Who is the "Sandwich Generation?"

The caregivers looking after their children, their parents...and themselves

 

Mother’s Day, like its counterpart Father’s Day, is a time to recognize those loving parents and caregivers who have shaped us into the people we are. But what about parents who, along with caring for their children, are also caring for their own aging parents?

This “sandwich generation,” wedged in the middle of two generations requiring care, is a relatively recent phenomenon, thanks in part to an aging population and people having children later in life. The responsibility of caregiving, although often a labor of love, is enormous, so how can these caregivers ensure their needs are met as they dedicate so much of themselves to meeting their loved ones’ needs?

Who is the “sandwich generation?”

First, some background: A study published in late 2022 by the Journal of the American Geriatrics Society found that, of all adult child caregivers in the United States, 24.3% also cared for a minor child. These 2.5 million individuals make up the “sandwich generation.”

The study reported that sandwich-generation caregivers experienced more financial and emotional hardships compared to non-sandwich caregivers, i.e., those adult child parental caregivers who are not also caring for their own children. Sandwich-generation caregivers also reported feeling more overwhelmed in their dual caregiving roles and were less likely to seek out support resources than their non-sandwich counterparts.

So, if this level of caregiving is as taxing as the data suggests, how have so many - largely women, by both Dr. Bowman’s and McCutcheon’s observations - found themselves doing it?

“The sandwich caregivers often don’t mind providing their loved ones with needed care, as they are appreciative of what their parents did for them, so they are mirroring that,” said Dr. Jenee Bowman, a pulmonologist at PAM Health Specialty Hospital of Rocky Mount (North Carolina). Dr. Bowman has seen this firsthand as she often interacts with “sandwich” caregivers as she care for patients.

“They don’t mind doing it. It’s just an extension of who they are. It’s not easy by any stretch,” Dr. Bowman said.

Jennifer McCutcheon, Vice President of Clinical Services and Quality at PAM Health-affiliate Voyages Behavioral Health and a licensed clinical social worker, agreed. Despite the immense responsibilities of the sandwich generation, “we are natural caretakers of other people and are often validated or find our self-worth in the care we provide others,” McCutcheon said.

As for why so many sandwich generation caregivers are women, both McCutcheon and Dr. Bowman believe it’s a role that comes more naturally to and is more of a societal expectation for women, for better or for worse. These women are “trying to balance the values of how we were brought up with empowering ourselves as strong female leaders and advocates for others,” McCutcheon said.

Supporting the sandwich generation

Dr. Bowman acknowledged that it’s important to support these primary caregivers, as the patient’s own health and well-being depends on it.

“If providers do find that the patient’s care seems to fall on one or a few family members, we [as providers] usually try to, in a respectful way, point that out, but we also explain that it may be difficult if just one person or a few carries the load," Dr. Bowman said. She believes it’s part of her duty as a physician, as well as a responsibility of case managers, to try to identify early on in the patient relationship the situations where one individual is carrying the majority of the caregiving burden.

It’s easier said than done to spread the load, Dr. Bowman said, but ideally, there would be a sole caregiver – the designated healthcare power-of-attorney – who could then delegate tasks to others on the patient’s support team. 

One way to ease the burden on these primary caregivers is by simply listening to them and seeing their perspective, McCutcheon said. “Take time to get to know these caregivers and all the things they are balancing at one time...Ask the tough questions and seek to understand,” McCutcheon said.

Dr. Bowman, whose own mother has lived with her and her family for years, aimed to shed light on the strength it takes to do everything involved with being a caregiver to a parent, especially as most people in this situation have no previous medical background.

“I’m utterly amazed at what family caregivers can do and learn over time, especially when providing medical care. Some of the best tracheostomy care comes from family members who have learned in the hospital and have done it at home…Some of the folks who I’ve gained the most strength from are family members who have done the most with what limited resources they have,” Dr. Bowman said.

The evolution of the sandwich generation

Over the course of her 25-year career, Dr. Bowman has seen the sandwich generation grow as alternative out-of-hospital care methods, like home healthcare and skilled nursing facilities, have increased.

“It’s obviously better for patients to not be in a hospital setting indefinitely,” Dr. Bowman said. Still, families are often unprepared to become caregivers when they do, and someone has to step up unexpectedly to meet the patient’s new needs.

In recent years, the COVID-19 pandemic and a nursing staffing shortage have further compounded the strain on sandwich-generation caregivers. “Even in the best circumstances, it’s very frustrating for families,” Dr. Bowman said.

Tips for self-care for caregivers

Amidst the expectations for sandwich-generation caregivers, how can they look out for themselves? Self-care and mindfulness have to be intentional, McCutcheon said.

“You have to pay attention to what your needs are and make time to validate yourself and fill those areas that are often unintentionally neglected for those that work in the field of healthcare…We have to make sure our ‘buckets’ are filled so that we can then take care of others.”

She recommends that these caregivers carve out time for themselves to do what makes them happy. “Do what feeds your soul,” McCutcheon said.

Caregivers’ physical health is just as important as their mental health, as well, Dr. Bowman stressed. “We try to remind all caregivers that they need to care for themselves in terms of their own healthcare,” Dr. Bowman said.

The future of the sandwich generation

Dr. Bowman and McCutcheon agreed that these caregivers need more support resources. “We are evolving as a society and are slowly moving forward in the acceptance of self-advocacy being seen as a strength as opposed to selfishness,” McCutcheon said.

Support groups, whether in-person or virtually via Facebook or elsewhere on the internet, could be a good tool for sandwich caregivers to connect with others, Dr. Bowman said. Several PAM Health hospitals offer support groups for various types of medical conditions and encourage caregivers to attend along with the patient.

The vital role these caregivers play cannot be understated, and supporting them is necessary for providing the best care for patients, Dr. Bowman said. “I’m always amazed that they are able to do what they can. It’s just a tough job.”

Bibliography:

Lei, L, Leggett, AN, Maust, DT. A national profile of sandwich generation caregivers providing care to both older adults and children. J Am Geriatr Soc. 2023; 71( 3): 799- 809. doi:10.1111/jgs.18138