The family caregiver's role in Alzheimer's disease

Entlastung pflegender Angehöriger

Zusammenfassung: Pflegende Angehörige von Personen mit Demenz sind ungeheuren täglichen Belastungen ausgesetzt, die Jahre und Jahrzehnte andauern können. Pflegende Angehörige haben ein erhöhtes Risiko zur Entwicklung depressiver und körperlicher Symptomatik, sowie ein erhöhtes Mortalitätsrisiko im Vergleich zu Personen, die keine Pflege durchführen. Diese Menschen brauchen dringend Entlastung. Dringend benötigt wird auch das entsprechende Wissen und die emotionale Unterstützung, die es möglich macht, dass pflegende Angehörige diese Lebensperiode gesund erleben können. Die österreichische M. A. S Alzheimerhilfe führt seit dem Jahr 2000 ein zweiwöchiges Therapie- und Förderungsprogramm für Personen mit Demenz und ihre pflegenden Angehörigen durch. Betroffene werden von einem multiprofessionellen Team betreut, stadiengerecht gefördert und aktiviert. Die Angehörigen erhalten die Möglichkeit, an einem umfassenden Schulungs- und Beratungsangebot teilzunehmen. Ein wichtiger Bestandteil des Programms ist ein anregendes Freizeitprogramm für Angehörige und Betroffene. In der vorliegenden Untersuchung wurde die Wirksamkeit dieser komplexen Intervention in Bezug auf den Belastungsgrad und die depressive Stimmung der pflegenden Angehörigen überprüft. Untersucht wurden 104 Angehörige vor und nach der Intervention. Die statistische Analyse ergab eine signifikante Reduktion der depressiven Stimmung und der direkt durch die Krankheitssymptomatik bedingten Belastungen. Dieses Programm hat sich sehr bewährt und wird von Angehörigen und Betroffenen sehr positiv aufgenommen.

Behavior disorders and subjective burden among caregivers of demented patients

Many patients with dementia live within the community supported by their family and friends. Majority of patient caregivers suffer from high levels of stress.

METHODS

A quasi-experimental study, which compared the effects of nursing interventions on behavior disorders in both patients with moderate to severe dementia and their caregivers, followed over 18 months. The assessments were performed at the outpatient clinic of the Federal University of São Paulo and again at patients' homes with their primary caregiver, after informed consent form. Measurements were performed at baseline and after 18 months (pre and post-test). The instruments used were: The CDR, NPI and NPI-D; Katz Index and FAQ. Simultaneously, caregivers were enrolled onto the Dementia Education Program.

RESULTS

The final sample was composed of 31 subjects, having a mean age of 77.4 y.o. (±8 SD). Nursing interventions were effective in reducing some of the behavioral disturbances (Z= -3.1; p=0.002), such as Aggression (Z= -3.7; p<0.001) and anxiety (Z= -2.3; p=0.023). Caregiver distress also reduced upon interventions (Z= -2.2; p=0.030).

CONCLUSION

Our results indicate nursing interventions may be effective in reducing the frequency and severity of behavioral disorders and subjective burden among caregivers. Education Programs can improve caregiver burden through conveying information on difficulties related to the disease and how to deal with them.

Psychological distress in Brazilian caregivers of relatives with dementia

The authors evaluated stress, anxiety, depression, and feelings of hopelessness in caregivers of relatives with dementia. One hundred and twenty-nine caregivers and 145 non-caregivers who lived in metropolitan Porto Alegre, Brazil completed Lipp's Inventory of Stress Symptoms for Adults, (ISSL), and Beck's Anxiety (BAI), Depression (BDI), and Hopelessness (BHS) scales. Caregivers showed higher levels of anxiety, depression, hopelessness, resistance/pre-exhaustion stress than controls. This study indicates that constant caregiving may significantly increase the risk of physical and mental health problems for caregivers in Brazil.

Cuidando do paciente com Alzheimer: o impacto da doença no cuidador

OBJETIVO: Avaliar o impacto subjetivo da Doença de Alzheimer (DA) na vida dos cuidadores primários de idosos com esse diagnóstico. MÉTODO: Foi realizado um estudo transversal com 29 cuidadores de pacientes com DA. Os instrumentos utilizados foram: a Caregiver Burden Scale (CBS), um questionário para avaliação social do cuidador e um formulário para elaboração do perfil do paciente. Procedeu-se estatística descritiva simples, Coeficiente de Correlação de Pearson (r), Test T, para amostras independentes, e ANOVA, seguida do método de Bonferroni, a d" 0,05. RESULTADOS: A maioria dos cuidadores era do sexo feminino (89,7%), com idade média entre 48 e 58 anos, sendo 55,2% filhos, 27,6% cônjuges; e 55,2% com 8 anos de estudo. O escore médio global da CBS foi de 2,18. A média do escore total da CBS é maior nos cuidadores de pacientes restritos ao leito (p = 0,020). Os cuidadores com menor grau de escolaridade apresentaram maior escore total na CBS (p = 0,039). CONCLUSÕES: O impacto subjetivo da DA no cuidador foi considerado importante e depende de fatores como o seu nível de escolaridade e o grau de dependência dos pacientes.

Characteristics and views of family carers of older people with heart failure

AIMS

to explore the characteristics and views of the family carers of older people with heart failure.

METHOD

213 family carers of heart failure patients >60 years were recruited from UK general practitioner (GP) practices. Carer strain, quality of life (QOL) and service satisfaction questionnaires were completed every 3 months for 2 years, as well as 16 interviews with patients and carers, and 9 focus groups with health care professionals.

