The Consequences of Unmet Needs for Assistance With Daily Life Activities Among Older Adults: A Systematic Review

Abstract

Many older adults are experiencing unmet needs for assistance with the activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Such unmet needs might threaten their physical and psychosocial well-being. We conducted a systematic review to provide a comprehensive picture of the health consequences of unmet ADL/IADL needs among older adults. Twenty-eight published articles were included for qualitative synthesis. We found that unmet ADL/IADL needs were consistently associated with higher health care utilization (e.g., hospitalization, medical spending) and adverse psychosocial consequences (e.g., anxiety, depression), while the findings of falls and mortality remain inconsistent. More studies are needed to draw firm conclusions and to allow for quantitative synthesis. This review advocates for more coordinated and comprehensive long-term care services for older adults. Future studies should explore how the adverse health outcomes identified in this review can be prevented or improved by adequately meeting older adults’ needs for assistance.

Keywords

unmet needs insufficient help long-term care activities of daily living instrumental activities of daily living health consequence

Introduction

Older adults experience functional decline as they age. When they have significant function loss, they may need assistance with their activities of daily living (ADLs) and instrumental activities of daily living (IADLs). However, not all such assistance needs can be adequately met. Approximately 20% of older adults with ADL limitations report unmet needs for assistance with ADLs (Desai et al., 2001; Gibson & Verma, 2006; Newcomer et al., 2005). The rates of unmet IADL needs ranged from 7.1% (Andrade & Andrade, 2018) to 39% (Quail et al., 2011b).

Unmet ADL/IADL need is a combined result of the inadequacy of both formal care and informal care (Allen et al., 2014). In the current long-term care systems globally, there are some shared challenges in both formal and informal sectors. In the formal sector, the ballooning older population and their growing health demands are posing significant challenges to the health care systems (World Health Organization [WHO], 2015). Furthermore, the current health care systems are geared more toward the cure of acute conditions rather than addressing the complex health dynamics and long-term needs of older persons (WHO, 2015). Individuals’ coexisting health issues are, for instance, managed in disconnected and fragmented ways, with a lack of coordination across health professionals, and treatment levels and settings (WHO, 2017).

In all health care systems, the responsibility for providing long-term care for those in need falls predominantly on families (WHO, 2015), and yet the sustainability of the kind of long-term informal care they can provide is questionable for several reasons. First, the number of potential family caregivers is decreasing due to both declining fertility rates and women’s higher levels of participation in the labor market worldwide (International Labour Organization, 2018; Spillman & Pezzin, 2000; United Nations, 2022). Second, the help that informal caregivers are able to provide is often limited, and they were reported to experience physical, psychological, social, and financial burdens when meeting caregiving demands (Alshammari et al., 2017; Hopps et al., 2017; Taylor & Quesnel-Vallée, 2017). With the challenges associated with both formal and informal care of older adults, those who receive inadequate long-term services and supports and/or family care may suffer from unmet ADL/IADL needs (Allen et al., 2014).

Unmet ADL/IADL needs may be harmful to the health and well-being of older adults. Studies have found associations between unmet ADL/IADL needs and various health outcomes, such as more physician visits (Allen & Mor, 1997), higher fall rates (Marrero et al., 2019), and greater mortality (Zhen et al., 2015). However, there are great levels of heterogeneity among existing studies in terms of the regions and populations examined, study designs, and health outcomes found. Results are inconsistent between studies with different settings. A more systematic review is therefore required to gain a more thorough understanding of how unmet ADL/IADL needs impact different aspects of the health and well-being of older adults.

Conceptual Framework

This review was guided by Andersen’s Behavioral Model of Health Services Use, a comprehensive framework that elucidates the factors shaping individuals’ use of health services, taking into account individual and contextual determinants (Andersen, 1995). As exhibited in Figure 1, the model posits that predisposing factors, enabling factors, and need factors collectively influence individuals’ health behaviors, encompassing the components of “personal health practices” and “use of health services” (Andersen, 1995). Personal health practices recognize the interplay of personal behaviors (e.g., diet, exercise, self-care) and the utilization of health services in shaping health outcomes (Andersen, 1995). Despite most previous studies using the model focused on the use of formal health services, several studies have also applied it to assess the use of informal care (Kim & Kim, 2021; Willis et al., 2007). Furthermore, these health behaviors, in one pathway, can proceed to outcomes, including perceived health status, evaluated health status, and customer satisfaction (Andersen, 1995). In the other path, health behaviors can cyclically influence the contributing factors and subsequent behaviors and outcomes (Andersen, 1995).

In the context of this review, older adults have needs for assistance with ADLs/IADLs due to illness and impairment. Their responses involve performing personal health practices, utilizing informal care, and seeking formal health services (Porteous et al., 2015). When informal care and formal health services are inadequate, unmet ADL/IADL needs arise (Allen et al., 2014), which can in turn function as a need factor and further influence health behaviors and outcomes. Therefore, the consequences of unmet ADL/IADL needs are related to personal health practices, use of health services, and health outcomes. Despite facing unmet needs, individuals continue self-care practices. However, due to inadequate assistance, undesirable self-care consequences may occur, such as failing to maintain a diet and wearing soiled clothing (Allen & Mor, 1997; Porteous et al., 2015). The use of health services encompasses both informal and formal sectors, reflecting the health care seeking behavior when individuals face unmet ADL/IADL needs (Porteous et al., 2015). Health outcomes are also multidimensional as informed by the definition of health (WHO, 1946), including both physical and psychosocial health consequences.

New Contributions

Previous reviews related to unmet needs were mostly focused on populations with specific diseases, such as stroke survivors and persons with cancer, and provided overviews of the types of unmet needs among these patient groups (T. Wang et al., 2018; Zawawi et al., 2020). To our knowledge, this is the first review focusing on unmet needs among general older adults and exploring the consequences of these unmet needs. With the global aging population and increasing burdens of long-term care for older adults, it is important to understand the gap in current health care systems. The gap is not limited to unmet needs but includes a series of adverse health consequences caused by these unmet needs. Furthermore, this review will inform the potential benefits of better long-term care for older adults and lay the foundation for future research.

Method

Search Strategy

The systematic review was conducted following PRISMA guidelines (Moher et al., 2009). Six electronic databases were searched systematically, from the inception of each database to January 2022, including EMBASE, PubMed, CINAHL Plus, Web of Science, and two Chinese databases—Wan Fang Data, and China National Knowledge Infrastructure (CNKI). Four groups of keywords were used: (a) “unmet,” “undermet,” and “insufficient”; (b) “need,” “care,” “assistance,” and “help”; (c) “daily life activities,” “Activities of Daily Living,” “Instrumental Activities of Daily Living,” “functional status,” “disabled,” and “disability”; (d) “older,” “elderly,” “senior,” “aging,” and “aged.” While the keywords within each group were connected by “OR,” the four groups were linked by “AND.” In addition, reference lists of the included studies were searched manually.

