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Mason SL, Barker RA, Andresen K, Gracey F, Ford C. The meaning of apathy in Huntington's disease: A qualitative study of caregiver perspectives. Neuropsychol Rehabil 2024:1-30. [PMID: 39102382 DOI: 10.1080/09602011.2024.2384519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 07/21/2024] [Indexed: 08/07/2024]
Abstract
Although one of the most prevalent and impactful features of Huntington's disease (HD), little is known about the impact of apathy on HD caregivers, although there is evidence it affects perceptions of distress and burden. Given the importance of the caregivers, we aimed to explore the lived experience of people supporting someone with HD and associated apathy. Semi-structured interviews were conducted with 11 caregivers and analysed using reflective thematic analysis, informed by a phenomenological framework. Five overarching themes were produced: (1) What even is apathy? (2) It makes my life harder: the practical impact of apathy, (3) They haven't forgotten me, but they have forgotten that they ever loved me, (4) I'm grieving for someone who hasn't died yet, and (5) I need a safe space to say what I really feel without fear of judgement. Inter-woven between these themes were complex narratives about the unspoken nature of HD, the invisibility of caregivers who felt trapped and unheard, and the one-sided nature of loving someone with the disease. Findings are discussed in relation to theoretical frameworks of anticipatory grief and ambiguous loss, and situated within the wider literature on caregiving for people with a neurodegenerative condition.
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Affiliation(s)
- Sarah Louise Mason
- Department of Clinical Psychology and Psychological Therapies, University of East Anglia, Norwich, UK
| | - Roger Alistair Barker
- Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK
- NIHR Biomedical Research Centre, Cambridge University Hospitals Foundation Trust, Addenbrookes Hospital, Cambridge, UK
| | - Katie Andresen
- Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK
| | - Fergus Gracey
- Department of Clinical Psychology and Psychological Therapies, University of East Anglia, Norwich, UK
| | - Catherine Ford
- Department of Clinical Psychology and Psychological Therapies, University of East Anglia, Norwich, UK
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2
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Ng YH, Jiao K, Suen MHP, Wang J, Chow AYM. The role of the social environment on dementia caregivers' pre-death grief: A mixed- methods systematic review. DEATH STUDIES 2024:1-20. [PMID: 38497324 DOI: 10.1080/07481187.2024.2329755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
This systematic review examined the role of social environment in pre-death grief experiences of dementia caregivers. Ninety-three Chinese and English articles were included from a comprehensive search of empirical studies using nine databases. Six social environment domains were generated: the person with dementia, dyadic relationship, family members and the wider community, health and social care services, place of care, and social-cultural contexts. A complex interplay between caregivers and their social environments that aggravate and attenuate pre-death grief experiences is evident. Research has focused mainly on the effects of people with dementia and dyadic relationships and has paid modest attention to the effects of family, relatives, and health and social care services. Caregivers' experiences with their friends, fellow caregivers, the wider community, and social-cultural norms are influential but understudied. Future research could adopt a systems thinking approach with sociological perspectives to generate a comprehensive and nuanced understanding of pre-death grief experiences.
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Affiliation(s)
- Yong Hao Ng
- Department of Social Work and Social Administration, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Keyuan Jiao
- Department of Social Work and Social Administration, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Margaret H P Suen
- Department of Social Work and Social Administration, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Juan Wang
- Department of Social Work and Social Administration, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Amy Y M Chow
- Department of Social Work and Social Administration, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
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Abstract
In this article, I address the experiences of family members of people with dementia, as they expressed the sensation of gradually losing the person with dementia. Based on ethnographic fieldwork in nursing homes in the Netherlands, and contributing to the anthropology of grief, I explore the co-existence of experiences of anticipatory grief and manifestations of care to maintain meaningful relations. I show how my interlocutors adapted to changing circumstances as the disease progressed, and in so doing found new ways to relate, as well as prepared for future losses and the expected end of life. I argue that anticipatory grief is temporal and relational, encompassing both present and future losses, and involving a continuous negotiation between the loss and the continuing relationship. I underscore the entanglement of loss and connection, showing how both exist parallel to, and may emerge from one another, and demonstrating how an anthropological approach to anticipatory grief can reveal the nuanced and equivocal character of experiences of illness and at the end of life.
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Affiliation(s)
- Natashe Lemos Dekker
- Institute of Cultural Anthropology and Development Sociology, Leiden University, Wassenaarseweg 52, 2333 AK, Leiden, The Netherlands.
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Paulson D, McClure N, Wharton T, Gendron E, Allen Q, Irfan H. Caregiver Preparedness: A Therapeutic Mechanism and Moderating Factor on Outcomes for the Savvy Caregiver Program. Clin Gerontol 2023:1-15. [PMID: 37530457 PMCID: PMC10834848 DOI: 10.1080/07317115.2023.2242357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
OBJECTIVES Evidence-based interventions for dementia caregivers, such as the Savvy Caregiver Program (SC), seek to address skills and knowledge deficits, caregiver burden, depressive symptoms, and grief. Little research has examined mechanisms by which these interventions accomplish their goals. Caregiver preparedness may be a possible mechanism by which caregiver interventions may confer benefits. METHODS The sample included 76 dementia caregivers who completed the 6-session SC. Participants completed the Anticipatory Grief Scale, Center for Epidemiological Studies-Depression Scale, the Preparedness for Caregiving Scale, and the Zarit Burden Interview-Short Form. RESULTS A repeated measures ANOVA was utilized to determine the interaction between baseline scores and pre-post change in caregiver preparedness. Analysis significantly predicted caregiver burden, (F(1) = 6.68, p=.012, partial η2=.10), depressive symptom endorsement, (F(1) = 6.41, p=.014, partial η2=.09, and anticipatory grief, (F(1) = 6.22, p=.02, partial η2=.1), post-treatment. CONCLUSIONS Pre-post change in caregiver preparedness significantly predicted pre-post change across measures of caregiver burden, depressive symptom endorsement, and anticipatory grief. Findings suggest that caregiver preparedness may be one mechanism by which the SC confers positive outcomes. These findings provide an empirical and theoretical basis for tailoring future dementia caregiver interventions. CLINICAL IMPLICATIONS Clinical Interventions may seek to improve caregiver preparedness and subsequent outcomes through utilization of programs like SC.
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Affiliation(s)
- Daniel Paulson
- Department of Psychology, University of Central Florida, Alzheimer's and Dementia Resource Center, Orlando, Florida, USA
| | - Nicole McClure
- Department of Psychology, University of Central Florida, Orlando, Florida, USA
| | - Tracy Wharton
- Principal Research Scientist, National Network of Public Health Institutes, Washington, USA
| | - Edith Gendron
- Chief Operating Officer of ADRC, Winter Park, Florida, USA
| | - Quinn Allen
- Psychology, University of Central Florida, Orlando, USA
| | - Hanya Irfan
- Health Sciences, University of Central Florida, Orlando, USA
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Ziebuhr B, Zanasi M, Bueno Aguado Y, Losada Durán R, Dening T, Tournier I, Niedderer K, Diaz A, Druschke D, Almeida R, Holthoff-Detto V. Living Well with Dementia: Feeling Empowered through Interaction with Their Social Environment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6080. [PMID: 37372667 DOI: 10.3390/ijerph20126080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/26/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023]
Abstract
This study was designed to advance our understanding of how feelings of empowerment in people living with dementia still residing at home can be promoted. We conducted qualitative interviews with 12 participants with mild-to-moderate stages of dementia in Germany and Spain as part of a European study on mindful design for dementia. A qualitative thematic content analysis was performed to elicit the key features of the experience reported by the interviewees. Three overarching categories were identified: the first category 'experiencing changes in personal life and coping with changes in life' covered losses and coping strategies; the second category 'retaining a sense of usefulness' included social participation and the need for activities with others; the third category 'feeling empowered' covered reflections on lifetime achievements, accomplishments in the present life, being in control and self-worth. Participants placed a strong emphasis on continuity and on the importance of making active decisions and meaningful social contributions. Empowerment within the person living with dementia was achieved through their interactions with their social environment, including the significance of communication about their needs and wishes and enabling shared decision-making and interactions with others in reciprocity.
