Sleep disturbances in spousal caregivers of individuals with Alzheimer's disease

Correlates of Sleep Disturbance Experienced by Informal Caregivers of Persons Living with Dementia: A Systematic Review

OBJECTIVES

This study aims to comprehensively review and update the literature concerning the correlates of sleep disturbance among caregivers of persons living with Alzheimer's disease and related dementias to identify gaps in the literature and antecedent targets for interventions.

METHODS

We searched PubMed, CINAHL, PsycINFO, and Embase using terms related to "sleep," "caregiver," and "dementia."

RESULTS

Thirty-six articles were included in this review. Based on the antecedents within the 3P model of insomnia, predisposing factors associated with caregiver sleep included caregiver demographics, and physiological factors like genotype and biomarkers. Precipitating factors related to caregiver sleep included caregiving status and responsibilities, and person living with dementia factors.

CONCLUSIONS

Sleep disturbance is a significant issue for caregivers of persons living with dementia. However, this review has identified multiple precipitating factors that are modifiable targets for interventions to improve or enhance caregiver sleep.

CLINICAL IMPLICATIONS

Numerous predisposing and precipitating factors contribute to caregivers of persons living with dementia being susceptible to sleep disturbance. Healthcare providers should ask patients about their caregiving status during annual visits. Healthcare providers should also evaluate caregivers' sleep patterns, and the predisposing and precipitating factors of sleep disturbance, with a focus on the modifiable factors, to enable timely intervention.

The feasibility of a sleep education program for informal dementia care dyads: A pilot randomized controlled trial

BACKGROUND

Untreated sleep problems in both persons living with dementia (PLWD) and their family care partners (CP) impact their health and quality of life. This pilot study tested a sleep intervention program for both dyad members.

METHODS

Thirty dyads were randomized to a 5-session Care2Sleep intervention (n = 15 dyads) or an information-only control group (n = 15 dyads) delivered in-person or by video-telehealth by trained sleep educators. Care2Sleep is a manual-based program, incorporating key components of cognitive behavioral therapy for insomnia, daily light exposure and walking, and problem-solving for dementia-related behaviors. Adherence with Care2Sleep recommendations was assessed. Sleep outcomes included actigraphy-measured sleep efficiency (SE) and total wake time (TWT) for dyads, and the Pittsburgh Sleep Quality Index (PSQI) for CP. Other outcomes for CP included the Zarit Burden Interview (ZBI) and positive aspects of caregiving (PAC). Outcomes were measured at baseline, posttreatment, and 3-month follow-up. A 2 (group) by 3 (time) mixed model analysis of variance tested treatment effects.

RESULTS

Study feasibility was demonstrated, with 13 dyads completing all five sessions of Care2Sleep program and 14 completing the control condition. In the Care2Sleep group, the dyads adhered to recommended sleep schedules of 76% for bedtime and 72% for get-up time for PLWD, and 69% for bedtime and 67% for get-up time for CP. There were several nonsignificant trends in outcomes from baseline to 3-month follow-up between the two groups. For example, SE increased by 3.2% more for PLWD and 3.2% more for CP with Care2Sleep versus control. TWT decreased by 14 min more for PLWD and 12 min more for CP with Care2Sleep versus control at the 3-month follow-up. CP in Care2Sleep also showed improvement in the PSQI, ZBI, and PAC scores.

CONCLUSIONS

A dyadic approach to sleep improvement is feasible. Larger trials are needed to test effects of this intervention for PLWD and their family CP.

CLINICALTRIALS

gov: NCT03455569.

Factors associated with reduced sleep among spouses and caregivers of older adults with varying levels of cognitive decline

BACKGROUND

Caregivers of persons with cognitive decline (PWCD) are at increased risk of poor sleep quantity and quality. It is unclear whether this is due to factors in the caregiver versus in the PWCD.

METHODS

This secondary data analysis using Aging, Demographics, and Memory Study data from the Health Retirement Study examined factors contributing to reduced sleep/rest among spouses and caregivers of older adults with varying levels of cognitive decline (cognitively normal (CN), cognitive impairment but not dementia (CIND), or dementia).

RESULTS

In our preliminary analysis, among N = 218 spouses (not necessarily caregivers) (mean age (SD) = 73.77 (7.30); 70.64% female) of older adults with varying levels of cognitive decline, regression revealed that frequency of sleep complaints was lowest among spouses with CN partners, second highest with CIND partners, and highest with dementia-partners, X2  = 26.810, P = 0.002.

PRIMARY AIM

among n = 136 caregivers of PWCD (mean age (SD) = 59.27 (13.97); 74.26% female; 22.79% spouses), we analyzed whether caregiver reduced sleep/rest was predicted by PWCD factors (i.e., frequent nighttime waking, dementia severity) and/or caregiver factors (i.e., depression symptoms, caregiver role overload). Regression revealed that caregiver depression symptoms (d = 0.62) and role overload (d = 0.88), but not PWCD factors, were associated with reduced caregiver sleep/rest after adjusting for demographic factors, caregiving frequency, and shared-dwelling status (overall model: X2  = 31.876, P = 0.002). Exploratory analyses revealed that a caregiver was 7.901 times more likely (95% CI: 0.99-63.15) to endorse experiencing reduced sleep/rest if back-up care was not available (P = 0.023).

CONCLUSION

Findings highlight that the frequency of reported sleep problems among spouses increases in a stepwise fashion when partners have dementia versus CIND versus CN. The results also emphasise that caregiver mental health and burden are strongly associated with caregiver sleep disturbances and thus may be targets of intervention for caregiver sleep problems.

Caregiving and all-cause mortality in postmenopausal women: Findings from the Women's Health Initiative

BACKGROUND

Caregiving is commonly undertaken by older women. Research is mixed, however, about the impact of prolonged caregiving on their health, well-being, and mortality risk. Using a prospective study design, we examined the association of caregiving with mortality in a cohort of older women.

METHODS

Participants were 158,987 postmenopausal women aged 50-79 years at enrollment into the Women's Health Initiative (WHI) who provided information on current caregiving status and caregiving frequency at baseline (1993-1998) and follow-up (2004-2005). Mortality was ascertained from baseline through March of 2019. Cox regression with caregiving status defined as a time-varying exposure was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for mortality, adjusting for sociodemographic factors, smoking, and history of diabetes, hypertension, cardiovascular disease (CVD), and cancer. Stratified analyses explored whether age, race-ethnicity, depressive symptoms, frequency of caregiving, optimism, and living status modified the association between caregiver status and mortality.

RESULTS

At baseline, 40.7% of women (mean age 63.3 years) self-identified as caregivers. During a mean 17.5-year follow-up, all-cause mortality (50,526 deaths) was 9% lower (multivariable-adjusted HR = 0.91, 95% CI: 0.89-0.93) in caregivers compared to non-caregivers. The inverse association between caregiving and all-cause mortality did not differ according to caregiving frequency or when stratified by age, race-ethnicity, depressive symptoms, optimism, or living status (interaction p > 0.05, all). Caregiving was inversely associated with CVD and cancer mortality.

CONCLUSION

Among postmenopausal women residing across the United States, caregiving was associated with lower mortality. Studies detailing the type and amount of caregiving are needed to further determine its impact on older women.

The Effect of Tele-Savvy on Sleep Quality and Insomnia in Caregivers of Persons Living with Dementia

Introduction

Sleep disturbance is prevalent in caregivers of persons living with dementia (PLwD). Tele-Savvy, a 7-week virtual psychoeducational intervention, enhances caregivers' competence and self-care, and reduces depression. While not explicitly designed to do so, Tele-Savvy can potentially improve caregivers' disturbed sleep. The present study aimed to examine the longitudinal effects of Tele-Savvy on caregivers' sleep quality and insomnia.

Methods

This was a secondary data analysis of a 3-arm randomized control trial [Tele-Savvy (active treatment), Healthy Living (attention control), and usual care (waitlist control)]. Multilevel mixed modeling with intent-to-treat principles tested for group, time, and group-by-time effects. Effect sizes were estimated for all changes from baseline to the initial 6-month post-intervention point. Following completion of the 6-month post-randomization delay, we examined combined outcomes for Tele-Savvy.

Results

Participants (n=137; mean age 64.7 years) were predominantly female (68.6%) and White (68.6%). We found no initial group-by-time effects for the Pittsburgh Sleep Quality Index (PSQI) and the Insomnia Severity Index (ISI). For the combined Tele-Savvy group, there was a statistically significant improvement in ISI scores across time (p=0.050). The combined Tele-Savvy effect size for PSQI was d=0.126 and ISI was d=0.310.

