Care Recipient Behavioral Problems Research Articles

Caregivers' Internet-Delivered Insomnia Intervention Engagement and Benefit: SHUTi-CARE Trial Primary Quantitative Analysis.

Delivering insomnia treatment by the Internet holds promise for increasing care access to family caregivers, but their ability to adhere to and benefit from such fully-automated programs has not been rigorously tested. This fully-powered, single-group trial tested whether characteristics of the caregiving context influence high-intensity caregivers' engagement with and benefit from an empirically validated Internet intervention for insomnia. At baseline, caregivers providing unpaid time- and responsibility-intensive care who reported insomnia (N = 100; age M = 52.82 [SD = 13.10], 75% non-Hispanic white, 66% ≥college degree) completed questionnaires about caregiving context and sleep, then 10 prospectively-collected online daily sleep diaries. Caregivers then received access to SHUTi (Sleep Healthy Using the Internet), which has no caregiver-specific content, for 9 weeks, followed by post-assessment (questionnaires, diaries). Engagement was tracked by the SHUTi delivery system. Sixty caregivers completed SHUTi, 22 initiated but did not complete SHUTi, and 18 did not initiate SHUTi. Caregivers were more likely to use SHUTi (than not use SHUTi) when their care recipient (CR) had worse functioning, and were more likely to complete SHUTi when supporting more CR activities of daily living (ADL; ps < .03). Higher caregiver guilt, more CR problem behaviors, and being bedpartners with the CR related to more improved sleep outcomes, whereas supporting more CR instrumental ADL related to less improvement (ps < .05). Factors associated with greater caregiving burden, including greater CR impairment and caregiving guilt, were generally associated with better engagement and outcomes. Caregivers with substantial burdens can adhere to and benefit from a fully automated insomnia program without caregiver-specific tailoring.

Caregivers' Internet-Delivered Insomnia Intervention Engagement and Benefit: SHUTi-CARE Trial Primary Quantitative Analysis.

Delivering insomnia treatment by the Internet holds promise for increasing care access to family caregivers, but their ability to adhere to and benefit from such fully-automated programs has not been rigorously tested. This fully-powered, single-group trial tested whether characteristics of the caregiving context influence high-intensity caregivers' engagement with and benefit from an empirically validated Internet intervention for insomnia. At baseline, caregivers providing unpaid time- and responsibility-intensive care who reported insomnia (N = 100; age M = 52.82 [SD = 13.10], 75% non-Hispanic white, 66% ≥college degree) completed questionnaires about caregiving context and sleep, then 10 prospectively-collected online daily sleep diaries. Caregivers then received access to SHUTi (Sleep Healthy Using the Internet), which has no caregiver-specific content, for 9 weeks, followed by post-assessment (questionnaires, diaries). Engagement was tracked by the SHUTi delivery system. Sixty caregivers completed SHUTi, 22 initiated but did not complete SHUTi, and 18 did not initiate SHUTi. Caregivers were more likely to use SHUTi (than not use SHUTi) when their care recipient (CR) had worse functioning, and were more likely to complete SHUTi when supporting more CR activities of daily living (ADL; ps < .03). Higher caregiver guilt, more CR problem behaviors, and being bedpartners with the CR related to more improved sleep outcomes, whereas supporting more CR instrumental ADL related to less improvement (ps < .05). Factors associated with greater caregiving burden, including greater CR impairment and caregiving guilt, were generally associated with better engagement and outcomes. Caregivers with substantial burdens can adhere to and benefit from a fully automated insomnia program without caregiver-specific tailoring.

Longitudinal effects of cognitive fusion in depressive and anxious symptoms of family caregivers of people with dementia.

