Family Support and Diminished Control in Older Adults: The Role of Proxy Control

Abstract

Diminished personal control over tasks and decisions in later life, shifted to caregiving kin or others, has been associated with negative psychosocial outcomes. This study employs qualitative interview data from older adults in assisted living to examine their accounts of how control was transferred to kin or quasi-kin, focusing on decisions by older kin to delegate tasks (proxy control). Narratives were searched for instances of transfer/loss of control; these instances were reviewed to determine if transfers used proxy control (i.e., transfer chosen by the older adult) and how this change was evaluated. While many transfer events were not fully described, among those with full information there was a clear connection between use of proxy transfer and a positive evaluation. Proxy control shows promise as a strategy to minimize negative outcomes from age-related loss of control and warrants further study.

INTRODUCTION

This paper proposes a potentially-important and under-researched linkage between two developed research literatures, the first on family care for older adults and the second on loss of control with advanced age. First, the topic of personal control carries a rich history in aging research, under many names and conceptual constructions (Pearlin, Lieberman, Menaghan & Mullan, 1981; Skinner, 1996; Smith, Kohn, Savage-Stevens, Finch, Ingate & Lim, 2000). Discussion of control, mastery, autonomy, agency, self-efficacy and age-related threats to them has flourished for decades in both sociological and psychological research (Heckhausen & Schulz, 1995; Skinner, 1996). This literature establishes associations between one’s personal sense of control and negative life events (Cairney & Krause, 2008), functional and physical health statuses or their change (Mendes de Leon, Seeman, Baker, Richardson, & Tinetti, 2004; Rodin, 1986; Seeman & Lewis, 1995); and psychological well-being (Avison & Cariney, 2003; Heckhausen & Schulz, 1995; Pearlin et al., 1981), among other important variables. This literature concludes that a continuing sense of personal control, reflecting its strong value in Western cultures, is pivotal to well-being as people age (Heckhausen & Schulz, 1995). Age-related loss of control or mastery is also well-established in the literature, although proposed causes (e.g., negative life events, cognitive challenges and health problems) and direction of causation remain under investigation (Cariney & Krause 2008; Rodin 1986; Schulz, Wrosch & Heckhausen 2003; Wolinsky, Wyrwich, Babu, Kroenke. & Tierney, 2003).

Second, decades of literature demonstrate consistently that family members provide significant assistance to older kin and are at the top of the hierarchy of informal care providers (Horowitz, 1985; Pinquart & Sorensen, 2005; Robinson, Fortinsky, Kleppinger, Shugrue & Porter, 2009; Stone, Cafferata and Sangl, 1987). Age-related changes in physical and cognitive abilities are associated with increased family assistance, often requiring others to take on the responsibility for daily tasks formerly under the control of the older relative, such as managing finances or legal matters, household duties, and health care. In some instances, family members must make choices during emergencies if their relative is unable to do so, such as selection of a setting for rehabilitation following surgery (Frank, 2002). The family caregiving research has indirectly considered the older person’s loss of control when kin step in to undertake tasks in response to physical or cognitive limitations. Loss of control is clearly reflected in long-established family caregiving concepts such as role reversal (Arling, 1976; Glasser & Glasser 1962; Matthews, 2002) and learned dependency, each of which involves the largely unwanted transfer of control to others (i.e., family caregivers, health care personnel) pursuant to real or perceived reduction in the older person’s capacities to manage these tasks of daily life (Baltes & Carstensen, 1999; Baltes & Wahl, 1996). The attention to diminished control in the caregiving literature is limited, however, since most of that research focuses on positive and negative outcomes in the care provider, rather than those pertaining to the recipient of care (Martire, Schulz, Wrosch, & Newsom, 2003; Robinson et al., 2009).

The limited findings on care recipients are somewhat mixed with regard to personal control. On the one hand, family care providers have a uniquely deep and nuanced knowledge of their older relative’s needs and preference, making them well-suited to make choices reflecting the recipient’s preferences (Collins & Smyer, 2007; Wolff & Agree, 2004). However, receipt of instrumental support from kin has been associated with threats to recipient psychological well-being (Krause, 1997). Other research describes resistance to and conflict arising from caregiving situations when kin assume control that the older relative is not prepared to relinquish, (Clark & Stephens, 1996; Matthews, 2002; Pruchno, Burant & Peters, 1997), when dependency results in violations of the norm of reciprocity, when care involves negative interpersonal interactions (Rook, 1984; Wolff & Agree, 2004), or when care relationships lack respect and responsiveness to the wishes of the older person (Wolff & Agree, 2004).

