Depression and quality of informal care: a longitudinal investigation of caregiving stressors

This research examined longitudinal associations between caregiving stressors, caregiver depression, and quality of care. Informal caregivers of elderly care recipients were interviewed at baseline (N = 310) and again one year later (N = 213). Hierarchical regression analyses indicated that increases in caregiving stressors (i.e., caregiver physical health symptoms, caregiver activity restriction, and care recipient controlling and manipulative behavior) were related to increased caregiver depression. In turn, increased caregiver depression and decreased caregiver respectful behavior predicted increases in potentially harmful behavior. These results extend previous cross-sectional findings and indicate that changes in caregiving stressors, caregiver depression, and caregiver respect over time may signal that intervention is warranted in order to forestall or prevent poor quality of care.     

Interpersonal loss in the context of family caregiving: Implications of communal relationships theory

Abstract

Much is known about the emotional costs of providing care to an ill or disabled family member. However, surprisingly little attention has been devoted to investigating how caregiver distress is related to interpersonal loss (i.e., reactions to changes in the typical day-to-day support behaviors that formerly characterized the caregiver–care recipient relationship). Drawing on the theory of communal relationships (e.g., Clark & Mills, 1979, 1993), this study proposes that the magnitude of interpersonal loss that caregivers experience, as well as its contributions to depressed affect, both directly and indirectly (through impact of interpersonal loss on perceived caregiving burden) are likely to depend on the type of relationship that existed between caregiver and care recipient prior to the onset of illness or disability. In this context, several hypotheses and directions for further research are proposed. It is hoped that future researchers will incorporate loss measures into their research and consider how aspects of preexisting relationships influence associations among interpersonal loss and variables (e.g., burden, social support) known to predict caregiver well-being.     

Relationship quality and potentially harmful behaviors by spousal caregivers: how we were then, how we are now. The Family Relationships in Late Life Project

Structured interview data from 142 caregivers (98 wives, 44 husbands) indicate that more depressed caregivers are more likely to treat their spouses in potentially harmful ways. However, consistent with hypotheses derived from communal relationships theory, when the preillness relationship between caregiver and care recipient was characterized by mutual responsiveness to each other's needs (i.e., was more communal), caregivers were less depressed and less frequently engaged in potentially harmful behaviors. These effects were not attributable to demographic factors, amount of care provided, care recipient dementia status, or length of time in the caregiving role. Rather, multivariate analyses suggest that the extent to which premorbid relationships were communal in nature determines whether caregivers perceive their current relationships as rewarding, which, in turn, predicts caregiver depression and potentially harmful behaviors.     

Models of self and others and their relation to positive and negative caregiving responses

The burden of providing informal care to a family member can lead to caregiver depression and potentially harmful caregiving behavior. Given the interpersonal nature of caregiving, the relationship between caregivers and care recipients may impact caregiver responses. We applied attachment theory to understanding caregiver depression, and both potentially harmful and exemplary caregiving responses. We present data from 430 caregivers in the Family Relationships in Late Life (FRILL 2) Project, a multisite, longitudinal study of caregiving. Age, gender, and model of self were related to caregiving responses, suggesting that model of self may help identify caregivers at risk for poor responses.     

Caring for a Family Member With Cancer: Past Communal Behavior and Affective Reactions1

An important recent development in the caregiving literature is an increased focus on the role played by the interpersonal relationship between caregiver and care recipient. In this study, a prediction derived from communal relationship theory (Clark & Mills, 1979, 1993; Mills & Clark, 1982) was tested in a sample of patients with recurrent cancer and their family caregivers. Specifically, it was hypothesized that if a relationship had been communal in the past (i.e., characterized by mutual demonstrations of concern for and responsiveness to one another's needs), positive feelings about helping one's partner should continue even when one partner's needs far outweigh those of the other. Consistent with this hypothesis, results indicated that caregivers whose relationship with the patient before illness onset had been characterized by relatively infrequent communal behaviors evidenced more symptoms of depression that did those whose relationship had been characterized by more frequent communal behaviors. In addition, the effects of prior communal behavior on depressed affect were both mediated and moderated by feelings of burden. Caregivers who recalled relatively few communal behaviors in their past relationship felt more burdened by their caregiving role, and burden in turn predicted greater depressive symptomatology. Implications for early identification of caregivers at risk for becoming distressed are discussed.     

