Predicting desire for institutional placement among racially diverse dementia family caregivers: the role of quality of care

The Senior Companion Program Plus for African American Caregivers of Persons With Alzheimer Disease and Related Dementias: Protocol for a Randomized Controlled Trial

BACKGROUND

Alzheimer disease and related dementias (ADRD) pose significant challenges as chronic health conditions in the United States. Additionally, there are notable disparities in the diagnosis and prevalence of ADRD among diverse populations. Specifically, African American populations have a higher risk of developing late-onset ADRD than White people, and missed diagnoses of ADRD are more common among older African American populations than older White populations. These disparities also impact African American ADRD family caregivers.

OBJECTIVE

The overall goal of this project is to develop a culturally informed, lay provider psychoeducational intervention named Senior Companion Program Plus (SCP Plus), which is specifically designed for African American ADRD caregivers and is potentially accessible, affordable, and sustainable.

METHODS

In the proposed explanatory sequential mixed methods study, a randomized controlled trial will be used that includes 114 African American family caregivers of a relative with ADRD who will participate in the 3-month SCP Plus program.

RESULTS

The study was funded on September 15, 2018, by the National Institutes of Health (1R15AG058182-01A1). Data collection began on May 16, 2019, but due to COVID-19 restrictions, ended 12 months into the planned 27-month recruitment period on March 31, 2023. The study was completed in June 30, 2023, and currently the results are being analyzed.

CONCLUSIONS

The SCP Plus offers promise as an intervention that utilizes an existing platform for the delivery of a lay provider intervention and offers a novel approach for addressing gaps in accessible, community-based support for caregivers of people with ADRD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03602391; https://classic.clinicaltrials.gov/ct2/show/NCT03602391.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/49679.

An integrative review of measures of transitions and care coordination for persons living with dementia and their caregivers

Introduction

High rates of hospital visits and readmissions are common among persons living with dementia, resulting in frequent transitions in care and care coordination. This paper identifies and evaluates existing measures of transitions and care coordination for persons living with dementia and their caregivers.

Methods

This integrative review builds off a prior review using a systematic search of online databases (PubMed, EBSCO, CINAHL, PsycInfo, and Scopus) to identify records and locate reports (or articles) that use measures of care transitions and care coordination. Identified measures were compared to the Alzheimer's Association's Dementia Care Practice Recommendations to evaluate strengths and weaknesses of the measure in this population, such as if measures were person- and family-centered.

Results

Seventy-one reports using measures of transitions in care and care coordination for persons living with dementia and their caregivers were identified. There were multiple measures identified in some reports. Three main areas of measures were classified into: identification of the population (3 measures, 8 reports), transitional care and care coordination delivery (14 measures, 17 reports), and transitional care and care coordination outcomes (e.g., health-care use, cost, and mortality; 17 measures, 60 reports). A strength of the three main areas of measures was that a portion of the measures were person- and family-centered. Variability in the operational definitions of some measures and time intensiveness of collecting the measure (e.g., number of items, the time it takes to complete the items) were common weaknesses.

Discussion

Transitions and care coordination measures are varied across studies targeted at persons living with dementia and their caregivers. Existing measures focus heavily on outcomes, specifically health-care resource use, and cost, rather than the elements of transitional care or care coordination. Future measure development focused on care transitions and service coordination is needed.

The Senior Companion Program Plus (SCP Plus): Examining the Preliminary Effectiveness of a Lay Provider Program to Support African American Alzheimer's Disease and Related Dementias (ADRD) Caregivers

OBJECTIVES

A culturally informed, peer-led, lay provider model, the Senior Companion Program (SCP) Plus, was implemented to decrease caregiving burden/stress and improve coping skills and social support for African American ADRD caregivers. This study reported the preliminary effectiveness of this intervention.

METHODS

An explanatory sequential mixed methods design was used in this study, and a randomized control trial was conducted for the SCP Plus intervention among participants in three sites (n = 20). A subsample of participants (n = 7) consented to a qualitative interview about their experiences with the intervention. Wilcoxon signed-rank tests, Friedman tests, and one-way repeated measures ANOVA were computed for quantitative analyses. Thematic analysis was used for the qualitative interviews.

RESULTS

Results demonstrated that knowledge of AD/dementia (KAD) and preparedness for caregiving were significantly improved for all senior companions in the intervention group. Results also showed that caregivers in the intervention group reported significantly decreased caregiving burden, as well as increased KAD, satisfaction with social support, and positive aspects of caregiving. Themes from the qualitative interviews included: learning new skills about caregiving, gaining knowledge about ADRD, and benefits for the dyad.

