Caring for individuals with dementia and cognitive impairment, not dementia: findings from the aging, demographics, and memory study

2024 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including prevalence and incidence, mortality and morbidity, use and costs of care and the ramifications of AD for family caregivers, the dementia workforce and society. The Special Report discusses the larger health care system for older adults with cognitive issues, focusing on the role of caregivers and non-physician health care professionals. An estimated 6.9 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060, barring the development of medical breakthroughs to prevent or cure AD. Official AD death certificates recorded 119,399 deaths from AD in 2021. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death in the United States. Official counts for more recent years are still being compiled. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2021, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 140%. More than 11 million family members and other unpaid caregivers provided an estimated 18.4 billion hours of care to people with Alzheimer's or other dementias in 2023. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $346.6 billion in 2023. Its costs, however, extend to unpaid caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Members of the paid health care and broader community-based workforce are involved in diagnosing, treating and caring for people with dementia. However, the United States faces growing shortages across different segments of the dementia care workforce due to a combination of factors, including the absolute increase in the number of people living with dementia. Therefore, targeted programs and care delivery models will be needed to attract, better train and effectively deploy health care and community-based workers to provide dementia care. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2024 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $360 billion. The Special Report investigates how caregivers of older adults with cognitive issues interact with the health care system and examines the role non-physician health care professionals play in facilitating clinical care and access to community-based services and supports. It includes surveys of caregivers and health care workers, focusing on their experiences, challenges, awareness and perceptions of dementia care navigation.

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.

Association between clinical dementia rating and clinical outcomes in Alzheimer's disease

INTRODUCTION

We examined associations between the Clinical Dementia Rating Scale (CDR) and function (Functional Assessment Scale [FAS]), neuropsychiatric symptoms (Neuropsychiatric Inventory Questionnaire [NPI-Q]), and cognitive impairment in Alzheimer's disease (AD).

METHODS

We used data from the National Alzheimer's Coordinating Center Uniform Data Set and defined cognitively unimpaired and AD stages using CDR-global.

RESULTS

Functional and neuropsychiatric symptoms occur as early as the mild cognitive impairment (MCI) phase. The adjusted lest square mean FAS (95% confidence interval [CI]) was lowest in cognitively unimpaired (3.88 [3.66, 4.11] to 5.01 [4.76, 5.26]) and higher with more advanced AD (MCI: 8.17 [6.92, 9.43] to 20.87 [19.53, 22.20]; mild: 18.54 [17.57, 19.50] to 28.13 [27.14, 29.12]; moderate: 26.01 [25.31, 26.70] to 29.42 [28.73, 30.10]). FAS and NPI-Q scores increased steeply with MCI (NPI-Q: 5.55 [4.89, 6.20] to 7.11 [6.43, 7.78]) and mild AD dementia (NPI-Q: 6.66 [5.72, 7.60] to 8.32 [7.32, 9.33]).

DISCUSSION

CDR-global staged AD by capturing differences in relevant outcomes along AD progression.

Highlights

There were strong associations among CDR and the various outcomes relevant to healthcare providers, patients, and their care givers, such as activities of daily living.Overall, activities of daily living, neuropsychiatric symptoms, and cognitive function outcomes deteriorated over time and can be observed in early stages of AD (MCI or mild dementia).Our findings directly inform the current understanding of AD progression and can aid in care planning and benefit assessments of early AD interventions to delay the progression of AD to more advanced stages.

Perceived discrimination and nativity status: risk of cognitive impairment among Latin American older adults

OBJECTIVES

We examined the association between perceived discrimination and the risk of cognitive impairment with no dementia (CIND) and Alzheimer's disease and related dementias (ADRD) while considering the potential effects of nativity status.

DESIGN

A prospective analysis of discrimination and nativity status with dementia and cognitive impairment was conducted among Latinx adults aged 51 years and older who participated in the Health and Retirement Study.

SETTING

A national representative sample.

PARTICIPANTS

A sample of 1,175 Latinx adults aged 51 years and older.

MEASUREMENTS

Demographics, cognitive functioning, perceived discrimination, and nativity status (US-born vs. non-US born) were assessed. Traditional survival analysis methods (Fine and gray models) were used to account for the semi-competing risk of death with up to 10 years of follow-up.

RESULTS

According to our results, neither everyday discrimination nor nativity status on their own had a statistically significant association with CIND/ADRD; however, non-US-born Latinx adults who reported no discrimination had a 42% lower risk of CIND/ADRD (SHR = 0.58 [0.41, 0.83], p = .003) than US-born adults.

CONCLUSIONS

These results highlight the need for healthcare providers to assess for discrimination and provide support and resources for those experiencing discrimination. It also highlights the need for better policies that address discrimination and reduce health disparities.

2023 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease, including prevalence and incidence, mortality and morbidity, use and costs of care, and the overall impact on family caregivers, the dementia workforce and society. The Special Report examines the patient journey from awareness of cognitive changes to potential treatment with drugs that change the underlying biology of Alzheimer's. An estimated 6.7 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, and Alzheimer's disease was officially listed as the sixth-leading cause of death in the United States. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. This trajectory of deaths from AD was likely exacerbated by the COVID-19 pandemic in 2020 and 2021. More than 11 million family members and other unpaid caregivers provided an estimated 18 billion hours of care to people with Alzheimer's or other dementias in 2022. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $339.5 billion in 2022. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Members of the paid health care workforce are involved in diagnosing, treating and caring for people with dementia. In recent years, however, a shortage of such workers has developed in the United States. This shortage - brought about, in part, by COVID-19 - has occurred at a time when more members of the dementia care workforce are needed. Therefore, programs will be needed to attract workers and better train health care teams. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2023 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $345 billion. The Special Report examines whether there will be sufficient numbers of physician specialists to provide Alzheimer's care and treatment now that two drugs are available that change the underlying biology of Alzheimer's disease.

The Social Cost of Providing Care to Older Adults With and Without Dementia

OBJECTIVES

Social participation is known to enhance well-being. Caregiving responsibilities are more intense when caring for an older adult with than without dementia and may affect caregivers' ability for social participation. We estimate social participation restrictions among caregivers for older persons with versus without dementia, variation within racial/ethnic group, and the mediating effect of care hours.

METHODS

We use the 2017 National Health and Aging Trends Study (NHATS) and National Study of Caregiving (NSOC) to study family caregivers for older adults. We estimate the prevalence of social participation (e.g., visiting family/friends, religious activities, group/club activities, going out) that were important to the caregiver but missed due to caregiving. We use logistic models to test for differences in restrictions by the older adult's dementia status overall and within race/ethnic group, adjusting for caregiver and care receiver characteristics.