Conceptual Perspectives: Proxy Control as a Linkage

While the control/mastery literature focuses on negative outcomes associated with diminished personal control in later life, the concept of proxy control, conceptually linked with the Selective Optimization with Compensation (SOC) perspective, provides an alternative view of possible consequences following transfers of control (Baltes & Baltes, 1990: Bandura, 1986; Hyer & Intrieri, 2007). In the SOC perspective compensation becomes operative when older adults, for example, select alternative means to accomplish goals, such as actively deciding to delegate control over particular tasks to others.

Among the numerous control concepts in the literature, proxy control provides promise as a mechanism to link the process through which older adults actively delegate tasks to family members (or quasi-kin) with neutral or positive outcomes, rather than the typical negative outcomes discussed with diminished personal control. “Proxy control is a socially mediated form of perceived control that involves the relinquishment of all or some personal control to an intermediary to help achieve specific desired outcomes” (Bray, Gyurcsik, Culos-Reed, Dawson, & Martin, 2001). Granting proxy control both avoids the demands of completing a task oneself and diminishes downside risks of failing to meet such a delegated goal (Antonovsky, 1979; Bandura, 1986). When proxies fail to follow the wishes of the individuals granting them control, their actions may, however, result in negative consequences, such as undermining confidence or demoralizing the granter (Bandura, 1986). Proxy control has not been broadly applied to elder/kin relationships, but has been used in varied studies of consumer behavior, rehabilitation following sports injury, and charismatic political leaders (Dawson & Laurier, 2005; Madsen & Snow, 1991; Namasivayam, 2004), among other topics. Some interpretations of the traits of proxies suggest they need to hold recognized social power or expert knowledge, while others expect only that the proxy have sufficient skill, knowledge or energy to achieve the task delegated to them (Bray et al., 2001, Smith et al., 2000; Yamaguchi, 2001).

Thus, the logic of proxy control suggests that an older adult who actively chooses to turn over management of her finances, for example, to a relative or close friend, rather than having been forced to do so, may minimize or escape negative consequences typically associated with age-related decline in control (Bandura 1977; Smith et al. 2000). In a study employing a related concept, Smith and colleagues found that use of interpersonal agency (i.e., shared control) was correlated with both higher perceived primary control and psychological well-being in a sample of adults (Smith et al., 2000). Smith and associates further conclude that individuals’ strategies for acting through others to achieve their goals have been largely ignored in the caregiving literature.

To examine this connection further, we present narrative data from interviews with older adults residing in assisted living (AL) settings, focusing on descriptions of the transfer of tasks to kin or quasi-kin. Exercise of proxy control to cope with physical, social or cognitive challenges facing them would be evidenced by statements of active choice or decision to transfer tasks. If so, descriptions of these transfers should include neutral or positive reactions, rather than statements of stress, resentment or anger. Given that selection of the AL setting often occurs when older relatives are receiving inpatient medical treatment or rehabilitation, family or quasi-kin often select the AL setting with limited input from the older relative (Frank 2002). As a consequence of this structural barrier to active involvement, we focus most of our attention on tasks other than those specifically relating to selection of and entry into the assisted living setting.

We include discussion of quasi-kin in our sample. By quasi-kin, we mean individuals with long-standing relationships who undertake tasks typically reserved for family or are described as “like family” by the interviewee. An exemplar is Ms. Brubaker, who, despite having three biological children, prefers that her care in AL be directed by her fictive “niece” Nicole, whose mother was Ms. Brubaker’s best friend.

RESEARCH DESIGN AND METHODS

The data for this analysis come from a larger study, “Stakeholders’ Models of Quality in Assisted Living,” led by the first author. The goal of the overall study was to provide a grounded understanding of the criteria upon which the varied participants in assisted living settings, in particular older adults residing there, make their judgments of quality of daily life there. The analysis here examines selected narrative identified as relevant from the interviews with residents (N=77) living in seven assisted living settings in Maryland. Most of those interviewed were cognitively able to respond to open-ended questions. Given the high rates of cognitive impairment in AL settings (Magsi & Malloy, 2005; Sloane, Zimmerman, Gruber-Baldini, Hebel, Magaziner & Konrad, 2005), we attempted interviews with residents identified by providers and staff as having mild to moderate cognitive limitations in the study; not all of those interviews were highly successful. The study also interviewed family members, direct care staff and administrators (N=109 in total); family interviews were examined for this analysis only to clarify our understanding of task transfers events described by residents.

