Family involvement in residential long-term care: a synthesis and critical review

The Disproportionate Impact Of Dementia On Family And Unpaid Caregiving To Older Adults

The number of US adults ages sixty-five and older who are living with dementia is substantial and expected to grow, raising concerns about the demands that will be placed on family members and other unpaid caregivers. We used data from the 2011 National Health and Aging Trends Study and its companion study, the National Study of Caregiving, to investigate the role of dementia in caregiving. We found that among family and unpaid caregivers to older noninstitutionalized adults, one-third of caregivers, and 41 percent of the hours of help they provide, help people with dementia, who account for about 10 percent of older noninstitutionalized adults. Among older adults who receive help, the vast majority in both community and residential care settings other than nursing homes rely on family or unpaid caregivers (more than 90 percent and more than 80 percent, respectively), regardless of their dementia status. Caregiving is most intense, however, to older adults with dementia in community settings and from caregivers who are spouses or daughters or who live with the care recipient.

Family Involvement in Nursing Homes: Are Family Caregivers Getting What They Want?

The provision of person-centered care for nursing home residents with dementia suggests the need for family caregiver involvement. In this article, we argue that optimal family involvement differs by family caregiver and therefore depends on the degree to which family caregivers consider their own involvement to be important. In this Canadian study, we compare the importance that 135 family caregivers of residents with dementia place on 20 kinds of involvement with the degree to which they perceive opportunities for involvement. Family Involvement Congruence Scores are calculated in three ways: those for whom involvement is important, those for whom involvement is not important, and an overall congruence score. Congruence scores varied by involvement type. These scores show promise for use in future research on family caregiver involvement and as tools for use by facilities as they endeavor to meet family caregiver expectations for involvement.

Eldercare in the transnational setting: insights from Bangladeshi transnational families in the United States

Little is known about the emotional impact of caregiving for elderly parents on migrant child in the transnational setting. To address this gap in the literature, this study examines the stressors, mediators, and outcomes of eldercare in the transnational context. Data were collected from 21 Bangladeshi immigrant men and women living in the United States who had living parents in Bangladesh over 60 years old. Despite the geographic distance, the migrants provide care to their parents such as emotional support, financial assistance, and arranging for care. While the health status of the care recipients contributed to primary objective stressors, none of the transnational caregivers' narratives reflected the presence of any subjective stressors such as role overload, role captivity, and relational deprivation. Distance and depending on others for hands-on caregiving resulted in feelings of loss of control over the caregiving process. Caregivers experienced a range of emotions from guilt, excessive worrying, and distress over the unpredictability and uncertainty of their circumstances. Kin networks, communicative technologies, and a cultural norm of filial piety contributed to mediating stress. The findings underscore the importance of supportive institutional policies such as visa and travel policies, employment leave, and counseling services for caregivers who provide care for their elderly parents transnationally.

A Pilot Evaluation of Psychosocial Support for Family Caregivers of Relatives with Dementia in Long-Term Care: The Residential Care Transition Module

This multiple method pilot evaluation aimed to generate preliminary data on the effectiveness of the Residential Care Transition Module (RCTM). The RCTM is a six-session, 4-month psychosocial intervention designed to help families manage their emotional and psychological distress following residential care placement of a cognitively impaired relative. Seventeen family caregivers of relatives in a nursing home or assisted living memory care unit were randomly assigned to the RCTM treatment condition and 19 family caregivers were assigned to a usual care control group. Caregivers in the treatment condition reported significantly (p < 0.05) less emotional distress at 4 and 8 months on self-reported surveys than those in the control group. Post-RCTM focus groups emphasized the importance of readily available psychosocial support for families following the placement transition. The findings suggest that the provision of skilled psychosocial support can help families manage emotional distress and crises in the months following a cognitively impaired relative's admission to residential long-term care.

Between worlds: the experiences and needs of former family carers

While the financial, physical and psycho-social burden for caregivers is recorded, less is known about the post-caring experience. The purpose of this qualitative descriptive study was to explore the experiences and needs of Irish former family carers in the post-caring/care transitions period. Former family carers were defined as family members who provided physical and/or social care to a family member with an illness or disability in the home for at least 6 months prior to nursing home/hospice placement or death. A total of 40 family carers were recruited from members of or known to voluntary care groups/associations in Ireland. Fourteen participants took part in a focus group discussion and 26 participated in one-to-one, semi-structured interviews, all of which were undertaken in 2010. The focus group discussion focused on gaining a broad understanding of the participants' post-caring experiences and the emergent themes formed the basis for the development of a semi-structured interview guide. Data from the focus group were analysed inductively using Creswell's qualitative analysis framework, while template analysis was the method of analysis for the 26 individual interviews. For the participants in this study, post-caring was a transition that comprised three, interrelated, non-linear, iterative themes that were represented as 'loss of the caring world', 'living in loss' and 'moving on' and symbolised as being 'between worlds'. Transition was a complex interplay of emotions overlaid with economic and social concerns that had implications for their sense of health and well-being. This exploratory study begins to address the dearth of data on post-caring/care experiences, but further research is needed to inform support interventions to enable former family carers to 'move on'.