To determine the eligibility of the studies, the inclusion criteria were (a) studies that reported the consequences of unmet needs for assistance with ADL/IADL; (b) any type of primary study (quantitative, qualitative, or mixed methods); (c) studies that included a sample or subsample of older adults aged over 60 years; and (d) studies in English or Chinese. Exclusion criteria were (a) studies in which unmet need was examined as an outcome rather than as a predictor; (b) studies regarding unmet needs in terms of aspects other than ADL/IADL; (c) studies examining unmet needs in multicomponents but in which unmet needs for ADL/IADL were not examined independently; and (d) case reports, books, theses, proceedings papers, conference articles comprising abstracts only, expert opinions, editorials, guidelines, policies, treatment recommendations, and other materials that did not include original data analysis.

After the systematic search, duplicated studies were identified and removed through reference management software (EndNote). According to the inclusion and exclusion criteria, titles and abstracts of the remaining studies were screened independently by two reviewers (H.J. and Q.X.) to identify potentially eligible studies, and the full texts of these studies were subsequently retrieved and screened. Disagreements were discussed and resolved by the third reviewer (C.P.H.).

Methodological Quality Assessment

The methodological quality of the included studies was assessed using the NIH Quality Assessment Tool for Observational, Cohort, and Cross-Sectional Studies (https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools), due to its suitability for observational studies with different study designs. This tool consists of 14 questions with Yes/No answers to guide reviewers to consider the key points when assessing a study’s internal validity. Each study was rated to be “good,” “fair,” or “poor” according to an overall consideration of the risk of potential for selection bias, information bias, measurement bias, or confounding. Studies regarded as “good” held the least risk of bias; a “fair” study could hold some bias but not to the extent that it could invalidate the study’s results; and a “poor” study holds a significant risk of bias, such that it should be excluded from the body of evidence. Quality assessment was conducted independently and in a blinded format by two authors (H.J. and Q.X.), and disagreements were independently settled by the third reviewer (C.P.H.).

Data Extraction and Analysis

Data were extracted from the studies and summarized in tables, detailing author, year, country/region, study design, sample description, the definition of unmet need, consequences of unmet needs, and the studies’ main findings. Due to the heterogeneity of study design and the way in which they report the consequences of unmet needs, the results of the review were synthesized narratively.

Results

Search History

A total of 7,960 studies were identified by searching the six databases. After removing duplicate studies, 7,245 records remained for screening, including two records that were added as a result of searching the reference lists manually. The screening of titles and abstracts excluded 7,174 records, leaving 71 studies for full-text reviewing. Following full-text review, 43 studies were excluded due to ineligibility: 14 studies concerned unmet needs for aspects other than assistance with ADLs/IADLs (e.g., unmet need for mental support), 11 studies examined multicomponent unmet needs in which unmet ADL/IADL needs were not examined separately, 14 studies examined unmet needs as an outcome rather than as a predictor, three studies were conference abstracts, and one study was published in the Korean language. This resulted in 28 studies included for quality appraisal and data extraction. Figure 2 is the PRISMA Flow Diagram that shows the searching, screening, and study selection process.

Study Characteristics

The characteristics of all included studies are summarized in Table 1. All studies were quantitative and published in English. The majority of the studies (19 studies) were conducted in the United States, three were conducted in Canada, two in mainland China, one in England, one in Italy, one in Malaysia, and one in Taiwan.

Table 1.

Characteristics of the Included Studies (n = 28).

