Older Mexican Adults Research Articles

Prevalence of food insecurity and its association with depressive and anxiety symptoms in older adults during the COVID-19 pandemic in Mexico: A secondary analysis of ENCOVID-19 survey.

COVID-19 infection has caused high rates of morbi-mortality in older adults (OAs). In addition, conditions such as depression, anxiety, unemployment, and poverty frequently contribute to this population being at higher risk of food insecurity (FI) during the COVID-19 pandemic. This study aimed to analyze the prevalence of FI and its association with depressive and anxiety symptoms in Mexican OAs during the COVID-19 pandemic. This study involved a secondary analysis of the National Survey on the Effects of COVID-19 on the Wellbeing of Mexican Households (ENCOVID-19), a series of cross-sectional telephone surveys conducted between April and October 2020. The OA subsample was 1,065. FI was measured by using the Latin American and Caribbean Food Security Scale (ELCSA), and depression and anxiety symptoms were measured by using the Depression Scale of the Center for Epidemiological Studies (CESD-7) and the Generalized Anxiety Disorder Scale (GAD-2), respectively. Socioeconomic status (SES), occupation, schooling, and pension were also evaluated. ANOVA was used to compare the variables between the different FI groups, and logistic regression was used to analyze the risk between FI and the anxiety and depression variables. The mean age of the participants was 67.31 ± 6.4 years, and FI was classified as mild, moderate, and severe, with prevalences of 38.6, 15.04, and 8.16%, respectively. Overall, 28.01% of the OAs presented symptoms of anxiety and 39.09% of depression. In the comparison between groups, a higher prevalence of depressive symptoms was observed with a higher degree of FI, with 65.75% in moderate-to-severe, 10.39% in mild, and 9.40% without FI, p ≤ 0.000. Regarding anxiety symptoms, 48% of the OAs showed moderate-to-severe, 30.05% showed mild, and 15.38% were without FI, p ≤ 0.000. Using multiple logistic regression, an OR of 5.50 (95% CI 2.74-11.04) was observed for depressive symptoms when moderate-to-severe FI is present. In the case of the risk of anxiety symptoms, it was significant in all degrees of FI, in mild (OR = 2.43, 95% CI 1.66-3.59) and in moderate-to-severe (OR = 5.32, 95% CI 3.45-8.19). There is a high prevalence of FI in Mexican OAs during the COVID-19 pandemic. FI increases the risk of other conditions such as depression and anxiety. It is important to design and implement programs aimed at OAs with these conditions to reduce or prevent FI.

Psychometric Properties of the Access of Older Adults to Outpatient Primary-Care Health Services Scale.

This study evaluates the psychometric properties of the Access of Older Adults to Outpatient Primary-Care Health Services Scale (AOAOPHSS), in research conducted among 707 Mexican older adults selected by convenience from 14 rural and one urban locations. The AOAOPHSS explores 10 dimensions of two integrated subscales: Accessibility and Personal Abilities. Data analysis was performed in five phases. First, potentially biased responses were identified. Second, the response efficiency of the items and their association with external variables were evaluated. Third, the basic properties of the scores for the subscales' dimensions of the AOAOPHSS were identified using non-parametric Mokken Scaling Analysis (MSA). Fourth, the Structural Equation Modeling methodology was used to identify the properties of the internal structure of the latent construct. Finally, reliability and internal consistency were evaluated at both score and item levels. The following findings emerged. 13 items with inefficient response options were removed, and 24 were retained using the MSA. The latent structure of the latter was defined based on 21 items of five Accessibility Subscale dimensions. Its internal consistency reliability ranged between 0.67 and 0.81 (omega coefficients) and between 0.61 and 0.78 (alpha coefficients). Accordingly, this paper discusses the overall implications of using the Accessibility Subscale.