Relatives’ participation in everyday care in special care units for persons with dementia

Background:

Research concerning relatives’ participation in the everyday care related to persons living in special care units for persons with dementia is limited.

Research questions:

To examine relatives’ participation in their near one’s everyday care, the level of burden experienced and important factors for participation, in this special context.

Design:

The study had a cross-sectional design, and data collection was carried out by means of a study-specific questionnaire.

Participants and context:

A total of 233 relatives from 23 different special care units participated.

Ethical consideration:

The study was approved by the Norwegian Social Science Data Services.

Results:

A great majority of relatives reported that they visited weekly and were the resident’s spokesperson, but seldom really participated in decisions concerning their everyday care. Participation was seldom reported as a burden.

Discussion:

This study indicated that relatives were able to make a difference to their near one’s everyday life and ensure quality of care based on their biographical expertise, intimate knowledge about and emotional bond with the resident. Since knowing the resident is a prerequisite for providing individualised care that is in line with the resident’s preferences, information concerning these issues is of utmost importance.

Conclusion:

This study prompts reflection about what it is to be a spokesperson and whether everyday care is neglected in this role. Even though relatives were satisfied with the care provided, half of them perceived their participation as crucial for the resident’s well-being. This indicated that relatives were able to offer important extras due to their biographical expertise, intimate knowledge about and emotional bond with the resident. Good routines securing that written information about the residents’ life history and preferences is available and used should be implemented in practice.

Reaction to Caregiving by Hospice Caregivers Upon Enrollment

Significant research exists demonstrating the challenges faced by informal family caregivers as they care for their loved ones. How caregivers react to this experience, especially in the case of a terminal illness, is less understood. This study explores the reactions of hospice caregivers to their caregiving experience prior to enrollment in hospice and identifies potential stressors associated with those reactions. Results found anxiety to be a significant predictor in the reaction of caregivers to their caregiving experience upon hospice enrollment.

The existential life situations of spouses of persons with dementia before and after relocating to a nursing home

OBJECTIVES

The aim was to describe the existential life situations of spouses who care for persons with dementia, before and after relocation to nursing homes.

METHOD

This was a qualitative study among 11 spouses of persons with dementia, recruited via purposeful sampling. Data were collected through interviews and analysed with interpretive content analysis.

RESULTS

Before the relocation to nursing homes, the spouses' existential life situations were characterized by feelings of shame and guilt, being isolated in the home. Spouses were also exposed to psychological threats, physical violence, and had feelings of placing one's own needs last. After the relocation, spouses described feelings of guilt and freedom, living with grief and thoughts of death, feelings of loneliness in the spousal relationship, and striving for acceptance despite a lack of completion.

CONCLUSION

The existential life situation of spouses of persons with dementia is about being in limit situations which changes when the ill person relocates to a nursing home. This is important knowledge for health care staff to bear in mind at nursing homes when encountering spouses.

The Impact of Family Visitation on Feeding Assistance Quality in Nursing Homes

The purpose of this study was to determine: (a) the frequency of family visitation during mealtime and (b) whether the presence of family during meals had an impact on the quality of feeding assistance care and resident intake. Participants included 74 nursing home residents from two Veterans Affairs (VA) and four community facilities in one geographic region. Mealtime periods in which family was present were compared with mealtime periods when family was not present for the same resident. Results showed that family visitation was infrequent during mealtime; however, feeding assistance time was significantly higher when visitors were present. Despite the increase in assistance time, there was not a significant difference in intake. Strategies that encourage the involvement of family in mealtime assistance may have additional benefits not directly associated with meal consumption, including providing family members with meaningful activity during a visit and enhancing residents’ quality of life and well-being.

Experiences faced by next of kin during their older family members' transition into long-term care in a Norwegian nursing home

AIMS AND OBJECTIVES

To describe and explore experiences of next of kin during the older persons' transition into long-term care.

BACKGROUND

Moving into long-term care is a challenge for both resident and next of kin. Next of kin experience transitions at the same time as they play significant parts in their family members' transition into long-term care placement.

DESIGN

Constructivist hermeneutical design.

METHODS

Ten next of kin to newly admitted eight residents were recruited by purposeful sampling and interviewed. Periodic participant observation periods following new residents on arrival day and the first week after admission and some written documentation were the backdrops to the interviews.

RESULTS

What happened prior to the long-term care placement as well as what happened in the initial period of transition influenced the experiences of next of kin. Characteristics of their experiences were: 'striving to handle the new situation', 'still feeling responsible', and 'maintaining dignity and continuity'.

CONCLUSIONS

Next of kin were unprepared for the transition and had little support from staff. Staff lacked awareness about next of kin's transition experiences. Their involvement with next of kin was unpredictable, and this added to the burdens of next of kin in this period.

RELEVANCE TO CLINICAL PRACTICE

Knowledge about experiences of next of kin needs to be acknowledged among healthcare professionals. Health professionals need to pay attention to what happens across institutional borders within families as well as between staff and family members. Individual family members need support in this period of change.

