Staging dementia based on caregiver reported patient symptoms: Implications from a latent class analysis

Evaluating a mobile-based intervention to promote the mental health of informal dementia caregivers in Singapore: Study protocol for a pilot two-armed randomised controlled trial

BACKGROUND

Informal caregivers of persons with dementia (PWD) often suffer adverse impacts on their mental health and require interventions for effective support. As they are often occupied with providing care, web-based interventions could be more convenient and efficient for them. However, there is currently a dearth of evidence-based mobile interventions to enhance the mental well-being of dementia caregivers locally, especially ones that are user-centered and culturally relevant. Hence, having designed an app based on feedback from local dementia caregivers, this study will evaluate the effectiveness of this mobile app in promoting the mental health of informal caregivers of PWD in Singapore.

METHODS

A pilot two-armed randomised controlled trial will be conducted on 60 informal caregivers of PWD recruited via convenience and snowball sampling. Thirty participants will be assigned to the intervention group, while another 30 will be in a waiting-list control group. Questionnaires will be administered at baseline and one month after, with the primary outcome being the difference in the change of depressive symptoms among the two groups.

STATISTICAL ANALYSIS

Primary analyses will follow the intention-to-treat principle and compare changes from baseline to the one-month follow-up time point relative to the control group. A repeated measures ANOVA will be conducted to examine differences between the groups over time.

SIGNIFICANCE

To our knowledge, this is the first study in Singapore that seeks to promote the mental health of informal dementia caregivers through a mobile-based intervention. The findings can inform the development and evaluation of future evidence-based digital interventions for local informal caregivers of PWD to address the gap in availability of such resources for them.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05551533). Registration date: September 22, 2022.

Portuguese Caregivers of Persons With Alzheimer's Disease in the Context of the COVID-19 Pandemic: A Qualitative Study of the Grieving Process

This study addresses the experiences of informal caregivers caring for elderly family members with Alzheimer's disease (AD) during the COVID-19 pandemic. The study includes a sample of eight informal caregivers who were evaluated through a semi-structured interview six months after the death of a loved one they cared for. A thematic content analysis was applied to the interviews and yielded two higher-order domains: (1) Experiencing the AD and the death of a family member and (2) The grieving process during the COVID-19 pandemic. The results provide valuable insights into family caregivers' experiences regarding the profound emotional impact of caregiving and grief during the COVID-19 pandemic. Caregivers maintain their identity even after loss, underscoring the enduring impact of caregiving. The identity as a caregiver impacted coping and grief responses, highlighting the need for tailored interventions.

The effect of structured education and phone follow-up on moderate stage Alzheimer's disease caregiving: Outcomes for patient and caregivers

AIM

To determine the effectiveness of a caregiver education (needs tailored) and telephone follow-up intervention for caregivers of people with moderate stage Alzheimer's disease on caregiver burden, caregiving impact on life, and patients' neuropsychiatric symptoms, dependence on activities of daily living.

METHODS

This quasi-experimental study sampled caregivers of people with moderate stage Alzheimer's. Caregivers in the intervention group received education and telephone follow-up over 12 weeks, while the control group received routine care. Caregivers were assessed for burden, changes in life, and patients for neuropsychiatric symptoms, and dependence on daily living activities.

RESULTS

The caregiver burden, life changes, distress, and patients' neuropsychiatric symptom scores showed apparent trend toward betterment, but no statistically significant differences were found in study outcomes between the two groups (P > .05).

CONCLUSION

The caregiver need-based, structured education and telephone follow-up intervention was not empirically effective. With the promising effect from this study, managing behavioral symptoms with need-based, structured, and skill-oriented training has the potential to alleviate the burden on caregivers.

Different Trajectories of Depressive Symptoms in Alzheimer's Disease Caregivers - 5-Year Follow-Up

OBJECTIVES

The care of individuals with Alzheimer's disease (AD) relies on family caregivers (FCs) who face increasing demands. This study aimed to identify trajectories of depressive symptoms in FCs.

METHODS

226 FCs and individuals with AD were followed up for 5 years as a part of the ALSOVA study. Depressive symptoms in FCs were measured with the Beck Depression Inventory from the time of the AD diagnosis to the 5-year follow-up. We compared the trajectory of groups regarding age, education, and sex of both FC distress and AD symptoms.

RESULTS

We identified three trajectories of FC depressive symptoms throughout follow-up: (1) declining (7.5% of FCs), (2) minor (59.7% of FCs), and (3) increased (32.7% of FCs). These groups exhibited differences in demographic variables, FC distress, and individuals with AD neuropsychiatric symptoms.