Positive aspects of caregiving and adaptation to bereavement

This study examined how positive aspects of caregiving affect adaptation to bereavement among older adults who cared for a family member with dementia. The sample consisted of 217 caregivers who were part of the Resources for Enhancing Alzheimer's Caregiver Health Study. Using pre- and postloss data, hierarchical regressions were carried out to examine the effects of positive aspects of caregiving (caregiving benefit) on postloss depression and grief. Findings show that preloss caregiving benefit was associated with higher levels of postloss depression and grief, even after controlling for caregiver demographic characteristics, contextual factors, and caregiving burden. This effect was particularly strong for the relation between benefit and grief. Results demonstrate the importance of studying both positive and negative aspects of caregiving and their relation to bereavement outcomes.     

Positive aspects of caregiving as a moderator of treatment outcome over 12 months

The authors examined the influence of positive aspects of caregiving (PAC) as a moderator of treatment outcome across 12 months in 1 of the original sites of the Resources for Enhancing Alzheimer's Caregiver Health I project. They used multilevel random coefficients regression analysis to predict time-varying PAC, depression, behavioral bother, and daily care burden in Alzheimer's caregivers (N = 243; mean age = 60.89, SD = 14.19). They found that time-varying PAC was predicted by time-varying daily care burden. They also found significant effects of time-varying PAC for depression, behavioral bother, and daily care burden. Notably, a PAC x Phase x Treatment effect was found for daily care burden, such that individuals who endorsed less PAC benefited most from the intervention across 12 months. The tendency to positively appraise the caregiving experience (i.e., PAC) in response to chronic stressors such as Alzheimer's caregiving may affect individuals' responsiveness to, and benefit from, interventions, whereas only daily care burden affected the tendency to find enjoyment in caregiving across 12 months. Future intervention research should assess individual PAC in order to better tailor interventions to caregiving needs.     

Dementia caregiving: recent research on negative health effects and the efficacy of caregiver interventions

Provision of care to an older adult with dementia is an important societal resource. This resource may also come at a high cost to informal caregivers, most of whom are family members. In this paper we provide an overview of recent research on dementia caregiving and caregiver interventions. First, we provide background information on the prevalence and costs of Alzheimer's disease and related disorders. Second, we describe the specific stressors and broader mental and physical health outcomes of dementia caregiving. Third, recent evidence of the efficacy of caregiver interventions for both caregiver and patient outcomes is reviewed. Throughout the paper, we describe promising new directions for future research in this area, including assessment and intervention with family caregivers of older patients with comorbid dementia and depression, and the focus on sleep disturbance as a critical health consequence of dementia caregiving.     

Leisure activities, caregiving demands and catecholamine levels in dementia caregivers

This study examined whether satisfaction from leisure activities moderates the relationship between caregiving demands (i.e., hours per day spent caring for a spouse with dementia) and resting levels of the catecholamines norepinephrine (NE) and epinephrine (EPI). Spousal caregivers (n?=?107; mean age?=?73.95?±?8.12 years) were assessed in home for plasma levels of NE and EPI, amount of care provided, and leisure satisfaction. Regression was used to determine whether leisure satisfaction moderated the relationship between hours providing care per day and catecholamine levels. A significant interaction was found between hours caregiving and leisure satisfaction for NE, but not for EPI. Post?hoc regressions were conducted for both NE and EPI. At low leisure satisfaction, time spent caring for a spouse was positively associated with plasma NE (β?=?0.41; p?=?0.005) and EPI (β?=?0.44; p?=?0.003). In contrast, at high levels of satisfaction, time caregiving was not significantly associated with plasma NE (β?=?-0.08; p?=?0.57) or EPI (β?=?0.23; p?=?0.12). These findings suggest that leisure satisfaction may protect caregivers from increases in catecholamines, which have been implicated in cardiovascular risk. Further support for these findings may impact psychological treatments for distressed caregivers.     

