Family boundary ambiguity predicts Alzheimer's outcomes

Quality of family relationships and outcomes of dementia: a systematic review

OBJECTIVES

To evaluate the association between the quality of relationship between a person with dementia and their family carer and outcomes for the person with dementia.

DESIGN

Systematic review.

ELIGIBILITY CRITERIA

Cohort studies of people with clinically diagnosed dementia and their main carers. Exposures of interest were any elements of relationship quality, for example, attachment style, expressed emotion and coping style. Our primary outcome was institutionalisation, and secondary outcomes were hospitalisation, death, quality of life and behavioural and psychiatric symptoms of dementia ('challenging behaviour').

DATA SOURCES

MEDLINE, Embase, Web of Science, PsycInfo, the Cochrane Library and Opengrey were searched from inception to May 2017.

STUDY APPRAISAL AND SYNTHESIS METHODS

The Newcastle-Ottawa Scale was used to assess risk of bias. A narrative synthesis of results was performed due to differences between studies.

RESULTS

Twenty studies were included. None of the studies controlled for all prespecified confounding factors (age, gender, socioeconomic status and severity of dementia). Reporting of results was inadequate with many studies simply reporting whether associations were 'statistically significant' without providing effect size estimates or CIs. There was a suggestion of an association between relationship factors and global challenging behaviour. All studies evaluating global challenging behaviour provided statistical evidence of an association (most P values below 0.02). There was no consistent evidence for an association for any other outcome assessed.

CONCLUSIONS

There is currently no strong or consistent evidence on the effects of relationship factors on institutionalisation, hospitalisation, death or quality of life for people with dementia. There was a suggestion of an association between relationship factors and challenging behaviour, although the evidence for this was weak. To improve our ability to support those with dementia and their families, further robust studies are needed.

PROSPERO REGISTRATION NUMBER

CRD42015020518.

Spousal dementia caregiving in the context of late-life remarriage

Increasing numbers of older couples entering late-life remarriage will face dementia and spousal caregiving. This qualitative study, informed by grounded theory methods, is a first to explore spousal caregiving in the late-life remarried context. Interviews with nine late-life remarried wife caregivers identified complex intergenerational stepfamily dynamics that appear to amplify isolation and stress for this group of caregivers. Most women reported experiencing rejection of remarriage by adult children, minimal family involvement in caregiving, and intergenerational conflict regarding decision making. Nonetheless, caregivers described proactive, strategic approaches toward caregiving. This study examines the construct of boundary ambiguity as it relates to late-life remarriage and dementia caregiving, thus merging the unique challenges of caregiver and stepfamily dynamics. Findings are discussed in light of the potential risks highlighted for remarried couples facing chronic health issues. Future dementia research that accounts for diverse marital and family histories is suggested.

Linking family dynamics and the mental health of Colombian dementia caregivers

This cross-sectional, quantitative, self-report study examined the relationship between family dynamics (cohesion, flexibility, pathology/ functioning, communication, family satisfaction, and empathy) and mental health (depression, burden, stress, and satisfaction with life [SWL]) in 90 dementia caregivers from Colombia. Hierarchical multiple regressions controlling for caregiver demographics found that family dynamics were significantly associated with caregiver depression, stress, and SWL and marginally associated with burden. Within these regressions, empathy was uniquely associated with stress; flexibility with depression and marginally with SWL; and family communication marginally with burden and stress. Nearly all family dynamic variables were bivariately associated with caregiver mental health variables, such that caregivers had stronger mental health when their family dynamics were healthy. Family-systems interventions in global regions with high levels of familism like that in the current study may improve family empathy, flexibility, and communication, thereby producing better caregiver mental health and better informal care for people with dementia.

The problem with "problem behaviors": a systematic review of the association between individual patient behavioral and psychological symptoms and caregiver depression and burden within the dementia patient-caregiver dyad

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSDs) are routinely cited as important predictors of caregiver burden and depression. Although BPSDs include a wide variety of patient behaviors, they are routinely grouped together as one construct to differentiate them from cognitive symptoms of dementia. Determining the specific BPSDs that result in increased depression and burden for caregivers may elucidate the stress process for caregivers and facilitate the development of effective interventions for caregivers.

METHODS

We conducted a systematic review of English-language articles published from 1990 to 2010 to determine whether there are known symptoms or symptom clusters which exert undue negative impact on caregiver depression and burden. Additionally, we review systems used for classifying BSPD symptom clusters and determine whether there have been any mechanisms studied by which individual BPSD symptoms negatively affect caregivers. Finally, we examine how the role of timing of symptoms has been examined within the literature.

RESULTS

Thirty-five original research articles examined the impact of an individual behavior symptom on caregiver burden or depression/depressive symptoms. The studies had no consistent system for categorizing symptoms. Although depression, aggression, and sleep disturbances were the most frequently identified patient symptoms to impact negatively on caregivers, a wide range of symptoms was associated with caregiver burden and depression.

CONCLUSIONS

The evidence is not conclusive as to whether some symptoms are more important than others. The studies reviewed were largely exploratory relative to the differential impact of individual BPSDs and did not focus on testing causal mechanisms by which specific symptoms exert more impact on caregiver mental health than others. Future research may benefit from the re-conceptualization of BPSDs from the perspective of their impact on the caregiver to examine hypothesis-driven differences among BPSD symptom clusters.

