Marital quality in the context of mild cognitive impairment

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.

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.

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.

Hypnosis Intervention for Couples Confronted with Alzheimer’s Disease: Promising Results of a First Exploratory Study

Background: Dementia has a negative impact on the quality of life of the person with dementia and their spouse caregivers, as well as on the couple’s relationship, which can lead to high levels of distress for both partners. Hypnosis has been shown to be effective in managing distress and increasing the quality of the relationship. Objective: The aim was to develop a standardized hypnosis intervention for couples confronted with Alzheimer’s disease and evaluate its feasibility, acceptability, and helpfulness in managing the distress of both partners and increasing the quality of the relationship. Methods: In a single-arm study, sixteen couples received the 8-week intervention. Qualitative and quantitative assessments were conducted pre- and post-intervention as well as three months after. Results: 88.9% of couples (n = 16) of the final sample (n = 18) completed the intervention. Despite the negative representations of hypnosis, several factors led couples to accept to participate in this study: positive expectations, professional endorsement, medical application, non-drug approach, home-based, free, flexible, and couple-based intervention. The results showed a significant decrease in distress for both partners. These effects were maintained three months after the intervention. Couples felt more relaxed, had fewer negative emotions, accepted difficulties more easily, were more patient, and reported better communication and more affection in the relationship. Conclusion: Overall, this pilot study shows the feasibility and acceptability of hypnosis with couples confronted with Alzheimer’s disease. Although measures of the preliminary pre- and post-intervention effects are encouraging, confirmatory testing with a randomized controlled trial is needed.

The association between relationship strain and emotional well-being among older adult couples: the moderating role of social connectedness

OBJECTIVES

The present study examines the moderating role of social connectedness (i.e. closeness, talk frequency, social network size, and neighborhood social ties) in the association between one's own and spouse's relationship strain and emotional well-being (i.e. depressive symptoms, happiness, and loneliness).

METHOD

Married couples (N = 865) were drawn from the second wave of the National Social, Health, and Aging Project. One Actor Partner Interdependence Model (APIM) and one Actor Partner Interdependence Model with Moderation (APIMoM) were conducted.

RESULTS

In terms of actor effects, relationship strain was associated with all emotional well-being outcomes. Wives' and husbands' greater relationship strain was associated with spouses' loneliness. Only wives' greater relationship strain was associated with her husbands' higher level of depressive symptoms and no partner effects were found for happiness. In six instances, social connectedness factors helped to ameliorate the association between self/spouse relationship strain, depressive symptoms, and happiness. However, wives' greater neighborhood social ties amplified the association between wives greater relationship strain and husbands' greater depressive symptoms. We did not find that social connectedness factors moderated the associations between self/spouse relationship strain and loneliness.

CONCLUSION

Even in late life marriages, marital strain is associated with less happiness and greater depressive symptoms and loneliness. Practitioners addressing emotional well-being may need to pay attention to spousal perceptions of relationship strain and social relationships external to the marital relationship when working with heterosexual couples. Efforts throughout the life course should be made to ensure connections with diverse types of social networks.Supplemental data for this article is available online at https://doi.org/10.1080/13607863.2021.1910786.

Cognitive Functioning, Gender, and Marital Quality Among Older Married Couples: A Dyadic Approach

This study examines associations of older husbands' and wives' cognitive functioning with both partners' marital quality. Generalized structural equation modeling analyzed data from 1,432 opposite-sex couples drawn from the 2016 wave of the Health and Retirement Study. Findings revealed that wives' poorer cognitive functioning was associated with wives reporting greater closeness and enjoyment of time with a spouse, whereas husbands' poorer cognitive functioning was associated with wives reporting greater marital strain, lower marital support, lower closeness, and less enjoyment of time with a spouse. This suggests that cognitive functioning has dyadic consequences for marital quality, which are highly gendered.

Marriage and Post-stroke Aphasia: The Long-Time Effects of Group Therapy of Fluent and Non-fluent Aphasic Patients and Their Spouses

BACKGROUND

Studies of therapy influence on after-aphasia marital relations are lacking. Much needs to be learned about the range of factors associated with couples benefiting from therapy. Understanding these issues is key to facilitating optimal post-aphasia outcomes from the perspective of the patient and his caretaking spouse. This paper reports an evaluation of a group therapy intervention conducted with aphasic people and their life partners.

METHODS

The intervention comprised of 10 sessions of approximately 90 min duration and included two groups of couples, with fluent and non-fluent aphasic partner. The therapy program consisted of basic communication activities within the group which encouraged sharing of personal experience but mostly relied on psychoeducation, gaining knowledge about after-stroke aphasia. The respondents were interviewed and completed neuropsychological assessment. Quality of marriage was determined using Dyadic Adjustment Scale. Marital adjustment was measured twice, before intervention and after 6 months. Long-time effects of therapy included a significant mean difference in quality of marriage between therapy attendants and controls. Marital relationship decline seems to be worse amongst control subjects, who were not involved in any kind of psychological support. In spite of initial non-distressed relationship they report deterioration of their bond in half a year's time. We also showed changes in dynamics of quality of marriage during this time in all investigated groups. The implications of these findings for counseling services are discussed.

Behavioural issues in late life may be the precursor of dementia- A cross sectional evidence from memory clinic of AIIMS, India

Background

Mild Behavioural Impairment (MBI), an “at risk” state for incident cognitive declin, is characterized by late onset, sustained neuropsychiatric symptoms of any severity which cannot be accounted for by other formal medical and psychiatric nosology. There is no study related to MBI from India.