Discussion

Tele-Savvy resulted in a significant long-term reduction in insomnia symptoms in this sample of caregivers of PLwD and demonstrated a positive trend for improvement in their sleep quality. Since sleep disturbance is so prevalent among caregivers of PLwD, the inclusion of sleep health education into psychoeducation caregiver interventions may yield even better outcomes for caregivers.

Development and Initial Evaluation of Web-Based Cognitive Behavioral Therapy for Insomnia in Rural Family Caregivers of People With Dementia (NiteCAPP): Mixed Methods Study

BACKGROUND

Informal caregivers of people with dementia frequently experience chronic insomnia, contributing to stress and poor health outcomes. Rural caregivers are particularly vulnerable but have limited access to cognitive behavioral therapy for insomnia (CBT-I), a recommended frontline treatment for chronic insomnia. Web-based delivery promises to improve insomnia, particularly for rural caregivers who have limited access to traditional in-person treatments. Our team translated an efficacious 4-session standard CBT-I content protocol into digital format to create NiteCAPP.

OBJECTIVE

This study aimed to (1) adapt NiteCAPP for dementia caregivers to create NiteCAPP CARES, a tailored digital format with standard CBT-I content plus caregiver-focused modifications; (2) conduct usability testing and evaluate acceptability of NiteCAPP CARES' content and features; and (3) pilot-test the adapted intervention to evaluate feasibility and preliminary effects on sleep and related health outcomes.

METHODS

We followed Medical Research Council recommendations for evaluating complex medical interventions to explore user needs and adapt and validate content using a stepwise approach: (1) a rural dementia caregiver (n=5) and primary care provider (n=5) advisory panel gave feedback that was used to adapt NiteCAPP; (2) caregiver (n=5) and primary care provider (n=7) focus groups reviewed the newly adapted NiteCAPP CARES and provided feedback that guided further adaptations; and (3) NiteCAPP CARES was pilot-tested in caregivers (n=5) for feasibility and to establish preliminary effects. Self-report usability measures were collected following intervention. Before and after treatment, 14 daily electronic sleep diaries and questionnaires were collected to evaluate arousal, health, mood, burden, subjective cognition, and interpersonal processes.

RESULTS

The stepped approach provided user and expert feedback on satisfaction, usefulness, and content, resulting in a new digital CBT-I tailored for rural dementia caregivers: NiteCAPP CARES. The advisory panel recommended streamlining content, eliminating jargon, and including caregiver-focused content. Focus groups gave NiteCAPP CARES high usefulness ratings (mean score 4.4, SD 0.79, scored from 1=least to 5=most favorable; score range 4.2-4.8). Multiple features were evaluated positively, including the intervention's comprehensive and engaging information, caregiver focus, good layout, easy-to-access intervention material, and easy-to-understand sleep graphs. Suggestions for improvement included the provision of day and night viewing options, collapsible text, font size options, tabbed access to videos, and a glossary of terms. Pilot-test users rated usefulness (mean score 4.3, SD 0.83; range 4.1-4.5) and satisfaction (mean score 8.4, SD 1.41, scored from 1=least to 10=most satisfied; range 7.4-9.0) highly. Preliminary effects on caregiver sleep, arousal, health, mood, burden, cognition, and interpersonal processes (all P<.05) were promising.

CONCLUSIONS

Adaptations made to standard digital CBT-I created a feasible, tailored digital intervention for rural dementia caregivers. Important next steps include further examination of feasibility and efficacy in a randomized controlled trial with an active control condition, a multisite effectiveness trial, and eventual broad dissemination.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04632628; https://clinicaltrials.gov/ct2/show/NCT04632628.

Sleep Profiles of Caregivers for Persons Living with Dementia: A Qualitative Study

Sleep disturbance is prevalent among caregivers of people living with dementia. However, gaps exist about caregivers' sleep patterns before and during their caregiving trajectory. This exploratory secondary analysis using a qualitative descriptive approach aimed to (1) identify and describe current caregivers' patterns of change in sleep before and during caregiving, and (2) understand caregivers' perceptions of their current sleep compared to their pre-caregiving sleep. We conducted semi-structured interviews with 19 caregivers taking part in a larger randomized controlled trial. Participants were female (n = 11), white (n = 13) and on average 63 years of age. Interview questions focused on caregivers' sleep patterns. The interviews were audio-recorded using a videoconferencing platform and ranged from 20 to 45 minutes. We conducted thematic analysis of the interview transcripts. Three distinct caregiver-sleep profiles emerged from the qualitative data: changed and dissatisfied, changed and satisfied, and unchanged and dissatisfied. Caregivers whose sleep was categorized as changed reported a difference when comparing their current sleep pattern to their pre-caregiving sleep pattern. This was usually a change from good to poor sleep. Caregivers whose sleep was unchanged had poor sleep pre-caregiving and continued to have poor sleep during caregiving. Caregivers also reported being satisfied or dissatisfied with their current sleep pattern, defined in terms of distress and impairment. These three subtypes highlight the heterogeneity of caregivers' sleep experiences and debut a useful clinical framework with which to identify, categorize, and target caregivers at risk for sleep disturbance, many who may be ready to engage in behaviors to improve their sleep. Knowing caregivers' sleep profiles will enable health care providers and researchers to determine caregivers' needs and readiness for interventions then work collaboratively with them to improve their sleep problems.

Resilience as a moderator of role overload and sleep disturbance among caregivers of persons with dementia

The purpose of this study was to examine if resilience moderates the association between role overload and sleep disturbance among caregivers of persons with dementia. This was a secondary analysis of data on 437 informal caregivers (mean age=61.77 years, SD=13.69) of persons with dementia in the United States. Data from the 2017 wave of the National Study of Caregiving were analyzed using multiple regression with interaction terms to evaluate the moderation effect of resilience, while controlling for caregivers' age, race, gender, education, self-rated health, caregiving hours, and primary caregiving status. Higher role overload was associated with greater sleep disturbance and this association was attenuated among caregivers with higher levels of resilience. Our findings highlight the stress-buffering effects of resilience in the context of sleep disturbance in dementia caregivers. Interventions to improve caregivers' ability to recover, resist, and rebound during challenging situations may mitigate role overload and optimize sleep health.

Prevalence of sleep disturbances in people with dementia living in the community: A systematic review and meta-analysis

This study aimed to systematically review and meta-analyse the prevalence of sleep disturbances in people with dementia and examine demographic predictors and whether overall prevalence has changed over time. We searched Embase, MEDLINE and PsycINFO for studies reporting the prevalence of sleep disturbances in people with dementia living at home. We meta-analysed the data and calculated the pooled prevalence of sleep disturbances in people with dementia overall and in dementia subtypes. We used meta-regressions to investigate the effects of study characteristics, publication dates and participant demographics. Eleven studies fulfilled the inclusion criteria. The pooled prevalence of any symptoms of sleep disturbance was 26 % (95 % confidence intervals, CI: 23-30 %; n = 2719) and of clinically significant sleep disturbance 19 % (13-25 %; n = 2753). The pooled prevalence of sleep disturbance symptoms was significantly lower among people with Alzheimer's disease (24 %; 16-33 %, n = 310) than Lewy body dementia (49 %; 37-61 %, n = 65). Meta-regression analysis did not find that publication year, participant's age, sex and study quality predicted prevalence. Sleep disturbances are common among people with dementia living in the community, especially in Lewy body dementia. There was no change in prevalence according to publication dates, suggesting treatment has not improved over time.

Factorial Structure and Psychometric Properties of the Spanish Version of the Pittsburgh Sleep Quality Index in Non-Professional Caregivers

Although sleep issues are among the symptoms commonly experienced by the non-professional caregiver population, and the Pittsburgh Sleep Quality Index (PSQI) is the most widely used instrument for the assessment of sleep quality, this has not been validated specifically for this population. The objective of this study was to analyze the factorial structure and psychometric properties of the Spanish version of the PSQI in a sample of Spanish non-professional caregivers. Trained clinical psychologists assessed sleep quality using the PSQI, as well as caregiver burden and psychological distress in 201 non-professional caregivers (87.1% female, Mage = 56.2 years). The internal consistency of the PSQI was 0.75. The two-factor model (Sleep quality and Disturbances) had an acceptable fit to the data, was found to be superior to the one-factor model, and more parsimonious than the three-factor model. There was a significant correlation between the PSQI and caregiver burden, as well as between the PSQI and psychological distress (p < 0.001 in all cases). A total score ≥ 9 allowed the identification of caregivers with possible anxiety and depression disorders (sensitivity 70.5%, specificity 71.9%). The results show that the PSQI is a reliable and valid instrument for the assessment of sleep quality in caregivers.

