Family caregiver satisfaction with medical care of their demented relatives

A qualitative study of unpaid caregivers of persons living with dementia and their interactions with health and community-based services and providers

BACKGROUND AND OBJECTIVES

Unpaid caregivers frequently feel underprepared and without adequate training, support, or access to services and resources to care for persons living with dementia. Health and community-based services and providers are critical to support persons living with dementia and their unpaid caregivers. The objective of this research is to understand how unpaid caregivers of persons living with dementia interact with health and community-based services and providers.

RESEARCH DESIGN AND METHODS

We used a qualitative descriptive approach to analyze data from one-on-one semi-structured interviews with unpaid caregivers of persons living with dementia (N = 25). We used framework analysis to organize themes and sub-themes within the systems approach to healthcare delivery.

FINDINGS

Participants described a need for additional guidance, information, and support from health and community-based services and providers. This need was described by participants at 4 levels: individual, care team, organization, and political and economic environment. Participants were active in proposing potential solutions to challenges at all 4 levels, including improving provider awareness and training in dementia, opportunities to provide resources and referrals upon dementia diagnosis, a central clearinghouse for information and resources for persons living with dementia and caregivers, and opportunities to close service gaps.

DISCUSSION AND IMPLICATIONS

Findings of this study highlight the need for increased involvement of caregivers of persons living with dementia as community stakeholders for improving care and services. Recommendations to promote high quality care and better support unpaid caregivers by developing interventions to address multiple aspects of healthcare delivery are consistent with recent legislation and are important areas of future research.

The DWQ-EMR Embedded Tool to Enhance the Family Physician-Caregiver Connection: A Pilot Case Study

The number of family caregivers to individuals with dementia is increasing. Family physicians are often the first point of access to the health care system for individuals with dementia and their caregivers. Caregivers are at an increased risk of developing negative physical, cognitive and affective health problems themselves. Caregivers also describe having unmet needs to help them sustain care in the community. Family physicians are in a unique position to help support caregivers and individuals with dementia, but often struggle with keeping up with best practice dementia service knowledge. The Dementia Wellness Questionnaire was designed to serve as a starting point for discussions between caregivers and family physicians by empowering caregivers to communicate their needs and concerns and to enhance family physicians' access to specific dementia support information. The DWQ aims to alert physicians of caregiver and patient needs. This pilot study aimed to explore the experiences of physicians and caregivers of people using the Questionnaire in two family medicine clinics in Ontario, Canada. Interviews with physicians and caregivers collected data on their experiences using the DWQ following a 10-month data gathering period. Data was analyzed using content analysis. Results indicated that family physicians may have an improved efficacy in managing dementia by having dementia care case specific guidelines integrated within electronic medical records. By having time-efficient access to tailored supports, family physicians can better address the needs of the caregiver-patient dyad and help support family caregivers in their caregiving role. Caregivers expressed that the Questionnaire helped them remember concerns to bring up with physicians, in order to receive help in a more efficient manner.

Service needs and interests: A comparison of African American and white caregivers seeking Alzheimer assistance

This paper is a report on the findings of a study of the use of Alzheimer's Association services in Washington, DC and Baltimore, Maryland by African American and white family caregivers. The findings reveal that both sets of caregivers contacted the Associations in similar stages of their caregiving situations. Both groups were well educated. Approximately one fourth of all caregivers were college graduates. The African Americans included a more diverse set of caregivers who also received more hours of assistance in their caregiving tasks. However, neither group felt understood by their supports and the African American perceived a significantly greater need for more assistance. All caregivers were interested in using the services of the Associations with the African Americans particularly more interested in the telephone advice program and the I.D. bracelets. The findings also reveal that the predictors of the need for help differ from those predicting future calls to the Associations.

Strategies for community-based dementia education and creating sustainable change: Lessons learned from the Community Outreach Education Program

The Community Outreach Education Program (COEP) was established to disseminate information about the diagnosis, assessment, management, and treatment of dementia to health care professionals, service providers, staff of community organizations and voluntary agencies, and family caregivers in communities throughout Michigan. This paper will describe the activities implemented as part of outreach educational interventions in Bay City, Saginaw, Grand Rapids, and Kalamazoo, Michigan. Lessons learned about community-based dementia education and strategies for creating sustainable change are discussed.

Older Persons 'Medical Encounters and their Outcomes

This article reviews research on older patients and their doctors, with particular attention to the medical encounter between an elderly patient and his or her physician. Major categories of variables affecting the medical encounter include provider and patient characteristics (age, gender, ethnicity, education, values) and the context or setting of the encounter (site, presence of a patient's companion, and whether the visit is an initial one for the physician-patient pair). The process and content of medical encounters are affected by participant characteristics and context variables, and these in turn affect outcome variables such as participant satisfaction, adherence to treatment regimens, and medical outcome. Process issues include transfer of information, medical decision making, and interpersonal relations. Methodological issues are discussed, including problems with theory generation, lack of standardized methodology, gaps in research knowledge, and prior emphasis on descriptive studies as opposed to testing of interventions to improve elderly patient-physician communication.