Family dementia caregiving has been commonly associated with psychological distress for caregivers. Cognitive fusion, that is, the tendency to become too entangled in thoughts, beliefs, or judgments (in the absence of objectivity) that may often lead to rigid thinking and impact psychological distress, is a transdiagnostic and central process of psychological inflexibility. Cross-sectional studies have shown that family caregivers of people with dementia who could present high levels of stress may be vulnerable to experiencing psychological symptoms such as depression and anxiety (even comorbidity) if they present this rigid way of thinking without seeing the objectivity of their thoughts, which could be related to aspects of the family member's dementia or helplessness in being a caregiver, for example. Specifically, studies in the caregiving field, as well as in other populations, suggest that cognitive fusion could play a mediating role in the relationship between stress and psychological symptoms. However, the predictive role of caregivers' cognitive fusion on psychological distress has not been analyzed in longitudinal studies. The objective of this study was to analyze the longitudinal effect of cognitive fusion in depressive and anxious symptoms after controlling for other relevant variables in a sample of Spanish family caregivers. Face to face assessments were conducted with a total of 176 Spanish family dementia caregivers. The study involved three assessments in a two-year period (baseline, 12 and 24 months). Linear mixed model analysis was used to analyze the associations between time-varying values of frequency and reaction to care-recipient behavioral problems, cognitive fusion, and caregivers' depressive and anxiety symptoms. Increases in cognitive fusion significantly predicted depressive and anxious symptoms (p < 0.01). In addition, reaction to care-recipients’ behavioral problems and being a female caregiver predicted increases in anxiety symptoms over time (p < 0.05). These results suggested that cognitive fusion may constitute a core dysfunctional mechanism involved in depressive and anxious symptoms. Psychological strategies aimed at reducing cognitive fusion and stress levels may be especially helpful for reducing caregivers' distress.

Predictors of Burden and Resilience in Family Caregivers of Individuals With Opioid Use Disorder.

Family caregivers are an essential resource for individuals with opioid use disorder (OUD). Overburdened caregivers often experience detrimental effects to their emotional and physical well-being. A cross-sectional, nonexperimental, correlational study was used to identify correlates and predictors of burden and resilience in caregivers of care recipients with OUD. Pearson product-moment correlation and multiple regression analysis were used to explore the relationships between caregiver characteristics, care recipient characteristics, the caregiver-care-recipient dyad characteristics, and burden and resilience among caregivers of individuals with OUD and to determine the best predictive model. Participants ( N = 152) completed the study using an online electronic survey. The standardized regression coefficients indicated that supervision of care recipient behavioral problems (β = .29), dyadic interaction (β = .29), caregiver stress (β = .28), and care recipient opioid use (β = .12) were the strongest predictors of caregiver burden, whereas caregiver mental health (β = -.31) and physical health (β = .30) were the strongest predictors of caregiver resilience. Caregiver and care recipient characteristics, and their dyadic interaction, directly influence the degree of burden and resilience reported by family caregivers. Caregivers experiencing increased stress who are tasked with supervising problematic care recipient behaviors are more likely to experience higher levels of burden. In contrast, caregivers with good physical and mental health and adequate resources showed higher levels of resilience.

Exploring caregiving stressors and informal resources among Alzheimer's caregivers

BackgroundWe use Pearlin's Stress Process Model to examine the objective stressors and subjective burdens of caregiving among family members who care for people with Alzheimer's disease. We ask how these factors are related, whether and how these factors are related to caregivers’ depressive symptoms, and whether their impact on caregivers’ mental health is reduced by caregivers’ informal resources. MethodsOLS regression analyses were used to examine the processes hypothesized by the stress process model using baseline and screen data from the Resources for Enhancing Alzheimer's Caregiver Health II (REACH II) study. Analysis was conducted using R. ResultsSocial structural disadvantages have little effect on the stress of caregiving. However, women experience greater subjective burden and greater depressive symptoms. The most important objective stressor is the care recipient's behavior problems, but its effects are mostly explained by subjective burden. Subjective burden tends to deplete caregivers’ informal psychosocial resources, but this does not explain why subjective burden is the most important determinant of depressive symptoms. Informal psychosocial resources do not play an important role in reducing the impact of caregiving stress on depressive symptoms. DiscussionThis study suggests that without a full understanding of the effects of the burden of caregiving, any interventions or preventive actions will be of limited utility. Researchers and policymakers should consider the utility of providing tangible services to offset the negative impact of caregiving.

Resources for Enhancing Alzheimer's Caregiver Health in Vietnam (REACH VN): Exploratory Analyses of Outcomes of a Cluster Randomized Controlled Trial to Test the Feasibility and Preliminary Efficacy of a Family Dementia Caregiver Intervention in Vietnam

ObjectiveFew support services and caregiving interventions exist to support family caregivers in low- and middle-income countries (LMIC). This paper presents exploratory analyses of outcomes of Resources for Enhancing Alzheimer's Caregiver Health in Vietnam (REACH VN). MethodsA cluster randomized controlled trial (RCT) was conducted in Soc Son, a semi-rural area in Hanoi. Nine clusters with 60 caregivers were randomized to either an enhanced control group or REACH VN, an in-home, multicomponent, family caregiver support intervention delivered over two to three months. Outcomes were assessed at baseline and three months. ResultsCaregivers in the intervention group experienced a significantly greater reduction in frustration levels compared to those in the control group. There were differences in other outcomes (e.g., care recipient problem behaviors and associated caregiver bother) favoring the intervention condition that did not reach statistical significance. ConclusionWe found additional evidence that REACH VN is a promising intervention to improve family caregiver outcomes in Vietnam.

