Family caregivers' assessments of caring for a relative with dementia: a comparison of urban and rural areas

Use of Caregiving Support Services Among Diverse Dementia Caregivers by Geographic Context

BACKGROUND AND OBJECTIVES

Little is known about how race/ethnicity and geographic context relate to support service use among dementia caregivers. Our objectives were to investigate (a) whether the use of at least one formal caregiving service-support groups, respite care, and training-differed by race/ethnicity and across metro and nonmetro areas; and (b) whether predisposing, enabling, and need characteristics influenced support service use by race/ethnicity.

RESEARCH DESIGN AND METHODS

Data were analyzed from a sample of primary caregivers of care recipients aged 65 years or older with probable dementia (n = 482) in the 2017 National Health and Aging Trends Study and National Study of Caregiving. We calculated weighted prevalence estimates and then used the Hosmer-Lemeshow goodness of fit statistic to find the best-fitting logistic regression models.

RESULTS

Among minority dementia caregivers, support service use was higher in metro than nonmetro areas (35% and 15%); the trend was reversed for non-Hispanic White caregivers (47% nonmetro and 29% metro). The best-fitting regression models included predisposing, enabling, and need factors for both minority and non-Hispanic White caregivers. Younger age and more disagreement within the family were consistently associated with more service use in both groups. Among minority caregivers, better caregiver and care recipient health were associated with using support services. Among non-Hispanic White caregivers, nonmetro geographic context and caregiving interfering with valued activities were associated with using support services.

DISCUSSION AND IMPLICATIONS

Geographic context differently affected support service use and the influence of predisposing, enabling, and need factors varied by race/ethnicity.

Understanding the health effects of caregiving stress: New directions in molecular aging

Dementia caregiving has been linked to multiple health risks, including infectious illness, depression, anxiety, immune dysregulation, weakened vaccine responses, slow wound healing, hypertension, cardiovascular disease, metabolic syndrome, diabetes, frailty, cognitive decline, and reduced structural and functional integrity of the brain. The sustained overproduction of proinflammatory cytokines is a key pathway behind many of these risks. However, contrasting findings suggest that some forms of caregiving may have beneficial effects, such as maintaining caregivers' health and providing a sense of meaning and purpose which, in turn, may contribute to lower rates of functional decline and mortality. The current review synthesizes these disparate literatures, identifies methodological sources of discrepancy, and integrates caregiver research with work on aging biomarkers to propose a research agenda that traces the mechanistic pathways of caregivers' health trajectories with a focus on the unique stressors facing spousal caregivers as compared to other informal caregivers. Combined with a focus on psychosocial moderators and mechanisms, studies using state-of-the-art molecular aging biomarkers such as telomere length, p16INK4a, and epigenetic age could help to reconcile mixed literature on caregiving's sequelae by determining whether and under what conditions caregiving-related experiences contribute to faster aging, in part through inflammatory biology. The biomarkers predict morbidity and mortality, and each contributes non-redundant information about age-related molecular changes -together painting a more complete picture of biological aging. Indeed, assessing changes in these biopsychosocial mechanisms over time would help to clarify the dynamic relationships between caregiving experiences, psychological states, immune function, and aging.

Practice of Supporting Family Caregivers of Patients with Life-Threatening Diseases: A Two-phase Study Among Healthcare Professionals

Background: Although support for family caregivers is an essential component of palliative care, routine provision of such support is often lacking. To improve support for family caregivers, we assessed current practice and influencing factors as perceived by healthcare professionals. Methods: A two-phase study was conducted including a survey exploring healthcare professionals' practice of supporting family caregivers in Western urbanized Netherlands in 2017, and focus groups exploring facilitators and barriers to supporting family caregivers in 2018. Focus group data were thematically analyzed with deductive coding based on the COM-B system. Results: Of the 379 survey respondents (response 11%), 374 were eligible (physicians, 28%; nurses, 64%; nurse assistants, 9%). The respondents practiced in academic hospitals (52%), general hospitals (31%), nursing homes (11%) and hospices (5%). They reported to always (38%), most of the time (37%), sometimes (21%) or never (5%) provide support to family caregivers during the illness trajectory. Respondents reported to always (28%), sometimes (39%), or never (33%) provide support after death. Four focus group discussions with 22 healthcare professionals elicited motivational facilitators and barriers to supporting family caregivers (e.g., relationship with family caregivers, deriving satisfaction from supporting them), and factors related to capability (e.g., (lacking) conversational skills, knowledge) and opportunity (e.g., (un)availability of protocols and time). Conclusions: Support for family caregivers, especially after the patient's death, is not systematically integrated in working procedures of healthcare professionals. The barriers and facilitators identified in this study can inform the development of an intervention aiming to enhance support for family caregivers.

