Applying Relational Turbulence Theory to Adult Caregiving Relationships

Qualitative Evaluation of Family Caregivers' Experiences Participating in Knowledge and Interpersonal Skills to Develop Exemplary Relationships (KINDER): Web-Based Intervention to Improve Relationship Quality

BACKGROUND

The onset of Alzheimer disease and related dementias (AD/ADRD) can alter relationships between family caregivers and persons living with AD/ADRD, such as through the occurrence of distressful behavioral and psychological symptoms of dementia. Poorly perceived relationship quality by caregivers contributes to negative outcomes for both care partners, such as low-quality caregiving and potential mistreatment of older adults. Knowledge and Interpersonal Skills to Develop Exemplary Relationships (KINDER) is a new, web-based, asynchronous psychoeducational intervention with content informed by focus groups with family caregivers. The program was developed to prevent low-quality caregiving and potential mistreatment of older adults by focusing on building healthy caregiving relationships.

OBJECTIVE

The purpose of this study is to describe caregivers' experiences participating in KINDER to understand intervention acceptability. Of particular interest was learning how comfortable caregivers were viewing content addressing potential mistreatment, as well as whether asynchronous delivery created any barriers to participating in the intervention. Findings will inform future program refinements before efficacy testing.

METHODS

Although 23 caregivers enrolled in the KINDER parent study, only 7 of them completed the 8-week intervention. In-depth, semistructured qualitative interviews were conducted with all participants who completed the program to understand their experiences while attending KINDER and to decipher barriers to participation. We also asked participants about which program elements were most valuable and which were least valuable to them, as well as how the program could be improved. Interview transcripts were analyzed by 2 coders using thematic analysis.

RESULTS

Our findings indicate that caregivers were overall satisfied with KINDER's focus and content. Participants particularly liked how KINDER materials felt authentic and relevant to supporting healthy care relationships (Theme 1). The program's multiple components were found to be valuable, especially story-based video vignettes and readings (Theme 2). Most caregivers were comfortable viewing depictions of mistreatment and understood the importance of this content (Theme 3). Notably, while caregivers appreciated the convenience of participating in an asynchronous web-based intervention, several expressed a desire for more opportunities to speak with other caregivers (Theme 4). Technology challenges, such as a lack of clarity about automated intervention activities, deterred completion.

CONCLUSIONS

Findings from this study suggest an asynchronous web-based intervention covering sensitive topics such as mistreatment is acceptable for at least some AD/ADRD caregivers. Caregivers' comments that materials felt authentic may suggest that the integration of caregiver voices before intervention development enhanced the relevance of content. To make KINDER easier to deliver and participate in, the investigators plan to reduce the use of automation and integrate more group-based programming, as recommended by participants. Further, given the higher-than-expected dropout rate, in future studies, the investigators will collect data to determine the reasons for participants not completing study activities.

Conceptualizing How Caregiving Relationships Connect to Quality of Family Caregiving within the Stress Process Model

Family caregivers provide the majority of care for older and disabled family members living with an illness or disability. Although most caregivers want to provide high-quality care, many report providing care that is potentially harmful. We apply the Stress Process Model to review the preponderance of literature implicating quality of the relationship between caregivers and care recipients as a factor contributing to quality of family caregiving. In drawing together literature on caregiving relationships and caregiving quality, this commentary identifies potentially modifiable intervention targets to develop programs to support high-quality caregiving to older adults living with a chronic illness or disability.

The relationship between perceived support and depression in spousal care partners: a dyadic approach

OBJECTIVES

Caregiving within a spousal partnership marks a novel relationship stage for couples. Caregiving introduces new stressors and affects couples' ability to cope, and potentially alters perceptions of emotional support. Prior research on older married couples illustrates how perceived support not only affects an individual's mental health, but also that of their partner. To date, the dyadic relationship between emotional support and mental health is largely unexamined among caregiving partners, where support expectations may differ.