Sleep Disturbance, Psychological Distress and Perceived Burden in Female Family Caregivers of Dependent Patients with Dementia: A Case-Control Study

This case-control study analyzed the sleep disturbance, psychological distress and perceived burden in female family caregivers of dependent people with dementia (n = 74) compared with female family caregivers of dependent people without dementia (n = 74) and with age-matched non-caregiver control females (n = 74). Participants completed the Pittsburgh Sleep Quality Index (PSQI), the 12-item General Health Questionnaire (GHQ-12), the Caregiver Burden Inventory (CBI) and an ad hoc questionnaire to collect sociodemographic data. There were significant differences between the groups in PSQI total (F = 24.93; p < 0.001), psychological distress (F = 26.71; p < 0.001) and in all sleep domains assessed: subjective sleep quality (F = 16.19; p < 0.001), sleep latency (F = 9.5; p< 0.001), sleep duration (F = 18.57; p < 0.001), habitual sleep efficiency (F = 19.77; p < 0.001), sleep disturbances (F = 9.22; p < 0.001), use of sleep medications (F = 4.24; p< 0.01) and daytime dysfunction (F = 5.57; p < 0.01). In all measures, the female family caregivers of dependent people with dementia showed the significantly higher mean scores. Regarding the two groups of female caregivers, statistically significant differences were found in daily hours of care (t = −2.45; p < 0.05) and perceived burden (t = −3.65; p < 0.001), as well as in the following dimensions of caregiver burden: time-dependence burden (t = −5.09; p < 0.001), developmental burden (t = −2.42; p < 0.05) and physical burden (t = −2.89; p < 0.01). These findings suggest that female family caregivers of dependent patients with dementia should be subject to psychopathological screening and preventive cognitive-behavioral interventions in clinical practice in primary health care.

Using Telehealth to Deliver Cognitive Behavioral Treatment of Insomnia to a Caregiver of a Person With Alzheimer's Disease

Cognitive behavioral therapy for Insomnia (CBT-I) is the gold standard treatment for insomnia. There is limited access to qualified providers to deliver CBT-I; moreover, there are patient populations who struggle with access to insomnia care due to limited time and resources. This includes caregivers for persons with Alzheimer's disease, for whom sleep disturbance is a common concern. Utilizing telehealth to deliver CBT-I may be particularly important for vulnerable populations such as caregivers of persons with dementia, as it can offer an accessible, safe, and cost-effective treatment option that can be tailored to meet the needs of a specific population. This case study illustrates the successful implementation of a four-session CBT-I protocol through telehealth with a caregiver of a person with Alzheimer's disease. Given the success of this case and the conditions for psychological care the recent pandemic has created, continued research into the efficacy of sleep-related interventions through telehealth is warranted.

Incremental Healthcare Utilization and Cost Burden of Comorbid Insomnia in Alzheimer's Disease Patients

BACKGROUND

Insomnia is associated with worsened clinical outcomes among Alzheimer's disease dementia (AD) patients, increased caregiver burden, and healthcare utilization.

OBJECTIVE

This study aimed to characterize the incremental healthcare burden of insomnia in AD using real-world data.

METHODS

A retrospective observational study was conducted on AD patients selected from the IBM® MarketScan Commercial and Medicare Supplemental Databases. AD patients with claims-based evidence of insomnia were direct matched to a non-insomnia cohort based on demographic factors. Healthcare utilization and associated costs were assessed for a 12-month follow-up period.

RESULTS

A total of 3,500 insomnia AD patients and 9,884 non-insomnia AD patients were analyzed. The insomnia cohort had a higher comorbidity burden at baseline (mean score on Charlson Comorbidity Index 2.5 versus 2.2, p < 0.001) and higher proportions of patients with baseline diagnoses for other conditions including depression: 40%, insomnia cohort versus 25%, non-insomnia (p < 0.001). AD patients with insomnia were more likely to have a claim for inpatient hospitalizations (39.8%versus 32.3%), emergency room services (56.4%versus 48.0%), and skilled-nursing services (42.6%versus 31.9%) (all p < 0.05). Mean total annual healthcare costs during the 12-month follow-up period were significantly higher among AD patients with insomnia as compared to those without. (Mean costs: $37,356 versus $27,990, p < 0.001).

CONCLUSION

AD patients with comorbid insomnia are more likely to use higher-cost healthcare services such as inpatient hospitalization, and skilled nursing, and have higher total healthcare costs. This real-world analysis provides evidence that AD disease management should consider proper treatment of comorbid insomnia due to the incremental burden and cost implications.

Adapting a whole health model to home-based primary care: Bridging person-driven priorities with veteran and family-centered geriatric care

Through the integration of Whole Health for Life into the Department of Veterans Affairs (VA) health care system, the VA aims to transform health care delivery from a disease management approach to one that embraces person-centered care. The home-based primary care (HBPC) program is a care model that, within the VA, provides holistic primary care services to homebound veterans with multiple chronic medical conditions, mental health issues, and functional declines. These veterans may have limited access to VA programs delivered in a traditional outpatient format. This article describes adaptations to the whole health model of care that could improve its accessibility and applicability to HBPC veterans, caregivers, and the interdisciplinary teams that serve this population. These modifications are informed by whole-person geriatric and gerontological and family-systems theories and address population-based differences in the focus and approach to care. The focus on care is expanded to (a) reflect the importance of attending to caregiver needs and well-being and (b) shift from a preventative model to one that prioritizes resilience and maintenance. The approach to care emphasizes alternative modes of delivery, adaptations to interventions, and integration of geriatric-specific medical considerations into the self-care domains and more directly centers the collaboration between family, the VA, and community partners. This adapted model also addresses the unique needs of health care teams providing in-home services to medically complex veterans and offers suggestions for enhancing self-care and preventing burnout. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Sleep Behaviors in Persons With Alzheimer's Disease: Associations With Caregiver Sleep and Affect

Poor sleep in persons with Alzheimer's disease (AD) is a common stressor for family caregivers. Retrospective reports support associations between sleep disturbance in persons with AD and worse caregiver mood; however, prospective associations between sleep in persons with AD and caregiver outcomes have not been studied. The current study determined associations between affect and sleep of persons with AD and their caregivers using daily diary data. Multilevel mediation models indicated that sleep in persons with AD is linked to caregiver affect; furthermore, these associations are mediated by sleep characteristics in caregivers and affect in persons with AD. Daily fluctuations in sleep behaviors in persons with AD-rather than average values-were most strongly associated with caregiver outcomes. Interventions to improve sleep in persons with AD may decrease their negative affect and improve caregiver mood.

Caregiver burden among informal caregivers in the largest specialized palliative care unit in Malaysia: a cross sectional study

BACKGROUND

Informal caregivers (IC) are often overshadowed by the attention required by the terminally ill. This study aims to reveal the estimated proportion of caregiver burden, psychological manifestations and factors associated with caregiver burden among IC in the largest specialized Palliative Care Unit (PCU) in Malaysia.

METHODS

This was a cross-sectional study involving IC attending a PCU. Caregiver burden and psychological manifestations were measured using previously translated and validated Zarit Burden Interview and DASS-21 questionnaires respectively. Two hundred forty-nine samples were selected for analysis.

RESULT

The mean ZBI score was 23.33 ± 13.7. About half of the population 118(47.4%) was found to experienced caregiver burden whereby majority have mild to moderate burden 90(36.1%). The most common psychological manifestation among IC is anxiety 74(29.7%) followed by depression 51(20.4%) and stress 46(18.5%). Multiple logistic regression demonstrated that women who are IC to patients with non-malignancy were less likely to experience caregiver burden. IC who were highly educated and spent more than 14 h per day caregiving were at least twice likely to experience caregiver burden. Finally, those with symptoms of depression and anxiety were three times more likely to suffer from caregiver burden.

CONCLUSION

Caregiver burden among IC to palliative patients is prevalent in this population. IC who are men, educated, caregiving for patients with malignancy, long hours of caregiving and have symptoms of depression and anxiety are at risk of developing caregiver burden. Targeted screening should be implemented and IC well-being should be given more emphasis in local policies.

Sleep Quality in Caregivers of Older Patients with Schizophrenia Spectrum and Bipolar Disorders: A Case-Control Study

OBJECTIVES

Prior literature has documented the global burden of serious mental illnesses. The present study aimed to compare the sleep quality in caregivers of older patients with schizophrenia spectrum and bipolar disorders with control participants who did not serve as caregivers.

