Symptoms of mood disorders in family carers of older people with dementia who experience caregiver burden: a network approach

Completeness of Telehealth Interventions Reporting in Randomized Controlled Trials for Caregivers of People With Dementia: Systematic Review

BACKGROUND

Telehealth interventions can effectively support caregivers of people with dementia by providing care and improving their health outcomes. However, to successfully translate research into clinical practice, the content and details of the interventions must be sufficiently reported in published papers.

OBJECTIVE

This study aims to evaluate the completeness of a telehealth intervention reporting in randomized controlled trials (RCTs) conducted for caregivers of people with dementia.

METHODS

A systematic search of relevant papers was conducted on July 26, 2023, in 9 electronic databases. RCTs of telehealth interventions for caregivers of people with dementia were included. Two independent researchers extracted the descriptive information and assessed the methodological quality (Cochrane risk of bias tool) and the completeness of reporting of the intervention by using the Template for Intervention Description and Replication (TIDieR)-Telehealth checklist, which consists of 12 items.

RESULTS

Thirty-eight eligible RCTs were included finally, and the overall quality of the studies was assessed as moderate. None of the studies completely reported all the TIDieR-Telehealth items. The most frequently reported items were the brief trial name (35/38, 92%), rationale (38/38, 100%), materials and procedures (35/38, 92%), and the modes of delivery (34/38, 90%). The least reported items were the type of location (0/38, 0%), modifications (4/38, 11%), and assessment and improvement of fidelity (9/38, 24%).

CONCLUSIONS

Many details of the telehealth interventions in RCTs are reported incompletely. Greater adherence to the TIDieR-Telehealth checklist is essential for improving the reporting quality and for facilitating replicability, which has substantial implications for translation into clinical practice.

Caregiving burden, social support, and psychological well-being among family caregivers of older Italians: a cross-sectional study

Objectives

This study aimed to identify factors affecting the psychological well-being of family caregivers of dependent older adults in Italy. Understanding these variables is essential for designing interventions to prevent negative outcomes in at-risk caregivers. The research explored how varying levels of caregiving burden and types of perceived social support influence psychological well-being.

Methods

A cross-sectional study was conducted among 387 family caregivers of older adults in the Marche region (Italy) between November 2019 and March 2020. Data were collected via a structured questionnaire assessing psychological well-being (WHO-5 Well-Being Index), caregiving burden, and social support (COPE Index). Statistical analyses were performed using Jamovi software, with a significance threshold set at p < 0.05.

Results

A significant negative correlation was found between caregiving burden and psychological well-being [r (364) = - 0.540, p < 0.001], with caregiving burden being a significant predictor of psychological well-being reduction (R 2 = 0.290; F = 150, p < 0.001). A threshold value of 2 (on a 1-4 scale) was identified, where caregiving burden predicted a significant reduction in psychological well-being. Conversely, greater perceived social support was positively correlated with better psychological well-being [r (357) = 0.348, p < 0.001] and was a significant predictor of it [R 2 = 0.121; F = 49.2, p < 0.001]. Support from social and health services had the most notable impact on psychological well-being. Moreover, social support mitigated the negative impact of caregiving burden on psychological well-being.

Conclusion

The study confirms that high caregiving burden adversely affects caregivers' psychological well-being, while social support plays a protective role. These findings highlight the need for interventions focused on reducing caregiving burden and enhancing support systems for family caregivers.

Translation and adaptation of Shared Care Instrument-Revised for the older adults and their caregivers in Taiwan

BACKGROUND

The aging population in Taiwan has resulted in an increase in the dependent population and the care load on caregivers. Shared care is an interpersonal process in which support is "traded" to "handle" chronic illnesses by home-care patients and family caregivers. The scale of shared care has received little attention in the Taiwanese cultural context. Thus, this study examined the reliability and validity of the Taiwanese versions of Shared Care Instrument-Revised (SCI-R).

METHODS

The content validity, construct validity, and discriminant validity were used to test the validity of the translated questionnaires. The Cronbach's α was used to examine reliability. A total of 500 older adults and their caregivers were recruited from three counties in Taiwan.