AL settings were purposefully selected to reflect diversity in size, ownership (chain/independent), for- or non-profit status, religious/non-religious affiliation, urban/rural locale, and the race/ethnicity and socioeconomic status of residents; this provides a broad base of resident experience. Table 1 provides descriptive data on the seven settings, employing AL pseudonyms. Participating assisted living settings received an honorarium of $2500 to be used to benefit those who reside there. Residents participating in interviews were demographically similar to samples in prior studies, being predominantly female (70.1%), white (85.7%) and well-educated (28% had a college degree or more). Ages ranged from 59–99, with a median of 85, and 14.3% of the sample self-reported ADL limitations in 3 or more of 6 listed tasks (Hawes, Rose and Phillips, 1999; Morgan, Gruber-Baldini and Magaziner, 2001).

Table 1.

Characteristics of AL Settings Participating in the Study

Pseudonym	Beds	Chain	Profit	Locale	Religious	% Non-White
Boxwood Gardens	104	Yes	For-Profit	Suburban	No	14
St. Brigid	18	No	Non-Profit	Suburban	Yes	10
Murray Hills	36	No	For-Profit	Rural	No	0
Wetherby Place	48	Yes	For-Profit	Suburban	Yes	3
Greenbriar	92	Yes	For-Profit	Suburban	No	75
Arcadia Springs	45	No	For-Profit	Suburban	No	9
Winter Hills	75	Yes	For-Profit	Rural	No	0

Data Collection and Processing

Once access to a setting was granted and participants informed of our study, project interviewers approached individual residents and gained taped verbal consent. Semi-structured interviews, which ranged from 20–120 minutes and were typically conducted in residents’ rooms or suites, covered a wide array of questions. Most interviews were audio recorded and transcribed. In the few cases of refusal to record, extensive notes were taken. Interviews included questions intended to identify elements important to everyday life in AL that provided the basis for respondents’ evaluations of quality. Questions asked, for example, what made for a good day or bad day, which elements of the current setting they would keep or change if they were in charge, or what advice they would give to someone seeking a good AL setting.

Interviews or interviewer notes were entered into an Atlas.ti database (Muhr, 2008). This software has a broad capacity to search, associate, and assist in testing linkages between concepts in the large narrative database generated by this project. Development of coding categories was a detailed and critical task, beginning with reading initial interviews by all members of the research team. Bimonthly meetings to discuss emerging concepts led to preliminary codes, which were further refined by additional reading, and re-tested through ongoing coding review. Once the code list was established, coding was completed by rotating, two-person teams to enhance coding reliability. Team members first coded items individually and then met to reconcile their results. Questions and unresolved issues relating to coding were brought back for discussion at team meetings throughout the data collection process.

Analysis

The analysis of resident interviews for this paper involved two steps. The first step involved identifying text quotes discussing the transfer of control of one or more specific tasks to a relative or another person acting in a quasi-kin role. For this step, we searched all resident interviews on two codes closely aligned to our research goals, “kin support” and “keep/delegate control,” as well as conducting word searches for “take care” or “taking care.” These combined search strategies resulted in an array of overlapping quotations, sometimes with multiple quotes from a single participant.

The authors reviewed the narrative material to select quotes from these broader coding topics, focusing on instances where control had been turned over to or taken by kin or quasi kin. The resulting set of quotations (N=26 resident interviews) meeting our criteria included residents from all seven AL settings. Once we identified the relevant quotations, in the second analytic step both authors reviewed of the narratives independently to assess: 1) whether the older person interviewed transferred control to the other person (proxy control), if the other took the control, or if the transfer process was unclear; and 2) whether the older adult’s reaction to this transfer of control was described positively, negatively, or was unstated, neutral or ambiguous. The authors subsequently met to discuss and reconcile evaluations of the selected quotations, sometimes reading or listening to full resident interviews or those of their relatives if there was uncertainty as to how each quotation should be rated. If the authors were still in doubt after these steps, we categorized the quotes conservatively, as “transfer process unclear” or “reaction unstated, neutral or ambiguous.”