Psychometric Properties of the 11-Item De Jong Gierveld Loneliness Scale in a Representative Sample of Mexican Older Adults

Recent studies have focused on the negative effects of loneliness on health and quality of life in older adults. The De Jong Gierveld Loneliness Scale (DJGLS) has been widely used and has proven to be a valid and reliable instrument for loneliness assessment. However, research on this topic and on the validation of measurement scales among the older population is still incipient. The objective of this study was to examine the psychometric properties of the Spanish version of the 11-item DJGLS in Mexican older adults. Data from a representative sample of cognitively intact older adults aged 60 years and over (mean, standard deviation [SD]) age = 72.0 years (SD 8.1) from two Mexican cities (n = 1913), interviewed face to face at their homes during 2018-2019, were analyzed. The psychometric properties of the DJGLS were examined, including (1) construct validity, examined by Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA), discriminate validity and convergent validity, (2) reliability, calculated using Cronbach's alpha. The overall data quality was high, and the scaling assumptions were generally met with few exceptions. Using EFA and CFA, the findings showed that the DJGLS presents a two-factor structure (Social Loneliness and Emotional Loneliness), with 11 items that explain 67.2% of the total variance. Reliability is adequate at the full-scale level (Cronbach´s α = 0.899), also for the two subscales Social and Emotional Loneliness (Cronbach´s α = 0.892 and 0.776, respectively). These results highlight that most participants with a low score for depressive symptoms and or with a high social support score belonged to the "No loneliness" group. The results showed that the Spanish version of the 11-item DJGLS is adequate for use in Mexican older adults and should be used not only for loneliness screening but also for social and emotional loneliness assessment.

Association of loneliness, social isolation, and daily cognitive function in Mexican older adults living in community during the first wave of COVID-19 pandemic

Introduction. Loneliness and social isolation are known risk factors for cognitive decline; their effect in older adults (OA) after COVID-19 lockdown is emerging. Objective. To establish an association between loneliness and social isolation, with daily cognitive function in Mexican OA during the first wave of the COVID-19 pandemic. Method. Cross-sectional study, derived from the cohort “The impact of COVID 19 on well-being, cognition, and discrimination among older adults in the United States and Latin America”, which included 308 OA recruited between March-August 2020 whose daily cognitive function were determined with the Everyday Cognition Scale (E-Cog) as dichotomized score (cut point: 1.31 for normal cognition). Loneliness and social isolation were binomial variables. Results. The mean age was 65.4 ± 7.9 years, 75.7% were women. The mean continuous E-Cog score was 57.4 (SD = ± 19.1), 49.1% had a score () 1.31 (normal cognition), while 50.9% had a higher score (cognitive impairment). Eighty four percent of participants reported loneliness, 79.9% reported social isolation. Multivariate regression model showed a negative and statistically significant association between social isolation and loneliness and E-Cog, adjusted by age, sex and education level (β = -.046, 95% CI = [-.8, -.013], p = .007; β = -.16, 95% CI = [-.08, -.018], p = .003), and a positive association with subjective memory complaint (β = .81, 95% CI = [-.16, -.11], p = () .001). Discussion and conclusion. These data suggest the need for increased vigilance of those who have loneliness and social isolation due to its potential deleterious effect on cognitive function.

Association of loneliness and social isolation with all-cause mortality among older Mexican adults in the Mexican health and aging study: a retrospective observational study

BackgroundPlenty of evidence shows how social isolation and loneliness are associated with increased risk for numerous diseases and mortality. But findings about their interactive or combined effects on health outcomes and mortality remains inconclusive.ObjectiveAnalyze the longitudinal association of loneliness, social isolation and their interactions, with the all-cause mortality among older adults in Mexico.MethodsA retrospective observational study was conducted. Mexican adults older than 50 years were included. Data from the Mexican Health and Aging Study (MHAS) in the 2015 and 2018 waves were used. The subjects were classified according to their level of loneliness and the presence of social isolation. Multivariate logistic regression analyzes were performed to determine the degree of association between loneliness and social isolation with all-cause mortality at a 3-year follow-up.ResultsFrom the total sample of 11,713 adults aged 50 years or over, 707 (6%) did not survive, 42% presented loneliness, and 53% were classified as socially isolated. After multivariate adjustment only social isolation (OR = 1.30, 95%CI:1.03–1.64) was associated with all-cause mortality, loneliness (Mild: OR = 0.83, 95%CI:0.59–1.16; Severe: OR = 1.03, 95%CI:0.71–1.64), and the interaction between loneliness and social isolation were not associated with all-cause mortality.ConclusionSocial isolation, but not loneliness or their interaction, was associated with all-cause mortality in Mexican adults older than 50 years. This finding may help direct possible future interventions that help improve mental health in older adults from a highly collectivistic country.

