Marital Relationship Quality in Early-Stage Dementia: Perspectives From People With Dementia and Their Spouses

Addressing relationship quality of people with dementia and their family carers: which profiles require most support?

Objective

The quality of the relationship between persons with dementia and family carers influences health and quality-of-life outcomes. Little is known regarding those at higher risk of experiencing a decline in relationship quality, who could potentially benefit the most from interventions. We aimed to identify these risk profiles and explore the underlying factors.

Methods

We applied a latent profile analysis to relationship quality data from a 1-year follow-up of 350 dyads of persons with dementia and their informal carers from the Actifcare cohort in eight European countries. Assessments included sociodemographic, clinical, functional, psychosocial and quality-of-life measures. Relationship quality was assessed with the Positive Affect Index. A discriminant analysis explored factors influencing the risk profiles.

Results

There were two relationship quality profiles among persons with dementia (gradually decreasing, 74.0%; low but improving, 26%) and two among carers (steadily poor, 57.7%; consistently positive, 42.3%). The 'gradually decreasing' profile (persons with dementia) was related to their levels of dependence and unmet needs, along with carers' social distress and negative feelings, lower baseline RQ and sense of coherence. The 'steadily poor' profile (carers) was influenced by their social distress and negative feelings, lower sense of coherence and perceived social support. These two predominant profiles showed significant decreases in quality-of-life over one year.

Conclusions

Specific profiles of persons with dementia and their carers are at risk of worse relationship quality trajectories. By considering modifiable related factors (e.g., carers' stress), our findings can help develop tailored, effective interventions.

Dyadic Ambivalence in Couples Managing Early-Stage Alzheimer's Disease: Linking Behavioral and Psychological Symptoms of Dementia to Life Satisfaction

OBJECTIVES

Caring for a spouse with Alzheimer's disease (AD) can elicit considerable distress but there are also positive moments. A growing body of work has examined caregivers' ambivalence in the care relationship and linked it to negative caregiver outcomes such as depression, but dyadic assessments of both parties' perspectives are missing. We examined ambivalence in both people with AD and their spousal caregivers, seeking to identify the correlates and well-being outcomes of such ambivalence in this unique context.

METHODS

Participants included 72 couples managing early-stage AD. People with AD and spousal caregivers independently self-reported positive and negative relationship qualities (used to indirectly calculate their ambivalence) and life satisfaction. Caregivers reported both partners' demographic characteristics and their spouses' behavioral and psychological symptoms of dementia (BPSD), focusing on memory-related behaviors and psychological symptoms.

RESULTS

Path analyses revealed that the number and frequency of psychological symptoms in people with AD were positively associated with their own and caregivers' ambivalence. Caregivers' distress ratings of memory-related behaviors and psychological symptoms were positively associated with their ambivalence. Greater ambivalence was associated with lower life satisfaction in both spouses. BPSD directly affected both spouses' life satisfaction but there were also indirect effects via ambivalence.

DISCUSSION

This study utilizes a dyadic approach to assess ambivalence in dementia care. Findings reveal the conflicting emotions that couples experience as they cope with early-stage AD, identify sources of such ambivalence, and shed light on the development of dyadic interventions that can promote positive outcomes in both partners.

Identifying predictors of transition to a care home for people with dementia: findings from the IDEAL programme

OBJECTIVES

This study investigates factors associated with the person with dementia and the caregiver to identify those associated with an increased risk of transition to a care home.

METHOD

IDEAL data were collected at baseline and at 12- and 24-month follow-up for 1545 people with dementia and 1305 caregivers. Modified Poisson regressions with an offset for 'person years at risk' were used. Person with dementia factors explored were personal characteristics, cognition, health, self- and informant-rated functional ability, and neuropsychiatric symptoms. Caregiver factors explored were personal characteristics, stress, health, and quality of the dyadic relationship.

RESULTS

A 5% people moved into care. Risk of moving into a care home was higher among people with dementia who were ≥80 years, among people with Parkinson's disease dementia or dementia with Lewy bodies, and among those without a spousal caregiver. Poorer cognition and more self-rated or informant-rated functional difficulties increased the risk of moving into care.

CONCLUSION

Factors related to increased dementia severity and greater disability are the primary influences that place people with dementia at greater risk of moving into a care home. Strategies that help to maintain everyday functional ability for people with dementia could help delay people with dementia moving into care.

