Caregiver Stress Process Research Articles

Mediators of burden and depression in dementia family caregivers: Kinship differences.

To investigate kinship differences in the caregiver stress process by developing multiple mediation models for two distinct caregiver subgroups (spouses and adult children of older adults living with dementia). The effect of four potential mediating variables (mastery, self-efficacy, satisfaction with social support, positive caregiving appraisals) on the relationship between perceived burden and depression was evaluated. Family caregivers of a person living with dementia were recruited through national dementia and carer organisations. Participants completed a paper-based or electronic version of the study survey. A bias-corrected, accelerated bootstrapping method was used to test the effect of the four proposed mediating variables on the relationship between perceived burden and depression in each caregiver subgroup (spouses and adult children). Perceived burden was directly and significantly related to depression for both spouse caregivers and adult child caregivers. The mediation models explained approximately 50% of the variance in the burden-to-depression pathway for both caregiver subgroups. Mastery and social support (but not self-efficacy, nor positive caregiving appraisals) were found to individually significantly influence the impact of perceived burden on depression in spouse caregivers. All four proposed mediators failed to reach statistical significance as individual mediators of the burden-to-depression pathway in adult child caregivers. These findings demonstrate differences in the dementia caregiver experience according to kinship, and that certain mediating variables are more relevant for some subgroups of caregivers than others. Implications for the design of psychosocial interventions are discussed.

ASSOCIATIONS BETWEEN WORKPLACE STRESS AND CAREGIVER STRAIN IN FULL-TIME EMPLOYED CAREGIVERS

According to the 2015 AARP and National Alliance for Caregiving report, Caregiving in the U.S., 60% of family caregivers in the United States are involved in the dual roles of caregiving and working. It is important to determine whether workplace impacts, and factors such as workplace and other supports are predictors of overall emotional, physical, and financial caregiving strain. Guided by the caregiving stress process and role conflict theory, the current study used hierarchical regression analyses to determine whether caregiver reports of impacts of caregiving in the workplace were associated with caregiver physical, emotional, and financial strain after accounting for the primary stressors of ADL/IADL assistance and hours of care provided. We also examined both workplace and informal support as potential resources that might attenuate the effects of primary stressors and workplace impacts on emotional, physical, and financial caregiving strain. Participants included 436 employed caregivers of adults ages 50 and above from the 2015 AARP and National Alliance for Caregiving population-based study, Caregiving in the United States. Regression analyses showed that caregiver reports of higher negative workplace impacts of caregiving were associated with greater emotional and financial strain, even after controlling for primary caregiving stressors. Among other findings, caregivers who reported disclosing their caregiving duties to supervisors reported higher levels of emotional strain. Results suggest the importance of workplace strain in the stress process and suggest that some workplaces may be unsympathetic to the challenges of impaired caregivers.

Male and Female Partner-Caregivers' Burden: Does It Get Worse Over Time?

The general view is that partner-caregiver burden increases over time but findings are inconsistent. Moreover, the pathways underlying caregiver burden may differ between men and women. This study examines to what degree and why partner-caregiver burden changes over time. It adopts Pearlin's Caregiver Stress Process Model, as it is expected that higher primary and secondary stressors will increase burden and larger amounts of resources will lower burden. Yet, the impact of stressors and resources may change over time. The wear-and-tear model predicts an increase of burden due to a stronger impact of stressors and lower impact of resources over time. Alternatively, the adaptation model predicts a decrease of burden due to a lower impact of stressors and higher impact of resources over time. We used 2 observations with a 1-year interval of 279 male and 443 female partner-caregivers, derived from the Netherlands Older Persons and Informal Caregivers Survey Minimum Data Set. We applied multilevel regression analysis, stratified by gender. Adjusted for all predictors, caregiver burden increased over time for both men and women. For female caregivers, the impact of poor spousal health on burden increased and the impact of fulfillment decreased over time. Among male caregivers, the impact of predictors did not change over time. The increase of burden over time supports the wear-and-tear model, in particular for women. This study highlights the need for gender-specific interventions that are focused on enabling older partners to be better prepared for long-term partner-care.

Mediating role of caregiver burden among family caregivers of patients with Parkinson's disease in Mexico.

