In both situations, the adult children struggled to find a way to care for their parents while staying sane themselves. People with Alzheimer's or dementia are plagued by more than just memory loss. A mother who was always calm may become agitated; an unfailingly kind father may turn aggressive or belligerent. Dementia affects brain tissue, and that can cause personality changes, says Dr.
Restlessness, wandering, even delusions are common behaviors associated with dementia. Sometimes memory loss can also trigger paranoia. If Mom can't remember where she left her purse, she may accuse family members of stealing it. That was the Alzheimer's talking. After hearing Chafetz speak recently at Belmont Village, where she resides, Jane Kemp recalls the hurt she felt when her mother accused her of stealing money before she passed away.
In fact, Kemp had been sending money to her mother every month. Dementia had clouded her mother's judgment. But what if the difficult parent is the same person you've been dealing with all your life? For those whose parents have mental illnesses, the emotional burden can be heavier. Laurie Kidder, co-administrator of Dallas-based MyCare Personal Assistance, worked with a client whose mother threatened suicide every time her daughter misbehaved.
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One way to maintain the necessary distance, Chafetz says, is to remember that loving an elderly parent doesn't mean taking responsibility for that person's happiness. That's what love is. One of Chafetz's patients has coped since childhood with a mother whose borderline personality disorder involved bouts of black moods, screaming fits and threats of suicide. Her mother, 88, recently moved nearby. It's like their emotions are on fire, and they'll do anything to put them out. That's what kids of difficult parents do. You're so exhausted because you've done that all your life.
For those caring for a parent with dementia, Kerwin advises respecting the older person's autonomy as much as possible. Ignore annoying but harmless behavior but intervene if it threatens health and safety. At the family's request, Kerwin is often the one who tells an Alzheimer's patient that it's time to hand over the car keys. For those parents who are not rational or impaired because of dementia, he recommends the "therapeutic fib. With rational people, speaking the truth is the moral choice because it provides meaningful feedback.
For those who are not rational, "the legitimate, loving and more effective approach is to finesse them into behaving better through such strategies as the therapeutic fib. Entering the impaired person's reality is a commonly recommended technique for caretakers working with dementia patients, says Bob Kidder. Attempts to reason, correct or confront can trigger aggression or further confuse the person. Chafetz's book offers a list of empathetic but vague responses that adult children can try when confronted with constant complaints or unreasonable demands.
Don't say yes and don't say no; instead respond with comments like, "You don't say" or "Let me check into that. Setting boundaries is important, too, says Smith of the Senior Source.
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For those who can afford it, she advises hiring help to handle caregiving tasks that feel overwhelming. Find support, whether through friends, a faith community or a support group. Smith says she's "in awe" of adult children who manage to overcome past resentments. While it's tempting to withdraw from a difficult parent, she says, sometimes it's also an opportunity to confront old demons. Find a way to let the parent's criticism and unkind remarks roll off your back, and you'll feel empowered and reduce the chances that one day your own kids will have to deal with a difficult older parent.
The group is free and open to the public; an RSVP is requested but not required. For instance, Dykstra and de Jong Gierveld [ 13 ] found that social and emotional loneliness among older Dutch women was negatively associated with weekly contact with their children. Similarly, older European parents who saw or talked to their children more often than once a week had significantly lower levels of depression [ 14 ].
Among the Chinese elderly, living alone was associated with low subjective well-being and living with immediate family members improved their general well-being [ 15 ]. In contrast, there are studies reporting better physical and emotional well-being among the left behind elderly parents. Waite and Hughes [ 17 ] found that left behind parents in the USA enjoyed improved health conditions over parents living with their children.
A study in China [ 18 ] reported non-empty nest elderly utilizing better health care than that of empty nest elderly. Wenger et al. Living alone provides parents with an opportunity for reconnection and reawakened interests [ 20 , 21 ]. However, this study and a similar study by Gibson et al. Among the left behind, a number of risk factors for poorer mental health have been identified ranging from predisposing inherent factors such as age, sex, education, existing disease status, previous mental illness, and place of residence to a wider community and social factors such as existing social support, number of social ties, community engagement and interactions, and access to health services.
