Dynamic structural equation modelling evaluating the progressively lowered stress threshold as an explanation for behavioural symptoms of dementia

Alcohol Use and Abusive or Neglectful Behaviors Among Family Caregivers of Patients With Dementia

Importance

The increasing prevalence of dementia presents challenges for family caregivers. Understanding how alcohol use among caregivers relates to abusive and neglectful behaviors (ANBs) toward care recipients with dementia may inform interventions to improve the well-being of both.

Objective

To explore alcohol use patterns among family caregivers of relatives with dementia and investigate whether hazardous drinking and drinking on a given day are independently associated with increased odds of ANBs toward care recipients.

Design, Setting, and Participants

This microlongitudinal cohort study included a baseline survey and 21 days of daily diary surveys among a convenience sample of family caregivers aged 18 years or older who coresided with and provided unpaid care to a community-dwelling relative with dementia across the US. Enrollment was from October 2019 to February 2023.

Exposures

Hazardous drinking at baseline, identified by the Alcohol Use Disorder Identification Test-Consumption screening tool, and daily alcohol consumption recorded in daily diary surveys.

Main Outcomes and Measures

Daily reports assessed engagement in physically aggressive, psychologically aggressive, and/or neglectful behaviors toward care recipients, categorized as binary outcomes. A generalized linear mixed model examined associations between caregivers' baseline hazardous drinking status and daily alcohol use and odds of ANBs.

Results

Of 453 family caregivers (394 of 451 [87.4%] female; mean [SD] age, 51.6 [14.0] years), 82 (18.1%) screened positive for hazardous drinking. Over the 21-day period, 38 (8.4%) consumed alcohol at least once and 341 (75.3%) engaged in abusive or neglectful behavior at least once. Baseline hazardous drinking was associated with higher odds of engaging in neglectful behaviors (odds ratio [OR], 2.89; 95% CI, 1.74-4.80; P < .001) and psychologically aggressive behaviors (OR, 2.32; 95% CI, 1.28-4.19; P = .006). Any alcohol use on a given day was associated with greater odds of physically aggressive (OR, 2.32; 95% CI, 1.10-4.88; P = .03) and neglectful (OR, 1.66; 95% CI, 1.31-2.10; P < .001) behaviors on the same day. No statistically significant interaction between baseline hazardous drinking and daily alcohol use was observed.

Conclusions and Relevance

In this microlongitudinal cohort study of family caregivers of relatives with dementia, hazardous drinking and daily alcohol consumption were significantly and independently associated with increased odds of ANBs, highlighting the need for personalized interventions that address caregiving complexities and alcohol use patterns.

Self-Compassion and Emotion Dysregulation Mediate the Effect of Stress Appraisals on Elder Abuse and Neglect Behaviors in Dementia Family Caregiving

OBJECTIVES

The purpose of this paper is to evaluate the mechanistic process by which family caregivers' situational stress appraisals of behavioral symptoms of dementia (BSD) increase the likelihood of a caregiver engaging in abusive and neglectful behaviors toward their care recipient with dementia. We test the hypotheses that (1) the effect of daily BSD stress appraisals on elder abuse and neglect (EAN) is mediated by the caregivers' emotion dysregulation (2) and the mediation path is moderated by self-compassion.

METHODS

This study employed a multitime series design in which participants (N = 453) completed traditional longitudinal surveys at enrollment followed by 21 sequential days of diary surveys (n = 9,513). The hypothesized moderated mediation path was evaluated through a multilevel structural equation model.

RESULTS

Hypotheses were supported. At the within-person level, daily BSD stress appraisal has a significant direct effect on daily EAN. At the between-person level, the path was no longer significant implying a full mediation of emotion dysregulation. The main effect of self-compassion and the interaction term (emotion dysregulation × self-compassion) were also statistically significant indicating the path between emotion dysregulation and EAN is moderated by self-compassion.

DISCUSSION

This study significantly advances the field by empirically showing a mechanistic pathway for a theoretical explanation of EAN. These findings represent a breakthrough for the field and identify modifiable intervention targets for future behavioral interventions to prevent EAN. Emotion (dys)regulation and self-compassion are modifiable traits and skills that can be learned, with robust evidence bases of efficacious interventions that can be adapted for context to dementia family caregiving.

Subsyndromes and symptom clusters: Multilevel factor analysis of behavioral and psychological symptoms of dementia with intensive longitudinal data

INTRODUCTION

Behavioral and psychological symptoms in dementia (BPSD) are dynamic phenomena with a high amount of intraindividual variability. We applied a multilevel framework to identify subsyndromes (between-person factors) that represent clinically relevant profiles of BPSD and identify symptom clusters (within-person factors) that represent contextually driven daily symptom experiences.