This study examined the mediating role of caregiver distress on family factors and caregiver life satisfaction among an understudied population of Parkinson's disease caregiver in Mexico. A cross-sectional design was used to examine psychosocial factors pertinent to caregiver of individuals with Parkinson's disease ( n = 95). Guided by a caregiver stress process model, relations among family factors (e.g., cohesion, flexibility, quality of functioning), gender, distress, and satisfaction with life among caregiver were examined. Mediation analyses were performed to test the role of caregiver distress on the associations between family factors, gender, and caregiver satisfaction with life. Mediation models demonstrated that caregiver distress fully mediated the relation between quality of family functioning and caregiver satisfaction with life and partially mediated the association between family flexibility and caregiver satisfaction with life. Caregiver gender did not emerge as a significant covariate, and null results were found in the model examining family cohesion as a predictor. These results underscore the critical role of caregiver distress and family factors on features of caregiver well-being, notably satisfaction with life. This evidence also offers cross cultural evidence for the caregiver stress process model, which has primarily been observed in Western samples. Accordingly, the need to build and disseminate empirically supported family-based treatments that emphasize caregiver distress is warranted.

Longitudinal trajectories of subjective care stressors: the role of personal, dyadic, and family resources

ABSTRACTObjectives: Stressors are critical to the caregiver stress process, yet little work has examined resources that contribute to longitudinal changes in subjective stressors. The present study examines a variety of factors that contribute to changes in subjective stressors across time. Method: Dementia caregivers (N = 153) completed an in-person interview and eight daily telephone interviews at baseline, and follow up interviews at 6 and 12 months. Growth curve analyses examine how care- and non-care stressors, respite, dyadic relationship quality, family support/conflict and care transitions (e.g. nursing home placement) are associated with changes in role overload and role captivity across 12 months. Results: Caregivers who transitioned out of their role had higher overload and captivity at baseline. Among caregivers who transitioned out of caregiving, higher captivity at baseline was associated with declines in captivity and overload; more non-care stressors at baseline was linked to increased captivity and greater overload across time. Adult day service use and family support were associated with lesser captivity over time; taking more breaks from caregiving was linked to lower overload. Higher dyadic relationship quality was associated with lower captivity and overload. Conclusion: Findings contribute to caregiver intervention efforts by highlighting important resources associated with subjective stressors across time.

Intergenerational Ambivalence and Dyadic Strain: Understanding Stress in Family Care Partners of Older Adults

ABSTRACTObjectives: The present study used Pearlin, Mullan, Semple & Skaff's (1990) caregiving stress process model as a framework to examine the comparative influence of two stressors: (a) intergenerational ambivalence as a unified construct and (b) dyadic strain, which is one isolated component of intergenerational ambivalence.Methods: Participants were 120 women providing healthcare and medication assistance to an earlier generation family member with physical and/or cognitive impairments.Results: Hierarchical regression confirmed that intergenerational ambivalence explained perceived stress in family care partners, beyond the variance accounted for by other commonly reported stressors such as length of caregiving experience, memory/cognitive and functional impairments of the care recipient, caregiver overload, family conflict and financial strain. Further analyses revealed that examining dyadic strain apart from intergenerational ambivalence may more accurately explain the influence of ambivalence scores on care partners’ perceived stress.Conclusions and Clinical Implications: The comparative influence of dyadic strain versus ambivalence suggests that stress-reducing interventions may benefit from a focus on reducing care partners’ experiences of negative strain in the dyadic relationship rather than managing ambivalence.

Care Tasks in the Stress Process for Family Caregivers in Urban China

ABSTRACTObjectives: To explore the role of care tasks in the caregiving stress process, this study tested the relationships between distinct care tasks, primary stressors, caregiver burden, and depressive symptoms among caregivers.Methods: The data were collected from a sample of 754 caregivers who provided care for frail, elderly family members in Shanghai, China. Path analysis was conducted to identify the relationships between the three types of care tasks (monetary support, physical care and emotional care), the caregivers’ background, primary stressors, caregiver burden, and depressive symptoms.Results: The results show distinct paths through the three types of care tasks in the stress process. Caregivers with higher incomes were more likely to provide monetary support to their care recipients. Being a female caregiver and having greater primary stressors were associated with more involvement in physical care, which predicted higher levels of caregiver burden and further exacerbated depression. The cognitive impairment of care recipients was associated with greater emotional care, with the caregivers who provided more emotional care reporting higher levels of caregiver burden but lower levels of depression.Conclusions: This study underscores the importance of considering different types of care tasks to properly understand caregiving stress across cultures and societies.Clinical Implications: This study highlights the need for interventions to alleviate the caregiving stress by helping family caregivers understand the importance of emotional care, training them to appropriately meet the psychological and social needs of their care recipients and providing financial support for caregivers with lower income to purchase respite care services.