In general, males, younger parents, living in urban areas, and better access to medical care are positively associated with improved mental health of empty nesters. Despite the increased focus of research in this area, the empirical findings are equivocal. To identify the association between the left behind or empty nest status and the mental health of elderly parents and to identify the common risk factors for poor mental health among those left behind.
This integrative review considered research relating to the migration of children and the mental health of the left behind parents. Integrative reviews are an effective method for combining studies with diverse methodologies and data sources in order to increase understanding of the topic, subsequently contributing to the evidence-base [ 24 ].
The search strategy was supplemented by review of the reference lists of the included research [ 25 ]. Studies were excluded if the focus was on the left behind children, spouse or family members. To account for the cohort effect, studies published before the year were excluded. The process of selection included reviewing the titles and abstracts to identify potential articles and then reading the full text to determine whether articles met the inclusion criteria.
Initial screening was carried out by the first author and then checked independently by all other authors. The final sample comprised 25 articles from 23 studies that met the inclusion criteria see Fig 1. The variety of tools and instruments used to assess mental health precluded a quantitative meta-analysis. Articles were scored Yes , No , Unclear or Not Applicable NA for the following: 1 criteria for inclusion in the sample clearly defined, 2 study subjects and the setting described in detail, 3 exposure measured in a valid and reliable way, 4 objective, standard criteria used for measurement of the condition, 5 confounding factors identified, 6 strategies to deal with confounding factors stated, 7 outcomes measured in a valid and reliable way, and 8 appropriate statistical analysis used.
See S1 Table. Twenty-three studies reported in 25 publications from six different countries were included. Four studies were longitudinal [ 26 , 30 , 35 , 53 ] with the remainder cross sectional with the exception of one qualitative study [ 64 ]. One used total sampling [ 49 ] and another used snowball sampling [ 64 ].
The sample size of quantitative studies ranged from to 28,, and the qualitative study had 29 participants. The age of subjects ranged from 50 to plus years. The remaining eight [ 12 , 22 , 28 , 43 , 49 , 50 , 56 , 57 , 64 ] did not report the response rate. The elderly without children were deemed empty nest if living alone or with a spouse, however one study [ 43 ] excluded elderly who were childless.
There were some variations in defining the duration of migration. He et al. Antman [ 12 ] and Downer et al. Sekhon and Minhas [ 49 ] considered families which had at least one member who had permanently emigrated abroad. A follow up study defined left behind as no children emigrated at baseline but one or more children emigrated at follow up [ 30 ].
Xie et al. Abas et al. The remaining seven publications [ 41 , 46 , 48 — 50 , 55 , 64 ] studied the left behind and did not have a comparison group. A range of measures were used to assess mental health status with many using multiple measures. Depression was assessed in 13 studies [ 28 , 30 , 38 , 41 , 43 , 45 , 49 , 53 , 55 , 58 — 60 ] and three studies assessed loneliness [ 30 , 45 , 62 ].
Other measures of mental health included anxiety [ 50 ], cognitive function [ 43 , 50 ], life satisfaction [ 60 ] and social isolation [ 62 ]. Some used broader measures such as symptoms of poor mental health [ 56 ], self-reported mental health [ 12 , 30 ], psychological well-being [ 64 ], psychological health [ 26 , 48 ] and measures of mental health status [ 18 , 22 , 33 ].
Twenty studies used standard instruments for measuring different aspects of mental health. Thirteen studies reported depression among the left behind elderly parents. Large variations in the mean score of depression were observed Table 2. Variation in scales resulted in large heterogeneity in depression prevalence as well as mean scores. The GDS consists of 30 items with a score ranging from 0 to 30, higher scores represent increased depression.
GDS scores of 11 and above suggest depressive symptoms. The studies using GDS reported the proportion of left behind elderly having depressive symptoms ranging from Wang et al. Zhai et al. Chang et al. Similarly, a study using SCLR [ 34 ] reported depression among Each of the 20 items was scored on a four-point scale leading to a total score of 60, with higher scores indicating higher depressive symptoms, with a mean depression score of 4. Two studies used the EQ-5D scale developed by The EuroQol Group [ 47 ] to measure health-related quality of life among the empty nest elderly in rural China.