Methods and findings

In this cross-sectional observational study 124 subjects 60 years and above were recruited between March 2017 to October 2018, from memory clinic of department of Geriatric medicine with memory or behavioural complains. Subjects with major neurocognitive impairment (CDR score of 1 or more), major depressive disorder, generalized anxiety disorder and impaired activities of daily living (ADL) were excluded. Subjects with Mild Cognitive impairment (MCI) (CDR- 0.5), and Subjective cognitive impairment (SCI) (CDR- 0) were included. Neuropsychiatric Inventory Questionnaire (NPI-Q) was used to identify the presence of NPS. The ISTAART-MBI (International Society of Advance Alzheimer’s Research and Treatment-Alzheimer’s Association) diagnostic criteria was used to diagnose MBI. All the participants underwent a geriatric assessment using standardised screening. The objectives of this study was to determine the frequency of mild behavioural impairment (MBI), and its domains, in MCI or SCI and its association with comorbidities and geriatric syndromes. The mean age of the participants was 69.21, 71.77% (89) were male and 28.23% (35) were female. 41.13% (51) of these individuals were diagnosed with MBI. The MBI and non MBI group differed significantly in marital status, cognitive status and MCI subtype. The proportion of domains involved are as follows: decreased motivation 60.78%(31), emotional dysregulation 54.90% (28), impulse dyscontrol 68.63% (35), social inappropriateness 21.57%(11), abnormal perception 2 (3.93%). Presence of multi-morbidity, and diabetes, were statistically significant between the groups.

Conclusion

This study presents the first clinic-based prevalence estimates of MBI from Asia. Findings indicate a relatively high prevalence of MBI in predementia clinical states, impulse dyscontrol was the most commonly involved MBI domain. Multimorbidity, diabetes, urinary incontinence were other determinants of MBI.

Study of the Risk and Preventive Factors for Progress of Mild Cognitive Impairment to Dementia

OBJECTIVE

To evaluate the risk factors for progress of mild cognitive impairment to dementia.

METHODS

This study was based on the epidemiological survey in 2011 (No. PKJ2010-Y26) and contained 441 MCI individuals. Cognitive function was measured by the Mini-Mental Status Examination, clinical dementia rating, and montreal cognitive assessment. The association between demographic characteristics and MCI outcomes were evaluated using single-and multifactor ordered logistic regression analysis models.

RESULTS

Of the 441 MCI, 77 progressed to dementia (MCIp: 17.5%, 95% CI: 14.4%-21.6%), 356 remained stable (MCIs: 80.7%, 95% CI: 77.0%-88.4%), and 8 reverted to normal cognition (MCIr: 1.8%, 95% CI: 0.6%-3.0%) at follow-up in 2017. Univariate ordinal regression analysis showed that diabetes (P = .052), marriage (P = .028), worker (P = .069), and manager (P = .075) may be the risk factor for the status of MCI. Multiple ordinal regression results showed that diabetes (P = .049) and marriage (P = .04) significantly affected the cognitive function changes in the MCI patients.

CONCLUSION

Nondiabetics and being married may prevent the progression from MCI to dementia.

Characterizing the symptom of misplacing objects in people with dementia: findings from an online tracking tool

OBJECTIVES

Misplacing objects is often reported as a clinically important symptom in dementia. Here we explored misplacing objects in relation to dementia type and stage in an online sample of individuals with dementia and their caregivers.

METHODS

Participants were recruited from www.dementiaguide.com, a web-based tracker for common dementia symptoms. Users provided information about symptoms that they selected as important for monitoring. We analysed cross-sectional data from respondents who tracked at least three symptoms, which allowed for staging dementia severity.

RESULTS

Of 2,775 users with three-plus symptoms, 787 (28%) identified misplacing objects for symptom tracking. Misplacing objects was monitored by users across all stages of dementia, but was more prevalent in mild and severe dementia. Three common clinical subtypes of misplacing were investigated: lost & found (forgetting the location of items), hidden away (hiding items so others would not find them), and odd places (putting items in usual spots). Of the 787, 96% targeted lost & found, the most frequent type. Odd places (targeted in 56%) significantly increased with dementia severity (p < 0.001). Misplacing objects was most strongly associated with the symptoms of interaction with strangers (OR 4.60, 95% CI: 3.20-6.62), reading (3.68: 2.86-4.73), shopping (3.55: 2.73-4.61) and travel/vacationing (3.31: 2.54-4.31).

CONCLUSIONS

Misplacing objects was most often selected for tracking in mild and severe stages of dementia. As disease advances, misplacing more often reflects odd placement of objects rather than their simple loss. Misplacing objects may be a clinically important therapeutic target for improving patients' quality of life and lessening caregiver burden.

Facing the Challenges of Primary Progressive Aphasia: The Spousal Perspective

PURPOSE

Primary progressive aphasia (PPA) is a cognitive-neurodegenerative disorder. Little is known about the personal impact PPA has on those living with this condition, particularly from a spousal perspective. The aim of this qualitative study was to gain an understanding of the personal experiences of spouses living with a partner diagnosed with variant forms of PPA.

METHOD

Thirteen spouses whose partners were diagnosed with PPA participated in 1:1 semistructured, in-depth interviews to explore their lived experiences of this illness. Using a constructivist grounded theory approach, analysis moved through a process of data-driven open and focused coding for the identification of emergent categories, themes, and subthemes that captured the challenges faced by spouses while supporting their partners.