Cross-cultural adaptation of the everyday cognition scale (M-ECog) in older Mexican adults with cognitive impairment.

To establish the cross-cultural adaptation, validity, and reliability of the ECog Mexican version (M-ECog) in participants with: SCD, MCI, and dementia coming from a memory clinic. There were 200 patients and their respective informants in a memory clinic of a third level hospital in Mexico City. Four groups were studied: 50 cognitively healthy (CH), 50 SCD, 50 MCI, and 50 dementia. The clinical evaluation included: sociodemographic and health characteristics, cognitive status by the Mini-Mental State Evaluation (MMSE) and Montreal Cognitive Evaluation Spanish version (MoCA-E), and caregiver information (informants) about the difficulty in ADLs as well as the ECog Spanish version (M-ECog). The M-ECog was significantly correlated with MMSE, MoCA-E, and ADLs. It showed the ability to discriminate the different cognitive declines (Cronbach's alpha 0.881). The intra-class correlation coefficient was 0.877 (95% confidence interval - CI, 0.850-0.902; p<0.001). The patient's group area under curve (AUC) of M-ECog for SCD was 0.70 (95%CI 0.58-0.82, p<0.005), for MCI it was 0.94 (95%CI 0.89-0.99, p<0.001) and for dementia 0.86 (95%CI 0.79-0.92, p<0.001). The M-ECog scale proves to be valid and reliable for measuring everyday abilities mediated by cognition. It is self-applicable without requiring extensive prior formation. It is useful to screen for SCD and MCI in older Mexican adults.

Adaptation and Validation of the Falls Efficacy Scale-International (FES-I) in Community-Dwelling Older Mexican Adults.

The objective of this study was to evaluate the reliability and validity of the FES-I scale in community-dwelling older Mexican adults. Participants were 222 older adults, with a mean age of 70 years; 75% were women who completed a sociodemographic data sheet, a Spanish version of the FES-I scale, intended to explore measures of depression, quality of life, and instrumental activities of daily living. Discriminant validity was demonstrated for all items on the FES-I scale and when groups of older adults were compared according to age. Evidence of internal consistency was found in all the items of the FES-I scale (α = .91) and convergent and divergent validity of the FES-I scale with measures of depression and quality of life, except instrumental activities of daily living. The Confirmatory Factor Analysis shows that the FES-I scale partially retains its two-factor measurement properties since five items were removed from the model to fit the data. The FES-I scale is a valid and reliable measure for clinical evaluations of fear of falls in older Mexican adults in the community.

Estimation of vaccination coverage and associated factors in older Mexican adults.

National vaccination programmes recommend the influenza vaccine for older adults, but this population group has the greatest morbidity and mortality from other preventable vaccine diseases. The aim of this article is to estimate the vaccine coverage in adults aged 65years and older and to analyse the factors that could increase or decrease vaccination uptake probability for the three listed vaccines in the national vaccination programme (influenza, tetanus and diphtheria, and pneumococcus) and the full scheme in Mexico. We conducted an analytical cross-sectional study with 2012, 2018, and 2021 rounds from the National Health and Nutrition Survey, in which we calculated the vaccine coverage estimations and performed multivariable logistic regression models to analyse the factors related to vaccine uptake. Tetanus and diphtheria vaccines had the greatest coverage estimation in all years (59-71%), whereas the pneumococcus vaccine had the lowest (32-53%). Full scheme vaccine coverage decreased from 37.80% to 24.77% in 2012 and 2021, respectively. The National Health Card property, morbidity, being a beneficiary of any health system institution, and use of preventive services increased the probability of vaccine uptake. In conclusion, vaccine coverage in older Mexican adults decreased over time, and the Mexican health system plays a strategic role in immunisation.

