The aging of the world’s population has increasingly called on family members to be full-time caregivers for their disabled elderly relatives.1 Doing so may cause these caregivers to suffer medical and emotional problems that reflect the tension between the demands of caregiving and other personal obligations. The tension particularly affects members of the so-called “sandwich generation,” who must take care of elderly parents while they are also raising young children. The dual caregiving experience of the sandwich generation is universal, as it cuts across different cultures and social classes and may well be considered a new syndrome emerging from the demographic changes of the last 50 years. Health care providers will be challenged by the unprecedented rate at which the number of elderly patients is increasing. Medical and nursing students must learn to care for elderly patients with chronic illnesses and non-disease-specific complaints.2 Additional support from patients’ families is both cost-effective and “human-effective,” but to ensure the well-being of these caregivers, the physical and psychological consequences of caregiving need to be satisfactorily included in medical school curricula.
I propose an eponym that encompasses all burdens and rewards of the dilemma of the sandwich generation and that is inspired by an ancient Greco-Roman myth. During a recent visit to the “Raffaello’s Stanze” in the Vatican Museums, I found “L’incendio di Borgo” to be most reflective of the dilemma of modern caregiving. In this painting, Aeneas flees Troy carrying his aging father on his shoulders and guiding his young son by his side. Thus, I propose to name this syndrome “the Aeneas syndrome.”
The son of the Trojan hero Anchises and the goddess Venus, Aeneas fought to defend Troy. When Troy was defeated, Aeneas fled the destroyed city with a few survivors and took to the sea. After a number of epic adventures he landed in the coast of Italy, and according to the legend narrated in Virgil’s Aeneid, the descendents of his son Ascanius are credited with the founding of Rome.
Raphael’s painting sends a powerful message about conciliating the competing demands of caregiving. The disabled father represents Aeneas’ past glory and foreshadows the future glory of his son—the foundation of the Eternal City. As a caregiver, Aeneas has cemented past and future, solidifying the continuity of history. Had he dropped the burden of his father, Aeneas would have dropped the foundation of his descendants’ future glory. At the same time, the consciousness of this destiny gave to Aeneas the strength to carry his disabled father in spite of the physical burden. Likewise, the excitement of his child’s growth and future enables Aeneas as a caregiver to recognize the persistence of meaning in a life that is fading. The elderly patient, a challenging and common patient in our time, allows the medical professional to perceive the persistence of the human spirit in a broken body. It is this human perseverance that calls for unreserved comprehensive care regardless of age.
Traditionally, most caregivers are women, though more and more men are sharing this conflict between the demands of care and personal development. But even individuals who decide to forgo a profession to care for their family may reach an emotional breaking point including burnout, depression, and medical illness.3 It has been shown that caregivers are less likely to engage in preventive health behaviors, have decrements in immunity measures compared with controls, exhibit greater cardiovascular reactivity, and experience slow wound healing. Emotional and logistic problems of caregiving are often complicated by financial burden. Most people enter retirement with modest savings, uncertain of how they will afford the routine costs of living, let alone catastrophic health care costs. Money spent on the care of the elderly may be subtracted from what can be spent on the children.
It may seem clear that the care of vulnerable and defenseless children should have priority over the care of frail elders. Yet the care of the younger generation is intertwined with that of the older one, to the point that child development is molded in part by the quality of care the elderly receive. Children may model their own caring behavior on how they observe their parents caring for older people. In particular, children learn to appreciate the value of all human lives, of personal commitment, and of sacrifice that is the foundation of human relationships. Derived from the Latin sacrum facere, “to sacrifice” means to make something or someone “hallowed,” reserved for a specific function that only that person can accomplish.4 Thus, in sacrifice children learn to appreciate their own sacredness, understanding that each person is endowed with unique talents that enable him or her to provide a unique contribution to the welfare of the human consortium. Our elders embody our history: We cannot disown them without disowning ourselves. Disregarding the elderly is tantamount to cutting off the roots of a tree. Abandonment or neglect of our elders cannot help being interpreted as abandonment and neglect of ourselves by children who witness it. The care of the elderly, thus, may represent the ultimate instrument for engrafting meaning into our children’s lives.
Realistically, the burden of taking care of growing children and withering adults may become overwhelming. Yet, as in the case of Aeneas, this burden represents one of the most critical challenges of human life, the lasting contribution to history. If we break under the weight of the challenge, the continuity of the human race will also break.
Ligia J. Dominguez, MD
Dr. Dominguez is assistant professor, Geriatric Unit, Department of Clinical Medicine and Emerging Pathologies, University of Palermo Medical School, Palermo, Italy.
1 Wolff JL, Kasper JD. Caregivers of frail elders: Updating a national profile. Gerontologist. 2006;46:344–356.
2 Tinetti ME, Fried T. The end of the disease era. Am J Med. 2004;116:179–185.
3 Schulz R, Beach SR. Care giving as a risk factor for mortality: The Caregiver Health Effects Study. JAMA. 1999;282:2215–2219.
4 Balducci L. And a time to die. J Med Person. September 2008;6:99–103.