Citation/region/design	Population/sample size (n)	Definition of unmet need	Study quality
Allen & Mor (1997) The United States Cross-sectional study	Community-dwelling adults with disability aged ≥ 65 years and 18–64 years. n = 632 (314 aged ≥ 65 years, 318 aged 18–64 years)	Participants were defined as having unmet needs if they: 1) did not have help, and reported needing it; 2) had disability-related help, but reported needing more help; 3) did not report needing help (or more help) but reported the occurrence of a negative consequence attributed to the absence of help.	Fair
Allen et al. (2014) The United States Cross-sectional study	Community-dwelling Medicare enrollees aged ≥ 65 years. n = 7,609	Participants who needed assistance with a given activity but had no one there to assist with the activity, or because it was too difficult to perform the activity without additional help.	Good
Beach & Schulz (2017) The United States Cross-sectional study	Family caregivers of community-dwelling Medicare enrollees aged ≥ 65 years and with disabilities. Family caregivers n = 1,996; Older adults n = 1,366	Same as Allen et al. (2014), since they used a common data source from the National Health and Aging Trends Study.	Fair
Chong et al. (2021) The United States Cross-sectional study	Older adults and adults with physical disabilities participated in Medicaid home and community-based services program. n = 10,263	Participants who did not always receive enough help with self-care activities (e.g., bathing, dressing, eating) or other daily activities (e.g., preparing meals, shopping, taking medications) when needed.	Fair
DePalma et al. (2013) The United States Longitudinal study	Community-living Medicare enrollees aged ≥ 65 years who were hospitalized within 90 days prior to the interview and reported ADL disability at the time of the interview. n = 522	Participants who did not receive needed help, could have used more help, or had to wait to do the task because they did not have enough help.	Good
Desai et al. (2001) The United States Cross-sectional study	Community-dwelling older adults aged ≥ 70 years. n = 9,447	Participants who reported having difficulty and needing more personal assistance than they were receiving.	Fair
Freedman & Spillman (2014) The United States Cross-sectional study	Community-dwelling Medicare enrollees aged ≥ 65 years. n = 7,609	Same as Allen et al. (2014), since they used a common data source from the National Health and Aging Trends Study.	Good
Gaugler et al. (2005) The United States Longitudinal study	Persons with dementia and their primary caregivers. n = 5,831	Care recipient not receiving enough help for each ADL task, as caregivers reported.	Good
Hass et al. (2017) The United States Longitudinal study	Community-dwelling Medicare enrollees aged ≥ 65 years with an ADL disability. n = 2,194	Same as DePalma et al. (2013), since they used a common data source from the National Long-Term Care Surveys.	Good
He et al. (2015) The United States Longitudinal study	Community-dwelling Medicare enrollees with one or more ADL disabilities. n = 6,730	Same as DePalma et al. (2013), since they used a common data source from the National Long-Term Care Surveys.	Good
Hu & Wang (2019) China Cross-sectional study	Older adults aged ≥60 years who reported difficulty in performing ADLs or IADLs and provided answers in the mental health module of the questionnaire. n = 1,324	Participants who had a disability in a particular ADL or IADL task but did not receive informal help with the task.	Fair
Khatutsky et al. (2006) The United States Cross-sectional study	Community-dwelling Medicare home and community-based services beneficiaries (aged <65 years and ≥65 years). n = 1,217 (aged ≥ 65 years)	Unmet need is an indicator of whether beneficiaries think they are getting all the services they require.	Fair
Komisar et al. (2005) The United States Cross-sectional study	Community-dwelling low-income older adults (aged ≥ 67 years) with disabilities who are covered by both Medicare and Medicaid. n = 2,123	Participants who received some help with the activity but needed more or received no help but needed some.	Good
LaPlante et al. (2004) The United States Cross-sectional study	Community-dwelling adults aged ≥ 18 years with disability. n = 9,646	Participants who lacked help or needed more help in one or more ADL/IADL activities.	Fair
Marrero et al. (2019) The United States Longitudinal study	Older adults aged ≥ 65 years who transitioned from institutions to community-based homes. n = 648	Participants who indicated they were unable to do these activities (bath, eating, taking medicine, using the bathroom) because there was no one there to help them.	Fair
Momtaz et al. (2012) Malaysia Cross-sectional study	Community-dwelling ADL/IADL disabled older adults aged ≥ 60 years. n = 400	Participants were not able to perform at least one of the ADLs at all and didn’t receive human assistance, or participants who were incontinent (of bladder or bowel).	Fair
Morasso et al. (1999) Italy Cross-sectional study	Cancer patients, aged ≥18 years, who were admitted for palliative care at 13 Italian centers and were consecutively registered when their Karnofsky Performance Status score declined to 60 or 50. n = 89	Participants could not cope with the problem and had no resources to overcome it.	Fair
Quail et al. (2007) Canada Cross-sectional study	Community-dwelling older adults ≥ 75 years who were disabled in at least one ADL. n = 508	1) Participants needing help but not receiving any; or 2) Participants receiving help, but needing more help; or 3) Participants experiencing a negative consequence of not having any, or enough help. (Negative consequences included falling, having to wear dirty clothing, or being unable to eat or drink when hungry or thirsty.)	Fair
Quail et al. (2011a) Canada Longitudinal study	Community-dwelling female older adults ≥ 75 years. n = 530	Same as Quail et al. (2007), since they used a common data source from the Montreal Unmet Needs Study.	Good
Quail et al. (2011b) Canada Cross-sectional study	Community-dwelling female adults aged ≥ 75 years. n = 530	Same as Quail et al. (2007), since they used a common data source from the Montreal Unmet Needs Study.	Fair
Read et al. (2021) England Longitudinal study	Older adults aged 50 years or older living in the community at baseline, and identified as having dementia. n = 165	Participants reported difficulty conducting any of these activities but did not receive help for that activity.	Fair
Sands et al. (2006) The United States Longitudinal study	Community-dwelling older people ≥ 55 years with one or more ADL dependencies. n = 2,943	Participants with the absence of informal (usually family caregiver) or formal (paid caregiver) assistance with ADL needs.	Good
Tennstedt et al. (1994) The United States Longitudinal study	Community-dwelling functionally disabled older adults ≥ 70 years who were alive at both baseline and follow-up. n = 235	Participants who reported substantial physical difficulty with a specific area of ADLs and received no assistance from another person in this specific ADL.	Fair
H. H. Wang et al. (2016) Taiwan Cross-sectional study	Older adults aged ≥ 65 years. n = 2,901	Participants with disability who received no help in the form of personal assistance (including formal and informal help) or assistive devices to perform their ADL tasks.	Fair
Wolff et al. (2019) The United States Cross-sectional study	Community-dwelling Medicare enrollees aged ≥ 65 years and survived 12 months. n = 3,716	Same as Allen et al. (2014), since they used a common data source from the National Health and Aging Trends Study.	Good
Xu et al. (2012) The United States Longitudinal study	Community-dwelling Medicare enrollees aged ≥ 65 years with one or more ADL disabilities. n = 5,884	Same as DePalma et al. (2013), since they used a common data source from the National Long-Term Care Surveys.	Good
Zhen et al. (2015) China Longitudinal study	Older adults aged ≥ 65 years who required assistance in any of the six ADLs for more than 3 months. n = 3,089	Participants who indicated the assistance provided by caregivers did not fully meet their needs.	Good
Zuverink & Xiang (2019) The United States Longitudinal study	Medicare beneficiaries aged ≥ 65 years with activity limitations at baseline. n = 3,936	Same as Allen et al. (2014), since they used a common data source from the National Health and Aging Trends Study.	Good

Note. ADL = activities of daily living; IADL = instrumental activities of daily living.

Of the 28 studies, 16 were cross-sectional studies, and 12 were longitudinal studies. All studies were observational. Five studies use the same data from one original study—the National Health and Aging Trends Study (NHATS), conducted in the United States (Allen et al., 2014; Beach & Schulz, 2017; Freedman & Spillman, 2014; Wolff et al., 2019; Zuverink & Xiang, 2019). Four studies used the data from the National Long-Term Care Surveys, from the United States (DePalma et al., 2013; Hass et al., 2017; He et al., 2015; Xu et al., 2012). Three studies analyzed the data sets provided by the Montreal Unmet Needs Study, from Canada (Quail et al., 2007, 2011a, 2011b). The remaining studies analyzed different and independent data sources.

The study sample sizes ranged from 89 to 10,263; all were larger than 200, except for two studies (Morasso et al., 1999; Read et al., 2021). Half of the studies focused on older adults aged 65 years or over, while the others had different lower bounds for age, ranging from 18 (mean age > 60 years) to 75 years. Two studies focused on female older adults (Quail et al., 2011a, 2011b). In terms of participants’ health conditions, eight studies included those who had difficulty with at least one ADL task (DePalma et al., 2013; Hass et al., 2017; He et al., 2015; Quail et al., 2007; Sands et al., 2006; H. H. Wang et al., 2016; Xu et al., 2012; Zhen et al., 2015), five studies selected those who had difficulty with at least one ADL or IADL task (Hu & Wang, 2019; Momtaz et al., 2012; Zuverink & Xiang, 2019), two studies screened participants through the use of a disability index (Allen & Mor, 1997; LaPlante et al., 2004), two studies concerned persons with dementia (Gaugler et al., 2005; Read et al., 2021), and one concerned terminal cancer patients (Morasso et al., 1999). The other studies had no restrictions on participants’ health conditions.

Methodological Quality Assessment

All 28 studies were of acceptable quality: 13 studies were rated as “good” and 15 studies were regarded as “fair.” Thus, all 28 studies were included for qualitative synthesis. The summary of the quality assessment for the included studies is shown in Table 1 and detailed evaluation is displayed in Supplementary Table 1.

