Dementia and Caregiver Stress: An Application of the Reconceptualized Uncertainty in Illness Theory

Uncertainty in surrogate decision-making about end-of-life care for people with dementia: An integrative review

AIM

To describe uncertainty in surrogate decision-making regarding end-of-life care for people with dementia using Mishel's reconceptualized uncertainty in illness theory.

DESIGN

Integrative literature review using Whittemore and Knafl's approach.

DATA SOURCES

PubMed, CINAHL, EMBASE, Scopus and Web of Science were searched using terms such as uncertainty/unpredictability, decision-making/advance care planning/end-of-life care planning, surrogate/family/caregiver/proxy and dementia. The search was initially conducted on 28 September 2021 and updated on 31 July 2023.

REVIEW METHODS

Through systematic screening, 20 research articles were included in the analysis. Content related to uncertainty in surrogate decision-making regarding end-of-life care was extracted and analysed, focusing on the reconceptualized uncertainty in illness theory.

RESULTS

First, surrogate uncertainty exists in various areas of surrogate decision-making regarding end-of-life care. Second, antecedents of surrogate uncertainty include numerous intrinsic and extrinsic factors. Third, surrogates exhibited some negative psychological responses to uncertainty but continually processed and structured their uncertainty through certain approaches, leading them to grow as decision-makers. Finally, research-based evidence on surrogates' processing of uncertainty and shifts to new life perspectives remains limited.

CONCLUSION

Surrogates' uncertainty in decision-making regarding end-of-life care for people with dementia is well characterized using the reconceptualized uncertainty in illness theory. Healthcare providers should help surrogates manage their uncertainty in surrogate decision-making more constructively throughout the dementia trajectory.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The findings highlight the importance of assessing how surrogates process uncertainty and gauging how to help them process uncertainty and transition to new life perspectives.

IMPACT

This review contributes to healthcare professionals' understanding of surrogates' uncertainty in end-of-life care planning for people with dementia, especially what they are uncertain about, what influences their uncertainty and how they process it.

REPORTING METHOD

This study adheres to the PRISMA reporting guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Effectiveness of an Uncertainty Management Psychoeducation Program for Schizophrenia Caregivers: A Randomized Controlled Trial

BACKGROUND

The inconsistent course of schizophrenia causes a long-term experience of uncertainty for individuals and their families. In Turkey, no studies yet exist that have attempted to address this constant uncertainty that is experienced by caregivers of schizophrenic patients.

AIMS

To evaluate the effects of the Uncertainty Management Psychoeducation Program on reducing uncertainty and intolerance to uncertainty, improving psychological well-being, and coping styles in caregivers of patients with schizophrenia.

METHOD

Single-blinded randomized controlled trial. Caregivers of schizophrenia inpatients were recruited from the psychiatry clinic of a university-affiliated hospital. Data were collected between April 2019 and August 2020. Eligible individuals were randomly allocated to one of the two groups: intervention or control. The intervention group had five individual psychoeducation sessions: "Recognizing Uncertainty," "Cognitively Reframing Uncertainty," "Solving Uncertainty-Related Issues," "Dealing with Uncertainty Using Communication Skills," and the "Closing Session." Participants in the control group received the usual care. Uncertainty, intolerance to uncertainty, psychological well-being, and stress coping strategies were measured at two points: at baseline and immediately following the intervention. Hypotheses were tested using the Mann-Whitney U and Wilcoxon tests.

RESULTS

A total of 54 participants were recruited. The intervention group's ratings for "seeking social support" and "optimistic approach" were higher than the control group's ratings. Significant within-group changes in terms of "uncertainty" and "optimistic approach" were reported for the intervention group in the post-intervention. In the control group, significant changes were seen in terms of "uncertainty" and "psychological well-being" over time.

CONCLUSION

The Uncertainty Management Psychoeducation Program was found to be effective in reducing the level of uncertainty, increasing their optimistic approach, and seeking social support of caregivers of schizophrenic patients.

The Relationship Between Uncertainty and Psychological Distress Among Family Caregivers of Patients With Delirium in Intensive Care Units: A Cross-Sectional Survey

BACKGROUND

Although family caregivers experienced negative psychological symptoms associated with witnessing intensive care unit delirium in their loved ones, there is a lack of clear understanding of how delirium is associated with family caregiver psychological distress. Uncertainty could be a factor contributed to this association.