RESULTS

General Orientations to Reduced Control

Not surprisingly, interviews often touched upon how the challenges of age or diminished health altered the respondents’ accustomed or preferred patterns of control, as exercised in earlier years. Those interviewed varied in the degree to which they acknowledged and accepted their current constraints in the exercise of control. Martha. St John showed a mixed pattern when she first told us “I’m completely independent ….I’m one of the few [at Boxwood Gardens] that is,” proudly recounting all the tasks she did for herself on a daily basis. But later she admitted, “I do need help, too – because I don’t have stamina and I tire very easily.” For Ms. Larson, in contrast, giving up her house to move to AL was “a case of necessity as far as I was concerned. Because I couldn’t stay by myself and I didn’t want to go live with any of my children.” The wish to avoid living with children, voiced by several people, was not necessarily indicative of strained relationships and may, in fact, have represented an exercise of control. For example, Carole Issacs said, “I’ll stay here [Winter Hills] as long as I can, because my daughter wouldn’t want me, and my son wouldn’t want me. And I don’t want them. I mean I love them dearly, and they love me - but I don’t want to go live with them, I don’t want that. I had that experience with my own family. My [father-in-law] came to live with us for a short while, and …I was the most unhappy person.”

A number of our respondents were quite proactive in their planning for their later lives. Calvin Epworth, when asked whether granting Power of Attorney to his sister-in-law was his choice said, “Oh, yes. I talked to a lawyer about it. I said, I can’t drive - I can’t drive my car. I’ve got a house - I can’t go back to the house, can’t walk up and down the steps, so I’ve got to turn it over to somebody. And she’s [sister-in-law] good - I’ve known her since she was 14 years old.” In contrast, Ms. Spivey at Arcadia Springs was less accepting, stating “I’m plenty old, but I guess I just can’t catch up to my age.” Having been a single working mother, she deeply missed having a car, going out with friends, and controlling her own money. In short, the issue of control or its loss, was on the minds of many AL residents interviewed.

Transfers of Control

Proxy control transfers

In seven interviews we found descriptions of active delegation of task responsibility to kin or quasi-kin (proxy control); in six of these instances the evaluation of this transfer of control was paired with a positive reaction by the interviewee. Only one description of a proxy control transfer was unclear/ambiguous as to the interviewee’s evaluation. Notably, none of the proxy transfer episodes described to us in interviews was paired with a negative evaluation. Examples of the proxy/positive combination included the opinionated Ms. Carson. She told us that living with her more proximate daughter would not be an option. “My daughter tells me she has her own life to live.” Nonetheless, she delegated control of her finances to another daughter, living out of state. “So anyway, I’m in here and I turned over all the paying to my daughter and I know it’s over $4,000, but I’m not sure how much it is - a month. And I think that’s high - but well, I never had a high salary myself and so that’s more than I get per month. So I said, I can’t - I can’t fathom this, I can’t manage it - I gave it to my daughter because she’s a CPA. Let her figure out how you can spend more than you’re making.” Ms. Carson was content that her daughter would work out the challenging details.

Another positive evaluation of proxy control came from Mrs. Wyler, who never had children but had numerous (in her words) “adopted granddaughters” from her years of teaching. These “girls,” now in their 50s, assisted her in relocating to AL by disposing of surplus furniture and moving things into her suite. Her gratitude was clear in the interview. Mrs. Wyler also relied on a long-time friend to handle her finances. “The man with the Power of Attorney….was a friend of my husband’s since they were boys. And they were our friends and I trust him with my life. And he asked me - he didn’t do it on his own, he asked me about it. There was no one else I would have wanted to do it. And he checks with me; he never pays a bill that he doesn’t check with me first. The end of the year he gives me a complete account….of what I had in the bank at the beginning of the year, what came in, what goes out a month, what I have at the end of the year. I get that all given to me every year. That’s how conscientious he is, so I don’t have to be afraid….God has been too good to me.” Not only has Mrs. Wyler selected her proxy for finances, but he provides her a sense of ongoing involvement.

