Burden of caregiving in mild to moderate dementia: an Asian experience

State of household need for caregivers and determinants of psychological burden among caregivers of older people in Thailand: An analysis from national surveys on older persons

OBJECTIVES

To explore the levels and trends of household need for caregivers of older people and to explore the impact of potential determinants of psychological burden among caregivers of older people in Thailand.

METHODS

The secondary data analysis was performed using the Survey of Older Persons in Thailand 2007, 2011, and 2014 datasets which conducted by the National Statistical Office of Thailand. The household need for caregivers of older persons refers to having at least one older person in the household who needs a caregiver for assistance with activities of daily living. Caregiver mental health, which is confined to the available 2011 data, is defined as a state of psychological burden. Ordinal logistic regression models were used to explore the impact of potential determinants of psychological caregiver burden.

RESULTS

The household need for caregivers in Thailand tends to be increasing, from 5.0% in 2007 to 6.6% in 2014. The levels of the household need for caregivers were significantly higher in urban areas, Bangkok, and high socioeconomic households. In terms of psychological caregiver burden, the Thai Mental Health Indicators in 2011 produced, on average, a fair level of mental health, but one-fourth of caregivers had poor mental health. Duration of care for older people, household wealth, and functional dependency significantly predict total caregiver burden. Household characteristics are vital in predicting psychological caregiver burden, and the adjusted effect of the fifth quintile of household wealth was high (odds ratio = 2.34; 95% confidence interval = 1.47-3.73).

CONCLUSION

The increasing need for caregiving in households with an older person can lead to a higher caregiver burden, particularly among those caregivers who care for dependent older people in poor households. Longer duration of caregiving is a factor that mitigates this burden.

Investigation into the causes of indwelling urethral catheter implementation and its effects on clinical outcomes and health care resources among dementia patients with pneumonia: A retrospective cohort study

There is a possibility that unnecessary treatments and low-quality medical care, such as inappropriate indwelling urethral catheter use, are being provided to older Japanese individuals.The aim of this study was to investigate contextual effects relating to indwelling urethral catheters in older people with dementia and to clarify the effects of indwelling urethral catheter use on patients' mortality, length of stay (LOS), and health care spending. This retrospective cohort study involved 4501 male and female Japanese participants. Those who were aged 75 or older with dementia and had a primary diagnosis of acute lower respiratory disease with antibiotics administered during hospitalization were eligible for inclusion. Patient mortality, LOS, and total charge during hospitalization were the main study outcomes. This study showed that indwelling urethral catheter use was significantly associated with higher mortality, longer LOS, and higher total charge for hospitalization. The pattern of indwelling urethral catheter use was clustered by care facility level. Physician density was significantly associated with indwelling urethral catheter use; the relationship was not linear but U-shaped, such that the approximate median had the lowest rate of urethral catheter use and this increased gradually toward both lower and higher physician densities. Our study found considerable variation in indwelling urethral catheter use between care facilities in older people with dementia. Additionally, indwelling urethral catheter use was related to poor outcomes. Based on these findings, we consider there to be an urgent need for constructing a framework to measure, report on, and promote the improvement of care quality for older individuals in Japan.

Caregiving Burden is Associated with Short rather than Long Duration of Care for Older Persons

This is a preliminary cross-sectional study of 51 caregivers of older persons attending the Geriatric Clinic at an urban hospital in Kuala Lumpur, Malaysia. A questionnaire helped determine how the duration of caregiving affects the outcome of caregiver burden. The short version of Zarit's Burden Interview (BI) allowed the burden level to be grouped as low or high burden. The duration of caregiving was also grouped into short (two or less years) or long (more than two years) durations. One third of the caregivers, 31% (16 out of 51) reported high burden and within this group 81%, (13 out of 16) are short duration caregivers. Majority of the longer duration caregivers, 88% (21 out of 24) reported low level of burden. This was a significant finding ( p-value 0.008). The study also showed that a higher proportion of caregivers are employed, working in the private sector, and earn less than RM2,000 per month. However, these findings were not significantly associated with high burden. It is concluded that although this study showed low level of caregiver burden, shorter duration of caregiving is associated with higher level of burden and longer duration of caregiving is associated with lower level of burden. Asia Pac J Public Health 2003; 15(2): 88-93.