RESULTS

A constructivist grounded theory analysis of the interview data revealed an overarching theme of "facing the challenges of PPA" that captured the experience spouses encountered when living with a partner diagnosed with PPA. Four interdependent and overlapping themes that sat within this overarching theme included acknowledging disconnect in the spousal relationship, living the decline, readjusting sense of self, and getting on with living. Each of these core themes revealed how spouses dealt with the ongoing and evolving challenges of PPA, particularly concerning changing relational dynamics with their partner and adjusting their own self-conceptualization.

CONCLUSIONS

Greater understanding of the spousal experiences of PPA is crucial to the development of intervention to help sustain spouses' emotional and relational connections with their partner.

Social Cognition, Behaviour and Relationship Continuity in Dementia of the Alzheimer Type

Social cognition can be impaired in a range of neuro-degenerative conditions, yet the impact of these difficulties on behaviour and social relationships is not yet fully understood. This study assessed social cognition in 27 participants with Dementia of the Alzheimer Type (DAT) and their co-residing partners (N = 27) and explored the relationships between social cognition, cognitive ability, relationship continuity and behaviour following diagnosis. In line with previous research, participants with dementia scored lower on social cognition tasks compared to their partners. Behaviour changes such as apathy, disinhibition and agitation in participants with dementia were significantly related to relationship continuity; however, no significant associations were found with measures of social cognition. The results of this study are discussed within a therapeutic context and in line with current guidelines and policies.

Anxiety and depression symptoms among caregivers of care-recipients with subjective cognitive decline and cognitive impairment

Background

Caregivers of care-recipients with mild cognitive impairment (MCI) or dementia experience high caregiver burden; however, the psychiatric burden of caregivers of care-recipients with subjective cognitive decline (SCD) has not been investigated. We aimed to explore the prevalence of and risk factors for anxiety and depression symptoms among the caregivers of care-recipients with SCD and cognitive impairment.

Methods

The Hospital Anxiety and Depression Scale (HADS) was used to examine the anxiety and depression symptoms among the caregivers of 343 care-recipients (84 with SCD, 120 with MCI and 139 with dementia) treated at the Memory Clinic of Huashan Hospital in Shanghai, China from May 2012 to October 2014. A logistic regression was used to explore the factors associated with caregiver’s anxiety and depression symptoms.

Results

In total, 26.5 % of caregivers had anxiety symptoms, and 22.4 % had depression symptoms. Totals of 17.9, 30.0 and 28.8 % of caregivers of care-recipients with SCD, MCI or dementia, respectively, had anxiety symptoms (P = 0.1140), whereas 22.6, 24.2 and 20.9 %, respectively, had depression symptoms (P = 0.8165). The risk factors for caregiver’s anxiety symptoms were increased caregiver age as well as having care-recipients who were male, had higher Cohen Mansfield Agitation Inventory (CMAI) scores, and higher Geriatric Depression Scale (GDS) scores. The risk factors for caregiver’s depression symptoms were increased caregiver age as well as caring for care-recipients with MCI or SCD, those with lower Toronto Empathy Questionnaire (TEQ) scores, and those with higher GDS scores.

Conclusions

Caregivers of care-recipients with SCD showed the same level of depression symptoms as those of care-recipients with MCI. Caregiver’s depression and anxiety symptoms were associated with their care-recipients’ psychiatric and behavioral syndromes.

Relationship and stage of dementia differences in caregiver perspectives on the meaning of activity

Caregivers of persons living with dementia (PWD) taking cholinesterase inhibitors, who care 3 + h over three days/week, were interviewed. This study uses thematic content analysis to compare responses to the open-ended question “ What do you believe getting involved in activities outside the home means for someone with dementia?” in spouse ( n = 613) and adult–children ( n = 260) caregivers, and across mild ( n = 314) and moderate–severe stages ( n = 280). For adult–children caregivers, activity participation promotes independence in their parents. Spouses describe activity in the context of their relationship with the PWD, and the experience is framed around their continued social roles as a couple. Mild-stage caregivers report the difficulty and negative outcomes (e.g. frustration, stigma) of engaging in activity, while moderate–severe caregivers discuss activity as preserving abilities in PWD and providing connection to cohort. This may indicate areas for improved activity provision and support for spouse (i.e. emotional) and adult–children (i.e. resources) caregivers across dementia stages.

Spouses' experience of living with a partner diagnosed with a dementia: a synthesis of the qualitative research

BACKGROUND

The majority of people diagnosed with a dementia live at home with the support of their spouse. While this situation has advantages, it brings many challenges for the spouse, particularly dealing with the emotional impact of the behavioral changes associated with the dementia. A growing body of qualitative research has focused on understanding the spousal caregiver perspective of living with a partner diagnosed with dementia. The aim of this study was to complete a synthesis of the results of published qualitative studies that have explored the spousal experience.

METHOD

An electronic database search of Ovid Medline, CINAHL, EMBASE, and PsychINFO from January 1980 to September 2014 was conducted. Sixteen studies met the inclusion criteria. Verbatim quotes of the participant interview data derived from these studies were collated and a thematic analysis was conducted.

RESULTS

Synthesis of the published data revealed five major themes. The theme of "loss of partner" was central, and around this central experience spouses described various processes: acknowledging change, being in crisis, adapting and adjusting, accepting and moving forward.

CONCLUSIONS

These findings provide insights into the day-to-day adjustments and experiences of spousal caregivers whilst highlighting the importance of considering the impact of cognitive decline and dementia in a social-relational context.

Psychosis associated behavioral and psychological signs and symptoms in mild cognitive impairment and Alzheimer's dementia

OBJECTIVES

The aim of this study is to determine the prevalence of psychosis in mild cognitive impairment (MCI, Petersen's criteria) and patients with Alzheimer's dementia, and to characterize the associated behavioral and psychological signs and symptoms of dementia (BPSD).