Predictors of institutionalization of dementia patients in mild and moderate stages: a 4-year prospective analysis

Background

Institutionalization is the most important milestone in the care of dementia patients. This study was aimed at identifying relevant predictors of institutionalization in a broad empirical context and interpreting them on the basis of the predictor model proposed by Luppa et al. [Dement Geriatr Cogn Disord 2008;26:65-78].

Methods

At the start of this study, 357 patients with mild to moderate dementia were examined by their general practitioners, and a telephone interview was conducted with their caregivers. Four years later, the outcomes ‘institutionalization’ and ‘death’ were determined from health insurance data. Forty-one variables were examined for their predictive influence by univariate and multivariate Cox regression.

Results

The risk of institutionalization increased significantly (p ≤ 0.05) with older ages of patients [hazard ratio (HR) = 1.05] and caregivers (HR = 1.03), a higher educational level of the caregiver (HR = 1.83), greater use of community health services (HR = 1.59), greater caregiver burden (HR = 1.02), and when the caregiver and patient lived apart (HR = 1.97).

Conclusion

The results show that there is a multifactorial influence on institutionalization of dementia patients by sociodemographic, health-related, and psychological aspects as well as the care situation, thus validating the predictor model by Luppa et al. [Dement Geriatr Cogn Disord 2008;26:65-78]. Caregiver burden was found to be the strongest predictor accessible to interventions.

Sense of community in long-term care: the views of family caregivers of elderly military veterans

BACKGROUND

Family involvement in long-term care (LTC) is important but it can prove challenging and result in conflict with staff if families do not feel connected to the LTC facility or if they believe that their contributions are undervalued. According to McMillan & Chavis (1986), sense of community (SOC) refers to a feeling of belonging, having influence, having needs met, and having an emotional connection to individuals in a community, and may be particularly essential for family caregivers of military veterans in LTC. This is the first study that evaluates SOC among family caregivers in LTC.

METHODS

Semi-structured interviews and self-report questionnaires assessing caregiver demographics, caregiving variables, and SOC were administered to 46 family caregivers.

RESULTS

Caregivers endorsed a SOC that was positively related to key caregiving variables, such as family adjustment and satisfaction with care, and was negatively related to conflict with staff. Notably, caregivers' connections to the military community were positively related to SOC in LTC. Multiple regression analyses indicated that satisfaction with care accounted for the most variance in SOC (32.7%).

CONCLUSIONS

This is the first study that examines SOC among family caregivers of military veterans in LTC, a subgroup of family caregivers with unique histories and needs. Although there are measures designed to assess family members' level of satisfaction with different facets of LTC, SOC provides unique information about whether family members feel part of the LTC community as valued partners in care. SOC is an important yet understudied construct that could contribute substantially to our understanding of family-focused care.

Dementia and its influence on quality of life and what it means to be valued: Family members’ perceptions

This pragmatic, exploratory qualitative study, as part of a larger funded research project, sought to explore families’ perspectives on what it means to value a person with dementia and how this value might influence the quality of life of people with dementia. In-depth interviews were conducted with 20 family members who used one long-term care service provider in Australia. Families described the factors influencing a positive quality of life for the person with dementia as being related to the environment and, in particular, to the resident’s room, supportive staff and individualised care that valued the person’s life experience. Family also reported a negative impact on quality of life when staff and the care facility neglected to provide an individualised approach. This study highlights the importance of demonstrating the value of the person with dementia, the family role and partnerships of care.

Convoys of care: theorizing intersections of formal and informal care

Although most care to frail elders is provided informally, much of this care is paired with formal care services. Yet, common approaches to conceptualizing the formal-informal intersection often are static, do not consider self-care, and typically do not account for multi-level influences. In response, we introduce the "convoy of care" model as an alternative way to conceptualize the intersection and to theorize connections between care convoy properties and caregiver and recipient outcomes. The model draws on Kahn and Antonucci's (1980) convoy model of social relations, expanding it to include both formal and informal care providers and also incorporates theoretical and conceptual threads from life course, feminist gerontology, social ecology, and symbolic interactionist perspectives. This article synthesizes theoretical and empirical knowledge and demonstrates the convoy of care model in an increasingly popular long-term care setting, assisted living. We conceptualize care convoys as dynamic, evolving, person- and family-specific, and influenced by a host of multi-level factors. Care convoys have implications for older adults' quality of care and ability to age in place, for job satisfaction and retention among formal caregivers, and for informal caregiver burden. The model moves beyond existing conceptual work to provide a comprehensive, multi-level, multi-factor framework that can be used to inform future research, including research in other care settings, and to spark further theoretical development.

Families Matter in Long-Term Care: Results of a Group-Randomized Trial

This group-randomized trial implemented and evaluated an intervention to reduce staff burden and improve family and resident outcomes by helping families create meaningful roles for themselves in residential care/assisted living and nursing homes. Across 24 sites, families (N = 490) and staff (N = 397) provided data over six months about family involvement, family and staff well-being and attitudes, and resident quality of life. Intervention subjects participated in workshops and created service plans to identify family roles. For families, the intervention decreased burden and improved resident quality of life but also increased guilt and conflict. Staff reported less burnout and greater partnership with families, and felt families were more empathic. Consequently, there are benefits to increasing family involvement, but attention must be paid to potential barriers and negative outcomes.

