Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0THE NORMAL AGED AMONG COMMUNITY-DWELLING ELDERS IN THE UK 83Support NetworksG. Clare WengerCentre for Social Policy Research and Development, University of Wales, Bangor, UKIt is difficult to find any text in social gerontology which does notrefer to social networks, care networks or support networks. Inthe 1980s, a shift in social gerontology research took place tofocus on networks of support rather than whether or not elderlypeople have contact with each of a range of categories ofrelationship (spouse, daughter, brother, etc.) 1–6 .Support networks here are defined as those within the largersocial network of the individual who regularly provide support ina range of contexts of day-to-day life, and include: members of thesame household; relatives seen most frequently; confidant(s); andthose people providing, or perceived by elderly respondents to beavailable to provide, emotional support, instrumental help,personal care or advice. Support networks may range in sizefrom two to 22 but modally cluster around five to seven 4,7,8 .Women have been shown to have more expansive networksthan men in a wide range of countries 9 . Research has shown thatolder people with strong social networks are happier and morelikely to perceive themselves to be healthy 10 . Others havesuggested that, for people with serious mental illness, socialsupport promotes normality in life styles 11 . A review of thefindings on social networks of older people 9 makes the followingobservations, which have significance for geriatric psychiatry.Dense networks (where a high proportion of members know oneanother) tend to provide better access to emotional support butmay shield or prevent people from seeking professional advice.For example, Veiel 12 found that for some patients, psychologicaland emotional support in crises received from close relatives wasassociated with a subsequent increase in depressive symptoms.Loose-knit networks provide better access to resources, includingprofessional care. Residential admissions are less common wherethere is a close supportive network but this can also be associatedwith the avoidance of needed professional interventions.The radius of support networks tends to follow a bimodaldistribution, with substantial numbers of older people havingeither all members within 5 miles or at least one member morethan 25 miles away. Support networks typically have a core offamily but also include friends, neighbours and home helps.Normative expectations of support for different relationships existthat are well defined but these are likely to be culturally specific.Such expectations are hierarchical. In the UK spouses top thehierarchy, followed by immediate family: daughters/sons andsisters/brothers. Following siblings come friends, and thenneighbours. Extended family of grandchildren, nieces/nephewsand cousins come below friends and neighbours 13,14 . Expectationsare affected by the intervening variables of distance, gender andhealth. Long-term residents in a community tend to rely on localkin, while retirement migrants are unlikely to have kin nearby andhave more diffuse networks 15,16 .The review of the literature referred to above suggests that olderpeople may use different network members in different ways inemergency and non-emergency situations. There is evidence toshow that vulnerable or stigmatized groups may be disadvantagedin network terms. Mentally ill people have smaller networks thanothers and the same is true for dementia sufferers. The moreintimate (e.g. bodily care), personal (e.g. washing clothes) orprivate (e.g. financial concerns) the need of the elderly person (asdefined by the culture), the more likely it is that this will be met bya family member. However, non-kin appear to be more importantthan family for morale, self-esteem and emotional support. 17,18 .Ahigh proportion of members of the support networks of elderlypeople are themselves elderly and/or female. Those who are orhave been married tend to concentrate most need for support onone member of their network (usually a spouse or adult child),while those who have not married tend to spread their needsthroughout their networks, relying on a wide range of others forone or two types of support.Based on longitudinal data from the UK 5 , it has been shownthat, contrary to expectations for largely elderly networks, the sizeof networks typically remains stable over time, suggesting someform of homeostasis. One exception to this is the supportnetworks of married men, which tend to shrink with widowhood.The average change is equivalent to +1–2 over 4 years. However,with increasing physical or mental frailty, networks tend to shiftto reflect more reliance on proximate kin, if available, orincreasing use of formal services and/or growing social isolation 19 .Loss from networks is predominantly due to death or disabilityand gains come from the pre-existing social network, withmembers moving into the supportive core. Tensions in networksmay arise from mismatch of expectations between the elderlyperson and the network member, i.e. where demands exceednormal expectations of the relationship or where different actorsdefine the relationship differently. Mental illness, particularly theresultant cognitive dissonance experienced by network members,can result in network contraction as non-kin withdraw and kintend to insulate the sufferer from non-kin contacts 19 .Several different typologies of the networks of older peoplehave been developed in Australia 8 , the USA 20 , the UK 6 andIsrael 21 . What is striking is the similarity between them. Eachtypology: (a) reflects a continuum from close-knit to loose-knit;(b) finds that density is related to the importance of kinship; (c)includes the identification of a household-focused adaptation,based on a privatized life style and a small network; (d) identifiesan association with social class (middle-class networks are lessdense); and (e) acknowledges the influence of neighbourhoodtype.Support networks demonstrate a range of types, which vary interms of: availability of local kin; levels of interaction withdifferent categories of membership; and the degree of communityinvolvement, as measured by voluntary association. This articlefocuses on the Wenger support network typology, developed inthe UK and subsequently validated in other countries. TheWenger typology identifies five types of network 6 , which havedistinct parallels with the other network typologies. The five typesof networks identified are summarized below. The first three typesare based on the presence of local kin; the other two types reflectthe absence of local kin:1. The local family-dependent support network has a primaryfocus on close local family ties, with few peripheral friends andneighbours; it is often based on a shared household with, orclose to, an adult child, usually a daughter. Communityinvolvement is generally low. These networks tend to be smalland the elderly people are more likely to be widowed, older orin less than good health.