Intimacy as a determinant of expressed emotion in carers of people with Alzheimer's disease

Expressed Emotion in Families of People With Dementia: A Review of Scale-Based Measures

PURPOSE

Research on the concept of expressed emotion (EE) has expanded in recent years but its role in dementia still requires elucidation. Understanding the role of EE in the dementia context could help in the development of appropriate interventions.

METHOD

The current review synthesized relevant literature to investigate the prevalence and correlates of EE status in families of people with dementia. A comprehensive search of four databases from inception to 2022 produced 2,683 papers; 18 studies met inclusion criteria.

RESULTS

The use of EE criteria differed not only across cultural contexts, but even within the same cultural context. Overall, the prevalence of EE in families with dementia compared with other psychiatric conditions was not high.

CONCLUSION

Specific changes in EE over time remain to be explored, and findings emphasize the need to carefully discriminate High EE status based on the cultural background of family members with dementia. [Journal of Gerontological Nursing, 50(2), 17-25.].

Psychological well-being in persons with dementia: The role of caregiver expressed emotion

OBJECTIVES

Dementia is a growing health concern. Persons with dementia experience higher levels of anxiety and depression, which correlates with poorer quality of life, disability and hospitalization. This is one of the few studies to use a longitudinal design to assess the impact of expressed emotion (EE) on well-being in dementia over time.

METHODS

Sixty-one people with dementia and their main informal caregiver were recruited from memory services. Caregiver EE was coded from a Camberwell Family Interview conducted at time one. Person with dementia's outcome measures (quality of life, depression and anxiety) were collected at time one and at 6-months follow-up.

RESULTS

Caregiver high EE was associated with higher levels of depression in people with dementia and greater anxiety at follow-up. Emotional over involvement predicted greater anxiety and critical comments predicted greater depression. Low EE appeared to have a protective effect on well-being in people with dementia. People with dementia with low EE caregivers experienced a small reduction in depression and anxiety over time, whereas those with high-EE caregivers maintained baseline levels of depression and anxiety.

CONCLUSIONS

Caregiver high EE is associated with poorer psychological outcomes for people with dementia over time. Psychological therapies, such as cognitive behavioural therapy informed family interventions should be used to reduce high EE within carer and person with dementia relationships.

A mindfulness-based intervention adapted to dementia caregivers: A study protocol for a randomized clinical control trial

Dementia caregiving, besides encompassing various challenges in tandem to the diagnosis of the care recipient, is associated with decreased psychological well-being and mental health. Accordingly, caregivers' wellbeing has an impact on the quality of care they provide and on the relationship quality with the person in their care. The aim of the present study is to examine the effectiveness of a mindfulness-based intervention on relational and psychological wellbeing, tailored to the needs of dementia caregivers. This clinical trial (NCT04977245) will apply a randomized controlled mixed method design. Caregivers will be randomly allocated to either the mindfulness intervention or the active control group. The intervention arm is based on experiential learning and is targeted to promote caregivers' well-being and empowerment. Assessments will include, standardized self-report questionnaires, task performance measures, and qualitative measures. All assessments will be held at three time points (baseline; t0, 0 months, post-intervention; t1, 2 months, and after maintenance; t2, 3 months) focused on three core domains (1. relational well-being, 2. psychological well-being, and 3. dementia patient's lifestyle/activities). The primary outcome will be relational well-being, and data will be analyzed using linear mixed modelling.

Affective temperament traits may explain high expressed emotion in caregivers of patients with Alzheimer's disease

BACKGROUND

The negative interactions between Alzheimer's disease (AD) patients and their caregivers may provoke criticism, hostility, and emotional overinvolvement that characterise highly expressed emotion (EE) attitudes. In this study, we hypothesised that affective temperament traits of AD caregivers are related to their high EE levels independent from other patient and caregiver characteristics.