RESULTS

76% of carers were female, 70% were >60 years and 73% were spousal carers. Predictors of carer strain were symptoms of depression, age and patient NYHA. Predictors of lower QOL were: spousal carer; 2+ health conditions and symptoms of depression. Qualitative findings related to the change in circumstances, impact of responsibilities and health conditions of the family carers.

CONCLUSION

carers were mainly older women, often experiencing multiple health conditions. Addressing the practical and emotional support required presents a challenge for specialist palliative care in responding to calls for increased involvement in heart failure. A shared care model with liaison between specialist heart failure nurses, cardiologists, primary care teams and hospice services is advocated.

Relationships between income, subjective health and caregiver burden in caregivers of people with dementia in group living care: a cross-sectional community-based study

BACKGROUND

Family caregivers of relatives with dementia report higher level of psychological distress than other caregivers and report their self-related health as poorer than that of comparison groups.

AIMS AND OBJECTIVES

The purpose of the study was to examine characteristics of family caregivers and to assess whether income, subjective health, age and relationship were associated with the burden of care they experienced.

SETTING

Group living units in southern Sweden.

PARTICIPANTS

Fifty caregivers who served as informal caregivers of relatives with dementia in group living care.

DESIGN

Interviews regarding economic and social conditions and well-evaluated scales for health and caregiver burden (CB) were used.

RESULTS

The majority of the family caregivers were adult children, and twice as many were female than were males. The investigation showed that total burden, strain and disappointment, adjusted for health and age, were related to income. Disappointment showed a relation to subjective health. The adult children showed a significantly higher degree of total burden, irrespective of age, compared to other family caregivers. Low income was associated with a higher degree of burden among adult children. However, elderly participants experienced less of burden than younger ones.

CONCLUSION

Our findings indicate that caregivers with low health profile and low income, especially adult children, are associated with higher CB.

RELEVANCE TO CLINICAL PRACTICE

People with coexisting risk factors (low income, low perceived health) are the ones who may benefit most from health-oriented interventions.

Effect of the Meeting Centres Support Program on informal carers of people with dementia: results from a multi-centre study

Because of the complex nature of the problems that carers of persons with dementia encounter, several comprehensive support programs for carers were developed in the past decade. One such program is the Meeting Centres Support Program (MCSP) that integrates different types of support for persons with dementia and their carers, which have proved to be effective in practice and/or research. Within the framework of a study into the national implementation of the MCSP, it was investigated whether the positive effects found in carers that participated in the first Amsterdam Meeting Centres, were also achieved in other regions of The Netherlands. A pre-test-post-test control group design with matched groups was applied. In total, 94 carers in the MCSP in eight meeting centres and 34 carers of dementia patients who frequented regular psychogeriatric day care (PDC) in three nursing homes were included in the study. During the study period 23 carers of the MCSP group and 21 carers of the PDC group dropped out. At baseline and after seven months indicators of burden (psychological and psychosomatic symptoms, feelings of burden and time between start of support and institutionalization of the persons with dementia) were measured, as well as potential determinants of burden (sense of competence, coping strategies, experienced support, loneliness and the emotional impact of behaviour problems). Though on a group level no effect was found, either in psychological and psychosomatic symptoms or in the determinants of burden, a subgroup of carers who felt lonely (n=22) at baseline benefited significantly more from the MCSP than from PDC in terms of psychological and psychosomatic symptoms. A majority of MCSP carers (82.1%) experienced less burden and more professional support. After seven months significantly fewer persons with dementia in the MCSP (4%) were institutionalized as compared to the patients in PDC (29%). Patients in the MCSP participated for a longer period of time before institutionalization. Although the effect on sense of competence of carers that was found in the Amsterdam study was not found in this multi-centre study, the effect on burden and delayed institutionalization of the person with dementia were confirmed. The integrated MCSP also proved more effective than PDC in decreasing psychological and psychosomatic symptoms in lonely carers. Further dissemination of the MCSP is therefore recommended.

Longitudinal study on the relationship between symptomatology of dementia and levels of subjective burden and depression among family caregivers in memory clinic patients

The objective was to evaluate the course and severity of dementia-related symptoms and their relationship to caregivers' subjective burden and depression over time. Forty-five patients with dementia and their caregivers were followed over a period of 2 years. Patients' cognition, function, and behavioral/psychological symptoms were assessed by the Mini Mental State Examination, Syndrome Kurz Test, Geriatric Depression Screening scale, Instrumental Activities of Daily Living Scale, Physical Self Maintenance Scale, Behavioral Abnormalities in Alzheimer's Disease Rating Scale, and Nurses Observation Scale for Geriatric Patients. Caregivers' depression and subjective burden were evaluated by the Geriatric Depression Screening scale or Beck Depression Inventory and the Caregiver Burden Interview. Global dementia severity, functional impairment, and behavioral disturbances increased significantly over the 2-year observation period. Caregivers' burden remained stable, and severe depression decreased over time. There were significant associations between burden and dementia-related symptoms. For deficits in activities of daily living as well as behavioral disturbances, these associations became stronger over time. It was concluded that stage of dementia, functional deficits, and behavioral disturbances are important factors when evaluating the relationship between patients' symptoms and caregivers' well-being.