RESULTS

One-third of family caregivers for older adults with dementia reported restrictions due to caregiving, double the prevalence among caregivers of an older adult without dementia (33.3% vs 16.0%; p < .001). This doubling gap persisted in adjusted models (odds ratio [OR] = 2.4; p < .01) but mainly for White, non-Hispanic caregivers (OR = 3.2; p < .001). Substantially greater caregiving hours for people with versus without dementia was found (104 vs 60 hr per month), which is responsible for about 21% of the total difference in restrictions (p < .05).

DISCUSSION

More time spent among caregivers of persons with versus without dementia may be an important factor undermining social participation, but hours only partially explain the gap. Future interventions should consider how to facilitate social participation among caregivers.

Mentalizing imagery therapy to augment skills training for dementia caregivers: Protocol for a randomized, controlled trial of a mobile application and digital phenotyping

More than 50 million people worldwide live with a dementia, and most are cared for by family members. Family caregivers often experience chronic stress and insomnia, resulting in decreased mental and physical health. Accessibility of in-person stress reduction therapy is limited due to caregiver time constraints and distance from therapy sites. Mentalizing imagery therapy (MIT) provides mindfulness and guided imagery tools to reduce stress, promote self and other understanding, and increase feelings of interconnectedness. Combining MIT with caregiver skills training might enable caregivers to both reduce stress and better utilize newly learned caregiving skills, but this has never been studied. Delivering MIT through a smartphone application (App) has the potential to overcome difficulties with scalability and dissemination and offers caregivers an easy-to-use format. Harnessing passive smartphone data provides an important opportunity to study behavioral changes continuously and with higher granularity than routine clinical assessments. This protocol describes a randomized, controlled, superiority trial in which 120 family dementia caregivers, aged 60 years or older, will be assigned to smartphone App delivery of caregiver skills with MIT (experimental condition) or without MIT (control condition). The primary objectives of the trial are to assess whether the experimental condition is superior to control on reducing family caregiver stress, insomnia and related outcomes and to demonstrate the feasibility of developing behavioral markers from passive smartphone data that predict health outcomes in older adults. Trial outcomes may inform the suitability of our intervention for caregivers and provide new methods for assessment of older adults.

2022 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on family caregivers, the dementia workforce and society. The Special Report discusses consumers' and primary care physicians' perspectives on awareness, diagnosis and treatment of mild cognitive impairment (MCI), including MCI due to Alzheimer's disease. An estimated 6.5 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, the latest year for which data are available. Alzheimer's disease was officially listed as the sixth-leading cause of death in the United States in 2019 and the seventh-leading cause of death in 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. More than 11 million family members and other unpaid caregivers provided an estimated 16 billion hours of care to people with Alzheimer's or other dementias in 2021. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $271.6 billion in 2021. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Members of the dementia care workforce have also been affected by COVID-19. As essential care workers, some have opted to change jobs to protect their own health and the health of their families. However, this occurs at a time when more members of the dementia care workforce are needed. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2022 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $321 billion. A recent survey commissioned by the Alzheimer's Association revealed several barriers to consumers' understanding of MCI. The survey showed low awareness of MCI among Americans, a reluctance among Americans to see their doctor after noticing MCI symptoms, and persistent challenges for primary care physicians in diagnosing MCI. Survey results indicate the need to improve MCI awareness and diagnosis, especially in underserved communities, and to encourage greater participation in MCI-related clinical trials.

Short Term Economic Evaluation of the Digital Platform "Support, Monitoring and Reminder Technology for Mild Dementia" (SMART4MD) for People with Mild Cognitive Impairment and their Informal Caregivers

BACKGROUND

A randomized controlled trial of the SMART4MD tablet application was conducted for persons with mild cognitive impairment (PwMCI) and their informal caregivers to improve or maintain quality of life.

OBJECTIVE

The objective was to conduct economic evaluation of SMART4MD compared to standard care in Sweden from a healthcare provider perspective based on a 6-month follow-up period.

METHODS

Three hundred forty-five dyads were enrolled: 173 dyads in the intervention group and 172 in standard care. The primary outcome measures for PwMCI and informal caregivers were quality-adjusted life years (QALY). The results are presented as incremental cost-effectiveness ratios, and confidence intervals are calculated using non-parametric bootstrap procedure.

RESULTS

For PwMCI, the mean difference in total costs between intervention and standard care was € 12 (95% CI: -2090 to 2115) (US$ = € 1.19) and the mean QALY change was -0.004 (95% CI: -0.009 to 0.002). For informal caregivers, the cost difference was - € 539 (95% CI: -2624 to 1545) and 0.003 (95% CI: -0.002 to 0.008) for QALY. The difference in cost and QALY for PwMCI and informal caregivers combined was -€ 527 (95% CI: -3621 to 2568) and -0.001 (95% CI: -0.008 to 0.006). Although generally insignificant differences, this indicates that SMART4MD, compared to standard care was: 1) more costly and less effective for PwMCI, 2) less costly and more effective for informal caregivers, and 3) less costly and less effective for PwMCI and informal caregivers combined.

CONCLUSION

The cost-effectiveness of SMART4MD over 6 months is inconclusive, although the intervention might be more beneficial for informal caregivers than PwMCI.

Risk and Resiliency Factors Related to Dementia Caregiver Mental Health

Prevalence rates for dementia are expected to rise exponentially as the elderly population rises. With this comes a corresponding increase in the number of family members who will become dementia caregivers. Caregivers of people with dementia often experience a deterioration in mental health. Identifying factors that relate to caregiver mental health is necessary to develop appropriate interventions. The current study explored how family functioning (measured with a latent variable that includes family cohesion, family balance, and family communication), caregiver expressed emotion (EE), and patient symptom severity related to caregiver mental health (measured with a latent variable that includes depression, anxiety, and stress). Participants included 107 dementia caregivers. The following specific hypotheses were tested: lower levels of both (1) EE and (2) patient symptom severity, and (3) higher levels of family functioning would be related to better caregiver mental health. Results produced a well-fitting model: X² (18) = 14.858, p = .672; CFI = 1.00; RMSEA = .00; SRMR = .037. Moreover, results indicated that better family functioning (Ɣ = -3.54, SE = 1.34, p = .008), lower levels of caregiver EE (β = .36, SE = 0.07, p < .01), and higher patient symptom severity (β = -3.03, SE = 0.88, p = .001) were related to better caregiver mental health. Results from this study suggest that efforts to bolster family functioning (i.e., enhance communication, promote cohesion, encourage flexibility) could help improve caregiver mental health.

Bilingual problem-solving training for caregivers of adults with dementia: A randomized, factorial-design protocol for the CaDeS trial

OBJECTIVE

Caregivers of individuals with Alzheimer's disease and related dementias (ADRD) often experience debilitating caregiver burden and emotional distress. To address these negative emotional consequences of caregiving, we will test and refine a strategy training intervention - Problem-Solving Training (PST) - that promotes self-efficacy and reduces caregiver burden and depressive symptoms. Previous research supports efficacy of PST; however, we do not know exactly how many PST sessions are needed or if post-training "boosters" are required to maintain PST benefits. Additionally, we translated and culturally-adapted PST into "Descubriendo Soluciones Juntos" (DSJ), our novel intervention for Spanish-speaking caregivers.