Mrs. Gentile chose to rely on friends rather than her children to sustain her sense of control over her life in AL. In affirming this self-described independence, she said (with a grin), “The day that my children tell me what I’m going to do - they are out of the will!…I don’t ever expect that my children will have any control over my life.” Instead, she relies on former neighbors to meet her needs, including one she described as her “personal shopper.” A fourth person still very much in control of aspects of her life at the Greenbriar, was Ms. Jacobs. On the day of our interview, she was preparing her “Irish temper” for a battle with the management over a proposed increase in fees. She told us that all of her relatives except one frail brother were “six feet under.” She instead relied on two of her friends, who are, “like family members.” They alternate in taking her to medical appointments or the hairdresser, tasks often undertaken by kin. Both friends were been added as signatories to Ms. Jacobs’ checking account many years ago. When there were tasks Ms Jacobs could not complete herself, her two friends undertook them, acting with her blessing and appreciation.

Non-Proxy Transfers of Control

Of the selected interviews, ten reflected transfers of control described to us as neither chosen nor desired by the older adult. Based on their descriptions, we classify these as non-proxy transfers of control. Among these ten interviews, seven included commentary that was negative regarding this change, two respondents were positive, and one was unclear/ambiguous. Clearly the preponderance of those whose control over aspects of their daily lives had, in their view, been taken from them said that this was not a preferred or acceptable circumstance. Three examples below clearly demonstrate this pattern.

One non-proxy transition involves Rich and Kathy Moyer, a married couple of professionals in their 60’s, who were moved from their home after both showed signs of cognitive/memory problems. After concerns arose about their ability to live independently, Kathy’s “very best friend from the age of 13,” Linda, was designated her Power of Attorney (POA). This occurred after Linda had, according to Kathy, “hammered me into signing” the documents. According to Kathy, Linda “took over their life,” and disposed of their belongings and their house. She placed them first in one AL and then later moved the couple into Boxwood Gardens, where our interview took place. Rich was also talked into designating Linda’s husband as his POA. Kathy, in this untaped interview, described her current life as a “hell hole,” after giving up control to Linda. Trained as a nurse, Linda and her husband felt they knew what was best for the Moyers; they seldom visited them but exercised extensive control, including forbidding them to take walks off the AL campus or go out to dinner with their friends. When interviewed, the couple was working toward revoking the Power of Attorney designations to regain control over their lives and funds. Clearly this transfer was neither desired nor positively viewed by Rich and Kathy.

Bruce Goddin had been living in an apartment as his health declined, getting some assistance from a woman who lived with him. He described her as having a drug problem and stealing from him to support her habit. Mr. Goddin’s daughter, despite having been abandoned by both of her parents at age 11 along with her two siblings, nonetheless took action when she learned her father was in a rehabilitation center after being hospitalized. According to Mr. Goddin’s description of events, she took over his life and moved him to Arcadia Springs without his knowledge or consent. According to Mr. Goddin, his youngest daughter, “…tore my apartment apart and took the furniture out of it and give it up while I was down at [a rehabilitation center].” He continued, “She took over everything I have,” including his beloved automobile. The daughter now has Power of Attorney, and, much to his frustration, control of his bank accounts. He added, “I have a bank over on Bloomfield Road with $1,000 in. [She] drew it out, closed it out. Just like my wife did one time. …..No, she ain’t spending the money on me - she’s got a house down there and a husband.” His sense of losing control was extensive in the interview. However, Mr. Goddin’s daughter described him as both illiterate and suffering from memory problems, and consequently confused about the events surrounding his move to AL.

Our third example comes from Ms. Volbrecht, who began on a clearly negative note by telling us, that in her move to AL that her son drove the decision-making. “My son wanted me to live here….He made it [the decision] for me. I agreed.” His control continued after she settled in. “My son takes care of all my financial…..and he don’t give me any money.” She went on to inform us that she was a smoker, but that her smoking was constrained by both her son and the rules at Boxwood Gardens. Her son’s strictness with money was because, “he’s afraid I’ll buy cigarettes with it,” but it also kept her from being able to go on AL outings. When asked how she got her cigarettes, she replied that her son brought them to the AL for her, but that she was not able to have free access to them. Instead, she said, “[T]hey keep them in the medicine room.” Her daily routine was driven by this rule. She elaborated, “I get 6 a day….I get one at 6:00 o’clock, one after breakfast, one after lunch, one at 3:00 o’clock, one after dinner and one at 7:00.” Ms. Volbrecht, who had reluctantly adapted to the regimen to receive her cigarettes, was planning at the time of our interview to move to another, smaller AL setting along with a male friend, hoping for lower cost.

