The Relevance of Gender in the Care of Elders: Assumptions and Realities

An examination of the common belief that gender determines a closer emotional bond between adult daughters and elderly parents than adult sons results in five paradoxes. By employing sociological and psychological theories, this paper looks at discriminatory socialisation that sets sons and daughters apart in childhood and argues that the performance of daily routine chores, rather than gender, lies at the core of how intergenerational bonds are shaped.

Caregiving and Perceived Generativity: A Positive and Protective Aspect of Providing Care?

OBJECTIVES

Although a sizable body of research supports negative psychological consequences of caregiving, less is known about potential psychological benefits. This study aimed to examine whether caregiving was associated with enhanced generativity, or feeling like one makes important contributions to others. An additional aim was to examine the buffering potential of perceived generativity on adverse health outcomes associated with caregiving.

METHODS

Analyses utilized a subsample of participants (n = 3,815, ages 30-84 years) from the second wave of the National Survey of Midlife Development in the United States (MIDUS).

RESULTS

Regression analyses adjusting for sociodemographic factors indicated greater negative affect and depression (p < .001) and lower levels of positive affect (p < .01), but higher self-perceptions of generativity (p < .001), in caregivers compared with non-caregivers. This association remained after adjusting for varying caregiving intensities and negative psychological outcomes. Additionally, generativity interacted with depression and negative affect (p values < .05) to lessen the likelihood of health-related cutbacks in work/household productivity among caregivers.

CONCLUSIONS

Results suggest that greater feelings of generativity may be a positive aspect of caregiving that might help mitigate some of the adverse health and well-being consequences of care.

CLINICAL IMPLICATIONS

Self-perceptions of generativity may help alleviate caregiver burden and explain why some caregivers fare better than others.

A one-year follow-up study of family caregivers of institutionalized elders with dementia

The purpose of this one-year follow-up study was to determine whether the caregiving experience of primary caregivers (N = 142) of institutionalized demented elders changed over time and to identify the factors predictive of caregiver well-being after a year. Based on the stress and coping model of Lazarus and Folkman, five dimensions of this experience were considered: caregivers’ stressors, their cognitive appraisal of these stressors, social support, coping strategies and well-being (psychological distress and positive affect). MANOVA and t test results revealed that two stressors changed over time. The elders’ functional impairment deteriorated and their depressive behaviors decreased. However, there was no change in the appraised disturbance associated with these stressors. Conflicts in informal social support decreased significantly, but there was no change in well-being. More formal support at T1 was predictive of decreased psychological distress and increased positive affect at T2. A coping strategy, the use of affective regulation at T1, was also predictive of increased positive affect at T2. Knowledge of the caregiving experience over time and of predictors of caregiver well-being provides guidelines for interventions that could be directed at this clientele by health care workers in institutional settings.

Effect of Giving Care on Caregivers’Health

This longitudinal study of 121 caregivers of the elderly evaluates the change in their self-assessed mental and physical health over two years. The care recipients, who were drawn from a random sample of noninstitutionalized urban elders, showed increased need for help with personal and instrumental activities of daily living in this period. Both the physical and mental health of the caregivers declined significantly during the study. Predictors of decline in physical health of the caregivers at the end of the study were poorer physical health at the start, the amount of help they provided, a decline in their own mental health, and an increase in the number of other persons also available to provide care. In contrast, decline in caregivers’ mental health at the end was predicted only by poorer mental health at the start and by decline in physical health.

Predictors of the Psychological Well-Being of Primary Caregivers Living With a Demented Relative: A 1-Year Follow-Up Study

This 1-year follow-up study aimed to examine the predictors of change in psychological well-being, using two negative indicators (psychological distress and negative feelings about the caregiver role) and two positive indicators (positive feelings about the caregiver role and positive affect) of well-being. The sample consisted of primary caregivers (n = 180) cohabiting with a demented relative. Four variables were involved in predictive relationships with psycho logical well-being The first variable, appraisal of the disturbance from dysfunctional behaviors at Time 1, was selectively predictive of an increase in the two negative indicators over a year. The second and third variables, increased conflicts in the exchange of informal support and less frequent informal support at Time 1, were predictive of an increase in psychological distress. The fourth variable, frequent use of affective-stimulative dementia management strategies at Time 1, appeared to predict an increase in the two positive indicators of well-being. Knowledge of these four predictors can be useful in designing interventions that target the improvement of well-being.