Family caregiver involvement for long-term care residents at the end of life

OBJECTIVES

To examine family caregiver involvement for long-term care (LTC) residents during the last month of life. Researchers examined direct (personal care and meals) and indirect (management and monitoring) types of caregiver involvement and the relationship between the type of involvement and predisposing, enabling, and need characteristics. Researchers also examined whether the frequency of involvement changed during the end-of-life (EOL) period.

METHOD

Researchers used an expanded version of Andersen's Behavioral Model to conceptualize predictors of family involvement for 438 residents in 125 residential care/assisted living and nursing home settings. Bivariate and multivariate analyses examined relationships among variables.

RESULTS

More than one-half of family caregivers monitored, managed care and assisted with meals, and 40% assisted with personal care tasks. The enabling characteristic of days visited and the need characteristic of caregiver role strain were related to each of the 4 types of involvement. However, the other correlates were distinct to the type of involvement.

DISCUSSION

Families are involved in EOL care in LTC settings. Higher role strain is related to more involvement in each of the 4 types of involvement, suggesting that whether involvement is by desire, perceived need, or both, there is cause to more critically examine the family caregiver's desired role and need for support.

Identifying at-risk dementia caregivers following institutionalization: the nursing home admission-burden and nursing home admission-depression prognostic tools

The current study developed prognostic tools to identify dementia caregivers at-risk for clinically relevant burden or depressive symptoms following nursing home admission (NHA) of their family members. A retrospective, longitudinal design was used that included 1,610 dementia caregivers who provided data prior to and up to 6 months following nursing home admission. Response operant characteristic (ROC) curves were constructed to test and validate two prognostic tools: the NHA-Burden and NHA-Depression tools. An ROC curve yielded a sensitivity of 77% and a specificity of 62.5% at a cutoff score of 5.41 for the NHA-Burden Prognostic tool. A second ROC curve indicated a sensitivity of 75.4% and a specificity of 62.5% at a cutoff score of 7.45 for the NHA-Depression tool. Clinicians may wish to utilize cutpoints on the NHA-Burden and NHA-Depression tools to ensure that more persons who are at-risk for clinically significant burden or depression during NHA are identified.

Stakeholder perspectives on transitions of nursing home residents to hospital emergency departments and back in two Canadian provinces

Major gaps exist in our understanding of transitions in care for older persons living in nursing homes. The purpose of the study was to identify key elements, from multiple stakeholder perspectives, that influence the success of transitions experienced by nursing home residents when they required transfer to a hospital emergency department. This interpretive descriptive study was conducted in two cities in the Canadian provinces of British Columbia and Alberta. Data were collected from 71 participants via focus groups and individual interviews with nursing home residents, family members, and professional healthcare providers working in nursing homes, emergency departments, and emergency medical services. Transcripts were analyzed using constant comparison. The elements contributing to the success of transitions reflected a patient- and family-centered approach to care. Transitions were influenced by the complex interplay of multiple elements that included: knowing the resident; critical geriatric knowledge and skilled assessment; positive relationships; effective communication; and timeliness. When one or more of the elements was absent or compromised, the success of the transition was also compromised. There was consistency about the importance of all the identified elements across all stakeholder groups whether they are residents, family members, or health professionals in nursing homes, emergency departments or emergency medical services. Aspects of many of these elements are modifiable and suggest viable targets for interventions aimed at improving the success of transitions for this vulnerable population.

Caregivers' desired patterns of communication with nursing home staff- just TALKKK!

Individuals with cognitive impairment often represent a significant percentage of the residents in a nursing home nurse's care. With years of experience caring for their placed family members, caregivers of these residents are often experts in knowing the resident's needs, habits, behaviors, and moods. Caregivers often wish to convey this insider knowledge to nursing home staff. Furthermore, communication with caregivers promotes trust that personalized, safe, and effective care occurs when they are not there. Based on an interpretive study of the experiences of caregivers who place a family member with Alzheimer's disease in the nursing home, six preferred patterns of communication are presented in this article. The six patterns are represented by the acronym TALKKK (tell them; ask them; listen to them; know their family member by relating and communicating; be knowledgeable about dementia, its progression, dementia-specific care, and commonly used medications; and share that knowledge with them).

Grey spaces: the wheeled fields of residential care

Many individuals living in residential care use a wheelchair as their primary means of mobility. Although studies have documented challenges encountered by residents in these facilities, few have addressed the role that wheelchairs, as potential enablers and barriers to mobility and participation, play in their lives. To better understand residents' experiences, an ethnographic study was conducted drawing on Bourdieu's theoretical constructs of capital, field, and habitus. Participant observations were conducted at two facilities, and residents, family members and staff took part in in-depth individual interviews. Our analysis revealed three themes. Ready to roll detailed how residents used wheelchairs as a source of comfort and means for expanding their social space, while staff could use them as a means to move and control some residents. Squeaky wheels described how residents solicited assistance from staff and family amid having to wait to perform activities of daily living. In, out and about revealed diversity in the places residents went, spaces they shared and the social activities in which they engaged inside and outside their residential facilities. The study findings emphasise how wheelchairs constitute capital that governs many fields of practice for residents and staff and suggest how practice and policy might be adjusted.