Definition of Unmet Needs for Assistance With Daily Living

The definitions given for unmet needs for daily living assistance were different across studies. Most studies defined unmet need as a person receiving insufficient help (Allen et al., 2014; Allen & Mor, 1997; Chong et al., 2021; DePalma et al., 2013; Desai et al., 2001; Freedman & Spillman, 2014; Gaugler et al., 2005; Hass et al., 2017; He et al., 2015; Khatutsky et al., 2006; Komisar et al., 2005; LaPlante et al., 2004; Quail et al., 2007, 2011a, 2011b; Wolff et al., 2019; Zhen et al., 2015; Zuverink & Xiang, 2019). This definition covered two different circumstances: (a) participants did not receive any assistance but reported needing assistance, or (b) the participants were receiving assistance but reported needing greater assistance. Among these studies, some considered additional circumstances. Allen and Mor (1997) and Quail’s studies (Quail et al., 2007, 2011a, 2011b) took the adverse consequence of unmet need as constituting part of the definition of unmet need. Thus, in addition to the two circumstances described above, participants were regarded as having unmet needs if they experienced adverse consequences of unmet needs for specific ADLs and IADLs, even if they did not report requiring assistance. DePalma et al. (2013) had one more circumstance in the definition of unmet need, which was a person having to wait to do a task due to insufficient assistance.

Some other studies defined unmet needs as requiring a complete absence of assistance, considering an unmet need as occurring in the circumstance that a participant had no assistance and needed it, and not in cases where participants were receiving some assistance but needed more (Hu & Wang, 2019; Marrero et al., 2019; Momtaz et al., 2012; Morasso et al., 1999; Read et al., 2021; Sands et al., 2006; Tennstedt et al., 1994; H. H. Wang et al., 2016). Moreover, Momtaz et al. (2012) specifically included incontinence (of bladder or bowel) as an unmet need.

Consequences of Unmet Needs for Assistance With Daily Living

Various consequences of unmet ADL/IADL needs were examined in the included studies. Based on the conceptual framework, we grouped the consequences into four categories: (a) undesirable self-care consequences, examined in six studies; (b) consequences for health care utilization, examined in 12 studies; (c) physical health consequences, examined in eight studies; and (d) psychosocial health consequences, examined in nine studies. The main findings from the included studies were summarized by category in Table 2 to 5.

Table 2.

Undesirable Self-Care Consequences Related to Unmet ADL/IADL Needs in Community-Dwelling Older Adults.

Citation	Results summary
Allen & Mor (1997) Cross-sectional evidence	The prevalence of undesirable self-care consequences due to unmet ADL/IADL needs among older adults with assistance needs for ADL/IADL in the past month: (1) ADL: 5% – 32.7% Most frequent consequences: “wet or soiled self when toileting” (32.7%); “not able to bath as often as would like” (29.1%). (2) IADL: 1.7% – 31.3% Most frequent consequences: “distressed because housework not done” (31.3%); “unable to go places for recreation” (26.1%).
Allen et al. (2014) Cross-sectional evidence	The prevalence of undesirable self-care consequences due to unmet ADL/IADL needs among older adults with assistance needs for each task category in the past month: (1) Self-care tasks: 23.9% Most frequent consequence: “wet or soiled self when toileting” (43.4%) (2) Household tasks: 17.3% Most frequent consequence: “made a mistake in taking prescribed medicines” (19.9%) (3) Mobility tasks: 29.6% Most frequent consequences: “had to stay inside” (29.6%); “did not go places inside the home” (26%)
Desai et al. (2001) Cross-sectional evidence	The prevalence of one or more undesirable self-care consequences among those with any unmet ADL needs in the past month was 47.6%. Most frequent consequences: toileting (50.6%)—“experience discomfort because unable to go to the bathroom or change soiled clothing as often as need”, “get wet or soiled when toileting”; bathing (42.1%)—“experience discomfort because unable to bathe as often as would have”, “experience a burn or scald caused by bathing”.
Freedman & Spillman (2014) Cross-sectional evidence	Overall, 32% of those who had difficulty or received help had an undesirable self-care consequence related to an unmet need. The prevalence of each consequence was the same as Allen et al. (2014).
Komisar et al. (2005) Cross-sectional evidence	The prevalence of one or more undesirable self-care consequences was 56% among people with any unmet ADL needs. Most frequent consequences: “wet or soiled self when toileting” (56%); “fell out of bed or a chair” (48%); not able to bathe or shower (42%).
LaPlante et al. (2004) Cross-sectional evidence	Prevalence of undesirable self-care consequences among people needing help with two or more ADLs last month: (1) ADLs: 1.8% – 57.7% Most frequent consequences: “stays in a chair most of the time” (57.7%); “skin problems because of soiling when toileting” (36.8%) “discomfort due to not bathing often enough” (34.6%). (2) IADLs: 8.1% – 51.6% Most frequent consequences: “does not move around the house as desired” (51.6%); “distress due to clothes going unwashed or house unclean” (39.4%); “distress due to dishes going unwashed or house untidy” (38.9%).

Note. ADL = activities of daily living; IADL = instrumental activities of daily living.

Table 3.

Unmet ADL/IADL Needs and Health Care Utilization in Community-Dwelling Older Adults.