Primary Care Physicians' Diagnostic, Management, and Referral Practices for Older Persons and Families Affected by Dementia

As the size of the older population increases, primary care physicians can expect to see growing numbers of patients who present with symptoms of cognitive dysfunction. This study examines how office-based primary care physicians in three states (N = 498) diagnose and manage dementia symptoms using clinical vignettes portraying a 72-year-old woman with either mild or moderate dementia symptoms and her adult daughter. Physicians were more likely to order a variety of laboratory tests than to perform mental and cognitive status tests as part of a diagnostic workup. Respondents also were much more likely to disclose a diagnosis of probable Alzheimer's disease to the daughter in the vignette than to her mother. Differences in reported dementia management behaviors were found according to physician specialty, number of years in practice, and experience with patients with dementia in actual practice. Results suggest that whereas primary care physicians can play a valuable role in the service system for families affected by dementia, barriers must be overcome to improve specific aspects of their diagnostic and management behaviors.

Issues in Caregivers' Stress and Providers' Support

This study examined whether support from care recipients' primary care providers affects the stress and health of caregivers. This two-year longitudinal study addressed changes in caregivers' mental and physical health, both self-assessed and evaluated by professional nurse practitioners in physical examinations, and the effects of provider support on caregivers' health. Randomly selected participants from three previous studies plus a group of volunteer Alzheimer's caregivers constituted the sample. Of 254 eligible individuals, 150 agreed to participate, but by time 2, care recipient deaths and other reasons had reduced the number of caregivers to 99. Participants showed significant increases in stress and service use but declines in all areas of health and in provider support. Provider support did not materially affect caregivers' health but had an indirect effect on caregivers' self-assessed health through rewards. Despite the need for bolstering caregivers' health, perceived support from care recipients' providers is limited.

Helping Family Caregivers by Linking Primary Care Physicians with Community-Based Dementia Care Services

The Alzheimer’s Service Coordination Program (ASCP) was developed based on the rationale that family caregivers of people with dementia could benefit in measurable ways from a care partnership arrangement linking primary care physicians with a community organization that specializes in dementia education and support. In metropolitan Cleveland, Ohio, USA, 29 physicians referred 62 family caregivers to a Service Coordinator (SC), who provided individualized consultation to family caregivers and capable patients with dementia regarding all non-medical aspects of dementia care and available resources in the community. Over a six-month intervention period, 44 caregivers with complete follow-up data reported statistically significant increases in self-efficacy for managing dementia symptoms, and self-efficacy for using community support services. Caregivers and participating physicians reported satisfaction with the ASCP. Despite relatively small numbers of participants, the service coordination and individualized consultation model featured in the ASCP has been adapted for two larger randomized trials in the USA.

Caregiver Satisfaction With Support Services

OBJECTIVES

This article examines factors influencing satisfaction with support services of caregivers of frail older adults and determines what types of support services are associated with greater satisfaction, controlling for frail individual and caregiver characteristics.

METHODS

The study includes 291 frail older adults-caregiver dyads from Montreal in which caregivers receive support services. The Client Satisfaction Questionnaire-8 is used to measure caregiver satisfaction with these services.

RESULTS

Caregivers receiving information, advice, or emotional support, and those caring for seniors receiving integrated care are more likely to be highly satisfied. Other factors increasing satisfaction are fewer number of health problems of frail individuals, caregiver being the spouse of the frail person, as well as greater caregiver perceived health, autonomy in instrumental activities of daily living, and available social support.

DISCUSSION

The results support the importance of integrated care for frail seniors and informational services for their caregivers.

Realizing Wrongness: Stories of Older Wife Caregivers

The purpose of this study was to gain an understanding of patterns of help-seeking by older wife caregivers of husbands with dementia using grounded theory methodology with a theoretical perspective of health as expanding consciousness. Eleven older wife caregivers were interviewed, leading to discovery of a new substantive theory titled “Help-Seeking Choices: Taking One Day at a Time,” which was grounded in reality as experienced by the participants. The antecedent category of realizing wrongness, with subthemes of recognizing a problem, accepting direction from others, and recognizing help needs, is described in this article along with implications of findings.

Increasing Community Capacity to Respond to Dementing Illnesses: Process Evaluation of the Community Outreach Education Program

The goal of the Community Outreach Education Program(COEP) is to disseminate information about the diagnosis, assessment, management, and treatment of dementia to health care professionals, service providers, staff of community organizations and voluntary agencies, and family caregivers in four rural and two urban sites in Michigan. To accomplish this, outreach educational interventions based on a community-development model were developed in the Thumb Area, Upper Peninsula, Northeast Michigan, Mid-Michigan, Detroit, and Flint. The present study describes a process evaluation of the COEP in these six sites, using a multiple case study approach. Shared themes in the successful implementation of the on-site interventions and in creating community capacity across the varied sites are discussed.