METHOD

A cross-sectional analysis of baseline data from an ongoing, prospective, longitudinal study on BPSD was performed, including 270 MCI and 402 AD patients. BPSD assessment was performed through Middelheim Frontality Score (MFS), Behave-AD, Cohen-Mansfield Agitation Inventory (CMAI) and Cornell Scale for Depression in Dementia (CSDD). Psychosis was considered to be clinically relevant when delusions and/or hallucinations occurred at least once in the last two weeks prior to the BPSD assessment.

RESULTS

The prevalence of psychosis in AD (40%) was higher than in MCI (14%; p < 0.001). AD patients with psychosis showed more severe frontal lobe, BPSD, agitation and depressive symptoms (MFS, Behave-AD, CMAI and CSDD total scores), whereas MCI patients with psychosis only showed more severe frontal lobe and physically non-aggressive agitated behavior. In addition, only in psychotic AD patients, all BPSD and types of agitation were more severe compared to non-psychotic AD patients. Comparing MCI and AD patients, MCI patients with psychosis did not show more severe frontal lobe, behavioral and psychological (Behave-AD), depressive symptoms or agitation than AD patients without psychosis.

CONCLUSION

AD patients clearly display psychosis associated BPSD, whereas MCI patients only display more severe frontal lobe symptoms and physically non-aggressive agitated behavior, but also less pronounced than in AD.

Meaningful activity for persons with dementia: family caregiver perspectives

Dementia threatens the capacity to engage in activity, suggesting meaningful activity may be helpful for persons with dementia (PWDs). This study explores the concept of meaningful activity, as defined by caregivers of PWDs. Family caregivers of PWDs, who provide 3 hours of care over 3 days/week, were interviewed after 6 months of cholinesterase inhibitors (ChEIs) therapy. Caregiver responses (N = 906) to the open-ended question What do you believe getting involved in activities outside the home means for someone with dementia are assessed. The themes are analyzed in terms of content, frequency, co-occurrence, and dementia severity. Caregivers emphasize the benefits of social connectedness, physical health, and mental stimulation. Activity is also viewed as respite, difficult, and has no meaning for care recipient. The implications of activity for self- and social-identity in PWD and caregiver are discussed. The benefits of activity varied by stage of disease. This knowledge indicates areas for improved activity provision and health care support.

Agitation-associated behavioral symptoms in mild cognitive impairment and Alzheimer's dementia

OBJECTIVES

The aim of this study is to determine the prevalence of agitation in mild cognitive impairment (MCI, Petersen's criteria) and patients with Alzheimer's dementia (AD), and to characterize the associated behavioral symptoms.

METHOD

A cross-sectional analysis of baseline data from a prospective, longitudinal study on behavioral symptoms was performed, including 268 MCI and 393 AD patients. Behavioral assessment was performed through Middelheim Frontality Score (MFS), Behavioral Pathology in Alzheimer's Disease Rating Scale (Behave-AD) and Cornell Scale for Depression in Dementia (CSDD). Agitated behavior was considered to be clinically relevant when one or more items of the Cohen-Mansfield Agitation Inventory (CMAI) occurred at least once a week.

RESULTS

The prevalence of agitation in AD (76%) was higher than in MCI (60%; p < 0.001). Patients with agitation showed more severe frontal lobe, behavioral and depressive symptoms (MFS, Behave-AD and CSDD total scores). In agitated AD patients, all behavioral symptoms and types of agitation were more severe compared to non-agitated AD patients, but in agitated MCI patients only for diurnal rhythm disturbances. This resulted in more severe Behave-AD global scores in patients with agitation as compared to patients without agitation. Comparing MCI and AD patients, MCI patients with agitation showed more severe behavioral and depressive symptoms than AD patients without agitation. The structure of agitation in AD consisted of more aggressive and physically non-aggressive behavior than in MCI.

CONCLUSION

Frontal lobe, behavioral and depressive symptoms are more severe in MCI and AD patients with clinically relevant agitation as compared to patients without agitation. However, this association is less pronounced in MCI.

Adjustment, depression, and anxiety in mild cognitive impairment and early dementia: a systematic review of psychological intervention studies

BACKGROUND

Many people with mild cognitive impairment (MCI) or early dementia suffer from concomitant depression and anxiety disorders, which in some cases, may be related difficulties adjusting to their diagnosis and associated cognitive problems. Successful adjustment and alleviation of depression and anxiety symptoms in these people is of critical importance for quality of life and may also help prevent, or delay, further cognitive decline. A variety of psychosocial intervention approaches has been trialed with this group.

METHOD

The literature was systematically searched for community-based intervention studies that aim to improve depression, anxiety, or adjustment. Studies were included or excluded using a priori criteria. Once included, the quality of studies was evaluated using pre-set criteria.

RESULTS

Seventeen of 925 studies identified through literature databases and manual searches met the inclusion criteria. Of these, 16 were considered to be of at least "adequate quality." These included seven randomized controlled trials and eight pre-post studies. A diverse range of psychotherapeutic approaches, formats (individual or group), outcome measures, inclusion criteria, and cultural contexts were apparent, making comparisons between studies challenging.

CONCLUSIONS

Several studies have demonstrated positive findings in the treatment of depression in older adults with early dementia using problem solving and modified cognitive behavior therapy (CBT) approaches. Amongst the large range of approaches trialed to improve adjustment and quality of life for patients with MCI and early dementia, some approaches, such as modified CBT, have shown promise. There is a need for replication studies using more rigorous methodology before clear clinical recommendations can be made.