Stress and depression in informal family caregivers of patients with Alzheimer’s disease

Family caregiving of older individuals with Alzheimer’s disease is becoming widespread in the USA and around the world because of the aging of the population. As a result, family members are increasingly being asked to perform complex tasks similar to those carried out by paid health or social service providers. Dementia caregiving presents unique and extreme challenges associated with caring for someone with cognitive and behavioral impairment. This article summarizes the extensive literature on dementia caregiving, identifies key issues and major findings regarding the definition and prevalence of caregiving, and reviews the epidemiological, cultural, individual and biological factors contributing to caregiver stress and depression. The author describes the psychiatric and physical health effects of caregiving and reviews various intervention approaches to improving caregiver burden, depression and quality of life. The author offers a perspective on future directions in dementia caregiver research and development of more effective interventions.

Reduction of caregiver burden in Alzheimer's disease by treatment with galantamine

Alzheimer's disease is a progressive condition characterized by a loss of cognition, altered behavior, and a loss of functional ability, such as bathing, dressing, toileting, and organizing finances. Family and friends provide nearly three quarters of all care for patients with Alzheimer's disease. This informal care results in significant burden to caregivers. Caregiver burden is the set of physical, psychological or emotional, social, and financial problems that family members may experience when caring for impaired older adults. Caregivers of Alzheimer's disease patients report higher rates of physical symptoms, mortality, depression, and fatigue, as well as adverse effects on employment compared with those who are not caregivers for Alzheimer's disease patients. In many cases, the same family members are responsible for both out-of-pocket expenditures and caregiving duties. For this article, a MEDLINE search using the key words "caregiver and Alzheimer's disease" and "cost and Alzheimer's disease" was performed. The purpose of this article is to review the literature on caregiver burden, the components of caregiver burden, effects of caregiving on the health of caregivers, the cost of Alzheimer's disease on the caregiver and society, and the benefits attainable with treatment.

Levels of depressive symptoms in spouses of people with lung cancer: effects of personality, social support, and caregiving burden

The authors sought to identify the personality correlates of depressive symptoms in 120 spouses of people with lung cancer. Spouses completed questionnaires, including measures of personality (neuroticism, extraversion, and interpersonal self-efficacy), social support, and caregiving burden. Their level of depressive symptoms was measured with self-report (Center for Epidemiologic Studies Depression Scale) and interviewer (Hamilton Depression Rating Scale) ratings. Structural equation modeling showed that neuroticism was directly associated with greater depressive symptoms and indirectly associated with less social support and greater caregiving burden. Interpersonal self-efficacy was indirectly associated with the severity of depressive symptoms through both social support and caregiving burden. These findings have implications for identifying spouses of individuals with lung cancer who are vulnerable to depression and could inform the design of programs to reduce depressive symptoms in the context of cancer caregiving.

Stress in carers of individuals with dementia and Community Mental Health Teams: an uncontrolled evaluation study

AIM

The aim of this was to evaluate the effectiveness of interventions provided by a Community Mental Health Team (CMHT) in reducing stress in carers of individuals with dementia.

BACKGROUND

The CMHT had been created to working specifically with older people with mental health problems and their carers. Following initial multidisciplinary assessment a range of interventions were provided to both clients and carers according to assessed need. There is an established need for mental health services to focus on the need of carers and the study attempts to see if the interventions provided were useful in reducing carer stress.

METHOD

The study used a time series design over a 2-year period on all referrals to the CMHT. All carers of individuals with dementia or clearly identified memory problems were invited to participate and a total of 26 carers consented and participated in all stages of data collection. Data were collected on initial assessment, as well as 3 and 6 months following the initial assessment using the Caregiver Strain Index (CSI). A questionnaire was also administered which collected basic demographic information and details of symptoms demonstrated by the carer's relatives.

RESULTS

On initial assessment the mean CSI score for the overall sample was 9.23. The mean CSI reading at 3 months (6.63) and 6 months period (4.12) demonstrated statistically highly significant reductions in carer stress (P = 0.000). A linear stepwise regression analysis of the impact of the different interventions on reductions in the CSI scores showed a statistically significant relationship between respite care and reduction in carer stress (B = 1.705, t = 2.586, P = 0.017).

CONCLUSION

The results add support to the role of multidisciplinary community based services for individuals with dementia, offering a range of interventions to both clients and their carers, in reducing carer stress. The authors also argue for the routine use of the CSI in such teams as means of monitoring the well-being of carers as well as evaluating the effectiveness of service delivery.

Assessment of everyday behavior in Alzheimer's disease patients: its significance for diagnostics and prediction of disease progression

