The loss of a shared lifetime: a qualitative study exploring spouses’ experiences of losing couplehood with their partner with dementia living in institutional care

Spouses' Experiences of Emotional and Existential Support When Caring for a Frail Partner Late in Life

INTRODUCTION

The ability to care for a frail older partner late in life often entails the need for support and help from others, a need that sometimes can go unmet. Exploring spouses' views of emotional and existential support can guide further development of supportive structures, which in turn can promote family caregivers' existential health and well-being. Therefore, the aim of this study was to explore what spouses experience as supportive of their emotional and existential concerns when caring, or after having cared for, a frail partner late in life.

METHODS

The study was explorative and based on multistage focus group interviews with older spouses (n = 10) divided in two groups who met three times each. The data were analysed using conventional content analysis. The checklist 'Consolidated criteria for reporting qualitative research' (COREQ) was followed when presenting the study.

RESULTS

The spouses described the importance of an atmosphere in which being sad was allowed for as much time as needed; it was safe to share experiences together with others, they could receive compassion and comfort from others, and they were free to feel hope, let their previous life go and dare to think of their future.

CONCLUSION

Providing emotional and existential support creates an atmosphere that allows older spouses to reflect together with others, listening to their own and others' thoughts, and thus be able to put feelings and experiences into words. A suggestion for organising such support considers the physical, social, personal and spiritual dimensions of people's lifeworlds.

IMPLICATIONS FOR PRACTICE

Nursing interventions aimed at improving emotional and existential support for older spouses should primarily target transitional phases in life and focus on relational aspects.

Residents' and spouses' experiences of loneliness and depression after separation due to long-term care placement: a qualitative systematic review

OBJECTIVE

The objective of this review was to describe the experiences of loneliness and/or depression for residents and their spouses who have been separated by long-term care placement.

INTRODUCTION

Loneliness and depression have a pernicious influence on the overall health and well-being of older adults. Older adults' mental health is significantly affected by social relationships, including those between spouses. However, there is limited research pertaining to long-term care residents' and community-dwelling spouses' experiences of loneliness and/or depression after separation due to long-term care placement.

INCLUSION CRITERIA

This systematic review included studies that recruited community-dwelling spouses and long-term care residents over 50 years of age with living spouses from whom they are separated due to long-term care placement. Studies on the experiences of loneliness and/or depression due to spousal separation with one or both spouses living in long-term care were included in this review.

METHODS

Ovid MEDLINE(R) was used for the initial search. A full search strategy was developed for Ovid MEDLINE(R), CINAHL (EBSCOhost), Embase (Ovid), and PsycINFO (Ovid). The review was conducted using the JBI methodology for reviews of qualitative research, with 2 independent reviewers performing study selection, critical appraisal, data extraction, data synthesis, and assessment of confidence in the findings.

RESULTS

Eleven papers were included in this systematic review. Four synthesized findings were extracted from 10 categories and 42 findings: i) Loneliness and depression result from a lack of physical and social connection for separated long-term care residents and community-dwelling spouses; ii) Community-dwelling spouses feel unprepared and upset with spousal separation due to a lack of psychological support; iii) Behavioral strategies can prevent community-dwelling spouses and long-term care residents from developing loneliness and/or depression; and iv) Community-dwelling spouses have differing abilities to adapt and cope with feelings of loneliness and/or depression.

CONCLUSION

This review provides a comprehensive synthesis of the feelings of loneliness and/or depression in spouses who are separated due to long-term care placement. This review has demonstrated that there is a lack of literature inclusive of the voices and perspectives of all spouses affected by spousal separation in long-term care. The limitations of this review include the small number of included studies and the range of quality in included studies. Recommendations include additional research on the lived experience of spousal separation from the perspectives of long-term care residents and their community-dwelling spouses. Further, additional psychological support is needed for separated spouses, guided by the suggestions and experiences of long-term care residents and their community-dwelling spouses.

REVIEW REGISTRATION

PROSPERO CRD42022333014.