The psychological and health consequences of caring for a spouse with dementia: a critical comparison of husbands and wives

Caring for someone with dementia can be demanding, particularly for spouses living with the care recipient. The main goal of this study was to clarify differences in the experience of caregivers who were husbands and wives with respect to burden, health, healthy behaviors, presence of difficult care recipient behaviors, social supports, and the quality of the premorbid relationship. The results of this study support research demonstrating a difference between the caregiving experiences of women and men. It is becoming increasingly apparent that female gender is a marker that places them at increased risk of high burden and less support.

Quality of life in dementia: a study on proxy bias

BACKGROUND

Measurement of health-related quality of life (HRQoL) in dementia is difficult. At some point people with dementia become unable to meaningfully assess their own HRQoL. At such a point in time researchers need to rely on other types of information such as observation or assessments from informal caregivers (proxies). However, caregiver assessments may be biased by several mechanisms. The current study explores whether caregivers project part of their own HRQoL in their assessments of patient HRQoL.

METHODS

The participants in the current study were 175 pairs, consisting of community-dwelling persons with dementia and their caregivers. The EQ-5D, the EQ-VAS and the QoL-AD were administered to collect HRQoL measurements from patients and caregivers at baseline, 6 months and 12 months. Two linear mixed models were used to investigate factors that bias proxy ratings, one with the EQ-VAS as dependent variable, and one with the EQ-5D utility as dependent variable. The independent variables were caregiver age, caregiver sex and caregiver QoL-AD items.

RESULTS

The linear mixed model with EQ-VAS as dependent variable indicated that 3 caregiver characteristics, namely caregiver age, money (caregiver's financial situation) and valuation of life as a whole were significant predictors of the patient-by-proxy VAS scores. The linear mixed model with utility value as the dependent variable showed that caregiver age and valuation of the ability to do things for fun were significant predictors of the patient-by-proxy EQ-5D utility values.

CONCLUSIONS

The current study was a first step in identifying factors that bias patient-by-proxy HRQoL assessments. It was discovered that caregivers project part of their own HRQoL onto patients when assessing patient HRQoL. This implies that patient-by-proxy HRQoL values should be interpreted with caution and not be used as a direct substitute for patient self-assessment, even when patients are no longer able meaningfully assess themselves.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Caregiving for Elderly Parents

Caregiving to elderly parents, in India, is primarily provided by adult children. This study aims at understanding the issues and concerns relating to elderly parental caregiving in the contemporary Indian sociocultural context. Qualitative methods have been used in this study to collect the data based on phenomenological principles. Data for this study was collected through in-depth interviews with 15 couples who were recruited through purposive and snowball method. Finding of the study highlighted five main themes: (a) The emotional bonding; (b) Implications on caregiver; (c) Impact on finance; (d) Who takes the responsibility and (e) Being a daughter. This study has tried to highlight that in India, being a collectivist nation, there are various aspects relating to elderly parental caregiving which affect the caregiver in different ways in the sociocultural context.

Community Services and Caregivers of à Demented Relative: Users and Those Perceiving à Barrier to Their Use

Le but de l'étude consistait à identifier les facteurs liés à l'utilisation de trois services communautaires (centre de jour, répit à domicile et aide ménagère) et ceux liés à leur non utilisation due à une barrière empîchant le recours à ces services. L'échantillon comprenait 265 aidants cohabitant avec un parent souffrant de démence. Pour chacun des services, des analyses de régression logistique polytomique ont été effectuées où un groupe d'utilisateurs et un groupe de non utilisateurs percevant une barrière ont été contrastés avec un groupe de non utilisateurs rapportant ne pas avoir besoin des services. Pour les trois services, lorsque le parent présente une condition de santé particulièrement fragile (perte d'autonomie fonctionnelle élevée ou comportements dysfonctionnels fréquents), les aidants ayant une détresse psychologique élevée, comparés à ceux ayant une faible détresse psychologique, ont plus tendance à rapporter ne pas avoir besoin de l'un ou l'autre service, suggérant que la détresse psychologique peut nuire à l'utilisation des services, mîme si la condition du parent est détériorée. Des facteurs de vulnérabilité (prendre soin d'un parent ayant de fréquents comportements dysfonctionnels ou avoir une détresse psychologique élevée et prendre soin d'un parent ayant une perte d'autonomie peu élevée) sont liés à l'utilisation du centre de jour ou du répit à domicile. Ces mêmes facteurs sont aussi liés à la non utilisation de ces services à cause d'une barrière, indiquant que des aidants avec les mêmes caractéristiques de vulnérabilité n'utilisent pas ces deux services. De plus, les aidants ayant peu de soutien informel et qui prennent soin d'un parent ayant une perte éleéee d'autonomie avaient plus tendance à percevoir une barrière à l'utilisation du répit à domicile.

