A two-factor model of caregiving appraisal and psychological well-being

Caring for a Yobiyose-rojin: a comparison of burden on daughters and daughters-in-law

The issue of "Yobiyose-rojin," elderly parents relocated to the home of one of their children because of the care required by their physical and mental conditions, has been the subject of recent attention in Japan. To determine the effective assistance that caregivers require, the authors compared daughters with daughters-in-law who care for an elderly parent in terms of characteristics and factors that might contribute to the caregiver's burden. Daughters-in-law perceived a much stronger burden although they took care of a less-impaired parent for fewer hours a day than daughters. The results indicated that an appropriate form of support must be carefully chosen based on the identity of the primary caregiver.

Using cognitive mapping to explore women caregivers' experiences

Women are often faced with the primary role of providing care for individuals with Alzheimer 's disease (AD). This study explored women caregiver's perceptions of caregiving through the use of Cognitive Mapping (CM), a qualitative research method. Volunteers were recruited from caregiver support groups to construct maps of their experience of "caregiving for someone with AD. " Maps were analyzed for commonly identified concepts and relationships. Twelve participants identified 280 concepts, 206 of which were unduplicated. Concepts were collapsed into 17 categories; the largest concepts being "friends and family," "sad," "frustration," and "time." The maps produced by the sample in this study were unique, providing evidence that the experience of AD caregiving varies significantly among caregivers. CM appears to be effective for identifying caregiver stressors and needed support services.

A psycho-educational intervention for family caregivers of patients receiving palliative care: a randomized controlled trial

This study describes an evaluation of a psycho-educational intervention for family caregivers of patients dying of cancer at home. In a randomized controlled trial, participants (n = 106) received standard home-based palliative care services (n = 52) or these services plus the new intervention (n = 54). Data were collected at three time points: upon commencement of home-based palliative care (Time 1), five weeks later (Time 2), and then eight weeks following patient death (Time 3). No intervention effects were identified with respect to preparedness to care, self-efficacy, competence, and anxiety. However, participants who received the intervention reported a significantly more positive caregiver experience than those who received standard care at both Times 2 and 3. The findings indicate that it is possible to increase caregiver rewards despite being immersed in challenging circumstances that often yield considerable negative psychosocial sequelae. Furthermore, it is feasible for health professionals to discuss emotive topics, such as impending death, with caregivers without adverse effects.

Economic Burdens and Quality of Life of Family Caregivers of Cancer Patients

OBJECTIVES

We conducted this study to identify factors influencing the burdens cancer brings to a patient's family and to evaluate the association between the burdens and the caregiver's quality of life (QOL).

METHODS

Participants were drawn from the primary family caregivers of cancer patients at 6 university hospitals and the National Cancer Center in Korea. Of the 738 eligible caregivers, 704 (95.4%) completed the questionnaire packets (Family Impact Questions and Caregiver's QOL-Cancer).

RESULTS

Caregivers, who were poor (OR, 2.11; 95% CI, 1.44-3.10), whose health status was poor (OR, 1.87; 95% CI, 1.29-2.70), who were married (OR, 1.75; 95% CI, 1.12-2.72), who provided care for a long time (OR, 2.29; 95% CI, 1.59-3.28), who cared for patients with poor performance status (OR, 1.35; 95% CI, 1.00-1.82), and who paid high medical expenses (OR, 1.70; 95% CI, 1.21-2.40), were more likely to lose their family savings. In multiple regression analysis, most burden variables--including requiring caregiving assistance, major life change, inability to function normally, loss of savings, loss of income, and altered educational plans--were associated with caregiver QOL. Loss of family income, which was related to economic issues, was most strongly associated with it (16.0%).

CONCLUSIONS

Our study suggests that to improve caregiver QOL, we should give priority to decreasing the economic burden that cancer places on patient's family.

Positive contributions made by children with an intellectual disability in the family: mothers' and fathers' perceptions

The aims of this article were to test the psychometric properties of the Positive Contributions Scale (PCS), and to compare perceptions of positive contributions reported by mothers and fathers. Participants were 140 mothers and 60 fathers of children with intellectual disabilities. Results supported the reliability and construct validity of the PCS. Internal consistency was good for all subscales bar one, and the PCS total score was associated with scores on the Positive Affect Scale. There were differences on PCS scales for mothers and fathers, with mothers generally reporting more positive contributions than fathers. The PCS is a reasonably robust measure and its use in future research should help to address questions about the nature and function of parental positive perceptions. The PCS might also be used in applied settings to help balance the effects of asking families about their difficulties and support needs.

Extending the demand-control model to informal caregiving

OBJECTIVE

Karasek's demand-control model of job strain was used in an attempt to extend previous work examining the psychological impact of informal caregiving in stroke.