Neuropsychological assessment of patients with alzheimer's Disease in the presence or absence of spouses

A common question in the neuropsychological testing of patients with Alzheimer's Disease is whether or not patients should be tested in the presence of their spouses. We addressed this issue by assessing the neuropsychological performances of Alzheimer's Disease patients in the presence or absence of spouses. Results showed no significant differences between patients' performances in the presence or absence of spouses on tests assessing general cognitive abilities, episodic memory, working memory, inhibition and flexibility. No significant differences were observed regarding either anxiety or depression in patients when tested alone, compared to when spouses were attending. However, patients demonstrated higher verbal fluency when tested alone compared to when spouses attended. Clinicians may carry out neuropsychological assessment in the presence or absence of spouses, except when assessing verbal fluency. In such cases, clinicians should privilege testing patients alone or, if spouses attend the test, take into account this variable when interpreting patients' performances.

The social process of involuntary separation and the search for connection

Placing a loved one in care does not relieve informal caregivers' physical and emotional stresses. This study identified the unique psycho-social-spiritual processes of involuntary separation among spouses following long-term care admission. Participants were 17 spouse-caregivers (12 women and 5 men) with a mean age of 84 years who had been involuntarily separated for an average of 20 months. The basic psycho-social-spiritual process of spouse-caregiver involuntary separation was connecting in disconnection, which had three distinct stages: (1) Initial coping, (2) Adjusting to the new situation, and (3) Moving forward. Movement through the three stages was influenced by individuals' capacity and willingness to reach out for connection and by the abilities of others to extend accurate empathy and practical help. The implications of this study highlight spouse-caregivers' needs for connection and support not only during the crisis of separation, but in the months and years that follow.

The Spousal Unit and Dementia: Investigating the Relational Basis of the Couplehood Concept

A strong emphasis is consistently placed upon the relational basis of experience within social scientific dementia research. Within this research corpus, the concept of couplehood is increasingly employed, albeit in rather undefined and loosely theorised ways. Moreover, the evaluation highlights that couplehood is often defined by a normative position that seeks to convey an affirmative perspective on dementia and spousal relationships. The lack of theoretical foundation, however, weakens the explanatory potential of the concept, both for theorising dementia, as well as for empirical research. This article critically evaluates the utility of the couplehood concept by delineating three underlying theoretical conceptions: phenomenological, interactional and relational perspectives. It will be argued that those theoretical threads offer different analytical angles and research opportunities. More thorough ontological development, however, can guide understandings of the complexities that underpin the relational experience of dementia. This will promote a conceptual starting point that offers a more balanced and multifaceted accommodation of two persons and their relationship.

Sustaining relational subjectivity: The experience of women with dementia

The experience of dementia can only be understood adequately if the influence of gender is fully recognised. Research accounts have, however, tended to portray dementia in gender-neutral terms. This qualitative research study aims to redress this imbalance by investigating the gendered experience of women with dementia. The research addressed women's negotiation of relationships with spousal partners, other family members, professionals, support groups and services. The study included 10 mixed-sex spousal couples in which the woman had been diagnosed with dementia. Women took part in semi-structured joint interviews alongside their partners. This research focuses on the responses provided by the women with dementia within these interviews. Four principal themes were identified within the data: upholding gendered subjectivities; the broader relational context; closer networks; and gendered care relationships. These themes elucidate the challenges women face in sustaining relational subjectivity via the spousal relationship and wider social associations while also dealing with the cognitive impacts of dementia. The article concludes by highlighting that a more nuanced social scientific perspective on dementia is required that acknowledges the complexity of gendered experience. This can assist policymakers and practitioners to tailor support to meet the requirements of women with dementia.