The SAS is a item scale with scores ranging from 20 to 80, with higher scores representing higher anxiety. The mean standardized score of The mean SAS standardized scores were higher in females In addition, the study also reported the association of anxiety with education level, occupation and monthly income of the elderly. Cognitive function of the left behind elderly was assessed using the Mini Mental State Examination MMSE , a item test to assess orientation, attention, calculation, language, and recall [ 44 ]. The MMSE yields a score of 0—30 cut-off of 24 with higher scores indicating better functioning.
Loneliness was assessed using the University of California, Los Angeles Loneliness Scale UCLA-LS [ 32 ] which consists of 20 questions, using a four-point scale, with a total score range of 20 to 80 with higher scores indicating increased loneliness. UCLA scores of 20—34, 35—49, 50—64 and 65—80 are considered to be mild, moderate, moderate—severe, and severe loneliness, respectively [ 66 ].
Cheng et al. Similarly, Liu and Guo [ 62 ] found The World Health Organization Quality of Life Questionnaire abbreviated version WHOQOL-BREF [ 40 ] consists of 26 items containing two objective items overall QOL and general health status and 24 other items divided into four domains: physiological seven items , psychological six items , social relationships three items and environment eight items.
In this review, only scores for the psychological domain are relevant. The equivalent centesimal score for the Cheng et al. The study used MHI-5, a five question scale based on Mental Health Inventory developed by Veit and Ware [ 29 ] ranging from 5 very poor to 30 very good. Studies reported mean scores of Adhikari et al.
Two studies [ 33 , 56 ] did not provide details on significance. Nine studies found the mental health status of the left behind elderly to be poorer than that of the elderly parents living with their children with statistically significant differences in six studies. More specifically, these studies showed that left behind parents had higher depressive symptoms [ 43 , 45 , 58 , 60 ], higher levels of loneliness [ 45 , 60 ], lower life satisfaction [ 60 ], lower cognitive ability [ 43 ] and poorer psychological health [ 12 , 18 , 33 , 45 , 56 , 62 ].
Three studies found statistically significant differences showing better mental health among the left behind, with one further study showing a non-significant difference. Gao et al. Decreased prevalence of depression among the left behind parents was reported [ 28 , 30 , 53 ]. Two studies classified left behind into two groups, among which Chang et al. Similarly, Abas et al. Guo et al. Sixteen studies analysed the association between the left behind and the mental health of elderly, of which 12 studies conducted multivariate analysis and the remaining four studies reported only bivariate association.
For multivariate analyses, seven studies [ 12 , 26 , 30 , 43 , 56 , 57 , 60 ] showed that parents whose children had migrated were at greater risk of mental health problems than those with non-migrant children Table 3. For instance, Gao et al. Depressive symptoms were found to be higher among the parents of migrant children [ 30 , 43 ]. Sun et al. In contrast, Abas et al. Having all children out-migrated reduced depression compared to none or some children out-migrated [ 53 ].
Three studies [ 22 , 28 , 38 ] found no association between migration of adult children and the mental health of the elderly. Among the studies reporting a bivariate association, three [ 18 , 45 , 58 ] reported higher prevalence of mental health problems for left behind parents while the remaining study [ 33 ] showed no significant association. Eight studies examined the relationship between gender and mental health among the left behind elderly.
Females had poorer mental health than males in five studies [ 12 , 26 , 33 , 41 , 50 ] while Xie et al.
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Gender differences were not observed in two studies [ 45 , 46 ]. Seven studies examined the influence of age on the mental health status of the left behind elderly and reported varied results. Multiple regression analyses showed cognitive ability and psychological health were negatively associated with age [ 26 , 33 ]. In addition, Liu and Guo [ 60 ] found age was positively related with loneliness in a bivariate analysis. No significant change in anxiety with increasing age was reported in a study conducted by Wang et al.
Marital status using marital status groups including currently married, never married, divorced, separated and widowed, was a frequently mentioned factor influencing mental health. Being currently married was associated with better mental health among the left behind elderly [ 26 , 58 , 62 ].
Similarly, living with a spouse decreased the risk of anxiety [ 50 ], depression [ 41 ], loneliness [ 45 ] and psychological ill health [ 48 ]. Two studies [ 33 , 46 ] found no difference in mental health with respect to marital status. Seven studies assessed the relationship between education level and mental health with inconsistent results. Four [ 12 , 41 , 46 , 50 ] indicated that left behind parents with higher educational level were less likely to develop mental health problems.