RESULTS

The reliability and validity of the Chinese version of the scale were within the acceptable range. The Cronbach's α was between 0.838 and 0.95. However, the scale's reliability was higher than that of the original version. This might be because of the inclusion of participants with less severe diseases than the participants in the original study, high social expectations in the Chinese traditional culture, and a large number of similar items. Future research should simplify the items and consider adopting diverse participant selection criteria.

CONCLUSIONS

The results of this study can be used to understand shared care in Taiwan.

Technology-Based Interventions to Address Social Isolation and Loneliness Among Informal Dementia Caregivers: A Scoping Review

OBJECTIVE

Social isolation and loneliness are major public health concerns. Informal dementia caregivers are particularly vulnerable, as many are older adults themselves and at elevated risk of adverse mental and physical health outcomes. Technology-based interventions could offer accessible, affordable, and convenient solutions. A previous review included Internet-based supportive interventions for informal dementia caregivers published up to 2013; however, new publications, technological advances, and targeted outcomes justify conducting this scoping review. Here, we identified and synthesized recent technology-based interventions that addressed social isolation and loneliness among informal dementia caregivers.

DESIGN

Scoping review.

SETTING AND PARTICIPANTS

Informal dementia caregivers in the community.

METHODS

Following Arksey and O'Malley's scoping review framework, we conducted a systematic search of peer-reviewed studies across 6 databases within the last 11 years, including identifying research questions, selecting relevant studies, charting data, and summarizing results.

RESULTS

From the 2937 articles identified, 10 eligible studies were included in this review. The intervention type, format, and duration varied widely. Three categories of interventions to address social isolation and loneliness among informal dementia caregivers included technology-assisted peer support, newly developed Web-based multicomponent psychoeducational programs and platforms, and virtual adaptation and modification of existing programs. Predominantly qualitative evidence suggests that technology-based interventions have the potential to reduce feelings of loneliness and improve caregiver well-being. Quantitative evidence tends to be preliminary and inconclusive.

CONCLUSIONS AND IMPLICATIONS

The findings offer preliminary evidence for technology-based interventions to reduce or prevent social isolation and loneliness in informal dementia caregivers. Technology-based interventions addressing social isolation and loneliness in informal dementia caregivers have the potential to overcome barriers to low uptake of services and withdrawal from interventions and improve the sustainability of the interventions. In the long run, by reducing or preventing social isolation and loneliness in informal dementia caregivers, the transition from home care to facility-based care might be delayed.

Depression and loneliness symptoms in Brazilian older people during the COVID-19 pandemic: a network approach

OBJECTIVES

Depression and loneliness in older people were a global challenge during the COVID-19 pandemic. Causal mechanisms to trigger depression might vary across different life events. We aimed to apply network analysis in a sample of Brazilian older people during the first wave of the COVID-19 pandemic, to investigate if loneliness and depression symptoms were connected within a psychological network. We explored how symptoms manifested and interacted, to discuss possible interventions that could mitigate late-life depression and loneliness symptoms in face of the COVID-19 pandemic.

METHOD

We collected data from 384 Brazilian older people who answered an online protocol to assess sociodemographic data, loneliness symptoms (assessed by the short version of UCLA-BR), and depression symptoms (assessed by the PHQ-2).

RESULTS

'Lack of companionship' was the bridge symptom connecting loneliness and depression communities. 'I feel shut out and excluded by others' and 'People are around me, but not with me' were the most predictable symptoms of loneliness.

CONCLUSION

Interventions aimed to promote older people's social participation and skills, combined with strategies to expand their sources of social support and combat ageism, might be relevant to mitigate symptoms of loneliness and depression in older people during a crisis like the COVID-19 pandemic.

The associations between depressive symptoms, functional impairment, and quality of life, in patients with major depression: undirected and Bayesian network analyses

BACKGROUND

Depressive symptoms, functional impairment, and decreased quality of life (QOL) are three important domains of major depressive disorder (MDD). However, the possible causal relationship between these factors has yet to be elucidated. Moreover, it is not known whether certain symptoms of MDD are more impairing than others. The network approach is a promising solution to these shortfalls.

METHODS

The baseline data of a multicenter prospective project conducted in 11 governances of China were analyzed. In total, 1385 patients with MDD were included. Depressive symptoms, functioning disability, and QOL were evaluated by the 17-item Hamilton Depression Rating Scale (HAMD-17), the Sheehan Disability Scale (SDS), and the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF). The network was estimated through the graphical Least Absolute Shrinkage and Selection Operator (LASSO) technique in combination with the directed acyclic graph.