METHOD

Data were gathered from 138 informal caregivers/patient dyads at two time points. The dependent variables were the caregiver's anxiety and depression [Hospital Anxiety and Depression Scale (HADS)]. The predictor variables were caregiver demand (stroke survivor's assessment of their physical and psychosocial functional limitations) and control (caregiver's perceived control over stroke survivor's recovery).

RESULTS

In a cross-sectional analysis of Times 1 and 2 data, main effects for demand and/or control were detected for anxiety and depression. Contrary to prediction, in longitudinal analysis of change, it was found that decreasing control, along with increasing demand, was associated with reduced distress.

CONCLUSION

The model was moderately successful in predicting emotional distress. The relative importance of caregiver demand and control in predicting outcomes changed over time in these data. Attempts to replicate these findings are recommended.

The relationships between depression and other outcomes of chronic illness caregiving

Background

Many caregivers with chronically ill relatives suffer from depression. However, the relationship of depression to other outcomes of chronic caregiving remains unclear. This study tested a hypothesized model which proposed that hours of care, stressful life events, social support, age and gender would predict caregivers' outcomes through perceived caregiver stress. Depression was expected to mediate the relationship between perceived stress and outcomes of chronic caregiving (physical function, self-esteem, and marital satisfaction).

Methods

The sample for this secondary data analysis consisted of 236 and 271 subjects from the Americans' Changing Lives, Wave 1, 1986, and Wave 2, 1989, data sets. Measures were constructed from the original study. Structural equation modeling was used to test the hypothesized model, and an exploratory structural modeling method, specification search, was used to develop a data-derived model. Cross-validation was used to verify the paths among variables.

Results

Hours of care, age, and gender predicted caregivers' outcomes directly or through perceived caregiver stress (p < .01). Depression mediated the relationship between perceived stress and psychological outcomes and explained 40% and 11% of the variance in self-esteem and marital satisfaction, respectively.

Conclusion

Depression predicted psychological outcomes. Whether depression predicts physical health outcomes needs to be further explored.

The manual wheelchair-handling skills of caregivers and the effect of training

OBJECTIVE

To test the hypothesis that the Wheelchair Skills Training Program (WSTP) is effective in improving the wheelchair-handling skills of untrained caregivers.

DESIGN

Within-participant comparisons.

SETTING

Rehabilitation center and community.

PARTICIPANTS

Twenty-four caregivers of manual wheelchair users.

INTERVENTIONS

Caregiver participants underwent the WSTP, version 2.4, adapted for caregivers. Training was individualized on the basis of an integrated testing-and-training protocol that took place on a single occasion (total, approximately 50 min).

MAIN OUTCOME MEASURES

Total percentage scores on the objective Wheelchair Skills Test (WST), version 2.4, for the pretraining (N=24), posttraining (N=24), and retention (n=9) evaluations. For the skill-transfer evaluation (n=10), we used the questionnaire version (WST-Q), administered by telephone to participants after return to their communities.

RESULTS

There were no serious adverse incidents. The mean pretraining total WST score +/- standard deviation was 77.8%+/-12.0%. Posttraining, this increased to 94.7%+/-7.1% (P <.001), a 22% relative increase. At retention testing, a median latency of 7 days later, the mean value, 94.2%+/-7.1%, did not decrease significantly from the posttraining level (P =.38). At skill-transfer testing, a median latency of 179 days posttraining, the mean value, 92.5%+/-8.7%, did not decrease significantly from the posttraining level (P =.73). The greatest improvements were at the advanced skill level.

CONCLUSIONS

The WSTP is a safe, practical, and effective method of improving the wheelchair-handling skills of untrained caregivers. Skill improvements are generally well retained and transfer well to the community. Such training could play an important role in the rehabilitation process.

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.

Advocating voice: organisational, historical and social milieux of the Alzheimer's disease movement

The Alzheimer's disease movement, despite the stated willingness of the Alzheimer's Association, has yet to comprehensively utilise people with Alzheimer's as spokespersons. This is particularly noteworthy given the increasing availability of those with Alzheimer's who, especially in the early stages, are fully capable of advocating their position. Qualitative interviews and focus groups with people who have been diagnosed with Alzheimer's demonstrate the active role they are beginning to take in informing research, practice and policy. Interviews with affiliates of the national association aiming to advocate for people with memory loss depict an enduring struggle to incorporate these perspectives. Although primary obstacles may involve the structural dynamics within a society that stigmatises those who are old and/or forgetful, there are clear organisational contradictions within the Association itself preventing such mobilisation efforts. The dynamics shaping this health social movement's endeavours portray characteristics that obstruct an ability to embrace as spokespersons the individuals for whom it advocates.