Caring through the hurt: Experts tell how to cope when elderly parents' behavior worsens
However, Liu and Guo [ 62 ] found a higher level of education had a higher level of loneliness for left behind with higher levels of education. Seven studies addressed the association between economic status measured mostly in terms of monthly or yearly income and self-perceived income and mental health of the left behind elderly with all observing higher income related with lower levels of mental health disorders.
The results of bivariate analyses showed that elderly in the lower income groups reported higher scores of anxiety [ 50 ]. In addition, low income was associated with higher levels of loneliness [ 45 , 62 ], lower life satisfaction [ 60 ], and poorer mental health symptoms [ 33 ]. Similarly, low levels of self-perceived income was identified as a significant predictor of depression [ 55 , 58 ]. Furthermore, He et al. Two studies used occupation as an economic indicator.
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Similarly, skilled workers had the lowest mean anxiety score with the highest among farmers [ 50 ]. Three studies assessed the association between place of residence urban or rural and mental health with two reporting improvements for those in urban areas. However, one study [ 33 ] showed no significant difference in mental health symptoms by place of residence. Chronic disease s was associated with poor mental health conditions [ 33 ], depression [ 41 ] and lower levels of life satisfaction [ 60 ].
Su et al. Four studies measured social support using the Social Support Rate Scale SSRS [ 67 ] comprising three dimensions: objective support, subjective support and support utilization. Social support was negatively associated with life satisfaction [ 60 ] and positively associated with loneliness [ 62 ]. Higher levels of exercise and physical activity were found to improve cognitive function and psychological health [ 26 ], and reduce depression [ 41 , 55 ] among left behind elderly parents. Left behind parents whose children visited more often had lower depression [ 41 ] and better psychological health [ 48 ].
Better relationships with children was also associated with higher levels of life satisfaction [ 60 ]. The primary objective of this review was to identify the association between migration of adult children and the mental health of elderly parents left behind. The study designs were mostly cross sectional. While this study design limits causal inference, the quality assessment based on the JBI checklist for cross sectional analytical studies found most to be of high methodological quality allowing for adequate assessment of associations.
The results were relatively consistent, where being left behind was negatively associated with mental health in 10 of the 16 studies with only 2 finding a positive association. The qualitative study [ 64 ] also found parents with adult children migrated experienced higher level of loneliness and depression.
Those left behind experienced higher levels of depression, loneliness, cognitive impairment, anxiety and had lower scores on psychological health compared to older parents with no migrant children. In a meta-analysis of studies concerning quality of life of the empty nest elderly by Lv et al.
In developed countries with higher standards of living and systems for social protection in older adults, independent living is often preferred [ 70 ]. In developing countries without social security and other welfare supports for older adults, intergenerational extended family is crucial for elderly health and well-being [ 71 ]. The majority of studies included in this review were conducted in countries where filial piety is the major guiding principle and a strong intergenerational relationship is important.
Older adults had emotional ties and high expectation for their children to provide physical, financial, instrumental and emotional support. Often when they are older, parents want to live with their children so that they can receive daily assistance and support. This may contribute to positive mental health and well-being. Being left behind may make them feel abandoned, and experience emotional ambivalence, anger and distress [ 74 ].
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Older parents living with their children are reported to receive better daily care and support leading to better health [ 15 ]. A number of studies reported positive associations between parent-child co-residence and the mental health of older parents. Older adults who were left behind by migrant children were more susceptible to psychological distress such as depression [ 75 ]. Intergenerational co-residence has shown to be protective in many countries in different populations including Korea [ 76 ], Japan [ 77 ], China [ 78 , 79 ] and Vietnam [ 80 ].
In Spain, Zunzunegui et al. Left behind adults in Sri Lanka had a higher prevalence of depression, anxiety and somatoform disorder [ 82 ]. Those left behind elderly may also feel a loss of status and fear for their future [ 83 ]. Cheng and Chan [ 84 ] demonstrated an association between filial behaviour of children and psychological well-being among Chinese older parents.