LIFECOURSE DETERMINANTS OF DEPRESSION AMONG OLDER MEXICAN ADULTS

Abstract Older adults’ exposure to poverty, poor health, and negative life events over their lifetime creates cumulative adversity, increasing their risk of depressive symptoms. We hypothesize that those with disadvantaged sociodemographic characteristics like household poverty, chronic health conditions, and negative lifecourse exposures will be more likely to report a high number of depressive symptoms in old age. Three sequential multivariable logistic regression models were estimated using Wave 3 (2012) of the Mexican Health and Aging Study (MHAS). The final sample included 5,610 respondents aged 50 and older, of which 34.3% reported depression measured by a modified 9-item CES-D scale. The sample was mostly female (63.3%) with a mean age of 69. Present-day conditions were measured by quality of the home, consumer durables, chronic health conditions, and health insurance. Early-life conditions were measured by the respondent’s mother’s education and exposure to poverty and illness during childhood. In 2012, older Mexican adults living in homes built with poor construction materials or homes that lack access to water and sanitation (OR=1.24) were more likely to experience high depressive symptoms. In addition, those living in homes without consumer durable goods (OR=1.23) were at increased risk. Older Mexican adults who experienced poverty (OR=1.16) or illness during childhood (OR=1.21) were more likely to report a high number of depressive symptoms in old age. In conclusion, we find evidence of a “long-arm” of childhood, whereas older Mexican adults’ exposure to poverty and illness in childhood increases their likelihood of poor mental health outcomes, regardless of their present-day conditions.

FOOD INSECURITY ACROSS THE LIFE COURSE AND COGNITIVE FUNCTION AMONG OLDER MEXICAN ADULTS

Abstract Food insecurity is a global public health problem and is related with poorer cognition among older adults. Few have examined how food insecurity, throughout life, relates with cognition among older Mexican adults. Data came from the 2015 Mexican Health and Aging Study (n=11,507, aged 50+). Early- and late-life food insecurity were self-reported. We evaluated how food insecurity related with cognition (Verbal Learning, Verbal Recall, Visual Scanning, and Verbal Fluency), controlling for health and sociodemographic confounders. In descriptive analyses, respondents who experienced food insecurity in early- or late-life performed worse on all cognitive tasks compared to the food secure. When adjusting for health and sociodemographic confounders, early-life food insecurity predicted worse Verbal Learning performance and late-life food insecurity related with poorer Visual Scanning. Food insecurity negatively related with cognition among older Mexican adults. The significance of effects depended on cognitive task and when in life food insecurity was experienced

COGNITIVE AGING IN LOW- AND MIDDLE-INCOME COUNTRIES

Abstract Cognitive aging is a highly complex, dynamic, and context-dependent process; and is influenced by individual and community characteristics and experiences across the life course. Low- and middle-income countries (LMICs) are critical components of the international dementia research community because the burden of dementia is rapidly rising in LMICs, and low-resource settings may have unique social and economic determinants of cognitive health. However, little population-based research focuses on these regions. The papers in this symposium use high-quality population survey data from Mexico, Brazil, South Africa, and China to study critical social determinants of cognitive function in countries across the globe. These papers cover a range of social and economic factors, including food insecurity, education, household material resources, and urban-rural settings and policy. First, Saenz will present findings on how food insecurity, throughout life, relates with cognitive function among older Mexican adults. Next, Farina will present evidence on both indirect and direct pathways from education to cognitive function among older Brazilians. Third, Kobayashi will present longitudinal data evaluating level and change in household resources in relation to subsequent cognitive function in South Africa. Finally, Zhang will present evidence on the interplay of rural/urban residence and household registration system across the life-course in creating cumulative advantage/disadvantage in cognitive aging using longitudinal data from China. The papers in this symposium provide new insights into social determinants of cognitive health in diverse contexts and have significant policy implications for improving cognitive health in LMICs across the globe.

ARE INTRINSIC CAPACITY AND MULTIMORBIDITY ASSOCIATED TO FRIED’S FRAILTY REVERSIBILITY?

Abstract Our objective was to characterize older adults with reversible frailty in their baseline intrinsic capacity and multimorbidity status. MethodsWe used data from the most recent waves of the SAGE Mexico study (3 and 4), representative of older adults at a national level. Study n=749.We objectively measured gait speed and grip strength based on Fried's frailty criteria. Weight loss exhaustion was self-reported and physical activity (using the IPAQ).Reversible frailty was defined as going from frailty to pre-frail or robust and from pre-frail to robust. Worsening and stable frailty were coded similarly. Intrinsic capacity was measured using a summary index (0-100) based on five domains: cognition, locomotion, sensory, nutrition, and psychological. Multimorbidity was coded yes/no if the participant self-reported two or more chronic conditions. We compared the odds of being in the reverse group versus not in it according to baseline intrinsic capacity score and multimorbidity status, adjusting for age, sex, rural/urban, and wealth. ResultsReversible frailty=33% of those pre-frail or robust at baseline. Intrinsic capacity was higher in the reverse group than in those with worsening frailty but not significantly higher than those with stable frailty.Having multimorbidity significantly decreased the chances of frailty reversibility, adjusting for covariates. ConclusionsAs an expression of lifecourse damage to the physiological reserve, multimorbidity limits the chances of reversible frailty in Mexican older adults. High levels of intrinsic capacity did not characterize frailty reversibility in our study. Yet, low intrinsic capacity levels are a marker for older adults prone to frailty worsening.