Longitudinal Effects of Stress and Cognitive Fusion in Anxiety and Depressive Symptoms of Family Caregivers

Dementia caregiving has been commonly associated with negative psychological consequences in caregivers. Cognitive fusion, that is, the tendency for been overly influenced by cognition, has been linked to psychological distress in caregivers in cross-sectional studies. Female caregivers and those who are exposed to more stressors such as behavioral and psychological symptoms of dementia report higher levels of distress. However, longitudinal analysis of predictors of caregivers levels of distress are sparse, with no available study analyzing the longitudinal effect of cognitive fusion. The aim of this study is to analyze the longitudinal effect of cognitive fusion in depressive and anxiety symptoms of family dementia caregivers, after controlling for other relevant variables. Face to face interviews were conducted each year through a two-year period (three assessments) with 143 caregivers. Linear mixed models analysis were used to analyze the associations between time-varying values for cognitive fusion, frequency and reaction to care-recipient behavioral problems and depressive and anxiety symptoms, after controlling for caregivers’ age and gender, daily hours and time caring, care-recipient functional capacity and caregivers’ transitions (cessation of caregiving). Results suggest that increases in cognitive fusion and in reaction to behavioral problems, being a female caregiver and being younger, significantly predicted increases in anxiety symptoms over time. Also, increases in cognitive fusion and in reaction to behavioral problems, decreases in care-recipient’s functional capacity and ending of the caregiving role significantly predicted increases in depressive symptoms. Psychological strategies aimed at reducing cognitive fusion and stress levels may be especially helpful for reducing caregivers’ distress.

Beta test of a mobile health application for dementia caregivers

AbstractBackgroundDementia caregivers are at risk for negative health outcomes. Caregiver interventions to address this risk are limited by time and personnel constraints. Mobile technology is one means of reaching many caregivers while mitigating these constraints. The aim of the current project was to obtain initial data from a month‐long beta test of a new mobile health tablet App for dementia caregivers.MethodA purposive sample of community‐dwelling dementia caregivers was given access to the CARE‐Well (Caregiver Assessment, Resources, and Education) App for one month. The App consisted of 6 primary sections: (1) Self‐Assessment of Stress and Care Recipient Behavioral Problems; (2) Psychoeducation; (3) Goal Diary; (4) Managing Behavior Problems; (5) Online Message Forum; and (6) Video Library. Feedback was collected from caregivers in a qualitative interview following study completion. Data were analyzed via a mixed‐methods approach.ResultCaregivers (n = 10) were White, in their mid‐60s (M = 66.2, SD = 12.12), and well educated (M = 16.00 years, SD = 1.63). Care recipients had either mild (80%) or moderate dementia (20%), and 90% had probable Alzheimer’s disease. The average total time spent on the App across all participants was 754.29 minutes (SD = 1584.12). The most heavily used (in minutes) sections of the App were: Managing Behavior Problems (M = 592.10, SD = 1595.75), Video Library (M = 54.33, SD = 88.18) and Psychoeducation (M = 53.18, SD = 54.50). Qualitative feedback was predominantly positive. Caregivers reported Managing Behavior Problems to be the most helpful section followed by Psychoeducation and Online Message Forum. Caregivers reported difficulty with or disinterest in the Goal Diary section. In general, caregivers reported that the App would have been more helpful earlier in their care recipient’s illness.ConclusionResults indicated that caregivers regularly used the App and provided mostly positive responses to content. Findings highlighted the importance of user feedback and an iterative approach for developing digital health technology for dementia caregivers. Future interventions that are introduced earlier in the disease process may be well‐received and more beneficial to a wider range of dementia caregivers and their care recipients.

Predicting depression in dementia caregivers: do religious/spiritual struggles play a role?