Sexuality and couple intimacy in dementia

PURPOSE OF REVIEW

The review assesses recent research and its impact on understanding of intimacy and sexuality in older adults with dementia.

RECENT FINDINGS

There is no universally accepted definition of inappropriate sexual behaviors (ISBs), but they have been divided into overt acts associated with increased libido and uninhibited sexual behaviors directed at oneself or other people. Couples affected by dementia frequently maintain physical intimacy. Nonintercourse intimate activities may be preferred over intercourse. Early therapeutic interventions may assist partners in modifying activities, behaviors, and expectations about the future of the relationship. Inappropriate sexual behaviors are commonly due to the disruption of interconnected brain structures. Trauma to the temporal lobes may lead to hypersexuality and ISB. Trauma to the limbic system can produce changes in sexual preference. Both temporal and frontotemporal dementias, or either of them, often present with socially and sexually inappropriate behaviors. Huntington's disease can exhibit hypersexuality, pedophilia, promiscuity, and marital infidelity. The involvement of the medial striatum of the basal ganglia in this disease explains the prevalence of ISB. There is no consensus regarding first-line pharmacotherapy for ISB. Little information is known about the adverse effects.

SUMMARY

Clinicians and society need to consider how dementia might affect physical intimacy.

The impact of early dementia diagnosis and intervention on informal caregivers

In the absence of disease modifying therapies for dementia, the question rises what the benefits are of an early dementia diagnosis for patients and their caregivers. This paper reviews the caregiver perspective in dementia and addresses the question what the consequences are of promoting earlier dementia diagnosis. An early diagnosis offers caregivers the opportunity to advance the process of adaptation to the caregiver role. Caregivers that are better able to adapt to the changes that characterize dementia, feel more competent to care and experience less psychological problems. However, drawbacks of an early diagnosis may outweigh the benefits if people are left with a diagnosis but little support. There is convincing evidence that multicomponent caregiver interventions in the mild to moderate dementia stages are effective to improve caregiver well-being and delay institutionalization. However, there still exist a gap between the improved possibilities to diagnose people in the predementia stage versus the scarce knowledge on intervention effects in this very early stage. This stresses the urgent need for more research on early caregiver interventions that enhance role adaptation and that include long-term follow-up and cost-effectiveness evaluation. Early interventions may help caregivers in anticipating and accepting the future care role and transitions, with the increased possibility that caregivers can still involve the patient in the decision making process. As levels of stress and burden are still low in the predementia stage it provides excellent opportunities to empower the resources of caregivers.

Behavioral symptoms in mild cognitive impairment as compared with Alzheimer's disease and healthy older adults

BACKGROUND

Mild cognitive impairment (MCI) is a clinical concept that categorizes subjects who are in an intermediate cognitive state between normal aging and dementia. The aim of this study is to characterize behavior in MCI compared with Alzheimer's disease (AD) and healthy older patients.

DESIGN

A cross-sectional analysis of baseline data from a prospective, longitudinal study on behavioral symptoms of dementia and MCI was performed. The study population consisted of 270 MCI, 402 AD patients, and 108 healthy controls. Behavioral assessment was performed by means of Middelheim Frontality Score, Behavioral Pathology in Alzheimer's Disease Rating Scale, Cohen-Mansfield Agitation Inventory, and Cornell Scale for Depression in Dementia.

RESULTS

Moderate-to-severe behavioral symptoms were present in 13% of MCI patients, as compared with 39% in AD patients and 3% in controls (p < 0.001). The general severity of behavioral symptoms was intermediate between controls and AD patients. The three most frequent symptoms in MCI patients were aggressiveness (49%), affective disturbance (45%), and anxiety (38%); in AD patients, the most frequent symptoms were aggressiveness (60%), activity disturbances (54%), and psychosis (40%). The prevalence and severity of frontal lobe symptoms, aggressiveness, activity disturbances, and delusions was intermediate between normal aging and AD. In addition, the severity of physically non-aggressive and verbally agitated behavior and the severity of depressive symptoms were also intermediate.

CONCLUSIONS

The behavioral profile of MCI patients is characterized as an intermediate state between normal aging and AD for the prevalence and severity of certain behavioral symptoms. Follow-up is ongoing to test the hypothesis that behavioral disturbances in MCI predict progression to dementia.

Community-dwelling older adults with memory loss: needs assessment

OBJECTIVE

To identify the health-related needs of community-dwelling older adults with mild memory loss.

DESIGN

Qualitative study using semistructured, audiotaped, face-to-face interviews and focus groups.

SETTING

A large community in Newfoundland.

PARTICIPANTS

Twenty-two adults between the ages of 58 and 80 years.

METHODS

This needs assessment used a qualitative methodology of collecting and analyzing narrative data to develop an understanding of the issues, resources, and constraints of community-dwelling older adults with mild memory loss. Data were collected through semistructured, audiotaped, face-to-face interviews and focus groups. Transcripts of the interviews were analyzed using interpretive phenomenologic analysis.

MAIN FINDINGS

Three constitutive patterns with relational themes and subthemes were identified: forgetting and remembering, normalizing yet questioning, and having limited knowledge of resources. Participants described many examples of how their daily lives were affected by forgetfulness. They had very little knowledge of resources that provided information or support. Most of the participants believed they could not discuss their memory problems with their family doctors.

CONCLUSION

It is important for older adults with mild memory loss to have access to resources that will assist them in understanding their condition and make them feel supported.

Predictors of comprehensive stimulation program efficacy in patients with cognitive impairment. Clinical practice recommendations

BACKGROUND

The aim of the present study was to identify which factors may predict the best response to a comprehensive stimulation program in patients with dementia and mild cognitive impairment (MCI) as well as in their caregivers.