RESULTS

Three centrality metrics of the graphical LASSO showed that social life dysfunction, QOL, and late insomnia exhibited the highest strength centrality. The network accuracy and stability were estimated to be robust and stable. The Bayesian network indicated that some depressive symptoms were directly associated with QOL, while other depressive symptoms showed an indirect association with QOL mediated by impaired function. Depressed mood was positioned at the highest level in the model and predicted the activation of functional impairment and anxiety.

CONCLUSIONS

Functional disability mediated the relationship between depressive symptoms and QOL. Family functionality and suicidal symptoms were directly related to QOL. Depressed mood played the predominant role in activating both anxiety symptom and functional impairment.

Social Networks Effects on Spouse and Adult-Child Dementia Caregivers' Experiences: A Cross-Sectional Study

OBJECTIVES

A large body of literature addresses experiences of spouse and adult-children caregiver of individuals with dementia (IWDs) but has not examined the role and strength of social networks in associations between spouses and adult-children caregivers' experience. Based on the stress process model, we aimed to explore the strength levels of social networks and their association with spouses/adult-children caregivers for IWDs.

DESIGN

A cross-sectional study.

SETTING AND PARTICIPANTS

A questionnaire-based survey was conducted with a total of 146 family caregivers of IWDs (78 adult-child, and 68 spouses) in China.

METHODS

Data collection comprised 4 sections: (1) care-related stressors (dementia stage, neuropsychiatric symptoms); (2) caregiver context; (3) social network, using the Lubben Social Network Scale; and (4) caregiving experience, using the short-form Zarit Burden Interview and 9-item Positive Aspects of Caregiving Scale. Linear regression, mediation model analysis, and interactive analysis were performed to explore the mechanisms of associations between variables.

RESULTS

Spouses had weaker social network strength (β = -0.294, P = .001) and reported greater positive aspects of caregiving (β = 0.234, P = .003) than adult-children caregivers; no significant difference was found between them for caregiver burden. Mediation analysis suggests that associations between caregiver type and caregiver burden are indirect-only mediation effects of social networks (β = 0.140, 95% CI = 0.066-0.228). The social network strength suppressed the association between caregiver type and positive aspects of caregiving. The caregiver type/social network interaction statistically significantly (P = .025) affected the "positive aspects": a stronger social network was associated with more positive aspects of caregiving among the spouse subgroup (β = 0.341, P = .003).

CONCLUSIONS AND IMPLICATIONS

Social networks mediate responses to caregiving experiences among different care provider types and are vital intervention targets, especially for spousal caregivers. Our results can serve as references for identifying caregivers for clinical intervention.

A network analysis of anxiety and depression symptoms in Chinese disabled elderly

BACKGROUND

Mental health is an essential dimension of healthy aging. The number and severity of disabled elderly in China show an increasing tendency year by year. Due to their impaired ability of daily activities, reduced social participation and reduced self-care ability, they are more prone to depression and anxiety.

METHOD

We included 2131 individuals aged 65 and older from the Chinese Longitudinal Healthy Longevity Survey (CLHLS 2017-2018). We used the 10-item Center for Epidemiologic Studies Depression Scale (CESD-10) and the Generalized Anxiety Disorder scale-7 (GAD-7) to assess depression and anxiety, respectively. The structure of depressive and anxiety symptoms was characterized using "Expected Influence" and "Bridge Expected Influence" as centrality indices in the symptom network. Network stability was tested using a case-dropping bootstrap procedure. Finally, a Network Comparison Test (NCT) was conducted to examine whether network characteristics differed by gender.

RESULTS

Network analysis revealed that nodes CESD3 (Felt sadness), GAD2 (Uncontrollable worry), and GAD4 (Trouble relaxing) were the primary symptoms of the anxiety-depression network. Anxiety and depression were united by the symptoms of CESD9 (Could not get going), GAD1 (Nervousness or anxiety), CESD10 (Sleep quality), and GAD4 (Trouble relaxing). Additionally, Gender did not significantly affect the network structure.