Living with their son is considered the traditional living arrangement, but those living with their daughters report better psychological health [ 15 , 77 ]. Unfortunately, no studies in our review reported the sex of the migrant children. A study in India showed that living in multigenerational households had protective benefits in physical health [ 85 ]. Other studies showed older adults with migrant sons were more likely to report lifestyle-related chronic diseases such as hypertension, diabetes and heart disease [ 86 , 87 ]. For those left behind, research shows increased time spent on agricultural and domestic work [ 88 ], especially among older women.
Zhou et al. Liu et al. Inadequate access to health care is likely to adversely affect mental health, given the relationship between physical and mental health disorders [ 90 ]. However, co-residence is not always influenced by parents needs. A study in China [ 91 ] emphasized parental support strongly influencing children to live with their parents.
Two of the 16 studies in this review both from Thailand [ 53 , 59 ] showed improved mental health for those left behind, whilst four reported null findings. Children, who are leaving, are more likely to feel that their parents have an alternative means of support with most families having more than one child who can provide emotional, physical and financial support. A study by Stohr [ 92 ] showed that children in Moldova made strategic migration decisions to ensure some children stayed behind to care for their parents.
Other children increase their contribution to compensate for their migrant siblings [ 93 ], and hence the effects of high rates of out-migration may be mitigated by this support [ 94 ]. Older parents with only some of their children migrated may not experience all the negative consequences compared to those with all their children migrated. These circumstances allow financial support from the migrant child and local support from the child ren at home which may have positive outcomes for their mental health and well-being.
In addition, technological developments, especially in communication, have enabled continuous communication between the left behind parents and migrant children, potentially decreasing the negative impact of adult child migration [ 95 , 96 ]. The departure of the last child from the household can have a positive impact for parents [ 20 ]. The impact of left behind on the mental health of the elderly also depends on the socio-cultural context of the families.
Indian parents found more difficulties due to their expectations that sons stay with the parents and daughters remain until marriage. This review also examined risk factors of mental health disorders among the left behind elderly. Fourteen factors were identified with different levels of influence, of which nine factors were associated with mental health disorders across the studies. The risk factors identified among the left behind elderly in this study are common to the elderly more generally. As there is a higher prevalence of mental health disorders for this cohort, consideration should be given to those most at risk.
Currently married older people had better mental health consistent with other studies showing widowhood negatively associated with subjective well-being [ 98 ] and mental health [ 99 ]. Living with a spouse was beneficial in reducing loneliness [ , ] and Turner and Brown [ ] noted co-residence with a spouse to be an important source of social support decreasing the risk of depression.
For Buber and Engelhardt [ 14 ] the presence of a spouse or partner was more important than living with, or having regular contact with, their children. Empty nest couples have to rely on each other with spouses often providing essential daily care and emotional support [ ]. Females may be at higher risk for mental health disorders consistent with other studies reporting older women at greater risk of loneliness [ ] and depression [ ]. Mothers often have a different bond with their child due to the time and effort they invest in raising their children.
In contrast, males are more often engaged in social activities [ 13 ] reducing their loneliness whereas women whose main role is domestic, may be limited from establishing and maintaining non-family contacts [ ]. The left behind elderly with lower education may be at greater risk of mental illness. This review supports the finding that educated empty nesters had greater subjective well-being [ 98 ] and cognitive function [ ]. Lower education is associated with greater risk of depression [ , ], dementia [ ] and loneliness [ ].
In general, educated older people are more likely to access health services [ ] and seek new social contacts, thereby improving mental health. Higher income was associated with better mental health consistent with research reporting higher levels of income associated with lower depressive symptoms [ , ], improved quality of life [ ] and decreased loneliness [ ].
Lund et al. Higher income elderly are more financially independent and hence can pay expenses, and afford social activities, which may contribute to improved mental health and well-being [ ]. Financial constraints may negatively affect self-esteem and self-efficacy, reducing social contacts. Four out of five studies identified physical health as a risk factor for mental health problems with the other study reporting no association.
Huang et al. Other evidence [ , ] shows that chronic disease is associated with poor psychological health consistent with our review results. Physical exercise is noted to be beneficial for the elderly, with several studies finding significant psychological and cognitive benefits from regular physical activity [ — ]. A systematic review and meta-analysis of randomized control trials showed that exercise was associated with significantly lower depression in older people [ ].
