, local careworkers were outnumbered by foreign ones as well.The layer of social convoy provided by the family hastransformed to either a layer of family plus paid careworkers, mostly foreign workers, or a layer of familywith care institutions. Without these supplementarysupport mechanisms, the family of centenarians wouldbe greatly distressed.

Although health care is a necessity, the weight ofsocial care or physical care for centenarians is greaterthan health care. The way Taiwanese families care fortheir centenarians demands such diligent monitoringthat the relationship between the primary caregiver(s)and the ‘cared-for’ centenarians seems almost symbi-otic, implying that their lives are bound tightly together.Family members guarantee constant companionshipand never let the centenarians feel or be physicallyalone. They are literally never apart. If families cannotperform such care by themselves, they may try to usehired maids or institutions to supplement the care.Many family caregivers said things like: ‘I cannot leavemy parent alone. Otherwise, if anything happens whileI am not with her, I will be guilty for the rest of my life’.

The researcher chose the term ‘symbiotic care’to describe the tightness of the care relationship inTaiwanese families. Individualism seems a foreignconcept to this generation of centenarians and theircaregivers. Family always comes first, and familymembers care, nurture and support each other. No

Table 6. Income status and well-being of the Taiwan centenarians.

Finance and well-being (%)


65+Taipei65+

Main source of incomeIncome 7.91 8.3Pension 7 5.49 17.37 43.0Savings/fixed deposits 9 6.66 14.93 19.7Support from spouse 0 0.39 5.23 7.4Sons and daughters 54 67.73 48.29 49.2Grandsons, granddaughters 3 2.70Relatives 0Borrowed money 0 0.06 0.06 0.2Public assistance or

allowance26 16.48 29.66 14.2

Charitable contributions 1 0.34 0.40 0.6Other 0 0.14 0.05 0.5

Economic satisfactionVery satisfied 30.2 1.32 13.18 11.9Satisfied 38.5 35.61 63.51 64.1So-so 10.4 30.47Dissatisfied 7.3 23.17 15.34 17.5Very dissatisfied 1.0 6.13 6.56 5.8No response 12.5 3.29 1.42

Well-beingVery satisfied 38.3 10.87 25.83 17.0Satisfied 31.9 47.93 52.17 56.7So-so 14.9 32.42Dissatisfied 1.1 7.36 8.46 14.8Very dissatisfied 0.0 1.42 3.24 3.6No response 13.8 10.30 7.9

Table 7. Chi-square analysis between centenarians living in urbanand rural areas.

Value df p-value

Education 21.381 5 0.001***Hospitalised in past year 5.783 1 0.016*ADL 22.500 19 0.260IADL 27.840 22 0.181MMSE 30.776 23 0.128Self-rated health 3.229 4 0.520Depression 5.800 7 0.563Economic satisfaction 6.082 5 0.298General life satisfaction 6.839 4 0.145

* p < 0.05, *** p < 0.001.

Table 8. Chi-square analysis between male and femalecentenarians.

Value df p-value

Education 20.927 5 0.001***Hospitalised in past year 0.134 1 0.715ADL 23.496 19 0.216IADL 29.447 22 0.133MMSE 32.519 23 0.090Self-rated health 1.458 4 0.834Depression 6.659 7 0.465Economic satisfaction 3.562 5 0.614General life satisfaction 6.216 4 0.184

*** p < 0.001.

Yang

402Int J Soc Welfare 2013: 22: 396–405


matter how high the costs, caring for the centenarians tillthe last day of their lives is perceived as an ultimatemeaning of life. Many examples can be seen of familymembers making sacrifices to deliver this kind of sym-biotic care, resulting in a pattern of highly labour-intensive care. For example, a 53-year-old daughter/caregiver reported that she slept by her centenarianfather’s bedside every night on a beach chair so that shewould be available whenever her father, afflicted withdementia, woke up and called out. Her care and moni-toring in fact exceeded the actual normative or expressedneeds of her father. The concept of care is culturally notsolely a response to needs, but a manifestation of arelationship or a set of values. For example, when theresearcher asked the woman how she could manage tolive her life in such an uncomfortable manner, shereplied: ‘I care for him this way because I am hisdaughter. Otherwise, I cannot sleep soundly’.