Modeling caregiver adaptation over time: the longitudinal impact of behavior problems

Although cross-sectional research has established the link between care demands and various indicators of caregiver adaptation, few studies have examined the impact of care recipients' problematic behavior over time. The present analysis determines the importance of behavior problems when predicting rates of change in subjective stressors (role overload and role captivity) and depression. Using 4-wave longitudinal data (N = 137) on dementia caregivers, the authors fit individual growth curve models for care demands (i.e., behavior problems, activities of daily living dependencies, and cognitive impairment), subjective stressors, and depression. Subsequent structural equation models found that increases in behavior problems were most likely to predict increases in role overload. The findings emphasize the deleterious long-term impact of behavior problems on individuals' emotional adaptation to caregiving.     

Leisure activities,caregiving demands and catecholamine levels in dementia caregivers

This study examined whether satisfaction from leisure activities moderates the relationship between caregiving demands (i.e., hours per day spent caring for a spouse with dementia) and resting levels of the catecholamines norepinephrine (NE) and epinephrine (EPI). Spousal caregivers (n?=?107; mean age?=?73.95?±?8.12 years) were assessed in home for plasma levels of NE and EPI, amount of care provided, and leisure satisfaction. Regression was used to determine whether leisure satisfaction moderated the relationship between hours providing care per day and catecholamine levels. A significant interaction was found between hours caregiving and leisure satisfaction for NE, but not for EPI. Post hoc regressions were conducted for both NE and EPI. At low leisure satisfaction, time spent caring for a spouse was positively associated with plasma NE (β?=?0.41; p?=?0.005) and EPI (β?=?0.44; p?=?0.003). In contrast, at high levels of satisfaction, time caregiving was not significantly associated with plasma NE (β?=?–0.08; p?=?0.57) or EPI (β?=?0.23; p?=?0.12). These findings suggest that leisure satisfaction may protect caregivers from increases in catecholamines, which have been implicated in cardiovascular risk. Further support for these findings may impact psychological treatments for distressed caregivers.     

Longitudinal impact of interhousehold caregiving on adult children's mental health

The wear-and-tear hypothesis of caregiving (the longer care provided, the more psychological strain on caregivers) was examined using panel survey data from 112 adult children providing interhousehold care to an impaired elderly parent. Measures included subjective caregiving stress and perceived caregiving effectiveness ("wear") and depression and affect balance ("tear"). Contrary to the hypothesis, data revealed variability in children's adaptation to caregiving, improvement rather than deterioration being the norm. In a recursive path model, both subjective stress and perceived effectiveness were significant predictors of changes in depression. Depression was not significantly related to duration of caregiving. Discussion suggests that future researchers consider other types of caregivers and care settings, factors predicting variability in caregivers' adaptation over time, and changes as well as stability in care arrangements.     

Changes in social support as mediators of the impact of a psychosocial intervention for spouse caregivers of persons with Alzheimer's disease

The spouse caregivers of 406 patients with Alzheimer's disease were randomly assigned to an enhanced counseling and support intervention or to a usual care control condition. Structured interviews were conducted to assess changes in social support and psychosocial outcomes for the 312 caregivers who provided care in the home for at least 1 year. The number of support persons, satisfaction with the support network, and support persons' assistance with caregiving all increased significantly as a function of the intervention. Structural equation models indicated increased satisfaction with the social support network mediated a significant proportion of the intervention's impact on caregiver depression. A portion of this mediated effect was further mediated by changes in caregiver stress appraisals. Implications for strengthening intervention programs for spouse caregivers of individuals with Alzheimer's disease are discussed.     

Wealthy families and their drug abusing adolescents

Abstract

Researchers have hypothesized that providing care to an elderly relative can negatively affect marital relationships of caregivers. However, no research has directly examined this issue. This study explored the impact of elderly depression and impairment, mental caregiving, caregiver/elderly person relationship closeness, spouse burden, and caregiver burden on caregiver marital happiness (and adjustment) in 90 multigenerational families. No significant relationship was found between these variables and caregiver marital adjustment. A causal model involving the six independent variables and caregiver marital happiness was developed and tested. Elderly depression and caregiver burden directly affected level of caregiver marital happiness. The other four independent variables affected caregiver marital happiness indirectly through caregiver burden. Implications for marriage and family therapists are discussed.     