Objectives Using a stress process framework model, the goal of this study was to address the current gap in our understanding of the prevalence and predictive power of specific types of religious/spiritual struggles for mental health outcomes in informal dementia caregivers. Method A convenience sample of 156 informal dementia caregivers completed a scale measuring six domains of religious/spiritual struggles, as well as other measures of primary stressors, background/contextual variables, and mental health outcome (depression). Results Overall levels of religious/spiritual struggle were low, but 26 percent of the sample were classified as possible cases of clinically significant religious/spiritual struggle for at least one of the six domains. Of this group, 49 percent acknowledged struggles with ultimate meaning. Religious/spiritual struggles predicted greater self-reported depression over and above number of care recipient problem behaviors (primary stressor), caregiver sex, and caregiver personality (i.e. emotional stability). Although no individual domain of religious/spiritual struggle emerged as most salient, caregivers reported significantly more ultimate meaning struggles than demonic or interpersonal struggles. Conclusion Consistent with the stress process framework model, religious/spiritual struggles appeared to operate as a secondary stressor for informal dementia caregivers, adding predictive power to background/contextual factors and to primary stressors for the measured outcome of self-reported depression. One-fourth of the sample self-reported potentially clinically significant religious/spiritual struggles, with ultimate meaning struggles most commonly reported. Further research in this area may advance efforts to better equip both secular and religious professionals to provide evidence-based counsel to informal dementia caregivers.

Initial Translation of a Dementia Caregiver Intervention Into a Mobile Health Application

Caring for a person with dementia is associated with negative outcomes. Few caregiver interventions have been implemented in community settings. Mobile technology is one method for reaching many caregivers. This project translated two empirically-supported interventions for dementia caregivers into a mobile health application. A team of clinical researchers and computer engineers developed an App called CARE-Well (Caregiver Assessment, Resources, and Education) over 6 months. The group worked closely to do the following: 1). translate interventional content to be compatible with a mobile platform; 2). create new materials; 3). determine App components that captured key intervention areas; 4). troubleshoot formatting, technology, and data security; and 5). educate each other about respective areas of expertise. We developed a beta version of the App that included: 1). assessment of caregiver stress and care recipient behavioral problems; 2). psychoeducation; 3). goal diary; 4). managing behavior problems; 5). online message forum; and 6). video library. Several challenges arose during the App development process, such as how to create navigation paths and goal lists based off users’ assessment responses, data storage and usage tracking, enlarging text, and how to ensure privacy and confidentiality in the online message forum. Our experience developing the CARE-Well App showed that translating behavioral interventions into mobile health applications is feasible and dependent upon regular communication among multidisciplinary team members. Next steps for the App include beta testing with dementia caregivers and conducting a pilot randomized trial to determine feasibility for a future trial and its effects on caregiver stress.

Caregiver Resilience as a Protective Factor for Elder Abuse

This study examines the protective function of caregiving resilience and caregiving self-efficacy for elder abuse. A convenient sample of 600 family caregivers of community dwelling older Chinese in Hong Kong were individually interviewed. Participants were assessed on the caregiving context, care recipient physical functioning and behavioral problems, perceived caregiver stress, neurotic personality, caregiving self-efficacy and resilience. Past year elder abuse was assessed using Revised Conflict Tactic Scale and Older Adult Financial Exploitation. Elder abuse is common in this sample: 7.5, 11.5, 24 per cent reported physical, psychological, and financial abuse respectively. Injuries were reported in 2.3% of the sample. Hierarchical linear regression analysis was conducted. Number of co-residing days and hours of care provided per week were entered into Model One; Care recipient physical functioning, behavioral problems, and caregiver stress were entered into Model Two; Caregiver resilience and caregiving self-efficacy were entered into Model Three. Care recipient behavioral problems and caregiver stress were prominent factors associated with abuse across all models. With the exception of physical abuse, caregiver resilience buffered the effects of care recipient behavioral problems and caregiver stress on all forms of elder abuse. No such effect was observed for caregiving self-efficacy. Intervention efforts aiming at fostering caregiver resilience could potentially prevent elder abuse.

Predicting Depression in Dementia Caregivers: Do Religious/Spiritual Struggles Play a Role?