Rural and urban differences in quality of dementia care of persons with dementia and caregivers across all domains: a systematic review

BACKGROUND

There are challenges in healthcare service delivery in rural areas, and this may be especially true for persons with dementia, who have higher needs to access to the healthcare system, and may have difficulties to commute easily and safely to these services. There is a growing body of literature regarding geographical disparities, but there is no comprehensive systematic review of geographical differences in persons with dementia across all domains of care quality. Therefore, the objective of this study is to conduct a systematic review of the literature on rural and urban differences in quality of dementia care outcomes of persons with dementia across all quality-of-care domains.

METHODS

We performed a digital search in Ovid MEDLINE on July 16, 2019, updated on May 3, 2021, for French or English records. We selected studies that reported outcome from at least one domain of quality of dementia care (Access, Integration, Effective Care, Efficient Care, Population Health, Safety, and Patient-Centered) in both rural and urban persons with dementia or caregivers. We used rigorous, systematic methods for screening, selection, data extraction and we analyzed outcomes reported by at least two studies using vote counting and appraised the certainty of evidence. Finally, we explored sources of heterogeneity.

RESULTS

From the 38 included studies, we found differences in many dementia care domains. Rural persons with dementia had higher mortality rates (Population Health), lower visits to any physicians (Access), more hospitalizations but shorter stays (Integration), higher antipsychotic medications (Safety), lower use of home care services and higher use of nursing home (Patient-Centered Care) compared to urban persons with dementia.

CONCLUSIONS

This comprehensive portrait of rural-urban differences in dementia care highlights possible geographically based inequities and can be used by researchers and decision makers to guide development of more equitable dementia care policies.

Predictors of Caregiver Burden Among Carers of Suicide Attempt Survivors

Background: Family members often provide informal care following a suicide attempt. Carers may be vulnerable to caregiver burden. Yet, little is known about what contributes to this. Aims: To determine the predictors of caregiver burden in those carers who support people who have attempted suicide. Method: An online survey of 435 participants assessed exposure to suicide, caring behaviors, and psychological variables and caregiver burden. Results: A multivariate model explained 52% of variance in caregiver burden. Being female, closeness to the person, impact of suicide attempt, frequency of contact pre-attempt, and psychological distress were positively associated with caregiver burden. Confidence in supporting the person after suicide attempt, perceived adequacy of healthcare the person received and the support the carer received, and suicidal ideation of the carer were negatively associated with caregiver burden. Moderation analysis suggested that carers with high levels of distress reported negative association between suicidal ideation and caregiver burden. Limitations: The cross-sectional online survey design of self-identified carers is a limitation of the study. Conclusion: Carers are highly distressed, and if unsupported report increased suicide ideation. In their caring roles they may have contact with support services, thus attending to their needs may ameliorate caregiver burden and associated negative outcomes.

Benefits of and barriers to telehealth for the informal caregivers of elderly individuals in rural areas: A scoping review

INTRODUCTION

Maintaining care for elderly individuals in rural areas is heavily dependent on support from informal caregivers. Many informal caregivers of the elderly in rural areas feel burdened and urgently require professional support. Interests in telehealth that can provide support irrespective of geographical location have been increasing.

OBJECTIVE

To identify the benefits of and barriers in telehealth engagement for rural caregivers to provide evidence for service improvement.

DESIGN

A scoping review method was used following PRISMA-ScR guidelines and Arksey and O'Malley's five-stage framework. Five databases were searched. The search terms were chosen based on the target intervention (i.e. telehealth), target population (caregivers of elderly individuals) and target context (rural areas). Two authors independently assessed the eligibility of studies and extracted data from eligible studies.

FINDINGS

Of 4220 retrieved studies, 19 articles met the inclusion criteria. This study identified four benefits of and two barriers to telehealth for rural caregivers. Four subthemes were identified as the key benefits in using telehealth for caregivers: decrease in psychological distress, increase in care efficiency, increase in social support and increase in access to resources, while inadequate telehealth infrastructures and caregivers' own reasons were the primary barriers in using telehealth for those populations.

CONCLUSIONS

Telehealth was shown to significantly benefit rural caregivers. Future research can be designed and conducted for overcoming the barriers to telehealth. Additionally, the benefits identified by this review need to be translated from research into practice for rural caregivers' care.

Territorial and Gender Differences in the Home Care of Family Members with Dementia

The increasing prevalence of dementia is threatening the capacity of health and social service systems to provide long-term care support at the territorial level. In both rural and urban areas, specific family members (gendered care) are responsible for the daily care of their relatives. The aim of this work is to explore gender and territorial implications in the provision of in-home care by family members. To this end, family caregivers in Navarre, Spain, were administered the Psychosocial Adjustment to Illness Scale (PAIS-SR) and a semi-structured interview. The results show the good psychosocial adjustment of caregivers of relatives with dementia but the negative impacts of caregiving in the domestic, relational, and psychological domains. Moreover, the feminization of psychological distress was found to predominate in rural areas since mainly women are responsible for instrumental and care tasks, while men seek other complementary forms of support. Place of residence (rural vs. urban) was found to exert a strong effect on the respondents’ conception, life experience, and provision of care. Consequently, territorial and gender differences in coping with and adjusting to care require the design of contextualized actions adapted to caregivers’ needs.