Custodial grandmother-grandfather dyads: Pathways among marital distress, grandparent dysphoria, parenting practice, and grandchild adjustment

An adaptation of the Family Stress Model was examined using structural equation modeling with data from 193 custodial grandmother-grandfather dyads. The model's measurement and structural components were largely invariant by grandparent gender. For grandmothers and grandfathers alike, the effects of their psychological and marital distress on grandchildren's adjustment difficulties were mediated by dysfunctional parenting. The effects of family-related contextual forces on grandchildren's adjustment were also indirect through direct effects on grandparents' psychological and marital distress.

Custodial grandmothers' psychological distress, dysfunctional parenting, and grandchildren's adjustment

An adaptation of the Family Stress Model (FSM) with hypothesized linkages between family contextual factors, custodial grandmothers' psychological distress, parenting practices, and grandchildren's adjustment was tested with structural equation modeling. Interview data from 733 custodial grandmothers of grandchildren between ages 4-17 revealed that the effect of grandmothers' distress on grandchildren's adjustment was mediated by dysfunctional parenting, especially regarding externalizing problems. The effects of contextual factors on grandchildren's adjustment were also indirect. The model's measurement and structural components were largely invariant across grandmothers' race and age, as well as grandchildren's gender and age. Group differences were more prevalent regarding the magnitude of latent means for model constructs. We conclude that parenting models like the FSM are useful for investigating custodial grandfamilies.

Caregiver's distress is associated with delusions in Alzheimer's patients

Behavioral disturbances in Alzheimer's (AD) patients might be caused by environmental factors. The authors tested the hypothesis that delusions in AD might be a result of caregiver's distress. Participants were 22 delusional and 21 nondelusional mild AD patients and their caregivers. Those who cared for nondelusional patients, compared with the delusional patients' caregivers, reported higher levels of distress because of behavioral disturbances other than delusions. When patients were stratified into 2 groups according to median distress value, 64% of the delusional patients and 33% of the nondelusional patients showed a high level of caregiver's distress, chi2(1, N = 43) = 3.94, p = .047. Although final conclusions about the causal direction of the association cannot be drawn, these findings are consistent with the hypothesis that distressed caregivers might use inappropriate coping strategies that, in turn, might favor the development of delusions.

Complaints of informal caregivers providing home care for dementia patients: the Pixel study

CONTEXT

Prospective study of the complaints, problems and requirements of the main caregiver providing home care for dementia patients.

OBJECTIVES

To determine the complaints of home caregivers, how they are interrelated and what causes them.

RESOURCES

Self-administered questionnaire of 42 questions on the patient and caregiver, including a list of complaints, given to the main caregiver. Medical questionnaire on the patient filled in by the attending physician, usually a specialist, freelance or salaried doctor.

RESULTS

408 sets of records were compiled, concerning 236 demented women (77.1 +/- 0.47 years) and 172 demented men (75.7 +/- 0.57 years). In two-thirds of cases, the main caregiver was a woman aged 60.6 +/- 0.79 years. Female caregivers were more vulnerable than male caregivers. The most frequent caregiver complaint, regardless of the stage of the disease, concerned loss of motivation and withdrawal. The patient's awareness of the disorder was accompanied by a reduction in motor dysfunction and aggressiveness, but associated with a higher frequency of the complaint regarding loss of motivation reported by the caregiver. The caregivers' problems concerned mainly the absence of relief and the impossibility of having any time to themselves. Caregivers' requests for information concerned medical information, care structures and day care facilities.

DISCUSSION

The attending physician comes into close contact with the patient, but must take into account the patient's environment. The physician can provides a separate analysis to the caregiver and does not completely answer to certain family questions or needs. He or she is not the family's prime source of information. The caregivers' requirements relate to the areas that are the attending physician's responsibility: the development and characteristics of the disease. The caregiver is anxious about the patient's future and is trapped by his or her involvement in the care, suffering greatly from the lack of relief.

CONCLUSIONS

It is necessary to change the focus of home care for dementia patients to fit the context in which they live and to allow for periods of relief for home caregivers.

Family, Alzheimer's disease and negative symptoms

BACKGROUND

The aim of this study is to look at the correlation between the presence of apathy measured by Marin's scale and family complaints related to withdrawal and the loss of motivation, or depression. The multicentre study was performed on 58 non-demented elderly people, 132 outpatients with Alzheimer's-type dementia, as well as their main caregiver.

METHODS

After agreement of the patients and the family, the patients were assessed using different scales: Cornell's for depression, Marin's for apathy, MMS for cognitive disorders, and IRG for dependence. At the same time, two self-administered questionnaires were given to the patients' families: one concerning a list of complaints scored from 1 to 4 relating to various disorders and the other addressing the boundary ambiguities translated from Boss' questionnaire. The 58 non-demented people were 81.20 years old+/-13.75. One hundred and thirty-two demented patients were included: 39 men and 93 women. The mean age was 79.47 years+/-9.03.

RESULTS

The first family complaint relates to the loss of motivation (65%). Apathy and depression occur more frequently in dementia, in particular when the MMS is degraded. Depression and apathy attracted a high complaint score. In our study the score of boundary ambiguity is higher among patients with a weak cognitive status. A high level of ambiguity is accompanied by a high score of family complaints. When the family complaint concerning the loss of motivation is present, apathy is significantly more common. Family complaints about withdrawal and loss of motivation are frequently present, and are congruent with the actual presence of apathy in the patient. It bears witness to the distress felt by families faced with the loss of ability noted in the demented person. The family's difficulties are increased by the patient's depression.