The parent they knew and the "new" parent: daughters' perceptions of dementia of the Alzheimer's Type

The role of the social environment on dementia caregivers' pre-death grief: A mixed- methods systematic review

This systematic review examined the role of social environment in pre-death grief experiences of dementia caregivers. Ninety-three Chinese and English articles were included from a comprehensive search of empirical studies using nine databases. Six social environment domains were generated: the person with dementia, dyadic relationship, family members and the wider community, health and social care services, place of care, and social-cultural contexts. A complex interplay between caregivers and their social environments that aggravate and attenuate pre-death grief experiences is evident. Research has focused mainly on the effects of people with dementia and dyadic relationships and has paid modest attention to the effects of family, relatives, and health and social care services. Caregivers' experiences with their friends, fellow caregivers, the wider community, and social-cultural norms are influential but understudied. Future research could adopt a systems thinking approach with sociological perspectives to generate a comprehensive and nuanced understanding of pre-death grief experiences.

A Brief, 6-Item Scale for Caregiver Grief in Dementia Caregiving

PURPOSE

Caregivers of persons with dementia (PWD) can experience loss and grief long before the death of the person. Although such experience of caregiver grief is measurable, available scales (such as the Marwit-Meuser Caregiver Grief Inventory, MM-CGI) are lengthy and have overlaps with other caregiving constructs. We developed a briefer scale that captures the essence of caregiver grief-with comparable psychometric properties and total score to MM-CGI, as well as less overlap with other caregiving constructs.

DESIGN AND METHODS

Family caregivers of community-dwelling PWD (N = 394) completed questionnaires containing MM-CGI and other caregiving scales. Initially, we split the study samples into two -the derivation sample (n = 179) was used to develop a brief scale that best predicts MM-CGI (using the best-subset approach with tenfold cross-validation), whereas the validation sample (n = 215) verified its actual performance in predicting MM-CGI. Thereafter, we evaluated the derived scale in its reliability and validity, and mapped its scores to MM-CGI using the equipercentile equating method.

RESULTS

We derived a 6-item scale, which explained 84.1% of the variability in MM-CGI and had area under the receiver operating characteristic curve of .96 in discriminating high caregiver grief (95% CI: .94-.99). It had single dimension in confirmatory factor analysis (comparative fit index = .98; Tucker-Lewis index = .97) and maintained good psychometric properties similar to those of MM-CGI, while showing lower correlation with caregiver burden and depression. It also had scores that could be mapped to MM-CGI with reasonable precision.

IMPLICATIONS

We developed the first brief scale with less than 10 items that can conveniently and accurately measure caregiver grief, which opens the way for grief-related interventions in clinical care. Notably, this 6-item scale was developed using rigorous methods and demonstrated consistent evidence of capturing the essence of caregiver grief.

Development and validation of a simple screening tool for caregiver grief in dementia caregiving

Background

Loss and grief are experienced by caregivers of persons with dementia (PWD), relating to the ambiguous loss of PWD even when they are still alive and the anticipation of future loss related to their physical death. Such experience of caregiver grief is not easily recognized in clinical practice, despite its association with adverse effects such as caregiver burden, caregiver depression and caregivers’ desire to place the PWD in nursing homes. We constructed a simple screening tool – based on factors associated with caregiver grief – to identify caregivers with high grief.

Methods

Spouses or children of community-dwelling PWD (n = 403) completed self-administered questionnaires containing a well-established grief scale and information related to the caregiver and PWD. We split the study sample into two – the derivation sample (n = 300) was used to identify factors associated with grief (using logistic regression) and derive a simple tool based on the number of identified factors; the validation sample (n = 103) evaluated the performance of the tool using the receiver-operating-characteristic-curve-analysis (ROC).

Results

Four key factors were identified by the multivariable regression – more severe dementia (odds ratio, OR 6.9), behavioral problems in PWD (OR 5.0), spousal caregivers (OR 6.0) and daily caregiving (OR 3.0). The screening tool (based on the number of key factors) had an area under ROC of 0.77. At the optimal cut-off of ≥2 key factors, the tool had a sensitivity of 0.91 and a specificity of 0.42.

Conclusions

The identified factors are consistent with current understanding on caregiver grief. They can be easily integrated into the workflow of routine services to screen for caregivers who are more likely to benefit from further grief-related assessment.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1070-x) contains supplementary material, which is available to authorized users.

Comparing the Effects of Grief and Burden on Caregiver Depression in Dementia Caregiving: A Longitudinal Path Analysis over 2.5 Years

OBJECTIVES

Caregivers of persons with dementia can experience loss and grief long before the death of the person. Although the phenomenon of caregiver grief has been increasingly described, it is uncertain if caregiver grief has independent effects-separate from the well-studied construct of caregiver burden-on adverse outcomes such as caregiver depression. We sought to compare the effects of baseline grief and burden on caregiver depression at baseline and 2.5 years later.

DESIGN AND SETTING

A cohort study with 2.5 years of follow-up.