Neuropsychiatric symptom clusters of Alzheimer disease in Hong Kong Chinese: correlates with caregiver burden and depression

OBJECTIVES

To investigate the relative effects of different neuropsychiatric syndromes of Alzheimer disease (AD) on caregiver burden and depression.

METHODS

One hundred forty-two Chinese family carers of persons with AD were individually interviewed using Neuropsychiatric Inventory (NPI), Revised Memory and Behavior Problems Checklist (RMBPC), Zarit Burden Interview, Pearlin's measure of role overload, Hamilton Depression Rating Scale, and other relevant measures (e.g., caregiving hours per week, relationship to care recipient [CR], CR's functional impairment). CRs were administered the Cantonese version of the Mini-Mental State Examination. AD severity was determined by Clinical Dementia Rating. NPI and RMBPC items were scored according to syndromal classifications (NPI: behavior problems, psychosis, mood disturbance, euphoria; RMBPC: disruptive behaviors, depression, memory-related problems). Data were analyzed using multiple regression, with caregiver gender, caregiving hours per week, and CR's functional impairment as covariates. The analysis with Hamilton depression as the outcome variable also included Zarit burden and role overload as predictors.

RESULTS

NPI behavior and NPI mood were consistent predictors of Zarit burden and role overload. RMBPC memory predicted Zarit burden. No other neuropsychiatric syndromes had independent effects on burden and overload. After partializing out the effects of burden, overload, and other covariates, NPI behavior was the only syndrome that predicted caregiver depression.

CONCLUSIONS

Not all neuropsychiatric symptoms affected caregiver burden and depression, and overt behavior problems and mood disturbances were consistent predictors of burden.

Perceived unmet needs of informal caregivers of people with dementia in Singapore

BACKGROUND

This study aimed to explore the experiences and challenges of informal caregivers in Singapore with the intent of identifying the multi-dimensional unmet needs from their perspective and generating caregivers' needs checklist based on the findings.

METHODS

Informal caregivers were relatives of people with dementia and were responsible for organizing care and providing regular physical and/or financial support. Using a qualitative research design, informal caregivers' experiences were explored. A total of ten focus group discussions and 12 semi-structured interviews were conducted with adult caregivers. Caregivers' perceived unmet needs were identified using thematic analysis. Findings from the qualitative study were combined with inputs from professionals to create a checklist of caregivers' needs for dementia.

RESULTS

The average age of the participants was 52.9 years; the majority of the participants were of Chinese ethnicity (50%), followed by Indian (23%), Malay (22%), and other (3%) ethnic groups. Informal caregivers perceived four categories of unmet needs: (i) emotional and social support, (ii) information, (iii) financial support, and (iv) accessible and appropriate facilities. Caregivers strongly expressed the need for emotional support to overcome the psychological and physical burden of care. Challenges with obtaining adequate information, access to services, and financial barriers were discussed. Based on these findings and expert panel discussions, a checklist of 26 items representing their unmet needs was designed.

CONCLUSIONS

Informal caregivers face several challenges while caring for their relative with dementia and hence there is a clear demand to address their unmet needs for information, services, respite, and emotional and financial support.

Investigation of toilet activities in elderly patients with dementia from the viewpoint of motivation and self-awareness

Toilet activities of the elderly patients with dementia were observed focusing on care conditions and investigated based on Hull's drive reduction theory (behavior = drive × habit × incentive) and our self-awareness model (consisting of theory of mind, self-evaluation, and self-consciousness) to evaluate the association between self-awareness and toilet activities in patients with dementia and to explain the time when and the reason why a series of toilet activities as habit once acquired become unfeasible. If theory of mind is lost, awareness of one's desire and intention becomes vague, and toilet activities begin to collapse. Furthermore, if incentive disappears, one's intention hardly arises and toilet activities further collapse. If self-evaluation is lost, time sense fades, future goals based on the present time cannot exist, and behavior loses directivity. As a result, toilet activities collapse, and with a decrease in drive toilet activities cease.

Behavioural and psychological symptoms of dementia, cognitive impairment and caregiver burden in patients with dementia

OBJECTIVE

This study aims to determine the relationships between behavioural and psychological symptoms of dementia (BPSD), cognitive impairment and burden of care of patients with dementia.