The role of attitudes and culture in family caregiving for older adults

This study evaluated cultural differences in attitudes toward caregiving and the stress levels of family caregivers. Participants included 98 Japanese American and 86 Caucasian American family caregivers caring for frail elders. Analyses using MANOVA and multiple regression analyses revealed that the Caucasian caregivers had more positive attitudes and provided more hours of care than the Japanese caregivers but that both groups had elevated levels of caregiver stress. The stress that family caregivers currently experience could lead to a future generation of care recipients who enter old age in worse condition than their predecessors. Professionals need to work together to develop culturally appropriate, evidence-based interventions to address this issue.

The effect of dementia patient's physical, cognitive, and emotional/ behavioral problems on caregiver well-being: findings from a Spanish-speaking sample from Colombia, South America

The current study aims to (1) determine whether there is a relationship between the problems of patients with dementia and the psychosocial functioning of the caregiver, (2) determine whether these relationships exist independent of sociodemographic and caregiving-related variables, and (3) determine which type of problems of patients with dementia best predict the psychosocial functioning of the caregiver. In all, 73 family caregivers were recruited from Bogota, Colombia. The caregivers completed a checklist of problems presented by the person with dementia, Patient Health Questionnaire (PHQ-9), Zarit Burden Interview (ZBI), Interpersonal Support Evaluation List (ISEL-12), and Satisfaction with Life Scale (SWLS). Number of cognitive and behavioral/emotional problems presented by the person with dementia was positively correlated with caregiver PHQ-9 and ZBI scores. Number of behavioral/emotional problems was negatively correlated with ISEL-12 scores. Cognitive and behavioral/emotional problems, but not physical, presented by the person with dementia were associated with higher levels of depression and burden of caregiver. Behavioral/emotional difficulties were associated with lower caregiver-perceived social support rating.

Widowhood and the end of spousal care-giving: relief or wear and tear?

This paper analyses the impact of spousal care-giving on survivors' depressive symptoms six months into widowhood, and examines the applicability of a ‘relief model’ of spousal adjustment during bereavement. We examine several aspects of the care-giving situation, including care-giver stress, care-giving demands, and type and duration of care and how these affect survivors' depressive symptomatology. The sample is drawn from two waves of the Changing Lives of Older Couples (CLOC) survey, which was conducted in the United States in the Detroit Metropolitan Area, Michigan. The first wave of data was collected from couples and the second from the surviving spouse six months after the death of the partner. We use multiple regression analysis to examine the effects of key variables on depressive symptoms six months into widowhood, controlling for various demographic characteristics and personal circumstances. The results demonstrate that the duration of care-giving is the most influential predictor of survivors' depressive symptoms six months after the death. Indeed, long-term care-givers experience greater relief than both non-caregivers and short-term care-givers, as the predicted probabilities indicate. The results lead us to emphasise that care-giving and spousal bereavement should be studied as related processes rather than distinct phenomena. Indeed, relief from a chronically stressful care situation may actually ameliorate the negative effect of spousal loss for survivors.

The health of family caregivers of older impaired persons in Lebanon: An interview survey

BACKGROUND

The majority of older persons in Lebanon live with their family, which provides the help and care required when their relative is functionally impaired. Knowing that taking care of an older impaired relative is considered a source of enrichment for the caregiver and an act of gratitude towards the older person in Lebanon. However, there are few formal resources to support these families. This study is informed by a theoretical framework of stress.

OBJECTIVE

Identify the dimensions of the caring context related to the health of Lebanese family caregivers living with an older impaired relative.

DESIGN

Exploratory correlational study.