In addition to cognitive decline, current diagnostic criteria for Alzheimer's disease (AD) require evidence of impaired social and/or occupational functioning. The Nurses' Observation Scale for Geriatric Patients (NOSGER) is used to rate the frequency of disturbances in everyday behaviors and, although not specifically developed for this purpose, is often applied for diagnostic purposes. The NOSGER assesses six dimensions: Memory, Instrumental Activities of Daily Living (IADLs), Self-Care (ADL), Mood, Social Behavior, and Disturbing Behavior. The goals of this study were 1) to establish normative data for the NOSGER as a function of demographic variables (i.e., age, years of education, and gender) in healthy elderly subjects; 2) to obtain cutoff values distinguishing healthy elderly subjects from probable AD patients with mild dementia; and 3) to describe the natural course of behavioral changes occurring in mild AD according to the NOSGER dimensions. NOSGER data of 445 normal controls [NCs, 376 men, 69 women; Mini-Mental Status Examination (MMSE) = 28.8 +/- 1.17] and 217 probable AD patients with mild dementia (97 men, 120 women; MMSE = 26.1 +/- 1.59) from the Memory Clinic of Basel, Switzerland, were analyzed. Cutoff scores for distinguishing between average NCs and mildly demented AD patients ranged between 7 and 9 for different NOSGER dimensions. Formulae to obtain demographically adjusted and z-transformed NOSGER dimension and MMSE scores for assessment of individual cases were determined. NCs were best distinguished from patients in the NOSGER dimension Mood, followed by Memory, ADLs, Social Behavior, and Disturbing Behavior. Linear courses of behavioral deterioration were found-in four NOSGER dimensions (Memory, IADLs, Mood, and Social Behavior) in these mildly demented patients. No quadratic course was found for any of the NOSGER dimensions. The NOSGER revealed good discriminatory power in those behavioral dimensions affected in early stages of AD and is suitable for monitoring behavioral changes as a function of disease progression. Its use in combination with the MMSE for dementia screening purposes is recommended.

Influence of behavioral and psychological symptoms of dementia (BPSD) and environment of care on caregivers' burden

With increasing population of older adults in need of care, caregiver's burden is becoming a major concern. We investigated the relative contributions of BPSD of care recipients, caregiver's background and the care environment to caregiver's burden assessed by using Zarit burden interview (ZBI). Among BPSD, inability of finding the way home, inability of managing money and fecal incontinence were the most difficult symptoms to cope with. A path analysis, by which we constructed a network model to clarify the contributions of the factors examined to the caregiver's burden, indicated that the severity of dementia, the feeling of "would rather die than be in the same condition" and the physical pain of the caregivers showed great direct influences on the score of the ZBI. In conclusion, we clarified kinetic and dynamic interactions of factors affecting caregiver's burden by using a path analysis. The model indicates that the caregiver's burden can be affected not merely by the illness of the care recipients but by the caregiver's background and the care environment.

Why Does Social Exclusion Hurt? The Relationship Between Social and Physical Pain

The authors forward the hypothesis that social exclusion is experienced as painful because reactions to rejection are mediated by aspects of the physical pain system. The authors begin by presenting the theory that overlap between social and physical pain was an evolutionary development to aid social animals in responding to threats to inclusion. The authors then review evidence showing that humans demonstrate convergence between the 2 types of pain in thought, emotion, and behavior, and demonstrate, primarily through nonhuman animal research, that social and physical pain share common physiological mechanisms. Finally, the authors explore the implications of social pain theory for rejection-elicited aggression and physical pain disorders.

Religiosity as a mediator of caregiver well-being: does ethnicity make a difference?

This study used an adaptation of the stress and appraisal model to examine the mediating effects of religiosity on caregiving strain and gain with an ethnically diverse sample of 384 Alzheimer's disease caregivers. While the regression analysis indicated that religiosity did not mediate the stress of providing care for the entire sample, there were significant differences in the use of religiosity depending on the ethnicity (African American, Hispanic, and White non-Hispanic) of the caregiver, as well as significant differences between the three cohorts in the levels of caregiving strain (depression) and gain (self-acceptance). Implications for the use of religiosity as a protective factor for AD caregivers are discussed.

Exaggerated Plasma Fibrin Formation (D-Dimer) in Elderly Alzheimer Caregivers as Compared to Noncaregiving Controls

BACKGROUND

The chronic stress of providing care for a spouse suffering from Alzheimer's disease has been associated with an increased risk for coronary artery disease and overall mortality. Procoagulant changes are kindled by mental stress, and they are prospectively associated with atherothrombotic events.

OBJECTIVE

To examine whether dementia caregivers would show greater coagulation activity and less fibrinolytic capacity than noncaregiving controls.

METHODS

Subjects were 48 (30 female and 18 male) elderly (mean age +/- SD, 72 +/- 9 years) community-dwelling spousal Alzheimer caregivers and 20 noncaregiving age- and gender-matched controls. Plasma levels of thrombin-antithrombin III, fibrin D-dimer, von Willebrand factor, tissue-type plasminogen activator, and plasminogen activator inhibitor 1 were measured.

RESULTS

D-dimer, a marker of fibrin formation and degradation, was significantly higher in caregivers than in controls (688 +/- 575 vs. 406 +/- 157 ng/ml, p = 0.021). Plasma levels of the four other hemostasis variables were not significantly different between the two groups. Controlling for the classic cardiovascular risk factors body mass index, hypertension status, smoking status, hypercholesterolemia, type II diabetes, and medication potentially affecting hemostasis did not change results.

CONCLUSION

The findings suggest that Alzheimer caregivers have an increased fibrin turnover as compared to noncaregiving controls independent of common confounders of hemostasis. Such an elevated clotting diathesis might contribute to increased cardiovascular risk and overall mortality with dementia caregiving strain.

Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia

The study tested the hypotheses that integrated support, in which patients and carers are both supported by one professional staff member, will be more effective in reducing the feelings of (over)burden of carers and in positively influencing some potential determinants of experienced burden than non-integrated support, such as psychogeriatric day-care. A quasi-experimental pre-test/post-test control group design was applied with matched groups and measurements at baseline and after seven months. Fifty-five of the eighty dyads (31% dropped out) of persons with mild-to-moderate dementia and their carers who presented for four community meeting centres and three day-care centres in nursing homes over an 18 month period, were included in the study. The carers in the Meeting Centres Support (MCS) Program participated in an integrated family support program together with the persons with dementia, while the carers in the control group only received respite through psychogeriatric day-care. Standardized questionnaires were applied to measure some indicators of burden experienced by the carers (feelings of stress, life dissatisfaction, psychological and psychosomatic complaints), as well as some potential determinants of experienced burden (feeling of competence, coping strategies, experienced support and loneliness). Furthermore, as an indicator of feelings of (over)burden of the carer, the time between start of participation in one of the programs and institutionalization in a nursing home was calculated. After seven months the carers in the MCS group (n = 36), compared to the carers in regular psychogeriatric day-care (n = 19), showed a moderate positive effect on the feeling of competence (effect size 0.45). No effect was found on feelings of stress, dissatisfaction or psychological and psychosomatic complaints. However, as compared to the control group in regular day-care, the persons with dementia in the MCS Program participated for a longer period of time before they were placed in a nursing home. The MCS Program proved more effective than psychogeriatric day-care in influencing the feeling of competence of the carers, and seems to lead to an increased delay of nursing home placement of the person with dementia, as compared to regular day-care. Because of the small sample and limited power of the study, and the possible influence of the selection of carers on the study outcome, further research into the value of meeting centres for carers of people with dementia is recommended.

Dementia caregiver burden: reliability of the Brazilian version of the Zarit caregiver burden interview

The object of this article is to examine the reliability of the Brazilian version of the Zarit Caregiver Burden Interview (ZBI). The instrument is a 22-item scale assessing the extent to which caregivers view their responsibilities as having an adverse impact on their social life, health, emotional well-being, and finances. We assessed 50 primary informal caregivers of demented patients coming from 3 different health care centers, using the test-retest method. Analysis of the results showed an intraclass reliability coefficient of 0.88, while Cronbach's coefficient alpha was 0.77 for the test and 0.80 for the retest items. The Brazilian version of ZBI shows sufficient reliability, comparable to the original version.

Alzheimer's disease: usefulness of the Family Strain Questionnaire and the Screen for Caregiver Burden in the study of caregiving-related problems

OBJECTIVES

The economic and psychosocial impacts of Alzheimer's disease (AD) on caregivers are so well documented that they have stimulated socioeconomic regulations that are international in scope. In Italy caregivers have the right to receive economic and psychosocial aid. However, to distribute such aid the needs of caregivers, must be properly assessed. Here we have attempted to integrate two measures, the Family Strain Questionnaire (FSQ) and the Screen for Caregiver Burden (SCB), in order to evaluate caregiver needs that are both general and specific to AD.

MATERIAL AND METHODS

The SCB and FSQ were administered to 91 primary caregivers of home-based patients with AD. Caregivers also were asked to rate the activities of daily living of their care recipients, the latter of which were administered the Mini-Mental State Examination.

RESULTS

The SCB and FSQ provide different, but complementary assessments of the needs of AD caregivers. The SCB identifies situations that are potentially stressful to AD caregivers and the FSQ identifies the needs of specific caregivers (e.g. men vs women, spouses vs children, unemployed vs employed).

CONCLUSION

Together these measures may help government agencies to assess caregiver needs beyond those assessed by each individual measure.

The Increasing Burden of Alzheimer Disease

Alzheimer disease is a progressive degenerative disease that affects cognition, the ability to perform activities of daily living, and behavior. Cognitive, behavioral, and functional decline associated with progressive Alzheimer disease places a considerable burden on caregivers and the health care system. Earlier detection, better diagnosis, earlier intervention, and increased treatment may help reduce this burden.

Differences in supporting families of dementia patients and cancer patients: a palliative perspective

OBJECTIVES

To investigate what staff working in close contact with patients perceive as good support of families in dementia care as compared with support of families in palliative cancer care.

DESIGN AND SUBJECTS

During four national courses on dementia care and one national course on palliative cancer care, 316 and 121 participants, respectively, responded to an open-ended question: In your experience, what are the two most important measures for supporting families of dementia patients/severely ill cancer patients? Sixty-one items were coded and allocated into 10 main categories and analysed with both a qualitative and quantitative approach.

RESULTS

The dominant items for both staff groups were to listen to the family member and to give information, although listening was significantly more often stressed in the palliative group (P < 0.001). The staff in dementia care stressed significantly more the importance to form support groups for families (P < 0.001), to offer respite care (P < 0.001), to educate families (P < 0.001) and to try to relieve the family's feeling of guilt (P < 0.001). In the palliative staff group, the importance of being available (P < 0.05), creating a sense of security (P < 0.001) and supporting the family after the patients death (P < 0.01) were significantly more focused on.

DISCUSSION

The respondents from the dementia staff group and from the palliative cancer group stressed the importance of supporting family members. However, the type of support needed partly differs because of the different trajectories in dementia compared with severe cancer phases.

Dyspnea and quality of life indicators in hospice patients and their caregivers

This study describe the assessment of dyspnea, symptom distress, and quality of life measures in 163 hospice patients with cancer who reported dyspnea. Mean age of the hospice patient sample was 70.22 years and 61.86 for caregivers (65% were spouses). The majority of patients and caregivers were white: 87%, 63% of the patients were male while 78% of caregivers were female. Mean dyspnea intensity as reported by patients was 4.52 (SD 2.29) and caregivers, 4.39 (SD 2.93). Patients' and caregivers' ratings of the patient's dyspnea intensity revealed no significant differences in ratings thus verifying that caregivers can assess dyspnea severity accurately. Patients' perceived quality of life ratings were not significantly correlated with ratings of their caregivers' perceived quality of life. For patients, symptom distress and education were significant predictors of variance in quality of life (R2 =.35, p =.04). However, mastery, symptom distress, age, and education were found to be significant predictors of variance in quality of life of caregivers (R2 =.40, p =.02).