METHOD

A cross-sectional, non-randomised study of 65 elderly patients with dementia and their caregivers was conducted over a 3-month period in January 2007 at the memory clinics of Universiti Kebangsaan Malaysia Medical Centre and Hospital Kuala Lumpur. Patients' cognitive functions were assessed with the Mini Mental State Examination (MMSE). Caregivers were interviewed to determine the severity of BPSD and caregiver burden (CB) using the Neuropsychiatric Inventory (NPI) Questionnaire and Zarit Burden Interview (BI) respectively.

RESULTS

Cognitive impairment did not contribute significantly to CB. Multiple linear regression analysis showed that high BPSD scores contributed 0.27 more in BI score, female patients contributed 0.37 less in BI score and caregivers with higher educational level contribute 0.5 more in BI score.

CONCLUSION

Patients' BPSD and male gender, but not cognitive impairment, were associated with CB. Even though CB was experienced more among caregivers with better education, all caregivers should be screened to ensure their general well-being.

Expert estimates of caregiver hours for older Singaporeans with dementia

AIM

To obtain experts' estimates of the number of non-medical care hours required by older Singaporeans at different stages of ageing-related dementia, with low or high behavioural features.

METHODS

Experts on dementia in Singapore attended one of two meetings where they provided estimates of the number of care hours required for individuals at mild, moderate and severe levels of dementia with either low or high behavioural features. The experts were shown the collated responses, given an opportunity to discuss as a group, and then polled again.

RESULTS

The estimated mean care hours varied by dementia severity and the level of behavioural features. There was no interaction between dementia severity and behavioural features.

CONCLUSION

Estimated care hours needed by individuals with dementia is independently influenced by severity of dementia and behavioural features. These estimates may be useful for policy-makers in projecting the impact of caregiving.

The problem with "problem behaviors": a systematic review of the association between individual patient behavioral and psychological symptoms and caregiver depression and burden within the dementia patient-caregiver dyad

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSDs) are routinely cited as important predictors of caregiver burden and depression. Although BPSDs include a wide variety of patient behaviors, they are routinely grouped together as one construct to differentiate them from cognitive symptoms of dementia. Determining the specific BPSDs that result in increased depression and burden for caregivers may elucidate the stress process for caregivers and facilitate the development of effective interventions for caregivers.

METHODS

We conducted a systematic review of English-language articles published from 1990 to 2010 to determine whether there are known symptoms or symptom clusters which exert undue negative impact on caregiver depression and burden. Additionally, we review systems used for classifying BSPD symptom clusters and determine whether there have been any mechanisms studied by which individual BPSD symptoms negatively affect caregivers. Finally, we examine how the role of timing of symptoms has been examined within the literature.

RESULTS

Thirty-five original research articles examined the impact of an individual behavior symptom on caregiver burden or depression/depressive symptoms. The studies had no consistent system for categorizing symptoms. Although depression, aggression, and sleep disturbances were the most frequently identified patient symptoms to impact negatively on caregivers, a wide range of symptoms was associated with caregiver burden and depression.

CONCLUSIONS

The evidence is not conclusive as to whether some symptoms are more important than others. The studies reviewed were largely exploratory relative to the differential impact of individual BPSDs and did not focus on testing causal mechanisms by which specific symptoms exert more impact on caregiver mental health than others. Future research may benefit from the re-conceptualization of BPSDs from the perspective of their impact on the caregiver to examine hypothesis-driven differences among BPSD symptom clusters.

Effect of shunt operation on idiopathic normal pressure hydrocephalus patients in reducing caregiver burden: evidence from SINPHONI

BACKGROUND/AIMS

Patients with idiopathic normal pressure hydrocephalus (iNPH) are often given shunt operations to reduce the triad symptoms (cognitive impairment, gait disturbance and urinary disturbance). We examined whether they also reduce caregiver burden.

METHODS

The personal strain (PS) and role strain (RS) factors, which are related to the stress and constraints, respectively, on the caregivers of 81 iNPH patients were evaluated with the Zarit burden interview (ZBI) and each of the triad symptoms was evaluated with the iNPH grading scale (iNPHGS) before and 1 year after the shunt operation.