PARTICIPANTS

Convenience sample (N=319) drawn from all the regions of Lebanon according to predetermined quotas on the basis of relative demographic weight and socio-economic class. The inclusion criteria are: aged 18 years or over; primary caregiver; provided help with at least one ADL or IADL once a week; lived with the older impaired person. 13.5% refused to participate in the study. The caregivers recruited were female (84%), adult children (48%) or spouses (22.6%) with a mean age of 46 years. Almost half of them reported a post-compulsory level of education and a low monthly household income and no medical coverage for 68% of them.

METHODS

The data were collected during a face-to-face interviews with the caregivers in their homes.

RESULTS

The results from regression analyses indicate that the degree of functional impairment, the frequency of depressive and disruptive behaviours of cared-for relative are linked to at least one of three caregiver health indicators (p<.01). Also, caregiver cognitive appraisal of these stressors is associated with either role strain or feeling of helplessness (p<.05). The informal emotional support received by caregivers is positively related to well-being (p<.001), whereas interpersonal conflicts with family and friends diminish caregiver well-being and increase role strain (p<.001). Sufficiency of emotional support received is negatively associated with role strain (p<.001).

CONCLUSION

Many stressors proved associated with one or other of the health indicators under study and the resources emerged as significant factors related to caregiver's health.

Implementation and effects of an individual stress management intervention for family caregivers of an elderly relative living at home: A mixed research design

The purpose of this project was to evaluate the implementation and effects of a stress management intervention for family caregivers of elderly persons. The intervention was implemented through an action research design with the collaboration of case managers working in community health centers. A total of 81 caregivers participated in the study. The quasi-experimental design used to test the effects of the intervention showed significant effects on perceived challenge associated with caregiver role, control by self, use of social support, and use of problem solving. Qualitative data demonstrate caregiver empowerment with respect to the caregiving role. This study illustrates the relevance of using a mixed research design in order to provide evidence for changes in practice.

The process of a group intervention for caregivers of demented persons living at home: conceptual framework, components, and characteristics

Most earlier group interventions for caregivers of demented persons lacked a theoretical basis to guide the intervention process and focused on providing information and practical advice and encouraging the expression of feelings. This article presents the process of a group intervention with emphasis on its conceptual framework, components and characteristics. As caregivers are exposed to numerous daily stressful demands, the intervention's conceptual framework was derived from Lazarus and Folkman's transactional theory of stress and coping and Folkman's Coping Effectiveness Training Program. The central aim of the intervention was to improve the ability of caregivers to cope with the stressful demands at the core of caring for a demented person, rather than to focus on information and the task-oriented aspects of caring. The two components of the intervention deal with the cognitive appraisal of stressors and coping strategies, with a view to determining which strategies are most appropriate on the basis of the changeability of stressors. Three coping strategies were proposed: problem solving (problem-focused coping to deal with changeable stressors), reframing (emotion-focused coping to manage the emotional response to unchangeable stressors), and seeking social support (problem- or emotion-focused coping). The most salient characteristics of this group intervention were its intensity (15 meetings) and its focus on the caregivers' daily reality, which provided concrete reference points for the discussion of conceptual notions.

Mental health, stress correlates and psychotropic drug use or non-use among aged caregivers to elders with dementia

The goal of the study was to compare caregivers who used psychotropic drugs with caregivers who were non-users in order to pinpoint differences in coping styles between the two groups. We performed a secondary analysis of a study on the stress and psychological well-being of persons caring for relatives with dementia. We compared elderly caregivers, as either psychotropic drug users (n = 61) or non-users (n = 133), over various psychosocial characteristics relating to the care-giving context. Results reveal that users, as compared to non-users were: (a) more disturbed (appraised a greater stress) by the relative's dysfunctional behaviours, after controlling for the frequency of the behaviours; and (b) experienced more conflict during interpersonal interactions, although their appraisal of self-satisfaction with formal and informal support to their care-giving activities did not differ significantly. Strikingly, users combined and called on a greater number of problem-focused and emotion-reducing coping strategies than did non-users. They more frequently used affective regulation and information seeking coping styles. Stress-related measures (especially stress appraisal and conflict) contributed more to the variation in mental distress of users than of non-users. Results provide a theoretical and empirical rationale for therapeutic interventions such as the cognitive behavioural approach.

COPE: towards a comprehensive assessment of caregiver need

Supporting family carers is a common policy objective across Europe. However, if appropriate help is to be provided there is a need for a sensitive assessment process. This article describes the COPE project, the purpose of which is to develop a first-stage assessment tool that can be used to identify carers requiring a further in-depth consideration of their support needs.