In Their Own Words: How COVID-19 Has Impacted the Well-Being of Persons Living with Dementia in the Community

COVID-19 has had a devasting impact on older adults in Canada, including persons living with dementia. This intrinsic case study sought to understand the perceptions of persons living with dementia regarding how COVID-19 has impacted their well-being. Ten persons living with dementia participated in in-depth qualitative interviews about their experience with COVID-19. Using thematic analysis, four themes were identified: (1) expressing current and future concerns; (2) social connections and isolation; (3) adapting to change and resilience through engagement and hope; and (4) we're not all the same: reflecting individual experiences of the pandemic. Results highlight that while COVID-19 contributed to isolation, concerns, and frustrations, persons with dementia also demonstrated adaptation and resilience. This study reinforced that persons with dementia and their responses to challenges are unique. Therefore, interventions to support persons with dementia must also be individualized to each person's abilities and circumstances.

Dementia: How does spouse perceive it?

The study aimed at finding how spouses perceive the condition of dementia experienced by their husband/wife in Bekasi, Indonesia. This study was qualitative research with a descriptive phenomenology approach involving 10 participants according to predetermined criteria. The results found 3 themes consisting of psychosocial responses of caregivers, caregivers' burden, and positive responses of caregivers during caring for their spouse. There are 3 sub-themes in the first theme, 3 sub-themes in the second theme, and 3 sub-themes in the third theme. The various responses, both negative and positive experienced by caregivers show that being a caregiver for spouse with dementia is not easy. It needs a professional assistance by health personnel to help caregivers understand the dementia-related problems.

Spouses' existential loneliness when caring for a frail partner late in life - a hermeneutical approach

Purpose: Spouses are in a vulnerable situation when caring for a frail partner late in life. Exploring their existential loneliness can be a way to understand more about their existential needs.

Method: A hermeneutic approach was used. Multistage focus group interviews were conducted with two groups consisting of five spouses, respectively, who met three times each. To work with the text, an approach was adapted where quotations are converted into poems in a linguistic manner.

Results: Existential loneliness can be understood as the following: 1) being in a transition from us to merely me, 2) being forced to make decisions and feeling excluded, 3) navigating in an unfamiliar situation and questioning oneself, and 4) longing for togetherness but lacking the energy to encounter other people. The main interpretation is that existential loneliness emerges when one is in moments of inner struggle, when one is forced to make impossible choices, when one is approaching and is in limit situations, and when one is experiencing the endless loss of the other.

Conclusion: For health care professionals to achieve a holistic picture, person-centeredness can be a way to make the spouses’ existential needs visible and to provide support based on their needs.

[In the Same Boat: How to Support Relatives of Patients with Dementia Using Diverse Interventions]

In the Same Boat: How to Support Relatives of Patients with Dementia Using Diverse Interventions Abstract. Caring for people with dementia has great psychological, physical, social, financial and spiritual effects on relatives. Support and counseling can contribute to an improved health of the relative, to the relationship with the dementia patient, as well as to better treatment (through shared decision-making/care planning) of the patient. This article reviews data from Switzerland and international studies.

Silent voices: Transition experiences of family members caring for relatives with dementia

Worldwide 46.8 million persons are living with dementia and many are requiring assistance with performing daily living or instrumental functions. It is often the task of family members to provide care for their relatives with dementia. However, they are often the silent, unseen and unacknowledged figures in the lives of people living with dementia. In 2015, we used a phenomenological design utilising visual participatory methods in the form of collages and interviews to explore and describe the transition experiences of eight family members (seven females and one male) living in a South African city regarding how they became caregivers of their relatives with dementia. They often entered their caregiving roles unexpectedly, often not having much choice regarding whether or not to take on the caregiving role. Family members caring for relatives with dementia have unique support needs as they transition into the caregiving role.

Relationship continuity and emotional well-being in spouses of people with dementia

OBJECTIVES

Qualitative research has suggested that spousal experiences of discontinuity in their relationship with a person who has dementia (i.e. the relationship is experienced as radically changed) may contribute to heightened feelings of burden, entrapment, isolation, guilt and intolerance of behaviours that challenge. By contrast, continuity in the relationship may contribute to a greater sense of achievement and gratification from providing care. The present study served as a quantitative test of these suggestions.