METHODS

A six-month longitudinal study has been performed on 145 patients (55 with MCI and 90 with dementia), participating to a cognitive motor rehabilitation program, and their 131 caregivers, attending informational/psychoeducational interventions. Mini mental state examination, Alzheimer's Disease Assessment Scale-Cognition, and Clinician's Interview-Based Impression of Change-plus were used as primary outcome measures.

RESULTS

Sixty-eight (46.9%) of the 145 subjects were classified as clinical responders. At baseline, responders had a significant less insight impairment, larger functional ability as well as less delusions, euphoria, and aberrant motor behaviors than the non-responder. After 6 months along with an improvement in cognition, responders showed decrease in behavioral disturbances and severity of the disturbances. During the 6 months of analysis, stability has been observed in caregiver's burden distress. After 6 months, the caregivers of MCI responders have their burden reduced.

CONCLUSIONS

The high level of insight, the preserved functional abilities as well as the lack of severe delusions, euphoria, and aberrant motor behaviors are significant predictors of responsiveness to stimulation program.

Making sense of nonsense: experiences of mild cognitive impairment

Alzheimer's disease (AD) is a stigmatised condition popularly assumed to be a death sentence for diagnosed individuals. Consequently, people with AD are often deemed incapable (and perhaps unworthy) of contributing to the social discourse surrounding their illness experience. Data from qualitative interviews with 18 people diagnosed with the potential precursor of AD known as mild cognitive impairment (MCI) are examined. Using grounded theory methods, analysis revealed overarching themes of uncertainty concerning definitions of memory loss, MCI, and AD as well as distinctions between normal ageing and dementia. While this confusion over the terminology and prognosis mirrors the lack of scientific consensus about nosology and appropriate treatment regimens, such ambiguity creates social and psychological tensions for diagnosed individuals. Arguably, participants' unequivocal fear of and subsequent desire to differentiate their experiences from Alzheimer's, however, stems from the exclusively negative social constructions of AD. Drawing from Goffman, these findings demonstrate the psychosocial impact of 'framing contests' and how 'courtesy stigma' can apply not only to associated persons but also associated conditions, such as MCI to AD. Given the underlying nosological creep - or medicalisation - of the recent diagnostic guidelines proposing two new pre-dementia stages, understanding the illness narratives of MCI is critical.

Locke-Wallace Short Marital-Adjustment Test: Psychometric Evaluation in Caregivers for Persons With Primary Malignant Brain Tumor

Background and Purpose: Caregivers’ well-being has been found to be associated with marital adjustment. This study’s purpose was to evaluate the psychometric properties of the Locke-Wallace Short Marital-Adjustment Test (LWSMAT) in a sample of caregivers of persons with primary malignant brain tumor (PMBT). Methods: Secondary analysis of data collected from 114 caregivers. The LWSMAT was tested for factor structure, internal consistency reliability, and construct validity. Results: 5 extracted factors explained 60.55% of the total variance. Four interpretable factors (Contentment & Communication, Leisure & Sociality, Intimacy, and Shared Philosophy) had Cronbach’s alpha between 0.63 and 0.74. Convergent validity (r = −.35 and r = −.43, respectively, both p < .0001) and discriminant validity (r = .07, p = .49; and r = −.04, p = .67) were confirmed by comparing four factors with subdimensions of the Caregiver Reaction Assessment (CRA). Conclusion: The LWSMAT is a multidimensional, reliable, and valid measure of marital adjustment in caregivers of persons with a PMBT.

Negotiating the joint career: couples adapting to Alzheimer's and aging in place

To understand the impact of memory loss on aging in place, this paper investigated dyads where one spouse had been diagnosed with memory loss. In-depth qualitative interviews were conducted with ten couples (N = 20). Grounded theory methods were used to collect, code, and analyze data into themes. Data revealed consensus among and between dyads that it was best to focus on living, rather than what had been or might someday be lost. Nonetheless, differences according to gender and cognitive status (e.g., diagnosed or spouse) were reported. Given population aging, identifying the impact of gender roles and social norms on the potential for aging in place with memory loss is critical. Community services and care practices must be sensitive to the ways that couples prioritized and organized their relationship prior to diagnosis in order to encourage positive patterns of care between couples, foster successful adaptation to changing needs, and support in-home arrangements as long as possible.

Content validity and acceptability of the daily enhancement of meaningful activity program: intervention for mild cognitive impairment patient-spouse dyads

Persons with mild cognitive impairment (PwMCI) are at greater risk for developing Alzheimer disease and experience various difficulties that decrease their quality of life. Very few interventions focus on helping PwMCI improve or maintain functional performance and enhance quality of life through meaningful activity engagement. The purpose of the study was to explore PwMCI and their spouses' perspectives on the content validity, usefulness, and acceptability of the Daily Enhancement of Meaningful Activity (DEMA) program, which included 6 biweekly face-to-face sessions between session assignments and a self-management tool kit of written educational handouts. Nine PwMCI-care partner dyads participated in 3 focus groups (PwMCI alone, spouses alone, and couples) to capture their perspectives on DEMA. The transcribed focus group data were analyzed through content analysis. The three groups provided support for content validity and acceptability of the program, and they suggested additional content areas important to couples experiencing MCI. They also attested to the usefulness of the tool kit and gave suggestions for its further improvement. The findings provide evidence of the content validity and acceptability of the DEMA program. A pilot study to assess feasibility and preliminary efficacy of the DEMA on health-related outcomes is the recommended next research step for this program.