CONCLUSIONS

The present study showed that FC depressive symptoms existed, and one-third of caregivers experienced increasing depressive symptoms over five years.

CLINICAL IMPLICATIONS

Family caregivers' health should be followed in clinical practice, and those at risk of depression could be recognized early in caregiving.

Positive aspects of caregiving among informal caregivers of persons with dementia in the Asian context: a qualitative study

BACKGROUND

Positive aspects of caregiving are important coping resources for informal caregivers of persons with dementia (PWD). However, existing studies mostly focused on caregivers from western societies and less attention was paid to the potential cultural differences. This study aims to explore positive aspects of caregiving in the Asian context.

METHODS

A qualitative methodology with semi-structured interviews was adopted. A total of 29 informal caregivers of PWD in Singapore were interviewed from Apr 2019 to Dec 2020. All the interviews were audio-recorded and transcribed verbatim for the analysis. Inductive thematic analysis was conducted.

RESULTS

The results revealed a total of three major themes with 11 sub-themes including: 1) positive aspects within self (i.e., better understanding of dementia and caregiving, personal growth, role satisfaction, and improved awareness of self-care); 2) positive aspects between caregiver and PWD (i.e., chance to demonstrate filial piety towards PWD, happiness and positive attitudes of PWD, positive interactions with PWD, and closer relationships with PWD); and 3) positive aspects between caregiver and others (i.e., empathy towards other caregivers, befriending peers, and sharing dementia and caregiving knowledge with others).

DISCUSSION

Findings from this study improved our understanding on positive aspects of caregiving among informal caregivers of PWD in the Asian context. In addition to similar themes across cultures such as personal growth, our study identified a few unique themes like improved awareness of self-care and chances to demonstrate filial piety. For future studies targeting Asian caregivers, it is necessary to include these cultural-specific positive aspects of caregiving.

The impact of having foreign domestic workers on informal caregivers of persons with dementia - findings from a multi-method research in Singapore

Background

Informal caregivers of persons with dementia (PWDs) sometimes engage foreign domestic workers (FDWs) to support their caregiving journey. However, there has not been much research to establish if this is really beneficial. The current study aims to investigate whether engaging FDWs specifically for caregiving of PWDs truly moderates caregiver stress and to explore caregivers’ experiences of engaging FDWs.

Methods

A multi-method study design with a quantitative and qualitative sub-study was adopted. For the quantitative sub-study, 282 informal caregivers of PWDs were recruited. Propensity score matching analysis was used. For the qualitative sub-study, 15 informal caregivers with FDWs were interviewed. Inductive thematic analysis was conducted.

Results

The quantitative sub-study confirmed that engaging FDWs did moderate the depressive symptoms of informal dementia caregivers (marginal effect = -3.35, p = 0.0497). However, such support did not affect their caregiving burden, self-efficacy, and perceived positive aspects of caregiving. The qualitative sub-study suggested that engaging FDWs is an ambivalent experience, which entails both support and challenges.

Conclusions

The current study confirmed previous research findings, that engaging FDWs moderated depressive symptoms among caregivers of PWDs, and it could be through their physical support such as in daily caregiving activities. Policy-makers may consider providing more subsidies to caregivers caring for PWDs with mobility issues to hire FDWs. They may also consider providing training to FDWs on dementia caregiving skills and improving the intake of such training as this might be helpful for both FDWs and caregivers during this journey.

Caregivers' experiences of patients with moderate-stage Alzheimer's disease: a qualitative study

BACKGROUND

Caregivers experience challenges in the longest stage of Alzheimer disease, the moderate stage, due to all day demanded caregiving, added with neuropsychiatric symptoms, and communication difficulties. Supporting challenges of caregiving is more effective when specific needs are assessed and real-life experiences are appreciated. This study sought to explore caregivers' experiences and support needs for moderate-stage Alzheimer's disease patients.

METHODS

This study had a qualitative phenomenological design. In-depth, semi-structured interviews were conducted with 46 caregivers via face-to-face interviews. Following transcription, an analysis was done with Colaizzi's steps by coding and defining the main themes and subthemes.

RESULTS

Caregivers stated they faced difficulties in the care activities of patients and needed support. Three themes were identified: (i) changes related to Alzheimer's disease; (ii) change in caregivers' life; and (iii) support needs and coping strategies about the care process.