METHOD

Actor partner interdependence models using linear mixed modeling were applied to data from spouses where one partner received caregiving within the 2014 and 2016 waves of the Health and Retirement Study. We examined the cross-sectional and lagged associations between perceived emotional support and strain from a spouse on actor and partner depression scores, as well as whether one was the caregiver or the care recipient moderated associations.

RESULTS

More positive perceptions of support were associated with lower depression scores for oneself (b= -0.55, p < 0.001) and one's partner (b= -0.24, p < 0.001). Actor effects-how one's own perceptions of support associate with one's own depressive symptomology-were stronger for care recipients than for caregivers (b= -0.83, p < 0.001 v. b= -0.26, p < 0.05). Higher perceptions of strain were also associated with higher depression scores for oneself (b = 0.57, p < 0.001) and one's partner (b = 0.39, p < 0.001), associations that remained even in lagged models.

CONCLUSIONS

The observation of both actor and partner effects in this study suggests opportunities to improve care recipient outcomes through intervention with caregivers or both members of the care dyad.

Dyadic Disruption Theory

Aspects of couples' romantic relationships are some of the most powerful psychosocial forces shaping mental and physical health, but even high-quality relationships are not universally beneficial for patients. Dyadic health theories have largely focused on chronic illness management that occurs after the couple understands the disease and prognosis, rather than focusing on couples' interdependence in the days and weeks following a sudden and disruptive medical event (e.g., an acute coronary syndrome [ACS] or a stroke). To address this gap, I propose Dyadic Disruption Theory to guide research on couples' reactions to acute medical events and their consequences for individual and dyadic mental health, physical health, and behavior. I propose that dyadic processes of social support, shared reality, and co-rumination can precipitate harmful patient and partner dynamics when couples are distressed early post-event and offer three propositions that inform testable hypotheses. Finally, I discuss implications for early dyadic intervention and future directions for research.

The Social Relationship Context of Elder Mistreatment

BACKGROUND AND OBJECTIVES

Elder mistreatment victims at risk of poor physical and psychological health may benefit from increased social support. This article identifies mistreatment victims among community-dwelling older Americans and maps their social networks to guide the design of social support interventions.

RESEARCH DESIGN AND METHODS

Using nationally representative survey data from Wave 3 (2015-2016) of the National Social Life, Health, and Aging Project (N = 2,334) and descriptive, latent class, and regression analyses, we estimate the prevalence of mistreatment since age 60, identify the alleged perpetrators' relationships to the victims, and examine victims' social networks.

RESULTS

Self-reported lifetime prevalence of elder mistreatment is as high as 21%, depending on the mistreatment behavior measured. Latent class analysis reveals two mistreatment classes: 12% of older adults experienced multiple types of mistreatment (polyvictimization), and 6% experienced primarily financial mistreatment. Although alleged perpetrators are unlikely to appear in older adults' core social networks, the most commonly reported perpetrators are children and relatives. Regression analyses show that experiencing mistreatment since age 60 is associated with having less current social support, more social strain, and fewer kin in the core social network. Older adults reporting polyvictimization also have less-dense core networks.

DISCUSSION AND IMPLICATIONS

Increasing family support should be done cautiously because children and relatives are frequently named as mistreatment perpetrators. Increasing communication across polyvictimization victims' network members may support their well-being. Providing outside assistance with financial management could benefit financial mistreatment victims.

Caregivers' Loss of the Dyadic Experience after Their Care Partners' Death

Little is known about the experience of family caregivers when their care partner dies and their dyadic relationship comes to an end. This study qualitatively examined and characterized the loss of the dyadic experience for the caregiver after the death of their care partner. Data was accrued as part of a randomized clinical trial in 29 older hospice caregivers. Iterative thematic analysis focused on dyadic processes before, during and post death. Using two relational parameters from Relational Turbulence Theory resulted in a preliminary characterization of a new concept-dyadic dissolution as a cognitive and affective process whereby a remaining member of a dyad experiences relational uncertainty and partner interference while adapting (or not) to the death of their care partner. Findings suggest that asking several open-ended questions about the dyadic relationship will enable assessment for any continuing impact of relational uncertainty and partner interference on bereaved caregivers.