Family triad perceptions of mild cognitive impairment

OBJECTIVES

We examined subjective perceptions of memory loss among older adults with mild cognitive impairment (MCI) and two other relatives in order to improve understanding of family coping. We also investigated contextual conditions associated with perceptions of family dynamics and relationships.

METHOD

We conducted interviews with 56 family triads (the elder with MCI, the primary care partner, and a secondary care partner). Guided by Pearlin and colleagues' caregiving stress process framework, questions addressed perceptions of memory changes and interpretation of the effects of MCI on family interaction patterns.

RESULTS

Analyses of family triads revealed four degrees of the extent to which family members similarly acknowledged elders' MCI. The acknowledgment groups differed on history of family dynamics, experience with dementia, and perceived extent of memory change in the elder. Families characterized by full acknowledgment coped better with perceived changes in the elder's functioning than those in which members' perceptions of MCI were incongruent.

DISCUSSION

Pursuing family-level data on responses to MCI uncovered more nuanced reactions, often differing across triad members, than individual-based research has found. Family perceptions about changes in elders' memory have important implications for within-family interactions and support that can help families cope successfully with MCI.

Spousal relationships in which one partner has early cognitive problems

The purpose of this literature review was to get an overview about the research on lived experiences of elderly spousal dyads, in which one partner has early cognitive problems.

Couples might first experience forgetfulness as something normal for old age. If symptoms become too great, the dyad will go and search for meaning. Through medical assessment the affected spouse will be diagnosed as either non-demented or demented. Both situations are experienced as hard and worrisome. However, if diagnosed with non-dementia, the dyad remains confused about what is going on and how to anticipate the future. In spite of the enormous impact of early cognitive problems on the relationship, both partners are still able to contribute to the quality of it and seem to have few reciprocity issues. How couples are different and what this means for the experience of early cognitive problems remains largely unexplored.

Trajectories of care: spouses coping with changes related to mild cognitive impairment

Mild cognitive impairment (MCI) refers to non-normative changes in memory and cognition. While researchers are beginning to address the social consequences of MCI, no investigations have tracked how married couples respond to MCI over time as symptoms stabilize or become more severe. Guided by life course and symbolic interactionist tenets, we examined how 40 older couples in the United States adjusted to daily life after one partner was diagnosed with MCI and how their marital roles and relationship changed over a three- to four-year period. Data were collected from 2004 through 2010. All couples experienced an initial period of transition in coping with MCI where they made adjustments in their daily lives and interactions. Following this adjustment period, four trajectories of care emerged depending on the extent of the older adult's decline and the spouse's response. We conclude that changes associated with MCI affect role identity and have consequences for spousal relationships.

Couple meaning-making and dementia: challenges to the deficit model

By combining a relationship- and strengths-based approach, the article suggests that, with the onset of progressive cognitive impairment, verbal, nonverbal, and embodied exchanges can function as meaning-making processes for life-partner co-carers. These exchanges can sustain a sense of relatedness, which has been shown to increase wellbeing. The article identifies gaps in knowledge and practice limitations that result from the deficit approach to dementia research and care that currently dominates the field. Suggestions for future research and the development of interventions are included. In addition, the article challenges theoretical assumptions about meaning-making, arguing for a reexamination of dementia-affected couplehood processes.

Ethnic Minority Status, Depression, and Cognitive Failures in Relation to Marital Adjustment in Ethnically Diverse Older Women

The authors investigated the relationship between marital adjustment and ethnic minority status, depressive symptomatology, and cognitive failures among 78 married, community-dwelling, and predominantly non-European-American older women (ages 57-89). Respondents were screened to rule out dementia. Level of depressive symptoms, self-report of cognitive failures, and marital adjustment were obtained. As hypothesized, higher depressive symptomatology and cognitive failures were associated with worse marital adjustment (p < .05 for both). The same was true for membership in a non-dominant ethnic group, albeit only when ethnic status was considered outside the context of the other two independent variables. These results have clinical implications and fit within the theoretical framework of the socioemotional selectivity theory (Carstensen, 1992) applied to marriage in older age, a conceptualization formulated by Bookwala and Jacobs in 2004.

Process of ambivalent normalisation: experience of family caregivers of elders with mild cognitive impairment in Taiwan

AIMS AND OBJECTIVES

To conceptualise the caregiving process in Taiwanese families caring for elders with mild cognitive impairment.

BACKGROUND

Family caregivers play an essential role in the lives of elders with mild cognitive impairment by dealing with their cognitive status and daily function. Little is known, however, about the development of the caregiving trajectory, particularly in Asian countries.

DESIGN AND METHODS

Grounded theory methodology was used. Data were collected via in-depth interviews with 10 family caregivers of patients with mild cognitive impairment and living at home in northern Taiwan. Data were analysed by constant comparative analysis.

RESULTS

The process most used by family caregivers to adjust to conflicts and changes in relationships with elders with mild cognitive impairment was 'ambivalent normalisation'. This dynamic process included three components: subtle changes, optimistic appraisal and ambivalent anticipation. Family caregivers who had developed this process were more likely to adopt multiple effective behavioural approaches to avoid conflict in their daily life and to begin outlining future caregiving tasks.

CONCLUSIONS

The process of ambivalent normalisation can sensitise healthcare providers to family caregivers' needs and provide a basis for developing frameworks for future substantive theory and possible future research.

RELEVANCE TO CLINICAL PRACTICE

This study's findings may help healthcare providers understand family caregivers' needs and effective patterns for taking care of elders with mild cognitive impairment. Interventions can be developed to facilitate family caregivers' awareness of the changes in their loved one in the initial stage of diagnosis and adopt multiple effective strategies to prevent conflicts in their lives. Healthcare providers can actively examine the cognitive function of older people in general outpatient departments, provide well-timed treatments and minimise caregiver burden.

