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

The impact of family burden on the psychological distress of informal caregivers for older adults living with dementia: The role of internal and external coping resources

OBJECTIVES

Numerous studies have demonstrated that informal caregivers of people living with dementia (PLWD) have serious adverse psychological problems, but little research has been done on the role of integrating caregivers' various coping resources in reducing psychological effects. Therefore, the current study aimed to investigate the impact of caregivers' internal (self-efficacy and positive coping) and external coping resources (family function and social support) on the family burden and psychological distress.

METHODS

A cross-sectional study, and a self-designed questionnaire, Family Burden Scale of Disease, Kessler Psychological Distress Scale, General Self-Efficacy Scale, Simplified Coping Style Question, The Family Adaptation, Partnership, Growth, Affection, Resolve Scale and Social Support Rating Scale were completed by 193 pairs of PLWD and caregivers. Partial least squares-structural equation modeling (PLS-SEM) was used to analyze the mediating effects of coping resources.

RESULTS

Self-efficacy, positive coping, family function, and social support respectively mediated the relationship between family burden and psychological distress (β = 0.402, β = 0.059, β = -0.111, β = 0.053; P < 0.05). Besides, the serial mediation effects of self-efficacy and positive coping, family function and social support were also significant (β = 0.104, β = 0.045; P < 0.05).

CONCLUSIONS

This study confirmed the mediating role of internal and external coping resources between family burden and psychological distress in caregivers of older PLWD, providing a theoretical basis for promoting the,mental health of caregivers.

Transitions in activities of daily living in Mexico, 2001-2012

OBJECTIVE

This paper describes the 2001-2012 progression of limitations in daily activities in the Mexican elderly population aged 60 or older and identifies how sociodemographic and health factors affect these progressions.

MATERIALS AND METHODS

Data come from the Mexican Health and Aging Study (MHAS), a national sample of adults born in 1951 or earlier, including a baseline survey in 2001 and follow-ups in 2003 and 2012.

RESULTS

Difficulty in getting dressed is the activity that has the highest prevalence in all three waves for both genders. In the 11-year transition, 42.8% of the respondents with no limitations in 2001 reported no limitations in 2012. In contrast, 60.8% of those who reported three or more limitations in 2001 had died by 2012.

CONCLUSIONS

With the rapid aging of the Mexican population, the knowledge of patterns of deterioration of functional limitations will prove useful for future public health policies.

UnderstAID, an ICT Platform to Help Informal Caregivers of People with Dementia: A Pilot Randomized Controlled Study

Information and communications technology (ICT) could support ambient assisted living (AAL) based interventions to provide support to informal caregivers of people with dementia, especially when they need to cope with their feelings of overburden or isolation. An e-learning platform (understAID application) was tested by informal caregivers from Denmark, Poland, and Spain to explore the technical and the pedagogical specifications, as well as evaluating the impact of its use on the psychological status of the participants. 61 informal caregivers completed the study taking part in the experimental (n = 30) or control (n = 31) groups. 33.3% of the caregivers were satisfied with the application and around 50% of the participants assessed it as technically and pedagogically acceptable. After using understAID the caregivers in the experimental group significantly decreased their depressive symptomatology according to the Center for Epidemiologic Studies Depression scale, but a possible benefit on their feelings of competence and satisfaction with the caring experience was also observed. The low scores obtained for satisfaction were highlighting issues that need to be modified to meet the informal caregivers' needs in national, social, and cultural context. Some possible biases are also considered and discussed to be taken into account in future improvements of understAID application.

Caregiver's distress related to the patient's neuropsychiatric symptoms as a function of the care-setting

Prevalence of neuropsychiatric symptoms (NPS) and correlation between its intensity and caregiver distress were evaluated as a function of the care-setting in a cross-sectional study including 72 patient-caregiver dyads. The Neuropsychiatric Inventory and the Caregiver Distress Scale were administered. The most prevalent symptoms were: in the formal care-setting, agitation/aggression and depression/dysphoria (42.4%), and in the informal care-setting, aberrant motor behavior (59.0%). While changes in appetite and eating behaviors, depression/dysphoria and irritability/lability were more prevalent in the formal care-setting (p < .0001, p = .011, p = .021), aberrant motor behavior was more prevalent in the informal care-setting (p = .007). NPS were positively correlated with caregiver distress. High patients' scores in hallucinations, sleep and night-time disturbances, anxiety, and aberrant motor behavior were the best predictors of professional caregiver's distress. Agitation/aggression, delusions, disinhibition, apathy/indifference, depression/dysphoria, and elation/euphoria were the best predictors of informal caregiver's distress. Findings may have important clinical implications.