OBJECTIVES

The aim of this study was to examine the relationship between uncertainty and psychological distress among family caregivers of patients with delirium in intensive care units.

METHODS

A cross-sectional correlational design was used for this observational study of adult family caregivers of patients admitted to the intensive care unit and who reported witnessing delirium symptoms in their loved ones. Family caregivers completed an electronic survey in January 2022 that consisted of a family caregiver and patient demographic form, the Mishel Uncertainty in Illness Scale-Family Member, and the Kessler Psychological Distress Scale. Descriptive, correlational, and regression statistical analyses were applied.

RESULTS

One hundred twenty-one adult family caregivers were enrolled. Family caregivers reported substantial uncertainty (mean, 106.15, on a scale of 31-155) and moderate to severe psychological distress (mean, 31.37, on a scale of 10-50) regarding their witnessing of delirium episodes in their loved ones. Uncertainty was significantly correlated with psychological distress among family caregivers (rs = 0.52, P < .001). Uncertainty significantly predicted psychological distress among family caregivers (regression coefficient, 0.27; P < .001).

DISCUSSION

Family caregiver uncertainty was positively associated with psychological distress. This distress can interfere with family caregiver involvement in patient delirium care. These findings are essential to increase critical care nurse awareness and inform the development of nursing interventions to alleviate possible uncertainty and distress.

Personal Health Planning in Adult-Child Former Caregivers of Parents Living With Dementia

PURPOSE

To examine how former caregivers for parents living with dementia engage in personal health planning.

DESIGN

An inductive, qualitative study.

SETTING

Virtual, audio-recorded, semi-structured interviews.

PARTICIPANTS

Thirty-two midlife former primary caregivers for parents who died following advanced dementia 3 months to 3 years prior.

METHOD

Participants responded to a series of open-ended interview prompts. Interview recordings were transcribed and evaluated by a trained, diverse team to generate Consensual Qualitative Research (CQR) domains and categories.

RESULTS

Caregivers developed health planning outlooks (ie, mindsets regarding willingness and ability to engage in personal health planning) that guided health planning activities (ie, engaging in a healthy lifestyle, initiating cognitive/genetic testing, maintaining independence and aging in place, ensuring financial and legal security). An agentic outlook involved feeling capable of engaging in health planning activities and arose when caregivers witnessed the impact and feasibility of their parents' health planning. Anxiety-inducing and present-focused outlooks arose when caregivers faced barriers (eg, low self-efficacy, lack of social support, perception that parent's health planning did not enhance quality of life) and concluded that personal health planning would not be valuable or feasible.

CONCLUSION

Caregiving for a parent living with dementia (PLWD) shapes former caregivers' personal health planning. Interventions should support former caregivers who have developed low self-efficacy or pessimistic views on healthy aging to support them in addressing health planning activities.

The Uncertainty in Family Caregivers of Hospitalized Persons With a Stroke in Saudi Arabia: Unitary Caring Perspective

Uncertainty is a universal experience of family caregivers caring for persons with a stroke and affects caregivers' readiness to care for their family members with a stroke. Guided by the unitary caring theory and unitary-caring hermeneutic-phenomenological research method, this study was conducted among 15 family caregivers of persons in the hospital who have survived strokes through in-depth semi-structured interviews. Five essences emerged from the analysis: living in a dark reality; yearning for professional support; enduring a life full of tribulations; attempting resolution; and creating new patterns of living. Each of the 5 essences was interpreted from Smith's unitary caring theory perspective.

The impact of dementia family caregiving on adolescent well-being: A scoping review

With rates of dementia on the rise and upward trends in multigenerational households, the number of families providing care to persons with dementia is likely to increase. Although caregiver stress in adults has been well-documented, less is known about the impact of dementia family caregiving on adolescents. We conducted a scoping review to assess research on the impact of dementia family caregiving on adolescents. Eight articles representing five studies were identified. Findings suggest that while adolescents developed strategies to cope with the challenges of dementia caregiving, the long-term impact of caregiving on overall well-being has not been well described. Further, research has shown inconsistent findings with studies reporting both improved and strained adolescent relationships. The paucity of research on the impact of dementia family caregiving on the well-being of adolescents is a serious omission given that adolescents are at high-risk for emerging health problems.