Using a stress process framework model, this study is the first to comprehensively examine the role that religious/spiritual struggles play in the lives of informal dementia caregivers. A convenience sample of 156 informal dementia caregivers completed a scale measuring six domains of religious/spiritual struggles, as well as other measures of primary stressors, background/contextual variables, and mental health outcome (depression). Overall levels of religious/spiritual struggle were low, but 26 percent of the sample were classified as possible cases of clinically significant religious/spiritual struggle for at least one of the six domains. Of this group, 49 percent acknowledged struggles with ultimate meaning. Religious/spiritual struggles predicted greater self-reported depression over and above number of care recipient problem behaviors (primary stressor), caregiver sex, and caregiver personality (i.e., emotional stability). Although no individual domain of religious/spiritual struggle emerged as most salient, caregivers reported significantly more ultimate meaning struggles than demonic or interpersonal struggles. These findings support the growing body of research suggesting that religious/spiritual struggles serve as a secondary stressor, adding predictive power to background/contextual factors and to primary stressors for informal dementia caregiver mental health outcomes. Further research in this area may advance efforts to better equip both secular and religious professionals to provide evidence-based counsel to informal dementia caregivers.

An Integrative Review of Measuring Caregiver Burden in Substance Use Disorder.

Family caregivers contribute to engagement in treatment and adherence, reduced substance misuse and relapse, and increased well-being of recipients with substance use disorder. However, providing care has also been associated with negative emotional and physical health outcomes for caregivers. The purpose of this integrative review was to determine what instruments are used to measure caregiver burden in informal caregivers of individuals with substance use disorder. An integrative review framework was applied to examine empirical and theoretical literature to answer the guiding research question, "How is caregiver burden measured in caregivers of individuals with substance use disorder?" PubMed, CINAHL, and APA PsychINFO were searched using a combination of search terms. The initial 1,198 articles were narrowed to 32 that fit the search criteria and purpose of the review. A variety of scales have been used to measure caregiver burden. Caregiver burden is operationalized as objective or subjective burden. Objective burden refers to changes in the home, finances, employment, social life, and leisure, whereas subjective burden refers to the emotional reaction of the caregiver in coping with providing care. Caregiver burden was most often reported as moderate to severe in populations with substance use disorder. Attributes measured included anxiety, depression, stress, worry, displeasure, care recipient behavioral problems and substance abuse, stigma, relationship strain, financial expenses, social support, family disruption, and the effect on caregiver physical and emotional health. Specific instruments that can accurately evaluate objective and subjective caregiver burden are needed to measure the quality of caregiver health. More research is necessary to better understand the physical and emotional health of caregivers of persons with substance use disorder and the factors that contribute to increased quality of life. Understanding the relationship between outcomes and protective factors could help nurses to develop prevention strategies and treatment interventions aimed at decreasing the psychosocial trauma and stress associated with caregiver burden.

ELDER ABUSE BY FAMILY CAREGIVER: DOES COGNITIVE IMPAIRMENT REALLY MATTER?

Previous research suggested that cognitive impairment is a risk factor for elder abuse. Persons with dementia experience elevated risk of abuse as compared to the general aging population. The present study compared rates of abuse reported by family caregivers of older persons with and without dementia. A total of 693 family caregivers participated, among which 592 were providing care older persons with dementia and 101 were providing care to older persons without. Participants provided information on their demographic characteristics, care recipient physical functioning (Instrumental Activities of Daily Living), behavioral problems (Cohen Mansfield Agitation Inventory), caregiver stress (Zarit Burden Interview), emotional and instrumental social support, and abusive behaviors directed at the care recipients (Conflict Tactics Scale and Potentially Harmful Behaviors). Abuse is common in this sample: 46.8% reported potentially harmful behaviors, 52.7% reported psychological aggression, 11% physical assault, and 1.3% injury. No significant difference was observed between caregivers providing care to older persons with or without dementia (p>.05). A series of logistic regression was conducted to determine factors associated with abuse. Care recipient behavioral problems and caregiver burden were two prominent factors associated with potentially harmful behaviors and all forms of abuse. Behavioral problems are common in persons with cognitive impairment and many caregivers feel stressful managing them. It is plausible that cognitive impairments per sec do not increases risk of abuse, but the associated characteristics do. Helping family caregivers manage the caregiving situation and their expectation, positive appraisal and cognitive restructuring may help prevent elder abuse.