Caring for a Relative with Dementia: Determinants and Gender Differences of Caregiver Burden in the Rural Setting

Dementia is a progressive disease that puts substantial strain on caregivers. Many persons with dementia (PwDs) receive care from a relative. Since male and female caregivers experience different issues related to stress, it is important to meet their different needs to prevent the early nursing home placement of PwDs. This study investigated the multifactorial aspects of caregiver burden and explored gender differences in caregiver burden in a rural setting. This was a cross sectional study that administered anonymous questionnaires to family caregivers of PwDs. Caregiver burden was assessed using the Burden Scale for Family Caregivers-short version. A path model was used to determine the multivariate associations between the variables. To reflect the multifaceted aspects of caregiver burden, we used Pearlin's model with its four dimensions. A total of 113 family caregivers responded to our survey. The overall burden of caregivers was moderate. According to the path model, gender differences were predictors of caregiver burden. The behaviour of the person with dementia and cohabitation had direct effects on caregiver burden. Our results suggest that the experiences of men and women caring for a PwD are different and highlight the need for tailored support in dementia care.

Social support and quality of life among rural family caregivers of persons with severe mental illness in Sichuan Province, China: mediating roles of care burden and loneliness

OBJECTIVE

To explore the relationship between social support and quality of life (QoL) among family caregivers of persons with severe mental illness (SMI) and examine the mediating roles of care burden and loneliness.

METHODS

A cross-sectional study was carried out between December 2017 and May 2018. A random sample of 256 family caregivers of persons with SMI in rural areas of Sichuan Province, China was recruited for participation. Survey data on socio-demographics, social support, care burden, loneliness, and QoL were collected via in-person interviews. Multiple linear regression analysis and structural equation modeling (SEM) were used to test the hypothesized relationships.

RESULTS

The majority (72.7%) of family caregivers of persons with SMI in this study reported having low QoL. Social support was positively associated with QoL and negatively associated with care burden and loneliness. The findings suggested the mediating roles of care burden and loneliness on the association between social support and QoL.

CONCLUSION

The hypothesized model was found to be a suitable model for predicting QoL among family caregivers of persons with SMI. The findings can help inform the design of future interventions aimed at enhancing social support, reducing care burden and loneliness, which may be helpful to improve caregivers' QoL. Future study is required to find a causal path to promote QoL among family caregivers of persons with SMI.

Influence of socio-economic profile of neighbourhoods on the selection of home care strategies for older dependants

Care strategies for older dependants are determined by not only individuals or network characteristics, but also contextual factors. The objective of this study is to determine whether urban contexts (neighbourhoods) are linked to the use of family care (informal), public services or private care at home (formal). We applied logistic regression analysis to data from the Survey of People in a Situation of Dependence 2018. The sample was composed of 530 older people (55 years old and over) living in two types of socio-economic groups of neighbourhoods in Barcelona, Spain. The type of neighbourhood is relevant in explaining the home care that older dependants receive. In neighbourhoods with a high socio-economic level, dependants are more likely to use private services and less likely to use informal care services and public services, even after controlling for household income, degree of dependency, sex, age and the number of people in the household. Understanding the factors that determine the use of public care services, private care services or family care-giving is important due to the increment in the number of older people in the population. Our results suggest that differences in urban socio-economic contexts determine some inequalities in the use of services even after controlling for socio-economic individual differences. The characteristics of neighbourhoods should be considered to adjust care policies for older dependants.

Self-reported symptoms of depression and anxiety among informal caregivers of persons with dementia: a cross-sectional comparative study between Sweden and Italy

Background

Around 50 million people worldwide are diagnosed with dementia and this number is due to triple by 2050. The majority of persons with dementia receive care and support from their family, friends or neighbours, who are generally known as informal caregivers. These might experience symptoms of depression and anxiety as a consequence of caregiving activities. Due to the different welfare system across European countries, this study aimed to investigate factors associated with self-reported depression and anxiety among informal dementia caregivers both in Sweden and Italy, to ultimately improve their health and well-being.

Methods

This comparative cross-sectional study used baseline data from the Italian UP-TECH (n = 317) and the Swedish TECH@HOME (n = 89) studies. Main outcome variables were the severity of self-reported anxiety and depression symptoms, as measured by the Hospital Anxiety and Depression Scale (HADS). HADS scores were investigated using descriptive and bivariate statistics to compare means and standard deviations. Linear regressions were used to test for associations between potential factors and self-reported symptoms of depression and anxiety.

