The Sandwich Generation

Clare Bostock is a Geriatrician in Aberdeen.

I can’t believe that I hadn’t heard of the Sandwich Generation until I became a slice of meat squashed between two slices of bread. It was October 2019: my mother-in-law had sustained a large frontal lobe haemorrhage and my father-in-law was already living with Parkinson’s disease. Suddenly, neither of them could drive.

It was a friend who introduced me to the concept of being sandwiched between caring for children and older relatives at the same time, but the terminology coined by Miller in 1981 is nearly as old as me.

I was fortunate to grow up with three healthy, working grandparents. Later, my grandfathers each experienced a sudden catastrophic event (in their 70s and 80s) resulting in hospitalisation followed by death within a few days. As a child, I never felt like the bottom slice of bread. And by the time my grandmother developed dementia, I had left home and had children of my own. My mother, however, was bearing the brunt of the Club Sandwich: providing a significant amount of care so that Nan could live as independently as possible, whilst juggling work and looking after grandchildren.

There are countless informal carers, so why use special terminology for the Sandwich Generation? Well, I would argue that Sandwich Generation is preferable to  “women in the middle” coined by Brody, also in 1981. Brody does acknowledge sons and other male relatives, but concurs with Miller that the bulk of caring for ageing parents is filled by the females in the family. The Office for National Statistics reports that 62% of the sandwich carers are female.

I'm not the only one. There were over 1300 sandwich carers in the UK in 2016-7. I suspect this is a vast underestimate. The support that I have provided to my upper slice is only a taste compared with the care provided by the amazing family members that I meet during my day job. But I have a day job – one that demands care and compassion, and my bottom slice also demands my attention. I don’t want a ‘third job’, but neither do I want to give up work to care for the generation above. Does this make me selfish?

The Sandwich Generation share the realisation of their own ageing and loss of youth. I fear that in only 30 years' time I might be limited in my daily activities and in need of care. I am already aware of my dwindling senses. At a recent eye test, I was warned of impending presbyopia. My children can smell and hear things that I can't detect, and they have already started telling me what to do! I get a taste of an empty nest as my pre-teen daughter disappears to spend time with her friends rather than her parents. There is an expectation that, with time, our children become less in need of care, but our parents are moving in the opposite direction. Through working with older people with frailty, I do have a sense of what my future may hold. My professional role also gives me a sense of what I feel is expected, right and just. I was able to train full time with the support of my in-laws for childcare. Is now the time to give back?

When my friend welcomed me to the Sandwich Generation, I realised that I was not alone. In particular, I was not alone in feeling guilt and frustration in dealing with ageing parents. The journalist Carol Abaya dedicated her life to caring for her parents and helping others to understand the Sandwich Generation. Her tips, featured in a 1999 New York Times article are still relevant:

• Empower our parents as we do our children. Help them to retain their independence.
• Whatever is done and whatever decisions are made must be with the parent.
• Get help and protect your Self.

In addition, the Sandwich Generation need to protect their own relationships and mental health, especially with more than a quarter of sandwich carers reporting symptoms of mental ill-health.

The older generation in my family acknowledge that I have my own life and responsibilities. In Brody's 1981 study, grandmothers felt that their children should not do household tasks for their parents – rather, there should be government programmes or professional services. But anyone who has been involved in arranging care packages will know that these are usually for personal care and typically don't include household tasks. I am fortunate that everyone in my top slice can afford a cleaner!

I’ve looked after many people who are the upper slice of bread in a complex multigenerational sandwich. I love hearing about their lives and their families. I’ve met the most incredibly squeezed sandwich fillings, and I’ve listened to the stories of those who were too physically, emotionally or financially strained to continue. I try to empathise, and I have heard myself say something like “modern life is so busy” or “there are so many demands on us these days.” Describing their situation as a care sandwich may not make it any more palatable, but it could potentially help with signposting to support.

My sandwich has been far from onerous: I’ve accompanied older relatives to hospital appointments, given emotional support, made some meals for the freezer, organised online shopping... But the most striking thing for me, as stated by Abaya, is that no one is ever really prepared for such a role. What is clear is that I have only just dipped my knife into the butter of this complex and dynamic role. (Pun intended!)