DISCUSSIONS

Findings from this study implied that SCP Plus was a promising model for African American family caregivers as it benefits both the SC volunteers and the African American ADRD family caregivers.

Neuropsychiatric symptoms and caregiver relationship quality for older Mexican Americans

OBJECTIVES

Caregivers play a key role in supporting older Mexican Americans, who are less likely to enter nursing facilities than other racial/ethnic groups in the US. However, there is little research on how Neuropsychiatric symptoms (NPS) affect relationship quality between caregivers and care recipients.

METHOD

Using data from the 2015 wave of the Hispanic Established Populations for Epidemiologic Studies of the Elderly (H-EPESE) (n = 416) study of older (age 85+) Mexican Americans, we examined relationship quality and NPS with ordered logistic regression. Relationship quality was measured using positive (enjoyment, appreciation) and negative (nerves, argue) assessments. NPS were categorized into hyperactivity, affective, and psychosis symptoms.

RESULTS

Hyperactivity symptoms were associated with appreciation, arguing, and nerves. Psychosis symptoms were associated with arguing and nerves. Spousal caregivers were more likely to report arguing and nerves and less likely to report feeling appreciated. Enjoyment assessments were not associated with NPS.

CONCLUSION

Relationship quality is related to behavioral changes in late life. Mexican American caregivers negatively evaluate their relationships, not in response to care tasks per se, but when the older person exhibits behavioral problems. The relationship between NPS and negative relationship assessments may be due to unanticipated behavior changes in late life and stigma around psychiatric symptomatology.

Caregiver Burden and Dementia: A Systematic Review of Self-Report Instruments

Background: As the demand for dementia care grows rapidly worldwide, heavy “caregiver burden” has been associated with stress and depression. Even so, standard metrics for interdisciplinary research of caregiver burden are limited. Objective: The objective of the present review is to recommend valid, reliable, and comprehensive self-report instruments of caregiver burden. Methods: A systematic review was performed using four databases, searched in April 2021. Articles that established or evaluated self-report instruments for dementia caregiver burden were included, while studies that involved non-dementia caregivers or did not clearly define caregiver burden were excluded. Established guidelines for reliability and agreement studies were used to assess quality and risk of bias. Assessments of self-report instruments were made based on reliability, validity, feasibility, and quality of psychometric evaluations, and comparative evaluations were presented in visual form using radar graphs. Results: Search terms yielded 1,720 articles, and 40 were included in the systematic review after excluding those of low quality. Based on the results of these studies, we recommend the Zarit Burden Interview, Screen for Caregiver Burden, Caregiver Burden Interview, and Burden Scale for Family Caregivers, due to their validity, reliability, and inclusion of multiple subjective and objective dimensions of burden. Conclusion: Targeting specific sources of caregiver burden can help prevent negative outcomes for both dementia patients and caregivers. Future studies should apply self-report instruments to measure and address caregiver burden longitudinally.

Towards a middle-range theory of 'Stability of home-based care arrangements for people living with dementia' (SoCA-Dem): findings from a meta-study on mixed research

BACKGROUND

Most people with dementia and their informal carers live at home and strive to create a stable care situation for as long as possible. This preference of dyads is consistent with the global policy of ageing in place. Therefore, we aimed to develop a middle-range theory of stability guided by two research questions: How is stability of home-based care arrangements for people living with dementia constituted? What are the essential factors influencing stability?

METHODS

Within the 'Stability of home-based care arrangements for people living with dementia' project (SoCA project) at the German Center for Neurodegenerative Diseases (DZNE), we conducted a meta-study on mixed research. The analytical steps of meta-data analysis, meta-method and meta-theory are merged in an integrative synthesis. Eligible publications were identified through systematic database searches (MEDLINE, CINAHL and PsycINFO; last searched on 3 January 2017), backward/forward citation tracking and snowballing. All publications were screened against predefined inclusion criteria and evaluated through a quality appraisal. The analytical approach was thematic synthesis.

RESULTS

99 publications were included. The middle-range theory conceptualises stability as a complex phenomenon comprising three components including eight concepts that are dynamically inter-related. The conceptual model visualises: (1) the trajectory of the dementia care arrangement, which involves a cyclic process of change and balancing over time; (2) the characteristics of the care arrangement, including needs, the carer role, the dyadic relationship and resources; and (3) the context, which is determined by society and culture and the respective healthcare system. The relevance of each concept in relation to stability changes over time. The forming of each concept is actively shaped by the informal carer.