Results

Italian informal caregivers reported more severe symptoms of depression and anxiety than Swedish caregivers. In Italy, a higher number of hours of caregiving was associated with anxiety symptoms (β = − 1.205; p = 0.029), being 40–54 years-old with depression symptoms (β = − 1.739; p = 0.003), and being female with symptoms of both depression (β = − 1.793; p < 0.001) and anxiety (β = 1.474; p = 0.005). In Sweden, a higher number of hours of caregiving and being < 39 years-old were associated with depression symptoms (β = 0.286; p < 0.000; β = 3.945; p = 0.014) and a higher number of hours of caregiving, the lack of additional informal caregivers and dementia severity were associated with anxiety symptoms (β = 0.164; p = 0.010; β = − 1.133; p = 0.033; β = − 1.181; p = 0.031).

Conclusion

Multiple factors are associated with self-reported symptoms of depression and anxiety among informal caregivers in Sweden and Italy. Factors found in this study partly differ between the two countries, suggesting the important role of cultural and social factors affecting the experience of caregiving. A deeper knowledge of these factors may increase the knowledge on potential protective and risk factors, provide information to policymakers and ultimately improve the psychological well-being of informal caregivers to people with dementia across Europe.

Basic Diagnostic Work-Up Is More Complete in Rural than in Urban Areas for Patients with Dementia: Results of a Swedish Dementia Registry Study

BACKGROUND

Life in rural areas differs from life in urban areas not only in geographical conditions, but also in health care structure.

OBJECTIVE

Our aim is to compare the diagnostic process and the management of dementia in rural and urban areas of Sweden.

METHODS

We performed a cross-sectional study of patients with dementia living in rural (n = 16,428), intermediate (n = 18,033), and urban (n = 23,680) areas in Sweden including patients registered from 2007 through 2014 in the Swedish Dementia Registry (SveDem). Descriptive statistics are shown. Odds ratios with 95% CI are presented for basic diagnostic examinations in rural compared to intermediate and urban areas, adjusted for age, sex, type of care (primary versus specialist), and comorbidities. Analyses were also stratified for diagnostic care unit (primary versus specialist).

RESULTS

Patients who lived in rural areas were more likely to receive a complete basic examination, MMSE examination, Clock test, blood analysis, and neuro-imaging, compared to patients living in urban areas, and also compared to patients living in intermediate areas. Sex differences were seen in nearly all domains, with men receiving more diagnostic work-up than women. Stratified analyses show that in primary care, the complete basic examination is less frequently performed in urban and intermediate areas compared to rural areas.

CONCLUSION

There are differences in diagnostic work-up for dementia between rural, intermediate, and urban areas in Sweden. These results should be considered in future healthcare decisions to ensure equality of health care across rural and urban areas.

The Transition From Spousal Caregiver to Widowhood: Quantitative Findings of a Mixed-Methods Study

BACKGROUND: The number of persons diagnosed with dementia is projected to triple to 14 million by 2050. The significance of these projections is particularly relevant to older women (>65 years), who are more likely to provide dementia caregiving for a husband than vice versa. Research has identified consistent themes around the impact of caregiving during the caregiving experience, yet there is limited research exploring the ongoing impact during the transition to widowhood. Moreover, there is a paucity of research examining differences between rural and urban spousal dementia caregivers. AIMS: The aims were to compare differences between older rural and urban spousal caregivers on physical and mental health factors affecting the transition from caregiver to widow and to identify resources the women used during this transition over 12 months. METHOD: This mixed-methods longitudinal study recruited 13 urban and nine rural female spousal caregivers. Participants were interviewed three times over 12 months. The dependent variables were depression (measured using Center for Epidemiologic Studies Depression Scale), physical and mental functioning (measured using the 12-item Medical Outcomes Study-Short Form Health Survey Version 2). RESULTS: No statistically significant differences were detected between rural and urban female caregivers on the dependent variables. However, rural caregivers scored higher on depression and lower on both physical and mental functioning compared to their urban counterparts. CONCLUSIONS: The findings have clinical and research implications. Psychiatric nurses are well positioned to provide education related to dementia information deficits; implement interventions that facilitate bereavement, resilience, self-care, and identity; advocate for additional services; and conduct larger scale studies with a more diverse sample of female spousal caregivers.

Comparing perspectives of family caregivers and healthcare professionals regarding caregiver burden in dementia care: results of a mixed methods study in a rural setting

Background

Persons with dementia (PwD) need support to remain in their own homes as long as possible. Family caregivers, homecare nurses and general practitioners (GPs) play an important role in providing this support, particularly in rural settings. Assessing caregiver burden is important to prevent adverse health effects among this population. This study analysed perceived burden and needs of family caregivers of PwD in rural areas from the perspectives of healthcare professionals and family caregivers.

Methods

This was a sequential explanatory mixed methods study that used both questionnaires and semi-structured interviews. Questionnaires measuring caregiver burden, quality of life and nursing needs were distributed to the caregivers; health professionals received questionnaires with adjusted items for each group. Additionally, in-depth qualitative interviews were carried out with eight family caregivers.

