A National Profile of Family and Unpaid Caregivers Who Assist Older Adults With Health Care Activities

Gender differences in cost-related unmet healthcare needs: a national study in Turkiye

BACKGROUND

Unmet healthcare needs are a complex and multifaceted issue, influenced by individual, socioeconomic, and healthcare system factors. This study aimed to investigate the determinants influencing cost-related unmet healthcare needs within the Turkish population, emphasizing a comprehensive analysis of gender disparities in accessing healthcare services.

METHODS

This secondary analysis scrutinizes the 2019 Turkiye Health Survey data of 16,976 individuals aged 15 and older. The dependent variables included cost-related unmet medical, dental, and prescribed medication, and mental services. The independent variables were considered under a three-domain approach for the determination of health service utilization, developed by Andersen. Logistic regression models with predisposing, enabling, and need factors were run for any self-perceived cost-related unmet need for each sex and overall population. Another six regression models for both sexes were run for each subgroup of indivuals with unmet healthcare needs.

RESULTS

The study revealed that 15.4% of individuals cannot access healthcare due to financial constraints, with 16.8% for women and 13.5% for men. The highest level of unmet needs is associated with accessing dental care services for both sexes. According to multivariate analyses, the unmet need for both sexes decreases with older age and higher education level, and it is greater for those who have difficulties communicating in Turkish. By adding enabling and needs factors, the odds ratios of education decreased for men, while education became nonsignificant for women. Having chronic disease impacts unmet needs for both sexes. However, the inability to perform daily activities due to health problems was not a significant factor for men. Poorer household income increases overall unmet needs. Education is a determinant of both medical and mental care needs.

CONCLUSIONS

This pioneering study illuminates the multifaceted gender disparities in cost-related unmet healthcare needs across Turkiye, reflecting the intertwined issues of access influenced by a complex interplay of factors. Our findings underscore the significance of adopting an intersectional approach to address health inequalities.

Determinants of trajectories of informal caregiving in later life: evidence from England

Although the long-term consequences of informal care provision have been well investigated, few studies have examined the trajectories of informal care provision among older people and the socioeconomic, demographic, health, and family characteristics associated with them. We use data from four waves of the English Longitudinal Study of Ageing, with 6561 respondents followed for 6 years (2012/3-2018/9). We used group-based trajectory modelling to group people's provision of care over time into a finite number of distinct trajectories of caregiving. Using multinomial logistic regressions, we then investigated the characteristics associated with these trajectories. Four distinct trajectories of caregiving were identified: "stable intensive", "increasing intensive", "decreasing", and "stable no care". Results suggest that although there are socioeconomic, demographic, and health differences across the trajectories of caregiving (with younger women in good health and poorer socioeconomic status more likely to care intensively throughout), family characteristics are their main drivers. Respondents who live alone, with no children, and no parents alive are more likely to never provide care, whereas those with older parents and who live with adults in poor health are more likely to provide stable intensive care. Also, changes in family characteristics (e.g. death of parents, widowhood, or deterioration of the partner's health) are associated with trajectories representing increases or decreases in caregiving over time. Overall, trajectories of informal caregiving undertaken by older people are varied and these patterns are mostly associated with both the availability and health of family members, suggesting that need factors represent the most immediate reason for caregiving commitments.

Development and Evaluation of a Web-Based Platform for Personalized Educational and Professional Assistance for Dementia Caregivers: Proposal for a Mixed Methods Study

BACKGROUND

Alzheimer disease (AD) and AD-related dementia are prevalent concerns for aging populations. With a growing older adult population living in the United States, the number of people living with dementia is expected to grow, posing significant challenges for informal caregivers. The mental and physical burdens associated with caregiving highlight the importance of developing novel and effective resources to support caregivers. However, technology solutions designed to address their needs often face low adoption rates due to usability issues and a lack of contextual relevance. This study focuses on developing a web-based platform providing financial and legal planning information and education for dementia caregivers and evaluating the platform's usability and adoptability.

OBJECTIVE

The goal of this project is to create a web-based platform that connects caregivers with personalized and easily accessible resources. This project involves industrial, academic, and community partners and focuses on two primary aims: (1) developing a digital platform using a Dementia Care Personalization Algorithm and assessing feasibility in a pilot group of caregivers, and (2) evaluating the acceptability and usability of the digital platform across different racial or ethnic populations. This work will aid in the development of technology-based interventions to reduce caregiver burden.

METHODS

The phase I study follows an iterative Design Thinking approach, involving at least 25 dementia caregivers as a user feedback panel to assess the platform's functionality, aesthetics, information, and overall quality using the adapted Mobile Application Rating Scale. Phase II is a usability study with 300 dementia caregivers in Texas (100 African American, 100 Hispanic or Latinx, and 100 non-Hispanic White). Participants will use the digital platform for about 4 weeks and evaluate its usefulness and ease of use through the Technology Acceptance Survey.

RESULTS

The study received funding from the National Institute on Aging on September 3, 2021. Ethical approval for phase I was obtained from the Texas A&M University Institutional Review Board on December 8, 2021, with data collection starting on January 1, 2022, and concluding on May 31, 2022. Phase I results were published on September 5, 2023, and April 17, 2024, respectively. On June 21, 2023, ethical approval for human subjects for phase II was granted, and participant recruitment began on July 1, 2023.

CONCLUSIONS

Upon completing these aims, we expect to deliver a widely accessible digital platform tailored to assist dementia caregivers with financial and legal challenges by connecting them to personalized, contextually relevant information and resources in Texas. If successful, we plan to work with caregiving organizations to scale and sustain the platform, addressing the needs of the growing population living with dementia.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/64127.

The Mediating Effect of Social Participation Restriction on the Association Between Role Overload and Mental Health Among Caregivers of Older Adults with Dementia

Caregivers of older adults with dementia (dementia caregivers) often experience high role overload (i.e., feeling overwhelmed by caregiving demands that exceed available resources), which can take a toll on their mental health. Moreover, dementia caregiving can restrict caregivers' participation in valued social activities. This study aims to examine the mediating effect of social participation restriction on the relationship between role overload and mental health among dementia caregivers. A total of 894 dementia caregivers (mean age = 61.77) were selected from the National Study of Caregiving. The sample was predominantly women (64%) and White (78%). Path analysis shows that social participation restriction partially mediated the associations between (1) role overload and psychological distress (indirect effect β = .08, p < .001) and (2) role overload and psychological wellbeing (indirect effect β = -.05, p < .05). Interventions targeting coping strategies and healthcare-recreation programs are needed to improve social participation among dementia caregivers.

Factors Influencing Caregivers' Use of Respite Care Services: Secondary Analysis of the National Study of Caregiving

This study examines when and why unpaid caregivers use respite services. We conducted a secondary analysis of the 2017 National Study of Caregiving (NSOC) Wave III, a U.S. nationally representative sample comprising 2652 unpaid caregivers. We found that unpaid caregivers reporting financial, physical, and emotional difficulties in caregiving were more likely to use respite care services than those not reporting these challenges. White, non-Hispanic caregivers reporting that they received support from their social networks (families/friends) were more likely to use respite care services than non-White and/or Hispanic caregivers receiving such support. Non-White and/or Hispanic caregivers who belonged to or attended support groups were more likely to use respite care support than those without social group affiliation. Respite care is underutilized in the U.S. despite its value and efficacy in supporting caregivers' mental and physical well-being. Policies are necessary to increase availability and access to respite services for diverse unpaid caregivers.

Self-Directed Home- and Community-Based Services Improve Outcomes for Family Caregivers: A Systematic Review

BACKGROUND AND OBJECTIVES

Self-direction is an approach that allows older adults and people with disabilities to determine the home- and community-based services they receive, including the ability to hire caregivers of their choice. Self-direction has been shown to improve outcomes for the service recipients. The promotion of choice and control in self-direction may also affect family caregivers. We conducted a systematic review examining the impact of self-direction on a broad range of caregiver outcomes.

RESEARCH DESIGN AND METHODS

We conducted a systematic review guided by PRISMA guidelines. Literature search was conducted in 8 databases. We appraised risk of bias using the Joanna Briggs Institute critical appraisal checklists and assessed certainty of evidence using the GRADE framework.

RESULTS

Sixteen studies meeting inclusion criteria were included. We found, with moderate certainty, that self-direction is associated with improved caregivers' personal and social well-being. Caregivers also reported reduced unmet needs and increased access to care for the care recipients under self-direction. Self-direction did not appear to reduce caregiving hours. With less certainty, self-direction was also positively associated with increased respite care use, perception of choice, and intention to continue caregiving by caregivers.