The effect of multiple roles on caregiver stress outcomes

Some caregivers focus exclusively on the caregiving role; others try to balance caregiving responsibilities with a simultaneous work role outside the home. This study examined competing hypotheses about the impact that greater immersion in a work role would have on the stress outcomes of individuals who provide care for a person with a disability. The authors used national survey data to examine whether hours of work were associated with caregiver stress outcomes. The authors also investigated whether type of disability moderated the relationship between hours worked and stress outcomes. Results suggest that spending more time in a work role generally has no effect on caregiver stress outcomes. However, caregivers who were caring for a person with a mental disability experienced significantly fewer stress outcomes as they spent more hours engaged in outside work.     

Attachment,perceptions of care and caregiving to romantic partners and friends

Across two studies, we examined the extent to which adults' caregiving responses reflect the quality of care received from their attachment figures. Study 1 showed that romantic caregiving reflected the quality of perceived parental and partner care. Moreover, perceived partner care mediated the link between parental care and romantic caregiving, suggesting that one's parental care affects the type of care one seeks or receives from partners, which in turn affects one's romantic caregiving. This describes a possible process for the intergenerational transmission of caregiving styles. Romantic attachment anxiety was associated with compulsive caregiving to partners. Study 2 examined causal mechanisms by priming a representation of perceived peer care and examining its effect on caregiving responses. As hypothesized, caregiving responses reflected the quality of primed peer care and were associated with attachment orientation. Findings provide evidence that individuals mentally represent the thoughts, feelings and behaviours of the care‐seeker and the caregiver during interactions and both influence one's caregiving to partners and friends. Copyright © 2012 John Wiley & Sons, Ltd.     

Caregiving in the close relationships of cardiac patients: Exchange,power, and attributional perspectives on caregiver resentment

Individuals with a cardiac condition and their spousal caregivers were recruited from cardiac rehabilitation centers and interviewed separately. Based on exchange theory, it was expected that greater caregiver resentment would be associated with feeling underbenefited in the relationship and with an orientation to relationships that did not focus on the needs of the partner (communal), but did focus on “tit-for-tat” reciprocity (exchange). It was also expected that those caregivers who were more likely to get their needs satisfied in the relationship before the cardiac incident would be more resentful at giving care. Finally, based on attributional theory, it was predicted that caregivers who thought that their spouses were not taking responsibility for improving their health would be more resentful. As predicted, more resentful caregivers were those who felt underbenefited, were more exchange oriented, and judged that their partners were not working toward improving their health. In addition, only those with a low communal orientation toward their spouse showed a relationship between feeling underbenefited and resentment. The needs centrality prediction was not supported. The findings illustrate the utility of applying theories developed in the close relationship area to the understanding of caregiving with chronically ill populations.     

The longitudinal effects of early behavior problems in the dementia caregiving career

Using multiregional, 3-year data from early career dementia caregivers, this study determines how behavior problems that occur early in the caregiving career influence time to nursing home placement and change in burden and depression over time. A Cox proportional hazards model indicated that caregivers who managed frequent behavior problems earlier are more likely to institutionalize. After controlling for important time-varying covariates in a series of growth-curve models, caregivers who were faced with severe, early behavior problems reported greater increases in burden and depression over the 3-year study period. The findings suggest the need to consider experiences early in the dementia caregiving career when accounting for key longitudinal outcomes and also emphasize the importance of attrition when attempting to model the health implications of informal long-term care over time.     

The psychosocial impact of caregiving in dementia and quality of life: a systematic review and meta-synthesis of qualitative research

ABSTRACT

Objective: A systematic meta-synthesis of qualitative studies was conducted to interpret and synthesise findings from studies investigating the experiences, quality of life, and psychosocial impact of caregiving on adult informal caregivers of people with dementia.

Design: The meta-synthesis was conducted according to the principles of meta-ethnography.

Results: Fourteen studies describing the experiences of 265 informal caregivers were reviewed. The meta-synthesis elicited the following themes: (1) understanding and making sense of the dementia diagnosis, changing symptoms, and the caregiver role; (2) coping strategies, psychological facilitators and rewards of caregiver role; (3) challenges of caring for a person with dementia and their behaviour; (4) caregivers' relationships with care-recipient and other informal caregivers; and (5) caregivers’ experiences of formal support services and material resources.

Conclusion: Our findings highlight the need for a person-centred approach to care planning that also accounts for the needs of the informal caregiver to promote better caregiver well-being and quality of life. Caregivers’ emotional support, coping, resilience, need for information and respite care and adjustment to caregiver identity should be reviewed as part of the care package for the person with dementia.