METHOD

In this 2 × 2 factorial design randomized controlled trial, we will test remotely-delivered PST/DSJ sessions for both English- and Spanish-speaking caregivers of persons with ADRD to determine the optimal number of PST/DSJ sessions and ongoing "booster" sessions needed to best help caregivers navigate their current and future needs.

AIMS

1) Compare the efficacy of three vs. six PST/DSJ sessions each with and without booster sessions for decreasing caregiver burden and depression and enhancing caregiver problem-solving; 2) Identify key factors associated with efficacy of PST/DSJ, including age, gender, primary language, relationship to care recipient, and uptake of the PST/DSJ strategy.

RESULTS

These results will establish guidelines needed for an evidence-based, culturally-adapted, and implementable problem-solving intervention to reduce caregiver stress and burden and improve caregiver health and well-being.

CONCLUSION

This work promotes inclusion of diverse and underserved populations and advances therapeutic behavioral interventions that improve the lives of caregivers of individuals with chronic conditions.

Tailoring Research Recruitment for Acute Care Settings: Recommendations from People with Dementia and their Caregivers

BACKGROUND

There is a pressing need to increase enrollment and representation in Alzheimer's disease and related dementia (ADRD) research. Current recruitment approaches focus largely on clinic and community settings, with minimal engagement of acute care environments despite their broad use across diverse populations. The objectives of this study were to examine views, preferences, and recommendations regarding acute care-based ADRD research recruitment among persons with dementia and their caregivers.

METHODS

The authors conducted semistructured interviews with recently hospitalized persons with dementia (N=3) and family caregivers (N=28). Interviews were analyzed using thematic analysis.

FINDINGS

All participants endorsed acute care as an appropriate time for recruitment into ADRD research studies and identified important elements of an appropriately tailored recruitment approach and an interpersonally effective research staff. Participants emphasized that this approach should consider the acute care context with respect to participant situation, uncertainty, and timing. Participant suggestions informed the design of a 5-step process to guide ADRD research recruitment in the context of acute care.

DISCUSSION

Findings provide valuable insights from people with dementia and their caregivers regarding opportunities for research engagement surrounding acute care and can inform expanded recruitment in these settings.

Depression and executive functioning bidirectionally impair one another across 9 years: Evidence from within-person latent change and cross-lagged models

BACKGROUND

Scar and vulnerability models assert that increased psychopathology may predict subsequent executive functioning (EF) deficits (and vice versa) over protracted timescales, yet most prior work on this topic has been cross-sectional. Thus, we tested the within- and between-person relations between EF, depression, and anxiety.

METHODS

Older adult participants (n = 856) were assessed across four waves, approximately 2 years apart. Performance-based EF and caregiver-rated symptom measures were administered. Bivariate latent change score and random-intercept cross-lagged panel models were conducted.

RESULTS

Within persons, random-intercept cross-lagged panel models revealed that prior greater depression forecasted lower subsequent EF, and vice versa (d = -0.292 vs. -0.292). Bivariate dual latent change score models showed that within-person rise in depression predicted EF decreases, and vice versa (d = -0.245 vs. -0.245). No within-person, cross-lagged, EF-anxiety relations emerged. Further, significant negative between-person EF-symptom relations were observed (d = -0.264 to -0.395).

CONCLUSION

Prospective, within-person findings offer some evidence for developmental scar and vulnerability models.

Experiences of Daughters Caring for a Parent With Alzheimer's Disease Living at Home

The current study used purposeful and snowball sampling to interview 12 daughters who were care-givers to their parents with Alzheimer's disease. Data were collected through in-depth, semi-structured interviews and were analyzed using Colaizzi's descriptive phenomenological approach. Caregiving years ranged from 1 to 10 years, with a mean of 5 years. Six themes were uncovered: (a) Where Are You When I Need You?; (b) Safety First; (c) I Don't Know What to Say or How to Say It; (d) They Are Beautiful People, but They Aren't Trained; (e) Letting Go of Who They Were; and (f) It Affects Every Area of My Life. Findings suggest that caregiver daughters of parents with AD living at home are struggling and indicate a need for better support of caregivers. Implications for nursing practice, research, and education are significant and require a greater focus on the support of informal caregivers of persons with AD. [Research in Gerontological Nursing, 14(4), 191-199.].

2021 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on caregivers and society. The Special Report discusses the challenges of providing equitable health care for people with dementia in the United States. An estimated 6.2 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, the latest year for which data are available, making Alzheimer's the sixth-leading cause of death in the United States and the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. This trajectory of deaths from AD was likely exacerbated in 2020 by the COVID-19 pandemic. More than 11 million family members and other unpaid caregivers provided an estimated 15.3 billion hours of care to people with Alzheimer's or other dementias in 2020. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $256.7 billion in 2020. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are more than three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 23 times as great. Total payments in 2021 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $355 billion. Despite years of efforts to make health care more equitable in the United States, racial and ethnic disparities remain - both in terms of health disparities, which involve differences in the burden of illness, and health care disparities, which involve differences in the ability to use health care services. Blacks, Hispanics, Asian Americans and Native Americans continue to have a higher burden of illness and lower access to health care compared with Whites. Such disparities, which have become more apparent during COVID-19, extend to dementia care. Surveys commissioned by the Alzheimer's Association recently shed new light on the role of discrimination in dementia care, the varying levels of trust between racial and ethnic groups in medical research, and the differences between groups in their levels of concern about and awareness of Alzheimer's disease. These findings emphasize the need to increase racial and ethnic diversity in both the dementia care workforce and in Alzheimer's clinical trials.

Caregiver identity in care partners of persons living with mild cognitive impairment

Research on caregiver identity in the context of memory impairment has focused primarily on more advanced stages of the cognitive impairment trajectory (e.g., dementia caregivers), failing to capture the complex dynamics of early caregiver identity development (e.g., MCI; mild cognitive impairment caregivers). The aim of this study was to develop a nuanced understanding of how caregiver identity develops in family and friends of persons living with MCI. Using constructivist grounded theory (ConGT), this study explored caregiver identity development from 18 in-depth interviews with spouses (n = 13), children (n = 3), and friends (n = 2) of persons recently diagnosed with MCI. The overarching themes influencing MCI caregiver identity development included MCI changes, care-related experiences, “caregiver” interpretation, and approach/avoidance coping. These themes influenced how participants primarily identified, represented as I am a caregiver, I am not a caregiver, or liminality (i.e., between their previous identity and a caregiver identity). Irrespective of their current self-identification, all conveyed thinking about their “future self,” as providing more intensive care. MCI caregiver identity development in family and friends is a fluid and evolving process. Nearly all participants had taken on care tasks, yet the majority of these individuals did not clearly identify as caregivers. Irrespective of how participants identified, they were engaging in care, and would likely benefit from support with navigating these changes and their new, ambiguous, and evolving roles.