PARTICIPANTS

Family caregivers of community-dwelling persons with dementia (n = 183).

MEASURES

Participants completed questionnaires with scales that assessed caregiver grief, burden, and depression. Baseline grief and burden scores were included in a path analysis to predict depression at baseline and at 2.5 years.

RESULTS

At baseline, grief and burden had synergistic relationships with each other (P = .012), where the high levels of grief amplified the effect of burden on caregiver depression. Both grief and burden had longitudinal effects on caregiver depression at 2.5 years (P <.001 and P = .047, respectively), albeit with some differences in mechanism; both had effects which were indirectly mediated through baseline depression (P < .001 and P = .002, respectively), but only grief had a direct path toward depression at 2.5 years (P = .030), which was distinct from baseline depression.

CONCLUSIONS AND IMPLICATIONS

The findings highlight the need to identify and address caregiver grief in dementia services. They present a window of opportunity to improve caregiving outcomes, especially during the "latent phase" when caregivers encounter loss and grief but have yet to fully experience the debilitating effects of depression.

Dementia grief: A theoretical model of a unique grief experience

Previous literature reveals a high prevalence of grief in dementia caregivers before physical death of the person with dementia that is associated with stress, burden, and depression. To date, theoretical models and therapeutic interventions with grief in caregivers have not adequately considered the grief process, but instead have focused on grief as a symptom that manifests within the process of caregiving. The Dementia Grief Model explicates the unique process of pre-death grief in dementia caregivers. In this paper we introduce the Dementia Grief Model, describe the unique characteristics of dementia grief, and present the psychological states associated with the process of dementia grief. The model explicates an iterative grief process involving three states- separation, liminality, and re-emergence-each with a dynamic mechanism that facilitates or hinders movement through the dementia grief process. Finally, we offer potential applied research questions informed by the model.

Grief in caregivers of persons with Alzheimer's disease and related dementia: a qualitative synthesis

This article provides a meta-synthesis of studies focusing on grief in caregivers of people with Alzheimer's disease or related dementia. Through a systematic search, 11 articles met the inclusion criteria that care receivers had a diagnosis of Alzheimer's disease or related dementia, caregivers were informal caregivers, and the study focused on caregiver grief. The meta-synthesis followed a meta-ethnography approach based on reciprocal translation. Six themes were identified, namely challenges of caregiving, losses and changes in the relationship, the role of dementia in grief, striving despite dementia, utilising social support and death as a relief from caregiving. Themes are discussed within an integrated framework showing the connected relationships between themes. The devised framework of themes illustrates the general experience of caregiver grief and can be used to devise specific, targeted interventions to help caregivers to identify and work through their grief.

The ambiguous relationships between aging and Alzheimer's disease: A critical literature review

One reason for the rise in the prevalence of Alzheimer's disease (AD) since the 1980s is the new association between the disease and aging. This paper explores the current representations of AD, questioning their relationships to aging, thanks to a literature review of 49 articles published in French and in English between 1995 and June 2010. Aging appears to be a concurrent diagnosis for AD, both for the lay public and for health professionals, but this confusion, which can be interpreted as a lack of medicalization of memory loss on the conceptual level, does not necessarily constitute an obstacle to medical intervention. The transformation of senile dementia into AD can diminish, as well as reinforce, stigmatization of people with AD. Moreover, elderly people with AD are subjected to both the persisting stigmas of aging and of dementia as well as, for most of them, that of feminine cognitive incompetence.

A literature review of palliative care, end of life, and dementia

Objective:Little attention has been paid in research to the palliative care of those dying with dementia. This literature review summarizes current research in the social sciences, including medical sociology on palliative care in the example of dementia.

Methods:A designated set of search words was applied to a comprehensive set of university-based search engines to ensure that relevant social science research since 200 was included.

Results:Primary themes discussed in the article include person-centered care, grief, agitation, aggression, pain management, care provision, training and education, decision-making, primary settings of care, and spirituality and dignity. Other key gaps in the literature are discussed.

Significance of the results:Given the projected increase within the next 20 years of people dying with dementia (Hanrahan et al., 2001), palliative care for those dying with dementia will become more relevant than ever.

Development and testing of a new outcome measure of relationship between patients with Alzheimer's disease and their partners

In mild Alzheimer's disease (AD), loss of relationship with the patient is a significant consequence for the partner (relative) and may be amenable to improvement with effective intervention. To evaluate relationship dynamics, the authors developed and tested content and discriminative validity of the self-administered Partner-Patient Questionnaire for Shared Activities among 100 partners of patients with mild to moderate Alzheimer's disease. Principal component analysis confirmed that interference in 17 activities derived from the literature and partner-specified activities comprised a relationship factor; internal consistency was very high. Time spent caregiving, caregiver esteem, lack of family support, and impact on partner health and activities were significant predictors of the Partner-Patient Questionnaire for Shared Activities, but the patient's cognitive and mood states were not. The Partner-Patient Questionnaire for Shared Activities warrants additional psychometric testing as a measure of Alzheimer's disease outcome.