DISCUSSION

This middle-range theory provides a thorough understanding of the stability of home-based care arrangements for people living with dementia and can be used to guide future research and practice.

OTHER

This meta-study was funded by the DZNE and registered in PROSPERO (registration number CRD42016041727).

Drivers of Long-Term Care Considerations by Persons With Cognitive Impairment

Consideration of place of care is the first step in long-term care (LTC) planning and is critical for patients diagnosed with Alzheimer's disease; yet, drivers of consideration of place of care are unknown. We apply machine learning algorithms to cross-sectional data from the CARE-IDEAS (Caregivers' Reactions and Experience: Imaging Dementia-Evidence for Amyloid Scanning) study (n = 869 dyads) to identify drivers of patient consideration of institutional, in-home paid, and family care. Although decisions about LTC are complex, important drivers included whether patients consulted with a financial planner about LTC, patient demographics, loneliness, and geographical proximity of family members. Findings about consulting with a financial planner match literature showing that perceived financial constraints limit the range of choices in LTC planning. Well-documented drivers of institutionalization, such as care partner burden, were not identified as important variables. By understanding which factors drive patients to consider each type of care, clinicians can guide patients and their families in LTC planning.

Utilizing the Senior Companion Program as a platform for a culturally informed caregiver intervention: Results from a mixed methods pilot study

To address the need for accessible, affordable, and sustainable Alzheimer's disease and related dementia caregiver interventions with minority populations, we developed the Senior Companion Program Plus, a three-phase pilot study that used a mixed methods experimental design. The intent was to determine if participation in a lay provider, peer-led psychoeducational intervention designed for African American Alzheimer's disease and related dementia caregivers (N = 16) improved caregiver burden and/or stress, coping skills, and social support. Focus groups with Senior Companions informed the intervention design. Quantitative results indicated that caregivers experienced improvement in their overall level of social support and well-being in meeting basic needs. Qualitative findings suggested that caregivers experienced improvement in their knowledge about the disease, experienced increased coping with Alzheimer's disease and related dementia caregiving, and reported benefits of using a lay provider model. Overall, the data suggest that the Senior Companion Program Plus is a promising intervention for African American Alzheimer's disease and related dementia caregivers.

Exemplary Care among Chinese Dementia Familial Caregivers

OBJECTIVE

This study investigates the feasibility of using the Exemplary Care Scale (ECS) among Chinese dementia familial caregivers, and reports its psychometric properties.

METHOD

Back translation was used to develop the Chinese version of ECS (C-ECS). Three hundred and ninety-seven dyads of caregivers and their relatives with dementia responded to an assessment battery which included questions on care recipients' cognition, behavioral and psychological symptoms, daily activities assistance, social support, and caregiver well-being.

RESULTS

Results of an exploratory principal component analysis revealed two subscales in the 11-item C-ECS: considerate caregiving and preserving esteem. C-ECS and its subscales demonstrated sufficient reliability, as well as criteria-related validity through its association with care recipient's cognition and health, and caregivers' well-being and social support.

DISCUSSION

Our findings provide preliminary support to C-ECS as a reliable and valid measure of exemplary caregiving among Hong Kong Chinese familial dementia caregivers. In the light of the increasing importance of familial care in dementia care planning, we recommend the use of this brief scale in regular caregiver assessment in research and service delivery.

A longitudinal study looking at and beyond care recipient health as a predictor of long term care home admission

Background

The unpaid care provided by informal caregivers allows care recipients to live longer in their homes, which often results in fewer unnecessary long term care home (LTCH) admissions. Although the relationship between care recipient’s health characteristics and institutionalization is well known, the influence of caregiver distress and caregiving coresidence and relationship on this outcome is less clear. This study examines the association of care recipient care needs, caregiver distress and caregiving coresidence and relationship with care recipient long term care home admission.

Methods

A total of 94,957 resident assessment instruments-home care (RAI-HC), completed between April 01st 2013 and April 01st, 2014 as part of a clinical practice by 14 Local Health Integration Networks (LHINs) in Ontario, Canada, were linked to LTCH admissions within 1 year after completion of the first RAI-HC assessment. Cox models were used to examine whether care recipient health care needs, caregiver distress and caregiving characteristics such as coresidence and relationship were associated with LTCH admission. Age, marital status and gender of the care recipient were included as covariates in the model.