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Affiliation(s)
- Berit Ziebuhr
- St. Hedwig Kliniken Berlin, Alexianer Krankenhaus Hedwigshoehe, Berlin 12526, Germany
| | - Michele Zanasi
- St. Hedwig Kliniken Berlin, Alexianer Krankenhaus Hedwigshoehe, Berlin 12526, Germany
| | | | | | - Tom Dening
- Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham NG7 2TU, UK
| | - Isabelle Tournier
- Department of Design, Manchester School of Art, Manchester Metropolitan University, Manchester M15 6BR, UK
- Department of Psychology, Laboratoire Cliniques Pathologique et Interculturelle, Université Toulouse 2 Jean Jaurès, 31058 Toulouse, France
| | - Kristina Niedderer
- Department of Design, Manchester School of Art, Manchester Metropolitan University, Manchester M15 6BR, UK
| | - Ana Diaz
- Alzheimer Europe, 1417 Luxembourg, Luxembourg
| | - Diana Druschke
- Center for Evidence-Based Healthcare, University Hospital Carl Gustav Carus, Carl Gustav Carus Faculty of Medicine, University of Technology Dresden, 01307 Dresden, Germany
| | - Rosa Almeida
- Fundación INTRAS, RDi Projects Department, 47016 Valladolid, Spain
| | - Vjera Holthoff-Detto
- St. Hedwig Kliniken Berlin, Alexianer Krankenhaus Hedwigshoehe, Berlin 12526, Germany
- Department of Psychiatry and Psychotherapy, Carl Gustav Carus Faculty of Medicine, University of Technology Dresden, Alexianer Krankenhaus Hedwigshoehe, 12526 Berlin, Germany
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Cimino V, Chisari CG, Toscano S, Patti F. Palliative care in multiple sclerosis. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:129-138. [PMID: 36599504 DOI: 10.1016/b978-0-12-824535-4.00009-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Main target in palliative care (PC) is burden care of patients and their families, with the aim to reduce suffering through the management of symptoms, rehabilitation, psychosocial issues, and spiritual well-being, using a multidisciplinary approach. Multiple sclerosis (MS) is a chronic disease which induces physical and psychosocial symptoms, with a significant impact on the quality of life. As a consequence, despite advances in research in disease-modifying drugs, MS remains a life-limiting disease with symptoms negatively impacting the lives of MS patients and their families. PC has been developed for end-of-life treatment in oncology, being little used in MS. Specific issues in MS, like pain due to spasticity, requires a different approach respect to cancer pain management. Moreover, it is difficult to anticipate life expectancy in people with severe MS, who often need palliative care for a long extended period. PC teams are trained to keep open full and competent lines of communication about symptoms and disease progression, advanced care planning, and end-of-life issues and wishes. Many studies investigated the effects of home-based PC in advanced MS, showing weak evidences about the efficacy of PC versus usual care in MS. However, current evidence does not support or refute the routine use of PC interventions for people with MS.
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Affiliation(s)
- Vincenzo Cimino
- Rehabilitation Division, Centro Neurolesi "Bonino Pulejo", IRCSS, Messina, Italy
| | - Clara Grazia Chisari
- Department G.F. Ingrassia, Section of Neuroscience, University of Catania, Catania, Italy
| | - Simona Toscano
- Department G.F. Ingrassia, Section of Neuroscience, University of Catania, Catania, Italy
| | - Francesco Patti
- Department G.F. Ingrassia, Section of Neuroscience, University of Catania, Catania, Italy.
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Dehpour T, Koffman J. Assessment of anticipatory grief in informal caregivers of dependants with dementia: a systematic review. Aging Ment Health 2023; 27:110-123. [PMID: 35168426 DOI: 10.1080/13607863.2022.2032599] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Informal caregivers of dependants with dementia commence their bereavement experience long before the physical death of their dependant, a process referred to as "anticipatory grief". This represents an ambiguous state that has been acknowledged as a measurable variable among informal caregivers. The use of assessment tools for the identification of anticipatory grief is important for timely intervention to promote well-being and positive bereavement experiences. The aim of this systematic review is to identify and examine existing tools for assessing anticipatory grief among caregivers of dependants with dementia. METHODS MEDLINE, EMBASE, PsychINFO, CINAHL and Web of Science were searched to July 2021. Studies focusing on the development/evaluation of instruments for measuring anticipatory grief in dementia caregivers were eligible. The quality of each measurement was graded as positive, fair, poor or no information based on defined criteria. RESULTS 100 studies were identified. 33 papers were selected for full-text assessment and 12 papers met the eligibility criteria. Seven assessment tools were identified for measurement of pre-death grief caregivers - the Anticipatory Grief Scale (AGS), Marwit-Meuser Caregiver Grief Inventory (MM-CGI), MM-CGI-short-form (MM-CGI-SF), MM-CGI-brief (MM-CGI-BF), Prolonged Grief Scale (PG-12), Caregiver Grief Scale (CGS) and Caregiver Grief Questionnaire (CGQ). Based on content/construct validity, internal consistency and test-retest reliability the MM-CGI/MM-CGI-SF scored highest for quality followed by the CGS. CONCLUSION Anticipatory grief in dementia has multiple facets that can be measured using self-scoring questionnaires. Our findings provide support for different measures of anticipatory grief. Further research is needed for the evaluation of the responsiveness and interpretability of these instruments.
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Affiliation(s)
- Tara Dehpour
- Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Jonathan Koffman
- Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
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8
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Gilsenan J, Gorman C, Shevlin M. Explaining caregiver burden in a large sample of UK dementia caregivers: The role of contextual factors, behavioural problems, psychological resilience, and anticipatory grief. Aging Ment Health 2022:1-8. [PMID: 35881027 DOI: 10.1080/13607863.2022.2102138] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVES Dementia caregiver burden is a significant public health concern, affecting both the wellbeing of caregivers and their care-recipients. This study investigated a range of variables associated with caregiver burden in a large sample of UK dementia caregivers. Clinical characteristics and novel psychological constructs were used - including anticipatory grief and psychological resilience. Anticipatory grief refers to the process of experiencing loss prior to the death of a significant person. METHOD Caregivers of persons with dementia (N = 530) completed a survey obtaining the Zarit-Burden Interview (ZBI-SF) and other psychological and demographic/caregiving-related factors. RESULTS Findings illustrate that 71% of the sample experienced high levels of caregiver burden and around 95% met the criteria for clinically significant levels of burden. A regression model explained 49% of the variance in subjective caregiver burden; contextual factors (care-recipients living situation, frequency of caregiving), behavioural challenges in the care-recipient (memory-related problem behaviours), caregiver psychological resilience and caregiver anticipatory grief (heartfelt long & sadness, worry & felt isolation) were all significant variables. Caregiver anticipatory grief, followed by psychological resilience, had the strongest association with burden. CONCLUSION Caregiver anticipatory grief and psychological resilience, have a significant interaction with the clinical presentation of the dementia sufferer in explaining subjective caregiver burden. More grief and resilience-focused interventions targeting both the practical and emotional challenges are imperative to reduce burden and thus to ensure caregiver wellbeing.