DISCUSSION AND IMPLICATIONS

Beyond delivering person-centered services that improve recipient outcomes, self-direction may also improve the outcomes of family caregivers.

Caregiving Appraisals and Emotional Valence: Moderating Effects of Activity Participation

The present study examines the extent to which a two-factor model of affect explains how caregiving appraisals experienced by caregivers influence their own well-being. We used data from three waves of Nation Study of Caregiving (NSOC) to conduct latent growth curve models with the time-varying predictors to investigate the effect of between-person (BP) and within-person (WP) caregiving appraisals on positive and negative affect. Furthermore, we simultaneously modeled WP differences in activity participation and affective experience with multilevel modeling. Then, we tested the moderating effect of activity participation in the association between WP caregiving appraisals and emotional valence. We found that BP and WP caregiving negative appraisal also contribute to caregiver positive affect similar to that of negative affect. Time-varying effects of negative appraisals and emotional valence are consistent with the two-factor model. Future longitudinal investigations could target WP and BP activity participation to alleviate caregiving cognitive appraisal among caregivers.

Older Caregivers: Who They Are and How to Support Them

Caregivers play a crucial role in providing health and social supports to their family and friends. Older adults who take on caregiving roles are themselves uniquely vulnerable to negative health and financial effects due to their age and underlying health risks. Many caregivers do not receive adequate support - either formally or informally - exacerbating the strains of providing care. Racial and ethnic minority caregivers may be less likely to report receiving support in their role and face additional challenges. We describe these caregivers over 65 and the burdens they face. We recommend community health workers, direct compensation, and normalization of respite care to support these essential care workers in their role and as they age.

Comparison of the EQ-HWB and EQ-HWB-S With Other Preference-Based Measures Among United States Informal Caregivers

OBJECTIVES

Several measures have been used or developed to capture the health and well-being of caregivers, including the EQ Health and Well-being (EQ-HWB) and its short form, EQ-HWB-S. This study aimed to evaluate the psychometric properties and construct validity of the EQ-HWB/EQ-HWB-S in a US caregiver population.

METHODS

A cross-sectional survey was conducted involving 504 caregivers. Eligible participants were 18+ years old, provided unpaid care to a relative/friend aged 18+ in the past 6 months, and spent on average of at least 1 hour per week caregiving. Survey included the following measures: EQ-HWB, Adult Social Care Outcomes Toolkit for Carers-Carer, CarerQol, and EQ-5D-5L. Psychometric properties were assessed using response distributions, floor/ceiling effects, Spearman's correlation for convergent validity, and effect sizes (ES) for known-group validity based on caregiving situations and intensity.

RESULTS

The average age of caregivers was 49.2 (SD = 15.4), with 57.5% being female. More than half (54.4%) reported high caregiving intensity, and 68.3% lived with the care recipient. The EQ-HWB-S index showed a strong positive correlation with the EQ-5D-5L (rs = 0.72), Adult Social Care Outcomes Toolkit for Carers (rs = 0.54), and CarerQol (rs = 0.54) indices. Notably, the EQ-HWB-S index showed the largest ES among measures in differentiating caregiving scenarios with a large ES for caregiver's general health (d = 1.00) and small ES for caregiving intensity (d = 0.39).

CONCLUSIONS

Results support construct validity of EQ-HWB and EQ-HWB-S as measures for assessing health and well-being of adult informal caregivers in comparison with other validated instruments. Differing levels of known-group validity across anchors emphasize the importance of selecting appropriate measures for caregivers, depending on research question and/or intervention aims.

A randomised controlled trial of the Learning Skills Together (LST) intervention to improve dementia family caregivers' self-efficacy with complex care

BACKGROUND

Nearly two-thirds of family caregivers of persons living with Alzheimer's disease or related dementias (AD/ADRD) provide complex care, including medical care. Family caregivers typically receive little to no training on how to provide this care. Furthermore, family caregivers simultaneously grapple with the presence of behavioral and psychological symptoms of dementia (BPSD), diminished communication abilities, and comorbidities such as diabetes. We developed Learning Skills Together (LST), a 6-week digitally delivered psychoeducational program, to facilitate family caregiver abilities to administer complex care tasks. The goal of the present study is to test the efficacy of LST and to reduce adverse outcomes associated with caregiving, such as depressive symptomology and negative appraisal of BPSD.

METHODS

To test the efficacy of LST, we will conduct a two-arm single-site randomized controlled trial (RCT) with N = 200 family caregivers of persons living with AD/ADRD. Eligible family caregivers will be randomly assigned to participate in either the LST intervention or a structurally equivalent control condition focused on healthy living. All family caregivers will complete four surveys, including a baseline survey administered prior to randomization, a post-intervention survey, and a 3- and 6-month follow-up survey to assess change in study outcomes. Between-group comparisons of each outcome will be evaluated using generalized estimating equation models. Mediation analyses will assess family caregiver self-efficacy as the intervention's mechanism of change in depressive symptomology and BPSD. We will also examine caregiver race, ethnicity, and gender as effect modifiers of the intervention.

DISCUSSION

LST findings will inform the field of AD/ADRD and caregiving regarding optimally supporting family caregivers in managing complex care tasks. If efficacious, the LST intervention will support family caregivers in preserving their own mental health while providing complex care.

TRIAL REGISTRATION

Clinical Trials.gov NCT05846984 . This study was registered on May 6, 2023.

Family Caregivers' Role in Navigating Diet: Perspectives from Caregivers of Older Asian Americans

Family caregivers uphold significant healthcare responsibilities including language translation and diet management. This study sought to understand family caregivers' experiences and challenges navigating and managing their older Asian American relative's diet. We conducted an exploratory sequential mixed-methods study with family caregivers involving (1) qualitative interviews (n = 40) and (2) a nationwide survey (n = 100). Interviewees discussed their role and challenges with (a) applying American/Western clinical dietary recommendations to their relative's traditional meal preferences and (b) managing misalignment between their relative's traditional dietary preferences and the food offered in hospitals and long-term care environments. Survey responses triangulated; almost 65% of family caregivers prepared and brought traditional meals to healthcare facilities upon observing a lack of culturally relevant food options. Culturally relevant nutrition training for family caregivers can help them support their relative in community settings. Creating an inclusive healthcare system requires transforming the food environment within healthcare facilities.

The Role of Social Isolation on Mediating Depression and Anxiety among Primary Family Caregivers of Older Adults: A Two-Wave Mediation Analysis

BACKGROUND

Primary family caregivers of older people with chronic care conditions are highly vulnerable to social isolation and psychological strains such as depression and anxiety due to their demanding responsibilities. This study examines how social isolation mediates the relationship between caregiving stress and mental health symptoms of primary family caregivers.

METHODS

The analytic sample included 881 primary caregivers of older adults from the 2015 and 2017 National Study of Caregiving (NSOC). Social isolation was measured using a composite structure that includes objective social disconnectedness and subjective loneliness. Two-wave mediation models were estimated to examine longitudinally if social isolation mediated the relationship between caregiving stress (subjective & objective stress) and mental health symptoms (depression & anxiety) of primary caregivers.

RESULTS

The study findings indicate that both subjective (β = 0.32, p < 0.001) and objective stress (β = 0.21, p = 0.003) have direct effects on depression among primary caregivers. Social isolation was found to only mediate the relationship between objective stress and depression (β = 0.18, p < 0.001). In contrast, no significant direct and indirect pathway was found in the anxiety model.

CONCLUSIONS

The study demonstrates the internal mechanism where objective strains of caregiving make family caregivers socially isolated, which in turn leads to increased symptoms of depression. Future interventions and practices aimed at improving the psychological well-being of family caregivers should prioritize strategies aimed at increasing social engagement, particularly for those with heavy caregiver burdens.

A randomised controlled trial of the Learning Skills Together (LST) intervention to improve dementia family caregivers' self-efficacy with complex care

Background

Nearly two-thirds of family caregivers of persons living with Alzheimer's disease or related dementias (AD/ADRD) provide complex care, including medical care. Family caregivers typically receive little to no training on how to provide this care. Furthermore, family caregivers simultaneously grapple with the presence of behavioral and psychological symptoms of dementia (BPSD), diminished communication abilities, and comorbidities such as diabetes. We developed Learning Skills Together (LST), a six-week digitally delivered psychoeducational program, to facilitate family caregiver abilities to administer complex care tasks. The goal of the present study is to test the efficacy of LST and to reduce adverse outcomes associated with caregiving, such as depressive symptomology and negative appraisal of BPSD.