Results

The cross-sectional survey population included GPs (n = 50), homecare nurses (n = 140) and family caregivers (n = 113). Healthcare professionals similarly assessed the psychosocial burden and stress caused by behavioural disturbances as most relevant. Psychological stress, social burden and disruptive behaviour (in that order) were regarded as the most important factors from the caregivers’ perspective. It was found that 31% of caregivers reported permanent or frequent caregiver overload. Eight themes related to caregiver burden emerged from the subsequent interviews with caregivers.

Conclusions

Professional support at home on an hourly basis was found to be highly relevant to prevent social isolation and compensate for lack of leisure among caregivers of PwD. Improvement of interprofessional dementia-related education is needed to ensure high-quality primary care.

Barriers and facilitators for caregiver involvement in the home care of people with pressure injuries: A qualitative study

Aim

To explore the barriers and facilitators perceived by home caregivers regarding their involvement in the home care of people with pressure injuries.

Background

Although home caregivers are key in the process of caring for people with pressure injuries, little is known about their perceptions regarding their involvement in the same.

Methods

A qualitative study based on grounded theory involving a theoretical sample of 15 home caregivers of people with pressure injuries within the health district of Puertollano, Spain.

Results

This study identified three barriers (feminization of care, necessary life adaptations as a home caregiver, and the organization of health services) and three facilitators (the perceived family duty for caring, willingness to provide care, and satisfaction with the care received on behalf of primary care services) associated with caregiver involvement in the home care of pressure injuries.

Conclusions

The care of a person with pressure injuries is perceived as a duty and requires important adaptations affecting the home caregiver’s personal, social and work life. The emotional closeness and trust that develops between a patient and the primary care staff equals an involvement which, in turn, also has positive results for both the home caregiver and the patient.

Dementia care-giving and employment: a mixed-studies review on a presumed conflict

Many persons with dementia live at home and are cared for by their relatives. If the relatives are still employed, this can lead to higher burden and losses in their work-life. The interplay between informal care-giving and working is complex. Different studies have explored this issue, but the results have not been yet synthesised. In this mixed-studies review, we elucidate the underlying complexity. Our objective is to identify the factors related to care-giving that influence employment, and to describe their impact on dementia care-givers’ employment. We performed a literature search of primary studies using four databases and one meta-database, and retrieved English- and German-language articles. We used the Mixed Methods Appraisal Tool to assess their methodological quality. Evidence identified was synthesised by a parallel-results convergent synthesis design. We included 55 qualitative, quantitative and mixed-method studies published up to January 2018. The emerging model identified factors linked to the care recipient with dementia, the informal care-giver and the care-giving context. The impacts of these factors on care-givers’ employment are mostly negative (e.g. stopped/reduced work, decreased job performance). Nevertheless, the results provide encouraging insights as working can counterbalance care-giving strain, and managing both roles can enhance care-givers’ wellbeing. Practical efforts should focus on enabling informal care-givers to better manage the balance between care-giving and work responsibilities.

Providing Care for Persons with Dementia in Rural Communities: Informal Caregivers' Perceptions of Supports and Services

Dementia is one of the costliest and most time-consuming diseases among older persons. Although informal caregivers provide the majority of care for persons with dementia, little is known about the self-perceived need for social services of caregivers of persons with dementia within rural areas. This pilot study examined the knowledge, access and intent of the practice-oriented service model of caregivers of persons with dementia in rural communities in the Midwest U.S. After a systematic training, researchers interviewed 11 rural caregivers of persons with dementia (n = 11). Data were analyzed using thematic analysis. Although similarities with other caregivers of persons with dementia were found, important differences suggesting unique issues among these rural caregivers of persons with dementia. Many participants found strength in their community, which often served as a safety net of support. Consistent with existing literature, participants expressed financial concerns, geographic barriers and lack of dementia-specific services when using formal services. The need for more specialized formal services in rural areas to supplement existing informal care networks is discussed. Policies and services based on rural caregivers' unique concerns and challenges and that build upon their existing care networks are recommended.

Informal Caregiving in a Medically Underserved Community: Challenges, Construction of Meaning, and the Caregiver-Recipient Dyad

Little is known about informal caregivers' challenges in medically underserved communities. This qualitative study explores their perceptions/experiences of caregiving in a medically underserved community in Midwest United States. Two focus groups (n = 12) were conducted and themes were extracted and analyzed. Theme 1 included perceived barriers/unmet needs; most prevalent of which were lack of informational resources and support groups. A second unsolicited and unanticipated theme highlighted how caregivers constructed meaning through reappraising challenges to create enriching experiences for themselves, reinforcing their evolving dyadic relationship with care-recipient. Challenging and enriching aspects of caregiving coexisted and were rooted in caregiver-care-recipient dyad. Caregivers used meaning-making as a coping strategy for challenges. Prior research corroborates caregivers' challenges and meaning-making; this study contributes by delineating how both become interrelated. Policy makers can (a) alleviate challenges by increasing informational resources and support groups and (b) provide training to optimize caregivers' meaning-making, thus enhancing their positive experiences.