METHOD

A convenience sample of 71 spouses of people with dementia completed three questionnaires - the Zarit Burden Interview (ZBI), the Positive Aspects of Caregiving measure (PAC) and the Birmingham Relationship Continuity Measure (BRCM).

RESULTS

In accordance with the hypotheses, the experience of greater relationship continuity (higher BRCM scores) was correlated with fewer negative emotional reactions to caregiving (lower ZBI scores; rho = -.795) and more positive emotional reactions (higher PAC scores; rho = .764).

CONCLUSIONS

The study provided some quantitative support for suggestions arising from qualitative research about how perceptions of continuity/discontinuity in the relationship may impact on the caregiving spouse's emotional well-being. Helping couples to maintain a sense of continuity and couplehood may assist their emotional adjustment to dementia.

Love between couples living with Alzheimer's disease: narratives of spouse care-givers

The aim of this interdisciplinary study is to describe and analyse the meaning of love in relationships between couples living with Alzheimer's disease (AD). Despite the wealth of studies describing relationships in the face of AD, little is known about the experience and changing meaning of ‘love’ between spouses when one of them is suffering from AD. A qualitative narrative approach was used to capture what love means for couples when one spouse is living with AD. A combination of open discussion along with a semi-guided interview was conducted with N = 16 spouses of persons living with AD. Data were analysed using Thematic Analysis. A leading theme that emerges from the interviews is that AD provides a significant indicator of the meaning and understanding of the experience of love. Five major types of relationship developments occurred after the disease emerged: love died, love became weaker, love did not change, love was enhanced and the spouse fell in love again. The need for further research is discussed. The findings of this study offer an additional perspective to the existing literature, thereby providing a more comprehensive outlook on marital relationships within the context of AD.

Holding on while letting go: trauma and growth on the pathway of dementia care in families

OBJECTIVES

Limited research explores the medical model of residential care in dementia from the family caregiver's perspectives.

METHOD

This study sought subjective interpretations of nine family caregivers who experienced relinquishing their status as primary caregiver to a medical model, dementia care residential setting. Following semi-structured interviews and transcription data was analysed using interpretative phenomenological analysis.

RESULTS

One superordinate theme, navigating 'system' control, overarched three subordinate themes: connecting/disconnecting, windows closing, and capacity for sensation. Navigating system control reflected participants' experience of circumnavigating a medical system fraught with hierarchical challenges inclusive of a complex maze of contradictions that appeared threatening, yet appeared comforting; authoritarian, yet often humane. For them, care of self, while advocating for a family member with dementia, required vigilance to manoeuvre a system of care that imposed its uninvited authority at will. Connection/disconnection highlights the enduring struggle for inclusivity in caregiving despite the omnipresent trauma of windows closing. Psychological growth came to these participants through an unexpected capacity for sensation which offered a unique lens to communication with the family member with dementia primarily through sensory exchange.

CONCLUSIONS

Models of dementia care and therapeutic interventions could inclusively involve dementia family caregivers who may be experiencing traumatic distress, and associated guilt, stigma, loss, and grief. Co-existing psychological wellbeing, however, is possible when family members are encouraged to transition communication to sensory awareness and exchange as windows close.

The development and preliminary psychometric properties of two positive psychology outcome measures for people with dementia: the PPOM and the EID-Q

BACKGROUND

Positive psychology research in dementia care has largely been confined to the qualitative literature because of the lack of robust outcome measures. The aim of this study was to develop positive psychology outcome measures for people with dementia.

METHODS

Two measures were each developed in four stages. Firstly, literature reviews were conducted to identify and operationalise salient positive psychology themes in the qualitative literature and to examine existing measures of positive psychology. Secondly, themes were discussed within a qualitative study to add content validity for identified concepts (n = 17). Thirdly, draft measures were submitted to a panel of experts for feedback (n = 6). Finally, measures were used in a small-scale pilot study (n = 33) to establish psychometric properties.