Primary Care Physicians' Knowledge and Behavior Related to Alzheimer's Disease

A national sample of primary care physicians from the American Medical Association database was surveyed to examine primary care physician knowledge and physician practices related to Alzheimer's disease (AD). A previously validated instrument, The University of Alabama at Bir mingham Alzheimer's Disease Knowledge Testfor Health Professionals, was used to assess phy sician knowledge. The survey also included questions regarding the frequency of performing di agnostic, treatment, and support behaviors for Alzheimer's patients and families. Scores on the knowledge portion of the questionnaire varied widely, with internists and family practitioners scoring better than general practitioners, and younger physicians scoring higher than older physicians. Overall, primary care physicians made few new diagnoses and infrequently per formed behaviors related to the diagnostic process, treatment, and recommendation of support services. Weak, positive associations werefound between physician level of knowledge and six of the nine AD practice behaviors investigated. Implications of these findings are discussed, and strategies to improve knowledge of physicians caring for people with AD are outlined.

How Linked Are Physicians to Community Support Services for Their Patients With Dementia?

Physicians increasingly are expected to link patients affected by dementia and theirfamilies with community support services; yet, little is known about physicians' referral patterns or their fa miliarity with such services. This study of 206 physicians found that respondents were more likely to refer dementia patients and families to home health agencies and nursing homes than to respite or adult day care, the local Alzheimer's Association, or the local Area Agency on Aging. Physicians with more than 20 dementia patients in their practices were most likely to refer. Un certainty about available community services was ranked higher than time or reimbursement constraints as a barrier to care for dementia patients. Physicians in practice 1 to 5 years were more uncertain about available services than physicians in practice more than 20 years. Crea tive interventions to link physicians with community support services specializing in dementia care would benefit physicians, patients, and family caregivers.

Strengthening the dementia care triad: identifying knowledge gaps and linking to resources

This article describes a project to identify the needs of family caregivers and health care providers caring for persons with dementia. Participants included 128 caregivers, who completed a survey, and 27 health care providers, who participated in a focus group and completed a survey. Caregivers reported their primary source of information about the disease was the doctor; however, the majority also reported they were primarily informed of medications and not about needed resources. Health care providers identified limited time with patients and families, and lack of awareness of community services, as their main challenges. Recommendations include strengthening the partnership between physicians, patients, and caregivers (the dementia care triad) through additional support and training for physicians and caregivers, increasing awareness of the Alzheimer's Association, and utilization of technology for families and professionals to track the needs of persons with dementia.

Caregiver Resources and Facilitation of Elderly Care Recipient Adherence to Health Regimens

We studied the relationship between caregivers' personal and social resources and facilitation of adherence by elderly care recipients to a prescribed health regimen. Adherence facilitation was measured among 240 caregivers on a 45-item instrument constructed for this research. The facilitation score was regressed on caregivers' role-specific self-concept (e.g., caregiver competence), informal social network support, utilization of the informal network as a lay referral system, formal network support, and reported health status of the care recipient. Background variables and health beliefs were considered as control variables. The resource variable best correlated with adherence facilitation was the personal resource of caregiver competence — perception of oneself as a good caregiver — followed by two social resources: support of the professional health care provider and the presence of a lay referral system (R2 = 0.37). Thus, although the care recipient is the beneficiary of adherence facilitation, the caregiving characteristics of the caregiver appear to affect its extent.

Dementia care consultation for family caregivers: collaborative model linking an Alzheimer's association chapter with primary care physicians

OBJECTIVE

The primary objective is to report on the efficacy of an individualized dementia care consultation intervention for family caregivers of patients with diagnosed dementia living in the community. The secondary objective is to present evidence on the intervention process to inform the feasibility and sustainability of the model featuring collaboration between primary care physicians and a voluntary sector organization.

METHOD

Randomization was based on primary care physician practice site. In the intervention group, dementia care consultants located at an Alzheimer's association chapter provided individualized counseling and support over a 12-month period, and sent copies of care plans developed with family caregivers to referring primary care physicians. In the control group, family caregivers received educational and community resource information but no care consultation. Nursing home admission of patients during the 12-month study period was the primary outcome; secondary outcomes included measures of caregiver self-efficacy for managing dementia, caregiver depressive symptoms, and caregiver burden.

RESULTS

A total of 84 family caregivers participated. After adjusting for baseline characteristics, patients whose family caregivers were in the intervention group were less likely than their control group counterparts to be admitted to a nursing home (Adjusted odds ratio = 0.40; 95% C.I. = 0.14-1.18; p = 0.10). No other outcomes were significantly different between treatment groups; however, intervention group caregivers reporting greater satisfaction with the intervention showed improved self-efficacy for managing dementia compared to their less satisfied counterparts. Medical record reviews found that care plans were found in most patient records, but that only 27% of intervention group caregivers reported discussing these care plans with physicians. Three different individuals occupied the dementia care consultant position during the study period, and this turnover led to family caregiver dissatisfaction.

CONCLUSION

The dementia care consultation intervention showed favorable effects on nursing home admission and on caregiver outcomes among intervention group caregivers more satisfied with the intervention, but there are important barriers to sustaining this collaboration between primary care physicians and a voluntary sector organization such as an Alzheimer's association chapter.