METHODS

Eighty AD patients were assessed through Clinical Dementia Rating Scale (CDR), and Mini-Mental State Examination. Expressed Emotion Scale (EES), Temperament Evaluation of Memphis, Pisa, Paris and San Diego auto-questionnaire, and Hamilton Depression Rating Scale were applied to the caregivers. The high (n = 41) and low EE caregivers (n = 39) were compared with respect to some sociodemographic and clinical characteristics of the patients and caregivers, and affective temperament traits of caregivers. The associations of caregiver EES scores with multiple variables related to patients and caregivers were examined by Pearson correlation tests. We performed multiple linear regression analysis to determine the possible predictors of total EES scores.

RESULTS

High EE caregivers had significantly higher depressive, cyclothymic, and anxious temperament traits than in low EE subjects. A weak positive correlation was found between the total EES scores and Personal Care scores of CDR. Home and hobbies subscale scores of CDR had a moderately significant positive correlation with total EES scores. There was also moderate significant positive correlations between total EE scores and depressive, cyclothymic, anxious, and irritable temperament traits. Linear regression analysis indicated that depressive temperament significantly predicted the high levels of caregiver EE.

CONCLUSION

These findings suggest that caregivers' depressive temperament is predominantly related to their EE levels even after controlling for the severity of AD, and lower educational level of caregivers. Our results may provide evidence that high EE might be a reflection of caregivers' depressive temperament traits, in accordance with the trait hypothesis.

Expressed Emotion in relatives of persons with dementia: a systematic review and meta-analysis

OBJECTIVES

Expressed Emotion (EE) refers to a number of key aspects of interpersonal relationships which have been shown to relate to outcomes in relatives of people with health conditions.

DESIGN

A systematic review and meta-analysis of EE and outcomes in relatives of persons with dementia is reported. Potential research studies were identified via a search of three electronic databases; PsychINFO, MEDLINE and the Web of Science between 1960 and 2015.

RESULTS

We reviewed 12 studies investigating correlations between EE and well-being in relatives of patients with dementia. Factors hypothesised to influence EE including attributions, social support, coping strategies and relationship quality were also reviewed.

CONCLUSION

High-EE relatives were found to have increased levels of burden (Z = 6.967, P < 0.001) and greater levels of depression (Z = 5.842, P < 0.001). Compared to low-EE relatives, high-EE relatives were more likely to attribute the patient's problems to factors that were personal to and controllable by the patient. Relatives with less social support, inefficient coping strategies and a poor relationship with the patients, were more likely to be classified as high-EE.

A caregiver perspective of how Alzheimer's disease and related disorders affect couple intimacy

OBJECTIVES

Alzheimer's disease and related disorders (ADRD) pose a potential threat to the interpersonal and intimate relationships in couples. The objective of this study was to understand the lived experiences of individuals with a spouse suffering from ADRD and how this diagnosis affects intimacy within these marital relationships.

METHOD

This qualitative study used a phenomenological approach to capture the lived experiences of caregivers of ADRD individuals. A total of 10 interviews were conducted, with six participants recruited from a neurology clinic and four participants drawn from support groups. Structured interviews with open-ended questions were conducted, with thematic units derived from the interview analysis.

RESULTS

All participants reported some strain in the ADRD relationship, with different aspects of the disease affecting closeness and connection within the couple. The quality of the marital relationship prior to diagnosis impacted every participant in some fashion as well as having to adjust to ADRD related behaviors. Outside effects on the relationship, coping with the disease and degree of intimacy were additional themes reported from the interviews, with positive and negative attributes given to these themes.

CONCLUSION

Although the caregiving role can be difficult for a spouse, it does not mean that the ADRD has to always negatively impact the marital relationship. Understanding the role that intimacy can play for these couples and how it might contribute to coping strategies for couples affected by ADRD can be a powerful adjunct to other treatments available.

Similarities and Differences in Caring Burden of Home Dwellers With Partners Suffering From Chronic Obstructive Pulmonary Disease or Dementia

The aim of this study was to explore caring burden of cohabitants ( N = 206) having partners with chronic obstructive pulmonary disease (COPD) or dementia in relation to aspects of social support. Caring burden was measured by the Relative Stress Scale and was found to be lower and to change less with severity in the COPD group. In multiple regression analyses, characteristics of the ill partners such as aggressive behaviors, degree of self-reliance, hours they could adequately be alone, in addition to public services, social support or withdrawal from family and friends, and gender of the caregiver were overriding the type of illness. Different factors added to the caring burden of females and males. In the total sample, those factors explained 62.9% of the caring burden, while for females 58% was explained, and 77% for males.