Methods

To test the efficacy of LST, we will conduct a two-arm single-site randomised controlled trial (RCT) with N = 200 family caregivers of persons living with AD/ADRD. Eligible family caregivers will be randomly assigned to participate in either the LST intervention or a structurally equivalent control condition focused on healthy living. All family caregivers will complete four surveys, including a baseline survey administered prior to randomisation, a post-intervention survey, and a three- and six-month follow-up survey to assess change in study outcomes. Between-group comparisons of each outcome will be evaluated using generalized estimating equation models. Mediation analyses will assess family caregiver self-efficacy as the intervention's mechanism of change in depressive symptomology and BPSD. We will also examine caregiver race, ethnicity, and gender as effect modifiers of the intervention.

Discussion

LST findings will inform the field of AD/ADRD and caregiving regarding optimally supporting family caregivers in managing complex care tasks. If efficacious, the LST intervention will support family caregivers in preserving their own mental health while providing complex care.

Longitudinal Care Network Changes and Associated Healthcare Utilization Among Care Recipients

This study examines caregiver networks, including size, composition, and stability, and their associations with the likelihood of hospitalization and skilled-nursing facility (SNF) admissions. Data from the National Health and Aging Trends Study linked to Center for Medicare and Medicaid Services data were analyzed for 3855 older adults across five survey waves. Generalized estimating equation models assessed the associations. The findings indicate each additional paid caregiver was associated with higher adjusted risk ratios (aRR) for hospitalization (aRR = 1.24, 95% CI 1.10-1.41) and SNF admission (aRR = 1.28, 95% CI 1.06-1.54) among care recipients, a pattern that is also observed with the addition of unpaid caregivers (hospitalization: aRR = 1.13, 95% CI 1.06-1.20; SNF: aRR = 1.12, 95% CI 1.02-1.23). These results suggest that policies and approaches to enhance the quality and coordination of caregivers may be warranted to support improved outcomes for care recipients.

Prevalence Estimates of Arthritis and Activity-Limiting Pain Among Family Caregivers to Older Adults

BACKGROUND AND OBJECTIVES

Little is known about the prevalence of physical pain among family caregivers to older adults. We used national survey data to assess the relative prevalence of caregivers' arthritis and activity-limiting bothersome pain by caregiver and care-recipient characteristics to identify which caregivers may be at a higher risk for physical pain.

RESEARCH DESIGN AND METHODS

We analyzed data collected from 1,930 caregivers who participated in the National Study on Caregiving (2017). We utilized modified Poisson models to estimate adjusted associations of caregiver and care-recipient characteristics with the relative prevalence of arthritis and bothersome pain.

RESULTS

Forty percent of caregivers had a lifetime diagnosis of arthritis. Seventy-five percent of caregivers with arthritis reported bothersome pain, nearly 30% of whom endorsed bothersome pain that limited their activities on most or every day of the previous month (i.e., activity-limiting bothersome pain). Regardless of whether they had arthritis, 51% of the sample reported bothersome pain in the previous month, 24% of whom indicated activity-limiting bothersome pain. Caregivers who were older or more highly educated had a higher prevalence of arthritis. Black caregivers had a lower prevalence of arthritis and activity-limiting bothersome pain compared to White caregivers. Caregivers with physical difficulty providing care had a higher prevalence of arthritis and activity-limiting bothersome pain than caregivers without physical difficulty providing care.

DISCUSSION AND IMPLICATIONS

Arthritis and activity-limiting bothersome pain are highly prevalent among caregivers. Given increased prevalence of pain among certain caregivers, it may be efficient to target these groups for pain management interventions.

Emotion Regulation Strategies and Mental Health in Dementia Caregivers: The Moderating Role of Gender

INTRODUCTION

Providing care for a loved one with dementia can engender intense emotions that contribute to symptoms of anxiety and depression. Caregivers often attempt to regulate their emotions using strategies like cognitive reappraisal (CR; changing how they think about the situation) or expressive suppression (ES; hiding their emotions). However, men and women caregivers may differ in their use of these strategies. The current study examines gender differences in reported CR and ES usage and their associations with depression and anxiety in dementia caregivers.

METHODS

We combined data from three independent studies of informal dementia caregivers (total N = 460) who reported on their use of CR, ES, and symptoms of anxiety and depression.

RESULTS

Women caregivers reported greater use of CR and less use of ES compared to men. Gender moderated the association between CR and depression, such that greater use of CR in women was associated with fewer depressive symptoms, but not for men. Gender did not significantly moderate the association between ES and depression, or between either emotion regulation strategy and anxiety.

CONCLUSION

Findings of a unique relationship between greater CR use and less depression among women CGs, although correlational, suggest that utilizing CR may be particularly helpful for reducing depression in women caregivers. These results underscore the need for further research to determine how best to support the mental well-being of dementia caregivers.

The Olera.care Digital Caregiving Assistance Platform for Dementia Caregivers: Preliminary Evaluation Study

BACKGROUND

The increasing prevalence of Alzheimer disease and Alzheimer disease-related dementia in the United States has amplified the health care burden and caregiving challenges, especially for caregivers of people living with dementia. A web-based care planning tool, Olera.care, was developed to aid caregivers in managing common challenges associated with dementia care.

OBJECTIVE

This study aims to preliminarily evaluate the quality and usability of the Olera.care platform and assess the preferences of using the technology and interests in learning about different older adult care services among caregivers.

METHODS

For interview 1, we aim to understand caregiving needs and let the participants start engaging with the platform. After they engage with the platform, we schedule the second interview and let the participants complete the Mobile Application Rating Scale. The survey also included sociodemographic characteristics, caregiving experiences, communication preferences in technology adoption, and older adult care service use and interests. Descriptive statistics were used to describe the quality and usability of the platform and characteristics of the participants. We conducted 2-sample 2-tailed t tests to examine the differences in the Mobile Application Rating Scale evaluation scores by caregiver characteristics.

RESULTS

Overall, 30 adult caregivers in Texas completed the evaluation. The majority were aged ≥50 years (25/30, 83%), women (23/30, 77%), White (25/30, 83%), and financially stable (20/30, 67%). The Olera.care platform evaluation showed high satisfaction, with an overall mean rating of 4.57 (SD 0.57) of 5, and scored well in engagement (mean 4.10, SD 0.61), functionality (mean 4.46, SD 0.44), aesthetics (mean 4.58, SD 0.53), and information quality (mean 4.76, SD 0.44) consistently across all participants. A statistically significant difference (P=.02) was observed in functionality evaluation scores by duration of caregiving, with caregivers dedicating more hours to care rating it higher than those providing less care (mean 4.6, SD 0.4 vs mean 4.2, SD 0.5). In addition, caregivers with less caregiving experience reported significantly higher evaluation scores for aesthetics (P=.04) and information quality (P=.03) compared to those with longer years of caregiving. All participants expressed a willingness to recommend the app to others, and 90% (27/30) rated the app overall positively. Most of the participants (21/30, 70%) favored anonymous interactions before receiving personalized feedback and preferred computer browsers over mobile apps. Medical home health services were the most used, with a diverse range of services being used. Caregiver support groups, medical providers, memory care, meal services, and adult day care were among the most desired services for future exploration.

CONCLUSIONS

The Olera.care web-based platform is a practical, engaging, easy-to-use, visually appealing, and informative tool for dementia caregivers. Future development and research are essential to enhance the platform and comprehensively evaluate it among a broader population.

Orchestrating Care: A Grounded Theory Study of Family Caregiving for Older Adults in Rural Areas

Family caregivers provide the majority of long-term care and support of older adults as they age or approach the end of life. Studies often refer to family caregivers as invisible because the American healthcare system, public policy, and society do not support or recognize their work. Family caregivers who provide care to older adults who live in rural areas face unique challenges due to the rural environment. The purpose of this study was to inductively develop a theoretical framework that explains the process of family caregiving to older adults who live at home in rural areas and require daily assistance while exploring their experiences regarding access, utilization, challenges, and effectiveness of patient healthcare services and caregiver resources in rural areas. The grounded theory method of Strauss and Corbin was used for sampling, data collection, and data analysis. Fifteen family caregivers who oversaw and/or provided care on a daily basis to an older adult living in two rural counties of New York State participated in the study. Data were collected through two semi-structured interviews with each participant, yielding 30 interviews. Findings revealed that family caregivers engaged in the process of orchestrating care by growing into caregiving, integrating technology, and utilizing networks when providing and managing caregiving. Understanding caregiving from the perspective of family caregivers engaged in the process can inform healthcare practice, healthcare education, and public policy and can support better outcomes for both older adults and their family caregivers.