Citation	Results summary
Beach & Schulz (2017) Cross-sectional evidence	Caregivers with recipients reporting two or more unmet needs were more likely than those whose recipients reported no unmet needs to spend more than 100 hr per month caregiving, frequently lift the care recipient from a seated position, help manage medical tasks, help with care of teeth, help with care of feet, and help with skin care and wounds.
Allen & Mor (1997) Cross-sectional evidence	• Participants with unmet ADL needs experienced significantly more physician visits, ED visits, and hospitalizations than did those without unmet ADL needs. • There was no association between health care utilization indicators and unmet IADL needs.
DePalma et al. (2013) Longitudinal evidence	Having unmet ADL needs was associated with increased risk for hospital readmission within 1 year (HR = 1.37, 95% CI = [1.03, 1.82]).
Sands et al. (2006) Longitudinal evidence	Those who lived with unmet ADL needs before enrollment in the Program of All-inclusive Care for the Elderly (PACE) were more likely to have a hospital admission before PACE enrollment (OR = 1.28, 95% CI = [1.01, 1.63]) and an acute admission in the first 6 weeks after enrollment (OR = 1.45, 95% CI = [1.00, 2.09]) but not after 6 weeks of receiving PACE services (OR = 0.86, 95% CI = [0.53, 1.40]).
H. H. Wang et al. (2016) Cross-sectional evidence	Absence of help for ADL tasks was significantly associated with hospital admission (OR = 4.57, 95% CI = [1.51, 13.82]) and ED visits (OR = 3.52, 95% CI = [1.15, 10.76]) within 1-year follow-up.
Xu et al. (2012) Longitudinal evidence	Insufficient help for ADLs was associated with hospitalizations within 1-year follow-up after controlling for demographics, co-morbidities, prior hospitalizations, and level of ADL disability (HR = 1.14, 95% CI = [1.01, 1.28]).
Chong et al. (2021) Cross-sectional evidence	Unmet needs for daily life activities were associated with more ED visits (OR = 1.31, 95% CI = [1.16, 1.48]) and dental exams (OR = 1.16, 95% CI = [1.02, 1.31]) in the prior year. The associations with hospital or rehabilitation stay (OR = 1.12, 95% CI = [0.99, 1.27]) and physical exam (OR = 0.95, 95% CI = [0.81, 1.12]) were not significant.
Hass et al. (2017) Longitudinal evidence	• Having unmet ADL needs was associated with increased risk for overall ED admission within 1-year follow-up (incidence rate [IR] = 1.19; 95% CI = [1.00, 1.40]). • Stratifying by the categories of diagnoses, having unmet ADL needs was associated with significantly increased risk for the ED admissions for falls and injuries (IR = 1.43; 95% CI = [1.10, 1.86]) and skin breakdown (IR = 2.02; 95% CI = [0.97, 2.88]), but it was insignificant with the ED admissions for dehydration (IR = 1.13; 95% CI = [0.79, 1.63]).
Quail et al. (2011a) Longitudinal evidence	• Compared to women with no unmet IADL need (with no need or met need), women with one IADL unmet need had an increased likelihood of visiting the ED within a 6-month follow-up (OR = 1.57, 95% CI = [1.02, 2.41]), and if they had two IADL unmet needs, their risk for visiting the ED increased again (OR = 2.47, 95% CI not reported). • The association between unmet ADL needs and ED visits is not significant (OR = 0.66, 95% CI = [0.35, 1.24]).
Gaugler et al. (2005) Longitudinal evidence	Having unmet ADL needs was associated with a higher risk for nursing home placement within an 18-month follow-up (OR = 1.26, 95% CI = [1.20, 1.33]).
Read et al. (2021) Longitudinal evidence	At lower levels of functional limitations, a higher number of unmet needs was associated with a lower likelihood of moving to a care home (coefficient = −0.07, 95% CI = [−0.14, 0.00]); at higher levels of functional limitation, the baseline level of unmet need was not associated with the likelihood of moving to a care home (coefficient not reported).
Tennstedt et al. (1994) Longitudinal evidence	The small numbers of subsequent nursing home admissions with unmet needs during 4-year follow-up (n = 4 for IADLs, n = 9 for ADLs) did not permit multivariable analysis.
Wolff et al. (2019) Cross-sectional evidence	Median Medicare spending within 1-year follow-up was higher for those who experienced negative consequences of unmet needs for household ($4,866 vs. $4,095), mobility ($7,266 vs. $4,115), and self-care ($10,935 vs. $4,436) versus those who did not.

Note. ADL = activities of daily living; IADL = instrumental activities of daily living; HR = hazard ratio; CI = confidence interval; OR = odds ratio; ED = emergency department.

Table 4.

Unmet ADL/IADL Needs and Physical Health Consequences in Community-Dwelling Older Adults.

Citation	Results summary
LaPlante et al. (2004) Cross-sectional evidence	People with unmet needs were more likely to experience adverse consequences, including discomfort, distress, mobility restriction, weight loss, dehydration, falls, injuries, and burns (unadjusted results).
Marrero et al. (2019) Longitudinal evidence	The association between unmet ADL needs and incidence of falls between 6 and 12 months after transition was not significant after adjusting other factors (OR = 1.37, 95% CI = [0.67, 2.77]).
Momtaz et al. (2012) Cross-sectional evidence	Unmet ADL/IADL needs increased two times the likelihood of falls (OR = 2.10, 95% CI = [1.01, 4.43]), after adjusting for age, gender, and disability.
Gaugler et al. (2005) Longitudinal evidence	Having unmet ADL needs was associated with a higher risk for mortality for 18 months follow-up (OR = 1.17, 95% CI = [1.09, 1.27]).
He et al. (2015) Longitudinal evidence	Having unmet ADL needs was associated with increased risk for 1-year mortality only for those with one (HR = 1.96; 95% CI = [1.29, 2.87]) or two ADL disabilities (HR = 1.37; 95% CI = [1.07, 1.75]), but not for those with three or more ADL disabilities.
Zhen et al. (2015) Longitudinal evidence	• When adjusting for demographic characteristics, older adults with unmet ADL needs had a 10% increase in 3-year mortality risk for the 3-year period compared with those with needs that were met. • The association between unmet ADL needs and mortality was not significant after controlling demographic characteristics, socioeconomic and psychosocial factors, and health behaviors (HR = 1.04, 95% CI not reported).
Quail et al. (2007) Cross-sectional evidence	• For each additional unmet IADL need, subjects were 1.70 (95% CI = [1.11, 2.61]) times more likely to report poorer self-rated health. • or each additional unmet ADL need, subjects were 2.26 (95% CI = [1.31, 3.91]) times more likely to report poorer self-rated health.

Note. ADL = activities of daily living; IADL = instrumental activities of daily living; OR = odds ratio; CI = confidence interval; HR = hazard ratio.

Table 5.

Unmet ADL/IADL Needs and Psychosocial Consequences in Community-Dwelling Older Adults.

Citation	Results summary
Allen & Mor (1997) Cross-sectional evidence	Unmet ADL/IADL needs were associated with worse depression scores (unadjusted results).
Hu & Wang (2019) Cross-sectional evidence	A higher level of unmet needs was associated with more severe depressive symptoms among rural older adults (coefficient = 0.66).
Zuverink & Xiang (2019) Longitudinal evidence	Experiencing adverse consequences of unmet needs was associated with a higher risk of the onset of anxiety symptoms: • Adverse consequences of unmet needs for self-care tasks (HR = 1.34, 95% CI = [1.01, 1.77]) • Adverse consequences of unmet needs for household tasks (HR = 1.43, 95% CI = [1.15, 1.79]) • Adverse consequences of unmet needs for mobility tasks (HR = 1.34, 95% CI = [1.05, 1.72])
Morasso et al. (1999) Cross-sectional evidence	• Cancer patients with unmet needs for daily activities showed significantly higher symptom distress (unadjusted results). • The association between unmet needs for daily activities and psychological distress was not significant (unadjusted results).
Quail et al. (2011b) Cross-sectional evidence	The association between unmet ADL needs and psychological distress is not significant after adjusting for covariates (coefficient = 0.11, 95% CI = [−0.14, 0.36]), but unmet IADL needs were significantly associated with higher psychological distress (coefficient = 0.42, 95% CI = [0.25, 0.60]).
Khatutsky et al. (2006) Cross-sectional evidence	Having unmet ADL/IADL needs was associated with decreased satisfaction with paid personal assistance (coefficient = −0.25, 95% CI = [−1.70, −3.30]).
LaPlante et al. (2004) Cross-sectional evidence	People with unmet needs were more likely to be left alone and dissatisfied with the help received (unadjusted results).
Chong et al. (2021) Cross-sectional evidence	Unmet needs for daily life activities were associated with being less active in the community (OR = 0.56, 95% CI = [0.48, 0.65]), less interaction with family or friends (OR = 0.64, 95% CI = [0.53, 0.78]), less satisfied with how they spend their time (OR = 0.68, 95% CI = [0.59, 0.65]), and less felt in control of their life (OR = 0.56, 95% CI = [0.48, 0.78]) in the prior year.
Beach & Schulz (2017) Cross-sectional evidence	• Caregivers with care recipients reporting multiple unmet needs were more likely to report frequent pain limitations, frequent breathing problems, and low energy limits. The differences were not significant in whether the caregiver has fair or poor health and whether has sleep problems every or most days. • Caregivers with care recipients reporting multiple unmet needs were more likely to report caregiving as financially, emotionally, and physically difficult; report restricted social participation in valued activities; those who were employed reported that caregiving negatively affected their work.