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Affiliation(s)
- Jane Gilsenan
- School of Psychology, Ulster University, Coleraine, United Kingdom of Great Britain and Northern Ireland
| | - Colin Gorman
- School of Psychology, Ulster University, Coleraine, United Kingdom of Great Britain and Northern Ireland
| | - Mark Shevlin
- School of Psychology, Ulster University, Coleraine, United Kingdom of Great Britain and Northern Ireland
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9
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Gilsenan J, Gorman C, Shevlin M. Exploratory factor analysis of the caregiver grief inventory in a large UK sample of dementia carers. Aging Ment Health 2022; 26:320-327. [PMID: 33148009 DOI: 10.1080/13607863.2020.1839856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Anticipatory grief (AG) is the process of experiencing loss prior to the death of a significant person. Coping with this multifaceted experience in the context of dementia caregiving is a relatively novel, yet significant area in caregiving literature. The Marwit-Meuser Caregiver Grief Inventory (MM-CGI) and its abbreviated MM-CGI-Short-Form (MM-CGI-SF) is the most widely used scale measuring AG. However, limited research has employed robust analytical strategies to assess its dimensional structure. This study employed contemporary factor analytical techniques to assess the dimensional structure of the MM-CGI/SF. METHOD Caregivers of persons with dementia (n = 508) completed a survey containing MM-CGI/SF and other associated psychological measures. Exploratory factor analysis was employed to compare eight alternative factor analytical models to determine the optimal model. Internal-consistency reliability was assessed by Cronbach's α and construct validity was assessed by Spearman's correlation-coefficient. RESULTS The best fitting model was the MM-CGI-SF three factor model (Personal Sacrifice and Burden, Heartfelt Sadness and Longing and Worry and Felt Isolation). The MM-CGI-SF three factor model demonstrated internal consistency reliability and factor correlations with associated psychological measures indicated construct validity. CONCLUSION The MM-CGI-SF three factor model demonstrated adequate fit and utility, however, the Worry and Felt Isolation subscale needs further replication and revision to assess its dimensionality. The MM-CGI-SF is the more useful tool due to its brevity and better model fit.
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Affiliation(s)
- Jane Gilsenan
- School of Psychology, Ulster University, Coleraine, UK
| | - Colin Gorman
- School of Psychology, Ulster University, Coleraine, UK
| | - Mark Shevlin
- School of Psychology, Ulster University, Coleraine, UK
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10
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Kunicki ZJ, Gaudiano BA, Miller IW, Tremont G, Salloway S, Darling E, Broughton MK, Kraines MA, Hoopes R, Epstein-Lubow G. Differences in Burden Severity in Adult-Child Family Caregivers and Spousal Caregivers of Persons with Dementia. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2021; 64:518-532. [PMID: 33820479 DOI: 10.1080/01634372.2021.1912242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 06/12/2023]
Abstract
Researchers are continuing to focus on the nature and sources of burden of family caregivers of persons living with dementia. Caregiving stress and burden are assessed and addressed by social workers, including at high-risk times such as hospitalization. This study tested whether adult-child family caregivers experience greater perceived burden than spousal caregivers, accounting for risks of acute stress which can accompany hospitalization for their care recipient, where social workers may be meeting with family caregivers for the first time. Family caregivers (N = 76; n = 42 adult-child; n = 34 spouse) were recruited during care-recipient clinical treatment. The settings of care included an outpatient memory care program and an inpatient geriatric psychiatry service. Results showed that adult-child caregivers reported greater burden as compared with spousal caregivers, but no differences regarding depressive symptoms, perceived stress, or grief. After controlling for demographics and location of care, being an adult-child caregiver remained a predictor of greater burden severity. Being an adult-child family caregiver may place an individual at increased risk for experiencing high burden. These findings suggest socials workers should consider how adult-child caregivers may benefit from strategies to address and reduce burden, beyond those typically offered to spousal caregivers.
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Affiliation(s)
- Zachary J Kunicki
- Brown University, Department of Psychiatry and Human Behavior, The Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Brandon A Gaudiano
- Brown University, Department of Psychiatry and Human Behavior, The Warren Alpert Medical School, Providence, Rhode Island, USA
- Butler Hospital, Providence, Rhode Island, USA
| | - Ivan W Miller
- Brown University, Department of Psychiatry and Human Behavior, The Warren Alpert Medical School, Providence, Rhode Island, USA
- Butler Hospital, Providence, Rhode Island, USA
| | - Geoffrey Tremont
- Brown University, Department of Psychiatry and Human Behavior, The Warren Alpert Medical School, Providence, Rhode Island, USA
- Department of Psychology, Clark University, Worcester, Massachusetts, USA
| | - Stephen Salloway
- Brown University, Department of Psychiatry and Human Behavior, The Warren Alpert Medical School, Providence, Rhode Island, USA
- Butler Hospital, Providence, Rhode Island, USA
- Brown University, The Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Ellen Darling
- Department of Psychiatry, Rhode Island Hospital, Providence, Rhode Island, USA
- Department of Psychology, Clark University, Worcester, Massachusetts, USA
| | | | - Morganne A Kraines
- Brown University, Department of Psychiatry and Human Behavior, The Warren Alpert Medical School, Providence, Rhode Island, USA
- Butler Hospital, Providence, Rhode Island, USA
| | - Ryan Hoopes
- Department of Psychology, Clark University, Worcester, Massachusetts, USA
| | - Gary Epstein-Lubow
- Brown University, Department of Psychiatry and Human Behavior, The Warren Alpert Medical School, Providence, Rhode Island, USA
- Butler Hospital, Providence, Rhode Island, USA
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
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DiLeone C. Experiences of Daughters Caring for a Parent With Alzheimer's Disease Living at Home. Res Gerontol Nurs 2021; 14:191-199. [PMID: 34288784 DOI: 10.3928/19404921-20210428-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The current study used purposeful and snowball sampling to interview 12 daughters who were care-givers to their parents with Alzheimer's disease. Data were collected through in-depth, semi-structured interviews and were analyzed using Colaizzi's descriptive phenomenological approach. Caregiving years ranged from 1 to 10 years, with a mean of 5 years. Six themes were uncovered: (a) Where Are You When I Need You?; (b) Safety First; (c) I Don't Know What to Say or How to Say It; (d) They Are Beautiful People, but They Aren't Trained; (e) Letting Go of Who They Were; and (f) It Affects Every Area of My Life. Findings suggest that caregiver daughters of parents with AD living at home are struggling and indicate a need for better support of caregivers. Implications for nursing practice, research, and education are significant and require a greater focus on the support of informal caregivers of persons with AD. [Research in Gerontological Nursing, 14(4), 191-199.].
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Gottschalk S, Neubert L, König HH, Brettschneider C. Balancing care demands and personal needs: A typology on the reconciliation of informal dementia care with personal life based on narrative interviews. DEMENTIA 2021; 20:2689-2707. [PMID: 33847550 PMCID: PMC8670745 DOI: 10.1177/14713012211008306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Finding a balance between care and personal needs is often challenging for individuals caring for a person with dementia. The present study aimed to understand how primary and secondary family carers of people with dementia perceive the reconciliation of informal care and their personal life throughout the course of care. Narrative interviews with 14 carers (n=10 female, mean age: 48.79) from seven care networks were conducted. The interviews were analysed using the documentary method. The result was a relational type formation which comprises different process types: ‘Respect your boundaries, stay calm, but plan ahead’, ‘Acting strategic is making it work’, ‘Reflect the situation, deal with it, and pull it through’ and ‘There is no alternative, you have to live with it’. This typology was based on two related dimensions: the way people negotiate their own needs against the demands of care (prospective, strategic, reflective and limited) and the resulting attitudes towards reconciling informal care and personal life (accepting, withstanding and enduring). The results yield implications for practice, such as considering individual needs and the care network to provide effective support and promoting the importance of self-care behaviours to achieve a balance between care and personal life.