Easing the burden of dementia caregiving: Protocol development for a telephone-delivered mindfulness intervention for rural, African American families

Background

There have been few interventions targeted for rural African American (AA) caregivers of persons with dementia despite their unique cultural, geographic, health-related and socio-economic needs, including relatively less access to-and willingness to engage with-formal supports and resources. One effective intervention, Mindfulness-based stress reduction (MBSR), has been found to be culturally acceptable in AA populations; however, no studies have assessed feasibility, acceptability and impact of an adapted mindfulness intervention targeting rural AA dementia caregivers.

Aims

The purpose of this study is to 1) determine the feasibility and acceptability of a telephone-delivered mindfulness training intervention in decreasing caregiver burden among rural, AA, informal caregiving teams of people with dementia; 2) to explore the effects of the training on caregiver burden and relevant secondary outcomes for both caregiving team members, including emotional regulation, tolerance of uncertainty, emotional and physical health, family conflict within the informal caregiving team, and self-efficacy; and 3) to explore comfort with and willingness to adopt technologies to access mindfulness practices and existing caregiving educational resources.

Methods

Our study utilizes a single-group, uncontrolled design to assess the feasibility and acceptability of telephone-delivered mindfulness training designed to alleviate burden for rural caregivers of AA individuals with moderate to severe dementia. A care partner-the person who provides additional help -is included in the intervention. The primary outcome is feasibility of the telephone-delivered mindfulness intervention as assessed by an 85% retention rate with completion of at least 6 of the intervention sessions. Pre- and post-participation interviews assess acceptability.

Living in uncertainty while a spouse is undergoing a cognitive assessment: Voices of women care partners

INTRODUCTION

Women often support partners with cognitive symptoms during the assessment process and when they are receiving a cognitive diagnosis. Living with a partner with cognitive symptoms can be stressful; however, there is limited insights into the specific experiences of older women during the assessment process. Previous research indicates that there are gender differences in the experiences of spousal caregiving; however, further research is needed in regard to the experiences of men and women as care partners. Therefore, the aim of the present study was to describe women's experiences of living with a partner undergoing a cognitive assessment.

METHODS

Semi-structured interviews were conducted with seven women when their male partners commenced a cognitive assessment and after the assessment had been completed. The interviews were analysed with abductive content analysis.

FINDINGS

Uncertainty permeated the women's experiences. Antecedents, attributes and strategies to manage the uncertainty were described.

CONCLUSION

The participants expressed informational and existential uncertainty when their partner underwent a cognitive assessment. A lack of knowledge regarding the assessment process and cognitive diagnoses, especially mild cognitive impairment, was identified. Further, there was a need to process existential uncertainty evoked by the situation.

"Can Everyday Assistive Technologies Provide Meaningful Support to Persons With Dementia and Their Informal Caregivers? Evaluation of Collaborative Community Program"

One of the most challenging caregiving roles today is providing informal care to an individual with dementia. A new program, "AT-Home with Dementia," was created by three collaborative social service agencies to offer simple assistive technologies to persons with dementia and their informal caregivers. Staff, equipped with a traveling kit of everyday devices, offered items during home visits to enhance memory, functional activities, safety, and comfort of persons with dementia. A limited formative program review led to improvements in the new program's reach, service delivery, and data. The results showed that the program enhanced the home environment of the caregiving dyad and led to greater independence of persons with dementia (PWD) and self-assurance among caregivers. Existing community agencies may refer to this program to serve individuals with early-stage dementia. Finally, community agencies and funders may consider adapting this program to provide support to the informal care providers and PWD.

Meeting own needs and supporting ability to care: Family caregivers' and health care professionals' perspectives on professional support provided through a potential mobile application

BACKGROUND

A majority of persons with dementia in Sweden live in their own homes and are often cared for by family members. Caring for a family member may be a positive experience. It may, however, also be a negative experience as symptoms like disturbing behavior and delusions may be difficult to encounter. The burden of being a family caregiver has been shown to affect the caregivers' quality of life.

OBJECTIVE

To explore stakeholders' perspectives on a potential mobile application through which family caregivers could be supported by healthcare professionals in caring for a person with dementia living at home.