Consistency of information from persons with dementia

This analysis examines the ability of persons with mild to moderate dementia (MMSE scores 13—30 and/or a dementia diagnosis) to provide consistent and accurate information. Data come from interviews with 213 persons with dementia (PWDs) and their family caregivers (CG). Consistency was assessed by determining agreement between responses provided by PWDs during two in-person interviews. Accuracy was assessed by determining agreement between PWD responses and CG responses. Overall, PWDs provided consistent and accurate responses to fact-based questions and were consistent in their responses to state-dependent items. Less impaired respondents were more consistent in their responses to fact-based items. Among respondents with more severe impairment, there were no significant differences in consistency by question type. This work responds to the need to gain a better understanding of the opinions and experiences of dementia and offers further evidence that many PWDs can provide consistent and accurate information. Findings support increased involvement of individuals with dementia in research and care planning.

Support to family carers of patients with frontotemporal dementia

OBJECTIVES

To examine the provision of support to patients with frontotemporal dementia (FTD) and their family carers compared with patients with early onset Alzheimer's dementia (AD) and their carers, and the carers' satisfaction with the support.

METHOD

Data came from 60 dyads of patients with dementia and their principal family carers, 23 subjects with frontotemporal dementia and their 23 carers, and 37 subjects with early onset Alzheimer's disease and their 37 carers.

RESULTS

Patients with a frontotemporal dementia diagnosis were significantly more frequently offered stays in nursing homes (p = 0.04). Carers of patients with frontotemporal dementia were significantly less satisfied with the provision of information about the disease compared with carers of early onset Alzheimer's disease patients (p = 0.05) and were significantly less satisfied with counseling and follow-up advice (p = 0.05).

CONCLUSION

Changes of personality in patients with frontotemporal dementia may be the major reason why they were offered more stays in institutions. These family carers tend to be less satisfied with the provision of support they received from the specialist health service compared to carers of Alzheimer's disease patients, and are in need of more, and other forms of support.

Development of quality indicators for memory clinics

OBJECTIVE

To develop and validate a set of relevant, feasible, and reliable quality indicators (QIs) for the Memory Clinics (MCs).

BACKGROUND

MCs are important care providers for people with dementia and their caregivers. A set of valid QIs is needed to incorporate evidence-based guidelines into MC clinical practice, and measure adherence to guidelines.

METHODS

A total of 17 MC specialists, 12 primary care physicians; and seven informal caregivers participated in several Delphi rounds to select and validate QIs. Ten MCs participated in the indicator compliance study involving the analysis of data extracted from 100 medical records.

RESULTS

The initial set of 56 single QIs was reduced to a final set of 14 indicators measuring the quality of processes, structures, and outcomes of care. The panels of representatives of MCs, primary care physicians, and informal caregivers judged overall face validity to be high. The differences in compliance rates between the three indicator types were significant (p<0.001) as were the differences between the MCs (p<0.005). The compliance measures were highest for the process indicators and lowest for the outcome indicators.

CONCLUSION

The final set of 14 QIs that met the psychometric requirements can be used to facilitate the implementation of guidelines and the assessment of the quality of care offered by MCs. The QIs are acceptable for a broad range of users (specialists, referring physicians, and informal caregivers), and are capable of discriminating between MCs in terms of quality.

Telling "the truth" in dementia--do attitude and approach of general practitioners and specialists differ?

OBJECTIVE

The prevailing opinion in the literature that disclosing the diagnosis of dementia to patients is important is not always put into practice. The purpose of this study was to investigate differences between GPs and specialists (neurologists and psychiatrists) in the German ambulatory care system concerning the disclosure of the diagnosis of dementia.

METHODS

Thirty in depth interviews with randomly selected GPs were conducted. On this basis a standardised questionnaire was developed and sent to 389 GPs and 239 neurologists and psychiatrists.

RESULTS

The postal survey revealed only minor differences between GPs and specialists, both groups being equally in favour of a timely disclosure. For example, 70% of the GPs and 77% of the specialists strongly agreed that "patients with dementia should be informed early because of the possibility to plan their lives". This positive attitude is pronounced among younger physicians, but is somewhat contradicted by difficulties in the communication with patients expressed in the interviews. In the interviews, what may be described as a "double taboo" emerges, in that GPs describe taboo topic areas related to dementia for them and for their patients.

CONCLUSION

The postal survey shows the two professional groups to be very much in favour of a timely disclosure--an attitude that is pronounced among younger physicians. These findings can be interpreted as a recent change of attitudes regarding the disclosure of the diagnosis of dementia in the medical profession.

PRACTICE IMPLICATIONS

Training opportunities are needed in order to overcome communication obstacles in the doctor-patient-communication about dementia.

Service use in family caregivers of persons with dementia in Belgium: psychological and social factors

This study aims to investigate whether selected social and psychological characteristics of family caregivers of persons with dementia are related to community-based service use in Belgium. Two aspects were distinguished in service utilisation: volume (number of contacts) and diversity (number of services). Within a selected region, dementia caregivers were traced via the detection of persons with dementia known to community health or social services. A probability diagnosis was made with the Geriatric Mental State and the computer algorithm AGECAT. Family caregivers of persons with dementia (N = 168) were interviewed at home by means of a structured questionnaire. Data were analysed with multiple regression analysis. Co-residence, a positive attitude towards home service use, and increased problem-solving coping were found to be direct predictors of increased diversity of services used, whereas a lower burden of behaviour problems, living apart, and increased avoidance coping were found to be direct predictors of increased volume of service use. Care recipients' behaviour problems and functional status were not found to be related to service use. The results suggest that social and psychological factors have a larger impact on service use in family caregivers of persons with dementia, compared to objective or subjective burden. Interventions to increase awareness of relevant services, to improve attitudes towards their use and support problem-solving coping in family caregivers may be considered to increase the use of appropriate services.