METHODS

We performed a case-controlled, cross-sectional study among family caregivers of older patients with psychotic disorders in Razi Hospital, Tunisia. Subjective sleep quality was assessed using the Pittsburgh Sleep Quality Index Scale (PSQI).

RESULTS

Fifty caregivers of older patients (≥ 60 years) with schizophrenia spectrum and bipolar disorders, and 50 matched controls were enrolled. The three sub-dimensions of the PSQI, namely subjective sleep quality, sleep duration, and sleep efficiency, as well as overall PSQI scores, were worse for caregiver participants. Hierarchical multiple regression analyses predicting PSQI scores revealed that caregivers' age and marital status were the only significant predictors in the final model.

CONCLUSIONS

Older adults with severe mental disorders constitute a vulnerable population which generates a significant burden of care, and impacts their caregivers' subjective sleep quality.

CLINICAL IMPLICATIONS

Family interventions, including sleep interventions, should be considered as an integral component of treatment for serious mental illnesses. When promoting sleep quality, older and single caregivers should be targeted.

Family Relationships and Alzheimer's Disease: A Systematic Review

BACKGROUND

Family caregivers of people with Alzheimer's disease are the most important support in concrete personal and economic terms. Family dynamics play a fundamental role in the provision of informal caregiving benefits.

OBJECTIVE

This review aims to identify factors related to the family caregiving of relatives with Alzheimer's disease, taking specifically into account the construct of coping and expressed emotion.

METHODS

This is a systematic review including articles selected using search terms including "caregivers," "Alzheimer's," "family," and "relationship" in research databases. Findings were synthesized and categorized into themes.

RESULTS

A total of 454 abstracts were identified. Following screening, lateral searches, and quality appraisal, 36 studies were included for synthesis. A total of 5 themes were identified: burden; demographics; coping strategies; caregiver mental health; and family dynamics and expressed emotions.

CONCLUSION

The quality and level of evidence supporting each theme varied. We need further research into family dynamics ameliorating the caregiving and how to measure it.

Spousal Caregiving in Community Settings in Canada: Implications for Nursing Professionals

Objective: Spousal caregivers report significantly more health effects and psychological consequences than caregivers of aging parents. Traditional approaches to assist these caregivers often include lifestyle approaches with a lack of health promotion initiatives. Consequently, alternative approaches to facilitate the adaptation to the social context of spousal caregivers’ experiences are needed. Method: This article systematically reviewed literature on spousal caregiving in Canada using a health promotion approach. Nine peer reviewed articles were identified from the health and social care literature and critically analyzed for relevant themes. Results: Gender, social support, health care, and income emerged as themes in the literature published to date. Discussion: The article concludes with directions for future research in Canada and suggested solutions for family nursing practice.

Resetting the Aging Clock: Implications for Managing Age-Related Diseases

Worldwide, individuals are living longer due to medical and scientific advances, increased availability of medical care and changes in public health policies. Consequently, increasing attention has been focused on managing chronic conditions and age-related diseases to ensure healthy aging. The endogenous circadian system regulates molecular, physiological and behavioral rhythms orchestrating functional coordination and processes across tissues and organs. Circadian disruption or desynchronization of circadian oscillators increases disease risk and appears to accelerate aging. Reciprocally, aging weakens circadian function aggravating age-related diseases and pathologies. In this review, we summarize the molecular composition and structural organization of the circadian system in mammals and humans, and evaluate the technological and societal factors contributing to the increasing incidence of circadian disorders. Furthermore, we discuss the adverse effects of circadian dysfunction on aging and longevity and the bidirectional interactions through which aging affects circadian function using examples from mammalian research models and humans. Additionally, we review promising methods for managing healthy aging through behavioral and pharmacological reinforcement of the circadian system. Understanding age-related changes in the circadian clock and minimizing circadian dysfunction may be crucial components to promote healthy aging.

The clinical and economic burden among caregivers of patients with Alzheimer's disease in Canada

OBJECTIVE

To estimate the clinical and direct medical economic burden among Alzheimer disease (AD) caregivers using real-world, longitudinal patient-level data in Canada.

METHODS/DESIGN

This retrospective observational study assessed the clinical and direct medical economic burden among individuals who cohabitate with AD patients ("AD caregiver cohort") compared with older adults who were cohabiting with another adult without dementia ("comparison cohort") using real-world data from the Southwestern Ontario database, a representative Canadian electronic health record (EHR) longitudinal EHR.

RESULTS

The AD caregiver cohort (n = 2749; mild AD: n = 2254, moderate AD: n = 302, and severe AD, n = 193) had a similar or higher level of clinical and economic burden than the comparison cohort (n = 12 152). The overall AD cohort and caregivers of patients with mild AD had a similar clinical burden to the comparison cohort. Those caregiving for more severely affected AD patients had an increased risk of comorbidities and required more medication, physician attention, and hospital encounters compared with caregivers of less severe AD patients and the comparison cohort. Mean annual costs were higher among the AD caregiver cohort than the comparison cohort, and those caregiving for moderate and severe AD patients incurred the highest costs. Overall mortality was higher in the AD caregiver cohort compared with the comparison cohort.

CONCLUSIONS

Caregivers of patients with mild AD had a similar clinical and direct economic burden to older adults who were not dementia caregivers, whereas the burden among caregivers of moderate and severe AD patients was much greater.

Development of a dyadic sleep intervention for Alzheimer's disease patients and their caregivers

PURPOSE

This study aimed to refine a behavioral sleep intervention program targeting patients with Alzheimer's disease and their caregivers.

METHODS

In this case series, key components of the sleep program were built upon previous intervention studies of patients with cognitive impairment/dementia. The intervention consisted of five weekly sessions covering sleep hygiene, sleep compression, stimulus control, daily walking/light exposure, relaxation/mindfulness, and caregiver training to manage patients' behavioral problems. The materials and structure were iteratively refined based on feedback from caregivers and sleep educators. Sleep diaries were used to evaluate sleep outcomes.

RESULTS

Five out of six enrolled dyads completed the sessions. Several revisions were made during testing: the last session was changed from telephone to in-person; some components (e.g., sleep scheduling, mindfulness) were rearranged within or across sessions; sleep educator guidelines for sleep scheduling, light exposure, and walking were revised. After the fifth dyad, no additional issues were identified by the caregiver or the sleep educator. Four patients and three caregivers had improved sleep at the last session.

CONCLUSIONS

The iterative refinement process was successful in finalizing the intervention program, with evidence of sleep improvements. Formal pilot testing of the program will provide further information on feasibility and effectiveness.IMPLICATIONS FOR REHABILITATIONOur dyadic behavioral sleep program can be tailored to various types of sleep problems among patients with Alzheimer's disease and their family caregivers, with the goal of improving daytime function by reducing sleep disturbances at night.Caregiver training and participation of both members of the dyad in sleep management may benefit the patients' sleep and other health outcomes, reduce caregiver stress and burden, and ultimately delay or prevent institutionalization of Alzheimer's disease patients.

Caregiver Burden and Sleep Quality in Dependent People's Family Caregivers

This study examined the relationship between caregiver burden and sleep quality in dependent people’s family caregivers. A cross-sectional study was carried out with 201 dependent people’s family caregivers and 92 non-caregivers controls. Participants completed the Pittsburgh Sleep Quality Index (PSQI), the Caregiver Burden Inventory (CBI), and an ad-hoc questionnaire to collect sociodemographic data. Based on CBI scores, subjects were categorized into three groups: family caregivers with high levels of perceived burden, family caregivers with low and medium levels of perceived burden and non-caregiver controls. There were significant differences among the groups in the PSQI total (F = 40.39; p < 0.001), subjective sleep quality (F = 25.55; p < 0.001), sleep latency (F = 16.99; p < 0.001), sleep disturbances (F = 14.90; p < 0.001), use of sleep medications (F = 6.94; p < 0.01) and daytime dysfunction (F = 20.12; p < 0.001). These differences were found only between the caregivers with high levels of perceived burden and the other two groups (p < 0.05). There were also significant differences between the groups in sleep duration (F = 18.34; p < 0.001) and habitual sleep efficiency (F = 24.24; p < 0.001). In these dependent measures, the differences were found in all the pairs examined (p < 0.05). These results suggest that caregiver burden is related to sleep quality, so that caregivers with greater perceived burden have a worse sleep quality.

[Quality of sleep in caregiving relatives of people with dementia: investigation of the prevalence and possible predictors]

BACKGROUND

Caregiving relatives of people with dementia (PwD) are exposed to exhausting tasks all day long. The results of a current study suggest that personality traits, sociodemographic and caregiving variables could be associated with poor sleep quality of caregivers of PwD. Nevertheless, the detailed impact of these variables on sleep quality of caregivers is still unknown.