Risk Factors of High Burden Caregivers of Dementia Patients Institutionalized at Day-Care Centres

We examined which variables are associated with day care centres utilization among caregivers of dementia patients. A cross-sectional analysis of socio-demographic variables, relationship with caring and psychological aspects was conducted in 58 informal caregivers with intense burden. 58.6 % used day care assistance and 41.4 % did not. The results showed the importance of the commitment between the caregiver and their family and friends. The use of day care services is independent of the age, gender, educational level, marital status, occupation and relationship with the patient. However, in the multivariate analysis the provision of help by families and friends predicted the use of day care assistance. The bivariate analysis showed a significant relationship between depressive symptoms and self-rated health with day care attendance. Screening the help provision from families and friends in caregivers of dementia patients with intense burden would be relevant to design interventions which delay their institutionalization and reduce costs.

Nutritional status and functional capacity of community-dwelling elderly in Southern Laos

OBJECTIVES

The aim of this study was to assess the nutritional status and functional capacity of 144 community-dwelling elderly in three rural ethnic groups, namely, the Oy, the Brau and the Lao, of southern Laos.

METHODS

The Mini nutritional assessment (MNA) questionnaire and Determine Your Nutritional Health checklist were used to assess nutritional status. The Barthel Activities of Daily Living questionnaire and Lawton and Brody's Instrumental Activities of Daily Living questionnaire were used to assess the functional capacity of the respondents.

RESULTS

The MNA score results indicated that 92.5 % of Oy respondents, 85.4 % of Brau respondents and 60 % of Lao respondents were malnourished. Analysis of variance tests showed that the MNA scores of the Oy and Lao ethnic groups and of the Brau and Lao ethnic groups were significantly different ( both p < 0.01), but that there was no significant difference between the MNA scores of the Oy and Brau ethnic groups (p > 0.05). In terms of functional capacity, 47.2 % of Oy respondents, 43.9 % of Brau respondents and 20 % of Lao respondents had limitations in their activities of daily living, whereas 98.1 % of Oy respondents, 97.6 % of Brau respondents and 86 % of Lao respondents had limitations in their instrumental activities of daily living. Body mass index, reduced appetite, number of meals consumed daily and presence of common diseases predicted nutritional status in all three ethnic groups; the remaining factors differed by ethnicity. This result implies that ethnic differences and other factors, such as location of the village, services, resources within the village and respondents' lifestyles, can affect nutritional status.

CONCLUSIONS

Because predictors of nutritional status varied by ethnicity, there is a need for area-specific interventions aimed at improving the quality of life of the elderly in these areas.

Nutritional and functional assessment of hospitalized elderly: impact of sociodemographic variables

Background. This work was constructed in order to assess the nutritional and functional status in hospitalized elderly and to study the associations between them and sociodemographic variables. Methods. 200 elderly patients (>65 years old) admitted to Internal Medicine and Neurology Departments in nonemergency conditions were included. Comprehensive geriatric assessments, including nutritional and functional assessments, were done according to nutritional checklist and Barthel index, respectively. Information was gathered from the patients, from the ward nurse responsible for the patient, and from family members who were reviewed. Results. According to the nutritional checklist, 56% of participants were at high risk, 18% were at moderate risk of malnutrition, and 26% had good nutrition. There was a high nutritional risk in patients with low income and good nutrition in patients with moderate income. Also, there was a high nutritional risk in rural residents (61.9%) in comparison with urban residents (25%). Barthel index score was significantly lower in those at high risk of malnutrition compared to those at moderate risk and those with good nutrition. Conclusions. Hospitalized elderly are exposed to malnutrition, and malnourished hospitalized patients are candidates for functional impairment. Significant associations are noticed between both nutritional and functional status and specific sociodemographic variables.

Stigma among Iranian family caregivers of patients with Alzheimer's disease: A hermeneutic study

Although there is evidence of stigmatization of patients with Alzheimer's disease, few studies have evaluated stigma among family caregivers. This study was aimed at understanding the experiences of family caregivers of persons with Alzheimer's disease within Iran. We conducted a qualitative study using hermeneutic phenomenology. Semistructured in-depth interviews with 10 Iranian family caregivers of persons with Alzheimer's were audiotaped and transcribed. The transcriptions were then analyzed using Van Manen's method. Family stigma emerged as one of the most important themes in this study. It consisted of two subthemes of "feeling of shame due to the unusual behaviors and speech of the patients" and "fear of judgments made by others." An understanding of the experience of family stigma may lead to the development of supportive strategies to manage this problem among the caregivers. Educating families of patients about the disease plays a critical role in facilitating the process of caregiving. In addition, promoting public awareness about Alzheimer's disease can diminish stigma and prejudice toward patients and their caregivers. Educating caregivers on stigma management may also be an important factor in alleviating their stress.