Well-being, appraisal, and coping in African-American and Caucasian dementia caregivers: findings from the REACH study

Although there has been considerable interest in racial differences in family caregiving for persons with dementia, most research to date has either ignored racial diversity or based conclusions on small numbers of caregivers drawn primarily from single site studies. The current study utilized participants from four sites of the REACH (Resources for Enhancing Alzheimer's Caregiver Health) multi-site study to compare well-being, appraisal, and religious coping by race. African-American (n = 295) and Caucasian (n = 425) dementia caregivers from four cities (Birmingham, Memphis, Boston, and Philadelphia) were compared in their demographics, care recipient characteristics, mental and physical health, and psychosocial coping resources including appraisal and religious coping. African-American caregivers reported lower anxiety, better well-being, less use of psychotropic medications, more benign appraisals of stress and perceived benefits of caregiving, and greater religious coping and participation, than Caucasian caregivers. Self-rated health did not differ by race, but African-American caregivers reported more unhealthy behaviors than Caucasian caregivers. Some results were specific to site, possibly due to differences in recruitment strategies, inclusion/exclusion criteria, and regional differences. Adjustment for covariates, including caregiver relationship to the care recipient, gender, age, socioeconomic status, and care recipient behavioral problems, altered few of these differences. Results are discussed in terms of their relevance to psychosocial intervention programs for ethnically diverse caregivers.

Meeting the supportive needs of family caregivers in palliative care: challenges for health professionals

Caring for a dying relative is demanding, and family caregivers have acknowledged many unmet needs associated with their caregiver role. Consistently, caregivers of dying patients with cancer have reported that they need more support and information from health care professionals. Moreover, a number of palliative care clinicians and researchers have called for interventions to enhance the support offered to family caregivers. However, before researchers can develop and test palliative care interventions directed to families, it is important to identify barriers that may confront health care professionals with regard to the provision of supportive family care. For new interventions to be feasible they must be applicable within the constraints of current palliative care service delivery environments. This paper provides an account of issues that may impinge on optimal transference of supportive strategies from health care professionals to family caregivers of patients receiving palliative care. By acknowledging these barriers to supportive care, researchers and health care professionals can begin to design and implement interventions that are clinically relevant and more likely to be effective.

Psychometric analysis of the Revised Memory and Behavior Problems Checklist: factor structure of occurrence and reaction ratings

A modified version of the Revised Memory and Behavior Problems Checklist (RMBPC; L. Teri et al., 1992) was administered across 6 different sites to 1,229 family caregivers of community-dwelling adults with dementia. The total sample was divided randomly into 2 subsamples. Principal components analyses on occurrence responses and reaction ratings from the first subsample resulted in a 3-factor solution that closely resembled the originally proposed dimensions (memory-related problems, disruptive behaviors, and depression). Confirmatory factor analyses on data from the second subsample indicated adequate fit for the 3-factor model. Correlations with other caregiver and care-recipient measures supported the convergent and discriminant validity of the RMBPC measures. In addition, female caregivers and White caregivers reported more problems, on average, than male caregivers and African American caregivers, respectively.

Alzheimer's disease caregiving information and skills. Part II: Family caregiver issues and concerns

In recent years researchers have carried out an increasing number of clinical trials with family caregivers of the elderly. The results of these interventions have suggested that caregiver skill-building interventions may be more effective than information/support interventions. Although researchers have given considerable attention to the information and support needed by family caregivers, less is known about how this information and support translates into caregiver skills or into changes in behavior. This is the second in a series of three articles on a study in which researchers used qualitative methods to analyze summaries from the group component of a larger caregiver clinical trial. In this article we describe caregiver issues and concerns in five major areas: (a). dealing with change, (b). managing competing responsibilities and stressors, (c). providing a broad spectrum of care, (d). finding and using resources, and (e). experiencing emotional and physical responses to care. We identify specific skills needed by caregivers in addressing these caregiving issues and concerns, and we compare and contrast skilled with less skilled caregivers. Further work is needed concerning the focus and methods of future caregiver skill-based interventions.

The effect of quality of the relationship between mothers and adult children with schizophrenia, autism, or down syndrome on maternal well-being: the mediating role of optimism

This article investigates the effects of the quality of the relationship between maternal caregivers and their adult child with disabilities on maternal well-being and whether this effect is mediated by dispositional optimism. Mothers caring for an adult child with Down syndrome (n=126), schizophrenia (n=292), or autism (n=102) were surveyed. Mothers of adults with schizophrenia and autism had better psychological well-being when the mother/adult child relationship was positive, but this effect was mediated totally or partially by optimism. For all 3 groups, optimism was related to better mental and physical health. The findings highlight the importance of dispositional optimism, a psychological resource that has been virtually ignored in studies of family caregivers of adults with disabilities.

Enmeshed Lives: Adult Children With Developmental Disabilities and Their Aging Mothers

This article uses equity theory to examine the ways in which aging mothers and their adult children with developmental disabilities support each other and the effects that this exchange has on the caregiving satisfaction and burden of the mothers. Data from 305 mothers revealed that exchange flows both from mother to child and from child to mother. Results indicate that caregiving satisfaction increased when affection from child to mother was greater. Caregiving burden was not affected by either functional support or affection from child to mother.