Who's Worried? Memory, Worries About Dementia, and Marital Strain in Midlife Same- and Different-Sex Marriages: A Dyadic Perspective

OBJECTIVES

Prior scholarship has highlighted the importance of marriage for cognition. However, little research has considered how cognition-related concerns may impact marriage. In this study, researchers examine how aging couples view each other's memory and worry about their potential development of dementia in the future. Additionally, researchers investigate whether these cognition-related concerns may strain marriage, and how these dynamics differ for men and women in same- and different-sex marriages.

METHODS

Researchers used 2 waves of dyadic data from the Health and Relationships Project (HARP; 2015-2022), including 594 respondents from 297 same- and different-sex married couples (aged 41-71 at Time 2). Researchers employed the Actor-Partner Interdependence Model (APIM) to explore associations between actor and partner reports of memory and dementia worry with marital strain.

RESULTS

Men and women in same- and different-sex marriages were equally likely to report worries about their own potential development of dementia. However, women reported more concerns about their spouse developing dementia in the future than men did, regardless of whether they were married to a man or a woman. Both partners' reports of memory and dementia worry played a complex role in influencing marital strain, with variations observed across couple types.

DISCUSSION

Concerns about cognitive decline and dementia are common in older populations, and for married couples, spouses have concerns about their own memory as well as that of their partner. Researchers finding identified the significance of concerns about a spouse's memory on marital dynamics among aging couples.

Felt Age and Its Psychological Correlates in Dementia Spousal Caregiving Dyads: Findings From the IDEAL Programme

OBJECTIVES

Evidence suggests spouses influence each other's subjective views on aging. Aligned with the Theory of Dyadic Illness Management, we investigated for the first time similarities in felt age (how old people feel relative to their chronological age) between people with dementia and their spousal caregivers, and how each partner's felt age was related to psychological correlates in the other partner.

METHODS

We used baseline (2014-2016) data from 1,001 people with dementia and their spousal caregivers who participated in the British Improving the experience of Dementia and Enhancing Active Life study. We ran linear regressions to analyze the extent to which the felt age of people with dementia and their caregivers were similar, and whether relationship quality was associated with the similarity. We utilized actor-partner interdependence models to analyze whether the felt age of people with dementia and their caregivers were associated with each other's well-being, satisfaction with life, and self-efficacy.

RESULTS

The felt age of people with dementia was associated with the felt age of their caregivers (β = 0.10; p = .001). Caregivers and people with dementia reported a more similar felt age when caregivers rated the caregiving relationship more positively (β = 0.07; p = .04). Caregivers' felt age was associated with well-being (β = 0.07; p = .02) and satisfaction with life (β = 0.06; p = .04), but not with self-efficacy, in people with dementia.

DISCUSSION

Felt age in caregivers and people with dementia may be interwoven, and important psychological variables in people with dementia are related to caregivers' felt age. Findings offer empirical evidence on dementia caregiving dynamics and how family relationships are related to views on aging.

Predictors of the quality of the relationship between informal caregiver and care recipient in informal caregiving of older people: presentation and evaluation of a new item

BACKGROUND

An important factor that has not been directly addressed very often in caregiver (CG) counseling to date is the quality of the relationship between the CG and the care recipient (CR). One reason is the lack of availability of a suitable assessment tool that is not strongly influenced by social desirability. Here, we present and evaluate a new item for the assessment of relationship quality (RQ) in the context of informal caregiving of older people.

METHODS

N = 962 informal caregivers of older people participated. Our item assessed RQ by providing three answer categories (positive, neutral, and negative) that were presented through the use of smiley faces. For evaluation, and to avoid bias due to social desirability, the neutral and negative categories were combined. We calculated a stepwise binary logistic regression.

RESULTS

Expected associations with the variables care burden, perceived positive aspects, and care motivation were found (all p values < 0.01). An exploratory analysis revealed that additional predictors of RQ consisted of the CR's age as well as whether the CR's diagnosis was dementia, CG's amount of dysfunctional coping, and whether the CG was caring for more than one CR.

CONCLUSIONS

We conclude that our item is well-suited for the assessment of RQ in the context of informal caregiving of older people. Because it uses language-free answer categories by means of smiley faces, our item can be applied easily. Bias due to social desirability can be minimized by dichotomization (i.e., combining the negative and neural answer categories). In future research, our tool should be evaluated in other contexts.