CONCLUSIONS

Current study confirmed that caregivers of moderate-stage Alzheimer's disease patients need proper support to cope with daily care activities and systems that help them overcome life challenges. The development of a system based on the stage-specific caregivers' need to decrease daily care challenges and overwhelming economic and emotional stress can be recommended.

Coping Patterns Among Primary Informal Dementia Caregivers in Singapore and Its Impact on Caregivers-Implications of a Latent Class Analysis

BACKGROUND AND OBJECTIVES

Existing studies typically explore the factor structure of coping strategies among dementia caregivers. However, this approach overlooks the fact that caregivers often use different coping strategies simultaneously. This study aims to explore the coping patterns of primary informal dementia caregivers in Singapore, examine their significant correlates, and investigate whether different patterns would affect the depressive symptoms of caregivers.

RESEARCH DESIGN AND METHODS

Two hundred eighty-one primary informal caregivers of persons with dementia (PWD) were assessed. Coping strategies were measured by the Brief Coping Orientation to Problem Experienced inventory. A latent class analysis was performed to explore caregivers' coping patterns, followed by logistic regressions to identify the significant correlates and the relationships between coping patterns and caregiver depression.

RESULTS

The latent class analysis suggested a three-class solution that was featured by the frequency and variety of coping strategies used by caregivers-high coping (36.3%), medium coping (37.7%), and low coping (26.0%). Factors influencing the coping patterns of our sample were mainly related to caregivers' individual resources such as personal characteristics and caregiving stressors like PWD's problematic behaviors and caregiving burden. Compared to caregivers in the low coping group, those in the medium coping group had significantly higher risks of potential depression.

DISCUSSION AND IMPLICATIONS

The current study confirmed that there are distinct coping patterns among primary informal dementia caregivers, and caregivers with the low coping pattern had fewer depressive symptoms. Future research is needed to explore if coping patterns from our sample are generalizable to dementia caregivers elsewhere.

Combining a variable-centered and a person-centered analytical approach to caregiving burden - a holistic approach

Background

Informal caregivers of persons with dementia often experience elevated levels of caregiving burden. However, existing studies tend to use a variable-centered approach to explore it. This study aims to understand the caregiving burden of informal caregivers of persons with dementia in Singapore through a combination of variable-centered and person-centered analytical approaches, and explore the correlates of identified factors and latent classes of caregiving burden.

Methods

Zarit Burden Interview was used to gauge the caregiving burden of 282 primary informal caregivers of persons with dementia recruited through convenience sampling in Singapore. Factor analysis and latent class analysis were conducted to identify the latent factors and the latent classes of Zarit Burden Interview, followed by multiple linear regression and multinomial logistic regression to explore their significant correlates.

Results

The analyses suggested a 17-item 3-factor structure for Zarit burden interview and three mutually exclusive caregiving burden classes. Regression analyses found that caregiving related variables especially care recipients’ memory and behaviour problems were correlated with both the factors and latent classes of caregiving burden.

Conclusions

The combination of these two approaches suggests that caregivers experiencing higher burden on one domain are likely to experience higher burden on the other two domains. This further supports the point that more attention should be given to caregivers who experience an overall high burden. Future research could explore the generalizability of our findings among caregivers elsewhere and explore the type of support needed by caregivers, especially those experiencing high burden.

Development of a self-assessment behavioral and psychological symptoms of dementia competency scale for care teams at long-term geriatric care facilities

Understanding the behavioral and psychological symptoms of dementia (BPSD) is important for caregivers in long-term geriatric care facilities. In this study performed in 43 long-term care facilities, we evaluated the ability of caregivers to recognize BPSD through the development and validation of self-assessment scales. Reliability and validity of the scales were determined using Cronbach's alpha coefficient, the test/retest method, exploratory factor analysis, confirmatory factor analysis, criteria-related validity, and construct validity. We analyzed cross-sectional data from 310 participants. Factor analysis showed a positive correlation for all scale items (r_s = .43-.73). Significant correlations arose from the test/retest method (r_s = .48-.76). The α coefficient of all items except one was .70 or more, indicating sufficient reliability. Criteria-related validity (r_s = .43-.73) and construct validity (r_s = .13-.52) revealed a positive correlation. The BPSD Team Care Self-Assessment Scale is reliable and could ensure BPSD competency in caregivers.