Trends in private caregiving cost after implementing a comprehensive nursing service covered by national health insurance: Interrupted time series

BACKGROUND

The Korean government has implemented a comprehensive nursing care service system (CNS) to mitigate the stress faced by caregivers.

OBJECTIVE

This study aimed to assess trends in the estimated average costs of private caregiving and determine the difference in costs between those using CNS and those not using it.

DESIGN

A comparative interrupted time series analysis with a 2-year lag period verified total private caregiving cost trends; biannual differences in costs were evaluated based on using CNS.

PARTICIPANTS

The main unit of analysis was episode. We extracted a total of 6418 episodes of hospitalization in acute care settings that included the use of caregiving services (formal, informal caregiving and CNS).

METHODS

We conducted segmented regression to assess the impact of CNS on total private caregiving costs using data from 2012 to 2018, excluding the years 2015 and 2016 of the Korean Health Panel dataset.

RESULTS

We presented that the immediate mean difference in total private caregiving costs between CNS users and non-users was -444.7 USD two years after the implementation of the CNS policy (95 % CI -714.5 to -174.5, p-value 0.001). Among individuals living in rural areas, two years after the implementation of the CNS policy, there was a significant immediate mean cost difference of -476.9 USD in total private caregiving costs between CNS users and non-users (p-value 0.011). Similarly, for episodes with a Charlson Comorbidity Index (CCI) score of 0 to 1, there was a substantial immediate mean cost difference in total private caregiving costs between CNS users and non-users, amounting to -399.9 USD two years after the CNS policy (p-value 0.008).

CONCLUSIONS

This study evaluated the trend of total private caregiving costs between groups using and not using CNS. After two years of being covered by CNS health insurance, those who utilized CNS paid $433 less for their total private caregiving cost over a 6-month period, compared to those who did not use CNS. The adoption of CNS may be an effective system for relieving the financial burden on inpatients in need of private caregiving services.

TWEETABLE ABSTRACT

Korean Comprehensive Nursing Service reduces private caregiving costs.

Organizational and Policy Challenges and Priorities for Integrating Family Care Partners Into the Healthcare Team

Family care partners are significantly involved in healthcare tasks in order to support adult relatives. Yet, unlike pediatric models of care where caregivers of children are formally integrated into healthcare teams, care partners of adults are rarely engaged in a formal, structured, or consistent manner. Their inclusion in the healthcare team is critical to their capacity to continue supporting their relative. A meaningful dialogue between policy and healthcare management is required to identify feasible and effective ways of engaging family care partners in healthcare teams.

Geographic Relocation in Response to Parents' Health Shocks: Who Moves and How Close?

Objective

This article examines how parent-child geographic proximity changes around the onset of parental health shocks in the United States. Differences in the likelihood of moving closer across social groups are also investigated.

Background

Adult children often care for older parents with health problems, but this requires relatively close proximity. As families are becoming smaller and many adult children live away from their parents, it is unclear how responsive families will be to older adults' health problems.

Method

We estimate a series of fixed effects and event study models on data from the Health and Retirement Study (2004-2018) to assess changes in parent-child proximity after parents' first onset of cognitive impairment and functional limitations.

Results

We find robust evidence that parents and children tend to stay close or move closer to each other in response to parent's health declines. Moves occur immediately and in subsequent waves after the onset of health shocks. Reductions in parent-child distance are consistently larger among mother-daughter dyads, dyads without spouses or multiple children, and non-Hispanic white families.

Conclusion

The geographic availability of adult children to provide care is responsive to parents' needs. After the onset of a serious health condition, most older adults have a spouse or child living close enough to provide care. Parents' and children's lives are dynamically linked, and either or both may relocate to facilitate care.

Exploring the health-related decision-making experiences of people with chronic kidney disease and their caregivers: A qualitative study

BACKGROUND

This study aimed to explore the decision-making experience of patients with chronic kidney disease (CKD) and their caregivers.

METHODS

This was a qualitative descriptive study of the decision-making experiences of individuals with stage 3-end-stage CKD and their family caregivers. One-on-one, semistructured interviews were conducted using a guide developed and approved by a community advisory group. Data were analyzed using thematic analysis.

RESULTS

Three themes were identified: (1) decisions triggered by declining health and broad in scope, (2) challenges to decision-making and (3) factors influencing decision-making. Participants' experiences with health-related decision-making demonstrated that decisions were triggered when health declined. Yet, decisions that impact disease progression were being made in stage 3. Decision-making was made difficult due to lack of information, complex co-morbidities, and poor resource utilization. However, the structure and nature of the medical appointment, supportive caregivers, and resources served to remove challenges.

CONCLUSION

Decision-support interventions must train patients and caregivers to be empowered participants in answer-seeking behaviours upstream of advanced illness.

PUBLIC CONTRIBUTIONS

This work was conducted in full collaboration with a community advisory board consisting of patients with CKD, caregivers and clinicians. These members are noted in the acknowledgement section, and those who worked with the team to develop the interview guide, study protocols, and manuscript preparation are included as authors. As part of their role, advisory members met monthly, providing input on recruitment, study progress, inclusion of diverse voices and added relevance to study findings.

Mental Health Outcomes of Immigrant- and US-Born Caregivers: California Health Interview Survey, 2019-2020

Objectives. To compare the mental health outcomes of US-born with immigrant caregivers of adult care recipients. Methods. We conducted a cross-sectional secondary analysis of the 2019 California Health Interview Survey (CHIS), administered via web or telephone to 22 152 participants between September and December 2019. We characterized (1) caregivers and noncaregivers, and (2) US-born versus immigrant caregivers. Then, we estimated and compared (3) the relationship between caregiving status and severe psychological distress among US-born and immigrant respondents, and (4) correlates of severe psychological distress among US-born and immigrant respondents. Results. Caregivers were more likely than noncaregivers to report severe psychological distress (P < .05). Immigrant caregivers residing separately from their care recipient were significantly more likely to experience severe psychological distress (odds ratio = 3.76; P < .01). Conclusions. US-born and immigrant caregivers may experience different risk factors for psychological distress associated with caregiving. Clinical and community resources should be tailored to caregivers' distinct needs with consideration of how access to resources (e.g., language), circumstances (e.g., acculturation), and cultural norms (e.g., filial piety) may be associated with exacerbation of psychological distress among immigrants. (Am J Public Health. 2024;114(S2):S189-S199. https://doi.org/10.2105/AJPH.2023.307396).

The Changing Demography of Late-Life Family Caregiving: A Research Agenda to Understand Future Care Networks for an Aging U.S. Population

Repeated claims that a dwindling supply of potential caregivers is creating a crisis in care for the U.S. aging population have not been well-grounded in empirical research. Concerns about the supply of family care do not adequately recognize factors that may modify the availability and willingness of family and friends to provide care to older persons in need of assistance or the increasing heterogeneity of the older population. In this paper, we set forth a framework that places family caregiving in the context of older adults' care needs, the alternatives available to them, and the outcomes of that care. We focus on care networks, rather than individuals, and discuss the demographic and social changes that may alter the formation of care networks in the future. Last, we identify research areas to prioritize in order to better support planning efforts to care for the aging U.S. population.

Implementation Costs of Technology-Enhanced Transitional Palliative Care for Rural Caregivers

OBJECTIVES

Compared to urban family caregivers (FCG), rural FCG experience greater burdens accessing coordinated care for their loved ones during and after hospitalization. The impact of technology-enhanced transitional palliative care (TPC) on caregiver outcomes is currently being evaluated in a randomized control trial. This study evaluates resource use and health system costs of this FCG-focused TPC intervention and potential Medicare reimbursement mechanisms.

METHODS

Rural caregivers of hospitalized patients were randomized into an 8-week intervention consisting of video visits conducted by a registered nurse certified in palliative care, supplemented with phone calls and texts (n = 215), or attentional control. Labor costs were estimated for a registered nurse and compared to scenario analyses using a nurse practitioner or social worker wages. Medicare reimbursement scenarios included Transitional Care Management (TCM) and Chronic Care Management (CCM) CPT codes.

RESULTS

In the base case, TPC cost was $395 per FCG facilitated by a registered nurse, compared to $337 and $585 if facilitated by a social worker or nurse practitioner, respectively. Mean Medicare reimbursement in the TCM-only scenario was $322 and $260 for high or moderate complexity patients, respectively. Reimbursement in the CCM only scenario was $348 and $274 for complex and non-complex patients, respectively. Reimbursement in the TCM+CCM scenario was $496 and $397, for high/complex and moderate/non-complex patients, respectively.