Factors affecting timely recognition and diagnosis of dementia across Europe: from awareness to stigma

BACKGROUND

Timely recognition and diagnosis of dementia is the pre-condition for improving dementia care, but diagnosis often occurs late in the disease process.

OBJECTIVE

To compare facilitators and obstacles to the timely recognition of dementia across eight European Union states, in order to implement established policies for earlier diagnosis.

METHODS

A modified focus group technique, including a pre and posterior procedure.

RESULTS

Twenty-three participants from different disciplines, purposively sampled for professional expertise in dementia research and innovative practice, attended two focus groups. Stigma in ageing and dementia, accompanied by a sense that there is little to offer until later on in the disease, underpinned the widespread reluctance of GPs to recognise dementia at an early stage and were major obstacles to the timely diagnosis of dementia across all eight countries. Dementia care services varied widely across Europe. Countries with the greatest development of dementia health care services were characterised by national guidelines, GPs fulfilling a gatekeeper function, multi-disciplinary memory clinics and innovative programmes that stimulated practice and new services. Dementia-related stigma was perceived as being less prominent in these countries.

CONCLUSIONS

Overcome of delays in the timely diagnosis of dementia needs more than specialist services. They should address the processes associated with stigma, age and dementia, especially where these relate to physician practice and diagnostic disclosure. Stigma is perceived as variable across European States, with a promising finding that its impact is relatively small in countries with the widest range of dementia care services.

The Northern California Chronic Care Network for Dementia

The Northern California Chronic Care Network for Dementia brings together Northern California's major providers of managed care, community-based care, consumer education, and advocacy in new partnerships to improve the care of persons with dementia enrolled in managed care plans and their family caregivers. These partnerships are part of a national initiative entitled the Chronic Care Network for Alzheimer's Disease (CCN/AD) sponsored by the National Chronic Care Consortium and the Alzheimer's Association. This initiative selected eight promising provider-consumer partnerships across the country to implement and evaluate a new model of coordinated care for people with dementia and their families. This paper describes the Northern California network's partnerships and its intervention and challenges. The intervention is grounded in the key components of the CCN/AD model: "identification of patients with possible dementia, diagnostic assessment, care management and family caregiver information and support." These components, in turn, are translated into protocols and pathways designed to create timely, comprehensive, appropriate, and effective systems of care services that address the unique needs of dementia patients and their caregivers over the course of the disease.

Outcomes for patients with dementia from the Cleveland Alzheimer's Managed Care Demonstration

This investigation evaluates effects of care consultation delivered within a partnership between a managed health care system and Alzheimer's Association chapter. Care consultation is a multi-component telephone intervention in which Association staff work with patients and caregivers to identify personal strengths and resources within the family, health plan, and community. The primary hypothesis is that care consultation will decrease utilization of managed care services and improve psychosocial outcomes. A secondary modifying-effects hypothesis posits benefits will be greater for patients with more severe memory impairment. The sample is composed of managed care patients whose medical records indicate a diagnosis of dementia or memory loss. Patients were randomly assigned to an intervention group, which was offered care consultation in addition to usual managed care services, or to a control group, which was offered only usual managed care services. Data come from two in-person interviews with patients, and medical and administrative records. Results supporting the primary hypothesis show intervention group patients feel less embarrassed and isolated because of their memory problems and report less difficulty coping. Findings consistent with the modifying-effects hypothesis show intervention group patients with more severe impairment have fewer physician visits, are less likely to have an emergency department visit or hospital admission, are more satisfied with managed care services, and have decreased depression and strain.

Primary care interventions for dementia caregivers: 2-year outcomes from the REACH study

PURPOSE

This study developed and tested two 24-month primary care interventions to alleviate the psychological distress suffered by the caregivers of those with Alzheimer's disease. The interventions, using targeted educational materials, were patient behavior management only, and patient behavior management plus caregiver stress-coping management. We hypothesized that the addition of the stress-coping component would improve caregiver outcomes.

DESIGN AND METHODS

A randomized clinical trial of 167 caregiver-care recipient dyads was run, of whom 76 completed the study without bereavement or placement.

RESULTS

During 24 months, caregivers who received the patient behavior management component only, compared with those who also received the stress-coping component, had significantly worse outcomes for general well-being and a trend toward increased risk of depression (i.e., a score of >16 on the Center for Epidemiological Studies Depression scale). There was a studywide improvement for bother associated with care recipient behaviors (according to the Revised Memory and Behavior Problems Checklist).

IMPLICATIONS

Our data suggest that brief primary care interventions may be effective in reducing caregiver distress and burden in the long-term management of the dementia patient. They further suggest that interventions that focus only on care recipient behavior, without addressing caregiving issues, may not be as adequate for reducing caregiver distress.