The experience of caring for a partner with young onset dementia: how younger carers cope

A growing body of literature suggests that the social context of experiencing dementia at a younger age may influence carers' and particularly partners' subjective experience and coping strategies. The current paper aims to explore the coping strategies adopted by six carers in order to adapt to changes in their relationship with their partner with young onset dementia. All were recruited from the north west of England and interpretative phenomenological analysis was used to analyse the data. Four major themes were evident: (1) 'this is not happening': the use of denial as a coping strategy; (2) 'let's not have anymore of this demeaning [treatment]': stigma in young onset dementia; (3) 'I've had to fight every inch': struggling to maintain control of events and emotions; (4) 'what will become of me?': carers' adaptation to loss. Comparisons with existing literature are made and implications for clinical practice are considered.

Mini Nutritional Assessment and functional capacity in community-dwelling elderly in rural Luozi, Democratic Republic of Congo

AIM

Good nutrition is beneficial both for the health and the functional capacity of the elderly. However, malnutrition is a serious health problem among the elderly, particularly the elderly living in rural areas in many developing countries. The aim of the present study was to carry out a cross-sectional study of the elderly in the city of Luozi, Democratic Republic of Congo, through the use of the long and the short forms of the Mini Nutritional Assessment (MNA) scale.

METHODS

We carried out a cross-sectional study in the city of Luozi, a city facing serious socioeconomic problems as a result of wartime conditions in the country. The study included 370 volunteer community-dwelling elderly people aged 65-88 years, both male and female. Investigations took into account the MNA, the activities of daily living, and the instrumental activities of daily living, falls, current diseases and lifestyle.

RESULTS

Approximately 57.8% of the participants were at risk of malnutrition, whereas 28.4% were malnourished according to the MNA scale. MNA scores were significantly lower (Student's t-test, P=0.03) in those with a fall history (MNA score 18.3±4.0) compared with those who did not (MNA score, 21.0±2.7). All the participants with malnutrition suffered from at least one chronic disease. The percentage of participants with dependency was significantly higher in the malnourished participants (87.6%) than in well-nourished participants (50.9%).

CONCLUSION

These findings provide information that malnutrition is a serious health concern among elderly people in the city of Luozi, and shows the need for adequate nutrition and social programs for the elderly.

Personalised caregiver support: effectiveness of psychosocial interventions in subgroups of caregivers of people with dementia

OBJECTIVE

Insight into the characteristics of caregivers for whom psychosocial interventions are effective is important for care practice. Until now no systematic reviews were conducted into the effectiveness of psychosocial interventions for caregiver subgroups.

METHODS

To gain insight into this relationship between caregiver subgroups and intervention outcomes, a first review study was done. This study reviews the personal characteristics of caregivers of people with dementia for whom psychosocial interventions were effective.

RESULTS

Electronic databases and key articles were searched for reviews on psychosocial interventions for caregivers studies published between January 1990 and February 2008. Based on these reviews, twenty-six studies met the inclusion criteria (i.e. having positive outcomes described in subgroups). Most positive effects were found in caregivers of people with a diagnosis of 'dementia not otherwise specified' and in the subgroup of female caregivers. Examples of outcomes were decreased depression and improved self-efficacy.

CONCLUSIONS

This study gives a first overview of successful psychosocial interventions in subgroups of caregivers of people with dementia. It makes clear that until now, relatively little research has been done into subgroups of these caregivers. It also suggests that more research is needed to better understand which psychosocial interventions are effective for specific subgroups of caregivers of people with dementia.

Living through end-stage dementia: The experiences and expressed needs of family carers

The focus of this paper is the experiences and needs of family carers of people with end-stage dementia. The project involved in-depth, qualitative interviews with 15 carers. The major themes emerging from the accounts of participants’ experiences were: getting support; having to trust others with care; managing the loneliness of being a carer; witnessing a loved one fade away; anticipating and experiencing death; and re-establishing life after the funeral. Carers expressed a range of instrumental and psychosocial needs. The study has provided a more personal account of the caring experience than much of the related literature. It has emphasized the need of carers for genuine understanding and connection — from family and friends as well as healthcare staff. The study highlights the amount of support carers can provide to each other through support groups and associated friendships, and stresses the importance of healthcare staff acknowledging and respecting this capacity of carers.