CONCLUSION

Central symptoms (e.g., felt sadness, uncontrollable worry and trouble relaxing) and key bridge symptoms (e.g., could not get going, nervousness and anxiety) in the depressive and anxiety symptoms network may be used as potential targets for intervention among disabled elderly who is at risk for or suffer from depressive and anxiety symptoms.

Inferred networks, machine learning, and health data

This paper presents a network science approach to investigate a health information dataset, the Sexual Acquisition and Transmission of HIV Cooperative Agreement Program (SATHCAP), to uncover hidden relationships that can be used to suggest targeted health interventions. From the data, four key target variables are chosen: HIV status, injecting drug use, homelessness, and insurance status. These target variables are converted to a graph format using four separate graph inference techniques: graphical lasso, Meinshausen Bühlmann (MB), k-Nearest Neighbors (kNN), and correlation thresholding (CT). The graphs are then clustered using four clustering methods: Louvain, Leiden, and NBR-Clust with VAT and integrity. Promising clusters are chosen using internal evaluation measures and are visualized and analyzed to identify marker attributes and key relationships. The kNN and CT inference methods are shown to give useful results when combined with NBR-Clust clustering. Examples of cluster analysis indicate that the methodology produces results that will be relevant to the public health community.

Association between thyroid dysfunction, metabolic disturbances, and clinical symptoms in first-episode, untreated Chinese patients with major depressive disorder: Undirected and Bayesian network analyses

AIMS

Thyroid dysfunction and metabolic disturbances are common in major depressive disorder (MDD) patients. We aimed to assess the relationship between thyroid dysfunction, metabolic disturbances, and clinical symptoms in Chinese first-episode, drug-naïve (FEDN) MDD patients using undirected and Bayesian network methods.

METHODS

1718 FEDN MDD patients were recruited. Serum levels of free triiodothyronine (FT3), free thyroxine (FT4), thyroid stimulating hormone (TSH), anti-thyroglobulin (TgAb), thyroid peroxidases antibody (TPOAb), total cholesterol (TC), total triglycerides (TG), high-density lipoprotein (HDL-C), low-density lipoprotein (LDL-C), and glucose were assessed. Blood pressure and body mass index were measured. Hamilton Rating Scale for Depression (HAMD), Hamilton Rating Scale for Anxiety, and positive subscale of Positive And Negative Syndrome Scales were used to detect clinical symptoms. An undirected network with EBICglasso default and a directed acyclic graph (DAG) using the Bayesian network approach was conducted.

RESULTS

The prevalence rates of clinical symptoms, thyroid dysfunction, and metabolic dysfunction were as follows: anxiety (n=894, 52%), psychotic symptoms (171, 10%), subclinical hypothyroidism (SCH, n=1041, 61%), abnormal TgAb (n=297, 17%), abnormal TPOAb (n=438, 25%), hyperthyroidism (n=5, 0.3%), hypothyroidism (n=3, 0.2%), hyperglycemia (n=241, 14%), hypertriglyceridemia (n=668, 39%), low HDL-C (n=429, 25%), hypercholesterolemia (421, 25%), abnormal TC (357, 21%), abnormal LDL-C (185, 11%). overweight or obesity (n=1026, 60%), and hypertension (n=92, 5.4%). Both networks demonstrated serum TSH and TC levels and the severity of depression played an important role in the pathophysiology of MDD.

CONCLUSIONS

MDD patients may have thyroid and metabolic dysfunction in the early stage. Targeting hypercholesterolemia, depressive symptoms, and SCH in MDD patients may hold promise in reducing clinical symptoms, metabolic disturbances, and thyroid dysfunction.

Interrelationships between childhood maltreatment, depressive symptoms, functional impairment, and quality of life in patients with major depressive disorder: A network analysis approach

BACKGROUND

Childhood maltreatment continues to pose a great challenge to psychiatry. Although there is growing evidence demonstrating that childhood maltreatment is an important risk factor for depressive disorders, it remains to be elucidated which specific symptoms occur after exposure to different kinds of childhood maltreatment, and whether certain pathways may account for these associations.

PARTICIPANTS AND SETTINGS

A total of 203 adult patients (18-53 years old) with MDD, diagnosed by Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, were recruited from the outpatient clinic of Beijing Anding Hospital, Capital Medical University.