Concordance for cognitive impairment: a study of 50 community-dwelling elderly female-female twin pairs

The present study sought to determine concordance of cognitive impairment among elderly female twins. Cognitive testing was performed by telephone interview in a sample of 100 female-female twins older than 65 years. The participants were 32 monozygotic (MZ) and 18 dizygotic (DZ) female twin pairs, all between the ages of 65 and 86 years; their mean age was 70.2 +/- 4.6 years. All were recruited from the Institute of Psychiatry Volunteer Twin Register (IPVTR). We used the Telephone Interview for Cognitive Status (TICS) and analyzed the modified total score. Correlation's of age and zygosity were computed in relation to score on cognitive interview, and differences between MZ twin pairs (n = 32) and DZ pairs (n = 18) were analyzed using the general linear model procedure. Five subjects of the 64 MZ females (7.8%) and one DZ female (2.4%) were found to be cognitively impaired. In no case was the second twin affected. No differences in cognitive score were found between MZ and DZ twin pairs. In both groups a highly significant correlation was found between age and lower score: R(2) = -0.32, P =.009. We conclude that aging-related impairment in cognitive testing did not differ between MZ and DZ elderly female twins. Although the overall sample size was relatively small and error variance may have been introduced by imprecise measures of zygosity, the present findings are suggestive of gender differences in cognitive performance that need further evaluation.

Implications of amyloid precursor protein and subsequent beta-amyloid production to the pharmacotherapy of Alzheimer's disease

Alzheimer's disease is the most common type of dementia in older people. It is highly prevalent, affecting 35-45% of those aged 85 years or older. This disease has devastating consequences to patients, their families, caregivers, and the health care system. Much has been learned about its pathobiology, which has led to the beta-amyloid (Abeta) hypothesis. This hypothesis continues to be the predominant postulate of the pathobiology of Alzheimer's disease. Under this hypothesis, abnormal accumulation of Abeta is followed by a cascade of neurotoxic effects, which eventually result in neurodegeneration and development of Alzheimer's disease. This is thought to be the result of altered processing of the amyloid precursor protein (APP), preferentially by beta- and gamma-secretase enzymes rather than nonamyloidogenic processing by alpha-secretase. The growing body of knowledge regarding the processing of APP to various forms of Abeta has resulted in new approaches to the investigation of putative anti-Alzheimer's disease compounds, including immune-based therapies and various agents that can positively affect APP processing.

User-friendly technology to help family carers cope

BACKGROUND

Increases in the older adult population are occurring simultaneously with a growth in new technology. Modern technology presents an opportunity to enhance the quality of life and independence of older people and their family carers through communication and access to health care information.

AIM

To evaluate the usability of a multimedia software application designed to provide family carers of the elderly or disabled with information, advice and psychological support to increase their coping capacity.

INTERVENTION

The interactive application consisted of an information-based package that provided carers with advice on the promotion of psychological health, including relaxation and other coping strategies. The software application also included a carer self-assessment instrument, designed to provide both family and professional carers with information to assess how family carers were coping with their care-giving role.

DESIGN

Usability evaluation was carried out in two stages. In the first stage (verification), user trials and an evaluation questionnaire were used to refine and develop the content and usability of the multimedia software application. In the second (demonstration), stage evaluation questionnaires were used to appraise the usability of the modified software application.

FINDINGS

The findings evidenced that the majority of users found the software to be usable and informative. Some areas were highlighted for improvement in the navigation of the software.

CONCLUSIONS

The authors conclude that with further refinement, the software application has the potential to offer information and support to those who are caring for the elderly and disabled at home.

Wives giving care to husbands with Alzheimer's disease: a process of interpretive caring

Wives giving care to spouses with dementia are a particularly vulnerable segment of the caregiving population. In this article a grounded theory study of 20 such wives is described, with their experiences explained as a process of interpretive caring. Wives began the process by either seeing changes in their husbands or recognizing changes in their work. Following this, the wives moved on to a phase of drawing inferences about what they observed and then took over their husbands' roles and responsibilities. These changes prompted the wives to rewrite identities for their husbands that incorporated the dementia and to rewrite identities for themselves to reflect their new roles, abilities, and strengths. Finally, the wives set about constructing a new daily life to sustain both partners. This process is neutral and allows for positive aspects of caring to be considered along with grief and frustration.

Assessment of dementia in nursing home residents by nurses and assistants: criteria validity and determinants

OBJECTIVES

To describe the criterion validity of nursing home staff's assessment of organic disorder compared with ICD-10 criteria, and to identify determinants of staff assessment of organic disorder.

METHOD

Two hundred and eighty-eight residents were diagnosed using the GMS-AGECAT. Nursing staff members were interviewed about the residents' activities of Daily Living, behavioural problems, orientation in surroundings and communication skills, and asked if the resident had an organic disorder. Multiple logistic regression was used to select the items that most strongly determined staff assessment of organic disorder.

