Quality of Life and Deficit Identification in Dementia

Numerous studies have examined self-identification of deficits in persons with dementia. Few of these studies consider the influence of interpersonal and social factors on deficit identification, and most focus on whether or why deficits are ‘underreported’ by persons with dementia. In our studies, we found considerable variation in deficit identification within and among persons with dementia, and some ‘overreporting’ of deficits in comparison with caregiver reports across all of the domains studied. Thus, focusing on ‘underreporting’ and aggregate level data neglects information that could be important to measuring and understanding quality of life in dementia. Current approaches to measuring and understanding quality of life in dementia make divergent assumptions about the impact of deficit identification. Emerging phenomenological perspectives suggest that proactive interventions that treat deficit identification as an interpersonal and social challenge inherent in the experience of dementia would enhance the quality of life of caregiving dyads.

The Relationship of Self-Restraint and Distress to Coping Among Spouses Caring for Persons With Alzheimer's Disease

This study investigated the relationship between two basic dimensions of social-emotional adjustment: distress and self-restraint, as identified by Weinberger and Schwartz (1990), and the use of four coping strategies by spouse caregivers of persons with Alzheimer's disease. Care givers were most frequently categorized as oversocialized (high distress, high self-restraint) and repressive (low distress, high self-restraint) according to Weinberger and Schwartz's (1990) social-emotional adjustment typology. A higher proportion of males than females were under- socialized (low distress, low self-restraint) and reactive (high distress, low self-restraint), whereas a higher proportion of females than males were oversocialized (high distress, high self-restraint). High distress caregivers were more likely to use the emotion-focused coping strategy of wishfulness, whereas low distress caregivers were more likely to use acceptance and the problem-focused strategy of instrumental coping. Although there were gender differences in distress and the use of specific coping strategies, the relationships between distress and coping strategies used held regardless of gender. Implications for caregiver intervention programs as well as directions for future research are discussed.

Does depression prior to caregiving increase vulnerability to depressive symptoms among caregivers of persons with Alzheimer's disease?

Based on the vulnerability model of depression, this study tested the hypothesis that caregivers with prior depression are more likely to be depressed during caregiving than caregivers without prior depression. We further hypothesized an interaction effect in which caregivers with prior depression would be affected more by care-recipient dependency in activities of daily living and care-recipient depressive symptoms than those without prior depression. In a sample of 111 caregivers of persons with Alzheimer's disease, in an additive regression model, neither 'prior depressive symptoms' nor the clinically more serious 'prior depressive syndrome' was related to depressive symptoms during caregiving. In an interaction model, for caregivers with either 'no prior depression' or 'prior depressive symptoms,' the greater the care-recipient dependencies in instrumental activities of daily living (IADL), the greater were the depressive symptoms during caregiving. For caregivers with a 'prior depressive syndrome', however, the greater the IADL dependency, the fewer were the depressive symptoms during caregiving. This unexpected finding suggests that caregivers with a history of clinically significant depression are not necessarily more prone to depressive symptoms when caregiving responsibilities, at least for instrumental activities, are high. This result questions the vulnerability model of depression when applied to older caregivers.

HIV-risk factors for midlife and older women

PURPOSE

The number of women aged 45 years and older infected with the HIV virus continues to increase. This study sought to identify, from the voices of midlife and older women living with HIV, the factors in their lives that put them at risk for HIV, so as to improve HIV-prevention efforts for women of this age group.

DESIGN AND METHODS

In this qualitative study, we conducted in-depth interviews with 24 HIV-positive women, aged 45 to 71 years, regarding their exposure to HIV.

RESULTS

From these narratives, we identified five individual factors or themes that put women at risk for HIV: drug and alcohol abuse; not knowing the HIV-risk histories of male sexual partners; mental health issues, including physical or sexual abuse and life crises; taking risks for the sake of relationships; and lack of HIV-prevention information. These individual factors and sociocultural factors related to gender, age, and race and ethnicity were organized into a model of HIV-risk factors for midlife and older women.

IMPLICATIONS

This model identifies themes to be addressed in HIV-prevention policy, practice, and research in order to reduce the number of new cases of HIV infection among midlife and older women.

Long-Term-Care Placement and Survival of Persons With Alzheimer's Disease

Although long-term-care (LTC) placement may shorten the survival of persons with Alzheimer's disease, studies have not examined whether the timing of placement matters. A sample of 258 persons with Alzheimer's disease and their family caregivers was used in a Cox survival model that included care-recipient impairments, caregiver characteristics, and LTC placement as covariates. Placement was associated with shortened survival, but the later the placement, the smaller the impact of placement on survival time. In an elaboration on prior work, the increased risk of death associated with wishfulness-intrapsychic caregiver coping was found to occur independently of LTC placement. This is the first study to link delayed LTC with a reduced risk of death in Alzheimer's disease. Interventions to assist family caregivers in the home are indeed appropriate; nevertheless, these findings may help long-term caregivers accept eventual institutionalization for their care recipients when care at home threatens their own health.

Survival of Persons With Alzheimer's Disease: Caregiver Coping Matters

PURPOSE

Although persons with Alzheimer's disease (AD) require increasingly more assistance with activities of daily living as their disease progresses, the caregiving environment has received little attention as a source of predictors of their survival time. We report here on a study to determine whether variation in survival time of persons with AD can be better explained by including caregiver variables such as coping style and depressive symptoms as predictors.