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Affiliation(s)
- Sophie Gottschalk
- Department of Health Economics and Health Services Research, 37734University Medical Center Hamburg-Eppendorf, Hamburg Center for Health Economics, Germany
| | - Lydia Neubert
- Department of Health Economics and Health Services Research, 37734University Medical Center Hamburg-Eppendorf, Hamburg Center for Health Economics, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, 37734University Medical Center Hamburg-Eppendorf, Hamburg Center for Health Economics, Germany
| | - Christian Brettschneider
- Department of Health Economics and Health Services Research, 37734University Medical Center Hamburg-Eppendorf, Hamburg Center for Health Economics, Germany
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13
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Flanagan J, Post K, Hill R, DiPalazzo J. Feasibility of a Nurse Coached Walking Intervention for Informal Dementia Caregivers. West J Nurs Res 2021; 44:466-476. [PMID: 33745386 DOI: 10.1177/01939459211001395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study's purpose was to determine the feasibility of a nurse coached walking intervention for informal caregivers of persons with dementia. Participants were randomly assigned to a nurse coached intervention or a control group. Five male and 27 female caregivers (n = 32) participated. Measures included steps, walked well-being, and perceived stress. For steps walked, each group experienced a statistical difference (p = .01 control; p = .02 intervention) and large effect size (0.90). Neither group had a statistical difference in well-being (p = .38 control; p = .08 intervention) or perceived stress (p = .56 control; p = .18 intervention). The intervention group achieved a large effect size in well-being (1.38) and moderate effect size in perceived stress (0.51). A 0.94 pedometer adherence, self-reported user ease with technology and 100% retention rate support feasibility. Many participants described feelings of loneliness and grief, but reported the pedometer motivated them to walk.
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Affiliation(s)
- Jane Flanagan
- Boston College, Chestnut Hill, MA, USA.,Massachusetts General Hospital (MGH), Boston, MA, USA
| | - Kathryn Post
- Massachusetts General Hospital (MGH), Boston, MA, USA
| | - Rebecca Hill
- Boston College, Chestnut Hill, MA, USA.,MGH Institute of Health Professions, Boston, MA, USA
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Jeon SH, Kim N, Ju YJ, Gee MS, Lee D, Lee JK. Phytohormone Abscisic Acid Improves Memory Impairment and Reduces Neuroinflammation in 5xFAD Mice by Upregulation of LanC-Like Protein 2. Int J Mol Sci 2020; 21:ijms21228425. [PMID: 33182586 PMCID: PMC7697599 DOI: 10.3390/ijms21228425] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 11/07/2020] [Accepted: 11/08/2020] [Indexed: 02/06/2023] Open
Abstract
Alzheimer's disease (AD), a type of dementia, is the most common neurodegenerative disease in the elderly. Neuroinflammation caused by deposition of amyloid β (Aβ) is one of the most important pathological causes in AD. The isoprenoid phytohormone abscisic acid (ABA) has recently been found in mammals and was shown to be an endogenous hormone, acting in stress conditions. Although ABA has been associated with anti-inflammatory effects and reduced cognitive impairment in several studies, the mechanisms of ABA in AD has not been ascertained clearly. To investigate the clearance of Aβ and anti-inflammatory effects of ABA, we used quantitative real-time polymerase chain reaction and immunoassay. ABA treatment inhibited Aβ deposition and neuroinflammation, thus resulting in improvement of memory impairment in 5xFAD mice. Interestingly, these effects were not associated with activation of peroxisome proliferator-activated receptor gamma, well known as a molecular target of ABA, but related with modulation of the LanC-like protein 2 (LANCL2), known as a receptor of ABA. Taken together, our results indicate that ABA reduced Aβ deposition, neuroinflammation, and memory impairment, which is the most characteristic pathology of AD, via the upregulation of LANCL2. These data suggest that ABA might be a candidate for therapeutics for AD treatment.
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Affiliation(s)
- Seung Ho Jeon
- Department of Fundamental Pharmaceutical Science, Graduate School, Kyung Hee University, 26, Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea; (S.H.J.); (Y.-J.J.); (M.S.G.)
| | - Namkwon Kim
- Department of Life and Nanopharmaceutical Sciences, Graduate School, Kyung Hee University, 26, Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea; (N.K.); (D.L.)
| | - Yeon-Joo Ju
- Department of Fundamental Pharmaceutical Science, Graduate School, Kyung Hee University, 26, Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea; (S.H.J.); (Y.-J.J.); (M.S.G.)
| | - Min Sung Gee
- Department of Fundamental Pharmaceutical Science, Graduate School, Kyung Hee University, 26, Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea; (S.H.J.); (Y.-J.J.); (M.S.G.)
| | - Danbi Lee
- Department of Life and Nanopharmaceutical Sciences, Graduate School, Kyung Hee University, 26, Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea; (N.K.); (D.L.)
| | - Jong Kil Lee
- Department of Fundamental Pharmaceutical Science, Graduate School, Kyung Hee University, 26, Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea; (S.H.J.); (Y.-J.J.); (M.S.G.)
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, 26, Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea
- Correspondence: ; Tel.: +82-2-961-9590; Fax: +82-2-961-9580
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Werner-Lin A, Young JL, Wilsnack C, Merrill SL, Groner V, Greene MH, Khincha PP. Waiting and "weighted down": the challenge of anticipatory loss for individuals and families with Li-Fraumeni Syndrome. Fam Cancer 2020; 19:259-268. [PMID: 32222840 PMCID: PMC7440840 DOI: 10.1007/s10689-020-00173-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Li-Fraumeni Syndrome (LFS) is characterized by risk of multiple primary malignancies in diverse sites, pediatric onset, near complete penetrance by age 70 years, limited options for prevention, and substantial uncertainty regarding disease manifestation and prognosis. Forty-five families, including 117 individuals aged 13-81 years, enrolled in the US National Cancer Institute's Li-Fraumeni Syndrome Study completed 66 interviews regarding their LFS experiences. An interdisciplinary team used modified grounded theory to examine family distress regarding expectations of loss and change due to likely cancer diagnoses, and the consequences of this likelihood across physical, social, and emotional domains. Disease-free periods were characterized by fearful anticipation of diagnosis or recurrence, uncertainty regarding post-treatment quality of life, and planning for shifts in family dynamics to enable caregiving. The chronicity of waiting for these changes incited dread and inhibited effective coping with the pragmatic, emotional, and existential challenges of the syndrome. Consequently, families reported high burden on roles and resources and limited guidance to prepare for, or achieve resolution with, grief. Anticipatory loss, the experience of bereavement prior to an expected change, distinguishes hereditary cancer risk from a sporadic diagnosis. Such grief is often incomplete in impact or meaning, subjected to rapid or profound change as conditions worsen, and poorly understood. In this study, losses were compounded by profound uncertainty, a chronic feature of LFS, which compromised mourning. Long-term engagement of mental health providers with bereavement training, in partnership with genetics providers, can provide invaluable educational and psychological support to families as they navigate these implacable challenges.
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Affiliation(s)
- Allison Werner-Lin
- School of Social Policy and Practice, University of Pennsylvania, 3701 Locust Walk, Philadelphia, PA, 19104, USA.
| | | | - Catherine Wilsnack
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Shana L Merrill
- School of Social Policy and Practice, University of Pennsylvania, 3701 Locust Walk, Philadelphia, PA, 19104, USA
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Victoria Groner
- Center for Genetic Medicine, Feinberg School of Medicine, Chicago, IL, USA
| | - Mark H Greene
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Payal P Khincha
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
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16
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Requena MDC, Suárez-Álvarez S. [Pre-death grief in caregivers of Alzheimer patients. A validation of a guide]. Rev Esp Geriatr Gerontol 2020; 55:216-224. [PMID: 32249007 DOI: 10.1016/j.regg.2020.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 02/13/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The pre-death grief in family caregivers (FC) of people with Alzheimer's disease has not been sufficiently treated in studies on this group. Thus, the design and validation of informative printed materials is relevant due to its important implications for the well-being of these FCs and their training in the proper performance of their role. The objective was to design and validate a booklet aimed at informing FCs about this topic, as well as the procedure for its dissemination and use. MATERIALS AND METHODS After a review of the literature, a booklet and a questionnaire were designed to determine the acceptability and dissemination procedure and use of the booklet by 73 professionals working with FCs. With the suggestions made, modifications were made to both the content and format of the booklet. RESULTS The questionnaire used presented adequate content validity and reliability in its different sections (α=0.793 and α=0.888). The level of acceptability of the booklet was high by professionals (83.85% of total score). Its dissemination was especially valued in the initial stages of the disease, and its use in therapeutic and supportive group contexts, with professional advice. CONCLUSIONS The study made it possible to verify the relevance and acceptability of a booklet as a training resource for FCs about pre-death grief, making it a useful tool for professionals that work in this area of great relevance.