Exercise training was found to increase fitness, physical function, cognitive function, and positive behaviour in people with cognitive impairments [ ]. Family and social support is a predictor of better mental health among the left behind elderly. Studies demonstrate the preventive effect of family and social support on depression [ ], cognitive impairment [ ] and loneliness [ ]. Ryan and Willits [ ] observed that the quality of relationships with spouse, children, and other family members was associated with feelings of well-being, rather than the quantity of relationships with the presence of family members not necessarily ensuring social support.
The absence of positive relations with children is related to depression [ ] as social support provides a buffering role [ 99 ]. Social support has direct as well as mediating effects among the elderly with mental health status and personality influencing the availability and perception of social support [ ]. Intergenerational social support networks are important predictors of old-age health and survival in developing countries [ , ]. Older adults who participate in socially engaging activities and have social support networks are less likely to become cognitively impaired than non-engaged older adults [ ].
Four out of seven studies identified older age as a predisposing risk factor for mental health problems. Previous studies have shown that social activities decrease with age, which is a risk factor for depression [ ]. Higher levels of loneliness [ ] and depression [ ] were reported with increased age among older adults as they reduced opportunities for social contact due to physical limitations and loss of close friends and family members [ ].
Three studies compared the mental health of rural and urban elderly left behind with two finding those living in urban areas at lower risk while the remaining study found no difference. Rural people often have closer neighbourhood relationships than urban people, which may help to improve psychological well-being [ ]. However, our findings favour urban inhabitants. Of the 16 studies that examined the associations between migration of adult children and psychological well-being of the left behind elderly, only four employed longitudinal design. Three of the four longitudinal studies reported increased risk of psychological ill health among the parents with migrant children.
The decision to migrate may be influenced by the health status of elderly parents. Children may be more likely to migrate if the older parents are in good health and they have strong family and social support networks. Conversely, adult children with elderly parents with poor health may migrate to pursue higher earnings to help pay for medical expenses. The findings of this review have important implications for programs and policies aiming to promote the mental health of older adults.
Targeting social security for the elderly left behind could enhance the feeling of security and support, thereby improving metal health and well-being [ ]. Given the higher prevalence of physical illnesses and chronic diseases among the left behind elderly and its association with mental disorders, it is recommended to consider this risk group in health service delivery.
The health care delivery system in low-income countries is inadequate to meet the mental health needs of older people [ — ] resulting in a range of unmet emotional and physical needs among the older adults left behind. Programs to extend emotional intimacy between older parents and their migrant children are required, with intergenerational relationships and translational care particularly important in reducing risk of mental illnesses among the older adults. Zechner [ ] enlisted the three basic elements of transnational care: distance, resources and circumstances.
Attention should be paid to the social policies involved in care-related activities. Migrant children can provide emotional support or may organize the care needs of the older parent s with someone who lives close by [ ]. Certainly, the availability of social media and communication technologies provides opportunities for more active communication and interaction within the family irrespective of geographical location. Consideration should be given to training community health workers and field workers in identifying older adults who are at risk, connecting to community resources to those who are at risk and counselling families to better support close family relationships.
Efforts to lower the prevalence of mental health disorders in the left behind elderly should target those at particular risk. Special attention should be given to the elderly who are unmarried or widowed, have lower education, poorer socioeconomic background, older, living in rural areas and with chronic disease.
Finally, physical activity plays an important role to offset the negative influence of an empty nest on health and well-being. A greater focus on the importance of physical activity levels by both professionals and volunteers [ ] may promote and support physical activities for the left behind elderly. A number of implications for future studies for the mental health of left behind elderly arise from this review.
Family support plays a pivotal role in determining the psychological well-being of the older parents. While the migration of the younger generation is unavoidable in many societies, its effect is often to undermine traditional care and support structures for older parents. Hence more research is required to address care and support needs from friends, neighbours and other community based organizations.
Such studies should also examine the effects of different types of social support to improve the mental health status among older adults left behind. The issue of transnational care; care giving across political and geographical spaces, is not well recognized in gerontology [ , , ]. Future studies are required to identify effective transnational care provision.