METHODS

This study used an intensive longitudinal design in which 68 co-residing family caregivers to persons living with dementia were recruited to proxy report on their care recipient's daily symptom experiences of 23 different BPSD for eight consecutive days (n = 443 diaries). A multilevel exploratory/confirmatory factor analysis was used to account for nested data and separate within-person variances from between-level factor estimates.

RESULTS

Exploratory factor analysis identified a 4-between 3-within factor structure based on fit statistics and clinical interpretability.

DISCUSSION

This study offers major methodological and conceptual advancements for management of BPSD within Alzheimer's disease and related dementias by introducing two related but distinct concepts of subsyndromes and symptom clusters.

HIGHLIGHTS

Because behavioral and psychological symptoms of dementia (BPSD) are dynamic temporal phenomenon, this introduces measurement error into aggregate group-level estimates when trying to create subsyndromes. We propose a multilevel analysis to provide a more valid and reliable estimation by separating out variance due to within-person daily fluctuations. Using a multilevel exploratory factor analysis with intensive longitudinal data, we identified distinct and meaningful groups of BPSD. The four factors at the between-person level represented subsyndromes that are based on how BPSD co-occurred among persons with Alzheimer's disease (AD). These subsyndromes are clinically relevant because they share features of established clinical phenomena and may have similar neurobiological etiologies. We also found three within-person factors representing distinct symptom clusters. They are based on how BPSD clustered together on a given day for an individual with AD and related dementias. These clusters may have shared environmental triggers.

Reciprocal effects between negative affect and emotion regulation in daily life

The extended process model of emotion regulation provides a framework for understanding how emotional experiences and emotion regulation (ER) mutually influence each other over time. To investigate this reciprocal relationship, 202 adults completed a ten-day experience-sampling survey capturing levels of negative affect (NA) experience and use of ten ER strategies in daily life. Residual dynamic structural equation models (DSEMs) were used to examine within-person cross-lagged and autoregressive effects of NA and ER (strategy use and between-strategy variability). Results showed that NA predicted lower between-strategy variability, lower subsequent use of acceptance and problem-solving, but higher subsequent use of rumination and worry. Moreover, reappraisal and between-strategy variability predicted lower subsequent NA levels, while expressive suppression and worry predicted higher subsequent NA levels. Stable autoregressive effects were found for NA and for maladaptive ER strategies (e.g., rumination and worry). Exploratory correlation analyses revealed positive associations between NA inertia and maladaptive ER strategies. Together, these findings provide evidence of a dynamic interplay between NA and ER. This work deepens how we understand the challenges of applying ER strategies in daily life. Future clinical and translational research should consider these dynamic perspectives on ER and affect.

A scoping review of intensive longitudinal methods in informal caregivers of people with dementia

BACKGROUND

The daily life of informal caregivers assisting individuals with dementia widely varies throughout the day and week. As an answer, an increasing number of researchers have used intensive longitudinal methods (ILMs) such as diary studies, experience sampling methods, or ecological momentary assessment.

OBJECTIVES AND METHODS

The present scoping review aims at synthesizing the use of ILMs in informal dementia caregivers to clarify what is currently done and how, as well as what remains unaddressed.

RESULTS

The screening process identified 48 studies from 22 different datasets. Synthesis of these studies showed the diversity of devices and uses of ILMs in informal care, including the exploration of associations between variables or accompanying an intervention. ILMs showed the important variability of caregiving phenomena, as well as the important association of momentary stress and well-being. Gaps were nevertheless identified, such as transparency in the construction of the tool or the absence of focus on emotions and dyads.

CONCLUSIONS

For now, this field of research remains in its infancy and does not seem to have reached its full potential as it has in other fields. Nevertheless, it appears that ILMs are promising tools for informal dementia caregivers as they contribute to understanding the complexity of their daily life, with changing resources and challenges. Future directions include focusing more on (emotion) regulation, temporal lags, and the use of ILMs in interventional designs.

TRIAL REGISTRATION

The present review was registered on OSF (osf.io/b2qr4).

The Willingness to Help People With Dementia Symptoms Among Four Occupation Practitioners in Macao

BACKGROUND

Dementia-friendly community has been promoted in Macao since 2016. There is no study investigating the understanding of nor attitudes towards dementia among public contact staff in Macao. This study aimed to (i) understand the level of knowledge of dementia, (ii) examine the attitudes towards people living with dementia, and (iii) explore the associated factors of the willingness to help people with dementia symptoms among police officers, bank officers, bus drivers, and building superintendents.

METHODS

A cross-sectional survey was conducted between January and May 2019 using a structured questionnaire.

RESULTS

A total of 351 valid questionnaires were received. Building superintendents had more knowledge while police officers and bank officers had more positive attitudes. All practitioners were more willing to help people with dementia symptoms when they were on official duty. Participants who had more knowledge about dementia were associated with a higher willingness to help people with dementia symptoms.