Mobile Health, Information Preferences, and Surrogate Decision-Making Preferences of Family Caregivers of People With Dementia in Rural Hispanic Communities: Cross-Sectional Questionnaire Study

BACKGROUND

Mobile health (mHealth) technology holds promise for promoting health education and reducing health disparities and inequalities in underserved populations. However, little research has been done to develop mHealth interventions for family caregivers of people with dementia, particularly those in rural Hispanic communities, who often serve as surrogate decision makers for their relatives with dementia.

OBJECTIVE

As part of a larger project to develop and test a novel, affordable, and easy-to-use mHealth intervention to deliver individually tailored materials in rural Hispanic communities, in this pilot study, we aimed to examine (1) characteristics of people with dementia and their family caregivers in rural Hispanic communities, (2) caregivers' preferences for types and amounts of health information and participation in surrogate decision making, and (3) caregivers' mobile device usage and their desire for receiving information via mobile devices.

METHODS

This was a cross-sectional survey. A convenience sample of 50 caregivers of people with dementia was recruited from rural health care facilities in Southwest Texas during 3 weeks of April 2017 to May 2017 via word-of-mouth and flyers posted at the facilities.

RESULTS

More women than men were in the patient group (χ21=17.2, P<.001) and in the caregiver group (χ21=22.2, P<.001). More patients were on Medicare and Medicaid; more caregivers had private insurance (P<.001 in all cases). Overall, 42% of patients did not have a power of attorney for their health care; 40% did not have a living will or advance directive. Caregivers were interested in receiving all types of information and participating in all types of decisions, although on subscales for diagnosis, treatment, laboratory tests, self-care, and complementary and alternative medicine, their levels of interest for decision-making participation were significantly lower than those for receiving information. On the psychosocial subscale, caregivers' desire was greater for surrogate decision-making participation than for information. Caregivers did not differ in their interests in information and participation in decision making on the health care provider subscale. All but 1 caregiver (98%) owned a mobile phone and 84% had a smartphone. Two-thirds wanted to receive at least a little dementia-related information via a smartphone or tablet. The amount of dementia-related information caregivers wanted to receive via a mobile device was significantly greater for women than for men (U=84.50, P=.029). Caregivers who owned a tablet were more likely to want to receive dementia-related information via a mobile device than those who did not own a tablet (U=152.0, P=.006).

CONCLUSIONS

Caregivers in rural Hispanic communities were interested in receiving a wide range of information as well as participating in making decisions for their relatives with dementia. There is much need for effective mHealth interventions that can provide information tailored to the needs and preferences of these caregivers.

The caregiving phenomenon and caregiver participation in dementia

Background

Dementia presents barriers to the collaboration between individuals and the healthcare system. Caregivers perform multiple functions helping patients with basic and instrumental activities but also communicating and mediating the dyads’ needs within the broader social group. Interventions focusing on caregivers show that caregiver burden can be reduced, improving patient outcomes in a cost‐effective way, but the generalisation of these findings is limited by several factors such as low participation rates of caregivers in studies. There is a global push to increase patient participation in health care, but this can be difficult for patients with dementia. Caregiver participation has arisen as a substitute, but there is a lack of standardised definitions, goals and outcome measurement tools for this participation.

Methods

In 2015, the Swedish Association of Local Authorities and Regions commissioned a study on possibilities of increasing caregiver participation within the Swedish Dementia Registry (SveDem). This discussion paper updates and adapts that report, aiming to broadly summarise the caregiving phenomenon in order to provide a backdrop for clinicians seeking to understand the legal, ethical and practical considerations of caregiver participation in dementia. Relevant literature on caregiver participation is presented, and its definition, extent and practical implementation are discussed.

Discussion

The Swedish legal framework compels care providers to facilitate patient and caregiver participation in dementia and provides support to caregivers through the local level of government, but further work is needed to clarify and define the extension and form that this participation must take in clinical practice. Advanced directives are one step in extending patient participation to the period of advanced dementia.

Conclusion

Little research exists on caregiver participation. There is a need to develop a framework for caregiver and patient participation to determine the extent, type and form that such participation should take in health care, research and quality initiatives pertaining to persons with dementia.

Factors affecting the use of home-based services and out-of-home respite care services: A survey of family caregivers for older persons with dementia in Northern Norway

Background

Family caregivers contribute substantially to the care for older home-dwelling people with dementia, although community healthcare services tend to be underutilized. In this study, we aimed to explore the use and predictors of use of home-based and out-of-home respite care services available to older home-dwelling persons with dementia, as reported by the family caregivers.