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17
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Meichsner F, O'Connor M, Skritskaya N, Shear MK. Grief Before and After Bereavement in the Elderly: An Approach to Care. Am J Geriatr Psychiatry 2020; 28:560-569. [PMID: 32037292 DOI: 10.1016/j.jagp.2019.12.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 12/20/2019] [Accepted: 12/20/2019] [Indexed: 02/01/2023]
Abstract
Grief is the natural response to the death of a loved one and is encountered frequently in clinical practice with the elderly; it can also precede the death. Knowledge about four distinct forms of grief can aid clinicians with the conceptualization of grief, and the assessment and care of grievers. First, predeath grief is experienced by many caregivers of terminally ill patients. Second, acute grief arises immediately after the death of a loved one; and third, this normally evolves to a permanent state of integrated grief after a process of adaptation. Finally, failure of adaptation results in Prolonged Grief Disorder (PGD) which has been recently included in ICD-11. The hallmark feature of PGD is intense longing for the deceased or persistent preoccupation with the deceased that lasts longer than 6 months after the death. Validated instruments are available to assist practitioners with assessment of predeath grief and screening for PGD, thereby enabling identification of patients in need of additional support. Increased risks of morbidity and mortality following bereavement are important health issues for clinicians to be aware of. All grievers can benefit from support focused on understanding their grief, managing emotional pain, thinking about the future, strengthening their relationships, telling the story of the death, learning to live with reminders of the deceased, and connecting with memories. A short-term evidence-based intervention for PGD is based upon these seven themes and is efficacious in the elderly. Caregivers of the terminally ill benefit from psychological support that validates and normalizes their grief experiences and helps them recognize and accept their losses.
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Affiliation(s)
- Franziska Meichsner
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt (FM), Frankfurt, Germany.
| | - Monique O'Connor
- Perth Clinic Medical Suites (MO), West Perth, Western Australia, Australia
| | - Natalia Skritskaya
- Center for Complicated Grief, Columbia School of Social Work (NS, MKS), New York, NY
| | - M Katherine Shear
- Center for Complicated Grief, Columbia School of Social Work (NS, MKS), New York, NY
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18
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Chan I, Yap P, Wee SL, Liew TM. The three dimensions of caregiver grief in dementia caregiving: Validity and utility of the subscales of the Marwit-Meuser Caregiver Grief Inventory. Int J Geriatr Psychiatry 2020; 35:213-222. [PMID: 31736107 PMCID: PMC7004032 DOI: 10.1002/gps.5238] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 11/07/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND The experience of grief in family caregivers as they provide care for persons with dementia is often overlooked. The Marwit-Meuser Caregiver Grief Inventory (MM-CGI) is one among the few scales that capture such experiences. In a recent study, MM-CGI was found to contain three subscales identifying dimensions of loss in caregivers-Personal-Sacrifice Burden (PSB), Heartfelt Sadness, Longing, and Worry (HSLW), and Felt Isolation (FI). We aimed to evaluate the validity and utility of these dimensions in a multiethnic Asian population. METHODS Family caregivers (n = 394) completed MM-CGI and scales assessing caregiver burden, depression, and gains. Internal consistency reliability was examined using Cronbach α; test-retest reliability using intraclass correlation coefficient; and construct validity using Pearson correlation coefficient. The utility of the MM-CGI dimensions was evaluated by comparing caregivers with high subscale scores across dementia stages and caregiving relationship. RESULTS The three dimensions of MM-CGI exhibited adequate internal consistency, test-retest reliability, construct validity, and known-group validity. PSB correlated most strongly with caregiver burden (r = 0.78); HSLW with caregiver depression (r = 0.75); and FI with caregiver burden and caregiver depression (r = 0.60, respectively). Caregivers with high total grief scores tended to experience most difficulty with HSLW (90.8%), followed by PSB (75.4%) and FI (46.2%). The three dimensions also increased across the dementia stages, with FI higher in mild dementia, PSB higher in moderate dementia, and HSLW higher in severe dementia. Spousal caregivers experienced most difficulty in HSLW, whereas children caregivers experienced similar levels of difficulty across the dimensions. CONCLUSIONS The three dimensions of MM-CGI captured distinct aspects of caregiver grief in a multiethnic Asian population and would enable more individualized assessments and interventions for caregiver grief.
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Affiliation(s)
- Ivana Chan
- Geriatric Education and Research InstituteSingapore
| | - Philip Yap
- Geriatric Education and Research InstituteSingapore,Department of Geriatric Medicine, Khoo Teck Puat HospitalSingapore
| | - Shiou Liang Wee
- Geriatric Education and Research InstituteSingapore,Health and Social Sciences ClusterSingapore Institute of TechnologySingapore
| | - Tau Ming Liew
- Department of Geriatric PsychiatryInstitute of Mental HealthSingapore,Psychotherapy ServiceInstitute of Mental HealthSingapore,Saw Swee Hock School of Public HealthNational University of SingaporeSingapore
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19
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Gilmore-Bykovskyi A. Commentary on Apathy as a Model for Investigating Behavioral and Psychological Symptoms in Dementia. J Am Geriatr Soc 2019; 66 Suppl 1:S13-S16. [PMID: 29659002 DOI: 10.1111/jgs.15325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/03/2018] [Accepted: 02/05/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Andrea Gilmore-Bykovskyi
- School of Nursing and Division of Geriatrics, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI.,Geriatric Research, Education, and Clinical Center, William S. Middleton Veterans Hospital, Madison, WI
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20
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Gibson K, Peacock S, Bayly M. Qualitative exploration of emotional and social changes from diagnosis to bereavement for spousal caregivers of persons with dementia. BMJ Open 2019; 9:e031423. [PMID: 31551389 PMCID: PMC6773340 DOI: 10.1136/bmjopen-2019-031423] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 08/30/2019] [Accepted: 09/05/2019] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES To understand how bereaved spousal caregivers of persons with dementia perceive and respond to changes over the course of their spouse's disease, from diagnosis into bereavement. DESIGN Qualitative interview study with convenience sampling and thematic analysis approach. PARTICIPANTS Participants included eight women and two men (n=10) who had been spousal caregivers for a person with dementia prior to his/her death. Participants were older adults who self-reported good health and were bereaved longer than a year. SETTING Data collected in a small Canadian prairie city between fall 2014 and winter 2015. FINDINGS Two overarching themes were developed as important components of participants' caregiving journey: emotional reactions to change and variation in social connectedness throughout the caregiving and bereavement journey. Four key sub-themes developed through the analysis of emotional reactions to events: memorable grief overshadows persistent grief, a progressive feeling of hopelessness and overwhelmed, relief is common but hidden and gratitude is a milestone in a constructive bereavement. Three key variations of social connectedness throughout the caregiving and bereavement journey were developed: the importance of social inclusion throughout a caregiving and bereavement journey, the repeated loss of companionship and withdrawing from social interactions is contingent on needs. CONCLUSIONS The findings suggest that emotional changes throughout caregiving and bereavement are not linear. The need for support from family, friends and new social supports is influential in enabling the caregiver to move forward during caregiving and bereavement.
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Affiliation(s)
- Kirstian Gibson
- College of Arts and Science (Psychology), University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Shelley Peacock
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Melanie Bayly
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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21
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Kilty C, Boland P, Goodwin J, de Róiste Á. Caring for People With Young Onset Dementia: An Interpretative Phenomenological Analysis of Family Caregivers' Experiences. J Psychosoc Nurs Ment Health Serv 2019; 57:37-44. [PMID: 31437284 DOI: 10.3928/02793695-20190821-02] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/19/2019] [Indexed: 11/20/2022]
Abstract
People with young onset dementia (YOD) experience many unique challenges. Similarly, family caregivers experience changing personal, familial, and societal roles. However, YOD is under recognized and under resourced with a lack of dedicated models of care. The current study explored family members' experience of caregiving for persons with YOD to identify barriers and opportunities to accessing support. Qualitative interviews were conducted with six family caregivers, using interpretative phenomenological analysis. Findings show that caregivers experience significant uncertainty within their role, difficulty accessing timely diagnosis, and face unclear care pathways and age-related restrictions to accessing support. These findings also reflect elements of ambiguous loss and anticipatory grief: caregivers experienced sudden changes to relationships and family structure, along with the anticipation of a changed future. Optimum models of care should target timely diagnosis and clear post-diagnosis pathways and services that are flexible, relevant, and accessible. Services should offer psychosocial support for family members as they adjust to their new role as caregivers. [Journal of Psychosocial Nursing and Mental Health Services, 57(11), 37-44.].