Note. ADL = activities of daily living; IADL = instrumental activities of daily living; HR = hazard ratio; CI = confidence interval; OR = odds ratio.

Undesirable Self-Care Consequences

The six studies assessed adverse consequences specifically related to each ADL/IADL by directly asking participants whether they experienced a specific adverse consequence due to inadequate help to perform the given activity. For example, individuals who needed assistance with bathing but received inadequate help might experience the consequences such as burning themselves while bathing or experiencing discomfort due to inability to bathe as often as they would like. These consequences were categorized as undesirable self-care consequences resulting from unmet ADL/IADL needs. The questions of undesirable self-care consequences were designed by the research teams according to items relevant to ADLs and IADLs and each activity could have one (Beach et al., 2020) or multiple (Allen & Mor, 1997; LaPlante et al., 2004) adverse consequences. There is no validated measurement or consensus on the items of adverse consequences of unmet needs for specific activities.

The prevalence of undesirable self-care consequences is summarized in Table 2. Some studies reported the prevalence among members of the older population who needed assistance. Freedman and Spillman (2014) found that approximately 32% of community-dwelling older adults who needing assistance with ADLs or IADLs were encountering at least one undesirable self-care consequence due to unmet needs. Using the same data, Allen et al. (2014) divided ADLs and IADLs into self-care tasks, household tasks, and mobility tasks. The rates for undesirable consequences occurring due to unmet needs for assistance with each task category were 24%, 17%, and 30% (Allen et al., 2014), respectively. Some studies reported the proportions of individuals experiencing undesirable self-care consequences among those with unmet needs. Among the older adults with unmet ADL needs, 48% (Desai et al., 2001) to 56% (Komisar et al., 2005) were experiencing one or more adverse consequences. Two studies (Allen & Mor, 1997; LaPlante et al., 2004) compared the rates of undesirable self-care consequences between individuals with and without unmet needs, and found that individuals with unmet needs experienced a significantly higher rate of undesirable self-care consequences.

Health Care Utilization

As exhibited in Table 3, one study investigated caregiving hours related to informal care utilization and the rest focused on formal health service utilization, including hospital admission and readmission (six studies), emergency department (ED) visits (six studies), nursing home admission (three studies), and health care spending (one study). The evidence was comparably robust: Almost all the included studies reported a significant association between unmet ADL/IADL needs and greater health care utilization.

Focusing on informal care utilization, Beach and Schulz (2017) cross-sectionally found that compared with family caregivers with care recipients who had one or none unmet ADL/IADL needs, those with multiple unmet ADL/IADL needs were more likely to provide over 100 hr of caregiving per month.

H. H. Wang et al. (2016) and Sands et al. (2006) showed cross-sectional evidence on associations of unmet ADL needs with an increased risk for hospital admission, with OR of 1.26 (95% confidence interval [CI] = [1.15, 10.76]) and 4.57 (95% CI = [1.51, 13.82]), which is consistent with an earlier study (Allen & Mor, 1997). Meanwhile, longitudinal evidence also suggested that having an unmet ADL need was associated with a higher risk for hospital admission (hazard ratio [HR] = 1.14; 95% CI = [1.01, 1.28]; Xu et al., 2012) and a higher risk for hospital readmission (HR = 1.37, 95% CI = [1.03, 1.82]; DePalma et al., 2013). However, a cross-sectional study did not find a significant association of unmet ADL/IADL needs with overnight hospital stays or physical exams, but it did find an association with dental exams (Chong et al., 2021).

Cross-sectionally, both H. H. Wang et al. (2016) and Chong et al. (2021) reported an increased risk of ED visits for participants with unmet ADL/IADL needs (OR = 3.52, 95% CI = [1.15, 10.76]; OR = 1.31, 95% CI = [1.16, 1.48]). Longitudinally, Hass et al. (2017) found a similar relationship, with unmet ADL needs associated with higher risk for ED visits (annual incidence rate = 1.19, 95% CI = [1.00, 1.40]) and specifically, unmet ADL needs were associated with the ED visits due to falls and injuries and skin breakdown. A longitudinal study focusing on older women (Quail et al., 2011a) found that having unmet IADL needs was significantly associated with ED visits (OR = 1.57, 95% CI = [1.02, 2.41]), but that having an unmet ADL need did not lead to a similar association, which is the opposite to Allen and Mor (1997), as they found a significant association for unmet ADL needs instead of unmet IADL needs.

Three longitudinal studies explored the association between unmet needs and nursing home admission. Both focusing on people with dementia, Gaugler et al. (2005) reported a higher likelihood of nursing home admission with unmet ADL needs (OR = 1.26, 95% CI = [1.20, 1.33]). The study by Read et al. (2021) showed the opposite association, with a higher number of unmet ADL/IADL needs related to a lower likelihood of moving to among persons with lower levels of physical limitations, and the association was insignificant among those with higher levels of physical limitation. The third study (Tennstedt et al., 1994), focusing on older adults with disability, was unable to draw conclusions in this regard, as the events of admission were too few in number to make any such determination. In another longitudinal study (Wolff et al., 2019), unmet needs with specific adverse consequences of ADL and mobility activities were associated with higher Medicare spending, when comparing older adults who were and were not suffering from at least one specific adverse consequence of unmet ADL/IADL needs.

In particular, Sands et al. (2006) reported the change of unmet ADL needs–related emergency visits after older adults enrolled in a long-term community-based care program, namely, Program of All-inclusive Care for the Elderly (PACE). The program provides comprehensive health and social services for community-dwelling older adults, including primary care, acute care, long-term services and supports (Eng et al., 1997). The participants in this program who had unmet ADL needs at enrollment showed significantly higher risks for emergency visits within the first 6 weeks after enrollment than those without unmet ADL needs at enrollment (Sands et al., 2006). However, the differences between these populations became insignificant after 6 weeks of receiving PACE services.