Rumiación y fusión cognitiva en el cuidado familiar de personas con demencia

IntroductionRumination has been described as a dysfunctional coping strategy related to emotional distress. Recently, it has been highlighted from the Acceptance and Commitment Therapy therapeutic approach, the negative role that cognitive fusion (the extent to which we are psychologically tangled with and dominated by the form or content of our thoughts) has on the explanation of distress. The aim of this study is to simultaneously analyze the role of rumination and cognitive fusion in the caregiving stress process. Material and methodsThe sample of 176 dementia caregivers was divided in four groups, taking into account their levels of rumination and cognitive fusion: HRHF=high rumination+high cognitive fusion; HRLF=high rumination+low cognitive fusion; LRHF= low rumination+high cognitive fusion; and LRLC=low rumination and low cognitive fusion. Caregiver stress factors, frequency of pleasant events, experiential avoidance, coherence and satisfaction with personal values, depression, anxiety and satisfaction with life, were measured. ResultsThe HRHF group showed higher levels of depression, anxiety, experiential avoidance and lower levels of satisfaction with life, frequency of pleasant events, coherence and satisfaction with personal values, than the other three groups. ConclusionsConsidering simultaneously rumination and cognitive fusion may contribute to a better understanding of caregiver coping and distress.

A Multifaceted Model of Changes and Adaptation among Korean Mothers of Children with Disabilities

The present study sought to strengthen existing research on parenting in the context of child disability in two ways. First, we applied the caregiving stress process model to systematically examine a dynamic process of change and adaptation among mothers raising children with disabilities over time. Second, we conducted six focus groups with 18 Korean mothers to enrich cultural understanding of what contributes to their adaptation in the context of Korean society, paying particular attention to informal support. A convenient, purposive sampling method was used to recruit Korean mothers from local special education centers, who were married and had at least one schoolage child with a disability. The focus group narratives primarily revolved around how mothers have come to embrace their child’s disability over time though they are aware that it is a never-ending endeavor in process. Caregiving experiences were shaped by their subjective appraisal of the child’s disability and their own lives, which had gone through significant changes over the years following an initial diagnosis of a child’s disability. Social support, particularly the informal support from other mothers who are also raising a child with a disability, was not something that was immediately available to them but gradually came to take a meaningful place in their lives over time. Findings suggest that for an intervention program to be effective, it should be embedded in the larger public policy that offers the context where mothers can build informal support network.

Family Triad Perceptions of Mild Cognitive Impairment

We examined subjective perceptions of memory loss among older adults with mild cognitive impairment (MCI) and two other relatives in order to improve understanding of family coping. We also investigated contextual conditions associated with perceptions of family dynamics and relationships. We conducted interviews with 56 family triads (the elder with MCI, the primary care partner, and a secondary care partner). Guided by Pearlin and colleagues' caregiving stress process framework, questions addressed perceptions of memory changes and interpretation of the effects of MCI on family interaction patterns. Analyses of family triads revealed four degrees of the extent to which family members similarly acknowledged elders' MCI. The acknowledgment groups differed on history of family dynamics, experience with dementia, and perceived extent of memory change in the elder. Families characterized by full acknowledgment coped better with perceived changes in the elder's functioning than those in which members' perceptions of MCI were incongruent. Pursuing family-level data on responses to MCI uncovered more nuanced reactions, often differing across triad members, than individual-based research has found. Family perceptions about changes in elders' memory have important implications for within-family interactions and support that can help families cope successfully with MCI.

The Role of Self-Efficacy in the Alzheimer's Family Caregiver Stress Process: A Partial Mediator between Physical Health and Depressive Symptoms

Physical health has been commonly regarded as an outcome in caregiving research; however, it may act as a predictor of depressive symptoms of caregivers. This current study investigated the relationship between physical health and depression in family caregivers of persons with Alzheimer's disease. Also, it examined caregiving self-efficacy as a possible mediator of the relationship. One hundred thirty-four family caregivers were interviewed. The caregivers self-reported their current physical health status, depressive symptoms, and perceived self-efficacy. Using a self-efficacy measure consisting of three subscales, path analyses were conducted to specifically assess these domains of caregiving self-efficacy. The results showed that poorer perceived physical health was directly and indirectly associated with increased depressive symptoms. The indirect path was mediated by the specific domain of caregivers' self-efficacy. These findings suggest that caregiving self-efficacy may function as a mechanism through which perceived physical health influences depressive symptoms, and this mechanism can be domain-specific.