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22
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Abstract
Chinese family caregivers of dementia patients suffer considerable grief in their caregiving activity; little research has been conducted on dementia caregivers' grief in China. This study aims to (a) confirm the factor structure of the Mandarin version of the Marwit-Meuser Caregiver Grief Inventory-Short Form (MM-CGI-SF), (b) evaluate the levels of family caregivers' grief, and (c) explore the best predictors of family caregivers' grief. A cross-sectional study was conducted to collect data from 91 caregivers of dementia patients. The Mandarin version of the MM-CGI-SF had a three-factor structure. Family caregivers' grief was at an average level. Family caregivers' monthly household income and caring time per day predicted their own grief. The Mandarin version of the MM-CGI-SF possessed the same factor structure as the original English version, and the Chinese family caregivers experienced an average grief which was predicted by the monthly household income and caring time per day of the caregivers.
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Affiliation(s)
| | - Yun Li
- The First Affiliated Hospital of Wenzhou Medical University, China
| | - Ping Li
- Wenzhou Medical University, China
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23
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Ryu YM, Yu M, Oh S, Lee H, Kim H. [Shifting of Centricity: Qualitative Meta Synthetic Approach on Caring Experience of Family Members of Patients with Dementia]. J Korean Acad Nurs 2019; 48:601-621. [PMID: 30396197 DOI: 10.4040/jkan.2018.48.5.601] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 08/02/2018] [Accepted: 09/18/2018] [Indexed: 11/09/2022]
Abstract
PURPOSE This study aimed to synthesize the caring experiences of Korean family members of patients with dementia through a qualitative meta-synthesis method. METHODS By searching through nine Korean and English databases, we compared 37 qualitative studies on caring experiences of family members of patients with dementia. The selected studies were synthesized through meta-synthesis, proposed by Sandelowski and Barroso (2007). RESULTS The meta-synthesis elicited four themes: tough life due to care for patients, changes in relationships, adaptation to caregiver's roles, and new perspectives of life through personal growth. Caregivers were shocked when a sudden diagnosis of dementia was made prior to any preparation on their part. They were tied to their patients all the time and their mind and body got exhausted. Their relationship with patients began to change and they looked at them differently. They experienced conflicts with the other non-caring family members and were alienated from them. They were also socially isolated. However, by building their own care strategies and utilizing social resources, they gradually adapted to their caregiver roles. Finally, they experienced personal growth and acquired a new perspective toward life by accepting their roles and finding meaning in their lives. Shifting the caregiver's centricity from themselves to the patient was the process of becoming human beings who actively constructed their realities while giving meaning to their painful lives and interacting with the environment. CONCLUSION The results of the study can be useful for nurses in understanding the experiences of caregivers of the patients with dementia and in providing them with practical interventions.
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Affiliation(s)
- Young Mi Ryu
- Department of Nursing, Baekseok University, Cheonan, Korea
| | - Mi Yu
- College of Nursing · Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
| | - Seieun Oh
- College of Nursing, Dankook University, Cheonan, Korea
| | - Haeyoung Lee
- Department of Nursing, Hoseo University, Asan, Korea
| | - Haejin Kim
- Department of Nursing, Suwon Women's University, Suwon, Korea.
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24
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Examining the Perceived Effects of an Adult Day Program for Individuals With Dementia and Their Caregivers: A Qualitative Investigation. CLIN NURSE SPEC 2018; 33:33-42. [PMID: 30499847 DOI: 10.1097/nur.0000000000000418] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Currently 564 000 Canadians are living with dementia, and this number is expected to rise significantly in the next 15 years. Many individuals with dementia use adult day programs; however, contradictory evidence exists as to the effects that adult day programs have on individuals with dementia and their caregivers. PURPOSE/AIMS The purpose of this study was to examine the perceived effects that an adult day program had on individuals with dementia and their caregivers, from the perspective of care providers at an adult day program. DESIGN A qualitative research design was used to guide this study. METHODS One-on-one semistructured interviews were completed with all of the adult day program care providers (n = 7). Thematic analysis was used to analyze the data. RESULTS The adult day program care providers identified several benefits of adult day programs for individuals with dementia and their caregivers. Two themes emerged, including (1) the role of care providers and (2) time to breathe. CONCLUSIONS Adult day programs have the potential to benefit caregivers and care recipients. Other community support programs may be able to use the knowledge gained from this qualitative study to implement strategies into existing adult day programs to provide support for care recipients and caregivers.
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25
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Liew TM, Yeap BI, Koh GCH, Gandhi M, Tan KS, Luo N, Yap P. Detecting Predeath Grief in Family Caregivers of Persons With Dementia: Validity and Utility of the Marwit-Meuser Caregiver Grief Inventory in a Multiethnic Asian Population. THE GERONTOLOGIST 2018. [PMID: 28633382 PMCID: PMC5946851 DOI: 10.1093/geront/gnx097] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background and Objectives Coping with predeath grief (PDG) is an unmet need in caregivers of persons with dementia (PWD). The Marwit-Meuser Caregiver Grief Inventory (MM-CGI) and its abbreviated MM-CGI-Short-Form (MM-CGI-SF) are among the few empirically developed scales that detect PDG, yet they have not been substantially validated outside United States. We evaluated the reliability and validity of the PDG scales in a multiethnic Asian population distinct from that of United States. Research Design and Methods Family caregivers of community-dwelling PWD (n = 300) completed self-administered questionnaires containing MM-CGI and other scales of related construct. Sixty percent of the participants repeated the questionnaires 1 week later for test-retest reliability. Internal-consistency reliability was assessed by Cronbach's α, test-retest reliability by intraclass-correlation-coefficient, construct validity by Spearman's correlation-coefficient, and factorial validity by confirmatory factor analysis (CFA). Cohen's κ was used to compare the agreement between MM-CGI and a commonly-used caregiver burden scale (Zarit Burden Interview). Results MM-CGI and MM-CGI-SF demonstrated internal-consistency reliability, test-retest reliability, construct validity, and known-group validity. In CFA, MM-CGI showed modest model-fit (comparative-fit-index, CFI = .80; Tucker-Lewis-index, TLI = .79), whereas MM-CGI-SF showed better model-fit (CFI = .91; TLI = .90). Eighty-six percent of the caregivers reported average or high levels of PDG, with 18% reporting high PDG. High scores in the caregiver burden scale only showed modest agreement with high scores in MM-CGI (κ = .47). Discussion and Implications MM-CGI and MM-CGI-SF demonstrated adequate psychometric properties and utility, beyond that of a caregiver burden scale, in detecting high PDG in a multiethnic Asian population. They open the way for PDG intervention in clinical care, as well as further exploration in caregiver research.