Physical Health Consequences

As displayed in Table 4, seven studies examined physical health consequences, which include falls (three studies), mortality (three studies), self-rated health (one study), and bedsores/pressure sores and contractures (one study). Among the three studies that examined falls as a consequence, two cross-sectional studies (LaPlante et al., 2004; Momtaz et al., 2012) suggested that people with unmet needs were more likely to experience a fall compared with those without unmet needs, and Momtaz et al. (2012) reported an adjusted odds ratio (OR) of 2.1 (95% CI = [1.01, 4.43]). However, the association was not significant in the longitudinal study of older adults who transitioned from institutions to community-based homes (OR = 1.37, 95% CI = [0.67, 2.77]; Marrero et al., 2019). Notably, two studies in Table 2 focusing on undesirable self-care consequences have reported the prevalence of falls, regarding falls as a consequence related to transferring. In one study, 21.5% of older adults who needed assistance with ADLs or IADLs had a fall incident (Allen & Mor, 1997), while the other study reported that 48% of older adults who had an unmet need for transferring had fallen out of a bed or a chair (Komisar et al., 2005).

Three longitudinal studies on mortality and unmet needs reported inconsistent results. One study (Gaugler et al., 2005) found that, among people with dementia, the mortality of those who had unmet ADL needs reported by caregivers was higher than those without unmet ADL needs (either no needs or received sufficient help; OR = 1.17, 95% CI = [1.09, 1.27]). Another study (He et al., 2015) found that such an association was only significant among older adults with one or two ADL disabilities (one disability: HR = 1.96, 95% CI = [1.29, 2.87]; two disabilities: HR = 1.37, 95% CI = [1.07, 1.75]), but not those with three or more ADL disabilities. In the remaining study (Zhen et al., 2015), unmet ADL needs increased mortality risk by 10% when adjusting for demographic characteristics; however, this was no longer significant when socioeconomic and psychosocial factors and health behaviors were adjusted.

One cross-sectional study (Quail et al., 2007) indicated that unmet needs for ADL and IADL assistance were significantly associated with poorer self-rated health. Another cross-sectional study (LaPlante et al., 2004) found people with unmet needs were more likely to experience bedsores/pressure sores and contractures than those without unmet needs.

Psychosocial Consequences

In Table 5, nine studies explored psychosocial consequences attributed to unmet ADL/IADL needs, including anxiety (one study), depression (two studies), psychological distress (two studies), symptom distress (one study), satisfaction with care received (two studies), being left alone (one study), community living outcomes (one study), and caregiver burden (one study).

Zuverink and Xiang (2019), which was the only longitudinal study among the nine studies, reported an increased risk of the onset of anxiety symptoms among those who experienced a specific undesirable consequence related to unmet need for self-care tasks, household tasks, and mobility tasks at baseline. The HRs ranged between 1.34 and 1.43, depending on the types of tasks associated with unmet needs. Considering the cross-sectional evidence, older adults with unmet needs were reported to have more severe depressive symptoms than those without unmet needs (Allen & Mor, 1997; Hu & Wang, 2019). Quail et al. (2011b) observed elevated psychological distress among older women with unmet IADL needs than those without unmet IADL needs (coefficient = 0.42, 95% CI = [0.26, 0.60]), but not among those with and without unmet ADL needs. The association between unmet ADL/IADL needs and psychological distress was not significant among terminal cancer patients, but it was significant with the patients’ symptom distress (Morasso et al., 1999).

More unmet ADL/IADL needs were found to be associated with decreased satisfaction with care received (Khatutsky et al., 2006; LaPlante et al., 2004). LaPlante et al. (2004) also found that people with unmet needs were more likely to be left alone. This is supported by a more recent study (Chong et al., 2021), where unmet needs were associated with being less active in the community and less interaction with family or friends. Chong et al. (2021) also suggested that people with unmet needs tended to be less satisfied with how they spent their time and felt less in control in their lives. In addition, Beach and Schulz (2017) reported a close relationship between unmet ADL/IADL needs and caregiver burden. Specifically, family caregivers with care recipients who had multiple unmet ADL/IADL needs were more likely to experience frequent physical health complaints (i.e., pain limitations, frequent breathing problems, and low energy limits) than those whose care recipients had one or fewer unmet ADL/IADL needs. These family caregivers were more likely to regard caregiving as financially, emotionally, and physically difficult, and to report their social participation and employment as negatively impacted by caregiving.

Discussion

This study systematically reviewed the consequences of unmet needs for assistance with daily living among older adults, guided by Andersen’s Behavioral Model of Health Services Use. Based on the framework, we synthesized them qualitatively into four categories: undesirable self-care consequences, health care utilization, physical health consequences, and psychosocial health consequences. Undesirable self-care consequences consist of a series of adverse consequences associated with specific ADLs/IADLs due to unmet needs for assistance, such as getting wet or soiled when toileting, having to stay inside, and errors in taking prescribed medicines. Health care utilization consequences included more caregiving hours, higher medical spending, and a greater risk for hospitalization, ED visits, and nursing home admission. Physical health outcomes encompassed higher mortality, a greater risk of falling, poorer self-rated health, and more occurrences of bedsores or pressure sores and contractures. Psychosocial consequences involved more severe depressive symptoms and anxiety symptoms, greater psychosocial distress, lower satisfaction with care received and their community life, and higher caregiver burden.

A great variability was observed among the included studies in terms of study design and examined consequences. Studies on undesirable self-care consequences are highly varied in terms of the specific consequences related to each activity and the ways they obtained the percentages for each consequence. The prevalence of undesirable self-care consequences was approximately 30% in older adults needing assistance with ADL/IADL and around 50% in those who reported unmet needs for assistance with ADL/IADL. The finding that unmet ADL/IADL needs were associated with higher health care utilization was largely consistent and it had comparably sufficient longitudinal evidence. For physical consequences, the associations of unmet ADL/IADL needs with mortality and the incidence of falls were inconclusive. For psychosocial consequences, although there was a lack of longitudinal evidence, the results consistently showed unmet ADL/IADL needs were associated with worse psychosocial health. In general, even though the evidence regarding each consequence of having an unmet need may not be sufficient, older adults having an unmet need for ADL/IADL assistance are highly likely to experience negative consequences.

The majority of the included studies were from the United States, revealing a noticeable dearth of research on the consequences of unmet ADL/IADL needs among older populations in other regions. This may reflect an insufficient level of attention to unmet needs for daily living assistance in many parts of the world. Given the global trend of population aging and shared challenges in the informal and formal care for older adults, there is a call for more research to comprehend the unmet needs for assistance and their consequences in diverse regions.

The way that unmet needs were defined varied widely across the studies. While some studies considered unmet needs occurring either when assistance was absent or insufficient, other studies only considered an absence of assistance as defining the occurrence of an unmet need. However, Allen and Mor (1997) found that individuals receiving assistance but reporting insufficient assistance could experience a comparable extent of specific adverse consequences of unmet needs to those reporting an absence of assistance. This finding indicated that a significant gap in care could exist among care recipients. Thus, future studies would benefit from considering occasions when assistance may be insufficient in addition to when such assistance is entirely absent.