The associations between social, built and geophysical environment and age-specific dementia mortality among older adults in a high-density Asian city

Background

Although socio-environmental factors which may affect dementia have widely been studied, the mortality of dementia and socio-environmental relationships among older adults have seldom been discussed.

Method

A retrospective, observational study based on territory-wide register-based data was conducted to evaluate the relationships of four individual-level social measures, two community-level social measures, six short-term (temporally varying) environmental measures, and four long-term (spatially varying) environmental measures with dementia mortality among older adults in a high-density Asian city (Hong Kong), for the following decedents: (1) all deaths: age >= 65, (2) “old-old”: age > = 85, (3) “mid-old”: aged 75–84, and (4) “young-old”: aged 65–74.

Results

This study identified 5438 deaths (3771 old-old; 1439 mid-old; 228 young-old) from dementia out of 228,600 all-cause deaths among older adults in Hong Kong between 2007 and 2014. Generally, regional air pollution, being unmarried or female, older age, and daily O₃ were associated with higher dementia mortality, while more urban compactness and greenness were linked to lower dementia mortality among older adults. Specifically, being unmarried and the age effect were associated with higher dementia mortality among the “old-old”, “mid-old” and “young-old”. Regional air pollution was linked to increased dementia mortality, while urban compactness and greenness were associated with lower dementia mortality among the “old-old” and “mid-old”. Higher daily O₃ had higher dementia mortality, while districts with a greater percentage of residents whose native language is not Cantonese were linked to lower dementia mortality among the “old-old”. Economic inactivity was associated with increased dementia mortality among the “young-old”. Gender effect varied by age.

Conclusion

The difference in strengths of association of various factors with dementia mortality among different age groups implies the need for a comprehensive framework for community health planning. In particular, strategies for air quality control, usage of greenspace and social space, and activity engagement to reduce vulnerability at all ages are warranted.

The Effect of Physical and Cognitive Impairments on Caregiving

BACKGROUND

Many older adults receive caregiving; however, less is known about how a change in a care recipient's functional activity limitations [instrumental activities of daily living (IADL) and basic activities of daily living (ADL)] as well as their cognitive impairment influence the amount of caregiving received.

METHODS

Using the Health and Retirement Study (2002-2014) we identified community-dwelling respondents with Alzheimer disease and related dementias (ADRD; n=674), cognitive impairment no dementia (CIND; n=530), and no cognitive impairment (n=6126). We estimated a series of two-part regression models to identify the association between care recipients' level of cognitive impairment, change in total number of IADL/ADL limitations and amount of caregiving received.

RESULTS

Persons with ADRD received 235.8 (SD=265.6) monthly hours of care compared with 26.0 (SD=92.6) and 6.0 (SD=40.7) for persons with CIND and no cognitive impairment, respectively. An increase in one IADL/ADL limitation resulted in persons with ADRD and CIND receiving 4.90 (95% confidence interval: 3.40-6.39) and 1.43 (95% confidence interval: 0.17-2.69) more hours of caregiving than persons with no cognitive impairment. Increases in total IADL/ADL limitations were associated with persons with ADRD, but not CIND, receiving more days of caregiving and having more caregivers than persons with no cognitive impairment.

CONCLUSIONS

Compared with persons with no cognitive impairment, increases in IADL/ADL limitations disproportionally increases the caregiving received for persons with ADRD. Policies and programs must pay attention to functional impairments among those living with ADRD.

Till Death Do Us Part: Intersecting Health and Spousal Dementia Caregiving on Caregiver Mortality

OBJECTIVE

We consider whether it is the healthiest dementia caregivers who experience a mortality benefit and whether a protective association is consistent for leading causes of mortality.

METHOD

Using the Health and Retirement study (2000-2012), Cox survival models predict time to death for dementia caregivers, including an interaction between dementia caregiver status and self-rated health. The nationally representative sample consisted of 10,650 married adults aged 51 or older (917 dementia caregivers).

RESULTS

A significant interaction between dementia caregiver status and self-rated health suggested that relative to noncaregivers, dementia caregivers had reduced mortality, with this effect particularly strong at lower levels of self-rated health. The protective effect of dementia caregiver status was consistent across death by heart disease, cancer, and cerebrovascular disease.

DISCUSSION

These findings add to a growing body of literature suggesting that caregiving may provide a mortality benefit and a reason to maintain health.

"Together Make a Visit; Together Make a Plan": Messaging to Adult Children with Concerns about a Parent's Memory Loss

Using the integrative model (IM), we developed and tested messages to encourage adults to accompany their parent to a memory doctor for a cognitive evaluation. We conducted in-depth interviews (n = 60) with African American and White adults with a parent age 65+ to identify key beliefs. Next, we carried out an IM-based telephone survey with a representative sample of the target population (n = 541). Analyses revealed that attitudes varied depending on the gender of the parent. Resulting messages featuring mothers countered the fear of hearing bad news and the belief that mother does not want to be accompanied to the doctor's office. Messages featuring fathers highlighted the belief that attending a doctor's visit will provide father emotional support. We subsequently tested messages with focus group participants (n = 48) and refined them. This study advances our understanding of opportunities to communicate about memory loss, including Alzheimer's disease and dementia, in ways that encourage a behavioral action that will benefit older adults and their families.

2020 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on caregivers and society. The Special Report discusses the future challenges of meeting care demands for the growing number of people living with Alzheimer's dementia in the United States with a particular emphasis on primary care. By mid-century, the number of Americans age 65 and older with Alzheimer's dementia may grow to 13.8 million. This represents a steep increase from the estimated 5.8 million Americans age 65 and older who have Alzheimer's dementia today. Official death certificates recorded 122,019 deaths from AD in 2018, the latest year for which data are available, making Alzheimer's the sixth leading cause of death in the United States and the fifth leading cause of death among Americans age 65 and older. Between 2000 and 2018, deaths resulting from stroke, HIV and heart disease decreased, whereas reported deaths from Alzheimer's increased 146.2%. In 2019, more than 16 million family members and other unpaid caregivers provided an estimated 18.6 billion hours of care to people with Alzheimer's or other dementias. This care is valued at nearly $244 billion, but its costs extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are more than three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 23 times as great. Total payments in 2020 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $305 billion. As the population of Americans living with Alzheimer's dementia increases, the burden of caring for that population also increases. These challenges are exacerbated by a shortage of dementia care specialists, which places an increasing burden on primary care physicians (PCPs) to provide care for people living with dementia. Many PCPs feel underprepared and inadequately trained to handle dementia care responsibilities effectively. This report includes recommendations for maximizing quality care in the face of the shortage of specialists and training challenges in primary care.