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Affiliation(s)
- Tau Ming Liew
- Department of Geriatric Psychiatry, Institute of Mental Health, Singapore.,Psychotherapy Unit, Institute of Mental Health, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore
| | - Beow Im Yeap
- Department of Geriatric Psychiatry, Institute of Mental Health, Singapore
| | | | - Mihir Gandhi
- Biostatistics, Singapore Clinical Research Institute.,Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Kheng Siew Tan
- Department of Geriatric Psychiatry, Institute of Mental Health, Singapore
| | - Nan Luo
- Saw Swee Hock School of Public Health, National University of Singapore
| | - Philip Yap
- Department of Geriatric Medicine, Khoo Teck Puat Hospital, Singapore.,Geriatric Education and Research Institute, Singapore
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26
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Enright J, O’Connell ME, Branger C, Kirk A, Morgan D. Identity, relationship quality, and subjective burden in caregivers of persons with dementia. DEMENTIA 2018; 19:1855-1871. [DOI: 10.1177/1471301218808607] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of the current study was to examine the associations between informal caregivers’ perception of identity change in their care-partner, the quality of the caregiver/care-recipient relationship, and caregiver burden in a sample of 56 informal caregivers of persons with dementia. Most (96.4%) of the caregivers of persons who received a dementia diagnosis reported a perceived change in the identity of their care-partner. Caregivers’ perception of relationship satisfaction was measured with the Burns Relationship Satisfaction Scale for premorbid relationship and current relationship quality, and caregiver burden was measured with the Zarit Burden scale. After controlling for variance due to dementia severity, premorbid relationship satisfaction, and current relationship satisfaction, caregivers’ perceived change in the identity of the person with dementia accounted for significant variance in caregiver burden. Using a mediational model, we found support for a direct effect between perceived change in identity and caregiver burden, but we also found support for an indirect effect of relationship quality on the relation between perceived identity change and caregiver burden. The demonstrated model provides an empirically supported theoretical framework for guiding potential research and development of future interventions, which we suggest should emphasize dyads.
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27
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Sikes P, Hall M. The impact of parental young onset dementia on children and young people's educational careers. BRITISH EDUCATIONAL RESEARCH JOURNAL 2018; 44:593-607. [PMID: 30147206 PMCID: PMC6099504 DOI: 10.1002/berj.3448] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
It is well established that having a parent with any illness or disability can have an adverse effect on individuals' experiences of education and on their educational progress. Advances in medical knowledge are leading to more people under 65 being diagnosed with young onset dementias and, concomitantly, to more children and young people who are in education having a parent with this diagnosis. Hardly any research has asked these young people directly about their experiences, but the limited evidence suggests that there will likely be significant emotional, mental and psychological damage with enduring impact on their lives. This article, drawing on findings from a unique narrative, auto/biographical study involving 24 British 6 to 31-year-olds, focuses on the consequences of parental young onset dementia for educational careers. These dementias are untimely progressive terminal illnesses with unpredictable trajectories and timelines, throughout the course of which physical, cognitive and emotional functions and abilities are inexorably lost. Participants' experiences show that living with a parent with young onset dementia, whilst negotiating the education system, can be extremely hard. Difficulties are exacerbated by the condition's distinctive characteristics, the current lack of any cure and anticipatory, pre-death grief. Lack of public awareness and understanding, both of young onset dementias and of dedicated resources and support services, also result in many feeling isolated and ignored. We make suggestions for positive provision and actions that educational institutions can make to begin to meet the particular needs of these young people.
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Affiliation(s)
- Pat Sikes
- University of SheffieldUK
- University of KwaZuluNatalDurbanSouth Africa
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28
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Dempsey L, Dowling M, Larkin P, Murphy K. Providing care for a person with late-stage dementia at home: What are carers’ experiences? DEMENTIA 2018; 19:352-374. [DOI: 10.1177/1471301218774937] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background It is widely reported that carers who provide care for a family member with dementia endure physical and psychological burdens. Not only do they fulfil an important role for the person with dementia but also for the wider society. This study aims to explore the experiences of carers who provide end-of-life care for a person with late-stage dementia at home. Method Semi-structured interviews were conducted with 17 current carers and 6 past carers of a family member with late-stage dementia. Data was analysed using interpretative phenomenological analysis. Results Four super-ordinate themes were identified which described the challenges faced by carers at different stages of their care giving journey: (1) The experience of dementia grief; (2) Parenting the parent; (3) Seeking support; (4) Death, dying and life after death. Conclusion Dementia grief was experienced by carers as a result of a relationship change and an inability to recognise the person with dementia as their mother, father or spouse. A role transition ensued resulting in the carer adopting the role of parent. Carers expressed a desire to provide care for the person with dementia at home until the time of death; however, support is required in this area at both individual and community level. Family carers require education to help identify the dying phase which will assist to minimise the shock of death. Strong evidence suggests that the burden of care may leave family carers poorly equipped to adapt to life after the death of the person with dementia. Greater pre-death support is required to facilitate a better post bereavement adjustment.
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Affiliation(s)
- Laura Dempsey
- School of Nursing & Midwifery, National University of Ireland, Galway, Ireland
| | - Maura Dowling
- School of Nursing & Midwifery, National University of Ireland, Galway, Ireland
| | - Philip Larkin
- School of Nursing, Midwifery and Health Systems, Health Sciences Centre, University College Dublin, Dublin, Ireland
| | - Kathy Murphy
- School of Nursing & Midwifery, National University of Ireland, Galway, Ireland
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Hansen BR, Hodgson NA, Gitlin LN. African-American caregivers' perspectives on aggressive behaviors in dementia. DEMENTIA 2018; 18:3036-3058. [PMID: 29578357 DOI: 10.1177/1471301218765946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Purpose Although African-American dementia caregivers report less upset and more confidence managing aggressive behaviors when compared to whites, their contextual experience remains unclear and this study explores that context. Methods Semi-structured interviews with 13 African-American family caregivers were analyzed using content analysis. Results Two themes emerged, “It’s the disease…not the person” and “You got to pick your battles.” “It’s the disease…not the person,” reframing aggressive behavior, included three sub-themes. Sometimes the person with dementia seemed like a stranger but caregivers remembered “In there somewhere is that person.” Aggressive behavior made this perspective difficult as they reported, “Sometimes it’s hard not to take it personal.” Premorbid dyadic conflict made caregiving difficult but caregivers remembered they were “Not who they were then.” “You got to pick your battles,” reflecting cognitive and behavioral strategies, also included three sub-themes. Participants prioritized caregiving over other commitments by reminding themselves “I got to do what I gotta do.” Preventing aggressive behaviors was most successful when “We didn’t argue…we didn’t insist” and caregivers remembered “Don’t put her in a position to fail” when involving the person with dementia in activities. Implications African-American caregivers described substantial challenges when confronted by aggressive behaviors. Strategies employed by caregivers enabled them to maintain a caring perspective and the person with dementia to maintain calm. Interventions that help caregivers manage aggressive behaviors may benefit by considering the challenges, cultural values, and effective strategies used by African-Americans.
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Affiliation(s)
| | - Nancy A Hodgson
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Laura N Gitlin
- College of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA
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Macdonald M, Martin-Misener R, Helwig M, Weeks L, MacLean H. Experiences of unpaid family/friend caregivers of community-dwelling adults with dementia: a systematic review protocol. ACTA ACUST UNITED AC 2018; 15:1298-1305. [PMID: 28498171 DOI: 10.11124/jbisrir-2016-002979] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTION/OBJECTIVE The objective of the review is to synthesize evidence regarding the experiences of unpaid caregivers of community-dwelling adults with dementia. Specifically, the review question is: What are the experiences and perceptions of unpaid caregivers providing care for community-dwelling adults with dementia?
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Affiliation(s)
- Marilyn Macdonald
- 1School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada 2WK Kellogg Library, Dalhousie University, Halifax, Nova Scotia, Canada
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Meichsner F, Köhler S, Wilz G. Moving through predeath grief: Psychological support for family caregivers of people with dementia. DEMENTIA 2017; 18:2474-2493. [DOI: 10.1177/1471301217748504] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
When caring for a family member with dementia, continuous losses and predeath grief can adversely affect the caregivers’ physical and mental health. Interventions for caregivers should therefore also aim at coping with loss and managing predeath grief. It was the objective of the present study to describe sources of grief caregivers report during therapy and to investigate how therapists can support caregivers. Two caregivers who participated in a randomized controlled trial were selected for this case study. Both caregivers received an intervention based on the principles of cognitive-behavioral therapy with grief-focused content that consisted of 12 sessions within six months. Three therapy sessions per participant were transcribed, coded, and analyzed using qualitative content analysis. Results illustrate that both caregivers experienced a loss of companionship with their respective care recipient and ambiguous loss that resulted in intense grief that they found difficult to manage. Therapists responded by supporting the caregivers to acknowledge their losses and identify individual ways to cope with and accept loss and grief. Both caregivers reported higher well-being and an increased ability to manage their grief-related emotions after the therapy ended. The identified intervention strategies fit well into a theoretical framework for grief interventions for dementia caregivers, i.e. the dementia grief model.