METHOD

This study is based on secondary data from the Tele.TAnDem project. First, descriptive data of 322 caregivers were analyzed regarding prevalence rates of poor sleep quality and high rates of daytime sleepiness in comparison to non-caregivers. Second, hierarchical regression analyses were conducted to calculate the predictive effect of interpersonal and caregiving related variables on subjective sleep quality and daytime sleepiness.

RESULTS

With respect to the prevalence, descriptive data indicate a poorer subjective sleep quality and higher rates of daytime sleepiness of caregivers of PwD compared to non-caregivers. Regression analyses revealed significant effects for gender, disturbed day-night rhythm, burden of caregiving, stress coping strategies and depressive symptoms regarding subjective sleep quality. The number of disturbed behavior patterns, the burden of caregiving and depressive symptoms were significantly associated with higher rates of daytime sleepiness.

CONCLUSION

Caregiving of PwD affects subjective sleep quality as well as daytime sleepiness of caregiving relatives. Both dimensions of sleep quality were associated with several personal and caregiving related variables. Chronic poor sleep quality is a high-risk factor for psychological and physical health problems and should be considered in further research and development of interventions for caregiving relatives of PwD.

Co-resident care-giving and problematic sleep among older people: evidence from the UK Household Longitudinal Study

In light of current pressures within formal social care services, informal carers assume an important role in meeting the care needs of a growing number of older people. Research suggests relationships between care-giving and health are complex and not yet fully understood. Recently, wide-ranging associations between sleep and health have been identified, however, our understanding of the links between care-giving and sleep is limited at present. This study assesses longitudinal patterns in co-resident care-giving and problematic sleep among older people in the United Kingdom. Our sample included 2,470 adults aged 65 years and older from the UK Household Longitudinal Study. Problematic sleep was defined as two or more problems in going to sleep, staying asleep or sleep quality. Using logistic regression models, we assessed how co-resident care-giving status, intensity and transitions influence the likelihood of problematic sleep in the following year, adjusting for potential confounding factors. Adjusted analyses found co-resident care-givers were 1.49 (95% confidence interval = 1.06–2.08) times more likely to report problematic sleep in the following year, relative to those not providing care. Care-giving over 20 hours per week and continuous co-resident care-giving also significantly increased the odds of problematic sleep. This suggests older co-resident care-givers may be at greater risk of incurring sleep problems than non-care-givers. Further longitudinal research is needed to investigate care-giver-specific consequences of poor sleep.

Factors associated with sleep in family caregivers of individuals with dementia

PURPOSE

The study aimed to identify factors related to family caregivers' sleep.

DESIGN AND METHODS

The study used a cross-sectional design with objective and subjective methods to measure sleep in the home setting over a 7-day period.

FINDINGS

Findings indicated that poor sleep quality was found in 91.7% of the caregiver participants. Depression, sleep hygiene, burden, and care-recipients' sleep were significant predictors of various dimensions of caregivers' sleep.

PRACTICE IMPLICATIONS

Our study suggests that sleep quality for family caregivers of individuals with dementia varies considerably from night to night. Understanding the complex interrelationships among caregivers' sleep and other contributing variables is an important first step toward the development of individualized and effective treatment strategies.

Risky wandering behaviors of persons with dementia predict family caregivers' health outcomes

OBJECTIVES

To examine the relationships between dementia persons' risky wandering behaviors and family caregivers' physical and mental health.

METHODS

A secondary analysis was conducted using the original cross-sectional data from180 dyads. The Risky Wandering and Adverse Outcome model assessed behaviors of eloping and getting lost outside the house for dementia persons. Data were analyzed using descriptive statistics, Pearson's correlation coefficient and hierarchical regressions.

RESULTS

The mean age of caregivers was 56.01 years (SD = 13.8); 65% were female. Younger caregivers experienced greater physical fatigue and sleep disturbance. Presence of foreign helpers predicted a reduction in mental and physical fatigue of caregiver (β = -0.186, p < .05; β = 0.198, p < .05, respectively). Getting lost outside of the house influenced caregivers' mental fatigue (β = 0-0.215, p < .05); eloping behavior influenced caregivers' sleep disturbance (β = 0.231, p < .05). Care-receivers' activities of daily living affected caregivers' depressive symptoms (β = -0.179, p < .05).

CONCLUSIONS

Dementia family caregiver physical and mental health problems have distinct predictors. Employing the Risky Wandering and Adverse Outcome model could inform policy makers regarding long-term care resources to improve dementia care.

Longitudinal study of medication use in caregivers of people with Alzheimer's disease - Kuopio ALSOVA study

BACKGROUND

The longitudinal pattern of medication use among family caregivers of people with dementia is not well understood, despite the potential for medication over- or under-use.

OBJECTIVES

To investigate caregiver medication use over a five-year follow-up using data obtained via self-report and from a national prescription register, and compare agreement between medication data obtained from the two sources.

METHODS

Medication data for 222 family caregivers of people with Alzheimer's disease were obtained via self-report and from the Finnish Social Insurance Institution. Generalised estimating equations, Kappa statistics and related samples Wilcoxon signed rank test were used to analyse medication use over time.

RESULTS

The mean number of medications used by caregivers increased from 3.4 to 4.1 (self-reported current regular medications) and 2.4 to 2.8 (reimbursed prescription medications during the past 90 days) over five years (p < 0.001). Significantly, more medications were identified via self-report (mean 3.6, SD = 3.3) than the national prescription register (mean 2.6, SD = 2.4, Z= -12.300, p < 0.001). Agreement between the two data sources was good for cardiovascular medications and anti-hypertensives (Kappa = 0.883-0.967, p < 0.001) and medications for acid-related disorders (Kappa = 0.508-0.092, p < 0.001). Agreement was moderate for analgesics (Kappa = 0.281-0.477, p < 0.001) and psychotropics (Kappa = 0.281-0.562, p < 0.002). The proportion of caregivers using five or more medications increased from 27.5% to 44.6% (self-report), and 16.7% to 27.7% (register) (p < 0.001).

CONCLUSION

Caregivers use an increasing number of medications in the first five years of caring for persons with dementia, and self-report using a higher number of medications than data from the national prescription register suggest.

"What Hath Night to Do with Sleep?": The Caregiving Context and Dementia Caregivers' Nighttime Awakenings

OBJECTIVES

Care provision for persons with dementia can be rewarding yet may disrupt caregiver's sleep health. Using the National Health & Aging Trends Study and the National Study of Caregiving, we examine care receiver and caregiver contextual factors, caregiver health and psychological wellbeing as predictors of caregivers' nighttime awakenings.

METHODS

The sample for this cross-sectional study included 451 caregivers for individuals with dementia surveyed by telephone.

RESULTS

Nighttime awakenings (1 item measure of waking and not being able to return to sleep) almost every night were reported by 16% of caregivers and 10% reported that helping the care receiver caused their sleep to be interrupted most nights. In a multinomial logistic regression, caregivers' greater nighttime awakenings were associated with caring for care recipients with higher fall risk, as well as caregiver characteristics of more chronic medical conditions and emotional difficulty of the care role.

CONCLUSIONS

Emotional caregiving difficulties were associated with nighttime awakenings even accounting for caregivers' health and care receivers' disability. Thus, interventions improving caregiver distress may improve sleep health.

CLINICAL IMPLICATIONS

Clinicians should screen caregivers for nighttime awakenings so that evidence-based interventions and treatments can be implemented to prevent persistent sleep disturbances.

Impact of Alzheimer disease patients' sleep disturbances on their caregivers

Sleep disturbance symptoms are common in persons living with Alzheimer disease (AD). However little is known about the impact of sleep disturbance symptoms in patients living with AD on caregiver burden and quality of life (QOL). The aims of this study were to determine the prevalence of symptoms of disturbed sleep in patients with AD, identify the care-recipient sleep disturbance symptoms that predict caregiver burden and QoL, and determine how care-recipient sleep disturbance symptoms compare to other caregiver and patient characteristics when predicting caregiver QoL. Caregiver burden was assessed using the Screen for Caregiver Burden. Sixty percent of the care-recipients had at least one sleep symptom. In 130 caregiver/patient dyads, nocturnal awakenings, nocturnal wandering, and snoring predicted caregiver burden. Multivariate modeling demonstrated that caregiver burden, caregiver physical and mental health, and caregiver depression were predictors of overall caregiver QoL. Treating disturbed sleep in care-recipients and caregiver mental health symptoms could have important public health impact by improving the lives of the caregiving dyad.