A quasi-experimental mixed-method pilot study to check the efficacy of the "SOUND" active and passive music-based intervention on mental wellbeing and residual cognition of older people with dementia and dementia professionals' burnout: a research protocol

Purpose

The SOUND method offers an innovative blended intervention based on music circle-activities and cognitive stimulation approaches which was co-designed by musicians, health professionals, older people with dementia, family caregivers and researchers, for its application in dementia settings. The purpose of the paper is to describe the detailed procedure of the quasi-experimental pilot study.

Method

The experimental phase of SOUND uses a mixed-method design encompassing qualitative and quantitative observations, cognitive testing, self-report and interviewer-assisted questionnaires to investigate the effectiveness of the intervention for 45 people with dementia and 45 professionals (15 in every study country: Italy, Portugal, Romania).

Results

The pilot study will be the first implementation of the SOUND intervention aiming to investigate the feasibility and preliminary effects of the method.

Conclusion

The novelty of SOUND is its multicomponent method, including the most evidenced features for improving the wellbeing of participants.

The quality of family relationships in dementia: Mixed methods to unravel mixed feelings

Objective: Close relationships influence health and quality of life outcomes for people with dementia and their families. Yet, we know little on the role of different relationship domains with quantitative methods having proved to have limitations in this research field. We aimed to study these relationship domains over time, contrasting the views of people with dementia and their family carers, making use of both quantitative and qualitative approaches.Methods: A convergent mixed methods design was adopted, analysing longitudinal data (four time points over three years) from 66 dyads of Portuguese community-dwelling people with dementia and their primary carers, from the EU-Actifcare project sample. Quantitative assessments used sociodemographic and clinical variables, and Positive Affect Index scores, with descriptive and inferential analyses. Qualitative data, collected through individual and joint semi-structured interviews, were explored using thematic analysis.Results: Both quantitative and qualitative findings demonstrated that some domains of relationship quality are affected in different ways, with changes occurring at different stages. Some (e.g., 'communication') may even improve after initial decline. 'Closeness' was consistently altered over time, from carers' perspectives, and played an important protective role regarding institutionalisation. Overall, changes in the relationship quality were perceived differently by people with dementia and their carers, and these divergent perspectives often led to tension. Qualitative data revealed that 'mixed feelings' (ambivalence) involve complex experiences, arguably more difficult to manage than negative feelings alone. Furthermore, perceived informal support, particularly from the extended family, and receiving formal services' assistance, seemed to facilitate positive (re)appraisals of the relationship.Conclusions: A deeper understanding of relationship quality and its domains as dementia progresses may help tailoring interventions to tackle modifiable aspects of relationships, meeting the needs and cherishing the resources of dyads and families. Timely assessments could identify relationships at risk and need for support, including for alternative caring arrangements.

Dyadic influences on awareness of condition in people with dementia: findings from the IDEAL cohort

Introduction

The discrepancy between caregiver-ratings and self-ratings of abilities is commonly used to assess awareness in people with dementia. We investigated the contribution of caregiver and dyadic characteristics to the difference in perspective between caregiver-informants and people with dementia about difficulties experienced, when considering awareness of condition.

Methods

We conducted exploratory cross-sectional analyses using data from the IDEAL cohort. Participants were 1,038 community-dwelling people with mild-to-moderate dementia, and coresident spouse/partner caregivers. The Representations and Adjustment to Dementia Index (RADIX) checklist reporting difficulties commonly experienced in dementia was completed by 960 caregiver-informants and 989 people with dementia. Difference in scores was calculated for 916 dyads. Demographic information, cognition, informant-rated functional ability and neuropsychiatric symptoms were recorded for the person with dementia. Self-reported data were collected on mood, comorbidity, religion, importance of religion, relationship quality, and caregiver stress.

Results

For most dyads, caregivers reported more RADIX difficulties than people with dementia. Caregiver RADIX ratings were more closely associated with informant-rated functional ability and neuropsychiatric symptoms than with cognition. More RADIX difficulties and higher stress were reported by female caregivers. Greater RADIX difference was associated with more caregiver stress, and older age but less depression in people with dementia.

Conclusion

Few dyadic characteristics were important, but caregiver stress was higher where caregivers reported more RADIX difficulties and/or the difference in perspective was greater, whereas partners with dementia reported better mood. In addition to offering information about awareness of condition, the caregiver rating and difference in perspectives could indicate where more support is needed.