Planning end-of-life care for patients with dementia: roles of families and health professionals

We examined families' end-of-life decision making and their interactions with health professionals. Twenty-eight family members of institutionalized dementia patients participated in four focus groups. We found that participating family members were not well prepared for their decision-making roles, and that they: 1) experienced substantial burdens and loss in caring for institutionalized elders; 2) had limited understanding of the natural progression of dementing conditions; 3) were uncomfortable in setting goals for their relatives' end-of-life care; 4) had little experience with death, and were ambivalent about the anticipated death of their relative; and (5) reported that they had little substantive communication with health professionals regarding end-of-life care planning. We concluded that many of the needs of such families could be addressed through improved application of the principles of advance care planning, including regular structured discussions, involvement of surrogate decision-makers, and anticipation of clinical decisions. Health professionals should take the lead in 'normalizing' the discussion of death.

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

BACKGROUND

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

AIMS

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

DESIGN

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

RESULTS

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

DISCUSSION

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

The Cleveland Alzheimer's managed care demonstration: outcomes after 12 months of implementation

PURPOSE

This demonstration evaluates the effects of integrating Alzheimer's Association care consultation service with health care services offered by a large managed care system. The primary hypothesis is that Association care consultation will decrease service utilization, increase satisfaction with managed care, and decrease caregiver depression and care-related strain. Secondary modifying-effects hypotheses posit that the effects of the intervention will be intensified when patients have not received a firm dementia diagnosis, patients have more severe memory problems, caregivers use other Association services in tandem with care consultation, and caregivers are not patients' spouses.

DESIGN AND METHODS

The demonstration is a randomized trial that examines outcomes after a 12-month study period. Interview data from 157 primary family caregivers are combined with data abstracted from medical/administrative records.

RESULTS

Support for the primary hypothesis is found for selected, but not all, service utilization outcomes and for caregiver depression. Support for secondary modifying-effects hypotheses is found for satisfaction outcomes and care-related strain outcomes.

IMPLICATIONS

Care consultation delivered within a partnership between a managed care health system and an Alzheimer's Association is a promising strategy for improving selected outcomes for patients with dementia and their caregivers.

The carrot and the stick: benefits and barriers in getting a diagnosis

The goals of this study were to identify the benefits and barriers perceived by family caregivers of persons who have been through a diagnostic assessment for dementia symptoms and to determine which caregivers experience more benefits and barriers associated with assessments. A survey was mailed to caregivers involved in the decision to seek a diagnostic assessment for a family member at a University of Kentucky memory disorders clinic. A total of 528 family caregivers (response rate 71.7%) returned a 4-page survey designed to elicit benefits, barriers, and demographic information. Respondents delayed the diagnostic assessment for an average of 22.4 months after noticing symptoms. Perceived benefits involved confirmation of a medical condition, access to treatment, and help preparing for the caregiving role. Barriers were both emotional and pragmatic in nature. Respondents who were younger, visited the rural assessment clinic, and had less education experienced more barriers. All groups reported receiving the same number of benefits from the assessment. By incorporating these benefits and barriers, interventions can be designed to increase the likelihood of early diagnostic assessments.

Capturing the insights of family caregivers: survey item generation with a coupled interview/focus group process

The usefulness of qualitative methodologies to augment and enrich quantitative studies is often overlooked. The authors' goals are to describe the qualitative process employed to generate survey items and to compare the results to those of studies that used different methodologies for item generation. The study identified barriers to and benefits of memory assessments. The survey item generation methodology, which involved 24 key informant interviews and 3 focus groups, resulted in the identification of 31 barrier and 28 benefit items. The 34 unique items were rated among the most important by survey respondents. The authors, therefore, present a strong case for generating survey items using informant interviews as groundwork for focus groups.

Out of sight out of mind? Support and information given to distant and near relatives of those with dementia

OBJECTIVES

Increasing attention has been paid to the needs of family members caring for a person with dementia but little has been written about the impact on the wider family. This paper was intended to see whether the need for information would stretch to those relatives living far from the patient.

METHOD

A case-control study comparing two sets of relatives of community-dwelling probands in contact with secondary services and having a clinical diagnosis of dementia: one set of relatives living less than an hour away and another set living further away.The reported need for and source of information obtained by relatives was questioned using a specially designed questionnaire. Mini Mental State Examination (MMSE) and Clinical Dementia Ratings Scale were used with probands.

RESULTS

Relatives living distantly from the person with dementia reported similar rates of subjective distress but were more often dissatisfied with information received. Distant relatives were also less likely to access information from books or lay societies.

CONCLUSION

The impact of having a relative with dementia does not lessen with distance. The wider family need support and information as well as 'primary carers'. If the whole family is to be supported in their caring role, then clinicians and the lay societies need to widen their supportive net.

The quality of nursing home care: do the opinions of family members change after implementation of emotion-oriented care?

OBJECTIVE

The present study focuses on opinions on the quality of nursing home care of family members of nursing home residents with dementia. Furthermore, we examined whether family members' appreciation of the care increased as a result of the implementation of emotion-oriented care.

DESIGN

Randomized clinical trial.