RESULTS

Each of the iNPHGS scores, the total ZBI score and PS factor significantly improved after the shunt operation, but the RS factor did not. The improvement of cognitive impairment was the major factor in reducing caregiver burden.

CONCLUSION

Shunt operations reduced the caregiver burden of iNPH patients.

Relationship between low levels of high-density lipoprotein cholesterol and dementia in the elderly. The InChianti study

BACKGROUND

To evaluate the association between plasma lipid fractions and the prevalence of dementia in a large sample of Italian older individuals.

METHODS

A total of 1051 older community-dwelling individuals (age >/=65 years), enrolled in the InChianti study, were included. Diagnosis of dementia was established at baseline and at the 3-year follow-up using Diagnostic and Statistical Manual of Mental Disorder (Fourth Edition) criteria. Plasma lipids were measured by standardized methods at baseline and after 3 years.

RESULTS

At baseline, 61 individuals (5.8%) were affected by dementia. Demented individuals showed significantly lower total cholesterol (TC), nonhigh-density lipoprotein cholesterol, and high-density lipoprotein cholesterol (HDL-C) levels compared with controls; no differences were found in triglycerides (TG) and lipoprotein (a) levels. Of the 819 subjects reevaluated at the 3-year follow-up, 81 (9.9%) received a new diagnosis of dementia. Again, demented subjects were characterized by significantly lower TC, non-HDL-C, and HDL-C levels compared with controls, thus confirming the baseline findings. At multivariate logistic regression analysis, HDL-C levels (odds ratio: 0.96, 95% confidence interval: 0.93-0.99), but not TG and non-HDL-C, were associated with dementia independent of important confounders including age, gender, apo E phenotype, stroke, weight loss, interleukin 6 levels, and ankle-brachial index.

CONCLUSIONS

Among community-dwelling older people, individuals affected by dementia showed significantly lower TC, non-HDL-C, and HDL-C levels; however, at multivariate analysis, only HDL-C was associated with dementia. Our results suggest the existence of an independent relationship between dementia and low HDL-C levels.

Activities enjoyed by patients with dementia together with their spouses and psychological morbidity in carers

Caring for a spouse with dementia is stressful and respite care is sometimes used to reduce this burden. Spouses may find some aspects of caring rewarding but the literature on positive aspects of caring is limited. To describe activities enjoyed by patients with dementia together with their spouses, and examine their relationship with psychological morbidity in carers. A convenience sample of 46 patients with mild to moderate dementia (91% with Alzheimer's disease, AD) and their spouses were interviewed at home. Spouses completed the Pleasant Events Schedule (PES-AD) to identify activities enjoyed by patients and spouses on their own and together. Psychological morbidity in spouses was assessed using the General Health Questionnaire (GHQ-12). Cognitive functions, and non-cognitive symptoms were also assessed in patients. Multiple regression analysis using age, Mini-Mental State Examination, Cornell Scale for Depression in Dementia, Revised Memory and Behaviour Problems (RMBP) checklist frequency, and PES-AD- together scores as independent variables found PES-AD-together and RMBP-frequency to be independent predictors of GHQ-12 scores in spouses, but the model could explain only 28% of variance. Facilitating activities that are enjoyed by both patients with dementia and spouses may be an alternative intervention strategy to reduce carer burden.

Predictors of Institutionalization in Elderly People Living at Home: The Impact of Incontinence and Commode Use in Rural Japan

A 5-year cohort study was conducted to determine factors that predict the institutionalization of elderly people who reside at home in a geographically-defined rural community in southern Japan. Among 766 (321 men and 445 women) residents living at home, 742 (97%) were followed-up for 5 years. During that period, 55 (25 men and 30 women) subjects were institutionalized. In univariate analysis, institutionalization of men was significantly associated with incontinence (either urinary or fecal), speech impairment, impairment in activities of daily living (ADLs: transferring, eating, dressing, bathing), being housebound, and the use of a commode. In women, it was associated with incontinence, visual impairment, ADLs impairment, being housebound, and the use of a commode. Using Cox regression hazard model analysis, incontinence was identified as a predictor for institutionalization in men, but not in women. In women, visual impairment was a predictor for institutionalization. The use of a commode and the other variables had no association with institutionalization in either sex. In conclusion, incontinence is a predictor for institutionalization in elderly men. Use of a commode, however, does not appear to have a preventive effect with respect to institutionalization in elderly men.