Behavioural activation for family dementia caregivers: A systematic review and meta-analysis

The current study aims to investigate the effectiveness of behavioral activation (BA) for family dementia caregivers. A systematic literature search was conducted through PubMed, Medline, CINAHL, Cochrane, Embase and PsycINFO for studies published from March 1988 to September 2019. Standardized mean differences (SMDs) were combined to synthesize pooled effect measures using random effects. The review was based on ten randomized controlled trials. Depression was significantly reduced after participants received BA (n = 9; 786 participants; SMD = -0.69; 95% CI: -1.12 to -0.25; p = 0.002). BA also has a positive impact on other areas of psychological health (e.g., self-efficacy, anxiety, and distress) and physical health (e.g., interleukin-6) in family dementia caregivers. In conclusion, BA not only has a moderate effect on reducing depression but also has the potential to improve other areas of psychological and cardiovascular health in family caregivers. However, more interventional studies of BA for family dementia caregivers are needed.

Factors associated with long-term impact on informal caregivers during Alzheimer's disease dementia progression: 36-month results from GERAS

OBJECTIVE

To identify, in caregivers of patients with Alzheimer's disease (AD) dementia, factors associated with subjective (personal, physical, emotional, and social) and objective (informal caregiver time and costs) caregiver burden.

DESIGN

Prospective longitudinal European observational study: post-hoc analysis.

SETTING

Clinic.

PARTICIPANTS

Community-dwelling patients in France and Germany aged ≥ 55 years (n = 969) with probable AD and their informal caregivers.

MEASUREMENTS

Mini-Mental State Examination (MMSE), Alzheimer's Disease Cooperative Study-Activities of Daily Living (ADCS-ADL), 12-item Neuropsychiatric Inventory (NPI-12), Zarit Burden Interview (ZBI), informal caregiver basic and instrumental ADL hours (Resource Utilization in Dementia instrument), and informal caregiver costs. Mixed-effect models of repeated measures (MMRM) were run, including baseline and time-dependent covariates (change from baseline [CFB] to 18 months in MMSE, ADCS-ADL, and NPI-12 scores) associated with CFB in ZBI score/informal caregiver time over 36 months (analyzed using linear regression models) and informal caregiver costs over 36 months (analyzed using generalized linear models).

RESULTS

Greater decline in patient function (ADCS-ADL) over 18 months was associated with increased subjective caregiver burden (ZBI), hours, and costs over 36 months. Increased behavioral problems (NPI-12) over 18 months also negatively impacted ZBI. Cognitive decline (MMSE) over 18 months did not affect change in caregiver burden.

CONCLUSIONS

Long-term informal caregiver burden was driven by worsening functional abilities and behavioral symptoms but not cognitive decline, over 18 months in community-dwelling patients with AD dementia. Identifying the drivers of caregiver burden could highlight areas in which interventions may benefit both caregivers and patients.

Directed content analysis of Veterans Affairs policy documents: A strategy to guide implementation of a dementia home safety toolkit for Veterans to promote ageing in place

Older adults' preference to age in place, coupled with an increasing prevalence of dementia, creates an imperative to address home safety risks that occur due to cognitive impairment. Providing caregivers with home safety items and education can facilitate ageing in place for older adults living with dementia. In 2015-2017, we examined barriers and facilitators within 17 policy documents and dementia guidelines of the United States (US) Veterans Health Administration pertinent to implementation of a home safety toolkit (HST) for Veterans living with dementia. The documents were issued from 2000 to 2015. Directed qualitative content analysis of these documents guided by themes from stakeholder interviews revealed two key implementation barriers: a focus on physical rather than cognitive risks when determining medical necessity for home equipment, and a focus on rehabilitation and treatment rather than prevention. Mandates for person-centred care planning, including comprehensive assessment, interdisciplinary collaboration, staff education and a focus on population health in primary care facilitate HST implementation. Content analysis can identify policy-level barriers that slow innovation and facilitators that can increase access to care that support ageing in place.

Mild Cognitive Impairment and Caregiver Burden: A 3-Year-Longitudinal Study

OBJECTIVES

Mild cognitive impairment (MCI) is common, affecting 10%-35% of people over 65, and poses unique challenges for patients and their caregivers. Comparatively little research has examined caregiver burden in this population, with longitudinal research, in particular, lacking. We examined caregiver burden in a sample of people with MCI over 3 years.

DESIGN

Three-year observational study.

SETTING

Nine memory clinics in Australia.

PARTICIPANTS

One-hundred-and-eighty-five people with MCI and their caregivers.

MEASUREMENTS

Measures of caregiver burden, cognition, function, neuropsychiatric symptoms, driving status, and medication use were completed with patients and their caregivers at regular intervals over a 3-year period.

RESULTS

Between 21.1% and 29.5% of caregivers reported a clinically significant level of burden over the study. Patients' higher levels of neuropsychiatric symptoms, lower functional ability, and lack of driving ability, and caregivers' employment were associated with greater caregiver burden over time. Caregiver burden did not increase over time when controlling for patient and caregiver characteristics.

CONCLUSIONS

High levels of caregiver burden are present in a significant proportion of caregivers of people with MCI. Clinical characteristics of patients - including severity of neuropsychiatric symptoms and functional impairment - and the employment status of caregivers predict burden. Such characteristics may help identify caregivers at greater risk of burden to target for intervention.

Impact of Caregiving for Dementia Patients on Healthcare Utilization of Caregivers

The elderly, whom are vulnerable to the physical, mental and chronic diseases of aging, are the fastest growing segment of the US population. Dementia is of particular concern in this population, and caregivers of people with dementia are subjected to psychological, physical, emotional and functional stress. The purpose of this study was to investigate the impact of caregiving for dementia patients on health care services utilization of caregivers and to examine if caregivers utilize more healthcare services than the control group. The study recruited a total of 143 people in control and non-control groups through non-probability convenience sampling. The control group (non-caregivers) comprised of 71 people, whereas the experimental group (caregivers) consisted of 72 participants. The focus of the study was the health care utilization questionnaire, asking the caregiver about the frequency of specific health care services utilization-including medication use in the last six months, on the scale from 0 to 10. Results were statistically significant for each of the healthcare service utilization when comparing caregivers to the control group. By providing adequate support and assistance in form of support groups, we can alleviate caregivers' burden and more effectively address the needs of caregivers-thereby reducing the utilization of healthcare services.

TV-based assistive integrated service to support European adults living with mild dementia or mild cognitive impairment (TV-AssistDem): study protocol for a multicentre randomized controlled trial

BACKGROUND

Mild cognitive impairment and mild dementia progressively compromise the ability of people to live independently and can have a negative impact on their quality of life. Within the current European Active and Assisted Living programme (AAL), project TV-AssistDem has been developed to deliver a TV-based platform service to support patients with mild cognitive impairment or mild dementia and provide relief to their caregivers. The application is intended to be used daily at home, mainly by the participants themselves, with the help of their informal caregivers. The aim of this study is to evaluate the effectiveness of TV-AssistDem to improve quality of life in people with mild cognitive impairment or mild dementia.