The quality of life of spouse dementia caregivers: changes associated with yielding to formal care and widowhood

The focus of the study was the effect on spouse dementia caregivers of relinquishing care. The study used a longitudinal design, in which a group of 150 dementia caregivers were interviewed 2 years apart (designated Time 1 and Time 2), with data collected from both continuing caregivers and those who had relinquished care. The aims were to determine the extent to which changes over time in quality of life differed between continuing caregivers, those who had yielded to formal care, and those who had been widowed; and to examine whether change in quality of life variables was associated with time since yielding to formal care and time since death of the spouse. Quality of life was defined in terms of health status, psychological well-being, and activity participation. All participants were interviewed in their own homes. Three groups of participants were identified at Time 2: those who continued to provide care for their spouses (n=60); those who had yielded their caregiver role by admitting their spouses to permanent residential care (n=53); and those who had admitted their spouses to permanent institutional care, but whose spouse had then died (n=37). Different patterns of quality of life changes were observed between the three groups, with both positives and negatives associated with disengagement from the caregiving role. Positive changes were particularly evident in psychological well-being and activity participation. These findings were discussed in terms of their relevance for a life transitions approach to the relinquishment of caregiving.

Telephone Support for Caregivers of Patients With Cancer

Caregivers have complex needs as they care for a loved one with cancer at the end of life. The objective of this pilot study was to determine the feasibility of conducting a brief telephone intervention, Tele-Care II, for caregivers of hospice patients. Guided by Hogan's Model of Bereavement, nurse interventionists implemented Tele-Care II via teleconference calls with caregivers. Although 14 caregivers were recruited for the study, only 5 were able to complete the intervention before the patient's death. Those completing the intervention experienced decreased depression, despair, and disorganization although the patient's condition became more serious. Late enrollment in hospice continues to be problematic for patients, family caregivers, and hospice staff because it allows little time for completion of interventions with family caregivers before the patient's death.

Factors of positive appraisal of care among Japanese family caregivers of older adults

The purpose of this study was to examine factors of positive appraisal of care among Japanese family caregivers of older adults. The Positive Appraisal of Care (PAC) scale used in this study is a multidimensional Japanese measure and has four domains: relationship satisfaction, consequential gain, role confidence, and normative fulfillment. Three hundred and thirty-seven caregivers participated in this survey. Multiple regression analyses revealed that social support and caregiver belief in caregiving had a consistent impact on all domains of the PAC, whereas the impact of caregiver and care recipient characteristics varied among the domains. For example, caregiver age had a significant impact on role confidence and normative fulfillment but not on relationship satisfaction and consequential gain. The differential impact of caregiver and care recipient characteristics on the domains of the PAC underlines the usefulness of a multidimensional measurement.

Informal caregiving dynamics with a case study in blood and marrow transplantation

PURPOSE/OBJECTIVES

To develop a definition of informal caregiving dynamics through a selective literature review and explore the proposed definition in the context of blood and marrow transplantation using a case study.

DATA SOURCES

Published articles.

DATA SYNTHESIS

Informal caregiving dynamics are commitment, expectations, and negotiation that move a dyadic informal caregiving relationship along an illness trajectory.

CONCLUSIONS

The proposed definition of informal caregiving dynamics is useful in explaining how an informal caregiving dyadic relationship develops and is sustained.

IMPLICATIONS FOR NURSING

Understanding the dynamics underlying informal caregiving relationships enables nurses to intervene effectively to develop and sustain these vital relationships. Elements of the concept require further clarification. Research to validate the accuracy of the concept is needed.

Can burdened caregivers be effective facilitators of elder care-recipient health care?

BACKGROUND

Caregiving by informal family caregivers of dependent older people in the community may be affected by burden and by the personal and social resources available to the caregiver. Given the increase in the dependent older population, study of factors affecting informal caregiving is necessary.

AIMS

To examine caregiver resources, burden and competence as predictors of health-care facilitation on behalf of older patients.

DESIGN

Cross-sectional data were collected by an interview schedule from 240 randomly sampled spousal and filial caregivers in Jerusalem. Study variables included caregiver background variables, general self-concept and feelings of caregiver competence, informal and formal social support, burden and levels of health-care facilitation. Path analysis was performed to clarify the direct and indirect predictors of health-care facilitation.

RESULTS

Caregiver facilitation of health-care was positively related both to the presence of personal and social resources and to burden levels. The results suggest that quality caregiving can coexist with burden, provided that ample caregiver resources are present. The most important resources were caregiver sense of competence and support from the professional health-care provider.

DISCUSSION

Caregiving burden is not readily reducible, given the chronic nature of older people's health problems. However, caregiver resources can be bolstered, particularly by health professionals. Nurses, who are orientated to holistic family centred care, are especially well-suited for this important intervention.