High interleukin-6 plasma levels are associated with functional impairment in older patients with vascular dementia

In older individuals, inflammatory mechanisms have been linked to the pathogenesis of both dementia and functional impairment. In this cross-sectional study we have investigated the possible association between some markers of systemic inflammation and functional status, in a sample of one hundred and forty older demented patients including 60 patients with late onset Alzheimer's disease (LOAD) and 80 with vascular dementia (VD). Functional status was evaluated by Barthel Index (BI); the total score ranged from 0 (total dependency) to 20 (total autonomy). Interleukin-1beta, Tumor Necrosis Factor-alpha, Interleukin- 6, Interleukin- 8, and Transforming Grow Factor beta were quantified by ELISA. Among the cytokines evaluated, only IL-6 was correlated with the BI (r: -0.32, p < 0.001). The mean levels of IL-6 progressively decreased from I (9.50 pg/mL), to II (6.40 pg/mL), to III BI tertile (4.80 pg/mL) (p < 0.02). At multiple regression analysis, IL-6 was associated with BI in the whole sample and in VD, but not in LOAD, independent of age, gender, smoking, alcohol consumption, hypertension, diabetes, coronary heart disease, previous stroke, and mini mental state examination score. Our study suggests the existence of an independent and negative relationship between IL-6 plasma levels and functional status in older individuals with vascular dementia. This finding might contribute to explain the 'excess of disability' phenomenon described in older demented patients.

Recruiting Chinese Americans for dementia caregiver intervention research: suggestions for success

OBJECTIVE

The purpose of this study was to compare the relative effectiveness of three recruitment modalities for enrolling Chinese-American and white family caregivers into research studies to evaluate intervention strategies.

METHODS

A total of 116 Chinese Americans and 134 whites were screened for eligibility to participate in one of two clinical intervention trials. Participants were recruited using: 1) media sources; 2) nonprofessional referral sources; or 3) professional referrals. Each participant was asked an open-ended question about how they became aware of the programs offered.

RESULTS

A smaller proportion of Chinese Americans (39%) than whites (50%) who responded to recruiting strategies actually enrolled as subjects. There was a significant interaction between ethnicity and recruitment strategy. Chinese-American caregivers who were recruited by nonprofessional sources were less likely to enroll in the intervention studies than those who were recruited through media sources or professional referrals. Whites, on the other hand, were more likely to be recruited through nonprofessional sources than the other two.

CONCLUSIONS

A consumer-oriented approach, which included direct face-to-face contact with key community leaders, generated the highest number of Chinese-American participants. Culture-specific factors such as trust-building with social service agencies, demonstrating genuine commitment to the well-being of the target community, and linguistic and ethnic matching between research staff and potential participants appear helpful to successful research recruitment in this rapidly increasing segment of dementia caregivers.

Screening for dementia in the older Chinese with a single question test on progressive forgetfulness

OBJECTIVES

To assess the utility of asking for presence of progressive forgetfulness (PF) prior to administering the Abbreviated Mental Test (AMT) when screening for dementia in the community-dwelling elderly Chinese.

METHODS

This was a two-phased community-based survey of elderly subjects (>or=50 yrs). In phase one, subjects were asked for PF and administered the AMT. Those having PF or an impaired AMT performance were evaluated clinically for dementia in phase two, which also included a randomly selected sample of 35 subjects with no PF and who passed the AMT.

RESULTS

2,566 subjects completed phase one interview, of which 128 subjects completed phase two. Overall prevalence of PF, failed AMT and dementia were 2.4%, 2.2%, 0.9% respectively. The sensitivity of PF for dementia was 95.7% with specificity of 45.1%. PF was significantly associated with depression in the young-old (50-74 yrs) but not in the old-old (>or=75 yrs) age group, after adjusting for dementia. The probability of subjects (%) in the four possible diagnostic combinations of PF and AMT in the young-old and (old-old) age groups were 0 (0.06) in the no PF/ passed AMT, 0 (0.44) in the no PF/failed AMT, 0.23 (9.2) in the PF/passed AMT and 3.6 (43) in the PF/failed AMT groups.