FACTORS ASSOCIATED WITH CAREGIVER REACTIONS TO PROBLEM BEHAVIORS OF PERSONS WITH ALZHEIMER’S DISEASE

Problem behaviors among persons with Alzheimer’s Disease (AD) can have a major impact on caregivers. However, caregiver’s subjective reactions to the problem behaviors have a stronger impact on caregivers than the objective frequency of problem behaviors (Robinson et al., 2001). This study aims to examine the factors associated with caregiver’s subjective reactions to problem behaviors. Data were collected from a sample recruited from community agencies served AD caregivers in the southeastern region of the country (N=109). The caregivers’ reactions to problem behaviors were measured by the Revised Memory and Behavior Problem Checklist (Teri et al., 1992). Three subscale scores were used to measure the reactions to the behaviors related to memory loss, depression and disruption. Multivariate regression models were conducted including gender, race, employment, living arrangement, knowledge about the disease, resilience for caregivers; and ADL and IADL functioning, and frequency of problem behaviors for care recipients. Race (B=-.162; p<.05) and frequency of care-recipient problem behaviors (B= 0.733; p<.001) were significantly associated with caregiver’s reaction to problem behaviors. Caregiver’s knowledge about the disease (p<.01) only influence their reactions to memory loss problems but not for disruption and depression problems. African American caregivers had fewer reactions to disruption (p<.01) and more reactions to depression problems (p=0.06) than white caregivers, but no difference between the two groups in their reactions to memory loss problems. Personal resilience was not associated with reactions to any problem behaviors. Intervention should be tailored to the needs of caregivers to deal with behaviors of a person with AD.

Dementia Care Management in an Underserved Community: The Comparative Effectiveness of Two Different Approaches.

To compare the effectiveness and costs of telephone-only approach to in-person plus telephone for delivering an evidence-based, coordinated care management program for dementia. We randomized 151 patient-caregiver dyads from an underserved predominantly Latino community to two arms that shared a care management protocol but implemented in different formats: in-person visits at home and/or in the community plus telephone and mail, versus telephone and mail only. We compared between-arm caregiver burden and care-recipient problem behaviors (primary outcomes) and patient-caregiver dyad retention, care quality, health care utilization, and costs (secondary outcomes) at 6- and 12-months follow-up. Care quality improved substantially over time in both arms. Caregiver burden, care-recipient problem behaviors, retention, and health care utilization did not differ across arms but the in-person program cost more to deliver. Dementia care quality improved regardless of how care management was delivered; large differences in effectiveness or cost offsets were not detected.

Self-efficacy Is Associated With Less Burden and More Gains From Behavioral Problems of Alzheimer's Disease in Hong Kong Chinese Caregivers

To test the effects of different self-efficacy beliefs on caregiver appraisals and depressive symptoms. We hypothesized that self-efficacy has a direct effect on depression while moderating the effects of behavioral problems on both negative (i.e., burden) and positive (i.e., uplifting) appraisals. Ninety-nine Chinese caregivers of relatives with Alzheimer's disease responded to measures of self-efficacy, positive gains, burden, depression, and care recipient behavioral problems. Data were analyzed using confirmatory factor analysis and multiple regression. Confirmatory factor analysis supported a 3-factor structure for the Revised Scale for Caregiving Self-Efficacy (obtaining respite, responding to disruptive behaviors, and controlling upsetting thoughts). Interaction effects in regression showed that caregivers with higher self-efficacy in controlling upsetting thoughts had more positive gains and less burden when confronted with more behavioral problems. Self-efficacy in obtaining respite had direct effects on burden and depression, and self-efficacy in responding to disruptive behaviors had a direct effect on positive gains, but not moderating effects. The results supported the multidimensional structure of caregiver self-efficacy and showed that efficacy in controlling upsetting thoughts was most important in buffering the effects of behavioral problems on burden and positive gains among Chinese caregivers. Interventions for dementia caregivers may be more effective if more emphasis is given on changing negative thoughts.

Multiple mediators of the relations between caregiving stress and depressive symptoms

Objective: This study tested a model for explaining how stress is associated with depressive symptoms in a sample of spouse caregivers of patients with Alzheimer's disease. It was hypothesized that more depressive symptoms would be significantly correlated with both ‘primary’ caregiver stressors (i.e., care recipient problem behaviors) and ‘secondary’ stress (i.e., role overload), but that this relationship would be significantly mediated by four variables: (1) personal mastery, (2) coping self-efficacy, (3) activity restriction, and (4) avoidance coping. Method: We used an asymptotic and resampling strategy for simultaneously testing multiple mediators of the stress-to-depressive symptoms pathway. Results: Greater stress was significantly related to more depressive symptoms. Increased stress was also associated with reduced personal mastery and self-efficacy, as well as increased activity restriction and avoidance coping. Finally, these four mediators accounted for a significant amount of the relationship between stress and depressive symptoms. Discussion: These results suggest multiple pathways by which both primary and secondary caregiver stresses may be associated with increased depressive symptoms, and may argue for multiple treatment targets for caregiver interventions.