RESULTS

Sixty-two per cent of the residents were diagnosed by GMS-AGECAT as having organic disorder, 78% of these were correctly identified by the staff. Whether analysed among residents with or without organic disorder, or in the total group of residents, the staff assessment of the presence of organic disorder depended on a limited set of behavioural characteristics of the resident, namely 'going to the toilet in inappropriate places', 'saying things that do not make sense' and impairment in orientation.

CONCLUSIONS

Staff comprehension of organic disorder resulted in over- as well as under-labelling of residents, a tendency that will affect communication with medical personnel and may lead to inadequate or wrong medical treatment and to negative performance as well as negative role expectations in everyday life in nursing homes.

Patterns of elderly spousal caregiving in dementia care: an observational study

AIM

The aim of this study was to describe which caring activities eight spouses performed when caring for a partner with dementia, and in what way these activities were carried out.

BACKGROUND

Family caregivers are recognized as being the primary source of care for the community's older people. The largest group is comprised of spouses, with wives as the predominant caregivers. This informal care seems to be more or less invisible and performed in silence within the family. Despite the wealth of studies, the essence of family caregiving is not well understood.

METHODS

Data collection was conducted by observing the dyads in their homes. A qualitative approach inspired by grounded theory was chosen to discover qualities and describe patterns of spousal caregiving in dementia care.

RESULTS

The analysis yielded four broad themes, which included nine categories. Findings from the study shed some light on the invisible aspects besides the traditional hands-on caregiving.

CONCLUSION

The elderly carers were engaged in demanding and time-consuming care ranging from supervision to heavy physical responsibility. They were caring for as well as about their partners. The study also showed that spouses were successful in managing their situation in different ways. The results reported in this article are unique as they come from direct observations in family home settings where a spouse cared for a partner with dementia. Knowledge about family caregiving is valuable for nurses as there is an emphasis on collaboration between family caregivers and professionals.

Dementia caregiving: the role of the primary care physician

BACKGROUND

Family and friends play an important role in caring for individuals with dementia living in the community. In preparation for the Canadian Consensus Conference on Dementia held in Montreal, Canada in February 1998, the subject of dementia caregiving was reviewed in order to provide primary care physicians with some guidelines for their practice. The review was updated in June 2000 in preparation for this article.

METHOD

Pertinent English-language publications and resources from the Alzheimer Society of Canada were reviewed from 1985 onwards. Findings related to the consequences of caregiving, services for caregivers and recommendations regarding the role of the primary care physician were reviewed.

FINDINGS

Dementia caregivers experience many positive and negative consequences of caregiving. Some comprehensive services for caregivers have been shown to delay institutionalization and reduce negative consequences of caregiving. The primary care physician has a role to play in working with families and should address the following issues: 1) education about dementia; 2) psychological support for caregivers; 3) assistance mobilizing caregiver social support networks.

CONCLUSION

Primary care physicians have an important role to play in acknowledging and supporting the caregiving provided by family and friends to individuals with dementia.

Comparisons of African American and White women in the parent care role

Little is known about African American women's experiences providing care to impaired older relatives. This study investigated potential differences in depressive symptomatology, parent care stress and rewards, parent care mastery, and the quality of the parent care relationship between 261 White and 56 African American daughters and daughters-in-law who were providing care for an impaired parent or parent-in-law. Multivariate analysis of variance, controlling for significant background characteristics and interrelationships among caregiving experiences, revealed that African American women reported less stress and more rewards in the parent care role than White women did. Race did not have a significant effect on caregivers' depressive symptomatology, parent care mastery, or the quality of their relationship with the parent. However, this research demonstrates the importance of examining a broad range of caregiving experiences in order to detect both similarities and differences between African American and White caregivers.

Family issues in dementia: finding a new normal

Caring for individuals with dementia poses significant hazards and can have lasting effects on the health, well being, and quality of life of family members. Families need guidance from physicians to support and maintain the dignity of the patient with dementia throughout the degenerative disease trajectory. There is a rational basis for family education and counseling strategies aimed at increasing effectiveness and reducing risks to families who provide care. Family care for patients with Alzheimer's should be directed toward defining a "new normal."

Family-based therapy for dementia caregivers: clinical observations

Family caregiving for dementia patients is a major social and clinical problem. Family caregivers face major stressful emotional, social and economic burdens, and the negative consequences associated with caregiving are well documented. Given the projected increase in the number of people with dementia, there is a need to identify approaches that will help families manage the challenges of caregiving. Social support from friends and family members has consistently been found to mediate caregiver outcomes, yet many caregivers face problems with isolation and estrangement from family members. In this regard, family-based therapy is a promising intervention for increasing social support for caregivers, and enhancing their quality of life and ability to provide care.This paper will discuss how family-based therapy can be applied as an intervention for family caregivers of dementia patients.The clinical implications of specific interactional patterns will be presented via case examples from an ongoing clinical trial with white American and Cuban American caregivers of dementia patients.The intent is to demonstrate how identification of interactional patterns is a valuable tool for implementing family-based interventions.

Effectiveness of cognitive-behavioural family intervention in reducing the burden of care in carers of patients with Alzheimer's disease

BACKGROUND

The majority of patients with Alzheimer's disease live outside institutions and there is considerable serious psychological morbidity among their carers.

AIMS

To evaluate whether family intervention reduces the subjective burden of care in carers of patients with Alzheimer's disease and produces clinical benefits in the patients.

METHOD

A prospective single-blind randomised controlled trial with three-month follow-up in which the experimental group received family intervention and was compared with two control groups.