While most of the non-proxy transfers of control were evaluated negatively, there were two instances where positive evaluative statements were made about these transfers of control. One was Mr. Leland, who had been deeply disappointed at never having had children during his marriage. A widower, he relied heavily on his younger brother. Mr. Leland’s brother had, in his view, been the force behind his initial move into one AL; he subsequently relocated Mr. Leland to St. Brigid’s, when he “enticed me to leave” the first place. Despite expressing displeasure with the small size of his living space at St. Brigid’s, Mr. Leland clearly valued the ongoing support of his brother, who continued to take care of many things on his behalf. “[T]hank God that one brother takes care of me - if he didn’t I wouldn’t have that. That’s all I got you know to live for, [if] you put it that way. And if he weren’t doing it - I wouldn’t have anything - you know. You appreciate that he’s giving his time and energy and all the help.”

Unclear/Ambiguous Transfers of Control

Among the quotations we analyzed, approximately one third were unclear as to whether the control over a task had been delegated by the interviewee (proxy control) or taken by others. Interviews simply did not provide sufficient detail to determine whether this transfer of control was initiated by those we interviewed, the relative/other, as a joint decision, or arose from a recommendation from a professional, such as a physician or care manager. Examples include Marge Tunney, who told us her daughter takes care of everything related to her care at Murray Ridge. She said that if she wasn’t “treated right, or didn’t like it, my daughter would move me.” Clearly the quote suggests her daughter is in control, but does not explain how this came to be the case.

When we reviewed how these unclear control transfers were evaluated, we found that most also received unclear/ambiguous (5) or positive (3) evaluations. Among the unclear evaluations was Mary Knapp, who reported that her son manages her finances. “My son - he writes the checks. I did when I was home, but he does now….I think I have to pay a little more than Social Security [for AL fees]. I don’t know just how much; they take care of that.” Only one unclear transfer of control quote had a clearly negative evaluation attached. That a relatively large number of transfer events were unclear in terms of process is perhaps not surprising, given that interviews were not specifically designed to delve into transfers of control, and social desirability norms may constrain negative commentaries about control that was unwillingly lost.

DISCUSSION

The literature on diminished personal control in older adults suggests that it is associated with negative psycho-social outcomes, such as diminished sense of efficacy and psychological well-being. While the autonomy/control literature has not been integrated with the extensive literature on family caregiving, our focus here has been on drawing a connection between the two by an exploration of the concept of proxy control. In particular, we focus on the tasks undertaken by kin or quasi-kin on behalf of older adults residing in assisted living settings, whose residency in these settings is typically prompted by significant physical or cognitive challenges to living independently. Linking these two literatures via the concept of proxy control provides insights into the potential importance of the interpersonal processes involved in shifting task control to others in later life.

Narratives of 26 AL residents described transfers of control to others, primarily family but inclusive of quasi-kin. Although many interviews lacked details on how this transition occurred, the narratives that provided more detail suggest that older adults who described undertaking active delegation of tasks to kin/quasi kin (i.e., used proxy control) also provided positive evaluative statements about this transfer of control in our interviews. In contrast, control that was described as “taken” by others was predominantly discussed negatively by those we interviewed. In short, the active delegation of tasks to a proxy may serve to moderate negative outcomes of diminished control, a result that provides limited support for the concept of proxy control.

Findings here also support aspects of the care recipient literature in that not all informal assistance offered or provided by kin or quasi-kin was accepted or welcomed by older adults. Given our cultural emphasis on control and autonomy, it is not surprising that many we interviewed resisted handing over responsibilities of adulthood to others, despite possible difficulties in completing the tasks successfully themselves. Well-intentioned actions, such as those taken by Mr. Goddin’s daughter to remove him from a living environment no longer suited to his capacities and from an unreliable female companion, remained clearly a source of continuing intergenerational tensions. Despite the likelihood that objective others might have viewed Mr. Goddin’s living situation as precarious, in his view the daughter’s actions reflected none of his preferences; he neither recalled being asked about or informed of her choices to take financial control and relocate him to assisted living.