METHODS

Childhood maltreatment, depressive symptoms, functional impairment, and quality of life were evaluated by the Childhood Trauma Questionnaire - Short Form (CTQ-SF), 17-item Hamilton Depression Rating Scale (HAMD-17), Sheehan Disability Scale (SDS), and Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF). Undirected network analysis was used to explore the most relevant connections between them. Bayesian network analysis was used to estimate a directed acyclic graph (DAG) while investigating the most likely direction of the putative causal association.

RESULTS

In network analysis, the strongest edges were a positive correlation between emotional abuse and suicidal behavior as well as a negative association between emotional neglect and age of onset. In DAG analysis, emotional abuse emerged as the most pivotal network node, triggering both suicidal behaviors and depression symptoms.

CONCLUSIONS

Emotional abuse appears to be an extremely harmful form of childhood maltreatment in the clinical presentation of depression. This study has promise in informing the clinical intervention of depression.

Comparing Behavioral and Psychological Symptoms of Dementia and Caregiver Distress Caused Between Older Adults With Dementia Living in the Community and in Nursing Homes

OBJECTIVES

To investigate differences in behavioral and psychological symptoms of dementia (BPSD) and caregiver distress caused between older adults with dementia living in the community and in nursing homes.

DESIGN

A comparative cross-sectional study.

SETTING AND PARTICIPANTS

Participants were recruited from outpatient clinics of a tertiary psychiatric hospital and dementia units of a nursing home in Guangzhou, China.

METHODS

Neuropsychiatric Inventory was used to assess symptoms and caregiver distress. Dementia severity was determined using the Clinical Dementia Rating.

RESULTS

This study included 157 community and 112 nursing home residents with dementia. Clinically significant symptoms (item score ≥ 4) were found in 88.5% of the former and 75% of the latter. Caregivers of 79.6% of the former and 26.8% of the latter reported that at least one of these caused them moderate-to-severe distress (distress score ≥ 3). Among the community patients, anxiety was the most frequent "very severe" symptom, while sleep disorders and agitation caused the most frequent "very severe" caregiver distress. After controlling for dementia severity and medication use, family caregiving remained an independent risk predictor for clinically significant symptoms and moderate-to-severe caregiver distress. The prediction of caregiver distress based on symptom scores varied across caregiver types and individual symptoms (R² 0.36-0.82). Group differences in clinically significant symptoms and moderate-to-severe caregiver distress showed at the stage of moderate-to-severe dementia.

CONCLUSIONS AND IMPLICATIONS

Tailored management strategies to relieve family caregivers' BPSD-induced distress are needed, especially at the stage of moderate-to-severe dementia. An effective service system should be established for supporting family caregivers to cope with BPSD.

A network analysis of suicidal ideation, depressive symptoms, and subjective well-being in a community population

Although the relationship between subjective well-being (SWB) and suicidal ideation (SI) has been illustrated in previous research, few studies have conceptualized SWB as a comprehensive measure of life satisfaction in multiple domains, nor have they considered possible mediators such as depressive symptoms. Therefore, the present study aimed to identify dimensions of SWB correlated with SI, and to analyze associations among SWB sub-domains, depressive symptoms, and SI in a community population. A total of 1200 community adults in South Korea, aged 20-86 years, completed self-report questionnaires on demographics, depressive mood (Patient Health Questionnaire-9 [PHQ-9]), SI (item 9 of the PHQ-9), and 14 SWB sub-domains (Subjective Well-Being Inventory). Factors associated with SI, and interactions among SI, depressive mood, and SWB, were identified by logistic regression and phenotype network analyses, respectively. The five main factors influencing the regularized partial correlation network were life satisfaction, self-blame, job, hopelessness, and fatigue. Pathways were observed from work-life balance and life satisfaction to hopelessness; from self-blame and fatigue to safety and health; and from sleep disturbance, concentration difficulties, self-blame, and hopelessness to SI. Making job activities more emotionally rewarding, the potential for career progression and regular work hours could address anhedonia, hopelessness and sleep disturbance, respectively, thus enhancing SWB and reducing SI in the community population.