CONCLUSION

TPC is a feasible, low cost and sustainable strategy to enhance FCG support in rural areas. Potential reimbursement mechanisms are available to offset the costs to the health system for providing transitional palliative care to caregivers of patients recently hospitalized.

Lived experiences of older male caregivers: "That was the Worst!"

INTRODUCTION

Although caregiving is a traditional female role, older men represent an increasing proportion of family caregivers. This study's aim was to describe lived experiences of men who engaged in later-life caregiving.

METHOD

Streubert's phenomenological method, inclusive of unstructured interviews and respondent validation of a single formalized description, was applied to explore lived experiences of eight older male caregivers.

RESULTS

Three overarching themes characterized older male caregiving: 1) role and life changes, 2) "taking care of business," and 3) getting over "the worst". All caregivers spent extensive time in anticipatory planning for potential problems and were dissatisfied with existing resources and services. Each man described a profound, mentally-challenging caregiving crisis that triggered important caregiving decisions.

DISCUSSION

Study findings support an urgent need for research to clarify the mental health needs of older male caregivers and to test interventions that better meet the unique needs of this growing caregiver demographic.

Emergency Scenario-Based Training Curriculum Development: Enhancement of Caregivers for the Elderly' Emergency Assistance Competency in a Rural Thai Community

Background

Caregivers for the elderly are a critical component of the health care system, especially in rural communities. They play a crucial role, assisting older people in confronting emergency illnesses.

Objective

The study describes the process of developing an emergency scenario-based training curriculum (ESBTC) for caregivers of the elderly, focusing on geriatric life-threatening surveillance and emergency assistance (GLTSEA) in rural communities.

Methods

The descriptive qualitative research utilized for developing the ESBTC followed Karn's six steps of curriculum development: (1) needs assessment, (2) targeted needs assessment, (3) goals and objectives, (4) educational strategies, (5) implementation, and (6) evaluation and feedback. The research sample comprised community representatives engaged in providing care during emergency illnesses, emergency experts, and health care providers. A group discussion and focus group were conducted along with semi-structured interviews. The data were analyzed by content analysis following Creswell's six steps.

Results

The results revealed problems and needs related to the care and management of emergency illnesses in rural communities. Five main themes emerged, including insufficient knowledge, difficulties in communication, mindfulness and self-confidence, Unable to assess the initial symptoms, and a need for skills development. In the development step, the curriculum focused on skill development and continued follow-up to ensure necessary skills, such as providing basic life support, using automated external defibrillators, through training scenarios. In the evaluation step, the participants indicated that their emergency assistance skills had improved. The six main themes that emerged regarding the training continuity, courses, and competencies needed to support the emergency system for caregivers were benefits and value, competence enhancements, upstreaming confidence, sustainable development, challenges in curriculum development, and effective strategies.

Conclusions

The ESBTC combines community-based and realistic scenarios, involving the participation of community stakeholders. It is crucial to gather community feedback and needs assessments to formulate potential strategies as part of the curriculum.

Predicting Caregiver Communications in a Geriatric Clinic

The current study evaluated the use of a machine learning model to determine benefit of medical record variables in predicting geriatric clinic communication requirements. Patient behavioral symptoms and global cognition, medical information, and caregiver intake assessments were extracted from 557 patient records. Two independent raters reviewed the subsequent 12 months for documented (1) incoming caregiver contacts, (2) outgoing clinic contacts, and (3) clinic communications. Random forest models' average explained variance in training sets for incoming, outgoing, and clinic communications were 7.42%, 3.65%, and 6.23%, respectively. Permutation importances revealed the strongest predictors across outcomes were patient neuropsychiatric symptoms, global cognition, and body mass, caregiver burden, and age (caregiver and patient). Average explained variance in out-of-sample test sets for incoming, outgoing, clinic communications were 6.17%, 2.78%, and 4.28%, respectively. Findings suggest patient neuropsychiatric symptoms, caregiver burden, caregiver and patient age, patient body mass index, and global cognition may be useful predictors of communication requirements for patient care in a geriatric clinic. Future studies should consider additional caregiver variables, such as personality characteristics, and explore modifiable factors longitudinally.

Healthcare disparities: patients' perspectives on barriers to joint replacement

OBJECTIVE

Racial and ethnic disparities in arthroplasty utilization are evident, but the reasons are not known. We aimed to identify concerns that may contribute to barriers to arthroplasty from the patient's perspective.

METHODS

We identified patients' concerns about arthroplasty by performing a mixed methods study. Themes identified during semi-structured interviews with Black and Hispanic patients with advanced symptomatic hip or knee arthritis were used to develop a questionnaire to quantify and prioritize their concerns. Multiple linear and logistic regression analyses were conducted to determine the association between race/ethnicity and the importance of each theme. Models were adjusted for sex, insurance, education, HOOS, JR/KOOS, JR, and discussion of joint replacement with a doctor.

RESULTS

Interviews with eight participants reached saturation and provided five themes used to develop a survey answered by 738 (24%) participants; 75.5% White, 10.3% Black, 8.7% Hispanic, 3.9% Asian/Other. Responses were significantly different between groups (p < 0.05). Themes identified were "Trust in the surgeon" "Recovery", "Cost/Insurance", "Surgical outcome", and "Personal suitability/timing". Compared to Whites, Blacks were two-fold, Hispanics four-fold more likely to rate "Trust in the surgeon" as very/extremely important. Blacks were almost three times and Hispanics over six times more likely to rate "Recovery" as very/extremely important.

CONCLUSION

We identified factors of importance to patients that may contribute to barriers to arthroplasty, with marked differences between Blacks, Hispanics, and Whites.

Feasibility of a Multi-Component Strengths-Building Intervention for Caregivers of Persons With Heart Failure

Caregivers of persons with heart failure (HF) navigate complex care plans, yet support strategies often focus solely on meeting the needs of patients. We conducted a randomized waitlist control trial (N = 38) to test the feasibility and gauge initial effect size of the Caregiver Support intervention on quality of life, caregiver burden, and self-efficacy among HF caregivers. The intervention includes up to five remote, nurse-facilitated sessions. Components address: holistic caregiver assessment, life purpose, action planning, resources, and future planning. Caregivers were 93.3% female, 60% White, and 63.3% spouses. Average age was 59.4. Participants who completed the intervention reported high satisfaction and acceptability of activities. Between-group effect sizes at 16 and 32 weeks suggest improvement in quality of life (mental health) (.88; 1.08), caregiver burden (.31; .37), and self-efficacy (.63; .74). Caregivers found Caregiver Support acceptable and feasible. Findings contribute evidence that this intervention can enhance caregiver outcomes. Clinicaltrials.gov Identifier NCT04090749.

The caregiver burden of informal caregivers for stroke patients with and without dysphagia: A multi-center, cross-sectional study in Türkiye

Objectives

The aim of this study was to investigate the caregiver burden (CB) of informal caregivers for stroke survivors with and without dysphagia and to assess the relationship between the CB levels of informal caregivers for stroke survivors with dysphagia, patients' swallowing-related quality of life (QoL), and patients' stroke-specific QoL.

Patients and methods

This multi-center, prospective, cross-sectional study included a total of 120 stroke patients (76 males, 44 females; mean age: 61.1±12.3 years; range, 19 to 86 years) between October 2019 and 2020. Of the patients, 57 had dysphagia and 63 had no dysphagia. The Functional Oral Intake Scale (FOIS) was used to classify the degree of functional dietary limitation caused by each patient's swallowing impairment. Patients and caregivers completed the Eating Assessment Tool (EAT-10), Swallowing Quality of Life (SWQoL) questionnaire, Stroke Impact Scale (SIS), and the Zarit Caregiver Burden Interview (ZBI).

Results

The CB levels were higher in those caring for stroke patients with dysphagia than in those caring for stroke patients without dysphagia. Caregiver burden was found to be associated with patients' swallowing-related QoL and stroke-related QoL. Significant predictors of high CB scores (F=2.55, R2=0.59; p=0.007) were being an employed caregiver (B=17.48, p=0.003), being a caregiver with high school (B=-19.6, p=0.03), and secondary school (B=-16.28, p=0.02) educational status, being son, daughter (B=30.63, p=0.007) or other relative of the patient (B=20.06, p=0.01), lower FOIS stage (B=-3.14, p=0.011), lower SWQoL (B=0.52, p=0.009) and lower SIS (B=-0.37, p=0.04) scores.