The association between caregiver burden, distress, psychiatric morbidity and healthcare utilization among persons with dementia in Singapore

BACKGROUND

Caregivers of persons with dementia (PWD) face high caregiving burden, distress related to responsive behaviours, and psychiatric morbidity. The present paper examines how these are associated with healthcare utilization of the PWD in Singapore.

METHODS

The data of 399 caregiver-PWD dyads were extracted from a national cross-sectional survey. PWD completed the Client Service Receipt Inventory, which provided information on their healthcare utilization (i.e. emergency service use, hospital admission, length of stay in hospital, and number of outpatient visits) within a frame of 3 months. The Zarit Burden Interview  (ZBI), Neuropsychiatric Inventory Questionnaire (NPI-Q), and Self Reporting Questionnaire (SRQ-20) were administered to caregivers. Information on severity of dementia, physical multimorbidity of the PWD, household composition, and caregivers' sociodemographic characteristics such as age, gender, and education were collected. Variables significantly associated with healthcare utilization in the univariate analyses were selected and included in the final regression models. Emergency service use and hospital admission were investigated using logistic regression analyses, whilst negative binomial models were utilized for length of stay in hospital and number of outpatient visits.

RESULTS

After adjusting for significant correlates such as dementia severity and multimorbidity, only caregiver distress from responsive behaviours was positively associated with emergency room utilization, while caregiver burden was positively associated with length of hospital stay in the final regression model. Psychiatric morbidity was associated with healthcare utilization outcomes at the univariate level but did not reach statistical significance in final models.

CONCLUSION

The study identifies caregiver variables associated with the healthcare utilization of PWD. Policy makers and healthcare professionals should provide interventions to ease burden and distress amongst caregivers of PWD.

The Impact of COVID-19 Quarantine on Patients With Dementia and Family Caregivers: A Nation-Wide Survey

Introduction

Previous studies showed that quarantine for pandemic diseases is associated with several psychological and medical effects. The consequences of quarantine for COVID-19 pandemic in patients with dementia are unknown. We investigated the clinical changes in patients with Alzheimer’s disease and other dementias, and evaluated caregivers’ distress during COVID-19 quarantine.

Methods

The study involved 87 Italian Dementia Centers. Patients with Alzheimer’s Disease (AD), Dementia with Lewy Bodies (DLB), Frontotemporal Dementia (FTD), and Vascular Dementia (VD) were eligible for the study. Family caregivers of patients with dementia were interviewed by phone in April 2020, 45 days after quarantine declaration. Main outcomes were patients’ changes in cognitive, behavioral, and motor symptoms. Secondary outcomes were effects on caregivers’ psychological features.

Results

4913 patients (2934 females, 1979 males) fulfilled the inclusion criteria. Caregivers reported a worsening in cognitive functions in 55.1% of patients, mainly in subjects with DLB and AD. Aggravation of behavioral symptoms was observed in 51.9% of patients. In logistic regression analysis, previous physical independence was associated with both cognitive and behavioral worsening (odds ratio 1.85 [95% CI 1.42–2.39], 1.84 [95% CI 1.43–2.38], respectively). On the contrary, pandemic awareness was a protective factor for the worsening of cognitive and behavioral symptoms (odds ratio 0.74 [95% CI 0.65–0.85]; and 0.72 [95% CI 0.63–0.82], respectively). Approximately 25.9% of patients showed the onset of new behavioral symptoms. A worsening in motor function was reported by 36.7% of patients. Finally, caregivers reported a high increase in anxiety, depression, and distress.

Conclusion

Our study shows that quarantine for COVID-19 is associated with an acute worsening of clinical symptoms in patients with dementia as well as increase of caregivers’ burden. Our findings emphasize the importance to implement new strategies to mitigate the effects of quarantine in patients with dementia.

Factors associated with caregiving self-efficacy among primary informal caregivers of persons with dementia in Singapore

Background

Informal caregivers of persons with dementia (PWD) are often associated with negative health outcomes. Self-efficacy in dementia caregiving has been reported to have protective effects on caregiver’s health. This study aims to examine the factors associated with the domains of caregiving self-efficacy among informal caregivers in Singapore, a country with a rapidly aging population and a 10% prevalence of dementia among older adults.

Methods

Two hundred eighty-two informal caregivers were recruited and data including participant’s caregiving self-efficacy, sociodemographic information, perceived social support, positive aspects of caregiving, knowledge of dementia, as well as behavioral and memory problems of care recipients were collected. A confirmatory factor analysis (CFA) was performed for the 3-factor model of the Revised Scale for Caregiving Self-Efficacy (RSCSE), and multiple linear regressions were conducted using the RSCSE subscales as dependent variables.