METHODS

This is a 12-month European multicentre randomized controlled trial which will be performed in two countries: Spain and Romania. Two hundred and forty older adults will be recruited using identical inclusion/exclusion criteria. The primary outcome will be the change from baseline of TV-AssistDem on patient quality of life at 12 months. The secondary outcomes will be the changes from baseline of: 1) informal caregiver quality of life, 2) informal caregiver burden, 3) patient treatment adherence, 4) patient treatment compliance, 5) patient functional status, and 6) healthcare cost-effectiveness at 12 months. Patients in the intervention group will have access to an interactive platform which offers remote assistive services through a device connected to the television. The core services of the platform are: 1) Calendar and reminders, 2) Health monitoring and data transmission to a health server and 3) Videoconference; service-oriented applications are: 4) Cognitive stimulation; 5) Reminiscences; and 6) Patient and caregiver healthcare education. The analysis will be made following an intention-to-treat procedure. Linear and Generalized Mixed Model analysis will be performed.

DISCUSSION

We hypothesize that the regular use of TV-AssistDem will result in an improvement in patient quality of life. The uniqueness of this home TV-based intervention lies on its widespread accessibility and its integrative approach to quality of life in people with mild cognitive impairment or mild dementia and their informal caregivers. However, several anticipated challenges will need to be faced: poor engagement and connectivity problems.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03653234 , Date of registration: 31 August 2018.

Racial/Ethnic and Nativity Differences in Cognitive Life Expectancies Among Older Adults in the United States

BACKGROUND AND OBJECTIVES

To document racial/ethnic and nativity differences by gender in cognitive life expectancies among older adults in the United States.

RESEARCH DESIGN AND METHODS

Sullivan-based life tables were used to estimate cognitively normal, cognitively impaired/no dementia (CIND), and dementia life expectancies by gender for White, Black, U.S.-born Hispanic, and foreign-born Hispanic adults 50 years and older in the Health and Retirement Study.

RESULTS

Among women, the number of years spent living with dementia for Whites, Blacks, U.S.-born Hispanics, and foreign-born Hispanics was 1.6, 3.9, 4.7, and 6.0 years, respectively. For men, Whites lived 1.1 years with dementia compared to 3.1 years for Blacks, 3.0 years for U.S.-born Hispanics and 3.2 years for foreign-born Hispanics. Similar patterns were observed for race/ethnic and nativity differences in CIND life expectancies. Blacks and Hispanics spend a larger fraction of their remaining years with CIND and dementia relative to Whites, regardless of gender. Foreign-born Hispanic men and women and Black men are particularly disadvantaged in the proportion of years spent after age 50 with CIND and/or dementia.

DISCUSSION AND IMPLICATIONS

Disparities in cognitive life expectancies indicate that intervention strategies should target the specific needs of minority and immigrant older adults with dementia. Given that education is a strong predictor of cognitive health, improving access to the social and economic resources that delay dementia onset is key to improving the well-being of diverse older adults.

The Effects of the Digital Platform Support Monitoring and Reminder Technology for Mild Dementia (SMART4MD) for People With Mild Cognitive Impairment and Their Informal Carers: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Many countries are witnessing a trend of growth in the number and proportion of older adults within the total population. In Europe, population aging has had and will continue to have major social and economic consequences. This is a fundamentally positive development where the added life span is of great benefit for both the individual and the society. Yet, the risk for the individual to contract noncommunicable diseases and disability increases with age. This may adversely affect the individual's ability to live his or her life in the way that is desired. Cognitive conditions constitute a group of chronic diseases that predominantly affects older people. Recent technology advancements can help support the day-to-day living activities at home for people with cognitive impairments.

OBJECTIVE

A digital platform (Support Monitoring and Reminder for Mild Dementia; SMART4MD) is created to improve or maintain the quality of life for people with mild cognitive impairment (PwMCI) and their carers. The platform will provide reminders, information, and memory support in everyday life, with the purpose of giving structure and lowering stress. In the trial, we will include participants with a diagnosed neurocognitive disorder as well as persons with an undiagnosed subjective memory problem and cognitive impairment, that is, 20 to 28 points on the Mini-Mental State Examination.

METHODS

A pragmatic, multicenter RCT is being conducted in Spain, Sweden, and Belgium. The targets for recruitment are 1200 dyads-split into an intervention group and a control group that are in usual care. Intervention group participants will be provided with a data-enabled computer tablet with the SMART4MD app. Its core functionalities, intended to be used daily at home, are based on reminders, cognitive supporting activities, and sharing health information.

RESULTS

Inclusion of participants started in December 2017, and recruitment is expected to end in February 2019. Furthermore, there will be 3 follow-up visits at 6, 12, and 18 months after the baseline visit.

CONCLUSIONS

This RCT is expected to offer benefits at several levels including in-depth knowledge of the possibilities of introducing a holistic multilayered information and communication technology solution for this group. SMART4MD has been developed in a process involving the structured participation of PwMCI, their informal carers, and clinicians. The adoption of SMART4MD faces the challenge of this age group's relative unfamiliarity with digital devices and services. However, this challenge can also be an opportunity for developing a digital device tailored to a group at risk of digital exclusion. This research responds to the wider call for the development of digital devices which are accessible and affordable to older people and this full scale RCT can hopefully serve as a model for further studies in this field.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03325699; https://clinicaltrials.gov/ct2/show/NCT03325699.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/13711.

Quality of life predictors in informal caregivers of seniors with a functional performance deficit - an example of home care in Poland

Background: There is insufficient research into informal caregivers' quality of life (QoL) in Poland. The purpose of this work is to study predictors that considerably affect QoL of informal caregivers (IC) providing home care for seniors with chronic diseases and a functional performance deficit. Materials and methods: In the cross-sectional research design, ICs were randomly chosen among the geriatric population receiving care in 5 primary health care settings. The WHOQoL-AGE questionnaire was used to assess QoL of ICs (n=138). The Barthel scale and Polish version of the Abbreviated Mental Test Score (AMTS) were applied to assess individuals with chronic diseases and functional and mental performance deficits (n=138). The Geriatric Depression Scale Short Form (GDS-SF) was used to measure the extent of risk of depressive symptoms in care-receivers. A hierarchical regression analysis was carried out to determine predictors of caregivers' QoL. Results: Mean values in the group of seniors provided with home care were as follows: the Barthel scale M=43.20, SD=27.06, the AMTS M=7.78 (SD=1.65), and the GDS-SF M=7.34 (SD=3.10). QoL of ICs (the WHOQoL-AGE) was M=70.14 (SD=15.31). Significant predictors of caregivers' QoL turned out to be support in care given by others β =0.605, p<0.001, experience in care β =-0.220; p<0.001, caregivers' health self-assessment β =0.174, p<0.001, and depressive disorders in care-receivers GDS β = -0.178, p<0.001. Conclusions: The QoL of ICs who provide care for individuals with chronic diseases and a functional performance deficit improves with an increase in the support they receive from others, their higher health self-assessment, and greater experience in care. An increase in depressive symptoms in care-receivers determines a lower level of caregivers' QoL.