Couples' Cognition, Intimacy, and Activity Engagement: An Actor-Partner Interdependence Model Analysis

OBJECTIVES

This study examines the actor and partner effects of cognition on activity engagement and the potential mediating role of intimate relationship in older couple dyadic context.

METHODS

Data for this study were obtained from heterosexual couples who participated in the 2020 wave of the Health and Retirement Study. Constructing a dyadic model of couples' cognitions, activity engagement, and intimacy using structural equation modeling to analyze the relationship between variables and mediating effects.

RESULTS

At the actor level, cognition was positively correlated with their activity participation. At the partner level, wives' cognition and husbands' activity engagement were positively correlated. Husband's cognitive score affect wife's subjective feelings about intimacy. The mediation effect of Wife's intimacy on the relationship between husband's cognition and wife's activity engagement was significant.

CONCLUSIONS

In older couples, cognition influences activity engagement at a binary level, and this association is influenced by the level of intimacy. Improving intimacy can help increase activity engagement in older couples, which in turn promotes health. Clinical Implications Maintaining cognition helps older people enjoy good marriage and participation in activities. For women, the closer the partnership, the higher the frequency of participating in various activities.

A Live Video Dyadic Resiliency Intervention to Prevent Chronic Emotional Distress Early After Dementia Diagnoses: Protocol for a Dyadic Mixed Methods Study

BACKGROUND

By 2030, approximately 75 million adults will be living with Alzheimer disease and related dementias (ADRDs). ADRDs produce cognitive, emotional, and behavioral changes for persons living with dementia that undermine independence and produce considerable stressors for persons living with dementia and their spousal care-partners-together called a "dyad." Clinically elevated emotional distress (ie, depression and anxiety symptoms) is common for both dyad members after ADRD diagnosis, which can become chronic and negatively impact relationship functioning, health, quality of life, and collaborative management of progressive symptoms.

OBJECTIVE

This study is part of a larger study that aims to develop, adapt, and establish the feasibility of Resilient Together for Alzheimer Disease and Related Dementias (RT-ADRD), a novel dyadic skills-based intervention aimed at preventing chronic emotional distress. This study aims to gather comprehensive information to develop the first iteration of RT-ADRD and inform a subsequent open pilot. Here, we describe the proposed study design and procedures.

METHODS

All procedures will be conducted virtually (via phone and Zoom) to minimize participant burden and gather information regarding feasibility and best practices surrounding virtual procedures for older adults. We will recruit dyads (up to n=20) from Mount Sinai Hospital (MSH) clinics within 1 month of ADRD diagnosis. Dyads will be self-referred or referred by their treating neurologists and complete screening to assess emotional distress and capacity to consent to participate in the study. Consenting dyads will then participate in a 60-minute qualitative interview using an interview guide designed to assess common challenges, unmet needs, and support preferences and to gather feedback on the proposed RT-ADRD intervention content and design. Each dyad member will then have the opportunity to participate in an optional individual interview to gather additional feedback. Finally, each dyad member will complete a brief quantitative survey remotely (by phone, tablet, or computer) via a secure platform to assess feasibility of assessment and gather preliminary data to explore associations between proposed mechanisms of change and secondary outcomes. We will conduct preliminary explorations of feasibility markers, including recruitment, screening, live video interviews, quantitative data collection, and mixed methods analyses.

RESULTS

This study has been approved by the MSH Institutional Review Board. We anticipate that the study will be completed by late 2023.

CONCLUSIONS

We will use results from this study to develop the first live video telehealth dyadic resiliency intervention focused on the prevention of chronic emotional distress in couples shortly after ADRD diagnoses. Our study will allow us to gather comprehensive information from dyads on important factors to address in an early prevention-focused intervention and to explore feasibility of study procedures to inform future open pilot and pilot feasibility randomized control trial investigations of RT-ADRD.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/45532.