Conclusion

Caregivers of stroke patients with dysphagia suffer from a higher CB than those without dysphagia. In stroke patients with dysphagia, swallowing-related QoL is associated with the QoL levels of stroke patients and the CB levels of their caregivers. Employment status, educational status of caregiver, caregiver's relativity to the patient, FOIS stage, swallowing and stroke related QoL of the patients are factors related to burden levels of caregivers of stroke patients with dysphagia. These results may help health professionals to understand dysphagia as an essential source of CB and consider it, while planning treatments.

Social Activity Restriction and Psychological Health Among Caregivers of Older Adults With and Without Dementia

OBJECTIVES

We examined associations between social activity restriction and psychological distress and well-being for caregivers of older adults with and without dementia, and if the identified associations are different for the two groups.

METHODS

Using data from the 2017 National Study of Caregiving, we identified caregivers of older adults with (N = 541) and without (N = 1701) dementia. Linear regression models were estimated, adjusting for caregivers' age, gender, race, education, relationship to care recipient, and self-rated health.

RESULTS

Restriction in visiting friends and family and attending religious services were associated with higher distress in dementia caregivers. Restriction in visiting friends and family was associated with higher distress and lower well-being in non-dementia caregivers. Any activity restriction had stronger association with distress for caregivers of older adults with versus without dementia.

DISCUSSION

Findings highlight the need for tailored interventions based on caregivers' perceptions of meaningful social activities and dementia-friendly communities to promote social participation.

Integrating social determinants of health in medical education: a bibliometric analysis study

OBJECTIVES

Social determinants of health (SDH) are the prevalent enablers of health among populations, and integrating them in medical education will advance clinical care by integrating social and economic risk data into medical diagnosis and treatment. Despite the numerous publications on SDH and medical education, the publication trends are not known. The study aims to analyse publication trends in integrating SDH into medical education and the corresponding thematic areas.

STUDY DESIGN

This was a bibliometric analysis study.

METHODS

Bibliometric was used. Data from Scopus databases from January 2006 to June 2023 were retrieved with no language restriction. VOSviewer software was used for analysis. Bibliographic coupling was used to identify the clusters of published literature on the integration of SDH into medical education, followed by the analysis of annual distribution and growth trends, authors and co-author relationships and collaborations.

RESULTS

A total of 1047 articles were retrieved. The annual research publication exhibited a swift surge in the studies conducted during the reviewed period. Five clusters of information were derived: relating to curriculum development, community engagement and service-learning, stakeholder collaborations, development of assessment methods and tools for SDH, and the impact of integrating SDH into medical education.

CONCLUSION

Bibliometric analysis has revealed a growing trend in the field of integrating SDH into medical education, and the study has highlighted the research impact through bibliographic coupling by identifying the five thematic areas. This study lays a foundation for advancing knowledge on what has been published and possible areas for improvement in the integration of SDH into medical education.

"Caregiving is teamwork…" Information sharing in home care for older adults with disabilities living in the community

AIM

We examined information sharing between direct care workers, family caregivers, and clinicians involved in the care of older adults with disabilities.

METHODS

Semi-structured interviews with N = 11 representatives of home care agencies ("residential service agencies" in Maryland).

RESULTS

Work system and process characteristics relevant to information sharing included: (1) using electronic management systems and patient portals to communicate within agencies and with clinicians, (2) implementing tools to gather information about client goals, preferences, and routines, and (3) relying on family members for information about clients' needs. Participants did not report differences in dementia-related care coordination; however, dementia-related adaptations involved additional considerations for navigating relationships with family and standardizing processes to communicate with clinicians.

CONCLUSION

Findings highlight care demands experienced by direct care workers and support calls to better coordinate information sharing between interdisciplinary care teams.

Caregiving Time of Unpaid Family Caregivers Assisting Older Adults With Hearing Difficulty

Objectives: We aimed to investigate the association of older adults' hearing difficulty status with caregiving time. Methods: We used data from two linked surveys of Medicare beneficiaries and family caregivers. Hearing difficulty was defined by hearing aid use and hearing capacity in functional settings. Weighted multivariable linear regression examined the association between hearing difficulty and caregiving time. Stratified analyses were conducted to investigate the moderation effects of caregiving networks and care recipient's dementia status. Results: Among 3003 caregivers, those who assisted older adults with hearing difficulty were observed to spend greater time providing care (β = 1.18, 95% Confidence Interval [CI]: 1.04, 1.32). Stronger associations in magnitude were observed among caregivers without caregiving networks (β = 1.35, 95% CI: 1.13, 1.56) and assisting older adults without dementia (β = 1.22; 95% CI = 1.06, 1.37). Discussion: Hearing difficulty may contribute to greater caregiving time and remains a potential target for caregiver support programs.

LitCog Caregiver Cohort: a prospective, observational cohort study investigating US caregivers' health literacy, self-care skills and cognitive function

INTRODUCTION

Many older adults receive assistance in managing chronic conditions. Yet complicating the utility of caregiver support is whether caregivers have sufficient skills to aid in a patient's self-care. Health literacy and cognition are important determinants of older adults' health outcomes, but few studies have examined caregiver health literacy, cognition and self-care skills and their relations to patient outcomes.

METHODS AND ANALYSIS

We will expand an ongoing cognitive ageing cohort study (LitCog) to enroll a parallel caregiver cohort. Caregivers are eligible if they are (1) ≥18 years of age, (2) provided care for ≥6 months and (3) assisted with at least one activity of daily living, instrumental activity of daily living or health management task. Caregivers will complete interviews at time points corresponding with the LitCog participant interviews. Caregivers will complete assessments of health literacy, self-care skills, cognitive function, caregiver healthcare task difficulty, caregiver burden, caregiver self-efficacy, activation, technology use, busyness and routine and relationship quality. Caregivers will self-report the nature and intensity of care provided, and their own health status. Associations between caregiver presence and caregiver capacity with patient outcomes will be examined in a series of regression models, and mediating and moderating factors will be tested.

ETHICS AND DISSEMINATION

The Institutional Review Board at Northwestern University has approved the study protocol (STU00026255). Results will be published in peer-reviewed journals and summaries will be provided to the funders of the study as well as patients and caregivers.

Influence of medical care tasks on subjective burden and gain among older adults' family caregivers: structural equation modeling for testing the role of formal and informal support

BACKGROUND

The number of caregivers performing medical care tasks at home for older adults is expected to increase. Family caregivers, who are not healthcare professionals, are likely to find these activities difficult and burdensome. However, appropriate support may decrease the negative and increase the positive aspects of caregiving. This study investigated direct associations between caregivers providing medical care at home and their negative and positive appraisals of caregiving (burden and gain), indirect associations through healthcare professional support and informal support, and whether the associations between medical care tasks and caregivers' appraisals of caregiving differed based on the support received.

METHODS

Interview surveys were conducted in 2013, 2016, and 2019 in a Tokyo Metropolitan Area city with family caregivers of community-dwelling older adults who were certified as requiring care in Japan's long-term care insurance system. This study analyzed the combined data from each survey (n = 983). Structural equation modeling (SEM) analysis was utilized to examine direct associations between providing medical care and caregiver appraisals and indirect relationships through healthcare professional support and informal support. The modulating effects of these forms of support on the relationship between medical care and caregiver appraisals were assessed using multigroup SEM analyses.

RESULTS

Approximately 9% of family caregivers provided medical care at home. The results of SEM analyses, controlled for care recipients' physical and cognitive difficulties; caregivers' age, sex, and economic condition; and survey year, revealed no direct associations between providing medical care and caregivers' sense of burden and gain. They also did not reveal any indirect effects through either healthcare professional support or informal support. However, the results of multigroup SEM analyses indicated that caregivers providing medical care who used home-visit services by physicians and/or nurses, compared to those who did not, tended to exhibit a greater sense of gain.

CONCLUSIONS

These results suggest that family caregivers providing medical care at home can positively change their appraisals of caregiving if they receive appropriate support. Home medical care services provided by healthcare professionals can effectively support caregivers. Developing strategies and policies to make medical care services at home more accessible to caregivers is crucial.

Financial, Legal, and Functional Challenges of Providing Care for People Living With Dementia and Needs for a Digital Platform: Interview Study Among Family Caregivers

BACKGROUND

Alzheimer disease and Alzheimer disease-related dementia represent complex neuropathologies directly challenging individuals, their families, and communities in the United States. To support persons living with dementia, family or informal caregivers often encounter complex financial, psychological, and physical challenges. A widely used solution such as a consolidated web-based assistance or guidance platform is missing, compounding care challenges.