The Functional Ability of MCI and Alzheimer's Patients Predicts Caregiver Burden

Sixty patients and their caregivers participated in this study. Patients completed activities of daily living tasks and several neuropsychological tests assessing memory, abstract reasoning, and language. Caregivers completed self-report measures assessing caregiver burden and psychological distress. Results revealed that the mAD caregivers endorsed greater physical burden and feelings of missing out on life compared to MCI caregivers. The mAD caregivers indicated greater depression and anxiety relative to MCI caregivers. Stepwise regression found that fewer patient neuropsychological scores predicted caregiver burden, as compared to patients' daily functioning. Overall, mAD displayed more severe types of burden and psychological distress relative to MCI caregivers and patients' daily functional abilities better predicated caregivers' burden and psychological distress than patients' neuropsychological functioning.

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

OBJECTIVES

The present study used Pearlin, Mullan, Semple & Skaff's (1990) caregiving stress process model as a framework to examine the comparative influence of two stressors: (a) intergenerational ambivalence as a unified construct and (b) dyadic strain, which is one isolated component of intergenerational ambivalence.

METHODS

Participants were 120 women providing healthcare and medication assistance to an earlier generation family member with physical and/or cognitive impairments.

RESULTS

Hierarchical regression confirmed that intergenerational ambivalence explained perceived stress in family care partners, beyond the variance accounted for by other commonly reported stressors such as length of caregiving experience, memory/cognitive and functional impairments of the care recipient, caregiver overload, family conflict and financial strain. Further analyses revealed that examining dyadic strain apart from intergenerational ambivalence may more accurately explain the influence of ambivalence scores on care partners' perceived stress.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The comparative influence of dyadic strain versus ambivalence suggests that stress-reducing interventions may benefit from a focus on reducing care partners' experiences of negative strain in the dyadic relationship rather than managing ambivalence.

Examining the Perceived Effects of an Adult Day Program for Individuals With Dementia and Their Caregivers: A Qualitative Investigation

BACKGROUND

Currently 564 000 Canadians are living with dementia, and this number is expected to rise significantly in the next 15 years. Many individuals with dementia use adult day programs; however, contradictory evidence exists as to the effects that adult day programs have on individuals with dementia and their caregivers.

PURPOSE/AIMS

The purpose of this study was to examine the perceived effects that an adult day program had on individuals with dementia and their caregivers, from the perspective of care providers at an adult day program.

DESIGN

A qualitative research design was used to guide this study.

METHODS

One-on-one semistructured interviews were completed with all of the adult day program care providers (n = 7). Thematic analysis was used to analyze the data.

RESULTS

The adult day program care providers identified several benefits of adult day programs for individuals with dementia and their caregivers. Two themes emerged, including (1) the role of care providers and (2) time to breathe.

CONCLUSIONS

Adult day programs have the potential to benefit caregivers and care recipients. Other community support programs may be able to use the knowledge gained from this qualitative study to implement strategies into existing adult day programs to provide support for care recipients and caregivers.

Caring for an individual with mild cognitive impairment: a qualitative perspective of health-related quality of life from caregivers

OBJECTIVES

Little is known regarding the effect that caring for an individual with Mild Cognitive Impairment (MCI) has on health-related quality of life (HRQOL). We sought to identify the most important aspects of HRQOL related to caring for an individual with MCI.

METHODS

Six focus groups were conducted with caregivers of individuals with MCI (n = 32). Qualitative frequency analysis was used to analyze the data.

RESULTS

Findings indicated that caregivers most frequently discussed social health, including changes in social roles and an increased need for social support (51.2% of the total discussion). This was followed by mental health concerns (37.9%) centering on anger/frustration, and a need for patience in the caregiving role, as well as caregiver-specific anxiety. Other topics included physical health (10.0%; including the impact that stress and burden have on medical heath), and caregivers' cognitive health (0.9%; including memory problems in relation to caregiver strain, sleep disruption, and cognitive fatigue).

CONCLUSIONS

Findings illustrate the multiple domains of HRQOL that are affected in individuals providing care for someone with MCI. Moreover, the findings highlight the need for extending support services to MCI caregivers, a group that is typically not offered support services due to the 'less severe' nature of an MCI diagnosis.

Reliability, validity and relevance of needs assessment instruments for informal dementia caregivers: a psychometric systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this psychometric review is to identify needs assessment instruments for informal dementia caregivers which are:More specifically, the aim is to present an overview and an evaluation of the available needs assessment instruments, including: i) their psychometrics (reliability and validity) when available, and ii) their relevance according to the instrument characteristics, namely, their purpose, application method, administration burden, number of items and domain structure.

Life Enhancing Activities for Family Caregivers of people with dementia: protocol for a randomized controlled trial of a positive affect skills intervention

Given the increasing number of family caregivers of persons with dementia (PWD) and the associated burden and detriments to both physical and mental health, interventions that aim to improve such outcomes are important. Studies are increasingly demonstrating the unique importance of positive emotions in coping with stress, independent from the impact of negative emotions. However, none have examined the benefits of interventions that target positive emotions for caregivers of individuals with a chronic and debilitating disease such as dementia. This paper presents the design and methods for a randomized controlled trial (RCT) of a positive affect skills intervention for family caregivers of PWD. The RCT is of a skills-based intervention that seeks to increase the frequency and intensity of positive affect in order to improve outcomes such as well-being, coping, and physical and mental health. The skills are delivered by trained facilitators via five one-to-one Internet video sessions with family caregivers of persons diagnosed with dementia (eg, Alzheimer's disease, vascular dementia, unspecified). The control group is an emotion reporting/waitlist control. Follow-up assessments are conducted post-intervention and at 1, 3, and 6 months post-completion of the intervention. This study promises to be an important and needed step toward improving the lives of caregivers of PWD.

Feeling Older and the Development of Cognitive Impairment and Dementia

Objective

Subjective age is a biopsychosocial marker of aging associated with a range of outcomes in old age. In the domain of cognition, feeling older than one's chronological age is related to lower cognitive performance and steeper cognitive decline among older adults. The present study examines whether an older subjective age is associated with the risk of incident cognitive impairment and dementia.

Method

Participants were 5,748 individuals aged 65 years and older drawn from the Health and Retirement Study. Measures of subjective age, cognition, and covariates were obtained at baseline, and follow-up cognition was assessed over a 2- to 4-year period. Only participants without cognitive impairment were included at baseline. At follow-up, participants were classified into one of the three categories: normal functioning, cognitive impairment without dementia (CIND), and dementia.