A quasi-experimental design trial exploring the effect of a partnership intervention on family and staff well-being in long-term dementia care

OBJECTIVES

This study sought to explore the effect of the family involvement in care (FIC) intervention on family and staff well-being over a nine-month period in a long-term care (LTC) facility providing dementia care.

METHOD

A quasi-experimental design with randomised allocation of two LTC sites but not the participants was employed. Family caregivers (n = 57) of residents with dementia and staff (n = 59) from two LTC facilities in Queensland, Australia, were recruited. Participants were assessed once pre-intervention and three times post-intervention for knowledge, stress and satisfaction outcomes. Between-group and within-group effects were analysed using ANOVAs at <0.05 level of significance. Pre- and post-intervention interviews from a purposive sample of family caregivers were also conducted to enhance understanding of FIC benefits.

RESULTS

Beneficial intervention effects associated with family caregivers' knowledge of dementia were found (p < 0.001). Negative intervention effects were also found for family satisfaction outcomes in relation to staff consideration of their relatives and management effectiveness (p < 0.05). In addition, staff well-being and job satisfaction were found to be negatively affected by their perceived inappropriate behaviour of residents with dementia (p < 0.05).

CONCLUSION

Participation in the FIC intervention improved family caregiver knowledge. The major barrier to the success of the partnership intervention in achieving beneficial long-term psychosocial effects for family and staff caregivers was lack of resources and leadership required to support collaboration between family and staff, mainly due to environment and structural changes. This study contributes to our understanding of the importance of partnerships in promoting family involvement in dementia care.

Predictors of mobility among wheelchair using residents in long-term care

OBJECTIVE

To identify predictors of mobility among long-term care residents who use wheelchairs as their main means of mobility. Based on the Matching Person to Technology Model, we hypothesized that wheelchair-related, personal, and environmental factors would be independent predictors of mobility.

DESIGN

Cross-sectional study.

SETTING

Eleven long-term residential care facilities in the lower mainland of British Columbia, Canada.

PARTICIPANTS

Residents (N=268): self-responding residents (n=149) and residents who required proxy respondents (n=119).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Mobility was measured using the Nursing Home Life-Space Diameter. Standardized measures of personal, wheelchair-related, and environmental factors were administered and sociodemographic data were collected as independent variables.

RESULTS

Independent mobility decreased as the distance from the resident's room increased: 63% of participants were independently mobile on their units, 40% were independently mobile off their units within the facilities, and 20% were independently mobile outdoors. For the total sample, the significant predictors of mobility, in descending order of importance, were: wheelchair skills (including the capacity to engage brakes and maneuver), functional independence in activities of daily living, having 4 or more visits per week from friends or family, and use of a power wheelchair. This regression model accounted for 48% of variance in mobility scores.

CONCLUSIONS

Limited independent mobility is a common problem among facility residents. Residents may benefit from interventions such as wheelchair skills training or provision of powered mobility, but the effectiveness of these interventions needs to be evaluated.

Psychometric properties of the Caregiving Burden Scale for Family Caregivers with Relatives in Nursing Homes: scale development

AIM

Most family caregivers continue their caregiving for frail relatives after admitting them to long-term care facilities. The characteristics of this caregiving differ from those related to caregiving in home-care settings. Thus, a new tool to evaluate the burden of family caregivers in institutional settings is needed. The aim of this study was to develop a new scale, the Caregiving Burden Scale for Family Caregivers with Relatives in Nursing Homes, and to confirm its validity and reliability.

METHODS

We conducted two cross-sectional questionnaire surveys. The participants were a convenience sample of family members of residents in seven nursing homes for the validation study and in three nursing homes for the test-retest study in Japan. Statistical analyses examined exploratory/confirmatory factor analyses, internal consistency, concurrent/discriminate validity, and test-retest reliability.

RESULTS

A four-factor solution with 16 items was selected as the most interpretable questionnaire. In the confirmatory factor analysis, the indices of fitness highly supported these results. The Cronbach's alpha coefficient for the total score was 0.86 and varied between 0.77 and 0.87 in the four domains. The scale showed moderate correlation with the Nursing Home Hassles Scale, suggesting its concurrent validity. The four domains had only a medium correlation with each other, indicating discriminate validity.

CONCLUSIONS

The developed scale has acceptable validity and reliability for measuring the caregiving burden of family members with relatives in Japanese nursing homes. Future studies using the scale might lead to the improvement of care for family members with relatives in a long-term care setting.