Method

A cross-sectional survey was administered to family caregivers (n = 430) in Northern Norway during April to November 2016. The use of healthcare services was categorized into two types according to principal component analysis: home-based services and out-of-home respite care services (R² = 44.1%). Predictors of service use were examined with bivariate correlation, multiple linear regression, and Poisson regression analyses.

Results

The use of home-based services among persons with dementia was significantly higher for persons with advanced age, persons living in urban areas, persons living in an assisted living facility, persons living alone, and persons able to manage being alone for a short period of time. Among the family caregiver variables, higher age, status as a daughter, son, or other family member, higher educational level, and full-time employment also predicted greater use of home-based services. Same ethnicity was associated with use of fewer home-based services. The use of out-of-home respite care services was significantly higher among male persons with dementia and among those living in urban areas. In addition, fewer out-of-home respite care services were used by male caregivers or daughters of the care recipient, while the use was higher when the caregivers experienced more caregiving demands or had provided care for longer periods of time.

Conclusions

These results indicate areas that policymakers and healthcare providers should consider to identify families who underutilize healthcare services and to achieve a more equal and efficient allocation of services in accordance with families' needs.

End-of-life decision making by family caregivers of persons with advanced dementia: A literature review of decision aids

Objectives:

To investigate existing knowledge in the literature about end-of-life decision making by family caregivers of persons with dementia, focusing on decision aids for caregivers of persons with advanced dementia, and to identify gaps in the literature that can guide future research.

Methods:

A literature review through systematic searches in PubMed, CINAHL Plus with Full Text, and PsycINFO was conducted in February 2018; publications with full text in English and published in the past 10 years were selected in multiple steps.

Results:

The final sample included five decision aids with predominantly Caucasian participants; three of them had control groups, and three used audiovisual technology in presenting the intervention materials. No other technology was used in any intervention. Existing interventions lacked tailoring of information to caregivers’ preferences for different types and amounts of information necessary to make decisions consistent with patients’ values.

Conclusion:

Research is needed in exploring the use of technology in decision aids that could provide tailored information to facilitate caregivers’ decision making. More diverse samples are needed.

Financial and Health Barriers and Caregiving-Related Difficulties Among Rural and Urban Caregivers

PURPOSE

To assess whether financial or health-related barriers were more common among rural caregivers and whether rural caregivers experienced more caregiving-related difficulties than their urban peers.

METHODS

We used data from 7,436 respondents to the Caregiver Module in 10 states from the 2011-2013 Behavioral Risk Factor Surveillance System. Respondents were classified as caregivers if they reported providing care to a family member or friend because of a long-term illness or disability. We classified respondents as living in a rural area if they lived outside of a Metropolitan Statistical Area (MSA). We defined a financial barrier as having an annual household income <$25,000 or not being able see a doctor when needed in the past year because of cost. We defined a health barrier as having multiple chronic health conditions, a disability, or fair or poor self-rated health.

FINDINGS

Rural caregivers more frequently had financial barriers than urban caregivers (38.1% vs 31.0%, P = .0001), but the prevalence of health barriers was similar (43.3% vs 40.6%, P = .18). After adjusting for demographic differences, financial barriers remained more common among rural caregivers. Rural caregivers were less likely than their urban peers to report that caregiving created any difficulty in both unadjusted and adjusted models (adjusted prevalence ratio = 0.90; P < .001).

CONCLUSIONS

Informal caregivers, particularly in rural areas, face financial barriers. Rural caregivers were less likely than urban caregivers to report caregiving-related difficulties. Rural caregivers' coping strategies or skills in identifying informal supports may explain this difference, but additional research is needed to explore this hypothesis.

The relationship between geographical and social space and approaches to care among rural and urban caregivers caring for a family member with Dementia: a qualitative study

Knowledge about family caregivers in rural areas remains sparse. No studies to date have addressed the sociocultural aspects in caregiving, thus neglecting potentially significant data. This study aimed to explore and better understand family caregivers’ experiences in rural and urban areas and the sociocultural spheres that these two areas represent. How do family caregivers approach their caregiving situation? A hermeneutical approach was chosen to uncover the underlying meanings of experiences. Open-ended in-depth interviews were conducted. The ontological and epistemological roots are based on hermeneutic philosophy, where a human being’s existence is viewed as socially constructed. The study followed a purposeful sampling. Semi-structured in-depth interviews were conducted with 12 rural and 11 urban family caregivers to persons with dementia. These were then analyzed in accordance with the hermeneutical process. The findings provide insight into the variations of family caregiver approaches to caregiving in rural and urban areas of Sweden. There seemed to be a prevalence of a more accepting and maintaining approach in the rural areas as compared to the urban areas, where caregiving was more often viewed as an obligation and something that limited one’s space. Differences in the construction of family identity seemed to influence the participants approach to family caregiving. Therefore, community-based caregiving for the elderly needs to become aware of how living within a family differs and how this affects their views on being a caregiver. Thus, support systems must be individually adjusted to each family’s lifestyles so that this is more in tune with their everyday lives.