Psychometric properties of an abridged version of The Zarit Burden Interview within a representative Canadian caregiver sample

PURPOSE

Given the exponential increase in dementia prevalence anticipated in the coming years, measurement of caregiver burden has become common in gerontological research and clinical practice. The Zarit Burden Interview (BI) has emerged as the most widely utilized burden measure. The current study examines the psychometric properties of responses to an abridged, 12-item version of this scale.

DESIGN AND METHODS

Data were derived from a national epidemiological study of dementia incidence and patterns of care (N = 1,095). Informal caregivers of surviving institutionalized and community-dwelling index subjects were interviewed 5 years subsequent to initial recruitment (n = 770).

RESULTS

Results of both the exploratory and confirmatory factor analyses support a two-factor structure of responses to this abridged scale. Subsequent to control for demographic variables, dementia illness features, and baseline depressive symptoms at baseline, responses to this brief BI provide a significant increase to prediction of depressive symptoms at Time 2 (R(2) =.24, p <.01) with no additional variance provided by the 10 remaining items from the complete BI (deltaR(2) = 0, ns).

IMPLICATIONS

The results of this study are discussed relative to theory and the operational definition of caregiver burden. Findings can be generalized with greater confidence given the representative and national composition of caregivers recruited for this study.

Training family caregivers of patients with dementia. A structured workshop approach

The Minnesota Family Workshop consisted of seven weekly 2-hour sessions that provided education, family support, and skills training to primary family caregivers of patients with dementia, and other accompanying family members. The interdisciplinary faculty used a general stress and coping model to design the caregiver education program. To increase family involvement, the Minnesota Family Workshop required at least one other family member accompany the primary caregiver to the sessions. In addition, a concurrent adapted activity group was offered for the patients with dementia. This 14-hour curriculum with specific weekly objectives and activities detailed in this article was successful in reducing burden among caregivers of patients with dementia.

Strengthening research to improve the practice and management of long-term care

Past investments in long-term care (LTC) research have improved the quality of care and the quality of life for LTC recipients by conceptualizing the goals and measuring the outcomes of care, designing practical assessment tools, testing clinical interventions, and evaluating new service delivery programs and models. To build a balanced portfolio of LTC research that will yield and sustain increased dividends in quality and outcomes will require (1) increasing investment in both basic and applied LTC research to ensure that critical service delivery issues are addressed in a rigorous and timely fashion, (2) fostering better communication between researchers and users to ensure research salience and credibility, and (3) dedicating more resources to identifying and implementing successful methods for translating LTC research into practice.

Burden and well-being among caregivers: examining the distinction

PURPOSE

This study assessed overall quality of life of caregivers, using a path model in which burden was conceptualized as distinct from well-being.

DESIGN AND METHODS

Data were drawn from a representative sample of caregivers to dementia and nondementia care receivers in British Columbia, Canada (N = 243). The model used was based on a previously proposed stress/appraisal path model and used multiple regression path estimates. Primary stressors were care receiver cognitive status, physical function, and behavioral problems; the primary appraisal variable was hours of caregiving during the previous week. Mediators were perceived social support, frequency of getting a break, and hours of formal service use; secondary appraisal was subjective burden. The outcome measure was generalized well-being.

RESULTS

Well-being was directly affected by four variables: perceived social support, burden, self-esteem, and hours of informal care. Burden was affected directly by behavioral problems, frequency of getting a break, self-esteem, and informal hours of care and was not affected by perceived social support.

DISCUSSION

The finding that perceived social support is strongly related to well-being but unrelated to burden reinforces the conceptual distinctiveness of the latter two concepts. This suggests that quality of life of caregivers could be improved even with burden in their lives and that the overwhelming focus in caregiving research on burden should be supplemented with an emphasis on quality of life.

Family care for older adults with disabilities: toward more targeted and interpretable research

Family care of the elderly is key to the long-term care system, and its importance has led to an abundance of research over the past two decades. Several methodological and substantive issues, if addressed, could create even more targeted and interpretable research. The present review critically examines methodological topics (i.e., definitions of family caregiving, measurement of caregiving inputs) and conceptual issues (i.e., family involvement in long-term residential settings, and the care receiver's perspective on care) that have received insufficient attention in the caregiving literature. Throughout this review recommendations are offered to improve these areas and advance the state of the art.