METHOD

Eight individual interviews with family caregivers and a focus group with eight healthcare professionals specialized in dementia care were analyzed using content analysis method.

RESULTS

The findings suggest that a mobile application can support family caregivers to meet their own needs in terms of finding structure in everyday life, how to get information and support in their own pace, and how to care for themselves. The findings also suggest the necessity of accessing relevant contact networks to be supported in the ability to care for a family member with dementia.

CONCLUSION

Healthcare and social services mediated support provided through user-friendly mobile application has the potential to support family caregivers both in taking care of a person with dementia and caring for themselves. Moreover, it is important that the information provided to family caregivers is personalized according to the needs of the family caregivers as the family member's dementia advances.

A concept analysis of family caregivers' uncertainty of patient's illness

AIM

To analyze and examine the concept of uncertainty of the patient's illness among family caregivers.

BACKGROUND

Promoting family caregivers' health is significant in nursing. Family caregivers may experience uncertainty related to their loved ones' illness. A lack of clarity exists regarding the uncertainty concept among family caregivers and its implications in nursing.

DATA SOURCE

A review of the literature that focused on family caregivers of adult patients using PubMed, CINAHL, and Scopus databases was completed.

METHODS

The Walker and Avant framework was applied to identify the attributes, antecedents, and consequences of family caregivers' uncertainty.

RESULTS

Eight articles were analyzed. Attributes of family caregivers' uncertainty included the patient's illness probability and family caregivers' perception of the illness. Antecedents included the characteristics of the patient's illness, factors associated with the family caregivers' perception of the illness, and family responsibilities of caregiving. The consequences included family caregivers' emotional, psychological, and financial outcomes. Family caregivers' uncertainty is defined as the perception of the inability to process information regarding the patient's illness trajectory when caring for significant others' illness.

CONCLUSIONS

Individuals can perceive uncertainty differently as a patient-facing uncertainty in illness versus a family caregiver facing uncertainty of their loved ones' illness.

Involvement, worries and loneliness of family caregivers of people with dementia during the COVID-19 visitor ban in long-term care facilities

To prevent COVID-19 from spreading in long-term care facilities (LTCFs), the Dutch government took restrictive measures, including a visitor-ban in LTCFs. This study examined the relationship between involvement of family caregivers (FCs) of people with dementia (PwD) living in LTCFs and FCs mental health during the visitor-ban, and whether this relationship was moderated by the frequency of alternative contact with PwD during the visitor-ban and FC resilience. This cross-sectional study collected data from 958 FCs. FCs who visited PwD more frequently before, were more worried during the visitor-ban than those with lower visiting frequency. FCs who visited the PwD daily before, but had minimal weekly contact during the visitor-ban, worried less. Resilient FCs who did social and task-related activities before, experienced less loneliness during the visitor-ban. It is advisable for healthcare professionals to reach out to these groups, to facilitate ongoing contact and help them overcome their loneliness.

[Influence of Self-care on Burnout in Primary Family Caregiver of Person with Dementia]

PURPOSE

The purpose of this study was to identify the influence of self-care on burnout experienced by primary family caregivers of persons with dementia.

METHODS

The subjects of the study were 156 primary family caregivers of persons with dementia at home in Korea. Data were analyzed using descriptive statistics, independent t-test, one-way ANOVA, Pearson correlation coefficient, and hierarchical multiple regression using IBM SPSS Statistics ver. 24.0 for Windows.

RESULTS

The mean scores for self-care and burnout were 42.35 and 61.60, respectively. Self-care, subjective health status, living with a person with dementia, and behavioral and psychological symptoms of dementia were significant factors affecting burnout in family caregivers. Self-care was identified as the strongest factor affecting burnout, explaining 13.9% of burnout with controlling factors in caregivers and care receivers.

CONCLUSION

To prevent burnout in primary family caregivers of persons with dementia, self-care of family caregivers should be emphasized. In nursing education, family caregivers should be recognized and approached as nursing clients who are responsible for taking care of their health. In nursing practice and research, digital self-care or self-care improvement intervention programs should be designed to help family caregivers, and further studies on self-care centered on health of family caregivers should be conducted.