Relationship satisfaction and emotional language in frontotemporal dementia and Alzheimer disease patients and spousal caregivers

We studied the impact of 2 types of dementia on marital satisfaction and on the emotional language that spouses use during conflictive marital interactions. Fifteen frontotemporal dementia (FTD) and 16 Alzheimer disease (AD) patient-caregiver couples, and 21 control couples, discussed a relationship problem in a laboratory setting. Marital satisfaction was assessed through questionnaire, and emotion language was quantified using text analysis. FTD couples reported lower marital satisfaction than AD and control couples. During the interactions, FTD and AD caregivers used significantly more negative emotion words than their patient spouses (no spousal differences were found in control couples). FTD caregivers also used more negative words than AD caregivers and controls. We interpret these findings as reflecting challenges that the behavioral changes in FTD create for maintaining a healthy marital bond.

Family caregivers of people with dementia

Family caregivers of people with dementia, often called the invisible second patients, are critical to the quality of life of the care recipients. The effects of being a family caregiver, though sometimes positive, are generally negative, with high rates of burden and psychological morbidity as well as social isolation, physical ill-health, and financial hardship. Caregivers vulnerable to adverse effects can be identified, as can factors which ameliorate or exacerbate burden and strain. Psychosocial interventions have been demonstrated to reduce caregiver burden and depression and delay nursing home admission. Comprehensive management of the patient with dementia includes building a partnership between health professionals and family caregivers, referral to Alzheimer's Associations, and psychosocial interventions where indicated.

Determinants of burden in those who care for someone with dementia

OBJECTIVES

Caregiver burden is a key measure in caregiver research and is frequently used as a baseline measure in intervention studies. Previous research has found numerous factors associated with caregiver burden such as the relationship quality between carer and patient, the patient's cognitive ability, behavioural and psychological symptoms displayed by the patient, caregiver gender, adverse life events to name a few. Many studies have investigated these factors singularly however current thought suggests a multi-factorial role and inter-dependence of these factors. Based on this it was decided to investigate factors associated with caregiver burden using a multiple regression analysis in order to ascertain the predictive quality of these factors of caregiver burden.

METHOD

Cross-sectional study using validated measures of a patient's cognitive ability, ability to carry out day-to-day tasks and behavioural and psychological symptoms. Caregiver outcomes used are caregiver burden, relationship quality, caregiver confidence, experience of adverse life events, neuroticism, age and gender. Interviews and questionnaires were carried out on 74 patients diagnosed with dementia and their main caregivers from the Midlands of England.

RESULTS

Multiple regression analysis showed that caregiver overload, carer-patient relationship quality, the experience of adverse life events, caregiver gender, caregivers' level of neuroticism, caregiver role captivity and the level of caregiver confidence accounted for over 80% of the variance in caregiver burden.

CONCLUSION

These results confirm previous correlational research on caregiver burden. Furthermore, due to the use of multiple regression analysis the findings also show factors that are clear predictors of caregiver burden and we offer possible suggestions from these findings on future clinical practice interventions on caregiver burden.

Marital quality in the context of mild cognitive impairment

Profound behavioral changes in persons with dementia often negatively affect the quality of marital relationships. Yet, little is known about the extent to which the marital relationship may be affected when the care recipient has milder degrees of cognitive impairment. This study characterizes marital quality among 27 adults who live with a spouse with mild cognitive impairment (MCI). This study demonstrates that at mild levels of cognitive impairment, specific behaviors in the affected person are distressing and may degrade the quality of the marital relationship. These results have implications for clinical practice and the delivery of health care and social services to these families. It is important to develop interventions to address the needs of these individuals and their caregivers. Results of this study suggest the need for mental health interventions designed to preserve the quality of these marital relationships.