INSTRUMENT

An 18-item questionnaire was developed. The following subjects were addressed: communication activities between staff and family members; satisfaction regarding contacts with staff; the extent to which family members can participate in care; the contact that family members experience with the person with dementia, and opinions about the way in which nursing staff treat residents.

RESULTS

Most family members already had a positive opinion on the nursing home care prior to the implementation of emotion-oriented care. The most positive assessment concerned the way in which nursing staff treated residents. The lowest scores concerned communication activities between ward staff and family members. Comparison of the first and end measurements showed that in general opinions on the quality of care did not change.

STUDY LIMITATIONS

A large number of incomplete questionnaires made it impossible to conduct factor analysis on the classification of the questions in various sections and therefore allowed us only to make statements at the item level.

CONCLUSIONS

For the most part family members had a positive opinion on the nursing home care. In general, implementation of emotion-oriented care did not lead to a more positive assessment. Despite the generally accepted notion that involving family members in care is important, family members were regularly treated as outsiders. This demonstrates that there is room for improvement in the communication by nursing home staff with family members (e.g. more frequent contacts and information about the illness).

Measuring the opinions of memory clinic users: patients, relatives and general practitioners

BACKGROUND

The opinions of memory clinic users are important to assess the value of memory clinics.

OBJECTIVE

To measure the quality of care of an outpatient memory clinic for the elderly as perceived by patients, their relatives and general practitioners (GPs).

METHODS

An observational study was conducted to measure the opinions of the users of a typical outpatient memory clinic. Opinions on five aspects were measured: (1) communication of the results, (2) provision of diagnostic information, (3) attitude of the clinicians, (4) usefulness of the medical assessment, and (5) information and advice to relatives. Patients and relatives were both interviewed with a dementia care satisfaction questionnaire. The GPs' opinions were derived with a self-constructed questionnaire.

RESULTS

On 105 consecutive assessments, 101 opinions of GPs, 81 of caregivers and 31 of patients were recorded. Positive opinions were recorded on the way the results were communicated, the usefulness of the assessment and attitude of the clinicians. In contrast to GPs and relatives, patients were less positive about the clarity of the diagnostic information received. Both relatives and GPs were negative on information and advice to relatives.

CONCLUSIONS

Patients, caregivers and GPs had positive opinions about the diagnostic value of the memory clinic. Quality improvement could focus on the clarity of the diagnostic information for patients and on better advice to relatives.

Perceptions des aidant(e)s de la qualité des soins et des services en unités de courte durée gériatriques: Développement et validation d'un outil de mesure

The goal of this study is to develop and validate a tool for measuring perceptions of caregivers of the quality of care and services in Geriatric Assessment Units. It has been designed so as to reproduce the notion of quality for caregivers. The validation of the tool is based on analyses of responses provided by caregivers (n = 274) to questions of perceived quality and to a certain number of questions necessary for the evaluation of its metric qualities. The measurement scale developed includes 25 items and it demonstrates good internal consistency. The Alpha Cronbach coefficients are 0.95 for the global index and they range from 0.88 to 0.91 on the sub-scales. The various analyses support a three-dimensional structure of the notion of quality for caregivers, explaining 66 per cent of the total variance. These dimensions are: “exchanges with professionals on the relative's condition,” “care given to a loved one,” and “planning the discharge”. It is hoped that this tool will promote the inclusion of the points of view of caregivers in the process of the improvement and assessment of quality.

Comparisons of African American and White women in the parent care role

Little is known about African American women's experiences providing care to impaired older relatives. This study investigated potential differences in depressive symptomatology, parent care stress and rewards, parent care mastery, and the quality of the parent care relationship between 261 White and 56 African American daughters and daughters-in-law who were providing care for an impaired parent or parent-in-law. Multivariate analysis of variance, controlling for significant background characteristics and interrelationships among caregiving experiences, revealed that African American women reported less stress and more rewards in the parent care role than White women did. Race did not have a significant effect on caregivers' depressive symptomatology, parent care mastery, or the quality of their relationship with the parent. However, this research demonstrates the importance of examining a broad range of caregiving experiences in order to detect both similarities and differences between African American and White caregivers.

General practitioners on dementia: tasks, practices and obstacles

The objective of the study was to identify the GPs' perception of their tasks, their practice and obstacles concerning the diagnosis and management of dementia. Twenty-eight GPs participated in focus-group interviews and completed a questionnaire. The GPs perceived their tasks to diagnose, inform and manage dementia patients and their relatives preferably from an early stage on and in such a way that patients are able to stay at home as long as possible. Nevertheless, the GPs diagnose usually in a more progressed stage. As main reasons for this delay the GPs mentioned diagnostic uncertainty during the early stages, embarrassment to conduct a cognitive examination and communicate the diagnosis, non-consulting patients and a lack of time. A discrepancy was found between the GPs' views of their tasks and their clinical practice regarding dementia. Important obstacles were reported that can explain the diagnostic delay and may prevent appropriate education of family caregivers in dealing with demented patients such as embarrassment to examine and communicate this condition.