DESIGN AND METHODS

A sample of 193 persons with AD residing in the community and their family caregivers was used to estimate the parameters of a Cox regression model of survival time that included both caregiver characteristics and care-recipient impairments as covariates.

RESULTS

Caregiver wishfulness-intrapsychic coping was related to shorter care-recipient survival time, but instrumental and acceptance coping and caregiver depressive symptoms were not associated with survival time. Care-recipient impairments (dependency in activities of daily living, low score on the Mini-Mental State Examination, and problematic behaviors) were associated with shorter survival time.

IMPLICATIONS

Because this study is the first to report the link between caregiver coping and care-recipient survival, further study to understand the dynamics is required. We discuss several possible mechanisms, including the possibility that caregivers engaging in wishfulness-intrapsychic coping are less psychologically available to the person with dementia. These caregivers may therefore provide less person-centered care that is responsive to the true capacities of the person with dementia, and thus they may inadvertently contribute to excess disability and consequent accelerated decline. Because wishfulness-intrapsychic coping was uncorrelated with instrumental or acceptance coping, our findings suggest that interventions to enhance coping skills among caregivers, which have focused primarily on increasing problem solving and acceptance coping, also may have to include specific attempts to reduce wishfulness-intrapsychic approaches to benefit not only the caregiver but the care recipient as well.

A longitudinal study of the relationship between levels of depression among persons with Alzheimer's disease and levels of depression among their family caregivers

The purpose of this study was to examine the effects, over time, of depressive symptoms in persons with Alzheimer's disease on depression in their family caregivers. In a sample of 353 patients and caregivers, multilevel longitudinal analysis was used to accommodate an observational design in which the number of observation points and the intervals between points varied across caregivers. The rate of change (increase) in caregiver depression was predicted by the rate of change (increase) in patient depressive symptoms and by increase in patient dependency in instrumental activities of daily living (ADLs). Acceleration of the increase in caregiver depression was predicted by acceleration in patient dependency in instrumental and basic ADLs but not by acceleration in patient depressive symptoms. These findings indicate the importance of measuring the rate and acceleration of change in patient characteristics in order to understand caregiver depression. They also support early interventions for caregivers.

Burden and well-being: the same coin or related currency

To examine whether caregiver burden and general well-being are opposite sides of the same coin or distinct constructs, we compared burden (in physical, mental, financial, and social domains) and well-being (in the same domains, but with separate objective and subjective measures). The domains of burden and well-being were examined first as correlates of one another, second as correlates of antecedents in the caregiving situation, and finally, as predictors of likelihood to institutionalize. We conclude that burden and well-being are not opposite sides of the same coin, but rather related currency, each useful for tapping unique facets of the caregiving experience.

Effects of group interventions on cognition and depression in nursing home residents

The effects of cognitive-behavioral group therapy, focused visual imagery group therapy, and education-discussion groups on cognition, depression, hopelessness, and dissatisfaction with life were studied among depressed nursing home residents. Seventy-six depressed subjects with mild to moderate cognitive decline participated in nurse-led 24-week protocols. Data were collected 4 weeks before the interventions, 8 and 20 weeks after treatment initiation, and 4 weeks after treatment termination. There were no significant changes in depression, hopelessness, or life satisfaction scores for any of the three conditions. Participants in the cognitive-behavioral and focused visual imagery groups showed a significant improvement beginning 8 weeks after treatment initiation on cognitive scores. These findings are encouraging indications that cognitive-behavioral and focused visual imagery group therapies may reduce cognitive impairment in depressed nursing home residents with mild to moderate cognitive decline.

Coping and health outcomes in spouse caregivers of persons with dementia

The effects of different coping patterns on the physical health, depression, and anxiety experienced by 60 spouse caregivers of persons with dementia were examined, using Lazarus and Folkman's cognitive model of stress and coping. In addition to coping, the model included the following predictors: severity of the patient's memory and behavior problems, caregiver's appraisal of the stressfulness of those problems, and caregiver's appraisal of their options for managing caregiving. The predictors did not explain a significant amount of the variance in caregivers' physical health, but they did explain 43% of the variance in both depression and anxiety. The only coping pattern that added to the explanations was Wishing-Emotive coping, which consisted of the coping subscales of escape-avoidance, confrontive coping, and accepting responsibility. Caregivers' appraisal of stress was a significant predictor of depression and anxiety, but neither the severity of the patients' problems nor caregivers' appraisal of options was a significant predictor of any of the health outcomes.

Changes in resident mix in nursing homes: cognitive and sensory data from a (redesigned) sampling plan

In planning and implementing a study, we unintentionally and serendipitously obtained data about changes in resident mix over a 2.8-yr. period. We screened residents of a 184-bed nursing home for cognition and sensorium in October 1984 to assess sampling feasibility for a grant proposal in preparation. At that time, 65.2% of the residents met the sampling criteria. However, in July/August 1987, after award of funding, only 5.4% of residents of the same nursing home met the cognitive and sensory criteria. We were forced to recruit from an additional six nursing homes, in which only 9.3% of residents met the sampling criteria.

Alzheimer's disease. Involving nursing in the development and implementation of health care for patients and families

This article focuses on integrating nurses into the development, implementation, and evaluation of clinical, inpatient, community-based, and in-home services for patients with Alzheimer's disease and for their families.