OBJECTIVE

In preparation for designing an internet-based artificial intelligence-driven digital resource platform, a qualitative interview study was conducted to characterize the challenges and needs of family caregivers in the United States.

METHODS

A semistructured interview topic guide in English was developed by engaging community partners and research partnerships. Family caregiver participants were purposefully recruited via various means, such as word of mouth, local dementia community service providers, digital recruitment emails, flyers, and social media. Interested individuals were first invited to complete an eligibility screening survey, and eligible individuals were then contacted to arrange a web-based in-depth interview via Zoom (Zoom Video Communications) from January 1, 2022, to May 31, 2022. A follow-up survey was administered in May 2022 to provide an overview of the participants' demographics, socioeconomic characteristics, and caregiving information. Thematic analysis in a framework approach was used to identify and organize themes and the study findings.

RESULTS

Following the prescreening of 150 eligible respondents, 20% (30/150) individuals completed both the interviews and follow-up survey, allowing for an in-depth look into the challenges, experiences, and expectations of primary caregivers of people living with dementia. Most participants (20/30, 67%) were primary caregivers of persons with dementia, and 93% (28/30) had provided care for at least a year. Most participants were aged >50 years (25/30, 83%), female (23/30, 77%), White (25/30, 83%), and non-Hispanic (27/30, 90%) and held a bachelor's or graduate degree (22/30, 73%). Collectively, all participants acknowledged challenges in caring for people living with dementia. Thematic analyses elicited the challenges of caregiving related to functional care needs and financial and legal challenges. In addition, participants identified the need for an integrative digital platform where information could be supplied to foster education, share resources, and provide community support, enabling family caregivers to improve the quality of care and reducing caregiver burden.

CONCLUSIONS

This study emphasized the difficulties associated with the family caregiver role and the expectations and potential for a supportive web-based platform to mitigate current challenges within the caregiving role.

Cost effectiveness of non-drug interventions that reduce nursing home admissions for people living with dementia

INTRODUCTION

Six million Americans live with Alzheimer's disease and Alzheimer's disease and related dementias (AD/ADRD), a major health-care cost driver. We evaluated the cost effectiveness of non-pharmacologic interventions that reduce nursing home admissions for people living with AD/ADRD.

METHODS

We used a person-level microsimulation to model the hazard ratios (HR) on nursing home admission for four evidence-based interventions compared to usual care: Maximizing Independence at Home (MIND), NYU Caregiver (NYU); Alzheimer's and Dementia Care (ADC); and Adult Day Service Plus (ADS Plus). We evaluated societal costs, quality-adjusted life years and incremental cost-effectiveness ratios.

RESULTS

All four interventions cost less and are more effective (i.e., cost savings) than usual care from a societal perspective. Results did not materially change in 1-way, 2-way, structural, and probabilistic sensitivity analyses.

CONCLUSION

Dementia-care interventions that reduce nursing home admissions save societal costs compared to usual care. Policies should incentivize providers and health systems to implement non-pharmacologic interventions.

Factors that promote resilience for older adults and their informal caregivers during the COVID-19 pandemic

OBJECTIVES

The aim of this cross-sectional, descriptive study was to characterize the impact of modifiable activities on older adult mental health during the COVID-19 pandemic and to understand the interaction between older adult behaviors and the mental health of their informal caregivers.

METHODS

This study leveraged the National Health and Aging Trends Study and associated Family and Friends survey completed 2020-2021. Participants included 3,257 community dwelling older adults and 2,062 associated unpaid caregivers, weighted sample sizes 26,074,143 and 21,871,408, respectively.

RESULTS

Older adult engagement in volunteering, religious, or group activities was associated with decreased older adult depression, as was increased walking or vigorous activity. However, online compared to in-person participation correlated with greater loneliness in older adults and anxiety for their caregivers. Finally, increased appreciation by the care recipient correlated with decreased caregiver depression.

CONCLUSION

Overall, a close interaction exists between caregiver and older adult behavior and psychiatric symptoms. Online activities are not an equivalent substitute for in-person activities during required social isolation; however, they remain superior to no participation. Further, increased walking and caregiver appreciation may ameliorate some of the harms of isolation. Health care providers should continue to promote engagement, exercise, and appreciation as ways to improve older adult and informal caregiver mental health.

European Respiratory Society clinical practice guideline: palliative care for people with COPD or interstitial lung disease

There is increased awareness of palliative care needs in people with COPD or interstitial lung disease (ILD). This European Respiratory Society (ERS) task force aimed to provide recommendations for initiation and integration of palliative care into the respiratory care of adult people with COPD or ILD. The ERS task force consisted of 20 members, including representatives of people with COPD or ILD and informal caregivers. Eight questions were formulated, four in the Population, Intervention, Comparison, Outcome format. These were addressed with full systematic reviews and application of Grading of Recommendations Assessment, Development and Evaluation for assessing the evidence. Four additional questions were addressed narratively. An "evidence-to-decision" framework was used to formulate recommendations. The following definition of palliative care for people with COPD or ILD was agreed. A holistic and multidisciplinary person-centred approach aiming to control symptoms and improve quality of life of people with serious health-related suffering because of COPD or ILD, and to support their informal caregivers. Recommendations were made regarding people with COPD or ILD and their informal caregivers: to consider palliative care when physical, psychological, social or existential needs are identified through holistic needs assessment; to offer palliative care interventions, including support for informal caregivers, in accordance with such needs; to offer advance care planning in accordance with preferences; and to integrate palliative care into routine COPD and ILD care. Recommendations should be reconsidered as new evidence becomes available.

Caregiver burden related to feeding process in Alzheimer's disease

Difficulties in the feeding process, such as aversive feeding behaviors and dysphagia, are common in patients with Alzheimer's disease (AD) and can often overload their caregivers. Although dysphagia is already established as a factor contributing to caregiver burden, the impact of aversive behaviors is less studied.

Objectives

Evaluate the relationship between the feeding process in individuals with AD and their caregiver's burden.

Methods

Dyads of individuals with AD and their caregivers were recruited for a cross-sectional study. The Edinburgh Feeding Evaluation in Dementia (EdFED) scale, the Zarit Burden Interview (ZBI), the mini-mental state examination (MMSE), the Functional Activities Questionnaire (FAQ), and the Functional Oral Intake scale (FOIS) were performed.

Results

We included 60 AD individuals-caregivers dyads. The median (IQR) age of caregivers was 57 (19-81) years, and the most were females (70%). The individuals with AD had a median MMSE of 12 (6-15), and the disease duration was 4 (2-6) years. The mean (SD) Zarit score was 20.95 (6.51). In the multivariate linear regression, the EdFED score (95% CI 0.368-1.465) and time as a caregiver (95% CI 0.133-1.355) were associated with the caregiver's burden.

Conclusions

Aversive behaviors were associated with the caregiver burden of individuals with AD, even with a short duration of the disease. These findings show the importance of education for caregivers regarding the feeding process, as these measures have great potential to minimize the caregiver's burden.

Activity patterns related to depression symptoms in stressed dementia caregivers

OBJECTIVES

Self-reported activity restriction is an established correlate of depression in dementia caregivers (dCGs). It is plausible that the daily distribution of objectively measured activity is also altered in dCGs with depression symptoms; if so, such activity characteristics could provide a passively measurable marker of depression or specific times to target preventive interventions. We therefore investigated how levels of activity throughout the day differed in dCGs with and without depression symptoms, then tested whether any such differences predicted changes in symptoms 6 months later.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

We examined 56 dCGs (mean age = 71, standard deviation (SD) = 6.7; 68% female) and used clustering to identify subgroups which had distinct depression symptom levels, leveraging baseline Center for Epidemiologic Studies of Depression Scale-Revised Edition and Patient Health Questionnaire-9 (PHQ-9) measures, as well as a PHQ-9 score from 6 months later. Using wrist activity (mean recording length = 12.9 days, minimum = 6 days), we calculated average hourly activity levels and then assessed when activity levels relate to depression symptoms and changes in symptoms 6 months later.

RESULTS

Clustering identified subgroups characterized by: (1) no/minimal symptoms (36%) and (2) depression symptoms (64%). After multiple comparison correction, the group of dCGs with depression symptoms was less active from 8 to 10 AM (Cohen's d ≤ -0.9). These morning activity levels predicted the degree of symptom change on the PHQ-9 6 months later (per SD unit β = -0.8, 95% confidence interval: -1.6, -0.1, p = 0.03) independent of self-reported activity restriction and other key factors.