Is there a difference between family caregiving of institutionalized elders with or without dementia?

Based on the stress and coping model of Lazarus and Folkman, the aim of this comparative study was to determine whether the caregiving experience of the caregivers of an institutionalized demented relative is different from the one of the caregivers whose relative does not suffer from dementia. Five dimensions of the caregiving experience were considered: stressors, cognitive appraisal of the stressors, social support, coping strategies and well-being. The sample consisted of primary caregivers of a demented and a nondemented relative. Results revealed that the caregivers of a demented relative were exposed to more stressors than the caregivers of a nondemented relative. Functional impairment as well as depressive behaviors were appraised as more disturbing. According to MANCOVA analysis, formal and informal social support seems to play a protective role in the psychological distress of the caregivers of a demented relative. There was no difference between the two groups with regard to their coping strategies. Overall, the caregivers of a demented relative seemed to experience some dimensions of caregiving in a different way compared with their counterparts, and the nature of dementia in itself helps to explain this difference.

Empirical testing of a longitudinal model derived from the Roy adaptation model

This article presents the steps and results of the empirical testing of a theoretical longitudinal model, derived from Roy's nursing conceptual model, of the psychosocial determinants of adaptation in different target groups. The model was elaborated and empirically verified based on the integrated results of four longitudinal studies involving groups vulnerable to mental health problems. By means of structural equation analyses, the cross-sectional model was verified at two points in time. The results showed that the model was relatively stable over time. The model was also tested using longitudinal data. Results showed little consistency in the patterns of relationships across studies. The significant links that emerged from the analyses shed some light on the complexity of the process of adaptation to different types of stressors. They underscore the importance for nursing practice to develop interventions aimed at certain variables: perceived stress, conflicts in the exchange of support, and passive and avoidance coping strategies. The results also highlight the importance of the relationship between perceived stress, passive/avoidance coping strategies and psychological distress.

Depressive symptoms of Alzheimer caregivers are mainly due to personal rather than patient factors

OBJECTIVES

To investigate the predictors of caregiver's depressive symptoms in a sample of community-dwelling Alzheimer's patients.

DESIGN

A cross-sectional study was conducted in an Alzheimer's unit specifically devoted to the care of demented patients in Brescia Province (Italy). One hundred and three dyads were consecutively recruited between July 1994 and July 1995. Caregivers were sons/daughters (65%) or husbands/wives; mean age was 54.6 +/- 13.2. Alzheimer's patients Mini Mental State Examination score was 11.3 +/- 8.3; patients were equally distributed among disease severity levels. The following variables have been collected: (a) background and context variables (caregiver's age, gender, marital status, education, relationship and cohabitation with the patient, employment status, satisfaction with household income);(b) caregiver's personal resources (health, social relationships and social interactions, formal supports use, assistance and vigilance); (d) primary stressors (patient's age and gender, cognitive status, functional status, frequency of behavioural disturbances). Caregiver's depressive symptoms represented the main outcome measure.

RESULTS

Being husband or wife, low self-rated health and caregiving competence, high numbers of hours for assistance and patient's behavioural disturbances and younger age were associated caregiver's depressive symptoms. With multivariate analysis only relationship to the patient, caregiver's health and competence were independent predictors of caregiver's depressive symptoms.

CONCLUSION

Factors related to the caregiver--relationship, health and competence--rather than to the patient constitute the main risk factors for caregiver's depressive symptomatology.

Empirical verification of a theoretical model derived from the Roy adaptation model: findings from five studies

This article presents a theoretical model derived from the Roy adaptation model and the findings of an empirical verification of this model from five studies. Four groups of subjects were included in the studies: informal caregivers of demented relatives at home, informal caregivers of psychiatrically ill relatives at home, professional caregivers of elderly institutionalized patients, and aged spouses in the community. In at least three studies, a number of theoretical propositions derived from the Roy adaptation model were supported using LISREL VIII, thus adding credence to some tenets of Roy's model. Particularly, the focal stimulus of perceived stress, the contextual stimulus of conflicts in the exchange of social support, and one component of the coping mechanisms (the passive/avoidance coping strategies) were positively linked directly or indirectly with psychological distress, which is an indicator of adaptation in the self-concept mode. Given their importance, these elements should be considered in the development of a middle-range theory of psychological adaptation derived from the Roy adaptation model.