A cross-cultural study on expressed emotion in carers of people with dementia and schizophrenia: Japan and England

Expressed emotion (EE) research has been productive in investigating the influence of the interpersonal environment on a range of disorders. The majority of EE research on the influence of carers has been carried out in the west. This is the first EE study of the carers of people with dementia in Japan. The aim of this study was to investigate the relationships between EE status and aspect of burden through cross-cultural comparison of the two countries, Japan and England, with large cultural and linguistic differences. Comparisons were made between samples of EE of carers of dementia and schizophrenic patients. In total, data on 80 carer/relative-patient dyads were collected and examined: (1) 20 Japanese carers of people with dementia (JD), (2) 20 English carers of patients with Alzheimer's disease (ED), (3) 20 Japanese relatives of patients with schizophrenia (JS), and (4) 20 English relatives of patients with schizophrenia (ES). The Camberwell Family Interview was administered in each country to ascertain levels of EE. Large differences between Japan and England were found in the frequency of critical comments, in which ES>ED>JS>JD. EE correlated significantly with burden in the JD sample alone. With an operational cut-off of 2CC (CC, critical comments), EE correlated significantly with cognitive impairment as well as with clinical severity in the JD sample. There was a tendency for lower expression of both positive and negative emotional reactions towards family members in the Japanese sample. The results of this study indicate that EE is an appropriate measure for use with carers of sufferers of dementia and can be utilized across different cultures. However, flexibility with the cut-offs may be required in Eastern cultures. This needs to be tested on larger samples with sensitivity to illness and cross-cultural differences.

Expressed emotion in family members of depressed older adults

This study examined similarities between the Expressed Emotion (EE) construct developed in the psychiatric literature and interpersonally relevant constructs derived from gerontology caregiver research. Expressed emotion and other indices derived from the Camberwell Family Interview (CFI) were assessed in 46 adult children and spouses providing care to an older adult hospitalized for major depressive disorder. The relationship of CFI indices with the family member's past and current relationship with the depressed relative, illness attributions, and emotional functioning was examined. Of the family members, 60.9% were classified as high EE. Measures of past and current relationship and illness attributions were significantly associated with most of the CFI indices. In multivariate analyses, past relationship and illness attributions predicted high EE status. Only past relationship predicted the CFI index of warmth. There is conceptual and empirical overlap between the EE construct and interpersonally relevant gerontology variables. Expressed emotion holds promise for a more complex understanding of caregiving and better caregiver interventions.

Behavioural disturbances in dementia patients and quality of the marital relationship

OBJECTIVES

To investigate the relationship between behavioural problems in patients with dementia and changes in the marital relationship.

METHODS

Fifty-three spouse caregivers of patients with dementia participated in the study. Questionnaires and interviews were used to examine caregiver perception of changes in the quality of their relationship. Behavioural disturbances in the patient were measured with the NeuroPsychiatric Inventory (NPI).

RESULTS

Caregivers experienced a deterioration of their relationship, yet at the same time most felt closer to their spouse now than in the past. Regression analysis revealed that patient behavioural problems were, independent of patient cognitive status or functional impairment, associated with deterioration in the quality of the relationship between patient and caregiver. Patient apathy rather than depressive mood was associated with this deterioration. Apathy diminished the amount and reciprocity of interactions between partners.

CONCLUSIONS

These results show that passive behaviour rather than excessive behaviour has most impact on the deterioration of the marital relationship. Intervention programmes should target relationship problems when problem behaviour, especially apathy, is present in patients with dementia.

Expressed emotion and attributions in the carers of patients with Alzheimer's disease: the effect on carer burden

Burden of care, expressed emotion (EE), causal attributions, and salivary cortisol were assessed in 100 carers of patients with Alzheimer's disease. Forty-one carers were rated high EE, which was associated with higher scores of carer distress and strain, and greater reports of noncognitive features in the patient, but not with cortisol levels. High EE carers made more attributions personal to, and controllable by, the patient for negative events. Critical carers made more attributions of the patient's behavior that was idiosyncratic. Warmth toward the patient was associated with the opposite of this pattern. Overinvolved carers made attributions of the patient's behavior to causes external to the patient and internal to themselves. Cortisol levels were associated with self-reports of strain and distress.