Results

Our CFA found that the RSCSE 3-factor model proposed by the original scale developer was an acceptable fit among informal caregivers in Singapore. Having established that the 3-factor model of the RSCSE was compatible among our sample, a series of multiple regressions were conducted using each of the factors as a dependent variable. Regressions revealed several factors that were significantly associated with caregiving self-efficacy. Importantly, outlook on life was positively associated to all 3 domains of the RSCSE, while social support was positively associated with self-efficacy in obtaining respite and controlling upsetting thoughts.

Conclusion

The 3-factor model of the RSCSE was found to be an appropriate fit for our sample. Findings from this study elucidated important novel insights into the factors that influences caregiving self-efficacy amongst informal caregivers in Singapore. Crucially, caregivers’ outlook on life and social support should be improved in order to enhance their caregiving self-efficacy.

Use of Patient-Reported Symptoms from an Online Symptom Tracking Tool for Dementia Severity Staging: Development and Validation of a Machine Learning Approach

BACKGROUND

SymptomGuide Dementia (DGI Clinical Inc) is a publicly available online symptom tracking tool to support caregivers of persons living with dementia. The value of such data are enhanced when the specific dementia stage is identified.

OBJECTIVE

We aimed to develop a supervised machine learning algorithm to classify dementia stages based on tracked symptoms.

METHODS

We employed clinical data from 717 people from 3 sources: (1) a memory clinic; (2) long-term care; and (3) an open-label trial of donepezil in vascular and mixed dementia (VASPECT). Symptoms were captured with SymptomGuide Dementia. A clinician classified participants into 4 groups using either the Functional Assessment Staging Test or the Global Deterioration Scale as mild cognitive impairment, mild dementia, moderate dementia, or severe dementia. Individualized symptom profiles from the pooled data were used to train machine learning models to predict dementia severity. Models trained with 6 different machine learning algorithms were compared using nested cross-validation to identify the best performing model. Model performance was assessed using measures of balanced accuracy, precision, recall, Cohen κ, area under the receiver operating characteristic curve (AUROC), and area under the precision-recall curve (AUPRC). The best performing algorithm was used to train a model optimized for balanced accuracy.

RESULTS

The study population was mostly female (424/717, 59.1%), older adults (mean 77.3 years, SD 10.6, range 40-100) with mild to moderate dementia (332/717, 46.3%). Age, duration of symptoms, 37 unique dementia symptoms, and 10 symptom-derived variables were used to distinguish dementia stages. A model trained with a support vector machine learning algorithm using a one-versus-rest approach showed the best performance. The correct dementia stage was identified with 83% balanced accuracy (Cohen κ=0.81, AUPRC 0.91, AUROC 0.96). The best performance was seen when classifying severe dementia (AUROC 0.99).

CONCLUSIONS

A supervised machine learning algorithm exhibited excellent performance in identifying dementia stages based on dementia symptoms reported in an online environment. This novel dementia staging algorithm can be used to describe dementia stage based on user-reported symptoms. This type of symptom recording offers real-world data that reflect important symptoms in people with dementia.

The Impact of Educational Intervention on the Anxiety of Family Caregivers of the Elderly with Dementia: A Randomized Controlled Trial

Background

Due to the increasing population of elderly and the consequent increase in the number of chronic diseases such as dementia, the psychological complications such as anxiety in the family caregivers increase. The aim of this study was to determine the effect of educational intervention on the anxiety of family caregivers of the elderly people with dementia.

Methods

This randomized controlled trial was performed in the elderly Neurology Clinics in Shiraz from May to August 2017. This study was conducted on 70 families with elderly people with dementia who were randomly divided into an intervention (receiving in groups for seven sessions of educational intervention) and a control group (Conventional care). Data collection tool was Spielberger's Anxiety Inventory (40-items, score=20-80). Data were analyzed by SPSS version 21 using ANOVA test with repeated measures and independent t-test.

Results

One and three months after the interventions, the mean scores of anxiety in the intervention group were 70.51±3.78 and 70.31±3.43 and in the control groups they were 76.45±3.45 and 76.22±5.08 respectively. The results showed significant differences between the two groups regarding anxiety after the intervention (P<0.001).

Conclusion

Educational programs held to promote and maintain the physical and mental health of caregivers could reduce the anxiety of family caregivers of the elderly with dementia.Trial Registration Number: IRCT2017080915426N4.