Well-designed studies are also required to identify additional factors related to mental health among the left behind elderly, as this review did not identify the effect of important risk factors such as remittances, frequency and intensity of the communication between parents and migrant children, purpose of migration, migrant receiving place or country, physical environment e. In particular, information technology and religious attendance are likely to have a positive effect on mental health and increased social relationships among the elderly [ ]. Future research could also compare systematic differences in the risk factors of mental health disorders between the left behind and non-left behind older adults.
Longitudinal studies are required to provide clarity on the direction of causality between migration of adult children and mental health of elderly parents left behind.
Striking a Balance
Apart from the longitudinal studies, a matched-control design with parents whose children emigrated with those with children living nearby would help to distinguish the empty nest component from the left behind. Qualitative studies are essential to understand diverse and complex sociocultural contexts. Local surveys and investigations will also inform local service needs. This review is not without limitations. Studies were diverse and often did not report prevalence of any aspects of mental health, nor the strength of association for each risk factor.
The high level of heterogeneity among the studies precluded meta-analysis. Results of the multivariate analyses might be convoluted by adjustments for different variables in different studies. Likewise, only the main effects of risk factors on mental health disorders were reviewed and as such, it is not clear whether the concurrent occurrence of multiple risk factors results in a synergistic increase in the risk. The studies included in this review did not always measure potential risk factors that could have affected the mental health of the left behind elderly and often only provided bivariate analyses, making it difficult to confirm the association between migration of adult children and the mental health of parents left behind under the influence of potential confounders.
In addition, risk factors for mental health disorders identified in this review are based on studies reporting risk factors from left behind elderly. Comparison of putative risk factors between left behind and non-left behind groups would be more informative. The review did not assess publication bias, with negative or non-significant results being less likely to be submitted and accepted for publication [ ].
Other limitations of this review include the search was limited to peer-review articles published in English with grey literature excluded. Many studies employed secondary analyses of large samples, which may have produced statistically significant results for effect sizes which are small, limiting the clinical significance of the results. Almost half of the studies included in this review are from China. This may reflect a general lack of research in other low-income countries, which is unfortunate given the potentially higher vulnerability of older people being left behind and psychological disorders [ ].
The key finding of this review is that being left behind is negatively associated with the mental health of older adults. Empty nesters were at higher risk of mental health disorders such as loss of cognitive function, depression, anxiety and loneliness. Elderly living with their children may receive better care, economic and emotional supports. The risk factors for mental disorders include marital status, income, education, physical health status, gender, age, family and social support, and physical exercise. This study synthesises the research related to mental health of the left behind elderly parents, thereby advancing our theoretical and empirical understanding of out-migration of adult children and its implication on psychological well-being of the parents.
Authorities and organizations working in the field of gerontology should be aware that the left behind elderly are at increased risk of mental health problems. More responsive preventive measures and effective management approaches are required for this cohort. More rigorous studies are required to identify the additional risk factors of mental health problems using clinically relevant instruments.
The first author would like to acknowledge the support provided by the University of Tasmania through the Tasmania Graduate Research Scholarship. Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field. Objectives To identify the association between the left behind or empty nest status and the mental health of older parents, and to identify common risk factors for poor mental health among those left behind.
Results 25 articles met the inclusion criteria. Conclusions This review synthesised the various studies related to the mental health of left behind parents, advancing the theoretical and empirical understanding of the implications of out-migration of adult children on the psychological health and well-being of older parents.
Introduction Over the past decade, there has been a significant increase in both international and internal migration rates. Objective of the review To identify the association between the left behind or empty nest status and the mental health of elderly parents and to identify the common risk factors for poor mental health among those left behind.
Materials and methods This integrative review considered research relating to the migration of children and the mental health of the left behind parents. Download: PPT. Table 2. Prevalence and mean scores of mental health measures. Table 3. Factors related to mental health among 'left behind' older people. Results of the review Study characteristics Twenty-three studies reported in 25 publications from six different countries were included. Measures of mental health A range of measures were used to assess mental health status with many using multiple measures. Cognitive impairment. Other general measures of mental health.
Factors related to mental health status among the left behind parents Gender. Economic status.