The Sandwich Generation of Caregivers

By Kristin Gernon, LCSW, LMSW, Behavioral Health Training and Development Specialist, Blue Cross and Blue Shield of Kansas City    

It is not your imagination. Many middle-aged adults seem more overwhelmed by stress than ever before. While we may be in the habit of attributing any unwelcomed data point to the COVID-19 pandemic, this observation predates the pandemic. We’re talking about the stress of being part of the Sandwich Generation.   

A term first coined by social workers Dorothy Miller and Elaine Brody in 1981, the Sandwich Generation is used to describe adult children, between roughly 45 and 65 years of age, who are “sandwiched” between caring for their own children and their aging parent(s).    

Miller further described the generation as being in prominent “decision-making positions throughout society.” She thoughtfully continued in her 1981 Social Work journal article, “the position of the children of the aging in relation to their parents, children, and grandchildren exposes them to a unique set of unshared stresses in which giving of resources and services far outweighs receiving or exchanging them.”     

The more current definition offered by the Pew Research Center is similar: “Those who have a living parent, age 65 or older, and are either raising a child under 18 or supporting a grown child.” With a growing aging population, more and more adults are finding themselves in the caretaker role, which can take a significant emotional and financial toll, and it often negatively impacts the physical and mental health of caregivers.        

According to the National Alliance of Caregiving, an estimated 11 million adults in this country act as unpaid caregivers to an adult while also raising a child or children. This includes 54% of adults in their 40s. Approximately one third of sandwich generation caregivers report high levels of emotional stress. Twenty percent also report high levels of financial strain. According to the Bureau of Labor Statistics, working adults typically reach their peak earnings between the ages of 35 and 54. Just as a working adult may be reaching the pinnacle of their career, they may be faced with a choice to leave their career, reduce their work hours, or take a lower position to manage care of both children and elderly adults in their life. And the caretaker role does, disproportionately, fall to women. 

Financial Impact   

Even though our population is living longer, aging is rightfully associated with an increased need for healthcare, assistance with daily living activities and transportation, and the consequential need for coordination of activities, appointments, and monitoring. Many older adults live on limited, fixed incomes while the cost of many products and services they will need grow disproportionately. Therefore, adult children often supplement the incomes of aging adults or forego costly paid caregiving and make the choice to provide all forms of caregiving in the aging relative’s home or by asking the aging parent to move in with them.     

This is coupled with an increasing number of adults in the sandwich generation who are financially supporting adult children who are unemployed or under employed. Almost one in five in the sandwich generation financially support aging parents, minor children, and adult children.      

The financial impact to these dual caregivers has many implications. If their own career path is interrupted, they may have long-term loss of earning potential, may not be able to save sufficiently for retirement, and will likely have reduced Social Security benefits. Also, they may not be able to save for their children’s future education, thus passing along a potential financial burden to the next generation.     

For most families, taking on even some of the cost of caring for an aging parent will require a financial sacrifice somewhere else. Even families living comfortably may suddenly find it necessary to borrow from an emergency fund, savings account, or retirement savings.   

Emotional Impact   

In addition to the financial strains, it is important to be aware of the time and energy required to care for an aging parent on top of raising children. Many in this situation struggle with complex emotions, according to Mental Health America. Dual caregivers may feel guilt over not being able to fully attend to children while caring for aging parents and vice versa. Caregivers may also feel resentment toward adult siblings perceived to not be providing similar levels of emotional, financial, or practical support for a parent in need.     

An unresolved family history of conflict or estrangement may arise anew. Even close-knit families sometimes find themselves at odds over the many responsibilities to divide and make decisions, often in quick succession.       

The role reversal required for adult children to begin caring for their aging parents can evoke strong emotion. As elderly parents grapple with a loss of independence, adult caregivers often feel anticipatory grief as they cope with their aging parent’s mortality.     

Health Implications   

The Blue Cross Blue Shield Health Index data found, in 2018, that caregivers had an average Health Index score that is 2.2 points lower than the benchmark population. This equates to a 26% greater impact of physical and behavioral health conditions. Looking through the health equity lens, we also know the Health Index Score differential is greater for Black and Hispanic caregivers, 5.6% and 4.4% lower respectively.      

This data point was tabulated prior to the COVID-19 pandemic and is predicted to be much higher in response to the pandemic because, according to an Archangels Survey in 2020, 55% of those who self-identified as a caregiver said they did not self-identify as a caregiver before the COVID-19 pandemic.     

Clinically significant levels of stress, anxiety, or depression are reported by 57% of caregivers. Unhealthy coping strategies such as tobacco use, alcohol or medication misuse, and overeating are more prevalent in those who self report as caregivers. It should be no surprise, then, that hypertension is 64% more prevalent in the caregiver population. Caregivers also have much higher rates of anxiety (+36%), major depression (+37%), and obesity (+50%) when compared to the benchmark population.     

More recent data collected by Archangels is sobering. Of those who take the organization’s voluntary survey, 91% of caregivers who are in high-intensity caregiving roles report experiencing adverse mental health symptoms. Of caregivers overall, 70% reported at least one adverse mental health symptom during the pandemic such as anxiety, depression, suicidal thoughts, or trauma. Of those who are in the sandwich generation, 85% have experienced adverse mental health symptoms during the COVID-19 pandemic with 52% endorsing suicidal thoughts within the previous 30 days.     

Caregiver Tips     

Likely you or someone you know is having to juggle the needs of their loved ones young and old, and while at times it can be rewarding, it is hard work in the chaos of everyday life. Here are some ideas to consider:    

• Take time to plan and organize for the week or month ahead.     

• Have a family meeting to discuss the various activities, appointments, and schedules to ensure all family members are aligned.  
• Ensure all family members are helping you stay organized. Identify age-appropriate chores and household tasks for kids so they can contribute and set clear expectations for everyone in the household.     
• Schedule time to exercise, meditate, journal, or otherwise engage in self- care. Make those times non-negotiable. Plan and shop for healthy meals in advance and stick to your meal schedule even when pizza cravings arise. 
• Identify times when outside help with transportation or child/elder care may be needed, and do not be afraid to ask friends, family, and neighbors for help. Identify a resource for paid caregivers to use in a pinch.     
• Communicate openly with your employer to let them know the many demands you are facing outside of the workplace. Negotiate a flexible work arrangement, if available, to accommodate your unique needs.     
• Make a budget. If possible, continue contributing, if only a small amount, to your retirement or kids’ education savings. Use this as an opportunity to talk to your kids about your family’s financial priorities and values.  
• Create an open dialogue with your aging parents about their financial situation, if they are willing, long before you become a caregiver. Set boundaries around how much you are reasonably able to contribute to an elderly parent’s care without abandoning your own financial plan.   
• Make sure proper legal documentation is drawn up dictating who has authority to make medical, legal, and financial decisions in the event a loved one begins to experience memory loss or becomes incapacitated. 
• Know that your own children will likely become the next sandwich generation. Make it easier on them by legally documenting your intentions and wishes and making practical and financial plans far in advance.      

You are not alone. A Blue KC health plan gives members access to mental and behavioral health benefits through Mindful by Blue KC. A Mindful Advocate will discuss your unique situation and services available to help you and your family. The role of a caregiver is an important one so take care of yourself so you can take care of those you love most. 

Learn more about Mindful by Blue KC. Then contact a Blue KC Customer Service representative to learn about a health plan that fits your needs.