Clinically significant changes in burden and depression among dementia caregivers following nursing home admission

BACKGROUND

Although extensive research exists on informal long-term care, little work has examined the clinical significance of transitions in family caregiving due to a lack of established clinical cut-points on key measures. The objectives of this study were to determine whether clinically significant changes in symptoms of burden and depression occur among caregivers within 12 months of nursing home admission (NHA) of their relatives with dementia, and to identify key predictors of clinically persistent burden and depression in the first year after institutionalization.

METHODS

Secondary longitudinal analysis of dementia caregivers were recruited from eight catchment areas in the United States with 6- and 12-month post-placement follow-up data. The sample included data on 1,610 dementia caregivers with pre- and six-month post-placement data and 1,116 with pre-placement, six-month, and 12-month post-placement data. Burden was measured with a modified version of the Zarit Burden Inventory. Depressive symptoms were assessed with the Geriatric Depression Scale.

RESULTS

Chi-square analyses found significant (P < .05) reductions in the number of caregivers who reported clinically significant burden and depressive symptoms after NHA compared to pre-placement. Logistic regression models revealed that wives and daughters were most likely to experience clinically persistent burden and husbands were most likely to experience clinically significant depression after NHA.

CONCLUSIONS

In addition to suggesting that clinically significant decreases in caregiver burden and depression are likely to occur following institutionalization, the results reveal particular subsets of caregivers who are at continued risk of distress. Such findings can facilitate development of screening processes to identify families at-risk following institutionalization.

Caregiver participation in hospice interdisciplinary team meetings via videophone technology: A pilot study to improve pain management

This article discusses a pilot study testing a videophone intervention enabling hospice patients and caregivers to remotely participate in interdisciplinary team meetings, with the goal of improving pain management. The aim of this study was to test potential outcome measures and combine the data with qualitative observations to assess the overall feasibility and promise of the intervention. The outcomes evaluated included hospice patient quality of life, caregiver perceptions of pain medications, caregiver quality of life, and caregiver anxiety related to team participation. The pilot study showed that caregiver participation in the care planning process is feasible and may change caregiver perceptions of pain medication, potentially improving pain management for hospice patients.

Nursing home staffing and training recommendations for promoting older adults' quality of care and life: Part 1. Deficits in the quality of care due to understaffing and undertraining

Caught between the inability or unwillingness of nursing home corporations and owners to redistribute revenue and the reluctance of federal and state agencies to increase payments to nursing homes, the nation's most vulnerable older adults are not receiving the care they deserve. Widespread recognition of substandard care and quality of life of older adults in nursing homes has existed for decades. In addition, there is substantial evidence that poor quality of care is related to inadequate numbers and training of nursing staff. Still, policy makers and nursing home owners have failed to take needed action. In the first article of this two-part series, major deficits in the care of older adult nursing home residents are reviewed, and research documenting the relationship between nursing home staffing and the quality of care and life of residents is summarized.

Do trajectories of at-home dementia caregiving account for burden after nursing home placement? A growth curve analysis

Transitioning to the nursing home setting is a complex process for family caregivers of older adults with dementia. While nursing home placement (NHP) can alleviate certain caregiving responsibilities, new stressors can also emerge. In the present study, the researchers examined how care-related factors can change leading up to NHP and how these factors influence caregiver outcomes following NHP. A sample of 634 family dementia caregivers (n = 634) were surveyed at three six-month intervals prior to NHP and once during the 12 month period following institutionalization. Growth curve modeling revealed dynamic changes in certain factors leading up to NHP (e.g., caregivers' perceived health), while other factors remained stable (e.g., caregiver burden). Several factors emerged as significant predictors of caregiver burden following NHP, including pre-placement burden and adult day service utilization. For geriatric social workers, these findings may be useful in assessing family caregivers, and in the development and utilization of appropriate interventions.

Supporting relationships between family and staff in continuing care settings

In this Canadian study, a participatory action research approach was used to examine the relationships between families of residents of traditional continuing care facilities and the health care team. The objectives were to (a) explore the formation and maintenance of family-staff relationships, with attention paid to the relational elements of engagement and mutual respect; (b) explore family and staff perspectives of environmental supports and constraints; and (c) identify practical ways to support and enhance these relationships. Results indicate that the resource-constrained context of continuing care has directly impacted family and staff relationships. The nature of these relationships are discussed using the themes of "Everybody Knows Your Name," "Loss and Laundry," "It's the Little Things That Count," and "The Chasm of Us Versus Them." Families' and staff's ideas of behaviors that support or undermine relationships are identified, as are concrete suggestions for improving family- staff relationships in traditional continuing care settings in Canada.

Increasing mental health awareness and appropriate service use in older Chinese Americans: a pilot intervention

OBJECTIVE

This study evaluated the effectiveness of a community intervention in increasing awareness of mental health issues and available resources among elderly Chinese Americans.

METHODS

Twenty-seven members of a community church received a 1-h didactic presentation, in English and Mandarin, and completed surveys regarding their help-seeking preferences before and after the intervention. Results were analyzed using a series of Wilcoxon matched-pair signed rank tests and comparing pre- and post-test scores.