CONCLUSIONS

These novel findings suggest that morning activity may protect dCGs from depression symptoms. Future studies should test whether helping dCGs get active in the morning influences the other features of depression in this population (i.e. insomnia, intrusive thoughts, and perceived activity restriction).

Dementia care navigation: Building toward a common definition, key principles, and outcomes

INTRODUCTION

As the complexity of medical treatments and patient care systems have increased, the concept of patient navigation is growing in both popularity and breadth of application. Patient navigators are trained personnel whose role is not to provide clinical care, but to partner with patients to help them identify their needs and goals and then overcome modifiable patient-, provider-, and systems-level barriers. Due to its high incidence, duration, and medical-social complexity, dementia is an ideal candidate for a patient-centric health care delivery model such as care navigation.

METHODS

The Alzheimer's Association formed an expert workgroup of researchers in the field of dementia care navigation to identify evidence-based guidelines.

RESULTS

Recognizing the unique and challenging needs of persons living with dementia and their care partners, several U.S. dementia care navigation programs have been developed and assessed in recent years. Collectively these programs demonstrate that persons living with dementia and their care partners benefit from dementia care navigation. Improved care system outcomes for the person living with dementia include reduced emergency department visits, lower hospital readmissions, fewer days hospitalized, and shorter delays in long-term care placement. Well-being is also increased, as there is decreased depression, illness, strain, embarrassment, and behavioral symptoms and increased self-reported quality of life. For care partners, dementia navigation resulted in decreased depression, burden, and unmet needs.

DISCUSSION

This article presents principles of dementia care navigation to inform existing and emerging dementia care navigation programs.

Highlights

Several U.S. dementia care navigation programs have demonstrated outcomes for persons living with dementia, care partners, and health systems.The Alzheimer's Association formed an expert workgroup of researchers in the field of dementia care navigation to create a shared definition and identify evidence-based guidelines or principles.These outlined principles of dementia care navigation can inform existing and emerging dementia care navigation programs.

Gatekeepers: The Association of Caregiving Network Characteristics With Emergency Department Use by Persons Living With Dementia

OBJECTIVES

Caregivers are typically enmeshed in networks of family and friends who assist with care, yet this network is largely neglected in research. In light of the fact that caregivers are key medical decision makers and play a critical role in how persons living with dementia (PLwDs) interface with the health care system, this study explores how features of the caregiver network relate to PLwD emergency department (ED) use.

METHODS

Using 2015 National Health and Aging Trends Study data linked with fee-for-service Medicare claims, we examine ED use in a nationally representative sample of community-dwelling persons aged 65 and older with dementia and at least 1 caregiver. We consider aspects of the caregiver network including membership (e.g., daughter in network), network size, hours of care received, and the presence of generalists and specialists (i.e., broad vs narrow functional assistance) as predictors of ED encounters among PLwD.

RESULTS

PLwDs were 81.5 years old on average, 50% were female, and 33% were non-White. Care networks including nonimmediate family members involved in task sharing for mobility and self-care difficulties and those with more generalists had significantly higher odds of an ED visit. Networks that only consisted of specialist caregivers had significantly lower odds of an ED visit.

DISCUSSION

Greater complexity of care networks increases risk of presenting to the ED for care. Better understanding how caregiving networks help PLwD interact with the health care system can inform intervention design and targeting in order to help care networks improve care coordination, management, and shared decision making.

Caregiving-Related Work Productivity Loss Among Employed Family and Other Unpaid Caregivers of Older Adults

OBJECTIVES

Although nearly half of all family and unpaid caregivers to older adults work, little is known about short-term work impacts of caregiving using measures encompassing both missed work time and reduced productivity while physically at work. We quantify the prevalence, costs, and correlates of caregiving-related work productivity loss.

METHODS

We used the 2015 National Study of Caregiving and National Health and Aging Trends Study to estimate caregiving-related work absences (absenteeism) and reduced productivity while at work (presenteeism). We calculated costs of lost productivity using hours lost, compensation, and a wage multiplier, accounting for the additional cost of replacing employee time. We examined correlates of caregiving-related absenteeism and presenteeism separately, using multivariable logistic regression models, adjusting for caregiver sociodemographic characteristics, occupation and hours worked, role overload, older adult health, use of respite care, support groups, flexible workplace schedules, help from family or friends, and caregiver training.

RESULTS

Nearly 1 in 4 (23.3%) of the estimated 8.8 million employed family caregivers reported either absenteeism or presenteeism over a 1-month period owing to caregiving. Among those affected, caregiving reduced work productivity by one-third on average-or an estimated $5600 per employee when annualized across all employed caregivers-primarily because of reduced performance while present at work. Productivity loss was higher among caregivers of older adults with significant care needs and varied according to sociodemographic characteristics and caregiver supports.

CONCLUSIONS

Findings emphasize the potential economic value of targeted policy intervention to support working caregivers.

Co-created Technological Solutions for Caregivers in Health Care: Systematic Review

BACKGROUND

Support interventions for caregivers can reduce their stress, possibly improving the quality of patients' care while reducing care costs. Technological solutions have been designed to cover their needs, but there are some challenges in making them truly functional for end users. Co-design approaches present important opportunities for engaging diverse populations to help ensure that technological solutions are inclusive and accessible.

OBJECTIVE

This study aimed to identify co-created technological solutions, as well as the process followed for their co-creation, in the field of health for caregivers.

METHODS

The literature review was conducted in the Medline, Web of Science, Scopus, Science Direct, Scielo, and IEEE Xplore databases. The inclusion criteria were studies written in English or Spanish and with a publication date until May 2021. The content had to specify that the caregivers actively participated in the co-creation process, which covered until the development phase of the technological solution (prototype). The level of evidence and the methodological quality were analyzed when possible, using the Scottish Intercollegiate Guidelines Network criteria and the Mixed Methods Appraisal Tool, version 2018, respectively.

RESULTS

In total, 410 papers were identified, and 11 met the eligibility criteria. The most predominant articles were mixed methods studies and qualitative studies. The technology used in the analyzed articles were mobile or web applications (9 studies) and specific devices such as sensors, cameras, or alarm systems (2 studies) to support the health and social aspects of caregivers and improve their education in care. The most common patient profile was older people (7 studies); 6 studies used co-creation in the requirements phase, 6 studies detailed the design phase. In 9 studies, the prototype was iteratively refined in the development phase, and the validation phase was performed in 5 of the reviewed studies.

CONCLUSIONS

This systematic review suggests that existing co-created technological solutions in the field of health for caregivers are mostly mobile or web applications to support caregivers' social health and well-being and improve their health knowledge when delivering care to patients, especially older people. As for the co-creation process, caregivers are particularly involved during development and in the design. The scarce literature found indicates that further research with higher methodological quality is needed.

Insomnia Symptoms Among Hospice Family Caregivers: Prevalence and Association with Caregiver Mental and Physical Health, Quality of Life, and Caregiver Burden

BACKGROUND

Poor sleep exacerbates mental health problems and reduces quality-of-life (QOL) but prevalence of insomnia symptoms among hospice family caregivers and associations of poor sleep with caregiver health and QOL outcomes are not known.

OBJECTIVE

To describe prevalence of insomnia symptoms among hospice family caregivers and compare anxiety, depression, self-rated health, QOL, and caregiver burden between hospice family caregivers with and without insomnia symptoms.

METHODS

Descriptive sub-study using data collected during baseline interviews of hospice family caregivers involved in a randomized clinical trial in Midwestern United States (xxxxxxxx). Caregivers were dichotomized based on Insomnia Severity Index (ISI) scores (8+ indicated insomnia symptoms).

RESULTS

Among 57 hospice family caregivers, the mean ISI score was 8.2; nearly half (49.1%) experienced insomnia symptoms. Compared to caregivers without insomnia symptoms, caregivers with insomnia symptoms reported 2.4 times greater mean anxiety scores (4.7 vs 11.4); 3.5 times greater mean depression scores (3.1 vs 10.7); 2.1 times greater caregiver burden scores (5.6 vs 11.8); and 1.3 times lower self-rated health (3.5 vs 2.8); 1.3 times lower total QOL scores (29.3 vs 22.6); including differences in emotional QOL (7.9 vs 2.2), social QOL (7.2 vs 3.0), and physical QOL (7.4 vs 5.3).

CONCLUSIONS

Hospice family caregivers experience high prevalence of insomnia symptoms; caregivers with insomnia symptoms report worse anxiety, depression, caregiver burden, QOL, self-rated health. Clinicians must screen hospice caregivers for poor sleep and mental health and offer supportive interventions that improve their sleep and health. Policy makers must expand hospice benefits to better support family caregivers.