Global and caregiving mastery as moderators in the caregiving stress process

Objectives: The study tests the circumstances under which global mastery and caregiving mastery moderate the impact of objective and subjective stressors on depressive and anxious symptoms among Alzheimer's caregivers. Methods: Data from a sample of 200 spousal caregivers to people with Alzheimer's disease were examined. Sixteen separate models were tested with depression and anxiety regressed on two measures of objective demand (activities of daily living and problem behaviors) and two measures of subjective demand (role overload and role captivity) matched with each of the two mastery measures and their relevant interaction terms. Results: Caregiving mastery functions as a moderator in the relationship between subjective demands and depression and anxiety, that is, at higher levels of caregiving mastery, the positive association between role overload and role captivity on depression and anxiety was weaker. Although there is a strong main effect of global mastery on mental health, it was not found to act as a moderator in this study. Conclusion: The findings demonstrate the importance of evaluating role-specific measures, such as caregiving mastery, as well as assessing a variety of stressful demands, in order to explicate the pathways through which psychosocial resources exert their protective effects.

Care Partner Responses to the Onset of Mild Cognitive Impairment

We examined characteristics, responses, and psychological well-being of care partners who support and assist older adults recently diagnosed with mild cognitive impairment (MCI). Based on a sample of 106 care partners of community residents diagnosed with MCI at memory clinics, we conducted face-to-face interviews including scales and open-ended questions. Measures tapped elements of the caregiver stress process model advanced by Pearlin and associates (1990, Caregiving and the stress process: An overview of concepts and their measures. The Gerontologist, 30, 583-594), including background characteristics, knowledge and attitude resources, stressors, strains, and protective conditions. The outcome was psychological well-being as indexed by depressive symptoms. Care partners' depressive symptoms were higher in the context of poorer health, lower perceived importance of religion, less knowledge about dementia, being more bothered by the older adult's MCI symptoms, having a lower sense of environmental mastery, more perceived burden, more frequent use of coping strategies, and more social support. Narratives revealed multiple dimensions of stress, strain, and frustration, regardless of the level of depressive symptoms. Assisting a relative with MCI presents new and complex challenges, even though it is an early caregiving role. Care partners likely would benefit from strategies aimed at reducing self-blame, enhancing coping skills, sustaining their sense of mastery, managing their health, seeking and accepting respite, and communicating effectively with the person with MCI and significant others.

Factors Associated with the Psychological Health of Grandparents as Primary Caregivers: An Analysis of Gender Differences

Recent evidence documents that grandparents raising grandchildren face a great risk of psychological distress associated with this caregiver role. Information we know about grandparent caregivers heavily relies on grandmothers. Although the caregiver's gender is an important contextual factor in shaping the stress process, often unnoticed are grandfathers who assume the caregiving responsibility for their grandchildren. Guided by the Caregiver Stress Process model, this study examines common and differential factors associated with the psychological health of grandfathers and grandmothers living with their grandchildren without the parents of the child. Based on the National Survey of America's Families, data on 209 grandfathers and 1,781 grandmothers were analyzed. Results indicate that factors related to a lower level of the psychological health of grandmothers include their younger age, poor health, not having high school diploma, not being employed, living in poverty, and caring for grandchildren with severe behavioral problems. On the contrary, factors associated with the poor psychological health of grandfathers include their living without a spouse, poor health, and caring for very young grandchildren (under the age of five) or grandchildren with severe behavioral problems. Active social participation (volunteer activities and religious services attendance) is directly associated with better psychological health only for grandmothers. Findings suggest that social policy and interventions to help grandparents raising grandchildren should be designed in consideration of the differential factors associated with mental health by the gender of caregiving grandparents. Implications for policy and practice are discussed.

Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members.

To expand knowledge concerning the significance of kin relationships in caregiving, this study assessed predictors of the timing of institutionalization for persons with dementia. The focus was on whether use of adult day care by wives and daughters holds the same implications for placement. Guided by a caregiving stress process model, primary objective and subjective stressors, secondary stressors, caregiver well-being, and use of day care services were included as predictors. Cox proportional hazards models were tested using a sample of 371 community-dwelling caregivers, including 141 wives and 230 daughters and daughters-in-law. The main effect of kinship was found to be significant before interactions were introduced. Adult day care use at Time 1, role captivity, role overload, and social impact were subsequently found to interact with kinship. Analyses indicated that wives who used adult day care placed their husbands to a nursing home earlier than their counterparts. Among daughters, however, those who used adult day care were more likely to postpone the placement. The influence of role overload was also stronger in wives than in daughters in predicting the timing of placement. A similar pattern was observed in the interaction between social impact and kinship. The results demonstrate that factors influencing nursing home placement may vary according to the caregiver's familial relationship to the relative. Different approaches may be needed when targeting wife vs. daughter caregivers, especially when designing adult day care programs.