Fulfilling Our Obligation to the Caregiver: It's Time for Action

Family caregivers are relied upon by health care systems, yet, at the same time, neglected. They provide the bulk of care given to the more than 5 million persons diagnosed with Alzheimer's disease in the United States. They are expected to take on increasing amounts of complex care in the home, a task that requires entire health care teams in institutional settings. Their work keeps people out of nursing homes while providing high quality care at minimal cost to public and private health care systems. In return, their efforts and their wellbeing too often go ignored. Family caregivers are often thrust into this position, with no training and little support, resulting in increased prevalence of adverse physical, social, and psychological outcomes. Caregivers are at greater risk for depression and anxiety. They are less likely to engage in preventative health measures, and there is some evidence suggesting increased risk of mortality. Although caring for those with dementia requires significant out-of-pocket costs, many family caregivers stop working in order to care for their loved ones. In real word settings, little has been done to decrease these risks to caregivers. What can public and private health care systems do to foster healthy caregiving? Providing family caregivers information, skills, and support systems to help care for dementia patients is one way to approach this problem. Several different caregiver interventions have now shown improvements in caregiver wellbeing in randomized control trials. One intervention took the form of a collaborative care approach led by advanced practice nurses who worked with caregivers and were integrated within primary care.1 Another was REACH II , an individualized multi-component home and telephone based intervention designed to enhance the caregiver's coping skills and management of dementia related behaviors2. The REACH II intervention significantly improved caregiver quality of life in terms of burden, depression and emotional well-being, self-care and healthy behaviors, social support, and management of care recipient problem behaviors. It also resulted in an hour less per day that caregivers were required to provide direct care, giving much need respite in their busy day. A remaining question is whether these caregiver interventions can be implemented in real world health care settings outside the randomized controlled trial environment. In this issue of the Archives, Nichols and colleagues show with the REACH VA study that the answer is a resounding yes. Twenty-four Home Based Primary Care programs within the Veterans Health Administration (VHA) were able to put into practice a modified REACH II intervention. As in REACH II, the results improved caregiver outcomes including reductions in caregiver frustration, burden and depression. Some may argue that health care systems do not have a duty to provide caregiver support as their contractual obligation is with the patient and not the caregiver. However, if health systems are going to increasingly rely on family caregivers to deliver complex care, then they have the obligations to aid caregivers in this task and reduce the personal costs associated with it3. We now have compelling evidence that interventions focused on the caregivers are beneficial and can be practically implemented in existing health systems like the VHA. It is time that we fulfill our obligations to caregivers. The REACH II model should not suffer the same fate as many other proven geriatric models that were not disseminated widely, and there are hopeful indications that it may not. Congress has already passed a law providing supportive services such as training, education, and counseling assistance for caregivers of veterans (Public Law 111-163). The VHA should now take the next step by ensuring these services are universally available and based on proven multi-component caregiver interventions like REACH VA. Other health care systems should follow in its lead.

Sociocontextual Circumstances in Daily Stress Reactivity Among Caregivers for Elder Relatives

Using a daily diary design, we examined whether emotional and physical reactivity in the face of care-related stressors is more intense for caregivers (CGs) living with lower levels of available socioemotional support and higher numbers of extrinsic stressors. Sixty-three CGs reported their experiences based on the past 24 hr (i.e., number of caregiving tasks, care recipient problem behaviors, family disagreements regarding care, depressive symptoms, feelings of burden, physical symptoms) on eight consecutive survey days; they also reported on extrinsic stressors and available socioemotional support. Multilevel analyses indicated significant moderator effects: within-person patterns of reactivity to care-related stressors were especially strong for CGs with lower levels of available socioemotional support and higher numbers of extrinsic stressors. For example, managing additional care recipient problem behaviors on a given day was more strongly associated with increased depressive and physical health symptoms as well as feelings of burden for CGs with relatively high numbers of extrinsic stressors. Implications for intervention are discussed.