Families and aging professionals are often challenged in supporting a subjective sense of control when older adults face growing physical or cognitive limitations. Enabling choice and control is particularly challenging for instances of cognitive impairment, where input into a choice or making a decision may not be remembered later. As older adults accumulate limitations, it becomes easier for more powerful others to take control over various aspects of their lives “for their own good.” Family members and health professionals, for example, may unintentionally disempower older patients by speaking to each other, even if cognitive impairment is not an issue (Adelman, Greene & Charon, 1987). Walking a fine line between “role reversal” and “providing support,” family members sometimes feel compelled to take control of tasks, such as “taking away the car keys” from a parent with physical or cognitive problems, to ensure safety on the road.

Limitations

Several limitations to this research derive from the fact that the issue of control arose serendipitously and was not among the study’s primary aims. In particular, we did not systematically observe or ask detailed questions regarding control transfer process experienced by those in our sample. Instances were, instead, brought up as part of their stories of how they came to reside in assisted living settings or in general life history information. Consequently, we lack detail on when and how control transfers occurred and whether they might have involved purposeful selection of a proxy relative or close friend. In most cases we also lacked a sense of the respondent’s reaction to changes in control or their prior orientation to control during adulthood. However, other respondents were extremely clear and expressive on these points. Norms of social desirability may also have constrained respondents from speaking frankly about unwelcome challenges to their control, to save face for themselves or close kin. Since narratives were not systematically sought, our interviews may also selectively represent families where relationships were already either particularly strong or significantly troubled well before age-related changes reactivated parent/child bonds.

In addition, some of those we interviewed evidenced some degree of cognitive impairment, which may influence how or whether they recalled details of these changes in their lives. A full evaluation of proxy control would also require the structured examination of outcomes such as psychological well-being or self-efficacy, which were not included in our study’s design. Our reliance upon evaluative reactions provides only a suggestive association that may be reflected in these more detailed measures typically employed in the control/efficacy literature. Consequently, it is not possible to provide a strong test of the proxy control concept’s influence on subjective sense of control and psychological well-being from these data. While we were not able to verify their all of these accounts of transfers of control, respondents’ contemporary perceptions of and reactions to these events are, nonetheless, informative and important.

In this article we chose not to address overall change in control, which may include control that is granted to or taken by other professionals (e.g., doctors or judges) or by the assisted living setting or its staff through their rules and procedures. A study that included all of these aspects, as well as use of proxy control, would provide a broader picture of diminished control in later life and its consequences. Further research, particularly studies designed to examine proxy control more directly, should be able to more thoroughly test the use of proxy control and its consequences for well-being for older adults and their kin or quasi-kin care providers.

Implications

The concept of proxy control serves as a potential linkage between the caregiving and control literatures on older adults, since most of those who undertake tasks adults facing age-related physical or cognitive challenges, whether residing in the community, assisted living or a nursing home, are kin or close others, such as long-time friends. Findings here suggest that the process through which tasks are transferred to these others, and in particular the active role of the older person in deciding to undertake such transfers, is potentially important to the outcomes that follow. A simple statement that “My daughter takes care of that for me,” may indicate an active delegation of responsibility, such as Ms. Carson’s reliance on her CPA daughter to handle her finances. Both family members and family practitioners working with intergenerational care may also find proxy control useful as a technique in some of the tense decision-making involving older relatives, if further research verifies its linkages to psycho-social outcomes.

Second, the suggestive findings here support further research attention to the concept of proxy control. Additional research, designed specifically for this purpose, is clearly needed to provide explicit tests of the current and potential use proxy control as a strategy in age-related adaptation. Ideally such studies would include retrospective questioning of both older adults and their kin or quasi-kin supporters to identify how and by whom task transfer decisions were made (and whether there is consensus on this point), as well as evaluation of a broad array of outcomes including personal (efficacy, psychological well-being) and interpersonal (relationship quality) outcomes. Given possible variations in norms of familial interdependence (e.g., gender, cohort, socioeconomic) that might render transfers of task control to kin or quasi-kin more or less potentially stressful; thus, samples more diverse than the one used here are also warranted. In brief, the research on effects of control or autonomy in later life should expand beyond simply evaluating whether control is maintained or diminished to include specifics of process regarding how tasks are transferred to others.