Exploring Depressive Symptoms Among Healthcare Professionals and the General Population During the COVID-19 Pandemic in Brazil

Our study aimed to examine the symptoms that might play a role in the co-occurrence of 9 DSM-5 symptom criteria of major depression among Brazil's adult population and healthcare professionals after three months of detecting the new coronavirus in Brazil. We estimated regularized Gaussian graphical models for both samples and compared the network structures. Depressed mood was the most central symptom in the general population network compared to the healthcare professional network. The findings revealed some individual symptoms showed a differential association between the general population and healthcare professionals. Those symptoms may be valuable targets for future research and treatment.

Unexpected Findings During Double-blind Discontinuation of Acetylcholinesterase Inhibitor Medications

PURPOSE

The long-term effects of acetylcholinesterase inhibitors (AChEIs) used in the treatment of patients with various types of dementia remain unclear, largely due to challenges in the study of their discontinuation. We present several unexpected results from a discontinuation trial that might merit further investigation.

METHODS

This double-blind, placebo-controlled study of the discontinuation of AChEI medications was conducted in 62 US veterans. Participants were randomized to receive continued treatment with their medication (sham-taper group) or to treatment discontinuation via tapering (real-taper group), over a period of 6 weeks. The primary end point was the patient's/family caregiver's decision to discontinue the study medication.

FINDINGS

The study was underpowered to detect a significant between-group difference in the primary end point, but examination of the discontinuation process generated several unexpected results: (1) recruitment proved extremely challenging for a variety of reasons, with <5% of potentially eligible participants enrolled; (2) all 3 patients with Parkinson disease-associated dementia showed a worsening of symptoms when they discontinued their AChEI medication, but they showed improvement after they restarted it; (3) changes in symptom-scale scores varied quite broadly across participants, regardless of treatment arm; (4) unusual effects were noted in the sham-taper arm; and (5) the only significant predictor of the decision to discontinue the study medication was a worsening in the caregiver's mood.

IMPLICATIONS

These findings argue for the use of caution in discontinuing AChEIs in patients with Parkinson disease-associated dementia, although there may be potential benefits of a "drug holiday." The findings also urge the consideration of distress on the part of the caregiver while making medication treatment decisions in dementia. Future research must address challenges with recruitment and symptom fluctuations. (Clin Ther. 2021;43:XXX-XXX) © 2021 Elsevier Inc.

Characteristics Predicting a High Caregiver Burden in Patients with Vascular Cognitive Impairment: Using the Apriori Algorithm to Delineate the Caring Scenario

Purpose

The aim of this study was to elucidate the factors and caring scenarios associated with a moderate to severe care burden in the caregivers of patients with vascular cognitive impairment (VCI).

Patients and Methods

This cross-sectional study included 158 patients with VCI and their caregivers who were managed by the dementia collaborative care team at Changhua Christian Hospital, Taiwan. Gender, age, clinical dementia rating, walking ability, behavioral symptoms, and psychological symptoms were the variables from the patients with VCI. Age, marital status, relation to the VCI patient, education, employment status, help of key activities, type of primary care, frequency of care, ZBI (Zarit burden interview) caregiving burden, and caregiver's mood were the evaluated variables for the caregivers. The Apriori algorithm was used to identify the attributes that resulted in different caregiving burdens from a comprehensive viewpoint of both VCI patients and their caregivers.

Results

A total of 1193 rules were identified with 1134 rules belonging to caregivers with a mild to moderate burden and 59 rules belonging to caregivers with a moderate to severe burden. Seven general rules were created based on a summary of these 59 rules. The results showed that an employed female caregiver who was taking care of her husband alone for ≥6 days per week, and who was helping with all key activities was likely to experience a moderate to severe burden when the patient had VCI. Moreover, if the caregiver had a relatively low education level and expressed an abnormal mood during the assessment, this increased the likelihood of the caregiver having a moderate to severe burden.

Conclusion

The caregiver's gender, relation to the care recipient, education level, mood status, employment status, and care loading were associated with a higher burden of care for caregivers of patients with VCI. Therefore, a dementia care team should provide personalized training for caregivers about the disease, care skills for specific behaviors and psychological symptoms of dementia (BPSD), and strategies to cope with their own feelings. Caregivers should also be referred to appropriate social resources, such as support groups or respite care.