The effect of parental expressed emotion on glycaemic control in children with Type 1 diabetes. Parental expressed emotion and glycaemic control in children

OBJECTIVE

To measure expressed emotion (EE) in parents of young children with diabetes and to examine the relation between EE and glycaemic control in children with Type 1 diabetes in a longitudinal study over 24 months. We hypothesised that good glycaemic control, as measured by low glycated haemoglobin levels, would be predicted by high parental emotional over-involvement, low frequency of critical comments and absence of hostility. We predicted that these effects would be stronger in maternal than paternal scores.

METHODS

Forty-seven children attending a Paediatric Diabetes Clinic and their parents were studied over 24 months. Glycated haemoglobin was measured on three occasions, at the start of the study period, 12 and 24 months later. At 12 months, parental EE was measured using an adapted version of the Camberwell Family Interview, and child emotional and behavioural problems were measured using the parent version of the Child Behavior Checklist. Multiple regression models were used to test the hypotheses.

RESULTS

Forty-three maternal and 33 paternal interviews of adequate quality for analysis were obtained. Paternal hostility was found to be associated with elevated glycated haemoglobin measured 12 months before interview and 12 months after interview, accounting for 22% and 29% of the variation in glycated haemoglobin respectively.

CONCLUSIONS

We did not find that parental emotional over-involvement or criticism predicted glycaemic control. Presence of hostility was important, but in contrast to our hypothesis, this was paternal rather than maternal hostility. We suggest that (i) relatively absent, rejecting fathers play little role in diabetes management and children perceive this negatively, or (ii) mothers who are unsupported by fathers cannot in turn support their children in diabetes care.

Predictors of institutionalization of cognitively-impaired elderly cared for by their relatives

OBJECTIVES

The purpose of this study is to identify risk factors for nursing home placement of cognitively-impaired elderly, with special attention to the role of psychosocial factors such as the caregiver's preference for institutionalization and the quality of the dyadic relationship.

METHODS

Partners, children and children-in-law caring for a relative suffering from dementia (n = 144) were interviewed at home. Sociodemographic variables, patient characteristics, characteristics of the caregiving situation, caregiver characteristics, the support with care and the quality of the caregiving relationship are included as predictors of the caregiver's preference for institutionalization and of the actual institutionalization six to nine months later. Data are analyzed using multiple (logistic) regression analyses.

RESULTS

The hypothesis that a poor quality of the relationship, besides other determinants, will be predictive of institutionalization received partial support. No relationship is found between the premorbid relationship quality and institutionalization (preference and actual). However, a good current relationship between the caregiver and the patient reduced the risk of nursing home placement. Institutionalization rate was 16.5% and it was predicted by the caregiver's preference for institutionalization, the functional level of the patient, the quality of the current relationship and the performance of accommodation changes at home.

CONCLUSION

Research and interventions directed at delaying or preventing institutionalization should pay more attention to the role of psychosocial aspects in the process of nursing home placement. Specifically the relationship quality in terms of criticism or warmth might be a critical factor in the continuation of home care.

A review of expressed emotion research in health care

Much research has been carried out on the impact of family relationships on the development and course of different illness. Research on Expressed Emotion (EE) developed out of studies of the impact of family members on patients with schizophrenia, and has provided us with a robust measure of relatives' emotional attitudes towards patients, which has now been applied in the study of numerous psychiatric and medical illnesses. This review outlines the history of EE research in schizophrenia, and discusses the evidence for the association between family EE and the course of schizophrenic illness. Some of the factors which might moderate the association between EE and illness course are outlined and the issues of the meaning and development of EE are discussed in the light of recent theoretical advances. The application of the EE methodology in other psychiatric and medical conditions is then reviewed and conclusions are drawn about the extent to which EE predicts illness course in conditions other than schizophrenia. Consideration is given to the ways in which the application of the paradigm to a variety of illnesses or conditions with different features can enhance our understanding of the EE construct.