6‐month global cognitive function in Mexican older adults recovered of COVID‐19: a prospective cohort study using telemedicine

AbstractBackgroundSARS‐CoV2 infection affects the central nervous system, one of the manifestations is the cognitive function impairment (1,2). It is currently unknown to what degree and which cognitive domains are involved in this disease (3,4). This study aims to know the effect on global cognitive function in older adults recovered of COVID‐19MethodA prospective cohort study recruited adults aged over 60 years old. As dependent variable, the Global Cognitive Function (GCF) was assessed using the Mini‐Mental State Examination (MMSE) test via telemedicine in patients recovered of moderate and severe COVID‐19 6 months after hospital discharge. Patients with uncontrolled neurological, metabolic, and psychiatric diseases were excluded. Multivariate models were constructed, as well as Cox regression model to assess the association between GCF impaired with history of moderate and severe COVID‐19, adjusted for age, sex, and educationResultWe studied 607 patients, of which 108 survived the SARS‐CoV‐2 infection. One patient dies during the follow‐up. 107 patients were analyzed, median age was 70 years (SD 7.3), 54% were women, with 9.2 (SD 3.8) years of education, the mean of MMSE was 26.2 (SD 3.2). Regarding the severity of the COVID‐19, 74% presented a moderate infection and 26% was severe. 12% had GCF impaired, of which 14.3% were severe COVID‐19 and 11.4% with moderate infection. Cognitive domains most affected were episodic memory (43%) and constructional praxis (86%) in all patients, without statistic difference for infection severity. Factors associated with GCF impaired was the history of depression (HR 6.8; 95%CI: 1.4‐31.5, p = 0.01), higher education (HR ‐0.20; 95%CI: 0.68‐0.95, p = 0.01), and C‐RP level (HR 1.07; 95%CI: 1.01‐1.13, p = 0.01)ConclusionGlobal cognitive function in older adults recovered of severe COVID‐19 was impaired 6 months after hospital discharge. Cognitive domains of episodic memory and constructive praxis were the most altered. Future studies are needed in this geriatric population to confirm this long‐term outcome, especially in those patients with risk factors such as history of depression, lower education, and severe illness

Effect of a geriatric unit in the outcomes of hospitalized older Mexican adults with cancer: A case-control study

IntroductionGeriatric interventions may improve the care of hospitalized older adults with cancer, but information regarding their effect on geriatric-specific outcomes is lacking. We studied the effect of a specialized geriatrician-led inpatient geriatric management unit compared with a conventional internal medicine ward on the outcomes of hospitalized older adults with cancer in Mexico. Materials and MethodsCase-control study including persons aged ≥65 years with solid malignancies who had a cancer-related hospitalization at a university-affiliated hospital in Mexico City. Patients hospitalized in a geriatric unit (cases) were paired 1:2 with those in internal medicine wards (controls). Matching criteria included: age (+/− five years), tumor type (according to International Classification of Diseases [ICD]-10 code), and admission date (+/− three months). The association between being hospitalized in the geriatric unit on various outcomes was determined using conditional logistic regression models. ResultsOne hundred cases and 200 controls were included. Mean age was 75.3 years (standard deviation 6.4 years) and 53% had gastrointestinal tumors. No difference in median length-of-stay was found between cases and controls (9.0 days, vs. 9.5 days, p = 0.34). Hospitalization in the geriatric unit was associated with a reduced risk of delirium (odds ratio [OR] 0.18, 95% confidence interval [CI] 0.04–0.80). Being hospitalized in the geriatric unit was not associated with an effect on hospital-acquired complications (OR 0.83, 95% CI 0.47–1.45) or in-hospital mortality (OR 1.82, 95% CI 0.32–10.18). DiscussionAmong older Mexican adults hospitalized for a cancer-related diagnosis, receiving care in a geriatric management unit was associated to a decreased risk of delirium, without influencing other outcomes.