RESULTS

Findings indicated an increase (p<.05) in intention to consult a mental health professional for psychiatric symptoms at post-test. A significant increase also was found in preference for consulting a physician for physical symptoms.

CONCLUSION

The pilot educational intervention increased awareness of mental health and treatment issues and the role of mental health professionals, lending support to evaluate the intervention on a larger scale.

PRACTICE IMPLICATIONS

Greater awareness of mental health among Chinese Americans can be promoted via education forums provided through faith-based organizations. Stigma of mental illness leads many Chinese individuals to seek help for psychiatric problems from primary care physicians. Integrating mental health practitioners in primary care settings may help decrease stigma and encourage appropriate help-seeking behavior.

Predictors of change in caregiver burden and depressive symptoms following nursing home admission

Prior research has yielded discrepant findings regarding change in caregiver burden or depressive symptoms after institutionalization of persons with dementia. However, earlier studies often included small postplacement samples. In samples of 1,610 and 1,116 dementia caregivers with up to 6 months' and 12 months' postplacement data, respectively, this study identified predictors of change in caregiver burden and depressive symptoms following nursing home admission. Descriptive analyses found that caregivers reported significant and considerable decreases in burden in the 6- and 12-month postplacement panels. A number of variables predicted increased burden and depressive symptoms in the 6- and 12-month postplacement panels. Preplacement measures of burden and depressive symptoms, site (Florida), overnight hospital use, and spousal relationship appear to result in impaired caregiver well-being following nursing home admission. Incorporating more specific measures of stress, considering the influence of health-related transitions, and coordinating clinical strategies that balance caregivers' needs for placement with sustainability of at-home care are important challenges for future research.

Advocating for a parent with dementia in a long-term care facility: the process experienced by daughters

Daughter caregivers of elders with dementia become their parents' advocates over time. This role takes on even greater importance when one or both parents are placed in a long-term care facility. This article presents the results of a qualitative study aimed at explaining how this advocacy role evolves following institutionalization. In-depth interviews were conducted with daughters (N = 14) of an institutionalized parent with dementia and selected using a theoretical sampling procedure. Data analysis using grounded theory revealed three interrelated processes that explain role transformation of the daughters: integration in the care setting, evaluation of quality of care, and development of trust. Implications for involving daughters as care partners in long-term care settings are offered.

"I get along with most of them": direct care workers' relationships with residents' families in assisted living

PURPOSE

The purpose of this article was to explore staff-family relationships in assisted living facilities (ALFs) as they are experienced by care staff and perceived by administrators. We identify factors that influence relationships and explore how interactions with residents' families affect care staff's caregiving experiences.

DESIGN AND METHODS

The data are drawn from a statewide study involving 45 ALFs in Georgia. Using grounded theory methods, we analyze qualitative data from in-depth interviews with 41 care staff and 43 administrators, and survey data from 370 care staff.

RESULTS

Care workers characterized their relationships with most family members as "good" or "pretty good" and aspired to develop relationships that offered personal and professional affirmation. The presence or absence of affirmation was central to understanding how these relationships influenced care staffs' on-the-job experiences. Community, facility, and individual factors influenced the development of relationships and corresponding experiences. Insofar as interactions with family members were rewarding or frustrating, relationships exerted positive or negative influences on workers' caregiving experiences.

IMPLICATIONS

Findings suggest the need to create environments -- through policy and practice -- where both parties are empathetic of one another and view themselves as partners. Doing so would have positive outcomes for care workers, family members, and residents.

Emotional and physical health of informal caregivers of residents at the end of life: the role of social support

OBJECTIVES

The objectives of this study were to examine the relationship between selected decedent and caregiver characteristics, facility-related perceptions, and emotional and physical health of 434 informal caregivers (94% family) of recently deceased residents of residential care/assisted living facilities and nursing homes. We also examined potential mediating effects of social support (informal, staff, and spiritual).

METHODS

We analyzed data using linear mixed models.

RESULTS

Among caregivers, younger age, female gender, more education, financial burden, other dependents, poorer perceptions of care, and more care involvement were associated with more emotional strain. More staff support also was associated with more emotional strain and partially mediated the relationship between having a trusted staff member and emotional strain. Characteristics associated with poorer physical health included unemployment, financial burden, poorer physician communication, and trusted staff member. Informal social support was directly related to better physical health and mediated the relationships between physical health and both physician communication and financial burden.

DISCUSSION

Many characteristics related to end-of-life caregiving outcomes in long-term care are consistent with community-based studies, suggesting that end-of-life caregiving outcomes in long-term care are not markedly different than in other settings. However, the role of staff support may either facilitate or complicate emotional strain and merits additional study.

Can counseling and support reduce burden and depressive symptoms in caregivers of people with Alzheimer's disease during the transition to institutionalization? Results from the New York University caregiver intervention study

OBJECTIVES

To determine whether counseling and support reduce the burden and depressive symptoms of spouse caregivers of patients with Alzheimer's disease (AD) during the transition to institutionalization.