RESULTS

Salient positive psychology themes were identified as hope, resilience, a sense of independence and social engagement. Existing measures of hope and resilience were adapted to form the Positive Psychology Outcome Measure (PPOM). Due to the inter-relatedness of independence and engagement for people with dementia, 28 items were developed for a new scale of Engagement and Independence in Dementia Questionnaire (EID-Q) following extensive qualitative work. Both measures demonstrated acceptable internal consistency (α = .849 and α = .907 respectively) and convergent validity.

CONCLUSIONS

Two new positive psychology outcome measures were developed using a robust four-stage procedure. Preliminary psychometric data was adequate and the measures were easy to use, and acceptable for people with dementia.

The experiences of family caregivers of people with advanced dementia living in nursing homes, with a specific focus on spouses: A narrative literature review

Dementia affects individuals, families and their relationships. While there is increasing evidence about the experiences of family caregivers of people with dementia, relatively little is known of their experiences when their relatives are living in nursing homes with dementia. This narrative literature review aimed to synthesise current knowledge about family caregivers' experience of having relatives living in nursing homes with advanced dementia, particularly focussing on community-dwelling spouses. Using a systematic approach, textual narrative synthesis was undertaken. Four themes were identified: changing relationships, the need for companionship, adjusting to new roles and relationships and anticipating death/looking towards the future. Two additional themes were present only for spouses: changing identity - feeling married, being married; and alone but… The review demonstrates that some aspects of spouses' experiences are different from those of other family caregivers. Longitudinal studies are required to better understand spouses' motivations to continue caring in this context and to find ways of supporting them.

Constructing togetherness throughout the phases of dementia: a qualitative study exploring how spouses maintain relationships with partners with dementia who live in institutional care

AIMS AND OBJECTIVES

To explore and describe how spouses involve themselves in the relationship with their partners with dementia who live in institutional care.

BACKGROUND

Positive reciprocity between partners has been proven to be significant for spouses with partners living with dementia at home. However, little is known about spousal involvement after placement of a partner in an institutional setting. This subject was therefore the focus of this study.

DESIGN

Constructivist grounded theory was used to develop meaningful concepts considering the relational processes experienced and described by the spouses.

METHODS

Interviews were conducted with 15 spouses (eight women and seven men ranging in age from 64-90 years) of dementia-afflicted persons living in institutional care. Theoretical sampling, constant comparison and memo-writing guided the data collection and analysis.

RESULTS

The analysis showed how the spouses adopted different visiting routines to preserve continuity in their relationship throughout the phases of dementia. Three categories described how these visiting routines were used and adapted along with their partners' dementia progressions in the process of constructing togetherness: 'maintaining involvement and intimacy to preserve continuity in their relationship,' 'structuring visits to facilitate interaction and communication' and 'pursuing moments of mutuality to preserve continuity in a deteriorating relationship.'

CONCLUSIONS

Being involved and experiencing continuity in the relationship seemed important to the spouses after their partners' placement in institutional care. In the process of constructing togetherness, visiting routines were used to facilitate situations in which they could connect with their partners. These routines were continuously adjusted throughout the phases of dementia.

RELEVANCE TO CLINICAL PRACTICE

There is a need for a systematic approach to provide sufficient support to spouses throughout their partners' dementia progressions to assist their ongoing involvement.

Finding a place to connect: A qualitative study exploring the influences of the physical and social environments on spouses' opportunities to maintain relationships when visiting a partner with dementia living in long-term care

The purpose of this qualitative study was to explore how physical and social environments influence spouses' opportunities to maintain relationships when visiting a partner with dementia living in long-term care. Interviews with 15 spouses whose partners lived in long-term care facilities for persons with dementia, observations of physical environments and participant observations were conducted. The results showed how finding a place for spouses to connect in the long-term care facility was important in maintaining relationships. Access to individual rooms was an important feature that enabled connections throughout the phases of dementia, whereas common areas appeared more difficult to use because small spaces limited private interactions. Health personnel were important in sustaining spouses' abilities to maintain their relationships in long-term care facilities for persons with dementia.