Caregiving-Related Sleep Problems and Their Relationship to Mental Health and Daytime Function in Female Veterans

OBJECTIVE/BACKGROUND

To identify caregiving-related sleep problems and their relationship to mental health and daytime function in female Veterans.

PARTICIPANTS

Female Veterans (N = 1,477) from cross-sectional, nationwide, postal survey data.

METHODS

The survey respondent characteristics included demographics, comorbidity, physical activity, health, use of sleep medications, and history of sleep apnea. They self-identified caregiving- related sleep problems (i.e., those who had trouble sleeping because of caring for a sick adult, an infant/child, or other respondents). Patient Health Questionnaire (PHQ-4) was used to assess mental health, and daytime function was measured using 11 items of International Classification of Sleep Disorders-2 (ICSD-2).

RESULTS

Female Veterans with self-identified sleep problems due to caring for a sick adult (n = 59) experienced significantly more symptoms of depression and anxiety (p < 0.001) and impairment in daytime function (e.g., fatigue, daytime sleepiness, loss of concentration, p < 0.001) than those with self-identified sleep problems due to caring for an infant or child (n = 95) or all other respondents (n = 1,323) after controlling for the respondent characteristics.

CONCLUSIONS

Healthcare providers should pay attention to assessing sleep characteristics of female Veterans with caregiving responsibilities, particularly those caregiving for a sick adult.

Changes in Caregiving Status and Intensity and Sleep Characteristics Among High and Low Stressed Older Women

STUDY OBJECTIVES

To examine whether change in caregiving status and intensity among community-dwelling older women was associated with sleep characteristics at follow-up, and whether perceived stress modified these associations.

METHODS

The sample included 800 women aged 65 years or older who completed baseline and second follow-up interviews in the Caregiver-Study of Osteoporotic Fractures (Caregiver-SOF). Respondents were categorized into four groups based on change in caregiving status and intensity between the two time points: continuous noncaregivers, ceased caregivers, low-intensity caregivers (continuous caregivers with low/decreased intensity), and high-intensity caregivers (continuous caregivers with high/increased intensity or new caregivers). Perceived Stress Scale scores at the second follow-up were dichotomized into high versus low stress. Sleep outcomes at SOF Visit 8 (which overlapped with Caregiver-SOF second follow-up) included the Pittsburgh Sleep Quality Index total score; and actigraphy-measured total sleep time, sleep efficiency, wake after sleep onset, and sleep latency.

RESULTS

Multivariate-adjusted sleep characteristics did not differ significantly across caregiving groups. Among high-intensity caregivers, however, those with high stress levels had significantly longer wake after sleep onset (mean 82.3 minutes, 95% confidence interval = 70.9-93.7) than those with low stress levels (mean 65.4 minutes, 95% confidence interval = 55.2-75.7). No other sleep outcomes were modified by stress levels. Further, higher stress was significantly associated with worse Pittsburgh Sleep Quality Index scores, regardless of the caregiving group.

CONCLUSIONS

Overall, sleep characteristics did not differ among noncaregivers, ceased caregivers, or those with high-/low-intensity caregiving among older women. However, subgroups of caregivers may be vulnerable to developing sleep problems, particularly those with high stress levels.

Informal Care and Sleep Disturbance Among Caregivers in Paid Work: Longitudinal Analyses From a Large Community-Based Swedish Cohort Study

STUDY OBJECTIVES

To examine cross-sectionally and prospectively whether informal caregiving is related to sleep disturbance among caregivers in paid work.

METHODS

Participants (N = 21604) in paid work from the Swedish Longitudinal Occupational Survey of Health. Sleeping problems were measured with a validated scale of sleep disturbance (Karolinska Sleep Questionnaire). Random-effects modeling was used to examine the cross-sectional association between informal caregiving (self-reports: none, up to 5 hours per week, over 5 hours per week) and sleep disturbance. Potential sociodemographic and health confounders were controlled for and interactions between caregiving and gender included. Longitudinal random-effects modeling of the effects of changes in reported informal caregiving upon sleep disturbance and change in sleep disturbance was performed.

RESULTS

In multivariate analyses controlling for sociodemographics, health factors, and work hours, informal caregiving was associated cross-sectionally with sleep disturbance in a dose-response relationship (compared with no caregiving, up to 5 hours of caregiving: β = 0.03; 95% CI: 0.01, 0.06, and over 5 hours: β = 0.08; 95% CI: 0.02, 0.13), results which varied by gender. Cessation of caregiving was associated with reductions in sleep disturbance (β = -0.08; 95% CI: -0.13, -0.04).

CONCLUSIONS

This study provides evidence for a causal association of provision of informal care upon self-reported sleep disturbance. Even low-intensity care provision was related to sleep disturbance among this sample of carers in paid work. The results highlight the importance of addressing sleep disturbance in caregivers.

Sleep disturbances in caregivers of patients with advanced cancer: A systematic review

OBJECTIVE

Sleep disturbances are a common issue for those who provide informal care to someone with a life-limiting condition. The negative consequences of poor sleep are well documented. The purpose of the present study was to determine the sleep patterns of caregivers of patients with advanced cancer.

METHOD

An extensive systematic review of studies reporting empirical sleep data was undertaken in 2015 in accordance with the PRISMA Statement. A total of eight electronic databases were searched, with no date restrictions imposed. Additionally, a search of the bibliographies of the studies identified during the electronic search was conducted. Search terms included: "sleep," "insomnia," "sleep disturbance," "circadian rhythm," "caregiver," "carer," "advanced cancer," "palliative cancer," and MESH suggestions. The inclusion criteria required studies to be in English and to report primary qualitative and/or quantitative research that examined sleep in caregivers of patients with advanced cancer. Unpublished studies, conference papers, and dissertations were excluded.

RESULTS

Overall, 10 studies met the inclusion criteria and were included in the review. Two major findings emerged from the data synthesis. First, at least 72% of caregivers reported moderate to severe sleep disturbance as measured by the Pittsburgh Sleep Quality Index. Second, objective measurement of caregivers' sleep identified that some caregivers experienced up to a 44% reduction in their total sleep time compared to the recommended eight hours.

SIGNIFICANCE OF RESULTS

Reduction in total sleep time appears to be the biggest issue facing caregivers' sleep. Future studies need to explore the specific factors that cause these sleep disturbances and thus help to identify interventions to optimize sleep.

The Association of Sleep Disturbances With Quality of Life in Heart Failure Patient–Caregiver Dyads

Sleep disturbance is common in patients with heart failure and their family caregivers. The purpose of this study was to determine whether sleep disturbances of patients and their spousal caregivers predicted their own and their partners’ quality of life (QoL) in 78 heart failure patient–spousal caregiver dyads. Sleep disturbance was assessed using a composite score of four common sleep complaints. QoL was assessed by the physical and mental well-being subscales of the Short-Form 12 Health Survey. The multilevel dyadic actor–partner interdependence model analysis was used to determine the association between sleep disturbance and QoL. Each individual’s sleep disturbance predicted their own poor physical and mental well-being while spousal caregivers’ sleep disturbance predicted their partners’ mental well-being. Results indicated that patients’ mental well-being is sensitive to their spouses’ sleep disturbance. Interventions targeting improving sleep and QoL may have to include both patients and spousal caregivers.

The oldest carers: A narrative review and synthesis of the experiences of carers aged over 75 years

As populations age, numbers of older carers are increasing. These carers play a vital role in supporting others, often partners or spouses with dementia. This narrative review synthesised peer-reviewed evidence published over the last two decades concerning the experiences of carers aged over 75 years, specifically exploring whether their experiences differ from those of younger carers. Four electronic databases were searched and 4102 publications were identified. Eighteen studies involving over one thousand carer participants were included (11 quantitative, 6 qualitative, and 1 mixed-methods study). Most studies came from Europe or North America and almost all were cross-sectional, but few directly compared younger and older carers, making it difficult to determine whether carers' experiences vary with age. Quantitative studies generally emphasised the challenges of caring and frequently highlighted, for example, relationships between carer characteristics and negative outcomes such as burden. Qualitative studies were often more positive, emphasising carers' active responses and the rewards of caring. The normality of caring was highlighted, with some suggesting that caring may be less challenging for older than for younger carers. As with younger carers, being an older carer can be both rewarding and difficult. Our understanding of the experiences of these older carers would be enhanced with more research specifically comparing older and younger carers or comparing older carers and those not in a caring role. Carers are diverse and future research should explore the experiences of carers from different demographic groups. More longitudinal research perhaps focusing on caring dyads and mutual caring is needed.