Results

Care recipient health care needs and age were the strongest predictors of LTCH admission followed by caregiver distress and caregiving coresidence and relationship. Care recipient marital status was not significant in the survival model. Interestingly, care recipients who were cared for by a coresiding adult child caregiver were less likely to be admitted to a LTCH than care recipients cared for by a spouse caregiver coresiding or not with care recipient. Hazard rates (HR) of admission for care recipients cared for by caregivers coresiding and with other type of relationship with care recipient were not significantly different than HR of care recipients cared for by coresiding child caregivers.

Conclusions

These results emphasize the influence of caregiver distress in LTCH admission and highlight the impact of caregiving relationship and coresidence on this outcome. Policy and decision makers should consider these findings when developing and evaluating interventions aiming to avoid LTCH admissions. Moreover, caregiving coresidence and relationship should be explored in future studies with similar aims, as this information has been neglected in past research.

Predictors of Desire to Institutionalization in Dementia Caregivers From a Developing Country

Older adults with dementia have higher rates of institutionalization than those without dementia. Desire to institutionalization (DTI) is an important factor influencing the actual institutionalization but is less well studied. This cross-sectional study examines the DTI with the scale of same name developed by Morycz, in 1985, in a sample of 50 caregivers of patients with dementia in a tertiary clinical care setting in a developing country. Caregiver burden associated with personal strain (by factor analyzed Zarit Burden Interview scale), and stress perceived out of caregiving (by Perceived Stress Scale) predicted higher DTI. Besides, those who were married had lower DTI scores. The factors which didn't affect DTI were total caregiver burden, family and social support, age of patient and caregiver, education of caregiver, severity and duration of dementia, and treatment duration. These results were different from those of developed country-based DTI studies and may indicate sociocultural differences.

Experiences and Learning Needs of African American Family Dementia Caregivers

Dementia family caregivers display significant rates of psychological and physical symptoms. African Americans (AAs) are disproportionately affected by dementia. African American caregivers display unique patterns of symptomology and responses to interventions designed to promote caregiver well-being. This study analyzed qualitative focus group data from 32 AA caregivers to explore how issues of race and culture may be incorporated into a culturally sensitive intervention for AA dementia family caregivers. Caregivers were asked scripted questions about their caregiving experiences and to suggest alterations to an existing psychoeducation program. Analysis revealed 4 key themes: the tradition of family care, caregiving and caregiving issues, culturally appropriate care, and navigating without a map. Suggestions for an educational program included a focus on developing caregiver skills and knowledge for caregiving, promotion of self-care, and reflection on the AA family and community as resources for care.

Quality of in-home care, long-term care placement, and the survival of persons with dementia

PURPOSE OF THE STUDY

Caregivers of persons with dementia living at home adopt a variety of caregiving styles that vary in quality. Three styles of high-quality care and poor-quality care have been identified. The outcomes, however, of varying styles of caregiving are unknown. Our purpose was to investigate the linkage of quality of care to long-term care placement and survival.

DESIGN AND METHODS

We used a sample of 148 primary caregivers of a relative living at home and needing assistance due to memory or thinking problems. We used items from four existing scales and five new items to construct measures of high-quality and poor-quality care. Long-term care and survival were determined from two follow-ups. Cox proportional hazards regression was used to estimate the relationship of quality of care to long-term care placement and survival.

RESULTS

Poor quality of care increased the risk of long-term care placement, as expected, but high-quality care was not related to placement. Surprisingly, high-quality care increased the risk of death while poor-quality care decreased the risk. Secondary results were: wishful/intrapsychic coping (a dysfunctional type of emotion-focused coping) and long-term care placement shortened the survival; and caregiver personality traits of neuroticism and agreeableness lengthened the survival.

IMPLICATIONS

It is premature to recommend caregiver interventions based on our unexpected findings. Further studies are vital and should include care-recipient impairments and the quality of life of the person with dementia as additional outcomes.

Health Care Communication and Agreement and Disagreement About Symptoms Within the Context of Multimorbidity

Informal caregivers for older adults often act as medical 'proxies' based on their assumed knowledge of the care recipient's illness-related symptoms. Differences between symptom descriptions given by care recipients and caregivers, however, raise questions about the validity of proxy reports. Community-dwelling caregivers and their care recipients with chronic, multi-morbid conditions revealed similar numbers of symptoms reported as well as average symptom distress. Dyads with care recipients who scored higher on negative affect were more likely to have significantly lower. Results suggested the possibility of identifying and intervening with dyads who may be 'at-risk' for divergent symptom reporting. This awareness may increase the ability to engage in informed and shared medical decision making throughout the illness trajectory.