RESULTS

There were significant reductions in distress and depression in the intervention group compared with control groups at post-treatment and follow-up. There were significant reductions in behavioural disturbance at post-treatment and an increase in activities at three months in patients in the intervention group. Based on an improvement on the General Health Questionnaire resulting in a carer converting from a case to a non-case, the number to treat was three immediately post-treatment and two at follow-up.

CONCLUSIONS

Family intervention can have significant benefits in carers of patients with Alzheimer's disease and has a positive impact on patient behaviour.

Helping the family carers of Alzheimer’s patients: from theory…to practice. A preliminary study

Alzheimer's disease (AD) represents one of the most important health issues in the western world. The ongoing care that the AD patient requires typically causes high stress levels, fatigue, irritation and depression in the caregiver, as well as socio-economical problems. The current study aimed to introduce a support program for carers of AD patients, in order to improve their quality of life. A Questionnaire for Carers and an Anxiety State Feature Questionnaire (STAI) was used to assess the carers. Results showed an overall improvement in the carers' health. Their subjective wellbeing increased, and though their situation had not changed, they nevertheless described feeling less trapped. It can be concluded that possibly the mere fact that the carers feel that they have help available is enough to endorse the value of the program.

Elder care: a positive approach to caregiving

The primary focus of caregiving research over the past two decades has centered on the negative aspects of the caregiving process. The purpose of this paper is to show that there are positive aspects to caregiving and the importance of refocusing attention to this area. Lack of information regarding the positive dimensions of caregiving alters perceptions of the caregiving experience and limits the ability to enhance theory related to caregiver adaptation. Understanding positive aspects of caregiving may help clinicians and practitioners work more effectively with the family caregiver.

The impact of metrifonate therapy on caregivers of patients with Alzheimer's disease: results from the MALT clinical trial. Metrifonate in Alzheimer's Disease Trial

OBJECTIVE

To assess the impact on burden reported by caregivers of patients with mild to moderate Alzheimer's disease (AD) who were treated with metrifonate during a randomized double blind clinical trial.

DESIGN

Randomized clinical trial, with a 2-week screening period and a 26-week double blind, placebo controlled, treatment phase. Caregivers were assessed at baseline, at 12 weeks, and at end of trial.

SETTING

Caregivers were interviewed at clinics as part of the assessment of the patients.

PARTICIPANTS

Six hundred and three caregivers of AD patients who were enrolled in the MALT trial; 591 (98%) provided data suitable for analysis at baseline, and 546 (91%) provided data allowing for inclusion in the analysis of change scores.

MEASUREMENTS

The Caregiver Burden Assessment consisted of the Screen for Caregiver Burden, including both subjective (SCB-subj) and objective (SCB-obj) scores; the cognitive subscale of Poulshock and Deimling (PD); an abridged version of the Relatives Stress Scale (aRSS); assessments of time spent in providing care, including the Caregiver Activity Time Scale (CATS); and demographic and background variables on both the patient and caregiver.

RESULTS

Treatment of mild to moderate AD patients with metrifonate for a duration of 26 weeks significantly reduced the psychological burden of care to the caregivers, as measured by the SCB-subj, the PD, and the aRSS. There were no statistically significant differences on the measures assessing the time spent in caregiving, except for the caregiver's subjective impression of the change in time spent providing care during the trial. When comparing individual dose groups, most of the measures of burden showed the largest benefits in burden for the 60/80 mg group, followed by the 40/50 mg group, and then the placebo group. However, there was no statistically significant dose effect.

CONCLUSIONS

This study provides the first evidence from a randomized clinical trial of any acetylcholinesterase inhibitor used in the treatment of AD demonstrating a positive impact on the patient's caregiver as well as benefits to the patient. These results were shown consistently across several measurement scales and were observed after six months of treatment. These findings reinforce the clinical significance of research that has shown that metrifonate has beneficial impacts on the cognitive, behavioral, and functional abilities of AD patients. Because caregiver burden is a leading factor in the decision for institutional care placement, the ability to favorably impact that burden through pharmacological treatment of the patient is important.

Caregiving issues in the geriatric medical encounter

Families provide much-needed care for dependent older persons, which can be both burdensome and stressful. In addition to providing personal care, families often are essential for optimal chronic disease management. Thus, two critical functions of the medical encounter are to provide empathic support to family caregivers and to provide education about chronic diseases and their management. Concomitantly, a conscious effort must be made to not compromise the doctor-older patient relationship, insofar as possible. Managing the doctor-patient-family caregiver relationship is challenging, especially in the settings of cognitive impairment and end-of-life care. In these circumstances in particular, both older patients and their families need the care of their physicians.

Structural and kinetic features of amyloid beta-protein fibrillogenesis

Alzheimer's disease (AD) is an archetype of a class of diseases characterized by abnormal protein deposition. In each case, deposition manifests itself in the form of amyloid deposits composed of fibrils of otherwise normal, soluble proteins or peptides. An ever-increasing body of genetic, physiologic, and biochemical data supports the hypothesis that fibrillogenesis of the amyloid beta-protein is a seminal event in Alzheimer's disease. Inhibiting A beta fibrillogenesis is thus an important strategy for AD therapy. However, before this strategy can be implemented, a mechanistic understanding of the fibrillogenesis process must be achieved and appropriate steps selected as therapeutic targets. Following a brief introduction to AD, I review here the current state of knowledge of A beta fibrillogenesis. Special emphasis is placed on the morphologic, structural, and kinetic aspects of this complex process.