Circadian Disruption Reveals a Correlation of an Oxidative GSH/GSSG Redox Shift with Learning and Impaired Memory in an Alzheimer's Disease Mouse Model

It is unclear whether pre-symptomatic Alzheimer's disease (AD) causes circadian disruption or whether circadian disruption accelerates AD pathogenesis. In order to examine the sensitivity of learning and memory to circadian disruption, we altered normal lighting phases by an 8 h shortening of the dark period every 3 days (jet lag) in the APPSwDI NOS2-/- model of AD (AD-Tg) at a young age (4-5 months), when memory is not yet affected compared to non-transgenic (non-Tg) mice. Analysis of activity in 12-12 h lighting or constant darkness showed only minor differences between AD-Tg and non-Tg mice. Jet lag greatly reduced activity in both genotypes during the normal dark time. Learning on the Morris water maze was significantly impaired only in the AD-Tg mice exposed to jet lag. However, memory 3 days after training was impaired in both genotypes. Jet lag caused a decrease of glutathione (GSH) levels that tended to be more pronounced in AD-Tg than in non-Tg brains and an associated increase in NADH levels in both genotypes. Lower brain GSH levels after jet lag correlated with poor performance on the maze. These data indicate that the combination of the environmental stress of circadian disruption together with latent stress of the mutant amyloid and NOS2 knockout contributes to cognitive deficits that correlate with lower GSH levels.

Illustration of informal caregiving within Saudi society: demography, scope of care and enabling arrangements

Although informal caregiving is a vital element in the process of supporting individuals with dependency, it is unrecognised most of the time, particularly by caregivers themselves. In Saudi Arabia, little attention has been devoted to informal caregivers; therefore, scarce coverage of this topic is obvious within the literature. This descriptive cross-sectional study was carried to explore informal caregiving within Saudi society by (i) describing informal caregivers and their care recipients and (ii) measuring the scope of care and enabling arrangements in the lives of informal caregivers. Numerical measures of frequency distribution were used to describe the participants and the correlate of demography among 341 female primary caregivers of the elderly (40%), individuals with disabilities (10%) or/and children aged five or younger (51%). Inferential statistics were used to test for significant associations among study variables. The majority of the participants were married with children and were middle-aged. However, the majority of care recipients were living with their caregivers; in addition, they were primarily females cared for by a mother or, less often, by a daughter (in-law). Enabling arrangements were on a moderate level, mainly in healthcare access, financial resources and family support, with lower signs detected in the quality of sleep indicator. These arrangements were significantly associated with caregiver age, education, career status and source of assistance. In conclusion, the statistics revealed by this survey indicated certain challenges that have been encountered by informal caregivers, primarily involving financial and social support. More coverage within the formal system of childcare must be provided to facilitate healthier childhoods. The long-term needs of individuals with dependency must be considered in the planning process of healthcare services, as well, remembering the needs and expectations of informal caregivers.

The Concept of Missing Incidents in Persons with Dementia

Behavioral symptoms of dementia often present the greatest challenge for informal caregivers. One behavior, that is a constant concern for caregivers, is the person with dementia leaving a designated area such that their whereabouts become unknown to the caregiver or a missing incident. Based on an extensive literature review and published findings of their own research, members of the International Consortium on Wandering and Missing Incidents constructed a preliminary missing incidents model. Examining the evidence base, specific factors within each category of the model were further described, reviewed and modified until consensus was reached regarding the final model. The model begins to explain in particular the variety of antecedents that are related to missing incidents. The model presented in this paper is designed to be heuristic and may be used to stimulate discussion and the development of effective preventative and response strategies for missing incidents among persons with dementia.

Sleep Quality in Family Caregivers of Individuals With Dementia

Poor sleep quality in family caregivers may impact their health status and cause quality of life to decline. Nurses are conducting an increasing number of studies that use sleep quality or related concepts as a main indicator to assess caregiver’s sleep. Therefore, a clear understanding of sleep quality and how it is different from other relevant sleep domains is essential. This article aimed to analyze the concept of sleep quality using the steps outlined by Walker and Avant. Findings include (a) attributes of sleep quality including subjective perception of sleep, sleep hours, and evaluation of activity after awaking; (b) antecedents of sleep quality including the ability to get naturally into the sleep cycle and status of conscious state; and (c) consequences of sleep quality including bio-psycho-social and global dimensions of health. This article intends to help clinicians and researchers better understand and define sleep quality in dementia caregivers.

Prevalence of major depressive episodes in non-professional caregivers

Despite research demonstrating the psychological burden associated with caregiving, there is limited information regarding the real rates of clinical depression among non-professional caregivers (NCs) of dependent patients. The goals of the current study are (a) to report the prevalence of major depressive episodes (MDEs) and the frequency of depressive symptoms in NCs from Galicia (Spain) and (b) to examine the relationship between MDEs and characteristics of caregivers, care recipients, and the care situation. A sample of 504 NCs providing care to persons with all kinds of disorders that result in dependency was randomly selected, and the occurrence of MDEs was assessed by trained interviewers who applied the Structured Clinical Interview for DSM-IV Axis I Disorders-Clinician Version (SCID-CV). Overall, 8.9% of NCs met the criteria for a current MDE. Sleep problems, diminished ability to think or concentrate, and depressed mood were the clinical depressive symptoms most frequently reported. MDEs were significantly more common among NCs older than 55 years old (odds ratio [OR]=1.96; 95% confidence interval [CI]: 1.02-3.75) and those who were unemployed (OR=3.43; 95% CI 1.02-11.48). The findings highlight the magnitude of major depression in this population.

Avoidant Coping and Poor Sleep Efficiency in Dementia Caregivers

OBJECTIVES

Caring for a spouse with dementia is a source of chronic stress and is associated with a heightened prevalence of self-reported sleep problems. Styles and strategies for coping with stress have been associated with objective measures of sleep in non-caregiver populations. The current study evaluated relationships between caregiver coping style and sleep disturbance using in-home polysomnography.

METHODS

Sixty spousal caregivers (mean [standard deviation] age = 73.31 [7.05] years; 81.7% female) completed the Brief Cope, the Hamilton Rating Scale for Depression, and three nights of in-home polysomnography. Participants were categorized into two groups based on the presence or absence of clinically significant low sleep efficiency (<80%). A factor analysis of the Brief Cope yielded higher-order factors that included approach coping and avoidant coping (explained variance, 27.2% and 16.9%, respectively). Coping factors were entered into a binary logistic regression predicting sleep efficiency group while controlling for sleep apnea, medication use, and depression, as measured by the Hamilton Rating Scale for Depression.

RESULTS

In fully adjusted models, for each unit increase on the avoidant coping factor, participants were 3.4 times more likely to be classified in the low sleep efficiency group (B = 1.224, χ2(1) = 4.967, p = .026, exp(B) = 3.401, 95% confidence interval = 1.159-9.981). Approach coping was unrelated to sleep efficiency in both adjusted and unadjusted models.

CONCLUSIONS

These findings highlight the importance of coping among caregivers and indicate that avoidant coping may be a modifiable predictor of sleep disturbance in conditions of chronic stress.

Buying time: a rationale for examining the use of circadian rhythm and sleep interventions to delay progression of mild cognitive impairment to Alzheimer's disease

As of 2010, the worldwide economic impact of dementia was estimated at $604 billion USD; and without discovery of a cure or effective interventions to delay disease progression, dementia's annual global economic impact is expected to surpass $1 trillion USD as early as 2030. Alzheimer's disease (AD) is the leading cause of dementia accounting for over 75% of all cases. Toxic accumulation of amyloid beta (Aβ), either by overproduction or some clearance failure, is thought to be an underlying mechanism of the neuronal cell death characteristic of AD-though this amyloid hypothesis has been increasingly challenged in recent years. A compelling alternative hypothesis points to chronic neuroinflammation as a common root in late-life degenerative diseases including AD. Apolipoprotein-E (APOE) genotype is the strongest genetic risk factor for AD: APOE-ε4 is proinflammatory and individuals with this genotype accumulate more Aβ, are at high risk of developing AD, and almost half of all AD patients have at least one ε4 allele. Recent studies suggest a bidirectional relationship exists between sleep and AD pathology. Sleep may play an important role in Aβ clearance, and getting good quality sleep vs. poor quality sleep might reduce the AD risk associated with neuroinflammation and the ε4 allele. Taken together, these findings are particularly important given the sleep disruptions commonly associated with AD and the increased burden disrupted sleep poses for AD caregivers. The current review aims to: (1) identify individuals at high risk for dementia who may benefit most from sleep interventions; (2) explore the role poor sleep quality plays in exacerbating AD type dementia; (3) examine the science of sleep interventions to date; and (4) provide a road map in pursuit of comprehensive sleep interventions, specifically targeted to promote cognitive function and delay progression of dementia.