The process of a group intervention for caregivers of demented persons living at home: conceptual framework, components, and characteristics

Most earlier group interventions for caregivers of demented persons lacked a theoretical basis to guide the intervention process and focused on providing information and practical advice and encouraging the expression of feelings. This article presents the process of a group intervention with emphasis on its conceptual framework, components and characteristics. As caregivers are exposed to numerous daily stressful demands, the intervention's conceptual framework was derived from Lazarus and Folkman's transactional theory of stress and coping and Folkman's Coping Effectiveness Training Program. The central aim of the intervention was to improve the ability of caregivers to cope with the stressful demands at the core of caring for a demented person, rather than to focus on information and the task-oriented aspects of caring. The two components of the intervention deal with the cognitive appraisal of stressors and coping strategies, with a view to determining which strategies are most appropriate on the basis of the changeability of stressors. Three coping strategies were proposed: problem solving (problem-focused coping to deal with changeable stressors), reframing (emotion-focused coping to manage the emotional response to unchangeable stressors), and seeking social support (problem- or emotion-focused coping). The most salient characteristics of this group intervention were its intensity (15 meetings) and its focus on the caregivers' daily reality, which provided concrete reference points for the discussion of conceptual notions.

Burden among family caregivers of persons with Alzheimer's disease in nursing homes

PURPOSE

This article examines family caregiver burden after placement of a relative with Alzheimer's disease or a related dementia in a nursing home.

DESIGN AND METHODS

A systems-oriented contextual approach was used to study burden in 276 family caregivers.

RESULTS

SAS PROC MIXED analysis showed burden to be associated with caregiver age, length of time involved in caregiving, custodial units, involvement in hands-on care, and expectations for care.

IMPLICATIONS

The findings suggest that more services aimed at relieving caregiver burden after nursing home placement may be warranted, particularly so for caregivers who are older and for those who had a shorter length of involvement in direct caregiving before institutionalization.

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.

Types of marital closeness and mortality risk in older couples

OBJECTIVE

This study examines the impact of marital closeness on survival over 6 years in a community-dwelling sample of 305 older couples.

METHOD

Closeness is defined as 1) naming one's spouse as a confidant or source of emotional support (vs. not naming) and 2) being named by spouse on at least one of the two dimensions (vs. not being named). The survival effects of both naming and being named are examined in Cox proportional hazard regressions, controlling for sociodemographic, health status, and behavioral variables.

RESULTS

Husbands who were named by their wives but did not name them were least likely to have died after 6 years. Compared with them, husbands in marriages with the other three styles of closeness were from 3.30 to 4.68 times more likely to be dead. Wives' results showed the same pattern of effects, with the same marital style being most protective as for husbands, but the effects were weaker. However, wives' results were strongly moderated by parenting status: those who had ever had children who were in the marital closeness pattern of wife naming husband but not being named by him were highly protected. Compared with these wives, others who had had children were from 8.26 to 10.95 times less likely to be alive after 6 years.

CONCLUSIONS

The same pattern of marital closeness most benefited husbands and those wives who had had children. These findings are not explained adequately by social support or marital role theory although they fit the latter more closely.

The costs of caring: impact of dementia on family caregivers

With the aging of the population, an increasing number of older adults are diagnosed with Alzheimer's disease or a related disorder. Most people with a dementing illness will be cared for at home by a family member, who may experience a variety of physical, emotional, financial, and social burdens associated with the caregiving role. The purpose of this article is to (a) examine the physical and psychological effects of providing care to a family member with a dementing illness, (b) describe the factors that help determine the nature and magnitude of these effects, and (c) discuss several approaches to caregiver intervention designed to reduce the negative impact of this challenging role. Sociodemographic characteristics (e.g., gender, relationship to the patient, culture, race, ethnicity), caregiver resources (e.g., coping, social support, availability of a companion animal), and personal characteristics (e.g., personality, health behaviors) shape the dementia caregiving experience and have implications for interventions designed to prevent or lessen the stress and burden that often accompany the role.

A multidimensional measure of caregiving appraisal: validation of the Caregiver Appraisal Scale in traumatic brain injury

OBJECTIVE

To investigate the factor structure and concurrent validity of the Caregiver Appraisal Scale (CAS) in a sample of caregivers of adults with traumatic brain injury (TBI).

DESIGN

Prospective cohort study.

SETTING

Two sites: (1) Outpatient clinics associated with a comprehensive inpatient brain injury rehabilitation program and (2) a comprehensive residential postacute rehabilitation program in the Southern United States.

PARTICIPANTS

One hundred forty-nine caregivers of adults with TBI enrolled in the TBI Model Systems Project and 92 caregivers of adults with TBI admitted to a residential postacute rehabilitation program. Most caregivers were women and either parents or spouses of the injured person.

MAIN OUTCOME MEASURES

Caregiver Appraisal Scale (CAS); Subjective Burden Scale (SBS); Objective Burden Scale (OBS); General Health Questionnaire (GHQ).

RESULTS

Principal components analysis with varimax rotation yielded four factors: perceived burden (PB), caregiver relationship satisfaction (CRS), caregiving ideology (CI), and caregiving mastery (CM), which were found to be fairly stable across treatment settings. Adequate concurrent validity was demonstrated for the perceived burden factor, and adequate internal consistency was found for three of four scales.