CONCLUSION

In screening for the most common dementias, AMT administration is not required if PF is absent. AMT is also of no added utility for diagnosing dementia in older subjects with PF. Younger subjects with PF should be closely evaluated for depression especially if they passed the AMT, and dementia, if they failed the AMT.

Clinical Dementia Rating

In this study, the authors describe how the Clinical Dementia Rating (CDR) scale fits into the overall evaluation process in an outpatient memory clinic. Based on a retrospective review of 329 patients attending the clinic from 1994 to 1999, the evidence for the validity of the Clinical Dementia Rating's overall ability to stage dementia severity is presented. The Clinical Dementia Rating showed convergent validity when compared against clinical features, mental status, and psychometric test scores, and DSM III-R measures of dementia severity, thus underscoring the trans-cultural feasibility of the Clinical Dementia Rating instrument. The Clinical Dementia Rating is also congruent with the DSM-IV approach of identifying dementia, and demonstrates better discriminatory ability in the milder dementia stages compared with DSM III-R. Future research should focus on addressing the limitations of the Clinical Dementia Rating in other social settings, advanced cases, as well as detecting clinically significant change.

A multinational review of recent trends and reports in dementia caregiver burden

This systematic review of the literature focuses on the influence of ethnic, cultural, and geographic factors on the caregivers of patients with dementia. In particular, we explore the impact of cultural expectations on five important questions: 1) Do the characteristics of dementia affect caregiver burden? 2) Do characteristics of the caregiver independently predict burden? 3) Does the caregiver affect patient outcomes? 4) Does support or intervention for caregiver result in reduced caregiver burden or improved patient outcomes? 5) Finally, do patient interventions result in reduced caregiver burden or improved patient outcomes? Our findings suggest that noncognitive, behavioral disturbances of patients with dementia result in increased caregiver burden and that female caregivers bear a particularly heavy burden across cultures, particularly in Asian societies. Caregiver burden influences time to medical presentation of patients with dementia, patient condition at presentation, and patient institutionalization. Moreover, interventions designed to reduce caregiver burden have been largely, although not universally, unsuccessful. Pharmacological treatments for symptoms of dementia were found to be beneficial in reducing caregiver burden. The consistency of findings across studies, geographic regions, cultural differences, and heathcare delivery systems is striking. Yet, there are critical differences in cultural expectations and social resources. Future interventions to reduce caregiver burden must consider these differences, identify patients and caregivers at greatest risk, and develop targeted programs that combine aspects of a number of interventional strategies.

Predictors of institutionalization in an older population during a 13-year period: the effect of urge incontinence

BACKGROUND

Longitudinal data on predictors of institutionalization in random older populations are limited. The aim here was to identify predictors of institutionalization in an unselected older population during a period of 13 years with a special focus on the prognostic value of urge incontinence.

METHODS

A population-based prospective survey was conducted involving 366 men and 409 women aged 60 years and older. Age-adjusted and multivariate Cox proportional hazards models were used to examine the predictive association of urge incontinence, living arrangements, neurological, cardiovascular, musculoskeletal, and other chronic diseases, activities of daily living (ADL) disability, and depressive symptoms with institutionalization separately in men and women.

RESULTS

Adjusted for age, ADL disability and other chronic diseases predicted institutionalization in both men and women. Urge incontinence and depressive symptoms in men and living alone and cardiovascular diseases in women were also significant predictors. In multivariate analyses where all potential predictors were included simultaneously, age (RR [relative risk] 1.15; 95% CI [confidence interval] 1.10-1.19), urge incontinence (RR 3.07; 95% CI 1.24-7.59), and depressive symptoms (RR 1.22; 95% CI 1.00-1.48) remained significant predictors of institutionalization in men. In women, age (RR 1.15; 95% CI 1.12-1.19) and living alone (RR 2.02; 95% CI 1.27-3.21) were independent predictors.

CONCLUSIONS

In addition to age, urge incontinence and depressive symptoms in men and living alone in women are significant prognostic indicators of institutionalization. The greater prognostic value of urge incontinence in men compared with women emphasizes the importance of interventions aimed at promoting continence and coping with the problem both at the individual and caregiver levels especially among older men.