Sleep disturbances and predictive factors in caregivers of patients with mild cognitive impairment and dementia

Background and Purpose

We examined the characteristics of sleep disturbances and sleep patterns in the caregivers of patients with amnestic mild cognitive impairment (aMCI) and dementia.

Methods

We prospectively studied 132 patients (60 with aMCI and 72 with dementia) and their caregivers, and 52 noncaregiver controls. All caregivers and controls completed several sleep questionnaires, including the Pittsburgh Sleep Quality Index (PSQI). The patients were administered neuropsychological tests and the neuropsychiatric inventory to evaluate their behavioral and neuropsychiatric symptoms of dementia (BPSD).

Results

The PSQI global score was 6.25±3.88 (mean±SD) for the dementia caregivers and 5.47±3.53 for the aMCI caregivers. The Insomnia Severity Index (ISI) and short form of the Geriatric Depression Scale (GDS-S) predicted higher PSQI global scores in aMCI caregivers, and higher scores for the ISI, Epworth Sleepiness Scale (ESS), and GDS-S in dementia caregivers. BPSD, including not only agitation, depression, and appetite change in dementia patients, but also depression, apathy, and disinhibition in aMCI patients, was related to impaired sleep quality of caregivers, but nighttime behavior was not. Age and gender were not risk factors for disturbed sleep quality.

Conclusions

Dementia and aMCI caregivers exhibit impaired quality of sleep versus non-caregivers. ISI, GDS-S, and ESS scores are strong indicators of poor sleep in dementia caregivers. In addition, some BPSD and parts of the neuropsychological tests may be predictive factors of sleep disturbance in dementia caregivers.

Sleep disturbance, nocturnal agitation behaviors, and medical comorbidity in older adults with dementia: relationship to reported caregiver burden

The purpose of this secondary analysis study was to determine whether care recipients' nighttime sleep patterns, medical comorbidity, observed nocturnal agitation behaviors, and caregivers' perceptions of nocturnal agitation behaviors in care recipients with dementia are associated with caregiver burden. Sixty care recipient-caregiver dyads, comprising older adults with geriatrician-diagnosed dementia living at home with caregivers, participated. Caregivers' perceptions of the frequency of care recipients' nocturnal agitation behaviors were associated with caregiver burden; however, objective, real-time data on the frequency of nocturnal agitation behaviors were not associated with burden. Care recipients' increased minutes of wakefulness before falling asleep and severe cognitive impairment with musculoskeletal/integument and neurological comorbidities were associated with higher caregiver burden. These results suggest that targeted interventions to reduce sleep onset latency, medical comorbidity, and caregivers' perception of frequency of nocturnal behaviors may reduce caregiver burden.

Sleep patterns and sleep-impairing factors of persons providing informal care for people with cancer: a critical review of the literature

BACKGROUND

Sleep is increasingly recognized as an area of functioning that may be greatly affected in persons who are practically and emotionally involved in the care of patients with cancer. Clinician awareness is required to ensure that effective care for informal caregivers with sleep problems is provided.

OBJECTIVE

A 2-fold critical review of the published literature was conducted, which aimed at summarizing and critically analyzing evidence regarding sleep patterns of informal caregivers of adults with cancer and contributing factors to sleep-wake disturbances.

METHODS

Using a wide range of key terms and synonyms, 3 electronic databases (MEDLINE, CINAHL, EMBASE) were systematically searched for the period between January 1990 and July 2011.

RESULTS

Based on prespecified selection criteria, 44 articles were pooled to provide evidence on sleep-impairing factors in the context of informal caregiving, 17 of which specifically addressed sleep patterns of caregivers of people with cancer.

CONCLUSIONS

At least 4 of 10 caregivers may report at least 1 sleep problem. Short sleep duration, nocturnal awakenings, wakefulness after sleep onset, and daytime dysfunction seem to be the areas most affected irrespective of stage or type of disease, yet circadian activity remains understudied. In addition, despite a wide spectrum of potential sleep-impairing factors, underlying causal pathways are yet to be explored.

IMPLICATIONS FOR PRACTICE

More longitudinal, mixed-methods, and comparison studies are warranted to explore caregiver sleep disorders in relation to the gravity of the caregiving situation in the context of diverse types of cancer and disease severity.

Dementia behavioural and psychiatric symptoms: effect on caregiver's sleep

AIMS AND OBJECTIVES

To examine caregiver sleep quality, especially in relation to the daytime and night-time behaviours and psychological symptoms exhibited by persons with dementias.

BACKGROUND

Caregivers of persons with dementias experience poorer sleep in comparison with noncaregivers, and poor sleep is related to negative health outcomes. The reasons for caregivers' poor sleep are complex, and it is known that the night-time behaviours of the persons with dementia contribute to caregiver sleep disruption. However, the frequency of behavioural and psychological symptoms of dementia has hitherto not been sufficiently explored as a contributing factor to poor caregiver sleep.

DESIGN

A nonexperimental cross-sectional design.

METHODS

Eighty caregivers completed questionnaires on the frequency of behavioural and psychological symptoms of the persons with dementia, the Dementia Severity Rating Scale, the Pittsburgh Sleep Quality Index and the Center for Epidemiologic Studies Depression Scale.

RESULTS

Poor sleep was reported with awakenings by the persons with dementia occurring for more than half of the caregivers. The frequency of behaviours and symptoms did not make a unique contribution to the variance of caregivers' global sleep. The frequency of behaviours, and specifically of agitation and apathy, contributed to the variance in subjective sleep quality, as defined by the caregivers' appraisal of their sleep.

CONCLUSIONS

The findings demonstrate the relationship between (1) daytime and night-time behaviours of persons with dementias and (2) their caregivers' sleep quality and emphasise the complexity of the factors that contribute to caregiver sleep quality.

RELEVANCE TO CLINICAL PRACTICE

These findings suggest that nurses should be cognizant of the relationship between daytime behaviours of the persons with dementia and the caregivers' appraisal of their sleep, realising that appraising one's sleep as poor can be a contributing factor to perpetuating sleep problems. Interventions aimed at helping the caregiver manage the persons with dementia's agitation or the caregiver's emotional response to persons with dementia apathy may improve caregivers' perception of their sleep.

Sleep characteristics of family caregivers of individuals with a primary malignant brain tumor

PURPOSE/OBJECTIVES

To describe the sleep characteristics of family caregivers of individuals with a primary malignant brain tumor (PMBT).

DESIGN

Cross-sectional, correlational design using baseline data from a longitudinal study.

SETTING

Neuro-oncology and neurosurgery clinics at an urban tertiary medical center in the United States.

SAMPLE

133 family caregivers recruited one to two months following diagnosis of family member's PMBT.

METHODS

Subjective and objective measures of sleep were obtained via self-report and the use of accelerometers (three nights).

MAIN RESEARCH VARIABLES

Sleep characteristics including sleep latency, total sleep time, wake after sleep onset, number of naps, number of arousals, sleep-wake cycle, and sleep quality.

FINDINGS

Sleep latency in caregivers was, on average, 35 minutes (SD = 34.5)-more than twice as long as the norm of 15 minutes (t[113]) = 6.18, p < 0.01). Caregivers averaged a total sleep time of 5 hours and 57 minutes (SD = 84.6), significantly less than the recommended 7 hours (t[113] = -8, p < 0.01), and were awake in the night 15% of the time, significantly more than the norm of 10% (t[111] = 5.84, p < 0.01). Caregivers aroused an average of 8.3 times during nocturnal sleep (SD = 3.5, range = 2-21), with about 32% reporting poor or very poor sleep quality.

CONCLUSIONS

Caregivers experienced sleep impairments that placed them at risk for poor mental and physical health, and may compromise their ability to continue in the caregiving role.

IMPLICATIONS FOR NURSING

Nurses need to assess sleep in caregivers of individuals with PMBT and implement interventions to improve sleep.

KNOWLEDGE TRANSLATION

Sleep deprivation is common in family caregivers during the early stages of care for individuals with a PMBT. A single-item sleep quality question could be an easy but valuable tool in assessing sleep disturbances in family caregivers of individuals with a PMBT. The health trajectory of family caregivers warrants further longitudinal study, in addition to the examination of the bidirectional relationship of health status of care recipients and their family caregiver.