Caregiving issues in the geriatric medical encounter

Families provide much-needed care for dependent older persons, which can be both burdensome and stressful. In addition to providing personal care, families often are essential for optimal chronic disease management. Thus, two critical functions of the medical encounter are to provide empathic support to family caregivers and to provide education about chronic diseases and their management. Concomitantly, a conscious effort must be made to not compromise the doctor-older patient relationship, insofar as possible. Managing the doctor-patient-family caregiver relationship is challenging, especially in the settings of cognitive impairment and end-of-life care. In these circumstances in particular, both older patients and their families need the care of their physicians.

Carepartner experiences with hospital care

OBJECTIVES

Family members and other "carepartners" often play an important role in the care and support of patients during and after hospitalization, yet little is known about how they assess their hospital experience or the factors that may influence their perceptions.

METHODS

A nationwide telephone survey of 1,800 recently discharged patients and their carepartners about their hospital experience was conducted. Carepartner responses in six domains of care were summarized, and multivariable regression analysis was used to detect independent predictors of more frequent problem reports by carepartners.

RESULTS

Carepartners reported problems most frequently in the domains of emotional support (23.9%), discharge planning (20.3%), and family participation (17.6%). Independent predictors of more frequent carepartner problem reports included poor subjective patient health status, emergency hospitalization, nonsurgical admission, carepartner income less than $7,500/year, younger carepartner age, noninvolvement of the patient's regular doctor, less frequent carepartner visits during the hospitalization, and less time spent with the patient after discharge.

CONCLUSIONS

Better awareness of the problems carepartners experience and attention to improving quality in these areas may facilitate family involvement in patient care and enhance carepartner and patient satisfaction.

Spouse caregivers' attitudes toward obtaining a diagnosis of a dementing illness

OBJECTIVES

To examine attitudes of spouse caregivers about the process of obtaining a diagnosis of a dementing illness, including perceived benefits and obstacles to obtaining a diagnosis and suggestions for improving the process.

DESIGN

A mail survey of spouse caregivers of dementia patients followed by the Michigan Alzheimer's Disease Research Center.

PARTICIPANTS

The 233 spouse caregivers of dementia patients who returned a completed questionnaire.

RESULTS

More than three-fourths of the sample rated the following benefits of obtaining a diagnosis as very or extremely important: ruling out other causes of memory or behavior problems, allowing family members to get information about dementia, may qualify my spouse for drug treatment, and will allow me to plan for the future. Primary obstacles included the time required to obtain a diagnosis, the cost of procedures, lack of access to physicians trained to diagnose dementing illnesses, and not receiving a referral from a primary care physician (41.6%, 41.0%, 40.8%, and 24.1% of the sample, respectively, agreed or strongly agreed that the factor posed a barrier to obtaining a diagnosis). Content analysis of responses to two open-ended questions identified problematic or stressful aspects of obtaining a diagnosis and suggestions for making the process easier for the patient and family.

CONCLUSION

Results suggest the need to provide an orientation to the diagnosis and assessment process for patients and family members, develop a training session for physicians to better prepare them to address the emotional needs of patients and families and to disclose the diagnosis in an informative and compassionate manner, and provide outreach education to primary care physicians to increase knowledge and awareness of dementing illnesses and to increase referrals to community-based services and health professionals able to address the concerns of family members.

Women's views of cardiac rehabilitation programs

BACKGROUND

Previous approaches to understanding participation in cardiac rehabilitation programs based on middle-aged men may not be useful to explain the participation of women. The focus group research method produces unique data about attitudes and experiences that can serve as an adjunct to other forms of data collection in an effort to develop models explaining cardiac rehabilitation participation. The aim of this pilot study was to examine the perceptions and experiences of women participating in a cardiac rehabilitation program using focus groups.

METHODS

Ten women (mean age 72 years) who had recently participated in a cardiac rehabilitation program were interviewed in focus groups of 6 and 4 members each using a semi-structured interview guide. Verbatim transcriptions of the focus group interviews were analyzed by two individuals using content analysis methods.

RESULTS

Results indicated that prior to participation women had no idea what to expect in a cardiac rehabilitation program. Features women liked most about the program included: (1) feeling "safe" during exercise because they were monitored; (2) peer group support during rehabilitation; and (3) pleasant, encouraging staff. Women desired more: (1) social interaction during the cardiac rehabilitation exercise sessions; (2) emotional support from staff members about all dimensions of cardiac recovery; and (3) exercise options other than cycle or treadmill.

CONCLUSIONS

Several cardiac rehabilitation program design and operational features are perceived by women as not meeting their needs. Although limited by its small sample size, findings from this study provide valuable insights into women's perceptions of cardiac rehabilitation programs.

Problems of caregiving spouses of patients with dementia

Twenty-six caregiving spouses of patients with dementia in the Netherlands were interviewed to better understand their problems and needs. Special attention was paid to the information the caregivers received from their general practitioner. Nineteen caregivers indicated that they received little or no information about the disease and its possible consequences. Furthermore, they experienced many problems, because of the disease and the daily care they provided; eleven caregivers indicated a decrease in social contact, which resulted in further problems. Caregivers who sought professional help at an early stage experienced fewer problems in providing daily care. The results of this project suggest that in future health education policy special attention should be paid to the role of the general practitioner and to the importance of a caregiver's social network.