Results

An older subjective age at baseline was associated with higher likelihood of CIND (odds ratio [OR] = 1.18; 1.09-1.28) and dementia (OR = 1.29; 1.02-1.63) at follow-up, controlling for chronological age, other demographic factors, and baseline cognition. Physical inactivity and depressive symptoms partly accounted for these associations.

Conclusion

An older subjective age is a marker of individuals' risk of subsequent cognitive impairment and dementia.

Risk of Developing Dementia at Older Ages in the United States

Dementia is increasingly recognized as a major source of disease burden in the United States, yet little research has evaluated the lifecycle implications of dementia. To address this research gap, this article uses the Aging, Demographics, and Memory Study (ADAMS) to provide the first nationally representative, longitudinal estimates of the probability that a dementia-free person will develop dementia later in life. For the 1920 birth cohort, the average dementia-free 70-year-old male had an estimated 26.9 % (SE = 3.2 %) probability of developing dementia, and the average dementia-free 70-year-old female had an estimated 34.7 % (SE = 3.7 %) probability. These estimates of risk of dementia are higher for younger, lower-mortality cohorts and are substantially higher than those found in local epidemiological studies in the United States, suggesting a widespread need to prepare for a life stage with dementia.

A Claims-Based Examination of Health Care Costs Among Spouses of Patients With Alzheimer's Disease

Background

Spouses of Alzheimer's disease patients (AD spouses) may experience substantial health effects associated with their partner's chronic cognitive and behavioral dysfunction. Studies examining associations between the medical experiences of AD spouses in the period before and after their partner's AD diagnosis are limited, particularly those which measure health care resource use and cost.

Methods

AD patients were identified through multiple Medicare claims containing an AD diagnostic code. Their spouses were identified through special coding in the Medicare eligibility records. The AD spouses were matched demographically to the spouses of Medicare beneficiaries without a history of AD. Longitudinal and annual cross-sectional Medicare cost comparisons utilized log-transformed linear regression. The longitudinal period of observation began 12 months before the AD patient's initial claim listing AD and continued for up to 38 months afterwards.

Results

The study identified 16,322 AD spouses. Total per person costs were 24% higher in AD spouses than in the controls ($694/month vs $561/month). AD spouses' excess costs began 3 months before their partners' AD diagnoses and continued for ≥30 months. Being an AD spouse predicted 29% higher Medicare costs after adjustment for chronic health status (P < .001). Increasing AD patient care complexity had a substantial impact on AD spouse Medicare costs (P < .001).

Conclusions

This study documents a link between the health status of AD spouses and AD patients. Additional research is required to elicit the mechanism behind the association between AD spouse and AD patient diagnosis.

The Hidden Morbidity of Cancer: Burden in Caregivers of Patients with Brain Metastases

Caregiving is a highly individualized experience. Although numerous articles have been published on caregiver burden from a variety of diagnoses and conditions, this article presents the unique features of caregiving in patients with brain metastases. Improved long-term survival, concerns about disease recurrence or progression, the cancer experience (initial diagnosis, treatment, survivorship, recurrence, progression, and end of life), and the increasing complexity of cancer treatments add to the demands placed on the caregivers of patients with brain metastases. Health care professionals must identify caregiver burden and administer the appropriate interventions, which must be as unique and individualized as the caregivers' experiences.

Quantifying the unmet needs of caregivers of people with dementia: a critical review of the quality of measures

OBJECTIVE

The array of demanding tasks carried out by caregivers of people with dementia have significant negative impacts on their physical, mental and social well-being. Needs assessment allows individuals to indicate the extent to which their needs across different areas have or have not been met, allowing for estimations of the prevalence of needs and the extent to which help is required. This approach is extremely valuable in a clinical context, as it enables identification of the areas with which caregivers report a particular desire for help and allows targeting of support and resources to those who identify high levels of unmet needs. This systematic review aimed to critically examine the psychometric properties of measures that assess unmet needs of caregivers of people with dementia.

METHODS

Medline, Embase, PsycINFO and Cochrane electronic databases were searched between January 1990 and August 2015 for English-language publications describing the development or validation of measures assessing the unmet needs of adult caregivers of people with dementia. The psychometric properties of included measures were assessed against standard criteria for psychometric quality.

RESULTS

Four measures met the inclusion criteria. Only half of the indices of psychometric quality were tested across measures. Three measures had adequate internal consistency reliability, of which one also showed adequate test-retest reliability. Two measures reported adequate construct validity, while criterion validity was not assessed for any measure.

CONCLUSIONS

There is a clear need to develop a psychometrically rigorous instrument to identify the unmet needs of caregivers of people with dementia. Copyright © 2016 John Wiley & Sons, Ltd.

2016 Alzheimer's disease facts and figures

This report describes the public health impact of Alzheimer's disease, including incidence and prevalence, mortality rates, costs of care, and the overall impact on caregivers and society. It also examines in detail the financial impact of Alzheimer's on families, including annual costs to families and the difficult decisions families must often make to pay those costs. An estimated 5.4 million Americans have Alzheimer's disease. By mid-century, the number of people living with Alzheimer's disease in the United States is projected to grow to 13.8 million, fueled in large part by the aging baby boom generation. Today, someone in the country develops Alzheimer's disease every 66 seconds. By 2050, one new case of Alzheimer's is expected to develop every 33 seconds, resulting in nearly 1 million new cases per year. In 2013, official death certificates recorded 84,767 deaths from Alzheimer's disease, making it the sixth leading cause of death in the United States and the fifth leading cause of death in Americans age ≥ 65 years. Between 2000 and 2013, deaths resulting from stroke, heart disease, and prostate cancer decreased 23%, 14%, and 11%, respectively, whereas deaths from Alzheimer's disease increased 71%. The actual number of deaths to which Alzheimer's disease contributes is likely much larger than the number of deaths from Alzheimer's disease recorded on death certificates. In 2016, an estimated 700,000 Americans age ≥ 65 years will die with Alzheimer's disease, and many of them will die because of the complications caused by Alzheimer's disease. In 2015, more than 15 million family members and other unpaid caregivers provided an estimated 18.1 billion hours of care to people with Alzheimer's and other dementias, a contribution valued at more than $221 billion. Average per-person Medicare payments for services to beneficiaries age ≥ 65 years with Alzheimer's disease and other dementias are more than two and a half times as great as payments for all beneficiaries without these conditions, and Medicaid payments are 19 times as great. Total payments in 2016 for health care, long-term care and hospice services for people age ≥ 65 years with dementia are estimated to be $236 billion. The costs of Alzheimer's care may place a substantial financial burden on families, who often have to take money out of their retirement savings, cut back on buying food, and reduce their own trips to the doctor. In addition, many family members incorrectly believe that Medicare pays for nursing home care and other types of long-term care. Such findings highlight the need for solutions to prevent dementia-related costs from jeopardizing the health and financial security of the families of people with Alzheimer's and other dementias.