This symbiotic care is grounded in a family networkwith the centenarian at the centre. ‘She is like EmpressCixi. She basically sits in her grand seat every day.There are 10 to 12 family members who come to thishouse to see her daily’, explained a son of a centenar-ian. It is fair to say that the centenarian has becomea family legacy. Caring for the centenarian signifiescarrying on the family tradition. Taking good care ofthe centenarian brings the family fame and respectin the community from local to national levels. Onecentenarian proudly displayed the awards bestowedupon him by both the Japanese prime minister (his sonwas a naturalised Japanese citizen) and the presidentof Taiwan.

In today’s globally oriented world, some Taiwanesecentenarians have children and grandchildren livingabroad. This study found one centenarian who contin-ues to travel to her sons’ residences every year, one inThailand and another in Hong Kong. There were alsomany cases where family members managed to taketurns travelling back to Taiwan so that the centenarianwould never be alone. Today, the continuation of thefamily legacy involves increasing difficulties andhigher costs. While most families struggle to managethe care of centenarians, this traditionally valued sym-biotic family care structure faces tremendous chal-lenges as the family social convoy declines.

Discussion and conclusion

Centenarians, across many countries, appear to sharemore similarities than differences in their individualtraits, health status and subjective qualities of life orlife satisfaction. The gender ratio in the Taiwan Cente-narian Study – 1 male to 3.7 females – is very close tothe samples of other international centenarian studies.Women, much more than men, rely on family supportnetworks as their social convoy over the course of

their lives (Kahn & Antonucci, 1980; Leea & Dunkleb,2010; MacDonald, 2007). However, in super old age,when very few centenarians still have living spousesand many have lost their children, both male and femalecentenarians rely on extended support networks beyondthe immediate family systems. In other words, the careof centenarians requires a concerted effort on the partof the family, the local community and the government.Besides their own extended family, neighbours andfriends, national and municipal governments as well aslocal community members all play a role in providingsocial support to centenarians. In Taiwan, centenariansare great symbols of longevity and good luck. Peoplewho provide social support for centenarians often feelquite blessed in return. Such a reciprocal relationshipreinforces the commitment of the Taiwanese society tohonour and care for centenarians. National and localgovernments bestow centenarians with an annual giftof ‘red-envelope’ money and a gold decorative tokenof appreciation.

Similar to the findings of international studies,Taiwanese centenarians are more likely than youngerolder adults to live in institutions due to their frailty andfunctional decline (Kropf & Pugh, 1995). However, inaccordance with personal preferences and structuralfactors, a much higher percentage of Taiwanese cente-narians live with family members in their own homesthan do their Western counterparts. Similar patterns inthe living arrangements of the oldest old have beenobserved in other Asian countries, for example Japanand South Korea (Leea & Dunkleb, 2010; Tsukamotoet al., 2001). Filial support was and still is the mostvalued social support for centenarians, providingfinancial, emotional, instrumental and informationalsustenance. However, due to their own advanced age,children of centenarians mostly play the role of second-ary caregivers or care managers. Hired formal careworkers living with centenarians or in care institutionsare the key players in the delivery of daily care tocentenarians. As population aging accelerates further,the issue of securing a sustainable labour force ofcare workers will likely be the most challenging task incaring for the oldest old.

Although the centenarians appear to be resilient tothe vicissitudes of life, they have approached their finalyears. This study has shown that Taiwanese centenar-ians have many ADL and IADL disabilities and theyrequire a high level of care. A more alarming fact is thata high percentage has been diagnosed with dementia.As life expectancy increases, the number of dementiacases will inevitably rise (Alzheimer’s Disease Interna-tional, 2010). Twenty-four-hour monitoring and careare called for in many cases of demented elders. Neigh-bours, community volunteers as well as formal healthand social services may assist family members incaring for these demented centenarians, and function as



an extra layer of social convoy. However, this studyclaims that the Taiwanese society has not yet allocatedenough resources to face a time when centenarians areno longer a rare social phenomenon.

In general, centenarians do not utilise medical ser-vices disproportionately, but they do require extensivedaily monitoring and assistance in supporting theirdaily activities and functioning. The results of theTaiwan Centenarian Study emphasise that the primaryessence of centenarian care is not medical care, butsocial care or life care. Supporting centenarians andmaintaining the quality of their lives requires long-term commitment and a re-examination of resourceallocation. It cannot be done single-handedly by thefamily. Intensified public policy planning is called forto integrate the presently departmentalised care serv-ices. Laws have been passed to further integrate depart-ments of the central government of Taiwan, which willcome into effect on 1 January 2013. However, the con-sequences of such a grand political and organisationalinnovation remain uncertain.