The Influence of Home-Based Music Therapy Interventions on Relationship Quality in Couples Living with Dementia-An Adapted Convergent Mixed Methods Study

Relationship quality is important for well-being and quality of life in couples living with dementia. Home-based music therapy interventions may be conducted with the aim of enhancing relationship quality. However, the effects or influences of such interventions are only briefly investigated in previous studies. This study's aim was to identify how a 12-week home-based music therapy intervention may influence relationship quality in couples living with dementia, through an adapted convergent mixed methods design. In this case, 68 participating couples from the HOMESIDE RCT study, and four individually recruited couples, received the music therapy intervention. Relationship quality for all participants was measured by the standardized Quality of Caregiver-Patient Relationship scale, and qualitative interviews were conducted with the four individually recruited participants at baseline and post intervention. Quantitative analysis indicated no statistically significant intervention effect. However, relationship quality remained stable over the intervention period. The qualitative analysis identified that the music therapy interventions primarily led to positive emotions, closeness, intimacy, and communication between the persons with dementia and their care partners. Intervention influences could also be ambiguous, as sharing music experiences might involve a risk of evoking vulnerabilities or negative emotional responses.

Longitudinal Predictors of Informant-Rated Involvement of People with Dementia in Everyday Decision-Making: Findings from the IDEAL Program

The extent to which people with dementia are involved in everyday decision-making is unclear. We explored informant-rated involvement of people with dementia in everyday decision-making over 2 years and whether functional, behavioral, and psychological factors related to the person with dementia and the caregiver explain variability in involvement of people with dementia in everyday decision-making. We used IDEAL data for 1182 people with dementia and their caregivers. Baseline mean score on the decision-making involvement scale was 31/45; it minimally declined over time. People with dementia who were female, single, and/or whose caregiver was younger had greater involvement in everyday decision-making than those without these characteristics. Better cognition, fewer functional difficulties, fewer neuropsychiatric symptoms, less caregiver stress, and better informant-rated relationship quality were associated with higher involvement in everyday decision-making. Cognitive and functional rehabilitation, and educational resources for caregivers, could prolong involvement of people with dementia in everyday decision-making.

Influential factors of spousal relationship quality in couples living with dementia - A narrative synthesis systematic review

AIM

The aim of this systematic review is to identify factors that influence relationship quality in couples living with dementia. Previous research has shown how maintaining a positive spousal relationship quality is important for quality of life and coping for both the caregiver and the person with dementia. Knowledge of influential factors could contribute to a deeper understanding of the value of a couple-centred clinical practice and research, within the field of dementia.

RESEARCH DESIGN AND METHODS

Systematic procedures to database search, screening, data extraction and synthesis were followed. Qualitative, quantitative and mixed methods studies were included. A narrative synthesis was conducted through narrative summaries of included studies, thematic analysis and narrative descriptions of factors influencing relationship quality.

RESULTS

39 studies were included in the study: 28 qualitative, 8 quantitative and 3 mixed methods. Through the narrative synthesis, 20 factors were identified. The factors were grouped into two overarching themes: The world of us and The world outside of us, and further to six influencing factor categories: (1) Attitudes and strategies, (2) Behaviour and activities, (3) Emotional connectedness, (4) Activities and experiences outside of the home, (5) Social behaviour and roles, and (6) Belonging and safety.

DISCUSSION AND CONCLUSION

The identified factors influence relationship quality in couples living with dementia on various levels. The findings of this review study should inform clinical, couple-centred dementia care practise and intervention studies, and further research should seek to gain deeper understandings of the individual factors and broader understandings of the correlations between factors.

Through Thick and Thin: The Meaning of Dementia for the Intimacy of Ageing Couples

As the population ages, the number of people with dementia increases. An emerging body of research is focusing on living with dementia and understanding the experience of caring and the care burden. There is much less research on the meaning of dementia from the perspective of an older couple's spousal relationship and related intimacy. This qualitative study explores the meanings of emotional and physical intimacy and the changes brought by dementia in the couplehood of persons with dementia and their spousal carers. The data comprise semi-structured interviews with 35 persons. The interviews were analysed using inductive qualitative content analysis. Four themes describing the meanings of relational intimacy were identified: intimacy as a striving force, intimacy turning into worrisome behaviour, intimacy as physical and emotional dependency, and intimacy turning into one-sided caring for a partner. Dementia changes the intimate relationship in many ways, but shared affection and long-term partnership help maintain the spousal relationship. While dementia may bring about conflicts and behavioural challenges in an intimate relationship, the couple's shared intimacy and a sense of responsibility for one another may serve as a resource and support the continuity of couplehood.

Quality of relationship between adult children caregivers and parents with dementia