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Chan WCH, Wong B, Kwok T, Ho F. Assessing Grief of Family Caregivers of People with Dementia: Validation of the Chinese Version of the Marwit-Meuser Caregiver Grief Inventory. HEALTH & SOCIAL WORK 2017; 42:151-158. [PMID: 28575234 DOI: 10.1093/hsw/hlx022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 04/11/2017] [Indexed: 06/07/2023]
Abstract
Grief in dementia caregiving is underexplored in research studies in the Chinese context, yet social workers often work with caregivers of people with dementia (PWD) and who experience grief. Having a valid assessment tool can help social workers better identify the grief of caregivers and facilitate caregivers' articulation of grief. This article describes a study aimed to validate the Marwit-Meuser Caregiver Grief Inventory-Short Form (C-MM-CGI-SF) among Hong Kong Chinese caregivers of PWD. One hundred and twenty caregivers participated in this study. They were recruited from day care centers and a memory clinic. The short version of MM-CGI was translated into Chinese, and participants were asked to complete a questionnaire that included this scale and other scales validating it. Reliability and validity were examined. C-MM-CGI-SF was found to be a reliable and valid measure in the Hong Kong context. Its construct validity was demonstrated by the positive correlations with caregiving strain and depression, and negative correlations with presence of meaning and life satisfaction. The discriminant validity was supported by showing that spousal caregivers' grief level was significantly higher than that of nonspousal caregivers. Authors recommend social workers using the C-MM-CGI-SF to assess the grief of Chinese caregivers caring for people suffering from dementia.
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Affiliation(s)
- Wallace Chi Ho Chan
- Department of Social Work, Chinese University of Hong Kong, Shatin, 852h, Hong Kong. Jockey Club Centre for Positive Ageing, Shatin, NT, Hong Kong. Department of Medicine & Therapeutics, Chinese University of Hong Kong, Shatin, NT, Hong Kong, and Jockey Club Centre for Positive Ageing, Shatin, NT, Hong Kong. Jockey Club Centre for Positive Ageing, Shatin, NT, Hong Kong
| | - Bel Wong
- Department of Social Work, Chinese University of Hong Kong, Shatin, 852h, Hong Kong. Jockey Club Centre for Positive Ageing, Shatin, NT, Hong Kong. Department of Medicine & Therapeutics, Chinese University of Hong Kong, Shatin, NT, Hong Kong, and Jockey Club Centre for Positive Ageing, Shatin, NT, Hong Kong. Jockey Club Centre for Positive Ageing, Shatin, NT, Hong Kong
| | - Timothy Kwok
- Department of Social Work, Chinese University of Hong Kong, Shatin, 852h, Hong Kong. Jockey Club Centre for Positive Ageing, Shatin, NT, Hong Kong. Department of Medicine & Therapeutics, Chinese University of Hong Kong, Shatin, NT, Hong Kong, and Jockey Club Centre for Positive Ageing, Shatin, NT, Hong Kong. Jockey Club Centre for Positive Ageing, Shatin, NT, Hong Kong
| | - Florence Ho
- Department of Social Work, Chinese University of Hong Kong, Shatin, 852h, Hong Kong. Jockey Club Centre for Positive Ageing, Shatin, NT, Hong Kong. Department of Medicine & Therapeutics, Chinese University of Hong Kong, Shatin, NT, Hong Kong, and Jockey Club Centre for Positive Ageing, Shatin, NT, Hong Kong. Jockey Club Centre for Positive Ageing, Shatin, NT, Hong Kong
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McCormack L, Tillock K, Walmsley BD. Holding on while letting go: trauma and growth on the pathway of dementia care in families. Aging Ment Health 2017; 21:658-667. [PMID: 26881318 DOI: 10.1080/13607863.2016.1146872] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Limited research explores the medical model of residential care in dementia from the family caregiver's perspectives. METHOD This study sought subjective interpretations of nine family caregivers who experienced relinquishing their status as primary caregiver to a medical model, dementia care residential setting. Following semi-structured interviews and transcription data was analysed using interpretative phenomenological analysis. RESULTS One superordinate theme, navigating 'system' control, overarched three subordinate themes: connecting/disconnecting, windows closing, and capacity for sensation. Navigating system control reflected participants' experience of circumnavigating a medical system fraught with hierarchical challenges inclusive of a complex maze of contradictions that appeared threatening, yet appeared comforting; authoritarian, yet often humane. For them, care of self, while advocating for a family member with dementia, required vigilance to manoeuvre a system of care that imposed its uninvited authority at will. Connection/disconnection highlights the enduring struggle for inclusivity in caregiving despite the omnipresent trauma of windows closing. Psychological growth came to these participants through an unexpected capacity for sensation which offered a unique lens to communication with the family member with dementia primarily through sensory exchange. CONCLUSIONS Models of dementia care and therapeutic interventions could inclusively involve dementia family caregivers who may be experiencing traumatic distress, and associated guilt, stigma, loss, and grief. Co-existing psychological wellbeing, however, is possible when family members are encouraged to transition communication to sensory awareness and exchange as windows close.
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Affiliation(s)
- Lynne McCormack
- a School of Psychology, Faculty of Science & IT , University of Newcastle , Newcastle , Australia
| | - Katrina Tillock
- a School of Psychology, Faculty of Science & IT , University of Newcastle , Newcastle , Australia
| | - Bruce D Walmsley
- a School of Psychology, Faculty of Science & IT , University of Newcastle , Newcastle , Australia
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Sikes P, Hall M. ‘Every time I see him he’s the worst he’s ever been and the best he’ll ever be’: grief and sadness in children and young people who have a parent with dementia. ACTA ACUST UNITED AC 2017. [DOI: 10.1080/13576275.2016.1274297] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Pat Sikes
- School of Education, University of Sheffield, Sheffield, UK
| | - Melanie Hall
- School of Education, University of Sheffield, Sheffield, UK
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Abstract
Previous literature reveals a high prevalence of grief in dementia caregivers before physical death of the person with dementia that is associated with stress, burden, and depression. To date, theoretical models and therapeutic interventions with grief in caregivers have not adequately considered the grief process, but instead have focused on grief as a symptom that manifests within the process of caregiving. The Dementia Grief Model explicates the unique process of pre-death grief in dementia caregivers. In this paper we introduce the Dementia Grief Model, describe the unique characteristics of dementia grief, and present the psychological states associated with the process of dementia grief. The model explicates an iterative grief process involving three states- separation, liminality, and re-emergence-each with a dynamic mechanism that facilitates or hinders movement through the dementia grief process. Finally, we offer potential applied research questions informed by the model.
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Affiliation(s)
- Kesstan Blandin
- The Dartmouth Centers for Health and Aging, Lebanon, NH, USA
| | - Renee Pepin
- The Dartmouth Centers for Health and Aging, Lebanon, NH, USA; Geisel School of Medicine, The Dartmouth Institute, Lebanon, NH, USA
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Jewell A, Cole J, Rolph J, Rolph P. The faith of primary carers of persons with dementia. JOURNAL OF RELIGION, SPIRITUALITY & AGING 2016. [DOI: 10.1080/15528030.2016.1193098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Lindauer A, Harvath TA. Pre-death grief in the context of dementia caregiving: a concept analysis. J Adv Nurs 2014; 70:2196-207. [DOI: 10.1111/jan.12411] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Allison Lindauer
- Oregon Health & Science University; School of Nursing; Portland Oregon USA
| | - Theresa A. Harvath
- Oregon Health & Science University; School of Nursing; Portland Oregon USA
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