CONCLUSIONS

Preliminary support for the use of the CAS in caregivers of adults with TBI was obtained. However, further scale development, particularly for the CM factor, will likely improve the stability and usefulness of this instrument.

Caregiving appraisal and interventions based on the progressively lowered stress threshold model

The purpose of this article is to describe the impact of a theoretically driven, psychoeducational intervention based on the Progressively Lowered Stress Threshold (PLST) model on caregiving appraisal among community-based caregivers of persons with Alzheimer's disease and related disorders. A total of 241 subjects completed the year-long study in four sites in Iowa, Minnesota, Indiana, and Arizona. Caregiving appraisal was measured using the four factors of the Philadelphia Geriatric Center Caregiving Appraisal Scale: mastery, burden, satisfaction, and impact. Analysis of trends over time showed that the intervention positively affected impact, burden, and satisfaction but had no effect on mastery when measured against the comparison group. The PLST model was influential in increasing positive appraisal and decreasing negative appraisal of the caregiving situation.

The effect of religious coping on caregiving appraisals of mothers of adults with developmental disabilities

PURPOSE

This article explores the association between race and religious coping on caregiving appraisals for mothers who coreside with an adult child with mental retardation.

DESIGN AND METHODS

71 Black and 71 White women (aged 50 or older) were matched on demographic characteristics to control for the association between race and socioeconomic status. Structural equation analysis was used to examine the relationship between race, religious coping, and caregiving appraisals.

RESULTS

Black women were more likely to use religious coping. Religious coping was associated with higher levels of caregiving satisfaction, but not with burden. Blacks experienced higher levels of caregiving satisfaction. Blacks also experienced higher levels of caregiving burden due to their poor health.

IMPLICATIONS

The needs of Blacks should be considered when developing "best practices" in service provision. Culturally sensitive outreach approaches should not ignore the importance of faith and faith-based organizations in the lives of Blacks.

Lifestyle interference and emotional distress in family caregivers of advanced cancer patients

BACKGROUND

Providing end-of-life care at home to a family member with advanced cancer can have a negative impact on the emotional well-being of the family caregiver. The current study examined the impact of providing care on lifestyle and emotional well-being in a sample of caregivers to patients with advanced cancer. The mediation of lifestyle interference between the amount of care provided and emotional distress was specifically examined.

METHODS

Forty-four family caregivers participated in a structured quantitative interview. Lifestyle interference was assessed by the Caregiving Impact Scale, amount of care provided was assessed by the Caregiver Assistance Scale, and emotional distress was assessed by the Profile of Mood States-Short Form. Pearson and partial correlations tested whether lifestyle interference mediated the relationship between caregiving assistance and emotional distress. Regression analyses determined overall correlates of emotional distress.

RESULTS

Three criteria, required to substantiate mediation, were met for total mood disturbance and the depression and tension subscales. An overall regression model identified education level and lifestyle interference to be significant and unique correlates of emotional distress.

CONCLUSIONS

The current results suggest that caregivers experience increased emotional distress, regardless of the amount of care provided, when limited in their ability to participate in valued activities and interests. In addition, caregivers with less than a high school education experience more emotional distress. Therefore, helping caregivers maintain valued aspects of their lifestyle should be an important element of home care.

Progressive dementia: personal and relational impact on caregiving wives

The purpose of this exploratory study was to examine the perceptions of 115 female spouse caregivers of early to moderate stage dementia patients. Based on patients' cognitive status, cross-sectional comparisons of two groups of caregiving wives were conducted. No group differences were found in measures of caregiver burden, depression, or personal gain. However, wives of patients with greater cognitive impairment experienced lower levels of mastery and more relational deprivation when compared to wives of patients with higher mental status. Supportive approaches might be directed toward helping early dementia caregivers restructure their understanding of, and participation in, their marital relationships in anticipation of changes ahead. Interventions aimed at enhancing a caregiver's sense of personal mastery may help reduce the negative effects of dementia on caregivers' well-being.

Vulnerability of husband and wife caregivers of Alzheimer disease patients to caregiving stressors

This study assessed relationships between problem behaviors in 199 Alzheimer Disease patients and vulnerability factors in the well being and emotional health of their spouse caregivers. Among caregiver wives and the younger caregiver husbands (64 years old and under) the volume of patient problem behavior was significantly negatively associated with total scores on a summary well being measure. The association was not found within the older husband caregiver group. Considering five subdimensions of the summary well being scale (Anxiety, Depressive Symptoms, Positive Well Being, Vitality and General Health), correlational analyses showed that the total patient problems measure appeared to have impact primarily among wife caregivers, particularly those 64 years old and under. Multiple regression analyses showed that one patient problem behavior category, Emotional Lability, was the single strongest predictor of impaired well being of the caregiver among all five subdimensions of the caregiver well being measure. Although Destructive Behavior of the patient was not significant by itself, an Age by Destructive Behavior interaction showed that high levels of patient Destructive Behavior predicted high levels of Depression, Anxiety, and low levels of Positive Well Being more among younger caregivers. Husband caregivers had significantly higher Anxiety scores than wife caregivers. These findings document how particular patient problem behaviors can affect caregivers. They point up as well how both gender and age may help target which caregivers are most vulnerable to the stress of specific Alzheimer patient behavior problems. They also suggest the utility of examining specific dimensions of well being rather than a total score alone for purposes of understanding the relationship of particular patient behavior problems to caregiver emotional and physical health.

