Nearly a third of Americans who paid for care for an older adult or a dementia patient recently did not hire workers through a regulated agency, a new study from policy think tank RAND Corporation found.

The study, published by the Journal of Applied Gerontology, said workers who comprise the so-called gray market are typically unrelated to the person getting care and are potentially unscreened and untrained.

“Gray market care represents a substantial proportion of paid, long-term care for older adults and may fill gaps in access to care,” Regina A. Shih, the study’s lead author and a senior policy researcher at RAND,  said. “Better understanding of the use of gray market caregivers for older Americans is important to meet the needs of the nation’s aging population.’

In August 2017, RAND researchers randomly surveyed 1,037 members of the RAND American Life Panel, a national sampling of adults. Those surveyed were asked if they had sought care for an older adult and where the caregiver was employed.

The study found those who hired gray market caregivers were less likely to be employed and more likely to use unpaid care for their family members. In addition, people living in rural areas were five times more likely to arrange care for a dementia patient through the gray market than those living in urban settings.

Researchers said rural residents living with dementia and needing long-term care may have more difficulty accessing or paying for regulated home-and-community-based services than their urban counterparts.

Regulations for home care and home health agencies vary from one state to the next, but most are required to perform criminal background checks, verify education and training, and maintain clinical records. Agency caregivers are typically covered by disability and liability insurance to protect consumers and providers against on-the-job accidents.

“Without agency oversight, the quality of care provided by gray market caregivers is unknown, and the potential for exploitation or abuse — of both the care recipient or the care provider — has not been systematically studied,” Shih said.

The survey comes as many of the 72 million aging baby boomers will be in need of long-term care support over the next several decades. Demographic and social trends are reducing the number of family caregivers available to help older adults. As a result, the demand for long-term care is expected to increase approximately 37% by the end of the decade.

Researchers said there needs to be more analysis into the use of gray market care to identify the factors that contribute to its use, ways quality of care can be improved and how to provide better training for dementia care providers.