The Shift in Existential Life Situations of Adult Children to Parents with Dementia Relocated to Nursing Homes

BACKGROUND

Previous research describes spouses and adult children of people with dementia as a homogeneous group using one term: family caregivers. Recent research shows that the needs and experiences of spouses and adult children differ, therefore they cannot be studied as a homogeneous group.

AIMS

The aim of the study was to describe the shift in existential life situations of adult children of a parent with dementia relocated to nursing homes.

DESIGN

This is a qualitative study with an interpretive approach.

METHODS

Face-to-face interviews were held with 11 adult children aged 48-65 years. The interviews lasted 30-60 minutes and data were analysed using interpretive content analysis.

FINDINGS

The adult children described how they experienced their life situation before and after their parents' relocation. Before relocation they described feelings of powerlessness, loneliness in their responsibilities, loss and guilt. After relocation they had feelings of freedom, ongoing responsibility, living with loss and having a new relationship with death.

CONCLUSION

The most important finding in our study was that adult children developed a different relationship with death than before the parent became affected by dementia. It is essential that healthcare staff understand and address the adult children's existential life situations and the suffering they are experiencing. Healthcare staff need to be conscious about adult children's needs for support to address their existential life situations before and after their parents relocate to nursing homes.

Factors That Influence Self-Reported Health Changes With Caregiving

OBJECTIVE

This study examined factors associated with the self-reported change in health status as a result of caregiving.

METHOD

Multinomial logistic regression were performed to examine the sociodemographic characteristics, care recipients' characteristics, and caregiving experiences that affect caregivers' perceptions of health affected by caregiving using data from 1,087 caregiver respondents in the Caregiving in the U.S. 2015 data set. Data were collected through an online or telephone survey of randomly selected adults in 50 states.

RESULTS

Worsened self-reported health with caregiving occurred for caregivers aged 50 to 64, racial/ethnic minorities, those who lived within 20 min of the care recipient's home, the presence of cognitive deficits, prolonged caregiving, and limited availability of accessible and affordable care services. Importantly, the feeling of choice in taking on care responsibilities was associated with an over fourfold increase in the odds ratio (OR) of better health in response to caregiving (OR = 4.21; confidence interval [CI] = [1.95, 9.08]; p < .001).

DISCUSSION

Results suggest that improving accessibility of social service resources to assist caregivers in being better supported and having more choice in caregiving responsibilities may foster a positive change in health status with caregiving.

Factors associated with caregiver burden: comparative study between Brazilian and Spanish caregivers of patients with Alzheimer's disease (AD)

BACKGROUND

Transcultural studies regarding the comparison of levels of burden in caregivers of patients with Alzheimer's disease (AD) from Europe and Latin America are rare. We designed this study to investigate the differentiating factors associated with burden in Brazilian and Spanish caregivers of patients with AD.

METHODS

This is a cross-sectional study composed by samples of outpatients with AD and their caregivers from Brazil (n = 128) and Spain (n = 146). Caregivers answered the Zarit Burden Interview (ZBI) and a Sociodemographic Questionnaire. Patients were assessed with the Mini-Mental State Examination (MMSE), Functional Activities Questionnaire (FAQ), Disability Assessment for Dementia (DAD), Neuropsychiatric Inventory (NPI), and Clinical Dementia Rating (CDR) Scale.

RESULTS

In the multivariate regression analysis, high burden levels were reported in Brazil, when caregivers were female (p = 0.025) and when patients did not attend Day Care Center (p = 0.025). In Spain, high burden levels were associated with living with the patient (p = 0.014), younger caregivers (p = 0.003), and participation of patients at Day Care Center (p = 0.046). Also, different neuropsychiatric symptoms explained high burden levels: in Brazil, depression (p < 0.001) and anxiety (p = 0.024) and, in Spain, apathy/indifference (p < 0.001), agitation/aggression (p = 0.019) and irritability/lability (p = 0.027).

CONCLUSIONS

Caregivers' gender, patients who attended Day Care Center and neuropsychiatric symptoms were differentiating factors in the burden of Brazilian and Spanish caregivers.

The extended palliative phase of dementia – An integrative literature review

This article presents an integrative literature review of the experience of dementia care associated with the extended palliative phase of dementia. The aim was to highlight how dementia is defined in the literature and describe what is known about the symptomatology and management of advanced dementia regarding the needs and preferences of the person with dementia and their family carer/s. There was no consistent definition of advanced dementia. The extended palliative phase was generally synonymous with end-of-life care. Advanced care planning is purported to enable professionals to work together with people with dementia and their families. A lack of understanding of palliative care among frontline practitioners was related to a dearth of educational opportunities in advanced dementia care. There are few robust concepts and theories that embrace living the best life possible during the later stages of dementia. These findings informed our subsequent work around the concept, ‘Dementia Palliare’.