Association Between Self-Reported Health and Education with Past-year Dental Visits among Older Mexican Adults: Results of the Mexican Health and Aging Study 2018.

To explore the relationship between of self-reported health (SRH) and educational attainment with pastyear dental visits in older adults in México. For this cross-sectional study, data were derived from the Mexican Health and Aging Study 2018 (MHAS-2018), which used a nationally-representative sample of older adults (50 years or older) in Mexico (n = 14,085). Variables taken from the MHAS questionnaire included residence (rural/urban), years of education, SRH, multimorbidity, pain severity, and past-year dental visits. A logistic regression model was used to identify the association between the variables and past-year dental visits. While the percentage of past-year dental visits reported was 39.8%, this number declined with age [OR=0.76, p < 0.001], with older adults living in rural areas 34% less likely to report past-year dental visits than older adults living in urban areas. Older adults with no formal education were 73% less likely (OR=0.27; p < 0.001) to report past-year dental visits than older adults ≥10 years education. Older adults with poor SRH were 32% less likely (OR=0.68; p < 0.001) to report past-year dental visits than older adults with good/very good/excellent SRH. Sex, degree of multimorbidity, and pain level ([OR=1.37; p < 0.001] [OR=1.37; p < 0.001] and [OR=1.17; p < 0.001]) were all found to be positively associated with past-year dental visits in the study population. The present study highlights the association between poor SRH, a low level of educational attainment, and less frequent past-year dental visits, as well as the finding that past-year dental visits declined with age in the older adults sampled.

Word association norms in Mexican older adults

Abstract Aging involves a variety of cognitive and language changes. Word association norms (WANs), which describe the first word people say or write after reading or hearing a stimulus word, reflect the organization of semantic knowledge. The aim of this study was to create a WAN corpus for Mexican older adults, with 114 participants responding to 117 nouns. The results of eight measures of word-word relationships showed that participants generated an average of 38.14 different response words for each stimulus word. Of these responses, 41.88% were of high associative strength and 20.70% were idiosyncratic, demonstrating the uniqueness of responses of older adults. In addition, we compared their responses to a corpus for younger adults (Barrón-Martínez &amp; Arias-Trejo, 2014). A qualitative analysis categorizing the responses into syntagmatic and paradigmatic types showed that the older group tended to respond with words from a different grammatical class. Responses of the younger adults were also more cohesive and less varied than those of the older group. This corpus for older adults is an essential resource for evaluating age-related changes in semantic memory, and it provides a point of comparison for responses from people with neurodegenerative diseases.

SIOG2022-0040 - Transcultural Validation of Tools for the Assessment of Patient Preferences and Health Outcomes Prioritization among Older Mexican Adults with Cancer

SIOG2022-0040 - Transcultural Validation of Tools for the Assessment of Patient Preferences and Health Outcomes Prioritization among Older Mexican Adults with Cancer

SIOG2022-0169 - Factors associated with unplanned hospital readmission in Mexican Older Adults with cancer and the impact of geriatric management

SIOG2022-0169 - Factors associated with unplanned hospital readmission in Mexican Older Adults with cancer and the impact of geriatric management

Evaluation of anthropometric parameters in a national sample of Mexican older adults

Evaluation of anthropometric parameters in a national sample of Mexican older adults

Mediator effect of caregiver burden on the association between disability and quality of life among older adults.

To estimate the association of disability and qual-ity of life considering the potential mediating role of caregiver burden among a sample of older Mexican adults and their caregivers. Cross-sectional study with 93 dyads (elderly/caregivers) conducted in 2018 in five localities (urban and rural) of the State of Mexico. The quality of life (QoL) was determined using the WHOQoL (WHO Quality of Life) instrument. Disability was measured by assessing the basic activities of daily living (BADL), and the caregiver burden was evaluated by the Zarit Burden Interview (ZBI). The results showed that BADL disability is associated with a lower QoL (total effect: -14.3; 95%CI: -20.2,-8.4) and that a significant proportion of this associa-tion can be attributable to caregiver burden (25.0%; 95%CI: 17.9,43.2). Our findings show the need for designing effective interventions that prevent or ameliorate the adverse effects of caregiver burden.