Involuntary treatment in dementia care at home: Results from the Netherlands and Belgium

Aims and objectives

To gain insight into the request, use and associated factors of involuntary treatment in people with dementia (PwD) receiving professional home care in the Netherlands and Belgium.

Background

Most of the PwD remain living at home as long as possible. Due to complex care needs, this can result in an increased risk for care provided against the wishes of the client and/or to which the client resists, referred to as involuntary treatment.

Design

Secondary data analyses of two cross‐sectional surveys.

Methods

Dementia case managers and district nurses filled in a questionnaire for each PwD in their caseload. This study included data of 627 PwD receiving professional home care in the Netherlands and 217 in Belgium. The same methodology (questionnaire and variables) was used in both samples. Descriptive statistics and multi‐level logistic regression analyses were used to analyse the data. The study adhered to the STROBE checklist.

Results

More than half of the PwD (50.7%) living at home received involuntary treatment (Belgium 68.2% and the Netherlands 44.7%). Nonconsensual care (82.7%) was the most common, followed by psychotropic medication (40.7%) and physical restraints (18.5%). Involuntary treatment use was associated with living alone, greater ADL dependency, lower cognitive ability, higher family caregiver burden and receiving home care in Belgium versus the Netherlands. Involuntary treatment was most often requested by family caregivers.

Conclusions

Involuntary treatment is often used in PwD, which is in line with previous findings indicating dementia as a risk factor for involuntary treatment use. More research is needed to gain insight into variations in prevalence across other countries, which factors influence these differences and what countries can learn from each other regarding prevention of involuntary treatment.

Relevance to clinical practice

To provide person‐centred care, it is important to study ways to prevent involuntary treatment in PwD and to stimulate dialogue between professional and family caregivers for alternative interventions.

Uncertainty in Transition of African American Caregivers

The purpose of this study was to gain an understanding of the ambiguities and uncertainties experienced by a diverse group of African-American caregivers. The study applied Schlossberg's transition theory (TT) and Mishel's revised uncertainty theory to narratives of self-identified African-American caregivers who provided care at least 5 h a week. The men (6) and women (8) were mostly unmarried, mostly caring for a parent or grandparent. The caregivers' average age was 52 (SD = 19; ages ranged from 24 to 82 years); and the care recipients' average age was 84 (SD = 9). Six care recipients had dementia and the remainder had multiple disease diagnoses. Narratives were obtained by in-depth interviews or focus group discussions. These were audio-recorded, transcribed verbatim professionally and analyzed independently by trained coders. Schlossberg's TT contextualized whereas Mishel's RUIT illuminated the characteristics of the transition, its associated uncertainty, and their relationship to the development of caregiver stress. Situational factors such as difficulties with illness symptoms of the care recipient, conflict between previous experience and current expectations and the adjustments to the new caregiving role, burdened younger caregivers more than older caregivers. Self-factors related to lack of knowledge about the illness and feelings of lack of control. Social support was predominantly provided by family members, and its absence resulted in conflict among siblings and caregiver stress. The most common coping strategies include religiosity, expectations of reciprocity, and coming to terms with the uncertainty. Understanding the feelings, perceptions and needs of caregivers in transition is tantamount to providing nursing care.

Providing Social Support to Female Olympic Athletes

Support providers may experience positive and negative outcomes associated with supporting others. However, there is a lack of research on support provision to elite athletes and the views of athletes' support providers. This study addressed this gap by exploring the experiences of providing and receiving support between female Olympians and their main support providers. Five female Olympians and their main support providers participated in separate semistructured interviews. It appeared that support provision was personally and professionally rewarding, as well as challenging, for support providers, and athletes were generally satisfied with the support they received. Athletes appeared highly dependent on their support providers, but both athletes and support providers felt that high levels of support were necessary for athletic success. Further research is needed to understand how support providers are able to foster their own personally supportive relationships and whether high levels of interpersonal dependence are required to achieve athletic success.

The Living Experience of Feeling Unsure: A Parsesciencing Inquiry

The purpose of this article is to report the discovery of a Parsesciencing inquiry on the universal humanuniverse living experience of feeling unsure. In discussion with the scholar, 10 historians described their experiences. The discerning extant moment of the living experience of feeling unsure was found to be as follows: Feeling unsure is disquieting trepidation with pursuing endeavors arising with joining with-distancing from affiliations.