This study has highlighted the concept of symbioticcare, which emphasises the tightness of Taiwanesefamily care. While more individualist societies mayvalue centenarians living independently, Taiwaneseculture prefers centenarians to be closely monitoredon a 24-hour basis. Ironically, current Taiwan publicpolicies focus on meeting individual care needs ofolder persons, leaving family needs on the side. Suchan individualist perspective is completely in discordwith traditional values. It is no wonder that live-in careworkers/maids or institutional care have become twomajor alternatives for family care in Taiwan at a timewhen family composition is decreasing.

Limitations

This study has several limitations in research designthat future research should try to amend. First, the studydid not measure caregiver stress/burden to furtherclarify the difficulties faced by these caregivers of cen-tenarians, who are aged persons themselves. Second,due to the extremely limited interview duration thatcentenarians can tolerate, this study included only anevaluation of general life satisfaction and did not usea comprehensive quality-of-life scale that could haveproduced more insights on centenarians’ lives (Yao,2002). Third, the study included only samples of thesuper old. Therefore, more robust statistics cannotbe compiled to compare the centenarians and youngerelders to analyse possible changes of social convoyacross various stages of age.

In conclusion, this researcher strongly advocatesfor the following practitioner points: (i) public policyshould always consider the senior care recipientsand their family as a whole system; (ii) practitioners

should understand the trend of increasing numbers ofcentenarians and prepare to provide acceptable andadequate services; and (iii) aggressive actions need tobe taken to increase and integrate the community-basedhealth and social resources to help the super old andtheir families to live satisfactory lives despite theshrinking social convoy.

Acknowledgement

The author wishes to thank the National ScienceCouncil in Taiwan for the funding support of this studyunder NSC98-2410-H-002-131-SSS and NSC99-2410-H-002-167.

References

Alzheimer’s Disease International (2010). World’s Alzheimerreport: The global economic impact of dementia. Retrievedfrom http://www.alz.co.uk/research/files/WorldAlzheimerReport2010ExecutiveSummary.pdf

Andersen-Ranberg, K. & Jeune, B. (2006). The Danish longitu-dinal centenarian study. In: Y. Zeng, E. M. Crimmins, Y.Carrière, J.-M. Robine (Eds.), Longer life and healthy aging(Vol. 2, pp. 151–172). Dordrecht, The Netherlands: TheSpringer International Studies in Population.

Berges, I. M., Dallo, F., Dinuzzo, A., Lackan, N., & Weller, S. C.(2006). Social support: A cultural model. Human Organiza-tion, 65(4), 420–429.

Cantor, M. H. (1991). Family and community: Changingroles in and aging society. The Gerontologist, 31(3), 337–346.

Fiori, K. L., Smith, J., & Antonucci, T. C. (2007). Social networktypes among older adults: A multidimensional approach. TheJournals of Gerontology. Series B, Psychological Sciencesand Social Sciences, 62B(6), 322–330.

Gondo, Y., Hirose, N., Arai, Y., Inaqaki, H., Masui, Y.,Yamamura, K., Shimizu, K., Takayama, M., Ebihara, Y.,Nakazawa, S., & Kitaqawa, K. (2006). Functional status ofcentenarians in Tokyo, Japan: Developing better phenotypesof exceptional longevity. Journal of Gerontology, SeriesA-Biological Sciences and Medical Sciences, 61(3), 305–310.

Kahn, R. L. & Antonucci, T. C. (1980). Convoys over the lifecourse: Attachment, roles, and social support. In: P. B. Baltes,O. G. Brim (Eds.), Life-span development and behavior(pp. 253–286). New York, NY: Academic Press.

Kropf, N. P. & Pugh, K. L. (1995). Beyond life expectancy-socialwork with centenarians. Journal of Gerontological SocialWork, 23(3–4), 121–137.

Leea, I. & Dunkleb, R. E. (2010). Worries, psychosocialresources, and depressive symptoms among the SouthKorean oldest old. Aging & Mental Health, 14(1), 57–66.