Subjective responses to caregiving for a spouse with dementia

Family members, typically spouses, serve as the primary caregivers for individuals with dementia. While it is recognized that caregivers experience both positive and negative subjective responses to caregiving, relatively little research has been done on the relationship between these types of responses. The objectives of the study were to examine the relationships between and among spouse caregivers' positive and negative subjective responses to caregiving, and increase understanding of the experience of being a spouse caregiver for a person with dementia. Fifty spouse caregivers completed quantitative measures of positive subjective responses (Positive Aspects of Caregiving and Caregiver Competence) and negative subjective responses (Relational Deprivation, Role Captivity, and Loss of Self). Additionally, participants were interviewed concerning their caregiving experiences. Positive Aspects of Caregiving and Caregiving Competence were significantly related to each other (p < .01), as were the three measures of negative subjective responses (p < .01). No significant correlations were found between any measures of a positive and a negative subjective response, suggesting the two types of responses are independent. Duration of caregiving was significantly related to Positive Aspects of Caregiving (p < .05), Caregiver Competence (p < .05), and Relational Deprivation (p < .01). Qualitative interview data revealed that participants simultaneously experienced caregiving as self-affirming, while also enduring losses and difficulties resulting from their caregiving role. Integrating the positive and negative aspects of the whole of caregiving is important to understand the caregiving experience and to design interventions to support caregivers.

Relationship of empathy to appraisal, depression, life satisfaction, and physical health in informal caregivers of older adults

The relationship between empathy and caregiving appraisal and outcomes was examined among 140 informal caregivers of older adults. Caregivers with high cognitive empathy appraised the caregiving situation as less stressful and less threatening, were less depressed, and reported higher life satisfaction than did caregivers with low cognitive empathy. The caregivers' appraisal, along with educational levels and total household income, significantly predicted individual differences in caregiver depression, life satisfaction, and perceived physical health. Emotional empathy was negatively related to life satisfaction. There appeared to be distinct roles for emotional and cognitive empathy in informal caregiving outcomes. The study supported the important role of caregiving appraisal and resources in caregiving outcomes.

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.

Sleep and depression in cancer caregivers

A cross-sectional, correlational design was used to describe and explore the relation between caregiver sleep and depression. For the study, 51 caregivers were recruited from two sites in southern California. Caregivers were primarily white (84%), female (80%), spouses (61%), or adult children (29%), who had provided care for a mean of 16 hours per day for an average of 2 years. The Center for Epidemiological Studies-Depression (CES-D)and the Pittsburgh Sleep Quality Index (PSQI) were used to measure caregiver depression and sleep, respectively. Most of the caregivers (95%) expressed severe sleep problems, and more than half of them were experiencing depressive symptoms at a level that would suggest risk for clinical depression. Correlations were strongest between caregiver depression and the sleep subscales of overall quality (r = 0.70; p < 0.001), habitual sleep efficiency (r = 0.54; p < 0.001), and daytime dysfunction (r = 0.59; p < 0.001). The final regression model, which included these subscales, predicted 63.6% of the variance in depression scores (F = 27.32; p < 0.001). These findings, which are consistent with results from other studies, suggest that caregivers of persons with terminal illness are at risk for clinical depression. It is critical for nurses to be cognizant of the relation between sleep problems and depression, and to explore interventions that would allow the caregivers to obtain needed sleep without diminishing their ability to function in their role as caregiver.

Psychological distress of caregivers: moderator effects of caregiver resources?

Personal psychological, social and health resources of informal caregivers are often assumed to attenuate or increase caregiving stress. This hypothesis was tested by investigating the effect of caregivers' resources on the relationship between their appraisal of the caregiving situation and psychological distress. Caregiver resources measured were: problem-focused and emotion-focused coping, neuroticism, received emotional and instrumental support and physical functioning. Results show that none of these caregiver resources has moderator effects, neither for all caregivers together (n = 166), nor for subgroups of caregivers. These subgroups were: spouses, non-spouses, males, females, caregivers of minimally and mildly demented people and of moderately and severely demented people, respectively. The absence of moderator effects on caregiving stress suggests that caregivers of demented elderly people may need attention and support when they perceive pressure, regardless of their personal resources.