DESIGN

A randomized, controlled trial of an enhanced counseling and support program for spouse caregivers of persons with AD. Structured interviews were conducted with spouse caregivers at baseline, every 4 months during Year 1, and every 6 months thereafter for up to 16 years.

SETTING

Outpatient research clinic in the New York City metropolitan area.

PARTICIPANTS

Referred volunteer sample of 406 spouse caregivers of community-dwelling patients with AD enrolled over a 9.5-year period.

INTERVENTION

Enhanced counseling and support consisting of six sessions of individual and family counseling, support group participation, and continuous availability of ad hoc telephone counseling.

MEASUREMENTS

Outcome measures included burden (modified Zarit Burden Interview) and depressive symptoms (Geriatric Depression Scale).

RESULTS

Burden and depressive symptoms were significantly lower for caregivers in the treatment group than for controls receiving usual care at the time of and after institutionalization. Nursing home admission itself significantly reduced burden and depressive symptoms in the intervention and control groups.

CONCLUSION

Institutionalization alone can reduce caregiver burden and depressive symptoms, but enhanced counseling provides additional long-term benefits. The results offer some of the first clinical evidence of the benefits of enhanced counseling during the transition to institutionalization for caregivers of people with AD.

The Importance of Family Relationships With Nursing Facility Staff for Family Caregiver Burden and Depression

We explore the association between family caregiver depression and the quality of staff-family relationships, and we test burden as a mediator of this relationship. Using structural equation modeling, we used data from a representative sample of 932 family members from 20 nursing homes in Central New York to examine the association between staff-family relationship quality and family caregiver depression. We then tested family caregiver burden as a mediator of the relationship between staff-family relationship quality and family caregiver depression. Staff-family relationship quality, specifically perceived conflict with staff, is significantly associated with family caregiver depression. Further, caregiver burden mediates this relationship. Interventions to improve staff-family relationships may impact family caregiver depression by reducing the stress that family caregivers experience.

A Study of Family Councils in Nursing Homes

Families can remain actively involved in the care of their residents by participating in a Family Council within the nursing home (NH). A Family Council is an independent, self-determining group of NH residents' families and friends and often includes a nursing facility liaison.

PROBLEM

Less than half of NHs has an active council.

PURPOSE

To determine the presence, characteristics, and impact of Family Councils.

METHOD

A descriptive study was conducted. Mailed surveys to NH administrators and personal interviews of Family Council members were included in this study. The survey was mailed to administrators in all 60 licensed NHs in a metropolitan county in the southwestern United States.

RESULTS

Sixteen NH administrators responded, with 12 (75%) of the 16 reporting the presence of an active Family Council. Three administrators provided the name of a member of their facility's Family Council who were interviewed by telephone. Both the survey and personal interview results supported the positive effect of active Family Councils to provide mutual support, empower its members, and advocate change to improve the residents' quality of life.

Working with families in long-term care

Effective communication with families can improve clinical process and outcomes in long-term care. Such communication may be challenging to long-term care clinicians, who may feel they lack requisite skills or are uncomfortable with potentially charged and negative emotions that may result. These barriers can be overcome by using models of family behavior and of physician involvement in family counseling to foster understanding and organize family meetings. We present such models in this article. The first of these, the Pearlin Stress Process Model offers a framework for understanding family adaptation to long-term care. Within the Pearlin model, family function is a critical intervening variable. Structural Family Systems Theory is therefore examined next to guide to recognition of family characteristics that impact communication. We focus on translation of these theories to long-term care practice through clinical case vignettes. Applying the Levels of Physician Involvement in family oriented care to long-term care, we then suggest an organizing, stepwise process for the family meeting itself. We conclude with strategies for conflict management and a discussion of the importance of the interdisciplinary team in family care.

Family vigilance: improving the experience and outcome

PROBLEM

Our facility encourages family involvement, but some families are rude, intrusive, or disruptive. Occasionally, this derails staff-family relationships. How can we turn this around?

SOLUTION

Family vigilance at its most intense can become disruptive. Understanding the dynamics of family vigilance is key. Knowing, anticipating, and preventing its pitfalls make family involvement an asset.

Families and assisted living

PURPOSE

Despite growing research on assisted living (AL) as a residential care option for older adults, the social ramifications of residents' transitions to AL are relatively unexplored. This article examines family involvement in AL, including family structures of residents, types of involvement from family members living outside the AL facility, and outcomes for these family members.

DESIGN AND METHODS

We reviewed current literature utilizing the MEDLINE, PsycINFO, and CINAHL databases to identify AL studies that examined issues pertaining to families or informal care. Following the screening of abstracts, we retrieved 180 reports for further review and selected 62 studies for inclusion.

RESULTS

Families visit residents frequently and provide a wide range of instrumental assistance but provide only minimal personal care. Studies of family outcomes indicated relatively high satisfaction but potential care burden as well.

IMPLICATIONS

How family care and involvement occurs in AL in relation to formal care provision and whether various types of formal/informal care integration influence family outcomes remains unclear. We suggest a research agenda that attempts to tease out causal relationships for family involvement, differentiate family roles, and implement longitudinal analyses for a range of family outcomes.