The mechanism(s) between an unmet need and its associated consequences remains unclear. The undesirable self-care consequences of an unmet need might help explain its associations with health care utilization, physical, and psychosocial consequences. Being unable to eat when hungry may, for instance, lead to weight loss, nutritional deficiency, and psychological distress (Quail et al., 2007). Injuries, such as falls or burns, which lead to more emergency admissions and hospital admissions, might be attributed to unmet needs for assistance with tasks such as bathing and transferring (Komisar et al., 2005; LaPlante et al., 2004). Being unable to follow a specific diet or take medications as directed can lead to serious problems such as health emergencies. These negative consequences can compromise the safety, comfort, and hygiene of older adults; reduce their quality of life and well-being; and raise the risks for physical deterioration, hospital admission, and possibly death (LaPlante et al., 2004).

The findings in this review have important implications for research. The current picture concerning the impact of unmet ADL/IADL needs on older adults is far from complete and more studies are needed to further explore these issues. Regarding undesirable self-care consequences of unmet needs, although there have been population-based cross-sectional studies, all such studies were conducted in the United States. The prevalence of such adverse consequences in other regions is, therefore, unknown. The specific undesirable self-care consequences caused by unmet needs for a specific daily living activity were inconsistent across studies. Future qualitative studies may be needed for an in-depth understanding of the nature of adverse consequences for each activity to develop a comprehensive and valid assessment of these consequences. For each of the other three categories (i.e., health care utilization, physical consequences, and psychosocial consequences), more longitudinal evidence is needed, and there is more to be explored regarding the consequences of unmet ADL/IADL needs, such as length of institutionalization, nutritional status, and quality of life.

Of note, no controlled trial was found in this review. It is possible that the unmet ADL/IADL needs–associated adverse consequences can be improved by meeting such needs comprehensively. Sands et al. (2006) have indicated the potentiality that the increased risk for emergency visits caused by unmet ADL needs was resolved by reducing unmet needs through a comprehensive long-term care program (PACE). Nevertheless, as the program is a multidisciplinary program and without a control group, the effect of meeting ADL needs alone remains uncertain. Thus, future controlled trials are recommended to test for the effectiveness of meeting the needs for assistance, which may prevent or improve the related health consequences found in this review.

The findings in this review also have important implications for practice. Given the various adverse consequences of unmet ADL/IADL needs identified, the importance of meeting the assistance needs for daily living of older adults completely is emphasized. Health professionals and policymakers can, as a result of this review, be better aware of the negative impacts of unmet needs for daily living assistance on the well-being of older adults, so that more efforts can be dedicated to better outcomes.

This review calls for the provision of sufficient long-term care services and supports for functionally impaired older adults and their caregivers. The fulfillment of needs for assistance depends on both formal and informal care. Regarding formal care, more comprehensive and coordinated home-based and community-based health services are needed. Some integrated, coordinated, and well-managed care models for older adults have thus been put forward in the United States, such as PACE. In recent years, MediCare Accountable Care Communities have been proposed. This is a model of care guided by health care and social services providers to provide comprehensive services and to develop person-centered, longitudinal care plans for frail older adults and their families (Lynn & Montgomery, 2015). While these models were initially developed for the health care system in the United States, implementing a comprehensive care delivery system tailored to the specific context of various health care systems can offer a solution to meet the needs of older adults sufficiently, improve outcomes, and reduce the costly consequences of unmet needs.

We recommend that health professionals pay more attention to the dynamic relationship between older adults in need and their family caregivers. One in five family caregivers who were assisting with ADLs were reported to have difficulties with these tasks (The National Alliance for Caregiving of the United States, 2020). Family caregivers were also found to have difficulties assisting with IADLs, such as managing medicine and arranging transportation (Giovannetti et al., 2012). Such difficulties may contribute to the unmet needs among older adults and a higher prevalence of unmet ADL/IADL needs found among those who were cared for by family caregivers, compared with those with ADL/IADL limitation regardless of care source (Beach & Schulz, 2017). Moreover, family caregivers of older adults with more unmet ADL/IADL needs were more likely to report negative physical and psychosocial burdens of caregiving. This may also indicate that overburdened family caregivers are more likely to have difficulty providing the care needs adequately (Beach & Schulz, 2017). Thus, it is essential that effective and sufficient supports are provided not only for older adults, but also for their informal caregivers, equipping them to provide care tasks adequately in ways that reduce the levels of unmet ADL/IADL needs.

To prevent unmet needs and their adverse consequences, it is crucial to incorporate the appropriate assessments into care practices. Measuring unmet needs enables a more direct and precise assessment of the adequacy of accessible care resources and the types of care required by older adults (Gaugler et al., 2005). This may provide additional insights into the links between physical symptoms and subsequent outcomes. Among older adults who generally live with multiple chronic conditions and poor functional status, unmet needs may be a particularly useful predictor of negative health consequences (Marrero et al., 2019). Hence, health care systems may consider the need to screen community-dwelling functionally impaired older adults for unmet needs for ADL/IADL assistance (Hass et al., 2017).

There are several limitations to this review. First, a meta-analysis was unable to be performed to examine due to the heterogeneity and the insufficient number of studies in each group. Second, as most of the included studies were from the United States, the extension of the findings in this review to other regions should be approached cautiously, considering the variations in health care systems and family structures across regions. Third, there might be language bias as only English or Chinese papers were searched and reviewed. Finally, all the studies included in the review are observational studies with over 50% cross-sectional studies that are unable to indicate causality. Despite the limitations, this review has several strengths. It was conducted according to PRISMA guidelines. Papers published in both English and Chinese language were screened and most of the included studies had large, population-representative samples.

Conclusion

This systematic review provides a comprehensive insight into the consequences of the unmet needs for assistance with ADLs/IADLs. The collective evidence indicates that unmet ADL/IADL needs are associated with a range of adverse outcomes, including undesirable self-care consequences, higher health care utilization, worse physical health, and poorer psychosocial outcomes. This review advocates for increasing assessments on unmet ADL/IADL needs and raising awareness of the subsequent consequences. More comprehensive long-term services and supports are recommended for older adults as well as their family caregivers to reduce the unmet ADL/IADL needs and relevant adverse consequences.

Supplemental Material

sj-docx-1-mcr-10.1177_10775587241233798 – Supplemental material for The Consequences of Unmet Needs for Assistance With Daily Life Activities Among Older Adults: A Systematic Review

Supplemental material, sj-docx-1-mcr-10.1177_10775587241233798 for The Consequences of Unmet Needs for Assistance With Daily Life Activities Among Older Adults: A Systematic Review by Jing Huang, Xingxing Qian, Edmond Pui Hang Choi and Pui Hing Chau in Medical Care Research and Review

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Jing Huang

Supplemental Material

Supplemental material for this article is available online.

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