Prevalence of functional disability in activities of daily living (ADL), instrumental activities of daily living (IADL) and associated factors, as predictors of morbidity and mortality

The aim of this study is to establish the existing relationship among variables referred to the person, specifically age and gender, and the functional dependence in basic ADL and in IADL, as well as the possible relationship it has with the increase of morbidity and mortality in a random sample of 598 individuals older than 65 years. Of these individuals, 34.6% were categorized as dependent for at least one ADL, and 53.5% if we refer to IADL. Regarding the ADL, the risk of dependence increases (odds ratio=OR=1.089) per year of age, (OR=2.48) in women's case; while there is an IADL correlation between age and the score (r=-0.527; p<0.001). A relationship exists between dependence and the days of hospitalization (for ADL: r=-0.12, p=0.018 and IADL: r=-0.97, p=0.003), the number of visits to the doctor (ADL: r=-0.27, p<0.001; IADL: r=-0.25, p<0.001) or the presence of concomitant pathologies such as dementia (ADL: p<0.001; IADL: p<0.001). There is a significant association between age, gender and dependence, as well as between dependence and morbidity and mortality, so that dependence could be used as a predictor of both.

Impact of community care in enabling older people with complex needs to remain at home

Aim.  This aim of the study was to explore the impact of community care in enabling older people with complex needs to remain at home. Background.  Changing demographic trends and successive government policies have led to an increase in the number of older people with complex needs residing in the community. Design.  A qualitative approach using semi-structured interviews was used to collect data from older people (n = 17) and carers (n = 14). Method.  Social workers were asked to identify community dwelling older people (65+ years) with multiple needs requiring interventions from a range of health and social care practitioners. Results.  Community care enabled older people with complex needs who would otherwise have required residential or nursing home care to remain in their own homes. This was the expressed wish of both the older people and carers interviewed. Conclusions.  The provision of high-quality community care for older people is a globally significant challenge and one that requires creative solutions, both at a local and strategic level. Relevance to clinical practice.  Nurses and other health and social care professionals need to understand the significance of 'home' for older people and take steps to ensure that additional and appropriate resources are targeted towards community care.

Quality of life and cholinesterase inhibitors: a qualitative study of patients with Alzheimer's disease and their carers

OBJECTIVES

Cholinesterase inhibitors' (ChEIs) impact on cognitive functioning in Alzheimer's disease has been extensively researched. The effect of ChEIs on improving day-to-day living and quality of life in conjunction with level of functioning for patients or their carers has not been investigated.

METHOD

Five spouse dyads (patient and carer) and one additional carer were interviewed about their perceptions of ChEIs in relation to their influence on daily life for both parties. Interviews were transcribed and thematic analysis conducted.

RESULTS

Themes identified were forgetfulness, differences in long-term versus short-term memory, independence/dependence, negative emotion, no appreciable benefit, sense of hopelessness, carer as motivator, stabilization of the patient, and never regain what has been lost.

CONCLUSIONS

This study suggests that ChEI medication does not enhance life for the patient or their primary caregiver. Further qualitative and quantitative research is required into the impact of ChEIs upon both the patient and their caregivers.

An educational intervention to support caregivers of elders with dementia

The majority of home-dwelling elders with dementia are cared for by family members or friends. Interventions to support community-based caregivers are needed. A community-based seminar series was provided to 300 self-referred family caregivers with dementia. Participants were surveyed for caregiver burden and overload and perceived competence before and 6 months after the seminars. In all, 88 (29%) of participants completed a 6-month survey. Self-perceived caregiver competence improved (3.9 +/- 1.6 to 5.0 +/- 0.32, P < .006); a trend toward improvement in caregiver overload, and there was no change in caregiver burden. Caregivers with baseline parameters indicative of higher burden, overload, or lower competence showed improved scores at 6 months. The educational program was effective in improving competence and may have slowed the expected increase in burden associated with caring for those with a progressive dementia. Caregivers with higher burden may be targeted for this type of intervention, as they seemed to benefit the most.

A systematic review of intervention studies about anxiety in caregivers of people with dementia

BACKGROUND

There is considerable literature on managing depression, burden and psychological morbidity in caregivers of people with dementia (CG). Anxiety has been a relatively neglected outcome measure but may require specific interventions.

OBJECTIVE

To synthesise evidence regarding interventions that reduce anxiety in CGs.

METHODS

Twenty-four studies met our inclusion criteria. We rated the methodology of studies, and awarded grades of recommendation (GR) for each type of intervention according to Centre for Evidence Based Medicine guidelines, from A (highest level of evidence) to D.