Personal losses and relationship quality in dementia caregiving

Models of the dementia caregiving stress process specify that the impairments and behavioral problems of the person with Alzheimer's disease or related disorder (ADRD) and primary subjective stressors, such as burden, along with secondary stressors and appraisals, lead to negative outcomes such as depression. This cross-sectional study focused on the affective and relational aspects of this process, examining the associations of personal and relational losses and perceived relationship quality to ADRD caregivers' depressive symptoms, using a series of multiple regressions to specify a path model. This theoretical model specified personal losses and the subjective relationship quality as intervening variables between the care recipient impairments and subsequent subjective stressors, overload and role captivity. Loss of intimate exchange, current quality of relationship, and loss of self each had direct effects or indirect effects on caregiver depression that suggest the important role of personal and relational losses in the stress process.

A Path Analysis on Elder Abuse by Family Caregivers: Applying the ABCX Model

The purpose of this study was to investigate Hill’s ABCX model as an explanation for the caregiving stress process to elder abuse. However, due to ethical concerns on elder abuse studies, caregivers’ impulsive feelings to commit elder abuse were employed as an index to address elder abuse. The sample included 279 family caregivers for older adults with physical or cognitive impairments in South Korea. A path analysis was conducted to test the ABCX model. The results of path analysis did not statistically support the ABCX model as an explanation for caregivers’ impulsive feelings to commit elder abuse. Based on the findings of this study, the revised ABCX model was suggested for practitioners and researchers to better understand caregiving stress process to impulses of elder abuse.

The Caregiver Stress Process and Health Outcomes

The authors examine the impact of two caregiving stressors, care receivers' behavior problems (an objective stressor) and caregivers' feelings of overload (a subjective stressor), on three dimensions of caregiver health. The participants were 234 primary caregivers of elderly relatives with dementia living in the community who completed a comprehensive interview about their current care situation, including stressors and health. Higher levels of both objective and subjective stressors were associated with all three dimensions of caregiver health: poorer self-reported health, more negative health behaviors, and greater use of health care services. The association between objective stressors and health was mediated by caregivers' feelings of overload. These findings demonstrate caregivers' vulnerability to the effects of stressors across three dimensions of health and also underscore the importance of subjective appraisals of stress.

The Role of Family Functioning in the Stress Process of Dementia Caregivers: A Structural Family Framework

The purpose of the study was to evaluate the role of family functioning in the stress process in a sample of caregivers of dementia patients by using a structural family framework. The stress-process model of caregiver distress included family functioning as an intervening variable in the relationship between objective burden and distress. We theorized family functioning to partially mediate the relationship between objective burden and distress and to significantly account for the prediction of distress beyond well-recognized predictors. One hundred eighty-one family caregivers from the Miami site of the Resources for Enhancing Alzheimer's Caregiver Health project participated in this study. We assessed sociodemographics, burden, depression, anxiety, and perceived health for each caregiver. We measured family functioning by using a multidimensional and observational instrument. We used structural equation modeling to assess the fit of the model for the overall sample and for different caregiver subgroups and to examine whether demographic variables affected the relationships in the model. The results of the study indicated that family functioning significantly contributed to distress in the overall sample and partially mediated the relationship between objective burden and distress. We also found that the stress-process model was adequately fit by the hypothesized relationships between objective burden, family functioning, and distress for the overall sample and all of the subsamples, except for wives. This study provides support for the structural family approach as an explanatory model for the influence of family functioning on dementia caregivers. Family structural functioning is one contributor to the caregiver stress process. This suggests that interventions targeting structural family problems may reduce caregiver distress.

Understanding the Influence of the Complex Relationships among Informal and Formal Supports on the Well-Being of Caregivers of Persons with Dementia

This study examined the direct and indirect relationships between caring for a person with dementia and caregiver health. A conceptual model of the caregiver stress process considered informal caregiver characteristics, sources of caregiver stress, and the influence of informal and formal support on the well-being of the caregivers of persons with dementia. Structural equation modeling was used to test specific hypotheses in a sample of 327 caregivers of people with dementia who were living in the community, as part of the first wave of the Canadian Study of Health and Aging. Our findings show that the negative impact of the increasing disability of the care recipient on the psychological well-being of the caregiver was mediated mostly by the use of informal support systems and marginally by the use of formal support systems. The use of informal support by caregivers was associated with a decreased use of formal supports. The relationship between caregiver characteristics and their psychological health was mediated by the use of formal support but not by the use of informal support systems.