The impact of dementia and mild memory impairment (MMI) on intimacy and sexuality in spousal relationships

BACKGROUND

Sexuality and intimacy in couples in which one partner is affected by dementia has been widely researched. Few studies have explored these issues in couples where one partner is affected by mild memory impairment (MMI) or mild cognitive impairment (MCI). The objectives of this study were to (1) identify and contrast issues of intimacy and sexuality that spousal caregivers of persons with MMI and dementia may experience, and (2) identify future lines of research in this population.

METHODS

Fourteen dementia and nine MMI spousal caregivers participated in focus groups conducted between 2008 and 2009 at the Stanford/VA Alzheimer's Research Center. Content analyses were conducted to identify themes.

RESULTS

Five themes emerged: communication, marital cohesion, affectional expression, caregiver burden, and ambiguity concerning the future of the relationship. Dementia caregivers reported more difficulties with communication, cohesion, and perceptions of increased burden than their MMI counterparts. Both groups indicated reduced sexual expression due to physical limitations; substitute activities including hand-holding, massaging, and hugging were noted. Both groups reported difficulty anticipating the future of the relationship due to present stressors. While dementia caregivers could consider future romantic relationships with others, MMI caregivers were primarily able to consider future relationships only for companionship and emotional intimacy.

CONCLUSION

Early therapeutic interventions may assist couples in modifying activities, behaviors, and expectations about the future of the relationship. Such modifications may help maintain relationship satisfaction, decrease burden, preserve quality of life, and delay time-to-placement. Extending time-to-placement could have cost savings implications for families and the healthcare system.

[Caregiver burden with dementia patients. A validation study of the German language version of the Zarit Burden Interview]

Despite the large number of studies dealing with dementia caregivers in Europe, a valid German version of the most widely used measurement of caregiver burden, the Zarit Burden Interview, has not been published. The purpose of this study was to evaluate the psychometric properties of the German Zarit Burden Interview (G-ZBI). A sample of community-dwelling older couples (n=37) with the husband suffering from dementia and the wife being the primary caregiver participated in this study. The G-ZBI and related constructs were assessed in order to test for reliability and construct validity. The G-ZBI revealed psychometric properties comparable with those of the original instrument and empirically validated translations. Results indicate high internal consistency (Cronbach's alpha=0.91) and good validity due to strong correlations with caregiver life satisfaction and depression, as well as patients' dependency, neuropsychiatric symptoms, and dementia severity. The psychometric qualities of the G-ZBI indicate that it is both a reliable and valid instrument to assess caregiver burden and to detect highly stressed individuals.

Experience and perspectives of caregivers of spouse with mild cognitive impairment

The purpose of this paper is to describe commonalities of the lived experience of being a spouse caregiver of a person with mild cognitive impairment (MCI). The Colaizzi method of empirical phenomenology was used for inter-viewing and analyzing data obtained from 10 spouse caregivers of persons with MCI. Four major themes were found and labeled: (a) Putting the Puzzle Pieces Together-There Really is Something Wrong; (b) A Downward Spiral into a World of Silence; (c) Consequences to Caregivers of Living in a World of Silence; (d) Taking Charge of Care. The findings of this study provided rich data to guide interventions to help caregivers to improve their awareness of MCI, gain new information and skills to deal more effectively with and adjust to the caregiving of their spouse with MCI over the long-term.

Stress affects carers before patient's first visit to a memory clinic

OBJECTIVE

To measure and compare the burden on spousal carers of patients with and without dementia who were consulting a memory clinic for the first time.

METHODS

We included 413 dyads of patients and their spousal carers consulting a memory clinic for the first time. Of them 276 had a diagnosis of Cognitive Impairment No Dementia (CIND) and 137 had a dementia diagnosis. The burden of care was measured with the Relative Stress Scale (RSS). The gender of patients and their spouses was recorded and measures of cognition, depression and functional capacity of the patients were included in the analysis.

RESULTS

Of all carers, 27.6% had a score on the RSS of above 23, indicating a moderate to severe burden. The corresponding score for carers of patients with CIND was 20.3%, compared to 42.2% for those with dementia. However, in a linear regression analysis with RSS as the dependent variable, the dementia diagnosis variable was not significant. Three variables were significant (p < 0.05) and has explained 34% of the variance of the score on the RSS, impaired function in activities of daily living (ADL) was the most important variable (beta 0.56), followed by female gender of carers (beta 0.19) and the extent of the symptoms of depression observed in the patients (beta 0.10).

CONCLUSION

Carers of both CIND and dementia patients when attending a memory clinic for initial diagnostic assessment experience high levels of stress. Impaired function in ADL in patients is the strongest predictor of this stress.

Diagnostic labels, stigma, and participation in research related to dementia and mild cognitive impairment

Health care professionals use diagnostic labels to classify individuals for both treatment and research purposes. Despite their clear benefits, diagnostic labels also serve as cues that activate stigma and stereotypes. Stigma associated with the diagnostic labels of dementia and mild cognitive impairment (MCI) can have a significant and negative impact on interpersonal relationships, interactions with the health care community, attitudes about service utilization, and participation in clinical research. The impact of stigma also extends to the family caregivers of individuals bearing such labels. In this article, we use examples from our investigations of individuals with dementia or MCI and their family caregivers to examine the impact of labeling and stigma on clinical research participation. We also discuss how stigma can affect numerous aspects of the nursing research process. Strategies are presented for addressing stigma-related barriers to participation in clinical research on dementia and MCI.