RESULTS

Anxiety level was the primary outcome measure in only one study and no studies were predicated on a power calculation for anxiety level. There was little evidence of efficacy for any intervention. The only RCT to report significantly reduced anxiety involved a CBT and relaxation-based intervention specifically devised to treat anxiety, and there was preliminary evidence (no randomised controlled trials) that caregiver groups involving yoga and relaxation without CBT were effective. There was grade B evidence that behavioural management, exercise therapies and respite were ineffective.

LIMITATIONS

Many interventions were heterogeneous, so there is some overlap between groups. Lack of evidence of efficacy is not evidence of lack of efficacy.

CONCLUSIONS

CBT and other therapies developed primarily to target depression did not effectively treat anxiety. Good RCTs are needed to specifically target anxiety which might include relaxation techniques. Some of the interventions focussed on reducing contact with the care recipients but caregivers may want to cope with caring and preliminary evidence suggests strategies to help CGs manage caring demands may be more effective.

Volunteer support, marital status, and the survival times of terminally ill patients

This study examines the possibility that volunteer support can influence how long terminally ill patients survive. Hospice patient files (N = 290) were coded for marital status and volunteer support condition, respectively, the latter on the basis of whether visits from volunteers were requested and received (n = 94), requested but not received (n = 28), or neither requested nor received (n = 168). Baseline health, disease type, and demographic dimensions were comparable across support conditions. Results indicated that when a baseline health status effect was controlled for (p<.0002), patients in the volunteer support condition survived significantly longer than did patients in either unvisited condition (p<.0001). Neither marital status nor gender independently predicted survival time.

[Efficacy of caregiver support groups for dementia]

Counseling of caregivers is an essential component of the management of patients with dementia. According to the empirical research in this field, peer-led self-help groups have the potential to improve subjective outcomes including emotional support, social contact, and control over one's life and thus may facilitate caregiving and reduce psychological burdens. Self-help groups have not been shown, however, to modify objective outcomes such as the time spent for care or the frequency of nursing home admissions. The outcomes of counseling programmes led by professionals depend on the focus of intervention and may include benefits in psychological and psychosomatic symptoms, coping with stress, and managing behavioural disturbances. Studies in the U.S., Australia, and Finland have demonstrated that multimodal counseling programmes led by professionals significantly reduce the number of nursing home admissions and therefore may have considerable importance for health economics.

Dementia caregiver intervention research: in search of clinical significance

PURPOSE

We reviewed intervention studies that reported dementia caregiver outcomes published since 1996, including psychosocial interventions for caregivers and environmental and pharmacological interventions for care recipients. Our goal was to focus on issues of clinical significance in caregiver intervention research in order to move the field toward a greater emphasis on achieving reliable and clinically meaningful outcomes.

DESIGN AND METHODS

MEDLINE, PsycINFO, and Cumulative Index to Nursing & Allied Health databases from 1996 through 2001 were searched to identify articles and book chapters mapping to two medical subject headings: caregivers and either dementia or Alzheimer's disease. Articles were evaluated on two dimensions, outcomes in four domains thought to be important to the individual or society and the magnitude of reported effects for these outcomes in order to determine if they were large enough to be clinically meaningful.

RESULTS

Although many studies have reported small to moderate statistically significant effects on a broad range of outcomes, only a small proportion of these studies achieved clinically meaningful outcomes. Nevertheless, caregiving intervention studies have increasingly shown promise of affecting important public health outcomes in areas such as service utilization, including delayed institutionalization; psychiatric symptomatology, including the successful treatment of major and minor depression; and providing services that are highly valued by caregivers.

IMPLICATIONS

Assessment of clinical significance in addition to statistical significance is needed in this research area. Specific recommendations on design, measurement, and conceptual issues are made to enhance the clinical significance of future research.

Exploring the emotional support needs and coping strategies of family carers

This paper explores the emotional support needs and coping strategies of family carers derived from two focus group interviews, each group comprising seven family carers. The interviews were carried out in Northern Ireland as part of phase one of the ACTION (Assisting Carers using Telematics Interventions to meet Older persons Needs) project. The purpose of the interviews was to investigate family carers' needs and experiences, but this paper focuses specifically on the emotional support needs and coping strategies identified by group members. The issues discussed included information and social support needs, the emotional impact of caring, and coping with and adaptation to the caring role. The findings reveal that for the majority of family carers their experience was one of constant searching for support and information. The anxiety and frustration associated with inconsistent and irregular support and lack of information was a major source of concern for the carers in the study. However, the carers employed a number of positive and negative coping strategies to deal with the stress associated with their caregiving role. The study concluded with the recommendation for nurses and other health care professionals to become more proactive in assessing and meeting carers' emotional support needs.