MacDonald, M. (2007). Social support for centenarians’ health,psychological well-being, and longevity. Annual Review ofGerontology and Geriatrics, 27, 107–127.

Martin, P., Hagberg, B., & Poon, L. W. (2004). Predictorsof loneliness in centenarians: A parallel study. Journal ofCross-Cultural Gerontology, 12, 203–224.

Matt, G. E. & Dean, A. (1993). Social support from friends andpsychological distress among elderly persons: Moderatoreffects of age. Journal of Health and Social Behavior, 34(9),187–200.

Ministry of the Interior (2004). National Survey on People Aged90 and Above. Taipei: Ministry of the Interior.

Yang

404Int J Soc Welfare 2013: 22: 396–405


Ministry of the Interior (2009). Report of the Senior CitizenCondition Survey 2009, Republic of China. Taipei: Ministryof the Interior.

Ministry of the Interior (2011). Taiwan population statistics of2011. Retrieved from http://www.moi.gov.tw/stat/index.aspx/

Ministry of the Interior (2012). Taiwan population statistics of2012. Retrieved from http://www.moi.gov.tw/stat/index.aspx/

Nauck, B. (2009). Patterns of exchange in kinship systemsin Germany, Russia, and the People’s Republic of China.Journal of Comparative Family Studies, 40(2), 255–278.

Poon, L. W., Clayton, G. M., Martin, P., Johnson, M. A.,Courtenay, B. C., Sweaney, A. L., . . . & Thielman, S. B.(1992). The Georgia Centenarian Study. InternationalJournal of Aging and Human Development, 34(1), 1–17.

Poon, L. W., Johnson, M. A., Davey, A., Dawson, D. V.,Siegler, I. C., & Martin, P. (2000). Psycho-social predictorsof survival among centenarians. In: P. Martin, C. Rott,B. Hagberg, K. Morgan (Eds.), Centenarians: Autonomyversus dependence in the oldest old (pp. 77–89). New York,NY: Springer Publishing Company.

Samuelsson, S. M., Alfredson, B. B., Hagberg, B.,Samuelsson, G., Nordbeck, B., Brun, A., & Risberg, J.(1997). The Swedish centenarian study: A multidisciplinarystudy of five consecutive cohorts at the age of 100. Inter-national Journal of Aging and Human Development, 45,223–253.

Segerberg, O. Jr (1982). Living to be 100: 1,200 who did andhow they did it. New York, NY: Charles Scribner’s Sons.

Siegler, I. C., Longino, C. F., & Johnson, C. (1992). The GeorgiaCentenarian Study – comments from friends. InternationalJournal of Aging and Human Development, 34(1), 77–82.

Taipei City Government (2009). Taipei City Elder Survey of2009. Taipei: Taipei City Government.

Tsukamoto, M., Ogawa, N., Kinjo, R., Toyama, F., Okawa, M.,Tamayose, Y., & Akisaka, M. (2001). The research onthe life and care of centenarians living in their homes inOkinawa – comparison of Seikatsujiritsu and Netakirigroups. Journal of Okinawa Prefectural College of Nursing,2, 9–17.

United Nations Department of Economic and Social Affairs(2012). Retrieved from <http://esa.un.org/unpd/wpp/unpp/panel_indicators.htm>.

Willcox, D. C., Willcox, B. J., Wang, N. C., He, Q.,Rosenbaum, M., & Suzuki, M. (2008). Life at the extremelimit: Phenotypic characteristics of supercentenarians inOkinawa. Journal of Gerontology, Series A-Biological Sci-ences and Medical Sciences, 63(11), 1201–1208.

Yao, K. P. (2002). Development and application of theWHOQOL-Taiwan Version. Formosan Journal of Medicine,6(2), 193–200.

Zhou, M. & Qian, Z. (2009). Social support and self-reportedquality of life: China’s oldest old. In: Y. Zeng, D. L. Pston, D.Ashbaugh Vlosky, D. Gu (Eds.), Healthy longevity inChina (Vol. 20, pp. 357–376). Dordrecht, The Netherlands:The Springer Series on Demographic Methods andPopulation Analysis.



Surviving social support: Care challenges facing Taiwanese centenarians

Documents

Transcript of Surviving social support: Care challenges facing Taiwanese centenarians